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A patient with multiple myeloma was noted to have an IgA deficiency during investigation of a possible transfusion reaction due to IgA deficiency and anti-IgA. Because of the patient's age, otherwise good health, and early stage of disease, he was enrolled in a research treatment protocol that involved an allogeneic bone marrow transplant (BMT). The BMT successfully put the patient in complete remission from his multiple myeloma and corrected his IgA deficiency. Class-specific IgG anti-IgA antibody that had been identified prior to BMT was no longer detectable in his plasma. Anaphylactic transfusion reactions were successfully avoided by using a combination of IgA-deficient and washed blood components including the marrow graft, and IgA-reduced intravenous immunoglobulin.

Prostate cancer is now the most commonly diagnosed male malignancy and the second most common cause of male cancer death in the U.S. There is no standard role for medical therapy in the treatment of localized disease, although ongoing trials are investigating possible adjuvant and neoadjuvant roles. Subtotal androgen ablation by surgical or medical means is standard therapy for advanced disease, but such therapy does not exterminate the androgen-independent clone which is hypothesized to develop very early in the course of the disease. The current favored medical therapy for subtotal androgen ablation is the use of a depot formulation of an LHRH agonist accompanied initially by an antiandrogen. Once first-line hormonal therapy has failed, there is little to be gained by any other hormonal therapy, although withdrawal of the hormone(s) might itself be a therapeutic maneuver. Cytotoxic agents presently have no standard role in the management of prostate cancer. Future effective therapies for prostate cancer are being presaged by advances in prostate tumor biology.

Autologous bone marrow transplantation for leukemia was developed to extend the apparent curative potential of myeloablative therapy with allogeneic bone marrow transplantation to leukemia patients without histocompatible marrow donors. The conceptual problem with this approach is obvious: if the need for the transplant is based on overt or occult contamination of the marrow by leukemia, the use of autologous marrow seems destined to failure because of reinfusion of leukemia cells along with the harvested marrow. For this reason, ex vivo antileukemic treatment ("purging") of remission marrow was developed to justify autologous transplants for leukemia. Clinical trials involving thousands of patients worldwide have demonstrated curative potential of autologous bone marrow transplants, using purged or untreated remission marrow, for selected patients with acute myelogenous leukemia and acute lymphocytic leukemia. Purging appears to contribute to increased leukemia-free survival, at least in a subset of patients who are at very high risk of relapse, but this has not been tested in a prospective randomized trial and remains controversial. In acute myelogenous leukemia, in which the greatest experience exists, procedure-related mortality is much less for autologous than for allogeneic transplants; however, since leukemia relapse is much more frequent for autologous than for allogeneic transplants, the long-term disease-free survival is similar. In general, autologous transplants are preferred for older individuals and those without matched related donors, whereas allogeneic transplants are preferred for younger patients with matched related donors. Leukemia relapse has greatly limited the success of autologous transplants for acute lymphocytic leukemia. Autologous transplants for the chronic leukemias are in a much earlier stage of investigation. Autologous transplantation for leukemia is a fertile area for research. Important topics include conditioning regimens with improved antileukemic efficacy, the value of purging and the best method(s) for leukemia stem cell purging or normal stem cell selection, the possibility of inducing an autologous graft versus leukemia reaction, the use of immunomodulatory cytokines for postgrafting immune system manipulation, and the use of hematopoietic growth factors for ex vivo stem cell expansion and postgrafting support of marrow recovery.

A recent study demonstrated that the incidence of new arrhythmias occurring during central venous catheter insertion or exchange was 41% atrial and 25% ventricular arrhythmias (12% couplets or greater). Over-insertion of the guidewire, causing direct stimulation to the right side of the heart, has been postulated to be the causative factor. A new technique that allows the operator to control the length of guidewire inserted was developed. With this technique on a population of hospitalized patients, similar to those in the previous study, the incidence of atrial arrhythmias decreased to 32% and the incidence of ventricular arrhythmias to 6% (single premature ventricular contractions only). Although this new technique has limitations, there was a dramatic improvement in the incidence of cardiac arrhythmias. These results indicate a need for modifications in the available equipment to avoid the infrequent but life-threatening complication of malignant arrhythmia.

To explain the sequence-dependent in vitro cytotoxic synergism between 4-hydroperoxycyclophosphamide (4-HC) and cisplatin in the K-562 human leukemia cell line, we have hypothesized that 4-HC decreases cellular glutathione (GSH) levels and that the resulting diminution of the cellular protective effect of GSH leads to the increased cytotoxicity of cisplatin. Exposure of K-562 cells to 4-HC resulted in a concentration- and time-dependent depletion of cellular GSH. To determine the effect of modulation of GSH levels on the toxicity of cisplatin, K-562 cells were exposed to buthionine sulfoximine (BSO) and/or GSH ethyl esters. Depletion of GSH to approximately 10% of control values by BSO potentiated the cytotoxicity of cisplatin, while rapid replenishment of GSH to within normal levels by GSH esters abolished the potentiation of BSO. Doubling cellular GSH by incubation with GSH esters protected against cisplatin cytotoxicity. Of importance, pretreatment of K-562 cells with BSO, in addition to increasing the cytotoxicity of 4-HC and cisplatin, abolished the synergism between the two drugs. The working hypothesis was also tested in two other cell lines in which the cytotoxic synergism between 4-HC and cisplatin was exhibited: the Raji cell line, a human lymphoblastic cell line, and the L1210-CPA cell line, a subclone of the murine L1210 leukemia with resistance to 4-HC. GSH levels in these two cell lines were not altered by incubation with concentrations of 4-HC at which the synergism was observed. In conclusion, the data for the K-562 cell line, indicating that (a) 4-HC depletes cellular GSH levels, (b) the lowering of cellular GSH levels enhances the toxicity of cisplatin, and (c) intact GSH stores are required for the synergism, strongly support the postulate that the cytotoxic synergism between 4-HC and cisplatin is modulated by GSH levels in this cell line. However, the lack of 4-HC-mediated depletion of GSH at concentrations of 4-HC resulting in cytotoxic synergism in the Raji and L1210-CPA cell line indicates that mechanisms other than modulation of GSH levels by 4-HC are responsible for the synergism in these cells.

We are studying the usefulness of combinations of 4-HC and cisplatin as a potential purging regimen for autologous bone marrow transplantation. In all of our studies, in vitro cytotoxicity was determined by clonogenic assay, and drug interaction was quantitated using the multiple drug-effect analysis method. The cells were incubated for one hour (4-HC) and/or 4 hours (cisplatin). We found that the drugs in combination had cytotoxic synergism against human leukemia cell lines (K-562 and Raji). The synergism was sequence-dependent (cells must be exposed to 4-HC first), was present at various molar ratios of the drugs, and most pronounced at high levels of cell kill. We also found that the drugs had cytotoxic synergism against normal human marrow progenitors (CFU-GM). However, the leukemic cells were approximately 55 times more sensitive to the combination than CFU-GM. In a murine system, the drugs were synergistic against L1210 leukemia cells and normal murine CFU-GM, but L1210 cells were at least 130 times more sensitive to the combination than CFU-GM. To determine the ability of L1210 cells to grow in vivo after exposure to the drugs, BDF1 mice were injected with 2 x 10(4) cells which had been incubated with 4-HC and/or cisplatin. The survival time of untreated controls was 13 +/- 2.8 days. For treated groups, the cure rates after 50 days of observation were 33% (4-HC, 40 uM), 0% (cisplatin, 8 uM), and 100% (4-HC + cisplatin). Finally, at concentrations resulting in equivalent toxicity to marrow CFU-GM, cisplatin seemed to be more toxic to murine spleen blast colony forming cells (CFC-BC) than 4-HC. The drugs in combination appeared to have at least additive toxicities against CFC-BC.

Five monoclonal antibodies that identify the My-1 human granulocyte surface antigen were not reactive with other peripheral blood cells. These antibodies effected complement-dependent cytolysis of a large fraction of normal human marrow leukocytes. This My-1-positive marrow cell population consisted of morphologically identifiable granulocytic precursor cells. Colony-forming cells of the granulocyte-monocyte lineage (CFC-GM) did not express My-1, suggesting that the My-1 antigen is expressed later in normal granulocytic maturation. However, these antibodies did react with myeloid leukemic cell lines. The significance and potential utility of these probes for the understanding of granulopoietic differentiation is discussed.

Thymocytes from normal mice strains as well as from genetically determined stem cell defective W/Wv anemic mice were cocultured with syngeneic (or congeneic) bone marrow cells. We assayed these cocultures for the proliferation of erythroid progenitor cell types (BFU-E and CFU- E) using the plasma clot technique. Results indicate that when concentrations of thymocytes were lower than bone marrow cells, significant suppression of erythroid growth was observed. However, when the concentration of thymocytes exceeded that of the bone marrow cells in culture (greater than 1:1), significant enhancement of erythroid growth was demonstrated. The W/Wv anemic bone marrow appears to respond to this interaction by enhancement at all concentrations of added normal thymocytes. The regulatory functions observed can be diminished by treatment of the thymocytes in vitro with anti-theta serum plus complement. Thus, we establish regulatory functions for anti-theta- sensitive regulatory cells (TSRC) with both positive (enhancement) and negative (suppression) components.

This phase I study was conducted to determine the maximal safe concentration of 4-hydroperoxycyclophosphamide (4HC) that could be used for in vitro treatment of bone marrow from patients with acute leukemia undergoing autologous bone marrow transplantation. Concentrations of 40 to 120 micrograms/mL of 4HC were used in 30 patients with relapsed or high-risk acute leukemia and in six patients with nonleukemic malignancies. All patients received marrow-lethal cytoreductive therapy followed by infusion of the 4HC-treated marrow. Complete inhibition of granulocyte and macrophage colony-forming cells was obtained at 80 micrograms/mL. Nevertheless, only one transplant-related death and otherwise full hematologic recovery was observed at concentrations of 4HC up to 100 micrograms/mL. At 120 micrograms/mL, there were three transplant-related deaths, including two of the three patients who required the infusion of reserve marrow. Among the acute leukemia patients, three remain in complete remission at 1,337, 1,017, and 967 days after transplant. Among the nonleukemic patients, two remain in complete remission at 1,081 and 1,017 days after transplant. At the maximum safe concentration of 4HC (100 micrograms/mL), satisfactory hematologic recovery can be obtained, despite elimination of detectable hematopoietic progenitors.

We studied the effect of food deprivation on hematopoietic reconstitution of B6D2F1 mice given 900 rad total body irradiation followed by 2 x 10(5) syngeneic bone marrow cells. Animals deprived of food from the day of cell transfer to the day of sacrifice were compared to control animals allowed ad libitum laboratory chow. The body weight of food deprived mice decreased by 36% on day 7 as compared to a 9% decrease in fed controls. The mean number of nucleated cells/femur on day 7 was only 22% of that found in fed controls. The spleen weight in the experimental animals was only 48% of that in the controls. Food deprived animals showed complete suppression of macroscopic hematopoietic spleen colony formation. Both marrow and spleen from the primary recipients, when studied for content of CFU-s in secondary ad libitum fed recipients, showed that food deprived animals had less than 25% of the number seen in controls. A third group of animals receiving vitamin supplements and small amounts of dextrose, but no protein, showed hematopoietic suppression similar to that seen in the totally food deprived mice.

Antiinflammatory drugs may prevent thrombosis by inhibiting platelet prostaglandin (PG) synthesis. We have studied: 1. the effects of aspirin (ASA) and sulfinpyrazone (SPZ) in vitro on platelet PG synthesis. 2. PG synthesis in vitro using platelets from patients with transient cerebral ischemic attacks (TIA) who are receiving either placebo (PLC), ASA (1200 mg daily) or SPZ (800 mg daily). 3. the platelet release reaction (PRR) using platelets from PLC and SPZ-treated TIA patients. 4. PRR using platelets from control subjects in the presence and absence of added SPZ.

The effects of (PGE) prostaglandins E1 and E2 on the aggregation and release reaction induced in human platelets by ADP have been investigated. Measurements of cyclic-AMP content in (PRP) platelet-rich plasma were made concurrently. Although both PGE1 and PGE2 independently increased platelet cyclic-AMP and inhibited 1st phase ADP-induced aggregation (order of potency, PGE1 PGE2), the effect of a fixed concentration of PGE2 in the presence of PGE1 varied. At low PGE1 concentrations, the effects were additive, but at higher PGE1 concentrations PGE2 lowered the efficacy of PGE1. These results suggest that PGE2 may be a "partial agonist" of PGE1. PGE2 enhanced and PGE1 inhibited the 2nd phase of ADP-induced aggregation and the release of serotonin by a mechanism which appeared to be independent of cyclic-AMP content. A mixture of the 2 PGs produced responses intermediate between those observed with each PG independently. Binding of PGE1-3H to platelets was demonstrated in PRP and in concentrated platelet suspensions. PGE1 and PGE2 inhibited binding in a simular manner. It is proposed that PGE1 and PGE2 compete for a common receptor on the platelet membrane.

The Canadian Stroke Study has afforded us an opportunity to study the effect of sulfinpyrazone 800 mg daily, aspirin 1200 mg daily, both drugs together, and a placebo on the Ivy template bleeding time. Patients with transient cerebral ischemic attacks were randomized to one of the treatment groups and studied before and during treatment.In 352 patients studied pre-drug, the mean bleeding time was 5.02 ± 2.38 (± 1 SD) minutes. Aspirin significantly prolonged the bleeding time (p=.001). Sulfinpyrazone alone had no effect on the bleeding time. In patients receiving both drugs, the effect was no greater than that of aspirin alone. 51Cr platelet survival studies have been completed in 47 patients during treatment. The mean of 8.4 days was similar to the mean in 17 normal controls(8.3 days). However, analysis by treatment groups remains to be done.

The My-10 glycoprotein is an hematopoietic cell surface antigen expressed specifically by undifferentiated (blast) cells, constituting 1%-4% of normal adult bone marrow leukocytes. We used several immunological and in vitro culture methods to analyze the expression of this unique antigen on a variety of lymphohematopoietic progenitor cells. Colony-forming cells (CFC) for granulocyte-monocyte colonies (CFC-GM) and erythroid colonies (BFU-E) were predominantly My-10 positive. CFC with higher proliferative potential were more strongly My-10 positive than CFC with lower proliferative potential, and those for mixed-lineage and blast cell colonies were even more uniformly My-10 positive. Cells maintaining CFC-GM number in short-term marrow culture (pre-CFC) were found to be My-10 positive, as were lymphoid precursors defined by their content of intranuclear terminal deoxynucleotidyl transferase. More mature erythroid precursors (CFU-E) were heterogeneous for antigen expression and lost My-10 antigen progressively, in parallel with advancing maturational stage. The My-10 antigen permits rapid identification and purification of hematopoietic progenitor cells for further study or potential clinical application. The disappearance of the My-10 antigen, moreover, may be a probe for differentiation-linked cellular events.

Although standard supportive care for bone marrow transplant (BMT) recipients includes total parenteral nutrition (TPN), it has not been shown that this is the most appropriate method of nutritional support. To determine whether current BMT recipients require TPN during the early recovery period, we conducted a prospective, randomized clinical trial comparing TPN and an individualized enteral feeding program (counseling, high protein snacks and/or tube feeding). Nutritional assessment included measurement of serum proteins, anthropometry, and body composition analysis. For the latter, total body water and extracellular fluid were measured by standard radioisotope dilution techniques and used to quantitate body cell mass and body fat plus extracellular solids (FAT + ECS). In 27 TPN patients, body composition 28 days after BMT, expressed as a percentage of baseline, was body cell mass, 100%, extracellular fluid, 108%, FAT + ECS, 108%, and in 30 enteral feeding program patients, was body cell mass, 93%, extracellular fluid, 104%, and FAT + ECS, 94%. Only the difference in FAT + ECS was statistically significant (p less than 0.01). Compared to the enteral feeding program, TPN was associated with more days of diuretic use, more frequent hyperglycemia, and more frequent catheter removal (prompted by catheter-related complications), but less frequent hypomagnesemia. There were no significant differences in the rate of hematopoietic recovery, length of hospitalization, or survival, but nutrition-related costs were 2.3 times greater in the TPN group. We conclude that TPN is not clearly superior to individualized enteral feeding and recommend that TPN be reserved for BMT patients who demonstrate intolerance to enteral feeding.

The results of therapy with carbenicillin plus trimethoprim-sulfamethoxazole (C-T/S) were compared to those obtained with carbenicillin plus gentamicin (C-G) in a prospective double-blind study of empiric antibiotic therapy in granulocytopenic patients. Patients were stratified into two groups: favorable-prognosis, group 1 (carcinoma, lymphoma, multiple myeloma), or unfavorable-prognosis, group 2 (acute leukemia, bone marrow transplantation), based on anticipated duration of granulocytopenia. Over-all, empiric antibiotic trials were more often successful (P = 0.004) in group 1 (55 of 62 patients or 89 per cent) than in group 2 (42 of 64 patients, 66 per cent)mwithin group 1, there was a favorable outcome in 30 of 32 (94 per cent) C-T/S trials and in 25 of 30 (83 per cent) C-G trials (P = 0.25); within group 2, there was a favorable outcome in 23 of 30 (77 per cent) C-T/S trials and in 19 of 34 (56 per cent) C-G trials (P = 0.14), Combined results in both groups indicated a higher proportion of favorable outcome in C-T/S trials (53 of 62, 85 per cent) than in C-G trials (44 of 64, 69 per cent). Further analysis (Manetl-Naenszel test) showed the over-all difference in outcome to be significant (P = 0.049), but the general applicability of this result may be limited by the rather low incidence of gram-negative bacterial infections in this study. There was no difference between the treatment regimens in antibiotic toxicity, and serious superinfection occurred only in group 2 patients (21 per cent of trials), equally divided between treatment arms. Initial protocol dosing achieved target plasma levels of trimethoprim (3 to 8 micrograms/ml) or gentamicin (4 to 10 micrograms/ml) in 57 of 68 (84 per cent) C-T/S trials compared to 21 of 60 (35 per cent) C-G trials.

This institution has documented consistent reconstitution of hematopoiesis in patients treated with marrow lethal chemoradiotherapy who are "rescued" by reinfusion of autologous cryopreserved marrow cells incubated with 4-hydroperoxycyclophosphamide (4-HC) for in vitro purging of occult tumor cells. After 4-HC incubation, the reinfusion marrow cells showed marked reduction in committed progenitor cell (BFU-E, CFU-GM) frequency, and often total absence of detectable progenitors, without significant loss of marrow reconstituting ability. Since BFU-E and CFU-GM assays did not predict marrow reconstituting ability after 4-HC incubation, we sought to determine whether multilineage progenitor cells (CFU-GEMM) might be more resistant to 4-HC incubation and therefore a more reliable predictive assay in this setting. We found that BFU-E, CFU-GM, and CFU-GEMM all show similar dose-related sensitivity to in vitro incubation with 4-HC and do not appear representative of the cell(s) responsible for marrow reconstitution.

In a group of cancer patients selected to exclude common causes of abnormal lipid absorption, we have examined this function using a breath test. Abnormal breath tests of fatty acid absorption (FABT) are found in most cancer patients, as has been previously claimed. These tests are abnormal in both quality (delayed peak in nine of ten patients, and quantity (reduced maximum peak in five of ten patients) of fatty acid absorption. In many patients abnormal FABT is not due to chemotherapy. Our preliminary results indicate no definite malabsorption mechanism but more stringent tests of absorption need to be applied. Malnutrition is common in cancer patients, even in those with little or no weight loss, and some of the malnutrition may be related to abnormal lipid absorption or to other disturbed aspects of lipid metabolism.

Difficulties associated with the whole blood clotting time (W.B.C.T.) as a method of monitoring heparin therapy have led to the investigation of the activated partial thromboplastin time (A.P.T.T.) as an alternative. The conclusion is reached that the latter procedure possesses several advantages. Using the method described and a citrate-preserved blood sample collected just prior to the administration of the next serial dose of heparin, the suggested therapeutic duration of the A.P.T.T. is 70 seconds or twice the mean control value. A practical range for this method is 60 to 70 seconds.

SummaryThe activation of Factor XII (Hageman Factor) by bovine collagen has been studied in vitro and in vivo. Alkaline eluates obtained from collagen exposed to human and rabbit plasma contained Factors XII and XI, and were found to shorten markedly the whole blood clotting time of rabbits in vivo and in vitro. Formation of stasis thrombi could also be demonstrated in rabbits following injection of collagen eluates. The possible significance of collagen-induced Factor XII activation in the mechanism of hemostasis and thrombosis is discussed.