Autologous transplantation of ex vivo expanded bone marrow cells grown from small aliquots after high-dose chemotherapy for breast cancer

The collection of small aliquots of bone marrow (BM), followed by ex vivo expansion for autologous transplantation may be less morbid, and more cost-effective, than typical BM or blood stem cell harvesting. Passive elimination of contaminating tumor cells during expansion could reduce reinoculation risks. Nineteen breast cancer patients underwent autotransplants exclusively using ex vivo expanded small aliquot BM cells (900-1200 x 10(6)). BM was expanded in media containing recombinant flt3 ligand, erythropoietin, and PIXY321, using stromal-based perfusion bioreactors for 12 days, and infused after high-dose chemotherapy. Correlations between cell dose and engraftment times were determined, and immunocytochemical tumor cell assays were performed before and after expansion. The median volume of BM expanded was 36.7 mL (range 15.8-87.0). Engraftment of neutrophils greater than 500/microL and platelets greater than 20,000/microL were 16 (13-24) and 24 (19-45) days, respectively; 1 patient had delayed platelet engraftment, even after infusion of back-up BM. Hematopoiesis is maintained at 24 months, despite posttransplant radiotherapy in 18 of the 19 patients. Transplanted CD34(+)/Lin(-) (lineage negative) cell dose correlated with neutrophil and platelet engraftment, with patients receiving greater than 2.0 x 10(5) CD34(+)/Lin(-) cells per kilogram, engrafting by day 28. Tumor cells were observed in 1 of the 19 patients before expansion, and in none of the 19 patients after expansion. It is feasible to perform autotransplants solely with BM cells grown ex vivo in perfusion bioreactors from a small aliquot. Engraftment times are similar to those of a typical 1000 to 1500 mL BM autotransplant. If verified, this procedure could reduce the risk of tumor cell reinoculation with autotransplants and may be valuable in settings in which small stem cell doses are available, eg, cord blood transplants. (Blood. 2000;95:2169-2174)

Clinical progress and the future of HIV exceptionalism

In the 18 years since the first cases of the acquired immunodeficiency syndrome (AIDS) were reported by the Centers for Disease Control and Prevention (CDC), the epidemic has undergone profound transformations, and so, too, has the sociomedical context within which public health policy is fashioned and implemented. The early years of neglect and panic were also characterized by relative therapeutic impotence and deep uncertainty about the epidemiological course the new threat would take. In the United States and in other economically advanced nations, the threat of contracting the human immunodeficiency virus (HIV) has abated. The incidence of infection has declined, and the prevalence of infection has stabilized and, in some instances, begun to fall. The pattern of HIV spread, where it has continued, has been dramatically circumscribed to marginalized populations. The panic of the mid-1980s has passed, and in many nations, AIDS has lost its salience as a public issue. A sense of therapeutic impotence no longer prevails, and a new mood of triumphalism has taken hold. How have these crucial changes affected AIDS policies in America?

The synthesis of sialylated oligosaccharides using a CMP-Neu5Ac synthetase/sialyltransferase fusion

Large-scale enzymatic synthesis of oligosaccharides, which contain terminal N-acetyl-neuraminic acid residues requires large amounts of the sialyltransferase and the corresponding sugar-nucleotide synthetase, which is required for the synthesis of the sugar-nucleotide donor, CMP-Neu5Ac. Using genes cloned from Neisseria meningitidis, we constructed a fusion protein that has both CMP-Neu5Ac synthetase and alpha-2,3-sialyltransferase activities. The fusion protein was produced in high yields (over 1200 U/L, measured using an alpha-2,3-sialyltransferase assay) in Escherichia coli and functionally pure enzyme could be obtained using a simple protocol. In small-scale enzymatic syntheses, the fusion protein could sialylate various oligosaccharide acceptors (branched and linear) with N-acetyl-neuraminic acid as well as N-glycolyl- and N-propionyl-neuraminic acid in high conversion yield. The fusion protein was also used to produce alpha-2,3-sialyllactose at the 100 g scale using a sugar nucleotide cycle reaction, starting from lactose, sialic acid, phosphoenolpyruvate, and catalytic amounts of ATP and CMP.

Directly observed therapy and treatment completion for tuberculosis in the United States: is universal supervised therapy necessary?

OBJECTIVES

This study examined the relationship between directly observed therapy and treatment completion rates in the years before and after infusion of federal funding for tuberculosis (TB) control in 1993.

METHODS

An ecological study of estimated directly observed therapy rates and 12-month treatment completion rates from 1990 through 1994 was undertaken for TB control programs in all 25 cities and counties across the nation with 100 or more incident TB cases in any year from 1990 to 1993. Three cohorts were formed: high treatment completion, intermediate completion, and low completion.

RESULTS

In 1990, the median 12-month treatment completion rate was 80% for the entire study population, with a median estimated directly observed therapy rate of 16.8%. By 1994, those rates had increased to 87% and 49.4%, respectively, and increases were shown in all 3 cohorts.

CONCLUSIONS

Directly observed therapy has had a marked impact on treatment completion rates in jurisdictions with historically low rates. But TB treatment completion rates of more than 90% can be attained with directly observed therapy rates far lower than those proposed by advocates of universal supervised therapy.

Recombinant methionyl human stem cell factor and filgrastim for peripheral blood progenitor cell mobilization and transplantation in non-Hodgkin's lymphoma patients--results of a phase I/II trial

To examine the safety and efficacy of recombinant-methionyl human stem cell factor (r-metHuSCF), 38 patients with intermediate-grade or immunoblastic high-grade non-Hodgkin's lymphoma who were eligible for autologous transplantation were randomized to receive r-metHuSCF (5, 10, 15, or 20 microg/kg/d) plus Filgrastim (10 microg/kg/d) or Filgrastim (10 microg/kg/d) alone to mobilize peripheral blood progenitor cells. Subcutaneous administration of r-metHuSCF was well tolerated in conjunction with a multi-agent pre-medication regimen; local injection site reactions were the most commonly seen adverse event. The total mononuclear cell count, CD34+ cell content, granulocyte-macrophage colony-forming cells (GM-CFC), and burst-forming units-erythroid (BFU-E) per kilogram in the apheresis product was similar when all patients were analyzed by treatment cohort and mobilization regimen (Filgrastim or r-metHuSCF in combination with Filgrastim); however, when prior chemotherapy was taken into account in a supplementary analysis, clinically important differences were observed. Extensive prior therapy was defined as the amount of exposure to specific stem cell toxic chemotherapeutic agents that patients received. These agents include procarbazine, nitrogen mustard, melphalan, nitrosoureas (> or = 2 cycles of any of these drugs) or greater than 7.5 g of cytosine arabinoside. In these patients, there was an increased number of CD34+ cells (1.76 v 0.28 x 10(6)/kg), GM-CFC (20.5 v 5.0 x 10(4)/kg), and BFU-E (36.9 v 8.9 x 10(4)/kg) in patients receiving r-metHuSCF and Filgrastim (N = 18) compared with Filgrastim alone (N = 5). These patients also had a decreased time to an untransfused platelet count of 20 x 10(9)/L that was 10.5 days shorter in the patients who received r-metHuSCF and Filgrastim (12.5 v 23 days). These differences were not found to be statistically significant, possibly because of small size, but are clinically important.

High-dose chemotherapy with autologous transplantation for persistent/relapsed ovarian cancer: a multivariate analysis of survival for 100 consecutively treated patients

PURPOSE

To examine the prognostic factors associated with prolonged progression-free survival (PFS) and overall survival (OS) in 100 consecutively treated women undergoing autologous stem-cell transplant for advanced ovarian cancer.

PATIENTS AND METHODS

From October 1989 to February 1996, we transplanted 100 patients with ovarian cancer following chemotherapy with high-dose carboplatin, mitoxantrone, and cyclophosphamide with or without cyclosporine (n = 70); melphalan and mitoxantrone with or without paclitaxel (n = 25); or other regimens (n = 5). Their median age was 48 years (range, 23 to 65), 70% had papillary serous histology, 72% had grade III tumors, 66% were platinum-resistant, and 61% had > or = 1 cm bulk. The median number of prior regimens was two (range, one to six). Univariate and multivariate analyses were performed to examine age (< v > or = mean), stage, initial bulk, histology, grade, response to initial therapy, number of prior regimens, time from diagnosis to transplant, transplant regimen, platinum sensitivity, and bulk (< v > or = 1 cm) at transplant.

RESULTS

The median PFS and OS times for the 100 patients were 7 and 13 months. A stepwise Cox proportional hazards model identified tumor bulk (P = .0001), and cisplatin sensitivity (P = .0249) as the best predictors of PFS. Age (P = .0017), bulk at transplant (P = .0175), and platinum sensitivity (P = .0330) provided the best prediction of OS. The median PFS and OS times for the 20 patients with platinum-sensitive, < or = 1-cm disease were 19 and 30 months. No differences in OS were seen when chemotherapy or surgery was used to achieve a minimal disease state.

CONCLUSION

Before consideration of high-dose therapy for recurrent/persistent advanced ovarian cancer, patients should undergo debulking surgery or chemotherapy to achieve a minimal disease state. Patients with platinum-resistant, bulky disease should not be transplanted. The optimal patients for this therapy may be those with minimal disease responsive to initial chemotherapy.

Science, politics, and AIDS prevention policy

The relationships among science, politics, and health care policy have changed dramatically over the years since AIDS was first diagnosed in the United States. Initially politics was viewed as inimical to prevention; now it is viewed as central. The challenge is to ensure that policies facilitate prevention of the spread of HIV and do so in a way that protects those most vulnerable. The policies of the first decade of the epidemic were hostile to research in areas such as needle exchange and sexuality. More recently, the political climate has been more sympathetic, but whether this will result in a more effective health-care policy is not yet clear. Two important debates continue in AIDS prevention policy: (a) the issue of whether prevention efforts should be targeted to high-risk populations and geographic areas or should be more broadly focused, and (b) whether prevention priorities are best established through democratic participation that includes federal government agencies, local health departments, and community-based organizations.

A balancing act: the tension between case-finding and primary prevention strategies in New York State's voluntary HIV counseling and testing program in women's health care settings

This study sought (1) to identify factors that influence women's willingness to accept voluntary HIV counseling and testing at New York State Family Planning Programs (FPPs) and Prenatal Care Assistance Programs (PCAPs) and (2) to evaluate the effectiveness of such a voluntary counseling and testing program. Telephone interviews elicited organizational-level data from 136 agencies; a combination of telephone and face-to-face interviews was used to gather provider data from 98 HIV counselors; and client data were gathered from 354 women in face-to-face interviews at counseling sites. Slightly fewer than 60% of women agreed to be counseled, and, of those, under half consented to an HIV test at the counseling site. Approximately two thirds of the women who were tested returned for their results and posttest counseling. Clients' recall of pretest counseling content was relatively poor. Bivariate and regression analyses suggest that client, provider, and organizational factors are all associated with rates of pretest counseling and testing. The current voluntary counseling and testing program is achieving only moderate success. Although a substantial number of clients accept HIV counseling, many women remain reluctant to consent to HIV testing, and many who accept testing do not return for their results. Moreover, among those who receive pretest counseling, many do not recall important informational content, which suggests variation may exist in the quality of counseling or that one-time HIV counseling interventions are insufficient to communicate complex information. Medical Subject Headings (MeSH): AIDS, HIV serodiagnosis, women's health, patient education.

High-dose chemotherapy combined with escalating doses of cyclosporin A and an autologous bone marrow transplant for the treatment of drug-resistant solid tumors: a phase I clinical trial

High response rates are seen in patients undergoing dose-intensive chemotherapy and autologous marrow transplantation due to the ability of the therapy to overcome inherent or acquired drug resistance. However, relapse rates are also high because this drug resistance reversal is incomplete. Because both P-glycoprotein- and platinum-induced resistance appear to be clinically important and can be reversed in vitro with a short exposure of cyclosporin A (CSA) at 2000 and 5000 ng/ml, respectively, we undertook a trial of high-dose chemotherapy with carboplatin (1500mg/m2), mitoxantrone (75 mg/m2), and cyclophosphamide (120 mg/kg) over a 5-day period combined with escalating doses of CSA. Thirty-seven patients with primarily breast cancer (61% doxorubicin resistant) and ovarian cancer (85% platinum resistant) were treated with CSA given as a bolus 18 h prior to chemotherapy, followed by a 5-day infusion at doses of 5.0-28.2 mg/kg/day and the chemotherapy. The maximum tolerated dose of CSA was a bolus of 5.5 mg/kg and an infusion of 15. 9 mg/kg/day, which gave a mean serum CSA level of 1544 ng/ml. The dose-limiting toxicity was severe mucositis and enteritis, leading to infectious complications. Nephrotoxicity was seen in 42% and, while usually mild and reversible, was fatal in two patients with pretreatment creatinine clearances h80 ml/min. Grade III-IV isolated hyperbilirubinemia was seen in 39%, but appeared to be of no clinical significance. The overall response rate for the 26 patients with measurable/evaluable disease was 73% and 63% for those with doxorubicin- or platinum-resistant disease. The median overall survival and progression-free survival for the group were 18.1 and 8. 0 months. The overall survival for the nine patients with doxorubicin-resistant breast cancer was 19.3 months. Although we did not achieve CSA levels needed to reverse platinum resistance in vivo, levels approaching those needed to reverse P-glycoprotein resistance were reached at the maximum tolerated dose. The strategy of combining dose intensity with drug resistance reversal deserves further study, especially with the advent of potentially less toxic agents available to reverse P-glycoprotein-mediated resistance.

Neutrophil adhesion in leukocyte adhesion deficiency syndrome type 2

We have previously reported a newly discovered congenital disorder of neutrophil adhesion, leukocyte adhesion deficiency syndrome type 2 (LAD II). The clinical manifestations of this syndrome are similar to those seen in the classic leukocyte adhesion deficiency syndrome, now designated type 1 (LAD I), but the two syndromes differ in the molecular basis of their adhesion defects. LAD I is caused by a deficiency in the CD18 integrin adhesion molecules while LAD II patients are deficient in expression of sialyl-Lewis X (SLeX), a carbohydrate ligand for selectins. In this report we demonstrate that neutrophils from a LAD II patient bind minimally or not at all to recombinant E-selectin, purified platelet P-selectin, or P-selectin expressed on histamine-activated human umbilical vein endothelial cells, but have normal levels of L-selectin and CD11b/CD18 integrin, and adhere to and migrate across endothelium when CD11b/CD18 is activated. We compare LAD I and LAD II patient neutrophil function in vitro, demonstrating that integrin and selectin adhesion molecules have distinct but interdependent roles in neutrophil adhesion during an inflammatory response.

A phase I trial of interleukin 3 (IL-3) pre-bone marrow harvest with granulocyte-macrophage colony-stimulating factor (GM-CSF) post-stem cell infusion in patients with solid tumors receiving high-dose combination chemotherapy

In humans, interleukin 3 (IL-3) administration increases the cellularity and cycling of bone marrow progenitor cell populations. Initially, in primates and then in humans, IL-3 in sequence with GM-CSF has been shown to stimulate multilineage hematopoiesis. Based upon these effects, we designed a phase I trial of daily IL-3 administered subcutaneously for 10 days at dose levels of 2.5, 5.0, 10.0, 12.5, and 15.0 micrograms/kg followed within 72 h by bone marrow harvest, high-dose chemotherapy, and following chemotherapy, a fixed dose (5.0 micrograms/kg/day) of GM-CSF and bone marrow rescue. The study was designed to assess the toxicity and biological effects of IL-3 administered alone prior to bone marrow harvest and to determine the safety and clinical effects of IL-3 stimulated bone marrow with GM-CSF following high-dose combination chemotherapy. A total of 19 patients with chemotherapy-sensitive non-hematologic malignancies (13 breast, five ovarian, and one testicular cancer) were enrolled. IL-3 up to 15.0 micrograms/kg/day could be administered without dose-limiting toxicities. Flu-like symptoms and headaches were common and poorly tolerated at the highest IL-3 dose. Significant increases in neutrophil counts (P = 0.018) were observed following IL-3. Overall, IL-3 administration was associated with a modest, but significant increase in CFU-GM within the bone marrow (P = 0.034). IL-3 administration had no consistent effect on CD34+ cell number within bone marrow. For the entire group, engraftment of neutrophils to greater than 0.5 x 10(9)/l occurred at a median of 21 days (range of 13-63 days) and platelet independence occurred at a median of 17 days (range 11-120 days). When IL-3 dose levels were analyzed separately, engraftment of neutrophils and platelets, blood product (platelets and packed RBCs) utilization, and discharge date were not superior in those treated with the higher dose (15.0 micrograms/kg) of IL-3. While higher doses of IL-3 were associated with more toxicity, they did not appear to enhance the stem cell pool or speed engraftment later. The effects of pre-bone marrow harvest IL-3 are modest and likely not as impressive as other approaches aimed at enhancing hematologic recovery following high-dose chemotherapy.