Early diagnosis of relapse in acute myeloblastic leukemia: Serologic detection of leukemia-associated antigens in human marrow

Prevention of Chemotherapy-Induced Nausea and Vomiting in the Older Patient: Optimizing Outcomes

Chemotherapy-induced nausea and vomiting (CINV) are still two of the most feared side effects of cancer therapy. Although major progress in the prophylaxis of CINV has been made during the past 40 years, nausea in particular remains a significant problem. Older patients have a lower risk of CINV than younger patients, but are at a higher risk of severe consequences of dehydration and electrolyte disturbances following emesis. Age-related organ deficiencies, comorbidities, polypharmacy, risk of drug–drug interactions, and lack of compliance all need to be addressed in the older patient with cancer at risk of CINV. Guidelines provide evidence-based recommendations for the prophylaxis of CINV, but none of these guidelines offer specific recommendations for older patients with cancer. This means that the recommendations may lead to overtreatment in some older patients. This review describes the development of antiemetic prophylaxis of CINV focusing on older patients, summarizes recommendations from antiemetic guidelines, describes deficiencies in our knowledge of older patients, summarizes necessary precautions, and suggests some future perspectives for antiemetic research in older patients.

Antiemetics: an update and the MASCC guidelines applied in clinical practice

Nausea and vomiting are two of the most severe problems for patients treated with chemotherapy. Until the late 1970s, nausea and vomiting induced by chemotherapy was an almost neglected research area. With the introduction of cisplatin, the cytotoxin with the highest emetic potential, research was stimulated and has now resulted in the development of two new classes of antiemetics, the serotonin and neurokinin antagonists. A large number of trials have fine-tuned antiemetic therapy and made evidence-based recommendations possible for the majority of patients receiving chemotherapy. This Review discusses the pathophysiology of nausea and vomiting, the development of antiemetics, highlights some of the newest antiemetics, and finally summarizes recommendations from the evidence-based guidelines developed by the Multinational Association of Supportive Care in Cancer.

New perspectives in antiemetic treatment

Though antiemetic therapy has improved markedly in the past 15 years, patients still regard nausea and vomiting as two of the most distressing adverse events during chemotherapy. A major progress was the development of the serotonin3 (5-HT3) receptor antagonists. A possible antiemetic effect, achieved by interference with the "serotonergic system", is not restricted to antagonism at 5-HT3 receptors, however, but also includes agonism at 5-HT1A and 5-HT2 receptors, and serotonin synthesis inhibitors. The number of receptors thought to be involved in the emetic reflex has been augmented by neurokinin1 receptors with substance P as the preferred ligand. Animal studies have demonstrated a broad antiemetic profile of substance P antagonists. The somatostatin analogue octreotide has an antiemetic effect in patients with gastrointestinal obstruction, but has not been investigated against chemotherapy-induced emesis. The next few years will disclose, whether the efficacy and safety profiles of one or more of these drugs will make it clinically useful in the treatment of chemotherapy-induced nausea and vomiting.

Development of antiemetic therapy in cancer patients

Patients still consider nausea and vomiting to be severe adverse consequences of cancer chemotherapy. The physiology of chemotherapy-induced nausea is generally unknown, but the finding that high doses of metoclopramide induce the antiemetic effect by antagonizing 5-HT3 receptors, has evoked increased interest in serotonin as a possible neurotransmitter. This has led to development of more selective 5-HT3 antagonists, such as ondansetron, granisetron and tropisetron, with improvement of antiemetic therapy, especially in patients receiving cisplatin-based chemotherapy. The efficacy of serotonin antagonists is further optimized by the addition of steroids and the dopamine D2 antagonist metopimazine. Many questions in antiemetic treatment are still unanswered and future trials should focus on patients receiving multiple-day chemotherapy or multiple cycles of chemotherapy and on patients resistant to initial antiemetic therapy.

Acute promyelocytic leukemia associated with a paraprotein that reacts with leukemic cells

A 29-year-old woman developed acute promyelocytic leukemia during pregnancy. At diagnosis, immediately postpartum, she was found to have IgG kappa immunoglobulin on the surface of the leukemic cells as well as a monoclonal protein of IgG kappa specificity in her serum. These resolved with chemotherapy which induced a complete remission. Immunoglobulin gene rearrangement was not found in the leukemic cells, thus indicating that the blasts were not secreting the monoclonal protein. The authors believe that the patient had an autoantibody directed at myeloid cells which was amplified by the development of the leukemic process.

CAMAL: a new prognostic marker for remission in acute nonlymphoblastic leukemia

A leukemia-associated antigen, CAMAL, shown to be present in bone marrow (BM) cells from patients with acute nonlymphoblastic leukemia (ANLL) even during remission, has been examined using indirect immunoperoxidase and a monoclonal antibody, CAMAL-1. We are ending the third year of an ongoing blind study designed to monitor the number of BM cells expressing the CAMAL protein (CAMAL BM value) in ANLL patients over the course of their disease. Results thus far have revealed that the CAMAL BM value in individual patients often changed significantly post-chemotherapy. This change appeared to be a useful prognostic marker in many instances. ANLL patients at initial presentation whose CAMAL BM values increased or stayed the same post-chemotherapy had significantly (p less than 0.025) shorter remission lengths (x = 6.8 months, n = 24) than those whose CAMAL BM values decreased (x = 19.2 months, n = 10). There are indications that increasing CAMAL BM values during remission occur prior to clinical relapse.

Methodology of premature chromosome condensation and its potential for relapse prediction in acute leukemia of children and adolescents

Premature chromosome condensation has been examined as a method for measuring the proliferative potential of bone marrow cells derived from children with acute leukemia with the intention of finding a predictor of relapse. A proliferative potential index (PPI) has been determined for patients with active disease at diagnosis and relapse, as well as at onset of remission and at extramedullary relapse. A modification of the technique established by Hittelman is described, which can be easily performed by the leukemia cytogeneticist. A PPI of 35% or greater is usually obtained for patients at diagnosis or in relapse. At the onset of remission, the PPI declines to values significantly below 35% and during extramedullary relapse the value of the PPI is near normal (12%). The method for the determination of the PPI is given in detail.

Demonstration of antibodies binding to autologous and allogeneic leukemic cells in childhood ALL. Evidence for a common ALL antigen(s)

The humoral immune response to autologous leukemic cells was investigated in childhood ALL using a 125I protein A binding assay. In 5/7 patients antibodies were demonstrated at diagnosis and in 3/7 cases also after chemotherapy. Sera from 2/3 patients, which bound significantly to autologous leukemic cells, did not bind significantly to autologous remission cells. In allogeneic experiments sera bound significantly to ALL leukemic cells (6/7 positive combinations), but not to AML leukemic cells (8/8 negative combinations). We propose that ALL sera contain antibodies binding to autologous leukemic cells and that they are directed against a common ALL antigen(s).

The technique of premature chromosome condensation to study the leukemic process: review and speculations

The technique of premature chromosome condensation involves the fusion of mitotic cells with interphase cells resulting in the immediate condensation of the interphase chromatin into discrete chromosome units, the prematurely condensed chromosomes (PCC). The ability to visualize the interphase chromosomes of bone marrow and blood cells by this technique has proved useful in the study of human leukemia. This article describes how the PCC technique has been used to predict clinical outcome as well as gain insight into the biology of leukemia.

The control of cancer chemotherapy-induced nausea and vomiting

The incidence and consequences of the nausea and vomiting induced by many cancer chemotherapeutic regimes are explored and the emetogenic potential of the commonly used cytotoxic drugs evaluated. The physiology and pharmacology of chemotherapy-induced vomiting is largely unresolved but the postulated mechanisms are described and related to known properties of anti-emetic agents. The difficulties associated with the design and evaluation of trials assessing the effectiveness of single agent or combination therapy for this indication are discussed. After identifying general principles of anti-emetic prophylaxis, a critical evaluation is made of the effectiveness of the following drugs or classes of drugs, based on the available data: antihistamines, anticholinergics, phenothiazines, butyrophenones, domperidone, metoclopramide, cannabinoids, corticosteroids and benzodiazepines. Although there are still insufficient data to allow absolute recommendations to be made regarding the choice of anti-emetic therapy, considerations which should govern drug choice are listed and an algorithm presented as an aid to decision making. The contributions that can be made by a pharmacist in this area of drug use are noted.

Early relapse of acute lymphoblastic leukemia is not predictable by serial biochemical assays of terminal transferase activity in cells from peripheral blood

Serial samples of peripheral blood were collected from 37 children with acute lymphoblastic leukemia (ALL) in remission. Activity of terminal transferase (TdT) was assayed by a biochemical technique. False positive results were obtained infrequently (approx. 1%), in contrast to experience with bone marrow analyses. However, early relapse of disease was not predictable in ALL by repeated measurement of TdT in circulating mononuclear cells during remission.

Circulating immune complexes and the prognosis of acute myeloid leukemia

We studied the relation between the clinical course and the presence of circulating immune complexes at diagnosis and/or during complete remission in 186 patients with acute myeloid leukemia. Patients with immune complexes at diagnosis had significantly fewer complete remissions (32 vs. 94 per cent), remissions of shorter duration (median, 4.3 vs. 15.0 months), and shorter survival times (median, 1.8 vs. 22.3 months) than patients without such complexes (all comparisons, P less than 0.01). All patients with immune complexes during the first two months of remission remained in remission for less than six months, whereas only 11 per cent of patients without complexes within this period had such early relapse. Of 23 patients who relapsed after long remissions, 18 (78 per cent) had immune complexes that preceded hematologic evidence of relapse by three weeks to six months (median, 3.7 months). These findings suggest that circulating immune complexes may reflect an important aspect of the pathophysiology of acute myeloid leukemia, and that measurement of these complexes can provide useful prognostic information at diagnosis and during remission.

2' and 3' ribonucleoside monophosphate in leukocytes of acute myeloid leukemia: markers for early diagnosis of relapse

Levels of 2' and 3' purine and pyrimidine ribonucleoside monophosphates (2'-, 3'-NMP) in leukocytes from blood and/or bone marrow were measured in three adult patients with acute non-lymphoblastic leukemias. The measurements of 2'-, 3'-NMP were made by high-performance liquid chromatography (HPLC) at various times in the course of the disease. Complete remission (CR) was obtained for all three patients but two of these have since died after relapsing at 8 and 9 months, respectively. The third patient remains in CR at 1 1/2 year. The levels of 2'-, 3'-NMP in the leukocytes of the patient remaining in remission have not changed since the beginning of his remission. However, in the patients who relapsed 2'- and 3'-NMP levels increased first in bone marrow than in blood leukocytes. These increases occurred about 3 months before the relapse was detected by morphological criteria. These data suggest that 2'-, 3'-NMP measurements may have a prognostic value if used to monitor patients with acute myeloid leukemia in CR.

Simultaneous analysis of cell surface antigens and cell morphology using monoclonal antibodies conjugated to fluorescent microspheres

A new method for simultaneous analysis of cell surface antigens and cell morphology using monoclonal antibodies conjugated to fluorescent microspheres ('immunospheres') is described. Wright's staining was performed on cells after reaction with immunospheres, and a direct correlation of cell surface antigen expression and cell morphology was made. Mild formalin fixation of cells inhibited phagocytosis of microspheres, which is a potential source of confusion in the analysis of cell surface binding. Rapid, accurate analysis of cell surface antigen expression in single cell suspensions of heterogeneous human hematopoietic and lymphoid cell populations was facilitated by this method.

Acute myeloblastic leukemia-associated antigens: detection and clinical importance

Antigenic compounds from the surface of leukemic myeloblasts are shed in vitro on short-term culture. Blast cells radiolabeled by lactoperoxidase iodination release soluble compounds that react immunologically with alloantisera to leukemia-associated antigens. Partially characterized soluble antigens were used to raise heteroantisera in monkeys that are selectively reactive with leukemic myeloblasts and unreactive with nonleukemic cells. Monkey heteroantisera were used to further characterize soluble leukemia antigens. Sera from patients with acute myeloblastic leukemia inhibit the reactivity of the heteroantisera, suggesting that soluble leukemic antigen is released in vivo as well.

Predicting relapse of human leukemia by means of premature chromosome condensation

We attempted to determine whether the technique of premature chromosome condensation (PCC) could be used to predict relapse in patients with acute leukemia in complete remission. Nineteen patients received chemotherapy and were studied serially with the PCC technique. Of the 19 patients in this pilot study, 14 relapsed, and the PCC technique predicted relapse in 11 of these 14. The median time from an elevation in the fraction of G1 cells in the late G1 phase (a high proliferative-potential index) to the development of clinical evidence of relapse was 3.5 months. On the other hand, the median time from a low proliferative-potential index to relapse or to the end of the study was eight months. The incidense of false-positive or false-negative measurements was low. Two patients had high index values just before chemotherapy, and remission was estimated to be prolonged by 2.5 and six months by our therapeutic protocol. These results suggest that the PCC technique is useful and accurate in the early prediction of relapse in human leukemia.