Changes of granulopoiesis during and after adjuvant chemotherapy of breast cancer

Effect of colony-stimulating factor and conventional- or high-dose chemotherapy on FDG uptake in bone marrow

PURPOSE

Granulocyte or granulocyte-macrophage colony stimulating factor (CSF), usually used in conjunction with chemotherapy, may interfere with the( 18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) reading. The purpose of this study is to evaluate the effects of CSF, conventional-or high-dose chemotherapy on bone marrow FDG uptake.

METHODS

Two hundred and forty-one FDG PET scans obtained in 163 patients with lymphoma and no pathologically and radiologically proven bone marrow involvement were analyzed. The standardized uptake value (SUV) of each patient's spine was measured.

RESULTS

Among patients with no recent history of CSF use, the average SUV in 36 patients with no history of chemotherapy was 1.60+/-0.34, that in 49 patients with a history of conventional-dose chemotherapy was 1.37+/-0.32, and that in 12 patients with a history of high-dose chemotherapy was 1.26+/-0.25 (P=0.008 and 0.002, respectively by Mann-Whitney U test). In 80 patients treated with conventional-dose chemotherapy and CSF, the average SUV after discontinuation of CSF was as follows: 0-7 days, 2.37+/-1.19; 8-14 days: 2.04+/-0.67; 15-21 days: 1.87+/-0.52; 22-30 days: 1.59+/-0.18; 31-90 days: 1.54+/-0.36. In 45 patients treated with high-dose chemotherapy and CSF, no significant increase in bone marrow uptake was seen in most of them.

CONCLUSION

Bone marrow FDG uptake may be increased by CSF treatment and may be decreased by chemotherapy. In patients treated with conventional-dose chemotherapy and CSF, increased marrow uptake will return to the pretreatment value approximately 1 month after discontinuation of CSF.

A Randomized Phase-II Study of BB-10010 (Macrophage Inflammatory Protein- 1) in Patients With Advanced Breast Cancer Receiving 5-Fluorouracil, Adriamycin, and Cyclophosphamide Chemotherapy

BB-10010 is a variant of the human form of macrophage inflammatory protein-1 (MIP-1), which has been shown in mice to block the entry of hematopoietic stem cells into S-phase and to increase their self-renewal capacity during recovery from cytotoxic damage. Its use may constitute a novel approach for protecting the quality of the stem cell population and its capacity to regenerate after periods of cytotoxic treatment. Thirty patients with locally advanced or metastatic breast cancer were entered into the first randomized, parallel group controlled phase II study. This was designed to evaluate the potential myeloprotective effects of a 7-day regimen of BB-10010 administered to patients receiving six cycles of 5-fluorouracil (5-FU), adriamycin, and cyclophosphamide (FAC) chemotherapy. Patients were randomized, 10 receiving 100 μg/kg BB-10010, 11 receiving 30 μg/kg BB-10010, and nine control patients receiving no BB-10010. BB-10010 was well-tolerated in all patients with no severe adverse events related to the drug. Episodes of febrile neutropenia complicated only 4% of the treatment cycles and there was no difference in incidence between the treated and nontreated groups. Studies to assess the generation of progenitor cells in long-term bone marrow cultures were performed immediately preceding chemotherapy and at the end of six dosing cycles in 18 patients. Circulating neutrophils, platelets, CD 34+ cells, and granulocyte/macrophage colony-forming cell (GM-CFC) levels were determined at serial time points in cycles 1, 3, and 6. The results showed similar hemoglobin and platelet kinetics in all three groups. On completion of the six treatment cycles, the average pretreatment neutrophil levels were reduced from 5.3 to 1.7 × 109/L in the control patients and from 4.3 to 1.9 and 4.5 to 2.5 × 109/L in the 30/100 μg/kg BB-10010 groups, respectively. Relative to their pretreatment values, 50% of the patients receiving BB-10010 completed the treatment with neutrophil values significantly higher than any of the controls (P = .02). Mobilization of GM-CFC was enhanced by BB-10010 with an additional fivefold increase over that generated by chemotherapy alone, giving a maximal 25-fold increase over pretreatment values. Bone marrow progenitor assays before and after this standard regimen of chemotherapy indicated little long-term cumulative impairment to recovery from chemotherapy. Despite the limited cumulative damage to the bone marrow, which may have minimized the protective value of BB-10010 during this regimen of chemotherapy, better recovery of neutrophils in the later treatment cycles with BB-10010 was indicated in a number of patients.

© 1998 by The American Society of Hematology.

A Randomized Phase-II Study of BB-10010 (Macrophage Inflammatory Protein- 1) in Patients With Advanced Breast Cancer Receiving 5-Fluorouracil, Adriamycin, and Cyclophosphamide Chemotherapy

BB-10010 is a variant of the human form of macrophage inflammatory protein-1 (MIP-1), which has been shown in mice to block the entry of hematopoietic stem cells into S-phase and to increase their self-renewal capacity during recovery from cytotoxic damage. Its use may constitute a novel approach for protecting the quality of the stem cell population and its capacity to regenerate after periods of cytotoxic treatment. Thirty patients with locally advanced or metastatic breast cancer were entered into the first randomized, parallel group controlled phase II study. This was designed to evaluate the potential myeloprotective effects of a 7-day regimen of BB-10010 administered to patients receiving six cycles of 5-fluorouracil (5-FU), adriamycin, and cyclophosphamide (FAC) chemotherapy. Patients were randomized, 10 receiving 100 μg/kg BB-10010, 11 receiving 30 μg/kg BB-10010, and nine control patients receiving no BB-10010. BB-10010 was well-tolerated in all patients with no severe adverse events related to the drug. Episodes of febrile neutropenia complicated only 4% of the treatment cycles and there was no difference in incidence between the treated and nontreated groups. Studies to assess the generation of progenitor cells in long-term bone marrow cultures were performed immediately preceding chemotherapy and at the end of six dosing cycles in 18 patients. Circulating neutrophils, platelets, CD 34+ cells, and granulocyte/macrophage colony-forming cell (GM-CFC) levels were determined at serial time points in cycles 1, 3, and 6. The results showed similar hemoglobin and platelet kinetics in all three groups. On completion of the six treatment cycles, the average pretreatment neutrophil levels were reduced from 5.3 to 1.7 × 109/L in the control patients and from 4.3 to 1.9 and 4.5 to 2.5 × 109/L in the 30/100 μg/kg BB-10010 groups, respectively. Relative to their pretreatment values, 50% of the patients receiving BB-10010 completed the treatment with neutrophil values significantly higher than any of the controls (P = .02). Mobilization of GM-CFC was enhanced by BB-10010 with an additional fivefold increase over that generated by chemotherapy alone, giving a maximal 25-fold increase over pretreatment values. Bone marrow progenitor assays before and after this standard regimen of chemotherapy indicated little long-term cumulative impairment to recovery from chemotherapy. Despite the limited cumulative damage to the bone marrow, which may have minimized the protective value of BB-10010 during this regimen of chemotherapy, better recovery of neutrophils in the later treatment cycles with BB-10010 was indicated in a number of patients.

© 1998 by The American Society of Hematology.

The use of G-CSF or GM-CSF mobilized peripheral blood progenitor cells (PBPC) alone or to augment marrow as hematologic support of single or multiple cycle high-dose chemotherapy

High dose chemotherapy with autologous bone marrow support (ABMT) can achieve prolonged relapse-free survival in relapsed lymphomas, leukemias, and certain solid tumors. The principal morbidity and mortality relate to the infectious complications that occur during the 3-4 week aplasia until the marrow autograft recovers. Progenitor cells can be mobilized into the peripheral blood compartment by hematopoietic growth factors, used alone or after chemotherapy. We describe four trials using cytokine-mobilized peripheral blood progenitor cells (PBPC). In the first trial, PBPC collected after GM-CSF administration were used to augment marrow. Reconstitution of trilineage marrow function occurred promptly, resulting in short hospital stays and fewer platelet transfusions. In a second study, GM-CSF/chemotherapy-mobilized PBPC were used as the sole hematopoietic support during high dose chemotherapy. Granulocyte and platelet reconstitution was rapid. Time to hematopoietic recovery, transfusion requirements, and duration of hospital stay were all significantly improved for the patients receiving PBPC compared with similar patients receiving marrow alone. While most patients experienced prompt hematopoietic recovery they showed sluggish platelet engraftment. The next two trials built on the observation that a few PBPC alone could support both granulocyte and platelet recovery and were designed to test the feasibility of sequential high-dose therapies. In one trial, PBPC given with and without marrow made it possible to deliver two sequential cycles of high-dose therapy. The second trial utilized PBPC plus cytokines to deliver four cycles of dose-intensive chemotherapy at doses that could not be given with cytokine support alone.(ABSTRACT TRUNCATED AT 250 WORDS)

GM-CSF in marrow transplantation

Bone marrow transplantation (BMT) is being increasingly used in a wide variety of diseases. During the period of re-engraftment the patient is particularly susceptible to a number of opportunistic infections which can radically affect acute morbidity and mortality. Recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) has been shown to mobilise haemopoietic progenitor cells for use after high-dose therapy, to enhance myeloid engraftment and stimulate mature monocytes/macrophages and neutrophils. Evidence is emerging that GM-CSF may be useful in BMT. A review of clinical trials in patients receiving BMT has revealed that the administration of rhGM-CSF significantly reduces the duration to re-engraftment, number of antibiotic treatment days, and the period of hospitalisation. Thus, rhGM-CSF appears to be a useful adjunct to BMT.

GM-CSF potentiated peripheral blood progenitor cell (PBPC) collection with or without bone marrow as hematologic support of high-dose chemotherapy: two protocols

High-dose chemotherapy with autologous bone marrow support (ABMS) achieves prolonged relapse-free survival in relapsed lymphomas and leukemias and has provided durable complete responses in certain solid tumors. The principal morbidity and mortality result from the infectious and bleeding complications during the 3-4 week aplasia until the bone marrow autograft can recover. Hematopoietic growth factors, alone or used after chemotherapy, increase the number of circulating progenitor cells in the peripheral blood compartment. In one trial, 12 patients with solid tumors were treated with high-dose chemotherapy and supported with both bone marrow and peripheral blood progenitor cells (PBPC) collected after GM-CSF administration. Reconstitution of bone marrow function occurred quickly (ANC greater than 500/microliters by day 17; platelet-transfusion independence by day 16), resulting in short hospital stays (median, 28 days). In a second study, 12 patients with metastatic breast cancer responding to induction chemotherapy (doxorubicin, 5-fluorouracil, and methotrexate) were given GM-CSF during induction to collect PBPCs during leukocyte recovery. These PBPCs were used as the sole hematopoietic support during high-dose chemotherapy with cyclophosphamide, thiotepa, and carboplatin. Granulocyte and platelet reconstitution were extremely rapid (median, 14 and 12 days, respectively). When compared with 29 patients undergoing the same intensification therapy using ABMT as sole support, time to hematopoietic recovery, transfusion requirements, and duration of hospital stay were all significantly improved for the patients receiving PBPC. PBPC with or without marrow may enhance the safety, tolerance, and cost of high-dose therapy. Moreover, PBPC may render multiple course combination, high-dose therapy feasible.

Granulocyte-macrophage colony stimulating factor expands the circulating haemopoietic progenitor cell compartment in man

The effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) on bone-marrow and peripheral-blood progenitor cells was investigated in a three-phase study in 13 patients with sarcoma. In the first phase patients were given GM-CSF alone. In phase II, which started a week after completion of phase I, patients received a course of cytotoxic chemotherapy, then a course of GM-CSF. Phase III consisted only of cytotoxic chemotherapy. GM-CSF (phase I) alone produced an 18-fold increase in peripheral blood granulocyte-macrophage colony-forming units (CFU-GM) and an 8-fold increase in erythroid burst-forming units (BFU-E) in the peripheral blood. GM-CSF had no effect on bone-marrow CFU-GM and BFU-E in the group as a whole. Three patients were investigated after phases II and III. GM-CSF increased the absolute number of peripheral blood CFU-GM by approximately 60-fold compared with the pretreatment baseline. These effects of GM-CSF may be of clinical importance with regard to facilitating the harvest of peripheral blood progenitor cells for autotransplantation.

Effect of recombinant human granulocyte-macrophage colony-stimulating factor on hematopoietic reconstitution after high-dose chemotherapy and autologous bone marrow transplantation

Recombinant human granulocyte-macrophage colony-stimulating factor (rHuGM-CSF) has been reported to increase the leukocyte count in subhuman primates subjected to total-body irradiation and in patients with the acquired immunodeficiency syndrome. We administered this substance to 19 patients with breast cancer or melanoma treated with high-dose combination chemotherapy and autologous bone marrow support. Groups of three or four patients were treated with 2.0, 4.0, 8.0, 16.0, or 32.0 micrograms per kilogram of body weight per day of glycosylated rHuGM-CSF by continuous intravenous infusion for 14 days, beginning three hours after bone marrow infusion. Total leukocyte and granulocyte recovery was accelerated in these patients as compared with 24 historical controls matched for age, diagnosis, and treatment. Leukocyte counts (mean +/- SD) obtained 14 days after transplantation were 1511 +/- 1003 per microliter in patients given 2 to 8 micrograms per kilogram per day, 2575 +/- 2304 in those given 16 micrograms, and 3120 +/- 1744 in those given 32 micrograms, as compared with 863 +/- 645 per microliter in the controls. No consistent effect on platelet counts was noted. Toxic effects were generally mild and not clearly dose-related in patients given 2 to 16 micrograms per kilogram per day. Edema, weight gain, or myalgias occurred in all patients given 32 micrograms per kilogram; marked weight gain, generalized edema, pleural effusions, and hypotension developed in two patients, one of whom also had acute renal failure. Our results indicate that rHuGM-CSF can accelerate myeloid recovery after high-dose chemotherapy and autologous bone marrow transplantation, over a range of doses that can be tolerated. In this setting the ability to increase the dose is limited by the development of myalgias and fluid retention.

Effects of N-trifluoroacetyladriamycin-14-valerate (AD-32) on human bladder tumor cell lines

We have compared the in vitro activity of N-trifluoroacetyladriamycin-14-valerate (AD-32) and doxorubicin hydrochloride (ADR) on the clonal growth of human bladder tumor cell lines (HBTCL). In order to determine the relatively toxicity of ADR and AD-32 on hematopoietic stem cells, CFU-GM assays were set up using 10 normal human bone marrow samples. The mean lethal dose for 50% of the colonies (LD-50) for ADR was 1.6 +/- 1.4 microM and that for AD-32, 3.9 +/- 4.9 microM (P less than 0.55), suggesting that these agents have similar bone marrow toxicity. Both drugs produced enhanced inhibition of clonal growth of HBTCL with increasing C X Ts. The spectrum of activity of the two drugs was similar against a panel of seven HBTCL. The activity of ADR was inhibited at 4 degrees C while the activity of AD-32 was unaffected by temperature. ADR was more effective against HBTCL in the log growth phase than the plateau phase while the reverse was found using AD-32. Verapamil was found to enhance the activity of both ADR and AD-32 against a HBTCL (T24), found to be resistant to both agents. The lipophilic properties of AD-32, along with its enhanced activity when used over prolonged periods of time and its activity against tumor cells in the plateau phase, suggest that AD-32 could be useful in the management of patients with superficial bladder cancer.

Bone-marrow regeneration after therapy-induced hypoplasia monitored by serum measurements of lactoferrin, lysozyme and myeloperoxidase

Serum levels of lactoferrin, lysozyme and myeloperoxidase were measured sequentially after induction treatment in 30 patients with AML in order to test the hypothesis that these proteins may be used to monitor activity and different stages of myelopoiesis in the bone-marrow. The results showed that myeloperoxidase and lysozyme started to rise again 6-8 days after initiation of treatment as compared to 12 d for lactoferrin and 16 d for blood polymorphonuclear leukocytes. The rate of marrow regeneration was exponential and estimated to be 9-20% per d. The comparison between two different chemotherapy regimes showed that the initial reduction in lysozyme, in contrast to other measured variables, was significantly larger with the therapy that contained vincristine and glucocorticosteroids. This might reflect a reduction in lysozyme secretion in addition to the effects on the leukemic cell mass. We conclude that the measurements of lactoferrin, lysozyme and myeloperoxidase in serum under certain circumstances may be used to monitor the myelopoietic activity in the bone-marrow.

Role of culture conditions and exposure duration in determining sensitivity of human bone marrow progenitor cells to methotrexate

The effect of drug concentration, exposure duration, and culture conditions on the cytotoxic activity of methotrexate (MTX) on normal granulocyte-macrophage colony-forming units in culture (GM-CFUC) was studied using a bilayer soft agar system with nucleoside-free medium. The degree of inhibition of colony formation depended on the type of serum supplementation. A 1 h or 2 h pulse treatment with 2 X 10(-4) M (100 micrograms/ml) MTX failed to kill GM-CFUC, when the cells were subsequently plated in a system containing 15% undialyzed fetal bovine serum (FBS). For continuous exposure the observed LD50 of MTX in the agar system was higher than 10(-4) M for 15% undialyzed FBS, 10(-5) M for 15% dialyzed FBS plus 0.25% undialyzed FBS, 10(-6) M for 15% dialyzed FBS, and 10(-8) M for 15% undialyzed horse serum. The difference for dialyzed FBS versus horse serum can be explained by differences in nucleoside concentrations. The difference for dialyzed FBS versus horse serum may be secondary to an enhancer of MTX in horse serum. For studying MTX sensitivity of human tumor cells in vitro, we suggest testing conditions that lie within the dose survival curve of GM-CFUC.

Bone marrow morphologic changes after combination chemotherapy including VP-16

Bone marrow aspirates and biopsy specimens were examined from seven patients with small cell lung cancer. All patients had received recent combination chemotherapy including VP-16. No correlation between marrow biopsy cellularity and hematologic toxicity could be established. However, an unusual combination of morphologic changes was seen. This included an initial rapid increase in the M:E ratio, interference with cell division, and eventual cell death. There was little evidence of mitotic arrest or megaloblastosis. These changes are consistent with the known mechanism of action of VP-16, the only agent given to all patients. The small sample size and the unknown contributions of the other cytotoxic agents administered allow only limited conclusions.

The hematopoietic toxicity of regional radiation therapy. Correlations for combined modality therapy with systemic chemotherapy

Using circulating granulocyte-monocyte precursor colony-forming units in culture (CFUc) numbers as a probe along with standard blood count (CBC), the authors have quantitatively examined the hematopoietic toxicity of conventionally fractionated radiation therapy (RT) when combined with concurrent systemic chemotherapy or when used alone. Among 20 patients with limited stage small cell lung cancer receiving systemic chemotherapy with cyclophosphamide, CCNU, and methotrexate, the addition of involved field chest RT resulted in increased hematopoietic toxicity as judged by increased need for platelet transfusion (P less than 0.05) and decreased frequency of measurable CFUc (P less than 0.04). Among 22 patients receiving regional radiotherapy alone consistent hematopoietic toxicity was also observed. This toxicity, although generally of only mild to moderate clinical significance, was detected earlier and to a greater degree in patients who required radiation to larger treatment volumes, who had significant amounts of bone marrow in the port, and who had a high percentage of cardiac output flowing through the port. These data suggest that the hematopoietic toxicity of regional radiotherapy may be additive to that of concurrent systemic chemotherapy and may occur more promptly and to a greater degree when treatment volumes are larger or incorporate increased amounts of marrow volume or cardiac output.

Survival of human bone marrow cells after in vitro treatment with 12 anticancer drugs and implications for tumor drug sensitivity assays

We investigated the responsiveness of human normal granulocyte-macrophage colony-forming units in culture (GM-CFUC) continuously exposed in vitro to 1 of 12 anticancer drugs. All drugs except bleomycin showed a simple negative exponential dose-survival curve. The in vitro toxicity of drugs in GM-CFUC did not always correlate with the relative myelosuppressive potency observed in vivo. In addition, tumor specimens from 38 patients mainly with ovarian cancer were cultured in a human tumor colony-forming assay and continuously exposed to drugs at low, intermediate, and high concentrations capable of killing 40%, 78%, and 99% of GM-CFUC, respectively. The most active drugs were cis-platinum, velban, 5-fluorouracil, and 5-fluoro-ara-AMP. Dose-survival curves of bone marrow progenitor cells may serve as an in vitro reference system for selecting appropriate drug concentrations of myelosuppressive drugs in drug-sensitivity assays of human tumors.

New concepts in management of neutropenia

Neutropenia is a life-threatening sequel of hematological disorders and a dominant factor limiting the dosage of cytotoxic chemotherapy. The role of the neutrophil is of such importance in defence against microbial invasion that measures that modify the behaviour of residual hemopoietic tissue to promote a modest increase in neutrophils, can confer considerable benefit by reducing the frequency and severity of infection. Such a change can be mediated in bone marrow depression by diversion of more progeny of immature precursors into the neutrophil series, or by enhancement of the stimulatory drive operating on neutrophil production. The former effect can be achieved by hypertransfusion of red cells to reduce the demand on the limited precursor population for cells of the erythroid series. The latter effect can be achieved by administration of lithium carbonate. Neutropenia caused by autoimmune injury to the neutrophil series can also be successfully modified by measures which suppress the underlying immune dyscrasia or the function of the reticulo-endothelial system. Corticosteroid administration and splenectomy can be helpful in certain specific types of neutropenia. Administration of cyclophosphamide and azathioprine has both mutagenic and marrow suppressive potential, but can induce remissions in severe chronic isolated neutropenia and in systemic lupus erythematosis.

Serial incidence of bone marrow GM-CFC prior to the development of acute non-lymphoblastic leukaemia in a child treated for non-Hodgkin's lymphoma

A child treated for NHL developed acute non-lymphoblastic leukaemia 27 months after stopping treatment. Serial in vitro bone marrow studies showed a normal incidence of GM-CFC following treatment. However, GM-CFC incidence dropped at least 15 months prior to the development of leukaemia. This was associated with an asymptomatic neutropenia but no disturbance of bone marrow morphology. It is concluded that sub-clinical disturbances of bone marrow function may play an important part in leukaemogenesis.

Adriamycin impairs phagocytic function and induces morphologic alterations in human neutrophils

Normal human polymorphonuclear leukocytes (PMNL) were preincubated in vitro with methotrexate, 5-fluorouracil, vincristine, cisplatin, Adriamycin (doxorubicin), and daunomycin for 15 hours before being tested in a phagocytic-bactericidal assay. Anthracycline-treated PMNL were defective in phagocytosis and killing of the bacteria, in contrast to the other chemotherapeutic agents which allowed the PMNL to remain functional. The defect of Adriamycin-treated PMNL resulted from decreased ingestion: 3 micrograms/ml Adriamycin inhibited by 50% of the uptake of Oil Red-O particles. In this assay, the proportion of noningesting PMNL increased from less than or equal to 20% with 0.62 micrograms/ml to greater than or equal to 90% with 10 micrograms/ml Adriamycin. Electron microscopy revealed that Adriamycin-inactivated PMNL had rounded up, were depleted in glycogen, and had undergone profound nuclear changes. RNA and protein synthesis in PMNL were also affected. Adriamycin, besides producing neutropenia, may decrease the phagocytic function of circulating PMNL.

Adjuvant chemotherapy of breast cancer: hope--reality--hazard?

According to a NIH Consensus-Development Statement, adjuvant polychemotherapy following mastectomy is considered beneficial to premenopausal patients with positive axillary nodes. Nevertheless, the role of adjuvant chemotherapy in relation to menopausal status, axillary lymph node status, estrogen receptor status, choice and dose of agents, and long-term survival is not defined. Based on experimental background information and theoretical deductions, the clinical results have fallen short of expectations. The data of Bonadonna's CMF study reveal that the overall 5-year survival is increased by 4%; premenopausal patients benefit by 12% whereas treated postmenopausal patients have a 5% less chance of survival. Only those patients benefit who can tolerate a "full or nearly full dose"; these are only 17%. At this time it is not clear whether the small survival differences from adjuvant chemotherapy represent a real step forward in the fight against breast cancer. In the majority of patients (75 to 85%), at the time of adjuvant chemotherapy, systemically disseminated cancer cells are at mitotic rest or their proliferation is minimal. At this stage, adjuvant chemotherapy has no or little effect. Therefore, only a small proportion of patients (15 to 25%) has subclinical systemic cancer growth at the time of primary therapy or thereafter; only these patients have a chance to respond to chemotherapy. In view of this tumor kinetic problem and the hazards of chemotherapy, it seems advantageous (a) to focus on definition of patient subgroups at high risk for early recurrence post primary therapy to serve as participants in trials of adjuvant chemotherapy and/or (b) to concentrate on early diagnosis of recurrent disease for immediate institution of endocrine- and/or polychemotherapy.

Transfusion of circulating stem cells

Bone marrow collected from all species including man contains specific cells, putative pluripotential stem cells, capable of reestablishing hemopoiesis in a syngeneic or genetically identical member of the same species which has been treated with whole body irradiation. The question of whether similar pluripotential stem cells are present in the circulation in all animals is not yet resolved. In mice, reconstitution of hemopoiesis can be achieved by transfusion of peripheral blood cells only. The same result can be obtained in dogs and probably in baboons. In dogs, experiments with fresh and cryopreserved blood mononuclear cells have confirmed a dose-response relationship--below a certain number of mononuclear cells failure of hemopoietic reconstitution can be predicted. In man, isolated anecdotal case reports suggest that pluripotential stem cells in the circulation may or may not be valuable in repopulating a bone marrow defective as a result of primary disease or following chemotherapy. Indirect evidence from in vitro culture of circulating myeloid progenitor cells suggests but does not prove that pluripotential stem cells circulate in normal man. Pluripotential stem cell numbers are probably greatly increased in the circulation in patients with chronic granulocytic leukemia: such cells can be collected, cryopreserved, and used at a later date as "bone marrow autografts". Whether circulating stem cells can be collected and used in an analogous manner for patients with other leukemias or other neoplasms is not yet established.

Adjuvant chemo(immuno-)-therapy of primary breast cancer with adriamycin-cyclophosphamide (and levamisole)--six-year evaluation

In a phase II-type study 52 patients with no signs of metastases but with a high risk of recurrence were treated with 6 courses of adriamycin-cyclophosphamide as adjuvant systemic therapy following modified radical mastectomy of primary breast cancer. Half of the patients were randomized to receive additional immunotherapy with levamisole for 2 yr. The scheduled dose and time regimen could be achieved in over 90% of patients. A comparison of the actuarial disease-free and overall survival with data reported in the literature indicates a similar positive effect of adjuvant systemic therapy as described in adjuvant studies using polychemotherapy regimens. Immunotherapy with levamisole has no effect on disease-free and overall survival but added to general toxicity. Particular attention was paid to psychological consequences of adjuvant systemic therapy; consistent attention by one specifically trained physician during the whole therapy and follow-up period was effective in coping with the emotional problems. The difficulties in treating recurrences after adjuvant therapy became apparent. A high rate of loco-regional recurrences and of cerebral metastases was noted.

Marrow neutrophil reserve after adjuvant chemotherapy for carcinoma of the breast

The hematologic factors of 16 female patients with breast carcinoma who had received adjuvant chemotherapy with L-phenylalanine-based programs for two years were compared with those for 13 normal female volunteers of similar age. The findings include significant suppression of the mean hemoglobin level, of leukocyte counts, and of circulating neutrophils and lymphocytes in patients 3-27 months after chemotherapy. Marrow neutrophil reserve studies with prednisolone stimulation again demonstrated significant suppression for the patients who had received chemotherapy. The authors conclude that there is a chronic hematologic toxicity associated with this therapy.

Renal and haemopoietic proliferative defects as a delayed consequence of cis-platin, adriamycin and daunomycin treatments

The long-term effects of Adriamycin (ADR), daunomycin (DMN) and cis-dichlorodiammine platinum (II) (DDP) on the ability of murine renal tubular epithelium and erythropoiesis to respond to an acute proliferative stress was investigated. Folic acid (FA) and acute anaemia induced by bleeding were used as acute proliferative stimuli for renal-tubule epithelium and erythropoiesis respectively. The ability of these normal cell-renewal systems to mount a regenerative proliferative response was evaluated by radioisotopic, morphological and gravimetric techniques 4 months after drug treatment. The results indicate that pretreatment with these agents produce a long-lasting reduction in the ability of these cell-renewal systems to mount regenerative proliferation. In the kidney, the ability to respond to FA was most severely compromised by ADR and DDP, whereas in the erythropoietic system all 3 agents induced a long-lasting proliferative defect.

Attempt at quantification of the cytotoxic drug-induced changes of the human bone marrow compartments

In order to describe the changes of the human bone marrow compartments after repeated courses of adriamycin/cyclophosphamide in quantitative terms, 2 methods have been studied for their usefulness as indices of bone marrow cellularity: cell counts per ml of bone marrow aspirates obtained under standardized conditions, and cell counts per microliter of bone marrow spicules evaluated by morphometric techniques. Applied to a sufficiently large group of patients, both methods were useful to describe the cytotoxic drug-induced changes of the bone marrow compartments in accordance with the following indirect criteria: (a) the results in man are quite compatible with the changes of haematopoiesis described in animal experiments after cytotoxic drugs; (b) the changes of the peripheral blood cell pools - PMN and reticulocytes -, which can be assessed quantitatively, correspond to the changes of the respective bone marrow pools as determined by the described indices of cellularity; (c) this quantitative description of drug-induced changes in the human bone marrow compartments yields 'reasonable' results on the basis of both the mechanism of action of the cytotoxic drugs employed and the kinetics of the haematopoietic system studied.

Delayed recovery of peripheral blood cell numbers after adjuvant cytotoxic chemotherapy for stage II breast cancer

A study was made on the recovery of the bone marrow after adjuvant chemotherapy given to 30 post-mastectomy patients with stage II breast cancer treated with either melphalan or melphalan and methotrexate at 6-weekly intervals for 1 year. Counts of peripheral blood cells were made serially during treatment and then for a further 2 years after stopping chemotherapy. Mean counts for all cell types fell during chemotherapy and recovery was long-delayed. Thus 24 months after chemotherapy, mean counts for total leucocytes and platelets were significantly lower than mean pretreatment counts and counts for a normal female population, and the count for neutrophils was significantly lower than the count before treatment; after 24 months mean counts for lymphocytes were not significantly depressed. Melphalan was assumed to be the agent responsible. Slow haematological recovery after cessation of adjuvant chemotherapy with one particular regimen points to the need for including long-term post-chemotherapy observation of the bone marrow in the assessment of adjuvant chemotherapy programmes.

Mechanisms of levamisole-induced granulocytopenia in breast cancer patients

Five of 39 (13%) women treated with adjuvant combination chemotherapy plus levamisole immunotherapy after mastectomy for Stage II or III breast cancer developed levamisole-induced granulocytopenia. This complication occurred in each of the women between six and ten weeks after the completion of six months of combination chemoimmunotherapy when they were taking levamisole alone. Although none of the patients had an HLA B-27 locus and leukoagglutinins could not be demonstrated, complement-dependent, IgM mediated, peripheral destruction of granulocytes was documented using a microgranulocytotoxicity assay. In addition, a factor(s) present in serum from patients developing levamisole-induced granulocytopenia caused suppression of bone marrow granulocyte progenitor cells (CFU-C). The possible relationships between levamisole-induced peripheral granulocyte destruction and bone marrow CFU-C suppression are discussed.

The effects of surgical trauma on human granulopoiesis

Marked changes in the concentration and proliferative state of circulating granulocytic progenitor cells (colony forming units in culture; CFUc) were observed in female patients following surgical trauma. Within one day of an abdominal hysterectomy there was an abrupt fall in the number of blood CFUc to between 10% and 20% of normal and an increase in the proportion synthesizing DNA which coincided with the maximum neutrophilia. Subsequently, as the neutrophil count declined, the CFUc concentration increased to supranormal values and the proliferative response persisted, both parameters returning to normal 2 weeks after surgery. These results suggest that, following surgical trauma, the increased demand for neutrophils is rapidly met by increased CFUc proliferation.

No effects of levamisole on cytotoxic drug-induced changes of human granulopoiesis

The effect of Levamisole on the human granulopoiesis was studied in patients randomized to receive, in addition to adjuvant chemotherapy for primary breast cancer, either no other treatment or additional unspecific immune therapy with Levamisole. The reaction of granulopoiesis to the cytostatic drugs, as characterized by changes of peripheral blood polymorphonuclear neutrophils (PMN), functional bone marrow granulocyte reserve, serial bone marrow cytology, and granulopoietic stem cells (CFU-C) in marrow and blood, was not affected by administration of Levamisole. The data support the concept that Levamisole has no direct effect on human bone marrow granulopoiesis, but that an allergic mechanism is involved in the pathogenesis of Levamisole-induced agranulocytosis. The expectation that Levamisole exerts a beneficial effect by stimulation of the granulopoiesis, as previously suggested for BCG and Corynebacterium parvum, could not be substantiated in our studies.

Reaction of human granulopoiesis to high-dose cyclophosphamide therapy

The reaction pattern of an unperturbed human granulopoiesis to pulses of high-dose chemotherapy (cyclophosphamide 2000 mg/m2 plus vincristine 1.4 mg/m2 or adriamycin 20 mg/m2) was serially studied in 6 patients. The stem cells committed to granulopoiesis (CFU-C) of the bone marrow and the cells of the proliferative granulocytic marrow pool were considerably reduced during the first 8 days. Granulopoietic regeneration was first recognizable by increased proliferative activity of bone marrow CFU-C (3H-thymidine technique). The cytotoxic drug-induced injury to the early compartments of granulopoiesis, and granulocytic regeneration proceed sequentially through the ensuing, increasingly differentiated granulocytic compartments. In the peripheral blood, depletion and repletion of the CFU-C pool precede the corresponding changes of segmented neutrophils by 7 to 9 days; during granulocytic regeneration, peripheral blood CFU-C show a transient greatly overshooting decrease.