In Silico Pharmacokinetics Evaluation of Forgiveness for Doravirine and Rilpivirine

BACKGROUND

This study aimed to evaluate the concentrations of rilpivirine (RLP) and doravirine (DOR) after 3 days-off using simulations from population pharmacokinetics models.

METHODS

The authors conducted a series of 500 sets of 10,000 Monte Carlo simulations to examine the steady-state conditions for 2 common dosage levels: 25 mg/d for RLP and 100 mg/d for DOR. These simulations were conducted under 2 scenarios: 1 without drug cessation and another after a 3-day break. The validity of the implementation was established through a comparison of median trough concentrations (C24h) with previously reported data. Subsequently, the proportion of simulated patients with C24h and C72h after 3 days-off (C72h/3do) that exceeded the inhibitory concentration 50 (IC50), 5.2 mcg/L for DOR and 20.5 mcg/L for RLP respectively, was calculated. The inhibitory quotient (IQ) was also computed, which was 6 times IC50 for DOR and 4.5 times IC50 for RLP. Finally, nomograms were constructed to estimate the probability of having C72h/3do > IC50 or > IQ for different ranges of C24h.

RESULTS

Simulated C24h median ± SD for RLP were 61.8 ± 0.4 mcg/L and for DOR 397 ± 0 mcg/L. For RLP, 99.3 ± 0.1% exceeded IC50 at C24h, 16.4 ± 0.4% at C72h/3do, and none surpassed the IQ threshold. In contrast, DOR had 100% ± 0% above IC50 at C24h, 93.6 ± 0.2% at C72h/3do, and 58.6 ± 0.5% exceeded the IQ.

CONCLUSIONS

These findings suggest that treatment with DOR may offer a more forgiving therapeutic profile than RLP, given the larger proportion of patients achieving effective drug exposure with DOR. However, it is important to acknowledge a significant limitation of this study, namely, the assumption that drug concentration is a perfect surrogate for drug effectiveness.

Evaluation of Lung Density and Its Dosimetric Impact on Lung Cancer Radiotherapy: A Simulation Study

BACKGROUND

The dosimetric parameters required in lung cancer radiation therapy are taken from a homogeneous water phantom; however, during treatment, the expected results are being affected because of its inhomogeneity. Therefore, it becomes necessary to quantify these deviations.

OBJECTIVE

The present study has been undertaken to find out inter- and intra- lung density variations and its dosimetric impact on lung cancer radiotherapy using Monte Carlo code FLUKA and PBC algorithms.

MATERIAL AND METHODS

Density of 100 lungs was recorded from their CT images along with age. Then, after PDD calculated by FLUKA MC Code and PBC algorithm for virtual phantom having density 0.2 gm/cm3 and 0.4 gm/cm3 (density range obtained from CT images of 100 lungs) using Co-60 10 x10 cm2 beams were compared.

RESULTS

Average left and right lung densities were 0.275±0.387 and 0.270±0.383 respectively. The deviation in PBC calculated PDD were (+)216%, (+91%), (+)45%, (+)26.88%, (+)14%, (-)1%, (+)2%, (-)0.4%, (-)1%, (+)1%, (+)4%, (+)4.5% for 0.4 gm/cm3 and (+)311%, (+)177%, (+)118%, (+)90.95%, (+)72.23%, (+)55.83% ,(+)38.85%, (+)28.80%, (+)21.79%, (+)15.95%, (+)1.67%, (-) 2.13%, (+)1.27%, (+)0.35%, (-)1.79%, (-)2.75% for 0.2 gm/cm3 density mediums at depths of 1mm, 2mm, 3mm, 4mm, 5mm, 6 mm, 7 mm, 8mm, 9mm,10mm, 15mm, 30mm, 40mm, 50mm, 80mm and 100 mm, respectively.

CONCLUSION

Large variations in inter- and intra- lung density were recorded. PBC overestimated the dose at air/lung interface as well as inside lung. The results of Monte Carlo simulation can be used to assess the performance of other treatment planning systems used in lung cancer radiotherapy.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Performance Evaluation of Algorithms in Lung IMRT: A comparison of Monte Carlo, Pencil Beam, Superposition, Fast Superposition and Convolution Algorithms

BACKGROUND

Inclusion of inhomogeneity corrections in intensity modulated small fields always makes conformal irradiation of lung tumor very complicated in accurate dose delivery.

OBJECTIVE

In the present study, the performance of five algorithms via Monte Carlo, Pencil Beam, Convolution, Fast Superposition and Superposition were evaluated in lung cancer Intensity Modulated Radiotherapy planning.

MATERIALS AND METHODS

Treatment plans for ten lung cancer patients previously planned on Monte Carlo algorithm were re-planned using same treatment planning indices (gantry angel, rank, power etc.) in other four algorithms.

RESULTS

The values of radiotherapy planning parameters such as Mean dose, volume of 95% isodose line, Conformity Index, Homogeneity Index for target, Maximum dose, Mean dose; %Volume receiving 20Gy or more by contralateral lung; % volume receiving 30 Gy or more; % volume receiving 25 Gy or more, Mean dose received by heart; %volume receiving 35Gy or more; %volume receiving 50Gy or more, Mean dose to Easophagous; % Volume receiving 45Gy or more, Maximum dose received by Spinal cord and Total monitor unit, Volume of 50 % isodose lines were recorded for all ten patients. Performance of different algorithms was also evaluated statistically.

CONCLUSION

MC and PB algorithms found better as for tumor coverage, dose distribution homogeneity in Planning Target Volume and minimal dose to organ at risks are concerned. Superposition algorithms found to be better than convolution and fast superposition. In the case of tumors located centrally, it is recommended to use Monte Carlo algorithms for the optimal use of radiotherapy.

Quantitative tumor volume VS TNM staging: the impact on prognosis in head and neck cancer

OBJECTIVES

To evaluate the prognostic value of tumor volume (TV) by clinical method (CM) and Computerized Tomography (CT) scan in head and neck (H and N) cancer.

MATERIALS AND METHODS

Total 25 patients' (pts) pretreatment tumor volume (PT TV) was assessed clinically by cuboid volume method. Afterwards contrast enhanced computerized tomography (CECT) images of the pts were transferred to workstation by DICOM software. The computerized tomography tumor volume (CT TV) was obtained on Radworks 6.0, using mouse control cursor. After assessment, the patients were given 3 cycles of neoadjuvant chemotherapy followed by radiotherapy by conventional method on Co-60 Theratron 780 C. After 1 month of treatment, TV was again measured.

STATISTICAL METHOD

Statistical analysis was done on MSTAT statistical analysis software. Two-tailed student t test, chi square test and test for two proportions for significance had been used.

RESULTS

Large variations in tumor volume were found both in intra as well as inter T-stages. As the tumor size increases with T stages, the difference in measurement of TV by both methods decreases. CT TV results pre as well as post-treatment were more consistent than clinical method.

CONCLUSION

The use of TV as a prognostic factor by CT scan seems to be more useful parameter than the CM. TV should be included in the TNM (tumor, node, and metastasis) classification after setting the strict guidelines for tumor delineation, to solve the discrepancy of treatment outcome in the same clinical stage.

Quantitative assessment of breast density from digitized mammograms into Tabar's patterns

We describe a semi-automated technique for the quantitative assessment of breast density from digitized mammograms in comparison with patterns suggested by Tabar. It was developed using the MATLAB-based graphical user interface applications. It is based on an interactive thresholding method, after a short automated method that shows the fibroglandular tissue area, breast area and breast density each time new thresholds are placed on the image. The breast density is taken as a percentage of the fibroglandular tissue to the breast tissue areas. It was tested in four different ways, namely by examining: (i) correlation of the quantitative assessment results with subjective classification, (ii) classification performance using the quantitative assessment technique, (iii) interobserver agreement and (iv) intraobserver agreement. The results of the quantitative assessment correlated well (r2 = 0.92) with the subjective Tabar patterns classified by the radiologist (correctly classified 83% of digitized mammograms). The average kappa coefficient for the agreement between the readers was 0.63. This indicated moderate agreement between the three observers in classifying breast density using the quantitative assessment technique. The kappa coefficient of 0.75 for intraobserver agreement reflected good agreement between two sets of readings. The technique may be useful as a supplement to the radiologist's assessment in classifying mammograms into Tabar's pattern associated with breast cancer risk.

Bone marrow aspirates as part of routine donor assessment for allogeneic blood and marrow transplantation can reveal presence of occult hematological malignancies in otherwise asymptomatic individuals

Pre transplant screening work-up of donors for allogeneic blood and marrow transplantation is essential in an effort to minimize risks to the recipient and protect the donor. At Princess Margaret Hospital, every potential donor is screened with a bone marrow aspirate. The case histories of three asymptomatic potential donors who presented within 1 year with normal complete blood counts, history and physical examination are presented. A 65-year-old male patient was diagnosed with smouldering multiple myeloma, a 72-year-old male patient with chronic lymphocytic leukemia and a 42-year-old male patient with myelodysplastic syndrome. Bone marrow examination led to the diagnosis in each one of these cases. Of note is that each of the potential donors was discovered to have the same disease as the transplant recipient. In vitro clonogenic hemopoietic progenitor assays were compared to those of 20 normal volunteers. Inferior growth of hemopoietic progenitor colonies in all three was noted. In conclusion, particularly in older donors and donors with potential for familial malignancies, more screening investigations including bone marrow aspiration may be reasonable to investigate for occult hematological malignancies prior to stem cell donation. Clonogenic assays can contribute to detect hemopoietic abnormalities pre transplant.

A study of mean glandular dose during diagnostic mammography in Malaysia and some of the factors affecting it

The primary objective of this study was to determine the mean glandular dose (MGD) during diagnostic mammography in Malaysia. The secondary objective was to evaluate some of the factors affecting MGD. A survey of standard MGD was performed, based upon quality control records for the period October 1999 to August 2001. This covered 30 mammography units from 9 manufacturers. MGD was also measured for a series of patients attending mammography examinations at three other mammography units. MGD per film was estimated from recorded radiographic factors, the compressed breast thickness (CBT) and X-ray unit calibration data. MGD per woman was calculated by summing the MGDs for all films, and averaging it over both breasts. 300 women drawn equally from three major ethnic groups, namely Malay, Chinese and Indian, took part in the study. The difference of MGD per woman between ethnic groups was tested for significance using non-parametric Kruskal-Wallis and median tests. The factors affecting MGD per woman were tested for significance using a multivariate analysis of variance. The MGD for the phantom was 1.23 mGy (range 0.22-2.39 mGy) while the mean patient based MGD per film was 1.54 mGy and 1.82 mGy for the craniocaudal and mediolateral oblique views, respectively. The mean MGD per woman was 3.37 mGy. It was also found that there is no significant difference in MGD per woman among the ethnic groups (p>0.05, Kruskal-Wallis test). However, on the multivariate test two factors, namely half value layer of the X-ray beam and (CBT), had a significant effect on MGD per woman (p<0.05). No significant relationships were seen between MGD per woman with respect to ethnicity, body mass index or age.

Long-term medical outcomes and quality-of-life assessment of patients with chronic myeloid leukemia followed at least 10 years after allogeneic bone marrow transplantation

PURPOSE

Benchmark analysis of patients with chronic myeloid leukemia (CML) alive for more than 10 years after allogeneic bone marrow transplantation (BMT) including data on disease status, bone marrow reserve, long-term complications, and quality of life (QOL).

PATIENTS AND METHODS

Eighty-nine patients (46 in first chronic phase, 43 in advanced phase) received an allogeneic BMT for CML during the study period. Medical outcomes and QOL of patients were analyzed retrospectively.

RESULTS

Twenty-eight (31.5%) of 89 patients were alive at 10 years and included in this analysis. Thirteen (46.4%) of 28 long-term survivors never relapsed. Fifteen patients relapsed between 0.5 and 16 years after transplantation. Ten patients showed a hematologic relapse and received salvage treatment. Five patients showed transient low levels of BCR-ABL-positive cells by Southern blot with no subsequent hematologic relapse. One of the 28 patients died in blast crisis at 12 years. The most frequent long-term complications were chronic graft-versus-host disease, osteoporosis, and cataracts. Frequency of clonogenic progenitors remained persistently decreased. QOL assessment yielded lower scores in physical performance as compared with an age-matched normative population, whereas social functioning was equivalent. A high degree of satisfaction was noted with interpersonal relationships.

CONCLUSION

Patients with CML surviving their BMT long term do well in terms of medical outcomes. A constant rate of relapse was noted, with a high salvage rate of affected patients, suggesting the need for lifelong monitoring. QOL is perceived as good, particularly as related to social functioning; however, it is inferior to a normative population with regard to physical performance.

Prostate cancer cells induce osteoblast differentiation through a Cbfa1-dependent pathway

Metastases from prostatic adenocarcinoma (prostate cancer) are characterized by their predilection for bone and typical osteoblastic features. An in vitro model of bone metastases from prostate cancer was developed using a bicompartment coculture system of mouse osteoblasts and human prostate cancer cells. In this model, the bone-derived prostate cancer cell lines MDA PCa 2a and MDA PCa 2b induced a specific and reproducible increase in osteoblast proliferation. Moreover, these cells were able to induce osteoblast differentiation, as assessed by increased alkaline phosphatase activity, Osteocalcin expression, and calcified matrix formation. This osteoblastic reaction was confirmed in vivo by intrafemoral injection of MDA PCa 2b cells into severe combined immunodeficiency disease mice. In contrast, the highly undifferentiated, bone-derived human prostate cancer cell line PC3 did not produce an osteoblastic reaction in vitro and induced osteolytic lesions in vivo. The osteoblast differentiation induced by MDA PCa 2b cells was associated with up-regulation of the osteoblast-specific transcriptor factor Cbfa1. Moreover, treatment of osteoblasts with conditioned medium obtained from MDA PCa 2b cells resulted in up-regulation of Cbfa1 and Osteocalcin expression. In support of the differentiation studies, a microarray analysis showed that primary mouse osteoblasts grown in the presence of MDA PCa 2b cells showed a shift in the pattern of gene expression with an increase in mRNA-encoding Procollagen type I and Osteopontin and a decrease in mRNA-encoding proteins associated with myoblast differentiation, namely myoglobin and myosin light-chain 2. Taken together, these findings suggest that the bone-derived prostate cancer cells MDA PCa 2a and MDA PCa 2b promote differentiation of osteoblast precursors to an osteoblastic phenotype through a Cbfa1-dependent pathway. These results also established that soluble factors produced by prostate cancer cells can induce expression of osteoblast-specific genes. This in vitro model provides a valuable system to isolate molecules secreted by prostate cancer cells that favor osteoblast differentiation. Moreover, it allows to screen for therapeutic agents blocking the osteoblast response to prostate cancer.

Measurement of dose to the contralateral breast during radiation therapy for breast cancer: reduction by the use of superflab

The effect of radiation in regard to breast carcinogenesis is well studied and analysed from data from atomic bomb survivors, patients treated for acute mastitis and tuberculosis patients monitored by fluoroscopy. Therefore the radiation received by the untreated breast during breast irradiation of the other breast, is of concern to clinicians. Using thermoluminescence dosimeters, we have measured the dose received by contraleteral breast of six patients during radiation therapy. Most of the dose received will be from the collimator scatter and leakage. We investigated the effect of an absorber, superflab, in reducing the skin dose to contralateral breast. With the overlaying of a cm superflab on the breast, the skin (surface) dose could be reduced by 40-75% of its original value. This is an effective and practical method of reducing significantly the dose to contralateral breast during breast conservation therapy. Superflab can be made conveniently at low cost.

Comparative testing of peripheral blood and bone marrow for BCR-ABL transcripts in patients post allogeneic bone marrow transplantation and during interferon treatment for chronic myeloid leukemia

Patients with CML post allogeneic BMT or during treatment with Interferon were monitored in bone marrow and peripheral blood for BCR-ABL transcripts by RT-PCR and in the majority of cases also by Southern blotting. Bone marrow and peripheral blood samples were obtained simultaneously and tested by RT-PCR with the objective to determine the usefulness to follow CML patients by testing peripheral blood rather than bone marrow samples. For the purpose of this study we have considered the test results obtained from bone marrow samples as the standard. A total of 111 CML patients were examined who underwent either an allogeneic BMT (n=91) or were treated with Interferon (n=20) amounting to a total of 163 assessments for BCR-ABL. Concordance of results was observed in 153 samples (93.9%). 10 samples showed discordance. Seven of these were subjected to repeat testing by RT-PCR. The previously obtained discordant results were confirmed. The sensitivity of peripheral blood assays was calculated to be 96.2% with a specificity of 89.5%. RT-PCR results restricted to Southern blot negative patients showed concordance of bone marrow and peripheral blood in 91.1% of tested samples with a sensitivity of 92.7% and a specificity of 88.6%. The subset of patients in which Southern blot testing was not available showed concordance at a similar level. Complete concordance was seen in all patients that were found to be positive by Southern blotting. We conclude from this study that peripheral blood testing for BCR-ABL transcripts by RT-PCR is a test with high sensitivity and specificity and may potentially replace bone marrow testing. This approach will probably result in a high level of acceptance by patients and may permit more frequent monitoring.

Survey of a Bekaa community health needs

Rural underserved areas can benefit from private and non governmental organizations in improving health delivery. Many such organizations operate in the underserved Bekaa area in Lebanon. This study aimed to assess the nature, scope, utilization and satisfaction with health services available to the population living in the vicinity of the American University of Beirut Agricultural Research and Education Center in Bekaa. A random sample from the residents of the area (475 individuals) and all physicians and representatives of health delivery institutions serving this population were interviewed. Individuals interviewed reported 3.7 health related visits/person/year, 65% vaccination rate and 34.1% labeled available services as poor. Interviewed physicians and health institution administrators identified the study area priority needs as nurses, emergency transport units and primary care centers. Systematic evaluation and priority setting of the health needs of this population are necessary and the establishment of health centers should be strongly considered.

Clinical and economic analysis of allogeneic peripheral blood progenitor cell transplants: a Canadian perspective

Allogeneic peripheral blood progenitor cell (PBPC) transplants are an alternative to BMT, although G-CSF mobilization dose, timing of pheresis and risk of GVHD are not well defined. We compared harvest characteristics, donor and recipient outcomes and costs of two PBPC transplant strategies with historical controls who received BMT. Twenty donors mobilized with four daily s.c. G-CSF doses (5 microg/kg/day) (group 1) and 20 mobilized with 10 microg/kg/day G-CSF (group 2) were compared with 20 BM controls (group 3). G-CSF and phereses were well tolerated. Four of 40 PBPC donors required femoral catheter placement. At least 2.5 x 10(6) CD34+/kg recipient weight were collected with two phereses in 19/20 donors (group 1) and 18/20 donors (group 2). Time to neutrophil (18 vs 20 vs 22 days, P = 0.02) and platelet (21 vs 24 vs 27 days, P = 0.005) engraftment was shorter in the PBPC groups (group 2 vs group 1 vs group 3) but secondary engraftment outcomes were not different. The incidence of grade 2-4 aGVHD was higher in the low-dose G-CSF group (group 1) but there was no difference in cGVHD, 100-day or 1-year survival. The mean PBPC transplant cost (group 1) at first hospital discharge was less than BM (group 3) ($34,643 vs $37,354) but the mean overall cost for both groups was similar at 100 days ($46,334 vs $46,083). Allogeneic PBPC transplant with short course, low-dose G-CSF mobilization is safe, feasible and cost equivalent to allogeneic BMT.

An unusual presentation of pulmonary echinococcosis

A case of pulmonary hydatid disease presenting with right supraclavicular cystic swelling is being reported. Radiologically, the cyst had an extension into the chest wall with bony involvement in the form of destruction and thinning of the first and second ribs on the right side. The patient responded to albendazole therapy.

Extended duration between harvest and re-infusion of human bone marrow stored at room temperature

A major limitation of unrelated bone marrow transplantation is the duration of time that is safe between harvest and re-infusion of the marrow. We have been able to demonstrate safe re-infusion of bone marrow kept at room temperature during transport, after almost 36 h. In vitro colony-forming assays suggest that stability may be as long as 5 days.

Normal and leukemic SCID-repopulating cells (SRC) coexist in the bone marrow and peripheral blood from CML patients in chronic phase, whereas leukemic SRC are detected in blast crisis

Progress in understanding the abnormal regulation of hematopoiesis in chronic myelogenous leukemia (CML) would be facilitated if neoplastic cells, at all stages of the disease, could be studied in an animal model. In this report, we show that irradiated severe combined immunodeficient (SCID) mice can be transplanted with both normal (Philadelphia chromosome [Ph]-negative) and neoplastic (Ph+) cells from CML patients with either chronic or blast phase disease. Mice transplanted with peripheral blood (PB) or bone marrow (BM) cells from 9 of 12 chronic phase CML patients were well engrafted with human cells including multilineage colony-forming progenitors and CD34+ cells for at least 90 days posttransplantation. Repeated posttransplant injections of cytokines did not enhance the number of engrafted human cells. Interestingly, approximately 70% of the human progenitors found in the engrafted SCID BM were Ph-, suggesting that the growth of primitive normal cells is favored in this in vivo transplant model. A similar number of normal cells were found in mice transplanted with either PB or BM cells, suggesting that elevated numbers of primitive normal cells are present in CML PB. When cells from patients with CML in either myeloid or lymphoid blast crisis were transplanted into SCID mice, the BM of these mice was more rapidly repopulated and to a higher level than that observed with transplants of chronic phase cells. Moreover, all human colony-forming progenitors present in the BM of mice transplanted with blast crisis cells were Ph+, and the majority of cells showed the same morphological features of the blast crisis cells originally transplanted. These experiments provide a starting point for the creation of an animal model of CML and establish the feasibility of using this model for the future characterization of transplantable CML stem cells during disease progression.

Determination of IL6, IL1, and IL4 in the plasma of patients with multiple myeloma

Interleukin 6 (IL6) plasma levels were measured in 63 patients with multiple myeloma and 8 individuals with benign monoclonal gammopathy. 15 of these 71 samples showed by an enzyme linked immunosorbent assay (ELISA) detectable levels that ranged from 5 to 107 pg of IL6/ml. The IL6 levels of patients with multiple myeloma did not differ significantly from those of normal individuals (N = 25, range 5-27 pg IL6/ml) (Student's t-test, p = 0.295). The samples were negative for IL4; 3 were found positive for IL1 beta. A correlation between IL6, IL4 and IL1 beta levels and disease status was not observed for this group of patients.

Allogeneic bone marrow transplantation from a related donor undergoing long-term immunosuppressive and cytotoxic therapy

We report the case of a patient with acute myeloid leukemia in second remission who received an allogeneic bone marrow transplant from an immunosuppressed HLA-identical sibling donor. The donor was receiving prednisone, azathioprine and cyclosporine for a cadaveric renal allograft. Bone marrow growth in culture from the donor was normal. Engraftment was within normal limits. Moderate acute graft-versus-host disease (GVHD) developed. We suggest that transplants from immunosuppressed donors are feasible and that this does not preclude the development of GVHD.

Spontaneous remission of polycythemia vera: clinical and cell culture characteristics

A 20-year-old woman presented with polycythemia vera and was treated with phlebotomy alone for eleven years, following which all clinical manifestations of the disease disappeared. The clinical remission with normal physical findings and normal peripheral blood counts has persisted for a further 11 years. Erythroid colony culture results have paralleled the clinical state. Initial bone marrow cultures revealed spontaneous growth of erythroid burst-forming units (BFU-E). Subsequent cultures of peripheral blood cells throughout most of the period of spontaneous clinical remission have revealed little or no spontaneous growth of BFU-E. This suggests a suppression of the abnormal stem cell clone during the period of remission.

Differential sensitivity of human myeloma cell lines and normal bone marrow colony forming cells to a recombinant diphtheria toxin-interleukin 6 fusion protein

The cytotoxicity of a recombinant interleukin 6 (IL-6)-diphtheria toxin (DT) fusion protein towards human myeloma cell lines was investigated. DAB389-IL-6 inhibited protein synthesis and methylcellulose colony formation by U266 myeloma cells. In the clonogenic assay, the fusion protein approached the level of cytotoxicity achieved by native DT. The specificity of killing by DAB389-IL-6 was demonstrated by inhibition of cytotoxicity by a molar excess of free rhIL-6. The effect of DAB389-IL-6 on colony formation by six OCI-My cell lines was assessed. Similar to U266 cells, colony growth by the OCI-My 5 and -My 2 cell lines was inhibited in a simple dose dependent manner. However, a biphasic effect was observed for the IL-6 dependent OCI-My 4 cells; DAB389-IL-6 stimulated colony formation at low (< or = 10(-11) M) concentrations, yet was inhibitory at higher doses. Three other cell lines whose growth was not altered by IL-6 were relatively unaffected by DAB389-IL-6, despite their sensitivity to native DT. Flow cytometric analysis for IL-6 receptor expression using phycoerythrin-conjugated IL-6 demonstrated specific binding sites on both DAB389-IL-6 sensitive and certain insensitive cell lines, suggesting that other factors in addition to the expression of IL-6 receptors are involved in killing by the fusion toxin. Despite evidence for a role of IL-6 in myeloid cell development, normal bone marrow was insensitive to the IL-6 fusion toxin. In cultures containing both normal bone marrow and U266 cells DAB389-IL-6 effectively inhibited the growth of U266 myeloma colonies but had little effect on normal bone marrow erythroid, granulocyte and mixed erythroid/granulocyte colony growth. From these experiments we conclude that DAB389-IL-6 is specifically cytotoxic towards a subset of IL-6-responsive human myeloma cell lines and may be useful, in some cases, in the selective elimination of tumour cells from mixed populations of normal and malignant cells.

Merocyanine 540-sensitized photoinactivation of high-grade non-Hodgkin's lymphoma cells: potential application in autologous BMT

This paper reports on the preclinical evaluation of merocyanine 540 (MC540) as an agent for the inactivation of tumour cells in BM grafts from non-Hodgkin's lymphoma (NHL) patients. The three cell lines used for this study, OCI-LY13.1, OCI-LY13.2 and OCI-LY9, originate from two patients with high-grade NHL. The OCI-LY13.1 and OCI-LY13.2 lines are derived from the same patient. The OCI-LY13.1 line was established at the time of diagnosis while the OCI-LY13.2 line was established after the tumour had become refractory to therapy. When used under conditions that are known to preserve about 50% of normal human pluripotent hematopoietic progenitor cells (CFU-GEMM), MC540-sensitized photoirradiation reduced in vitro clonogenic OCI-LY9 cells by 4 orders of magnitude and OCI-LY13.1 and OCI-LY13.2 cells by > or = 5. Survival curves for OCI-LY13.1 and OCI-LY13.2 cells were similar and followed first order kinetics, while those for OCI-LY9 cells were distinctly biphasic. Suspension cultures established with photoinactivated lymphoma cells confirmed that MC540-sensitized photoirradiation was cytotoxic and capable of eliminating > or = 4 log of tumour cells. These results encourage the further exploration of MC540-sensitized photoirradiation as a means to purge autologous marrow grafts from NHL patients.

Cell culture assessment of hematopoietic progenitors in bone marrow transplantation

A number of cell culture techniques are now available to evaluate clonogenic hematopoietic progenitors as well as cell populations that represent an interactive network of cells with regulatory capabilities. Although clonogenic cells in allografts do not appear to be correlated with the time to recovery, they seem to predict their time to engraftment in autografts. However, these cell populations are likely to be only surrogate measurements because a reduction by various purging techniques does not seem to alter the ability of autografts to reestablishing hematopoiesis. Currently, it is not known whether or not these differences may relate to differences in the preparative regimens, graft-versus-host disease prophylaxis, or other differences in the management, such as administration of high concentrations of various antiviral agents. It is also now possible to measure growth factor production following the transplant procedure and to correlate the availability of endogenous factors and recovery after a transplant. Under normal conditions, the activity levels appear to return to normal values within 20-30 days, whereas in patients with late engraftment one may observe prolonged elevation of growth factors. If confirmed, this would suggest that in bone marrow transplants a delayed return is more related to reduced progenitor cells rather than a deficiency of growth factors.

Clonogenic hematopoietic progenitors and endogenous cytokine production in allogeneic bone marrow transplantation

The suboptimal return of hematopoietic precursors after bone marrow transplantation is suggestive of a limited bone marrow reserve in recipients of allografts. The problem does not appear to lie in the ability to produce some of the well-known hematopoietic growth factors such as G-CSF or activities considered to stimulate megakaryocytopoiesis. The persistence of factor production in patients with slow returning counts is suggestive of either a defect in the repopulating cells or in the function of the microenvironment that is not reflected in the production of factors that can be measured in the plasma. A defect in the graft may be overcome by altering the composition of engrafting cells. As seen in autologous transplants the addition of peripheral blood stem cells may be effective in reducing the period to engraftment. Putative defects in the microenvironment have to be addressed by further studies. Exogenously added stroma related factors such as kit ligand or IL-11 may be effective in correcting the deficiency.

Constitutive production of the interleukins IL-5 and IL-6 by the lymphoma cell line OCI-Ly 17 derived from a patient with malignant lymphoma and hypereosinophilia

Peripheral blood cells of a patient with diffuse large cell non-Hodgkin's lymphoma presenting with hypereosinophilia were used to establish an EBV negative lymphoma cell line termed OCI-Ly17. Cells of the line stained positive for CD2 and CD5 determinants and demonstrated rearrangement of the T-cell receptor beta chain. The immunoglobulin heavy chain gene was found to be in germ line configuration. Northern blot studies using probes for IL-1 alpha, IL-3, IL-4, IL-5, IL-6, and GM-CSF showed message for IL-5 and IL-6. Supernatants of the cell line were evaluated on normal non-adherent, E-rosette depleted bone marrow cells to determine the presence of growth promoting activities for clonogenic eosinophilic progenitors. Eosinophilic colonies were observed. Their frequency depended upon the amount of supernatant added to the cultures. The growth promoting activity in the supernatant was reduced in a dose dependent manner by preincubation with increasing concentrations of anti-IL-5 antibodies. The supernatants of the cell line were also tested on the IL-6 sensitive human myeloma line OCI-My4 and myeloma colonies grew in response. This stimulatory activity within the supernatant was neutralized by addition of increasing concentrations of anti-IL-6 antibodies. Although producing IL-5 and IL-6 constitutively, the lymphoma line did not increase proliferation in response to either interleukin, nor did it show a reduced proliferative rate when antibodies to IL-5 or IL-6 were added to the cultures.

Differentiation profiles of normal blast cell colonies derived from mononucleated cells, T cell depleted nonadherent cells and CD33-negative, CD34-positive normal human bone marrow cells

Blast cell colonies can be grown reproducibly in methylcellulose from normal human mononuclear bone marrow cells (MNC) in the presence of 30% human plasma, 1 U human recombinant erythropoietin and 10% of medium conditioned by phytohemagglutinin stimulated leukocytes as a source of growth factors. The colonies can be recognized by inverted microscopy by their display of highly refractile cytoplasmic structures that resemble small vacuoles. A proportion of cells within these colonies remains CD34-positive (CD34+). The blast-like morphology of these cells was sustained for at least 14 to 21 days. The frequency of blast cell colony forming units (CFU-BL) can be increased by a series of separation procedures to produce E-rosette depleted, nonadherent cells (E-NAC), CD34+ cells and CD33-CD34+ cells. The mean number of CFU-BL per 10(5) cells was 1.9 +/- 1.6 in MNC, 5.7 +/- 2.7 in E-NAC, 108 +/- 51 in CD34+ cells and 112 +/- 109 in CD33-CD34+ cells. The enrichment procedures were not specific for CFU-BL but also resulted in a similar increase of multilineage and single lineage progenitors. The relative proportions of CFU-BL and other progenitors remained unchanged among these subpopulations. The size of individual blast cell colonies on day 16 varied from 20 to 1,600 cells. After 14 to 21 days, cells within blast cell colonies acquired mature morphological features. The majority of blast cell colonies developed into multilineage colonies (62%); some (38%) were restricted to a single hemopoietic lineage. Larger blast cell colonies had a higher probability of developing into multilineage colonies than smaller blast cell colonies.

Growth and detection of human bone marrow B-lineage colonies

A reproducible method for growing normal human bone marrow B-lineage colonies in agar is described. The clonogenic cells require a rich medium, Opti-MEM (GIBCO/BRL, Burlington, Ontario, Canada), and a source of T-cell-derived factors for growth. The conditions described appear to be limiting for the colony progenitor, suggesting assay clonality. Three novel methods that permit routine and rapid detection of these human B-cell colonies are also described. Colonies containing cells that secrete immunoglobulin are detected by plaquing and protein immunoblotting, while RNA transcripts can be detected by RNA colony blotting. The detection of more than one secreted immunoglobulin isotype or RNA species in a single colony can also be achieved. This B-cell colony assay and the associated detection methods will allow the further delineation of human B lymphopoiesis in both normal and disease states.

Production of growth factors by malignant lymphoma cell lines

Fourteen Epstein-Barr virus (EBV)-negative cell lines were raised from bone marrow (BM), peripheral blood (PB), or lymph node samples of patients with intermediate- or high-grade malignant lymphoma. The cell lines were propagated in liquid suspension culture. They contain clonogenic progenitors capable of forming lymphoma colonies in semi-solid culture medium. Cells of these lines were used to examine the growth factor requirements of their clonogenic progenitors and to assess their ability to produce their own growth factors. Two of the cell lines (OCI-Ly9 and OCI-Ly13.1) required addition of exogenous factors for colony growth. These factors were routinely provided by media conditioned by phytohemagglutinin-stimulated leukocytes (PHA-LCM). Three lines formed some and nine lines gave rise to optimal numbers of colonies without addition of growth factors. Eight of these factor-independent lines were able to function as feeder cells and promoted colony formation by both factor-dependent lines. Cell lines that displayed feeder cell function released activities into supernatants able to replace their cellular source. Some of these endogenously produced growth-promoting activities could be replaced by known hematopoietic growth factors. Both factor-dependent cell lines were cultured with recombinant IL-1 alpha, IL-2, IL-3, IL-6, and GM colony-stimulating factor (CSF) and semipurified B-cell growth factor (BCGF) interleukin-4 (IL-4). A heterogeneous response pattern was observed. Both lines formed colonies with IL-4. The colonies were comparable in frequency and size with colonies observed with (PHA-LCM). OCI-Ly9 responded to IL-6 but showed no growth with IL-2. In contrast, the TAC-positive line OCI-Ly13.1 gave rise to colonies with IL-2 while remaining unresponsive to IL-6. A moderate number of colonies was observed when cells of this line were cultured with GM-CSF. Colony formation of both lines was uninfluenced by IL1 alpha or IL-3.

Hemopoietic colony growth-promoting activities in the plasma of bone marrow transplant recipients

Plasma samples were obtained from 34 bone marrow transplant (BMT) recipients before and after administration of the preparative regimen and tested for their ability to promote and/or support growth of hemopoietic colonies. The ability of plasma samples to promote colony formation on their own was tested on normal nonadherent target cells without addition of exogenous growth factors. The growth-supporting activity was examined in the presence of medium conditioned by phytohemagglutinin-stimulated leukocytes (PHA-LCM) and/or erythropoietin (EPO). A series of kinetic changes was routinely observed. Pretransplant samples rarely gave rise to colonies without addition of exogenous growth factors. Plasma samples obtained after completion of the preparative regimen demonstrated increments of growth-promoting activities for megakaryocyte and granulocyte-macrophage progenitors (CFU-Meg and CFU-GM), respectively, that peaked between 7 and 21 d after transplantation. By day 30, activity levels of some patients had returned to pretransplant values, whereas in other patients, activities remained elevated. Persisting activity levels were associated with delayed engraftment. In contrast, activities for progenitors committed to erythropoiesis (BFU-E) and pluripotent precursors (CFU-GEMM) were only rarely observed. The activities were independent of febrile episodes. Their growth-promoting influence on CFU-GM could be neutralized completely by anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) antibodies. These data suggest that at least some of the observed activities in post-BMT plasma are related to GM-CSF. The growth-supporting activities of pretransplant plasma samples are lower than normal plasma when tested on CFU-Meg and CFU-GM. The growth-supporting activities improved transiently within the first month after BMT. A decline during the second and third month was followed by a gradual return to activity levels that were comparable to normal plasma. The effects of these plasma samples on BFU-E and CFU-GEMM were assessed with PHA-LCM and EPO. Similar to CFU-Meg- and CFU-GM-supporting capabilities, they improved transiently after BMT with a return of normal support function after 5-6 mo. The observed endogenous production of growth-promoting and growth-supporting activities for hemopoietic progenitors may serve as a background to design clinical trials for the timely administration of recombinant hemopoietic growth factors to BMT recipients.

Megakaryocyte colony growth-supporting activities in human plasma: modification by platelets and platelet membranes

Human megakaryocyte colonies are grown in methylcellulose with platelet-poor plasma and medium conditioned by phytohemagglutinin-stimulated leukocytes (PHA-LCM) as a source of megakaryocyte colony stimulating factor (MEG-CSF). The megakaryocyte colony growth-supporting activity in human plasma can be absorbed by intact platelets or degranulated platelet membranes. It was possible to recover the activity by solubilizing platelet membranes with cholic acid. Filtration of the solubilized platelet membrane preparations through a Sephadex G-100 column yielded at least two activity peaks. The molecular weight of these two activities differs from that of the growth-promoting activity in PHA-LCM.

Clonogenic hemopoietic precursors in bone marrow transplantation

Multilineage and single-lineage hemopoietic precursors were studied in 102 bone marrow transplant recipients and their respective donors to determine their contribution to clinical outcome as measured by time to engraftment and survival. The patient population was heterogenous with respect to diagnosis and disease status. They included individuals with acute myeloid leukemia (AML), chronic myeloid leukemia (CML), acute lymphoblastic leukemia (ALL), aplastic anemia, and a few other hematopoietic malignancies. The frequency of various clonogenic precursors in the normal donor population varied considerably. The data yielded a symmetrical distribution. In contrast, most bone marrow transplant recipients presented with significantly reduced numbers of clonogenic cells before transplantation, resulting in skewed distribution profiles. Serial studies of recipients demonstrated a significantly lower than normal level of clonogenic precursors even 3 and 4 years after transplantation. The median values and distribution profiles approximated those observed before transplantation but did not return to measurements obtained for normal donors. Patients with ALL deviated from this pattern. The median values and distribution profiles of clonogenic precursors before transplantation approximated the pattern of normal donors. The frequency of clonogenic progenitors after transplantation, however, remained significantly lower than that of their respective donor or pretransplant values. Cell cycle studies performed after normalization of peripheral blood hematopoietic parameters demonstrated for most recipients that a higher than normal proportion of multipotent cells was in S-phase (P = .011). By univariate and multivariate approaches, clonogenic precursors and clinical parameters were assessed for their contributions to clinical outcome as measured by time to engraftment and survival time. The number of nucleated cells in the transplant inoculum contributed to survival independent of other risk factors. Patients with a higher cell load had a higher probability of surviving than did patients with a lower cell concentration in the transplant inoculum (P = .042). The frequency of clonogenic precursors in the transplant inoculum altered neither survival nor time to engraftment. The time to engraftment was significantly influenced by the frequency of clonogenic megakaryocyte precursors (CFU-M) observed in recipients prior to transplantation (P = .003). Patients with high values engrafted faster than did patients with a low frequency of CFU-M. This was independent of both diagnosis and disease status of the patients at time of transplantation.

Growth of human hemopoietic colonies in response to recombinant gibbon interleukin 3: comparison with human recombinant granulocyte and granulocyte-macrophage colony-stimulating factor

Supernatants of COS-1 cells transfected with gibbon cDNA encoding interleukin 3 (IL-3) with homology to sequences for human IL-3 were tested for ability to promote growth of various human hemopoietic progenitors. The effect of these supernatants as a source of recombinant IL-3 was compared to that of recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF) as well as to that of medium conditioned by phytohemagglutinin-stimulated leukocytes. The frequency of multilineage colonies, erythroid bursts, and megakaryocyte colonies in cultures containing the COS-1 cell supernatant was equivalent to the frequency observed in the controls and significantly higher than found in cultures plated with recombinant GM-CSF. G-CSF did not support the formation of multilineage colonies, erythroid bursts, and megakaryocyte colonies. In contrast, growth of granulocyte-macrophage colonies was best supported with GM-CSF, while recombinant IL-3 yielded colonies at lower or at best equivalent frequency. The simultaneous addition of higher concentrations of GM-CSF to cultures containing IL-3 in optimal amounts did not enhance the formation of multilineage colonies, erythroid bursts, and megakaryocyte colonies. However, the frequency of such colonies and bursts increased with GM-CSF when cultures were plated with suboptimal concentrations of IL-3. Growth of colonies within the granulocyte-macrophage lineage is optimally supported by GM-CSF and does not increase with further addition of IL-3.

The presence of clonogenic cells in high-grade malignant lymphoma: a prognostic factor

A culture system has been developed that promotes growth of clonogenic lymphoma cells of some patients with intermediate and high-grade malignant lymphoma. The formation of colonies in bone marrow, lymph nodes, and peripheral blood samples is best supported by human plasma. Colony formation of some patients was dependent upon growth factors, which in this study were added in the form of medium conditioned by phytohemagglutinin (PHA)-stimulated leukocytes (PHA-LCM). Some gave rise to lymphoma colonies without PHA-LCM but improved their frequency with PHA-LCM; others were completely independent of PHA-LCM. Colonies grown in primary cultures were routinely recloned and propagated as Epstein-Barr virus (EBV)-negative cell lines with stable B cell phenotype. The cell lines showed the same immunoglobulin rearrangement pattern as that observed in the primary lymphoma sample. In addition, a significant clinical correlation was observed between culture data and clinical outcome. Survival of patients who formed lymphoma colonies at any time during their clinical course was significantly shorter than survival of patients who did not give rise to colonies (P = 0.0009). The same observation was made when the survival assessment was performed for the subset of patients studied at diagnosis (P = 0.0014).

Colony growth and self renewal of plasma cell precursors in multiple myeloma

Culture conditions that support the growth of multi-and single-lineage hemopoietic colonies are also able to give rise to large myeloma colonies from bone marrow and peripheral blood samples of some patients with multiple myeloma. The culture system was used to determine the frequency of hemopoietic precursors and clonogenic myeloma progenitors in 71 patients with multiple myeloma studied in various clinical phases of the disease. The frequency of normal hemopoietic precursors in patients with benign monoclonal gammopathy and smoldering myeloma were indistinguishable from normal controls. Myeloma colonies were not observed in these subgroups. In contrast, patients with active disease showed significantly reduced hemopoietic colony formation, even before the initiation of therapy. A further reduction was demonstrated for patients with acute phase disease. A correlation between the frequency of hemopoietic colonies and the concentration of plasma cells in the plated sample was not observed. Large myeloma colonies with recloning potential were identified in cultures of specimens derived from 14 of the studied patients. These colonies were most frequently (ten cases) obtained from patients who had entered the acute phase of the disease. These patients manifested marrow failure (pancytopenia) and their marrow had a limited capacity to generate normal hemopoietic colonies. Three of the patients that formed myeloma colonies were studied in chronic phase following chemotherapy and one patient was examined at diagnosis. The myeloma colonies were composed exclusively of cells characterized by the same M protein as the patient. Some of the cells within the colonies retained their ability to self renew extensively, as demonstrated by serial recloning studies. Colonies derived from six of the patients are now propagated in semisolid and liquid medium for as many as nine to 34 generations. Patients that form myeloma colonies under these culture conditions represent a high-risk group with significantly shorter survival than patients not able to give rise to myeloma colonies. A Cox proportional hazards model was fitted to the data to determine the prognostic role of myeloma colony growth in culture after accounting for the influence of other well established risk factors, such as concentration of plasma cells and disease status. The analysis indicated that myeloma colony growth in culture serves as a strong and independent predictive indicator of poor clinical prognosis.