D. Joshua

ANDROGEN-INDUCED HEPATOMA

Three cases of hepatocellular carcinoma are reported in young men who had been taking androgenic-anabolic steroids. The tumours were histologically similar to those described in previous reports. The tumour progressed slowly in two patients during four and seven years of observation, but in the latter bony metastases occurred. In two patients the tumours regressed after administration of the drug was discontinued. These cases strengthen the evidence that exogenous androgenic-anabolic steroids may produce liver tumours. The use of these drugs should be confined to serious conditions in which they are known to be effective. Biochemical tests of liver function and serum alphs-fetoprotein estimation are not useful as screening-tests for hepatoma in patients taking androgens, and regular isotopic liver-scanning is recommended.

The prognostic significance of T cell receptor β gene rearrangements and idiotype-reactive T cells in multiple myeloma

Clonal T cell populations with idiotype specificity are present in the peripheral blood of a proportion of patients with multiple myeloma. We have identified the presence of both T cell sub-populations with a specificity for autologous immunoglobin fragments and T cell receptor β gene rearrangements in peripheral blood samples of patients with myeloma. T cell receptor β gene rearrangements were detected in 38 of 119 patient samples (32%) and were more common in progressive disease (70%), than at diagnosis (25%) or in stable disease (23%). The 38 patients who had T cell receptor β gene rearrangements detected at any time had a better overall survival (median not yet achieved) than the patients who never had rearrangements detected (median 45 months, n = 49;χ 2 = 6.2, P < 0.01). All 12 patients with T cell receptor β gene rearrangements at diagnosis are still alive whereas the median survival for 28 patients with a germline configuration at diagnosis was 40 months (χ 2 = 5.8, P > 0.01). The presence of T cell receptor β gene rearrangements even conferred a survival advantage during progressive disease (median survival 44 months vs 19 months;χ2 = 8.7, P < 0.003). Two colour flow cytometry with biotinylated autologous immunoglobulin fragments demonstrated idiotype-reactive T cells in the peripheral blood of five out of 15 patients all of whom had T cell gene rearrangements. The remaining 10 patients had neither idiotype-reactive T cells nor a detectable T cell receptorβ gene rearrangement in concurrent samples. Thus in patients with myeloma there was a good correlation between the presence of T cell receptor β gene rearrangements and idiotype-reactive T cells. Patients with a rearranged T cell receptor β gene had a significantly better prognosis.

Gallium scanning in the management of mediastinal Hodgkin's disease

Gallium‐67 scanning was performed pre‐ and post‐therapy in 25 patients with Hodgkins disease and a mediastinal mass. At restaging after therapy, radiographs (or CT scans) did not predict the presence of active disease whereas gallium scans did with a high degree of accuracy. Gallium‐67 determined disease activity in those patients who had a residual mediastinal mass predicting outcome in 11 out of 12 patients; one had a late relapse at 7 years. In patients without a residual mass gallium scanning was again accurate, predicting outcome in 11 of 13 patients. Two patients with negative gallium scans but subsequent active disease were scanned too soon after chemotherapy. The results suggest that gallium scanning has an important role in the mangement of mediastinal Hodgkins disease and is superior to all current methods of assessing disease activity irrespective of the presence of a residual mediastinal mass.

The Expression of T Cell Related Costimulatory Molecules in Multiple Myeloma

Presentation of tumour antigen by malignant cells not expressing costimulatory molecules is considered to be a major cause of the failure of the hosts immune response against tumours. This study has determined the expression of the B7 family of costimulatory molecules on malignant plasma cells and the expression of the counter receptor molecules, CD28 and CD152 (CTLA-4), on T cells of patients with multiple myeloma. CD28 expression was present on most CD4 cells but was lower on CD8 cells especially from those patients who also showed evidence of expanded T cell clones (median 40%. z=2.4; p<0.02). CD152 expression was increased in 50% (9/18) of patients with myeloma. CD80 (B7-1) expression was present on the plasma cells of only 1 of 27 samples but CD86 (B7-2) expression within the normal range was present on the plasma cells of 14 of 27 samples. Primitive plasma cells (CD38++ CD45++) had a higher expression of CD86 (median 78%) than mature plasma cells (CD38++ CD45-) (median 19%, z=3.7; p<0.01). Thus patients with expanded T cell clones have a downregulated T cell CD28 expression and lack B7-1 expression on their malignant plasma cells. These results are consistent with the concept that engagement of the T cell receptor by tumour antigen on B7-1 deficient malignant plasma cells would result in T cell anergy rather than productive immunity.

CD86+ or HLA-G+ can be transferred via trogocytosis from myeloma cells to T cells and are associated with poor prognosis

The transfer of membrane proteins between cells during contact, known as trogocytosis, can create novel cells with a unique phenotype and altered function. We demonstrate that trogocytosis is more common in multiple myeloma (MM) than chronic lymphocytic leukemia and Waldenstrom macroglobulinaemia; that T cells are more probable to be recipients than B or natural killer cells; that trogocytosis occurs independently of either the T-cell receptor or HLA compatibility; and that after trogocytosis, T cells with acquired antigens can become novel regulators of T-cell proliferation. We screened 168 patients with MM and found that CD86 and human leukocyte antigen G (HLA-G) were antigens commonly acquired by T cells from malignant plasma cells. CD3+ CD86acq+ and CD3+ HLA-Gacq+ cells were more prevalent in bone marrow than peripheral blood samples. The presence of either CD86 or HLA-G on malignant plasma cells was associated with a poor prognosis. CD38++ side population cells expressed HLA-G, suggesting that these putative myeloma stem cells could generate immune tolerance. HLA-G+ T cells had a regulatory potency similar to natural Tregs, thus providing another novel mechanism for MM to avoid effective immune surveillance.

CD10-(CALLA)-Positive Lymphocytes in Myeloma: Evidence that they are a Malignant Precursor Population and are of Germinal Centre Origin

CD10 antigen has been repeatedly detected on putative lymphoid precursor populations in both the bone marrow and circulation of multiple myeloma patients, as well as on the plasma cells in some cases of myeloma. The presence of these CD10-positive cells has raised questions regarding the ontogeny of the proliferating precursor cell in myeloma. The majority opinion has implicated a CD10-positive haemopoietic progenitor cell. However, the CD10 antigen has been detected on some mature B cells, i.e. germinal centre B cells. In this paper we postulate that the proliferating precursor cell in myeloma arises from the germinal centre. The germinal centre is the site of affinity maturation of antibody responses via somatic mutation and of isotype switching. Thus the siting of the clonogenic cell in myeloma in the germinal centre explains the overwhelming predominance of IgG and IgA myelomas, the phenomenon of point mutation which occurs in myeloma proteins in the presence of stable immunoglobulin gene rearrangements and the impaired primary immune response in myeloma. It is also consistent with the requirement for antigenic exposure in the development of myelomatosis.

Effects of glycosylated recombinant human granulocyte colony-stimulating factor after high-dose cytarabine-based induction chemotherapy for adult acute myeloid leukaemia

The Australian Leukaemia Study Group (ALSG) investigated whether G-CSF would accelerate haemopoietic recovery after induction treatment for acute myeloid leukaemia (AML) intensified with high-dose cytarabine, and therefore improve response rates and survival. Patients were randomised to receive lenograstim (glycosylated recombinant human G-CSF) 5 μg per kg body weight subcutaneously daily from day 8 after starting chemotherapy, or no cytokine, following chemotherapy with cytarabine 3 g/m2 every 12 h on days 1, 3, 5, and 7, together with idarubicin 9 or 12 mg/m2 on days 1, 2, and 3, plus etoposide 75 mg/m2 on days 1 to 7 inclusive. Patients had untreated AML, and were aged 16 to 60 years. Overall, 54 evaluable patients were randomised to receive lenograstim and 58 to no cytokine. Patients in the lenograstim arm had a significantly shorter duration of neutropenia <0.5 × 109/l compared to patients in the no cytokine arm (median 18 vs 22 days; P = 0.0005), and also shorter duration of total leucopenia <1.0 × 109/l (17 vs 19 days; P = 0.0002), as well as a reduction in duration of treatment with therapeutic intravenous antibiotics (20 vs 24 days; P = 0.015) and a trend to reduced number of days with fever >38.0°C (9 vs 12 days; P = 0.18). There were no differences between the two groups in platelet recovery, red cell or platelet transfusions, or non-haematological toxicities. For patients achieving CR after their first induction course, a reduction in the time to the start of the next course of therapy was observed in the lenograstim arm, from a median of 40.5 days to a median of 36 days (P = 0.082). The overall complete response rates to chemotherapy were similar, 81% in the lenograstim arm vs 75% for the no cytokine arm (P = 0.5), and there was no significant difference in the survival durations. We conclude that the granulopoietic stimulating effect of G-CSF is observed after induction therapy for AML intensified by high-dose cytarabine, resulting in an improvement in a number of clinically important parameters with no major adverse effects.

Measurement of free kappa and lambda chains in serum and the significance of their ratio in patients with multiple myeloma

An inhibition enzyme‐linked immunoassay technique using commercially available antibodies has been developed for the quantitation of both kappa and lambda light chains in the serum of patients with B‐cell malignancies. Assay conditions were selected to enable measurement of free light chains in the concentration range between 0.1 and 20 mg/1. The normal range for free lambda chains in serum was found to be 0.4–4.2 mg/1 and for free kappa chains it was 1.6–15.2 mg/1. At diagnosis the serum of most patients with multiple myeloma contained increased levels of the malignant free light chain and in some cases there was also elevation of the non‐malignant light chain. The absolute level of the malignant light chain at diagnosis did not correlate with survival nor with laboratory parameters such as IgM or creatinine. A correlation with β2M and serum paraprotein levels was evident only in cases of IgA myeloma. Although the absolute level of free serum light chain had no value as a prognostic indicator, the ratio of kappa: lambda chains closely followed the clinical assessment of disease status, being near the normal range (1.2–9.1) in plateau phase or stable disease. During periods of progressive disease this ratio ranged from 19 to 460 (n=14) in patients with kappa myeloma, and 0.0013–0.14 (n= 9) in patients with lambda myeloma. Determination of the ratio of free light chains in the serum may allow effective monitoring and earlier warning of disease progression in patients with multiple myeloma.

Syngeneic stem cell transplantation for HIV-related lymphoma

The treatment of human immunodeficiency virus (HIV)‐related lymphoma is beset by a number of therapeutic limitations. High‐dose chemotherapy followed by peripheral blood stem cell transplantation (PBSCT) for relapsed disease is one option, but may be compromised by unacceptable treatment‐related morbidity and mortality. We describe an HIV‐positive male with relapsed immunoblastic non‐Hodgkins lymphoma (NHL) who successfully received salvage chemotherapy followed by a syngeneic PBSCT from his HIV‐negative (hepatitis C positive) brother. At 15 months post‐transplant he remains in complete remission with low‐level HIV viral load, an improved CD4 lymphocyte count and absent anti‐hepatitis C antibodies. We believe selected patients with relapsed HIV‐related NHL should be considered for high‐dose therapy.

Characterisation and relevance of CD138-negative plasma cells in plasma cell myeloma.

Introduction:  The use of CD138 to isolate CD138 + plasma cells (PCs) from plasma cell myeloma (PCM) patients’ bone marrow samples has been used extensively in myeloma research. We sought to highlight the problem with this selection process, by demonstrating that a subpopulation of CD138− plasma cells exists which is not included in these analyses.