Eugene M. Berkman

Hypothyroidism after Treatment with Interleukin-2 and Lymphokine-Activated Killer Cells

The development of a goiter and hypothyroidism in a 28-year-old man in whom metastatic melanoma had been treated with interleukin-2 and lymphokine-activated killer cells (LAK cells) prompted us to assess thyroid function in patients undergoing this therapy. Thirty-four patients with advanced neoplasms who had received interleukin-2 and LAK cells were followed for at least four weeks after treatment. Seven patients (21 percent) had laboratory evidence of hypothyroidism, with a decline in the serum thyroxine concentration to below normal (less than or equal to 35 nmol per liter; normal, 65 to 148), a decline in the serum free thyroxine index, and a rise in the serum thyrotropin concentration (peak values, 7.2 to 166 mU per liter; normal, 0.5 to 5.5) 6 to 11 weeks after treatment. Two patients had elevated serum thyrotropin levels before treatment, which increased further after treatment. In two patients, these abnormal values returned to normal within 10 months. All five symptomatic patients had borderline or elevated serum antimicrosomal antibody titers after treatment; two had serum antibodies to thyroglobulin. Five of the seven patients with hypothyroidism (71 percent) but only 5 of the 27 euthyroid patients (19 percent) had evidence of tumor regression (P less than 0.02). None of 11 patients treated with interleukin-2 but not LAK cells had hypothyroidism. We conclude that treatment with interleukin-2 and LAK cells can cause hypothyroidism, possibly by exacerbating preexisting autoimmune thyroiditis, and that it may be associated with a favorable tumor response.

Increase in circulating colony-forming units-granulocyte-macrophage during large-volume leukapheresis: evaluation of a new cell separator

Peripheral blood stem cell (PBSC) collection was evaluated in two groups of normal donors who underwent large‐volume leukapheresis on a blood cell separator. In Group A (n = 10), a 3‐hour leukapheresis was performed. An average of 11.8 L of blood was processed with a mean flow rate of 66 mL per minute and a collection rate of 3 mL per minute. The PBSC product contained a mean 1.4 × 10(10) mononuclear cells (MNCs) (lymphocytes and monocytes), 1.27 × 10(6) colony‐forming units‐ granulocyte‐macrophage (CFUs‐GM), and an average hematocrit of 4 percent (0.04). Postapheresis blood counts showed significant reductions in MNCs (19%) and platelets (45%) (p < 0.005). Twenty‐four hours later, the MNCs had returned to preapheresis levels. The platelet count returned to baseline only after 7 days. Circulating CFUs‐GM remained stable for 3 days after apheresis but were increased twofold by Day 7 after apheresis (p = 0.025). Varying the product hematocrit from 1 percent (0.01) to 13.3 percent (0.13) did not change the number of CFUs‐GM collected per MNC. In Group B (n = 4), an average of 18.5 L of blood was processed with a mean flow rate of 94 mL per minute and a collection rate of 3 mL per minute. The PBSC product was collected as four sequential samples and assayed for MNCs and CFUs‐GM. Total MNCs averaged 1.7 × 10(10) (an increase of 21% relative to Group A) and CFUs‐GM averaged 3.08 × 10(6) (an increase of 143%). Mean MNCs did not vary significantly among the four samples. However, CFUs‐GM collected per minute (relative to the first sample) did show 1.26‐fold (p = 0.001), 1.86‐fold (p = 0.011), and 2.52‐fold (p = 0.04) increases in the second, third, and fourth samples. These data suggest that MNCs and committed progenitor cells are recruited during large‐volume leukapheresis. Moreover, there is a twofold increase in circulating CFUs‐GM 1 week after apheresis.

Extramedullary tumors of myeloid blasts in adults as a pattern of relapse following allogeneic bone marrow transplantation

Extramedullary tumors of lymphoid and myeloid blasts outside the well‐defined sanctuaries following allogeneic bone marrow transplantation (allo‐BMT) are rare. Little is known about the biology, treatment, and outcome of these tumors in this setting.

Immune hemolysis, disseminated intravascular coagulation, and serum sickness after large doses of immune globulin given intravenously for Kawasaki disease

One week after treatment with intravenously administered immune globulin and aspirin, a child with Kawasaki disease had persistent fever and an increase in coronary artery diameter to greater than 3 mm. Two additional doses of immune globulin were given intravenously. Rapid hemolysis occurred, followed by disseminated intravascular coagulation and serum sickness. Clinicians should be aware that immune globulin preparations contain antibodies to blood-type antigens that may cause significant hemolysis and disseminated intravascular coagulation.

The risk of cytomegalovirus infection in solid organ and bone marrow transplant recipients: transfusion of blood products

CYTOMEGALOVIRUS (CMV) INFECTION is transmitted by blood transfusion from seropositive (CMV antibodypositive) donors and generally ranges in the normal host from asymptomatic seroconversion to mild hepatitis.’ In the immunocornpromised patient or transplant recipient, however, CMV infection may cause serious morbidity, including fever, arthralgias, enteritis, hepatitis, thrombocytopenia, leukopenia, encephalitis, interstitial pneumonia, and even delayed engraftment of bone marrow, and i t may be fatal.’-S Whereas the experimental antiviral agent, ganciclovir, has shown promise in treating serious CMV infection in some transplant settings, this therapy is toxic and has been of limited efficacy.h-lc’ I t may also be possible to attenuate serious CMV disease with prophylactic CMV hyperimmune globulin” or very large doses of immune serum globulin.’2 Still, prevention of CMV infection in transplant recipients is critical. In this review, we will briefly describe CMV infection, the role of the white cell (WBC) in disease transmission, and the types of infection that afflict transplant recipients. We will then examine the relative risks of various blood products and note the distinctions between patient groups that have recently become extremely important in determining triage policy for the use of the limited supply of CMV-seronegative products or their equivalent. Finally, we will attempt to define those patients who clearly require these specialized components and classify those for whom the use of blood products that do not transmit CMV infection is less critical or remains controversial. While CMV immunoglobulin and antiviral medications may change both the incidence and course of CMV infection, we will concentrate on disease prevention via seronegative blood products or their equivalent in seronegative recipients of seronegative solid organs and bone marrow.

Evaluation of the red cell storage lesion after irradiation in filtered packed red cell units

Packed red cell units (n = 10) were filtered and divided equally. One‐ half unit from each donor was irradiated (x) (3500 cGy). On Days 0, 14, 28, and 42, ATP, K+, Na+, lactate dehydrogenase (LDH), plasma‐free hemoglobin (PFH), and pH were determined. The reduction in ATP was greater in the irradiated than the nonirradiated (y) units by Day 42 (mean x−y: −70, p = 0.0005). The increase in K+ was greater in the irradiated than nonirradiated units on Days 14, 28, and 42 (mean x−y: 17−20, p = 0.0001). Decrease in pH and increases in LDH and PFH were significant (p less than 0.05) on Day 42 only. K+ increases added only 1.7 to 2.0 mmol per unit, a difference felt to be clinically insignificant. The changes noted in ATP, pH, LDH, and PFH are significant but minimal on Day 42 and imply that viability changes would also be minimal. These biochemical data support the storage of irradiated units for at least 28 days.

Use of cytomegalovirus immunoglobulin in multiply transfused premature neonates.

We undertook a randomized, placebo‐controlled, double blind trial of cytomegalovirus (CMV) immunoglobulin (CMVIG) for prevention of CMV‐associated disease in 183 multiply transfused, premature neonates. CMVIG (150 mg/kg) or placebo was given within 24 hours of the first transfusion and at Day 10. If an intravenous catheter was still in place an additional dose was given between Days 20 and 30. The globulin and placebo groups were well‐matched with respect to birth weight, gestational age, Apgar score, birth to a CMV‐seropositive mother, requirement for assisted ventilation and exposure to CMV‐positive, unscreened blood products. Among infants followed for more than 10 days, 18 (10.5%) developed CMV infection; 9 had symptomatic CMV disease (5 placebo; 4 CMVIG). Among infants born to a CMV‐seropositive mother, CMVIG use was associated with a CMV syndrome rate of 3.2% (95% confidence interval, 0.2 to 18.5%) compared to 12.5% (95% confidence interval, 4.5 to 27.6%) among placebo recipients (P = 0.163). Among placebo recipients infants born to CMV‐seropositive mothers were more likely to have a virologically confirmed CMV syndrome than those born to a CMV‐seronegative mother, despite receipt of blood not screened for CMV antibody (P = 0.012). Multivariate analysis demonstrated that two factors were independently associated with CMV acquisition: the volume of CMV‐seropositive blood products transfused (P = 0.005); and birth to a CMV‐seropositive mother (P = 0.006). Infusions of CMVIG were well‐tolerated. This study reaffirms that perinatally acquired CMV disease is more common among infants born to CMV‐seropositive mothers than CMV‐seronegative mothers, even without use of CMV‐screened blood products.

Randomized trial of peripheral blood progenitor cell vs bone marrow as hematopoietic support for high-dose chemotherapy in patients with non-Hodgkin's lymphoma and Hodgkin's disease: a clinical and molecular analysis.

Filgrastim (r-metHuG-CSF)-mobilized peripheral blood progenitor cells (PBPC) and unstimulated bone marrow (BM) were evaluated and compared for reconstitution after high-dose chemotherapy in patients with relapsed Hodgkin’s disease (HD) or non-Hodgkin’s lymphoma (NHL) with respect to engraftment, overall and relapse-free survival, and contamination by lymphoma cells using molecular analysis of immunoglobulin gene rearrangements. Forty-four patients with either NHL or HD underwent autologous transplantation after high-dose chemotherapy. Patients were randomized to receive either Filgrastim-mobilized PBPC (n = 15) or unstimulated BM (n = 14). An additional 15 patients received PBPC without randomization because of a recent history of marrow involvement by lymphoma. Use of PBPC was associated with faster neutrophil engraftment than BM (11 vs 14 days to an absolute neutrophil count >0.5 × 109/l, P = 0.04), but without any difference in platelet engraftment, infectious complications, or overall or event-free survival. Both BM (65%) and PBPC (73%) were frequently contaminated by tumor cells as assessed by CDR3 analysis. Patients with negative polymerase chain reaction analysis of a BM sample during the study had a trend towards an improved survival; however, BM involvement by disease had no impact on the ability to mobilize or collect PBPC. We conclude that PBPC are as effective as BM in reconstituting hematopoiesis after high-dose chemotherapy and that both products are frequently contaminated by sequences marking the malignant clone.

Engraftment with peripheral blood stem cells collected by large‐volume leukapheresis for patients with lymphoma

Seven patients with refractory lymphomas underwent marrow reconstitution with peripheral blood stem cells (PBSCs) harvested by large‐volume leukapheresis (LVL). PBSCs were collected from all patients more than 1 month after the last cycle of chemotherapy, and no patient received growth factors. The median number of LVL procedures performed per patient was 4.5, with a mean volume of 24.5 L of blood processed per procedure to obtain 7 × 10(8) mononuclear cells per kg. Autologous PBSCs and platelets were frozen at a controlled rate in plasma and 10‐percent dimethyl sulfoxide and stored in the vapor phase of liquid nitrogen. This group of patients was compared to a control group (n = 18) who received medullary marrow (MM) transplants for the same diagnoses under the same protocols during the same period. Posttransplant days to white cell engraftment (PBSC = 17, MM = 15.5) were no different. Days to platelet independence were significantly longer in the LVL PBSC group (PBSC = 33, MM = 16; p < 0.05). This pattern of engraftment is typical of patients treated in this manner. Although Day 0 platelet counts (PBSC = 75.5 × 10(9)/L, MM = 85 × 10(9)/L) and total single‐donor unit platelet use (PBSC = 8, MM = 9) were no different, Day 1 platelet counts (PBSC = 128 × 10(9)/L, MM = 61.5 × 10(9)/L; p < 0.05) and Day 14 platelet use (PBSC = 5, MM = 8; p < 0.05) were significantly different, because of the transfusion of cryopreserved autologous platelets with PBSCs on Day 0.

Large-volume leukapheresis for collection of mononuclear cells for hematopoietic rescue in Hodgkin's disease

BACKGROUND: Peripheral blood mononuclear cells (MNCs) collected by leukapheresis contain hematopoietic stem and progenitor cells that provide autologous hematopoietic rescue after high‐dose chemotherapy, an approach that offers a significant benefit to patients with recurrent Hodgkins disease. However, patients with low MNC counts may require 10 or more standard leukapheresis procedures for the collection of sufficient cells for hematopoietic rescue. STUDY DESIGN AND METHODS: The effectiveness of steady‐state large‐volume leukapheresis (LVL; 15‐ 35 L blood processed) was evaluated as a method for collecting MNCs for hematopoietic rescue in seven patients with recurrent Hodgkins disease. LVL was performed on 2 consecutive days per week to collect 7 × 10(8) MNCs per kg. The circulating MNC counts on the first day of LVL and the total numbers of LVL, of MNCs collected, and of liters of blood processed were determined per patient. After high‐dose chemotherapy and MNC transfusion, days to granulocyte and platelet engraftment were recorded. RESULTS: On the first day of LVL, patients had median circulating MNCs of 1536 (range, 504–3950) × 10(6) per L. The median number of LVL procedures per patient was four (range, 1.25‐6), and the median L per kg of blood processed was 1.57 (range, 0.38‐4.03). Simple regression analysis plotting L per kg against initial MNCs gave a curve with the equation y = e(1.42‐(6.31 × 10E‐4)x) (correlation coefficient = ‐0.97, R2 = 0.95, exponential fit). Without posttransfusion growth‐ factor support, median days to granulocyte engraftment were 19 (range, 12–26) and those to platelet transfusion independence were 34.5 (range, 10–57). CONCLUSION: LVL provides a useful method of collecting MNCs for hematopoietic rescue in patients with Hodgkins disease. The patients baseline MNC count provides a useful estimate of the volume required for LVL.