Eva Ösby

Modulation of anti-idiotypic immune response by immunization with the autologous M-component protein in multiple myeloma patients.

Multiple myeloma is characterized by a proliferation of clonal B lymphocytes and plasma cells. The idiotypic structure of clonal immunoglobulin (Ig) expressed on the tumour B‐cell surface can be regarded as a tumour‐specific antigen and, as such, a potential target for anti‐idiotypic T and B cells in an immune regulation of the tumour‐cell clone. Active immunization using the autologous monoclonal Ig as a ‘vaccine’ was shown to induce tumour‐specific immunity in murine B‐cell tumours and in human B‐cell lymphoma. With the aim to induce or amplify an anti‐idiotypic response in multiple myeloma, five stage I–III patients were repeatedly immunized with the autologous monoclonal IgG. Induction of idiotype‐specific cellular immunity was analysed in vitro by an enzyme‐linked immunospot assay (interferon‐γ and interleukin‐4 secreting cells). B cells secreting anti‐idiotypic IgM antibodies were also analysed. An anti‐idiotypic T‐cell response was amplified 1.9–5‐fold in three of the five patients during immunization. The number of B cells secreting anti‐idiotypic antibodies also increased in these three patients. In two of the patients induction of idiotype‐specific immunity was associated with a gradual decrease of blood CD19+ B cells. The induced T‐cell response was eliminated during repeated immunization. Further studies are warranted to optimize the immunization schedule in order to achieve a long‐lasting T‐cell immunity against idiotypic determinants on the tumour clone. A role for immunity in controlling the tumour clone remains to be established.

T‐Cell Stimulation Induced by Idiotypes on Monoclonal Immunoglobulins in Patients with Monoclonal Gammopathies

The stimulation of peripheral blood mononuclear cells by purified autologous and/or allogeneic monoclonal IgG was studied in five patients with multiple myeloma (MM), nine patients with monoclonal gammopathy of undetermined significance (MGUS) and six healthy individuals.

Fatal adenovirus infection during alemtuzumab (anti-CD52 monoclonal antibody) treatment of a patient with fludarabine-refractory B-cell chronic lymphocytic leukemia.

Alemtuzumab (Campath-1H) is a humanized CD52 monoclonal antibody that targets normal as well as malignant B- and T-lymphocytes. Alemtuzumab has significant antitumor activity in chronic lymphocytic leukemia (B-CLL) but also induces immunosuppression. We describe a case of fatal adenovirus infection in a heavily pretreated patient with fludarabine-refractory B-CLL receiving alemtuzumab therapy, drawing attention to the fact that also viruses other than cytomegalovirus (CMV) and herpes simplex (HSV) need to be considered in B-CLL patients with fever of unknown origin while on alemtuzumab treatment.

Mitoxantrone, etoposide, cytarabine and prednisone as salvage therapy for refractory non‐Hodgkin lymphoma (NHL) and alternated with CHOP in previously untreated patients with NHL

Abstract: The treatment of relapsing or refractory high‐grade malignant non‐Hodgkin lymphoma (NHL) following CHOP chemotherapy remains a challenge for the clinician. In this study, 29 patients with relapsing or refractory high‐ or refractory low‐grade malignant NHL received a combination of mitoxantrone 12 mg/m2 i.v. on days 1–2, cytarabine 100 mg/m2 i.v., b.d. d 1–2, etoposide 100 mg/m2 i.v. d 1–3 and prednisone 100 mg/m2 orally d 1–3 (ENAP). An overall response rate of 55% encouraged us to use ENAP alternated with conventional CHOP chemotherapy in 45 previously untreated NHL patients (35 with high‐grade and 10 with “aggressive” low‐grade malignant NHL). All patients responded with a complete remission rate (CR) of (27%) and a partial remission rate (PR) of 73% after only one course of ENAP. After a median number of 3.5 ENAP/CHOP courses, the CR and PR rate was 69 and 22%, respectively. Myelo‐suppression was pronounced and fever of unidentified origin and documented infections followed 59% of all cases given ENAP courses. In the last 19 previously untreated patients mitoxantrone was given at a dose of 10 mg/m2 on d 1 and cytarabine 100 mg i.v., b.d. during d 1–2. Non‐hematologic toxicity was mild. We conclude that this novel chemotherapy program is effective both as first‐line and salvage treatment in patients with high‐grade malignant NHL. Furthermore, ENAP appears clinically to be partly non‐cross resistant with CHOP chemotherapy. The dose‐limiting toxicity is myelosuppression. The combination should be explored as primary therapy in combination with other chemotherapy or radiotherapy programs.

Antibody reactivities to skeletal muscle proteins in a patient with λ light chain secreting multiple myeloma, generalised amyloidosis and rhabdomyolysis

Abstract: Rhabdomyolysis is a rare complication in haematological malignancies, and a diverse range of factors has been implicated in the etiology of the syndrome. In the present study we analysed muscle morphology and antibody reactivities to skeletal muscle proteins in a patient diagnosed with lambda (λ) light chain‐secreting multiple myeloma (MM) and amyloidosis, who developed a progressive rhabdomyolysis. The muscle tissue analysis showed focal amyloid depositions and a low degree of atrophy and inflammation. Antibody reactivities against muscle proteins of approximately 42, 51 and 66 kD, respectively, were present in the patients serum. The antibody specificities were revealed by λ light chain‐ or IgM‐specific antibodies. The results indicate a possible etiologic link between antibody reactivities towards muscle proteins and muscle tissue disorder in a patient with the unique combination of rhabdomyolysis, amyloidosis and MM of the light chain type.

Parental longevity and prognosis in elderly patients with aggressive non-hodgkin's lymphoma

In general, elderly patients with aggressive non-Hodgkins lymphoma (NHL) have a less favourable prognosis than younger patients. Established predictors of prognosis in NHL are less discriminatory in the elderly, which is why there is a need for additional markers giving guidance on treatment decisions and prediction of outcome. The expected length of life of an individual in the general population is intimately associated with that of his/her parents. The aim of this study was to test the hypothesis that parental longevity is associated with improved outcome also among elderly patients with aggressive NHL and thus serves as an easily accessible non-disease associated prognostic factor. A total of 220 patients (>60 years) with aggressive NHL with a median age of 71 years (range 60–86) were included. Patients were randomized to receive CHOP or CNOP (doxorubicin replaced with mitoxantrone) chemotherapy with or without the addition of granulocyte colony-stimulating factor. The median follow-up time was 56 (19–89) months. Parental data regarding age at death were available through parish offices for 425 (97%) parents. Relative risk (RR) of death (disease-specific and all-cause) associated with parental lifespan was assessed using Cox proportional hazards regression analyses, with adjustment for sex, age, prognostic index, symptoms, and calendar period of diagnosis. Maternal lifespan below (versus above) median was associated with a borderline significant reduced disease-specific (adjusted RR of death from NHL=1.5; 95% confidence interval 1.0–2.1) and overall survival. The effect of maternal lifespan was somewhat more pronounced in patients receiving CHOP than CNOP treatment. Paternal lifespan below the median was associated with a borderline significant increased disease-specific (adjusted RR of death from NHL=0.8 [0.5–1.0]) and overall survival. Combined, maternal, and paternal lifespan had little impact on survival. These effects were true also when CHOP and CNOP treated patients were analysed separately. Maternal and paternal lifespan may predict survival in NHL, but with opposing effects. At present parental age appears not to be a clinically useful predictor of prognosis in the elderly with aggressive NHL.

Oral etoposide in patients with hematological malignancies

Tumor responses after daily oral administration of low-dose etoposide have been demonstrated in both hematological and solid tumors. The aim of the present phase II trial was to determine tumor response, and toxicity and to delineate the pharmacokinetics of oral low-dose etoposide in patients with hematological malignancies in a palliative treatment setting. Thirty-two patients with non-Hodgkin’s lymphoma (NHL), acute myeloblastic (AML) and lymphoblastic leukemia, multiple myeloma, and myelodysplastic syndrome (MDS) were included. Patients were given oral etoposide, 100 mg once daily for 14 d in a 21-d cycle. Serum etoposide concentrations were determined on d 1, 7, and 14 of every cycle before etoposide administration and, in addition, 1, 2, 3, 4, and 24 h after drug intake on d 1. The median age of patients was 68 yr (range: 50–89 yr). The median time from diagnosis to inclusion in the study was 21 mo (range: 0.5–144 mo) and most patients had advanced disease and were heavily pretreated. Eleven patients completed three or more cycles. Eight of 11 patients with acute leukemia and 1 of 2 with MDS received only 1 course because of toxicity (n=5) or progression (n=4). One patient with AML, a Jehovah’s Witness, was treated up-front and achieved a complete remission and two patients with low-grade NHL gained a complete and a partial remission, respectively. Twenty-one of 32 patients were evaluable for toxicity during the first cycle. In 67%, the white blood cell count nadir was <2.0 × 109/L and in 38%<1.0 × 109/L. Platelet count nadir was less than 25 × 109/L in 24% of evaluable patients. During all cycles (n=79), eight patients developed febrile neutropenia, four of whom with a fatal outcome. The correlation between the area under the curve (AUC) of the free fraction of etoposide and leukopenia was statistically significant at a log analysis (n=12; p<0.05). There was also a statistically significant correlation between the AUC and the 24-h concentration (n=15; p<0.005) and between the concentrations at 24 h and d 7 (n=11; p<0.005) of the free fractions of etoposide. In conclusion, etoposide had a moderate clinical effect in this group of heavily pretreated patients. Moreover, toxicity was substantial, in particular leukopenia, which correlated to the free-etoposide AUC.

Reproducibility of tumor response evaluation in patients with high-grade malignant non-hodgkin’s lymphoma

Estimation of complete response (CR) and partial response (PR) in patients with non-Hodgkin’s lymphoma (NHL) is associated with a number of potential sources of error. The aim of this study was to define the reproducibility of response evaluation performed by an independent review committee (RC).In a phase III study of patients >60 yr with aggressive NHL, 60 patients who were already evaluated by the independent review committee (RC 1) for response were randomized to three groups and re-evaluated (RC 2). The assessment was classified into one of seven mutually exclusive categories, where the important borderlines with regard to one of the major end-points of the study, the CR rate, were between CR, “CR uncertain” (CRU), and PR. A discrepancy between RC 1 and 2 was found in 8/60 patients (13.3%), influencing the CR/CRU status in four of these patients. Two CR and two PR patients were reclassified as CRU. Thus, CR/CRU was changed in 4/60 (6.7%). The reports of the local investigators were compared with that of RC 1 in 254 patients. The CR/CRU status was affected in 41 of these patients (16.1%). It is concluded that an independent RC is a major prerequisite for a uniform response evaluation in phase III clinical trials. However, the good RC reproducibility does not motivate a second assessment. Moreover, in the phase III setting end-points other than the CR rate, such as time to treatment failure, cause specific and overall survival are preferred.

Higher in vivo protein binding of etoposide in children compared with adult cancer patients

Etoposide is bound to plasma albumin (94%). Previous studies have revealed altered protein binding of etoposide in cancer patients. This has clinical implications since only the free fraction is considered pharmacologically active. We have studied the etoposide protein binding in 11 children (eight acute lymphocytic leukemia, two malignant histiocytosis, and one oligodendroglioma; age 1-17 years) and 46 adult patients (28 acute myelocytic leukemia, eight lymphoma, one multiple myeloma, and nine small cell lung cancer; age 38-81 years). All patients were treated with etoposide 50-200 mg/m2 i.v. or orally. Plasma from ten healthy volunteers, 26-50 years of age, was spiked with etoposide, 10 micrograms/ml, and the protein binding was compared with that in patient samples. The free etoposide concentration was determined by high performance liquid chromatography (HPLC) after ultrafiltration at room temperature. The free etoposide fraction was lower, 2.5 +/- 0.6% (mean +/- SD), in the children compared with 5.0 +/- 3.6% in adult cancer patients. In plasma from healthy adults it was 3.2 +/- 0.3%. It is concluded that children have significantly lower levels of free etoposide compared with adult patients (P = 0.03) as well as with healthy subjects (P = 0.001), which is likely to affect metabolism and renal clearance as well as cellular uptake of the drug.

Granulocyte function in elderly patients receiving chemotherapy for aggressive non-Hodgkin’s lymphoma: Effect of granulocyte colony-stimulating factor

BACKGROUND: Treatment with granulocyte colony-stimulating factor (G-CSF) is given in order to mitigate chemotherapy-induced granulocytopenia and the risk of infectious complications, which constitute a major threat to elderly patients, in particular, with malignant disorders. The aim of this study was to evaluate whether G-CSF therapy would improve granulocyte defence mechanisms against infectious agents in this elderly, high-risk patient population. METHODS: Fourteen elderly (>60 years) patients with aggressive non-Hodgkins lymphoma were enrolled in the study. Using flow cytometry we studied the expression of CD11b, before and after stimulation with fMLP, and CD16, as well as granulocyte metabolic activation measured as intracellular accumulation of dichlorofluorescein during induction chemotherapy. Eight patients were randomised to receive G-CSF treatment (5 &mgr;g/kg) on days 2-15. Granulocyte studies were done regularly during one 3-week cycle of chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) or CNOP (doxorubicin substituted by mitoxantrone). RESULTS: Patients receiving G-CSF showed a faster restitution of granulocyte counts. Granulocyte CD11b expression following fMLP stimulation in vitro decreased during G-CSF therapy (P<0.005). A less pronounced (but not significant) reduction in CD16 expression was noted in the G-CSF-treated group. In contrast, fMLP-stimulated metabolic activation did not show consistent changes during the treatment cycle. Two episodes of infections during granulocytopenia that required hospitalisation were observed in each group. CONCLUSIONS: G-CSF treatment efficiently accelerated granulocyte recovery following chemotherapy. This probably compensates for the transient functional aberrations in circulating granulocytes observed in this patient group.