G. A. R. Young

Analysis of human leukaemias and lymphomas using extensive immunophenotypes from an antibody microarray

A novel antibody microarray has been developed that provides an extensive immunophenotype of leukaemia cells. The assay is a solid phase cell‐capture technique in which 82 antigens are studied simultaneously. This paper presents the analysis of 733 patients with a variety of leukaemias and lymphomas from peripheral blood and bone marrow. Discriminant Function Analysis of the expression profiles from these 733 patients and 63 normal subjects were clustered and showed high levels of consistency with diagnoses obtained using conventional clinical and laboratory criteria. The overall levels of consensus for classification using the microarray compared with established criteria were 93·9% (495/527 patients) for peripheral blood and 97·6% (201/206 patients) for bone marrow aspirates, showing that the extensive phenotype alone was frequently able to classify the disease when the leukaemic clone was the dominant cell population present. Immunophenotypes for neoplastic cells were distinguishable from normal cells when the leukaemic cell count was at least 5 × 109 cells/l in peripheral blood, or 20% of cells obtained from bone marrow aspirates. This technique may be a useful adjunct to flow cytometry and other methods when an extensive phenotype of the leukaemia cell is desired for clinical trials, research and prognostic factor analysis.

Intensified Induction Chemotherapy with High Dose Cytarabine and Etoposide for Acute Myeloid Leukemia: A Review and Updated Results of the Australian Leukemia Study Group

Induction therapy of acute myeloid leukemia (AML) with standard dose chemotherapy will result in approximately 55-75% of patients achieving a complete remission (CR). Intensification of induction treatment with etoposide and high dose cytarabine does not alter the CR rate but appears to significantly improve the subsequent outcome. Updated results of the comparison of high dose cytarabine with daunorubicin and etoposide in induction (HIDAC-3-7) versus a standard dose combination (7-3-7) demonstrated a highly significant increase in relapse free survival, (RFS) on the high dose arm (p = 0.007) with RFS of 48% at 5 years with HIDAC-3-7 and 25% on 7-3-7. The high dose arm had a more modest survival advantage at 5 years of 33% compared with 25% on standard treatment, possibly because of a higher initial death rate with HIDAC-3-7. The improvement seen in patients with CR after high dose induction appear to parallel results obtained with post-remission therapies intensified with high dose cytarabine. These studies provide clinical evidence that a dose-response effect is present for cytarabine in AML. Intensified treatment is more toxic, gives more profound myelosuppression post-remission and has been shown to benefit younger patients only. Issues of patient selection and the optimal placement of intensification in the treatment sequence require further study. In the future, it is likely that remission duration may be a useful clinical tool to study the influence of new induction therapies on residual resistant leukemia.

The prognostic significance of proliferative activity in poor histology non-Hodgkin's lymphoma: a flow cytometry study using archival material☆

The DNA content and proliferative activity of paraffin-embedded lymph node tissue from 111 patients with poor histology non-Hodgkins lymphoma were measured by flow cytometry. These patients had been entered into a prospective randomized trial which, to date, has shown no survival difference by treatment arm. Forty-four (40%) samples showed evidence of aneuploidy with three samples having more than one aneuploid population. The aneuploid populations had a bimodal distribution with one group having a DNA index between 1.1-1.3 and the other 1.8-2.2. The incidence of aneuploidy did not correlate with age, stage or survival. In 56 diploid samples the S phase values below 10% had a significantly better survival than those with S phase values above 10% (P less than 0.011). For patients with diffuse large cell histology the corresponding discriminatory S phase value was 19% (P less than 0.009).

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.

Significance of secondary cytogenetic changes in patients with Ph-positive chronic granulocytic leukemia in the acute phase

The karyotypic abnormalities in 29 patients in the acute phase of Ph-positive chronic granulocytic leukemia are described. Of 18 Giemsa banded samples, 11 showed one or more of the typical additional abnormalities found in the acute phase, namely +Ph, +8, or i(17q). Survival data from these patients was combined with three published series providing 135 patients and the effect of one, two, or three of these abnormalities tested. The prognosis was significantly worse in patients with two or more additional abnormalities, compared with those with one or none. Analysis of the subset of patients with only one additional abnormality [+Ph or +8 or i(17q)] suggested a worse prognosis in those with +8 than in those with +Ph or i(17q), although the differences were not significant. There also was a trend for patients in whom all metaphases showed abnormalities in addition to the Ph chromosome to have a worse prognosis than those in whom some or all metaphases contained the Ph only. However, this trend just failed to reach a 5% level of significance.

Malignant melanoma: analysis by DNA flow cytometry

&NA; The DNA content of 14 primary and 111 secondary melanomas was determined by flow cytometry. Aneuploidy was detected in 67% of samples. The frequency with which aneuploid cells were found was similar in primary and metastatic melanomas and, in the metastatic group, for melanotic and amelanotic tumours. Aneuploid diversity was marked with a wide variation in DNA content between tumours. Serial biopsies were performed in 14 patients, and in 10 there was discordance in DNA profiles between first and subsequent biopsies. Tumour biopsies taken from different sites at the same time also showed discordance in 3 of 5 cases. These features highlight the degree of cellular heterogeneity in malignant melanoma.

Patterns of failure with increasing intensification of induction chemotherapy for acute myeloid leukaemia

Patterns of failure were studied in two consecutive randomized trials of intensified induction therapy carried out by the Australian Leukaemia Study Group (ALSG) between 1984 and 1991 to determine the impact of dose intensification. Patients received standard dose cytarabine and daunorubicin (7‐3), 7‐3 plus etoposide (7‐3‐7) or 7‐3 plus high‐dose cytarabine (HIDAC‐3‐7) chemotherapy. Patients with FAB M3 morphology were excluded. Time to failure (TTF) was defined as the time from randomization to induction death or removal from study for non‐responders, or to relapse or death in complete response (CR) for complete responders. An estimated 86% of 470 de novo patients with acute myeloid leukaemia failed within 10 years of randomization, as a result of death in induction in 17% of the randomized patients, failure to achieve CR in a further 17%, relapse in 44% and death in CR in 8% of patients. An estimated 66% of patients failed as a result of refractory disease or relapse within that period (disease‐related failures). Multifactor analysis identified age and peripheral blast count as the most significant pretreatment factors associated with overall TTF. These factors, together with cytogenetics, were significantly associated with disease‐related failures. High‐dose cytarabine in induction significantly decreased the disease‐related failure rate as did allogeneic transplantation in first CR. The impact of high‐dose cytarabine did not depend on the cytogenetic risk group.

Ph1 negative haematological chimaerism after marrow transplantation in Ph1 positive chronic granulocytic leukaemia

A 17‐year‐old girl with Philadelphia chromosome (Ph1) positive chronic granulocytic leukaemia (CGL) who has undergone two bone marrow transplants from her HLA identical brother is described. Following the second transplant, cytogenetic analysis of her bone marrow cells showed haematological chimaerism with equal numbers of normal male cells and Ph1 negative female cells indicating the probable eradication of the Ph1 positive clones with the retention of normal host stem cells.

Plasma lactoferrin in patients with neutropenia

SummaryThis study examines the role of plasma lactoferrin in the assessment of neutropenia. In particular, we have studied lactoferrin as an inhibitor of granulopoiesis and as an indicator of the size of the total blood granulocyte pool (TBGP). Plasma lactoferrin concentration was determined in a heterogeneous group of 30 patients with neutropenia. Serial plasma lactoferrin levels in a patient with cyclic neutropenia correlated with the cycles of the neutrophil count. Patients with splenomegaly had a grossly elevated lactoferrin: neutrophil ratio. Most chronic idiopathic neutropenia patients had no real clinical problems and a normal plasma lactoferrin level. The results provide further evidence to support the concept that plasma lactoferrin indicates the size of the TBGP and the lactoferrin: neutrophil ratio indicates the degree of granulocyte margination. There was no evidence to suggest that lactoferrin acting as a feedback inhibitor of granulopoiesis caused neutropenia in these patients.

The Influence of Induction Chemotherapy Dose and Dose Intensity on the Duration of Remission in Acute Myeloid Leukemia

The aim of this study was to assess the influence of dose and dose intensity (DI) of induction and consolidation chemotherapy on relapse rates in 264 de novo patients with acute nonlymphocytic leukemia (ANLL). Patients were randomised to receive cytosine arabinoside (ARAC) 100 mg/m2 continuous infusion for 7 days and daunorubicin (DNR) 50 mg/m2 IV day 1-3 (7-3) or the same drugs with the addition of etoposide 75 mg/m2 IV days 1-7 (7-3-7). Cox proportional hazards regression models were used throughout to identify prognostic factors, including dose delivery parameters, influencing the rate of relapse. Of 152 patients who achieved a complete remission (CR), 104 have relapsed with a median duration of CR of 15.8 months. Actual dose delivered was prospectively documented. Cox regression analysis identified the most significant prognostic factors jointly influencing duration of CR as performance status groups (p < 0.0001), percentage peripheral blasts (p = 0.0015), 7-3-7 arm (p = 0.0075), age < 40 years (p = 0.022) and induction dose ARA-C plus DNR (p = 0.029). In this analysis patients randomized to the 7-3-7 arm had an estimated 43% reduction in the relapse rate and each 10% reduction of doses ARA-C and DNR was associated with an estimated 45% increase in the relapse rate. The number of induction courses, delays in treatment and induction dose intensity did not significantly influence the duration of CR nor did any of the consolidation treatment parameters.(ABSTRACT TRUNCATED AT 250 WORDS)