Herbert F. Oettgen

E. coli L‐asparaginase in the treatment of leukemia and solid tumors in 131 children

One hundred thirty‐one children between 1 and 15 years of age have been treated. Ninety‐five children had acute lymphoblastic leukemia (ALL); 13 had other types of leukemia; 8 had lymphoma; and 15 had other solid tumors. The dosage ranged from 10 to 5,000 IU/kg daily. Treatment schedules included maintenance after remission and no maintenance. Nine patients in bone marrow remission with other chemotherapy prior to treatment with A‐ase received a 28‐day course. Six patients received the enzyme intrathecally for meningeal leukemia. Of the 73 adequately treated (over 14 days) ALL patients, the overall remission rate was 62%; the median duration of remission was 60 days with a range of 15 to 248 days. The duration of remission appeared to be independent of dose. Six nonlymphoblastic leukemias demonstrated transient fall in WBC and decreased organ size but no bone marrow remission. One of 4 with Hodgkins disease demonstrated decrease in size of nodes, liver, and spleen. None of the solid tumors responded. The usual side effects of conventional chemotherapeutic agents, mucous membrane ulcerations, alopecia, and diarrhea were not seen. Side effects included reversible abnormal biochemical liver function tests, fever, and anaphylaxis.

Clinical results of treatment with E. coli L‐asparaginase in adults with leukemia, lymphoma, and solid tumors

E. coli L‐asparaginase (A‐ase) was administered to 163 adults with different forms of leukemia, lymphoma, and solid tumors. Six of 11 patients with acute lymphoblastic leukemia and 4 of 32 patients with acute myeloblastic, myelomonoblastic, or undifferentiated leukemia had complete or good partial remissions. Doses of 10 to 5000 IU/kg/day were used, but there was no clear correlation between dose and therapeutic response, nor with any particular preparation of A‐ase. Some of the others had transient physical and/or hematologic improvement, but remission was not achieved. Nineteen patients with myeloblastic leukemia, 4 with lymphoblastic and 3 with undifferentiated, had no response. Eight patients with acute leukemia (7 lymphoblastic and one myeloblastic), who were already in complete remission induced with other agents, were treated with 1000 IU/kg/day or higher doses of A‐ase for one month or longer. Seven were given no further therapy. The disease relapsed within 2‐5 months in 6 patients, but one is still in remission after 8 months. The eighth patient is still in remission after 3 months but is receiving other chemotherapy. Partial hematologic responses occurred in one patient with untreated chronic granulocytic leukemia, in 4 of 5 patients in a blastic phase of chronic granulocytic leukemia, and in 2 of 3 patients with chronic lymphocytic leukemia, but in none of these patients was the response of substantial clinical benefit. Two patients with disseminated lymphosarcoma or reticulum cell sarcoma had excellent therapeutic responses to A‐ase, and 4 others showed some improvement while 14 had no detectable response. Eight patients with advanced Hodgkins disease showed no response. One patient with malignant melanoma with multiple cutaneous metastases had temporary regression of his metastatic nodules with A‐ase on several occasions, but evaluation of this case was complicated by other chemotherapy. Twenty‐nine other patients with melanoma had no response nor did 45 patients with other types of solid tumors. Some toxic manifestations of A‐ase occurred in almost all patients; these were generally more severe and sometimes were intolerable at higher dosage levels. The toxicity will be discussed in detail in an accompanying report.

L‐asparaginase activity in plasma and other biological fluids

An automated method has been developed for the assay of L‐asparaginase activity in plasma and other biological fluids. By means of this method, L‐asparaginase activity has been determined in plasma, cerebrospinal fluid, and urine in patients receiving E. coli L‐asparaginase (EC‐2) therapy. The height of the plasma activity was related to the dosage. In some patients, the plasma enzyme activity fell despite continued administration of L‐asparaginase. The disappearance of the E. coli L‐asparaginase from the plasma was related to the commercial source of the enzyme. From one source the half‐life in adults was 11.2 ± 2.7 hours and from another, 22.6 ± 4.7 hours. Intramuscular administration of enzyme resulted in plasma levels that were about half those observed following intravenous administration of enzyme. Following intravenous administration of L‐asparaginase at doses up to 5000 IU/kg/day, no activity was found in urine. At the highest dosage levels, small amounts of activity were observed in cerebrospinal fluid. When enzyme was injected directly into the cerebrospinal fluid, there was a rapid transfer of enzyme to the plasma, and the activity in the spinal fluid was reduced to negligible amounts within 24 hours.

Hemmung maligner Neoplasien des Menschen durch L-Asparaginase

Zusammenfassung88 Kranke mit malignen Neoplasien wurden mit dem ausE. coli hergestellten Enzym L-Asparaginase behandelt. Das therapeutische Ergebnis konnte bei 60 Kranken ausgewertet werden. Bei 20 von 33 Kranken mit akuter Lymphoblastenleukämie, bei 1 Kranken mit Lymphosarkom in leukämischer Phase und bei 1 von 5 Kranken mit akuter Myeloblasten- oder Myelomonocytenleukämie wurde eine Knochenmarksremission erzielt. Die Remissionsdauer betrug 1–8 Monate. Von 21 Kranken mit malignen Lymphomen, Sarkomen und Carcinomen sprach nur 1 Patient mit malignem Melanom auf die Behandlung mit Asparaginase an. Die Enzympräparation bewirkte in der bisher angewandten Dosis keine Knochenmarkshemmung. Reversible Nebenwirkungen waren gekennzeichnet durch Fieber, Gewichtsverlust, abnorme Leberfunktionsproben, Hypoalbuminämie, Hypofibrinogenämie, Hypolipidämie, Hyperlipidämie und Überempfindlichkeitsreaktionen gegenüber der Enzympräparation. Die Asparaginabhängigkeit der neoplastischen Zellen ließ sich auchin vitro nachweisen. Dieser Test erlaubt jedoch noch keine absolut sichere Vorhersage des Behandlungsergebnisses. Wenn sich während der Behandlung einer primär asparaginase-empfindlichen Leukämie Resistenz entwickelte, waren die Leukämiezellen auchin vitro nicht mehr asparaginabhängig.SummaryEighty-eight patients with malignant diseases were treated with L-asparaginase prepared fromE. coli. The therapeutic result could be evaluated in 60 patients. A bone marrow remission was obtained in 20 of 33 patients with acute lymphoblastic leukemia, in one patient with lymphosarcoma in leukemic phase, and in one of five patients with acute myelo- or myelo-monoblastic leukemia. The remissions lasted from 1 to 8 months. Of 21 patients with malignant lymphomas, sarcomas or carcinomas only one patient with malignant melanoma responded to treatment with asparaginase. The enzyme preparation, at the dose levels used, did not cause bone marrow depression. Reversible side effects were fever, weight loss, abnormal liver function tests, hypoalbuminemia, hypofibrinogenemia, hypolipidemia, hyperlipidemia, and hypersensitivity reactions. The dependence on L-asparaginase of the neoplastic cells could also be demonstratedin vitro. This test, however, does not yet make possible an absolutely safe prediction of the therapeutic result. When resistance developed during the treatment of a primarily asparaginase-sensitive leukemia, the leukemia cells no longer required asparaginein vitro.

Cyclic chemotherapy in lymphoma.

This study evaluates the cyclic use of a combination of four drugs—cyclophosphamide, vincristine, procarbazine, and prednisone in 12 patients with generalized lymphosarcoma (LSA) and 11 patients with reticulum cell sarcoma (RCS). Seven patients with LSA achieved a category I response, and of these, 4 are clinically free of disease. In the RCS group, only one achieved a category I response. Myelosuppression was severe in 4 patients (17%) and may have contributed to their deaths from infectious complication. A high incidence of extranodal involvement in this group of patients appeared to correlate with the low incidence of useful therapeutic responses.

Clinical experience with L-asparaginase.

Inhibition of acute leukemia in man by L-asparaginase was first reported in 1967 [7, 10]. As larger enzyme supplies became available, clinical trials have been conducted by several groups of investigators, and the therapeutic activity as well as toxic effects have been evaluated in patients with many types of neoplastic disease [1–8, 10–17]. This report is an account of the experience gained over a period of 2½ years at the Memorial Hospital in New York.

Die Erythrokinetik bei Osteomyelofibrose

ZusammenfassungBei 20 Patienten mit Osteomyelofibrose wurden Erythrocytenbildung und Erythrocytenzerstörung mit Hilfe von Cr51 und Fe59 z. T. nach simultaner Verabreichung dieser Isotope untersucht. Die Erythrocytenlebensdauer war oft verkürzt, jedoch meist nicht hochgradig. Nur bei wenigen Kranken war eine aktive Beteiligung der Milz an der vorzeitigen Zerstörung der Erythrocyten nachweisbar. Das Plasmaeisenturnover war fast stets erhöht, die Eiseninkorporation in die Erythrocyten vermindert. Eine extramedulläre Erythropoese war meist, aber nicht ausnahmslos, durch Oberflächenmessung nachzuweisen. Sie fand überwiegend in der Milz statt, doch war die Leber in zwei Fällen der wichtigste Ort der Erythrocytenbildung. Eine Produktion von Erythrocyten im Knochenmark war bei der Hälfte der entsprechend untersuchten Fälle noch in geringem Maße vorhanden. Die komplexe Korrelation dieser Befunde mit den hämatologischen Daten wurde besprochen und die Indikation zur Splenektomie erörtert.SummaryProduction and destruction of erythrocytes were investigated in 20 patients suffering from myelofibrosis. Cr51 and Fe59 were administered simultaneously. The erythrocyte life span was shortened frequently, but only moderately in most instances. In few patients only the spleen played an active part in the accelerated red cell destruction. The plasma iron turnover was increased in most cases, the incorporation of iron into the erythrocytes was decreased. Extramedullary erythropoiesis was demonstrated by means of surface activity measurements in most but not in all patients. It was localised most frequently in the spleen. In two cases, however, the liver was the most important site of erythrocyte production. Some degree of medullary erythropoiesis was seen in 50 percent of our cases. The correlation between these results and the remaining hematological findings as well as the question of when to remove the spleen are discussed.

L-Asparaginase: Ein neues Prinzip in der Chemotherapie maligner Neoplasien

In den letzten zwanzig Jahren sind erhebliche Anstrengungen gemacht worden, Substanzen zu finden, welche Krebszellen zerst6ren. Als Ergebnis dieser Bemfihungen ist eine Reihe yon Medikamenten entwickelt worden, mit deren Hilfe das Leben mancher Patienten entweder verl~ingert oder ertrfiglicher gemacht werden kann. Leider schiidigen jedoch alle bisher angewandten chemotherapeutischen SubStanzen mit antineoplastischer Wirksamkeit auch die Zellen normaler Gewebe, insbesondere die des Knochenmarks und des Darmepithels. Ihr praktischer Nutzen wird dutch diese toxische Wirkung stark eingeschr~inkt. Das Fehlen yon Mitteln, die nur Krebszellen angreifen und normale Zellen unbehelligt lassen, lag darin begrfindet, dab ein ffir Krebszellen spezifischer Des im Zellstoffwechsel, der chemotherapeutisch angreifbar gewesen wiire, bisher nicht bekannt war. Im Verlauf yon Versuchen, die bereits vor ffinfzehn Jahren begannen, ist nunmehr eine solche Eigentfimlichkeit im Stoffwechsel gewisser Krebszellen aufgedeckt worden, n/imlich ihre Abh~ingigkeit yon der Zufuhr der ffir normale Zellen nicht essentiellen Aminositure L-Asparagin. Darfiber hinaus hat sich gezeigt, dab dieser abnorme Asparaginbedarf therapeutisch nutzbar ist, wenn man das im Blut zirkulierende Asparagin durch Verabreichung des Enzyms I,-Asparaginase zerst6rt. Im Jahre 1953 berichtete Kidd [21] erstmals fiber immunologische Experimente, in denen er die Wirkung yon Kaninchen-Antiseren auf transplantierte Leuk/imien der Maus untersuchte. Die mit dem Antiserum behandelten Miiuse erhielten auBerdem Meerschweinchenserum in der Vorstellung, dab dessen Gehalt an Komplement die erhoffte antileukiimische Wirkung des Immunserums steigern wfirde. Zu Kidds groger t2berraschung war jedoch eine Leukfimiehemmung auch bei denjenigen Kontrollm/iusen deutlich, die nur mit Meerschweinchenserum behandelt worden waren. Kidd wies dann weiter nacb, dab 1. das Serum von Kaninchen, Pferd und Mensch keine antileukiimische Wirkung besitzt, 2. das Meerschweinchenserum wohl die Leukiimiezellen scMdigt, ffir normale Gewebe aber offenbar nicht toxisch ist, und 3. das Meerschweinchenserum bei einigen Leukfimien der Maus wirksam war, wiihrend andere unbeeinfluBt blieben. Da es sich bei den letzteren vor allem um solche jiingeren Ursprungs handelte, entstand der Eindruck, dab Trans-

Regionale Chemotherapie maligner Tumoren

ZusammenfassungTherapeutische und toxische Wirkung von Amethopterin und 5-Fluor-2′-desoxyuridin, verabreicht als intraarterielle Dauerinfusion, wurden bei 48 Kranken mit inoperablen bösartigen Geschwülsten der Ober- und Unterkieferregion, der Mundhöhle, der Zunge, des Nasopharynx und der Cervix untersucht. Zeichen von Toxicität an normalen Geweben sprachen dafür, daß im infundierten Gebiet eine zumindest geringgradig höhere Gewebskonzentration vorlag als im übrigen Organismus. Eine eindrucksvolle partielle Regression, insbesondere von Plattenepithelcarcinomen, wurde in mehreren Fällen beobachtet. Technische Schwierigkeiten mit den intraarteriellen Dauerkathetern werden erörtert.SummaryTherapeutic and toxic effects of Amethopterin and of 5-fluoro-2′-deoxyuridine, administered as continuous intraarterial infusion, were investigated in 48 patients with inoperable cancer of the maxillary and mandibular region, the oral mucosa, the tongue, the postnasal space and the cervix. Toxic effects on normal tissues indicated that the drug concentration in the area of infusion was at least slightly higher than in adjacent areas supplied by different arteries. Partial tumor regression, particularly of squamous carcinomas, was observed in several cases. Technical problems related to the arterial catheters are discussed.