Jw Smit

Autologous stem cell transplantation in multiple myeloma after VAD and EDAP courses : a high incidence of oligoclonal serum Igs post transplantation

Thirty-seven patients with multiple myeloma (stage II and III, 65% increased β2-microglobulin level) were prospectively treated with a median of 3.7 VAD courses (range 2–8) followed by cyclophosphamide (6 g/m2) in conjunction with G-CSF (5 μg/kg filgrastrim (n = 14), or 3.5 μg/kg lenograstrim (n = 22)), and peripheral stem cell (PSC) isolation. After regeneration this was followed by one EDAP course and high-dose melphalan (HDM, 200 mg/m2) in combination with re-infusion of PSC. Adequate stem cell mobilization was obtained with both G-CSF regimens. A median of 41 × 106 CD34+ cells/kg (range 4.5–161) was collected in a median of 1.6 leukapheresis procedures following filgrastrim (n = 14) and 24 × 106 CD34+ cells/kg (range 2.3–80) in a median of 1.7 leukapheresis procedures following lenograstrim (n = 22) which indicated no significant difference (P = 0.24) between both G-CSF regimens. A rapid hematological recovery was obtained after HDM with reinfusion of a median of 9.3 × 106 CD34+ cells/kg. After the total courses the overall response was 84% with a complete remission rate of 30%. Currently the median overall survival is 44.0 months (95% CI 38.9–49.1) with a median follow-up of 33 months (range 3–51) and a median event-free survival of 29.0 months (95% CI 25.3–32.7) (n = 33). Post transplantation a high incidence of oligloclonal serum immunoglobulins (Igs) was observed. In 73% of the patients new oligoclonal or monoclonal serum bands were noticed 3 months post transplantation. IgG-λ and IgG-κ bands predominated. In 48% of the cases the oligoclonal Igs disappeared after a median follow-up of 22 months (range 8–36), whereas in 52% of the cases the oligoclonal Igs persisted with a median follow-up of 31 months (range 21–45), which did not correlate with a significant difference in overall, and event-free survival between both subgroups. Bone Marrow Transplantation (2000) 25 , 723–728.

Successful chemotherapy with deoxycoformycin in adult T-cell lymphoma-leukaemia

A patient from the Caribbean area with active T‐cell lymphoma‐leukaemia was primarily treated with deoxycoformycin (DCF), 5 mg/m2 i.v. on 3 consecutive days, followed by 5 mg/m2 i.v. weekly. A complete remission was attained and maintained during several weeks with DCF. A single consolidation course with other cytostatics was then given. The patient continues in complete remission without further therapy, 24 months after diagnosis, 17 months after the last cytostatic drugs. T‐cell lymphoma‐leukaemia has a bad prognosis with conventional anti‐lymphoma therapy but was exquisitely sensitive to DCF in this patient.

The effect of cyclosporine on haematological parameters in patients with paroxysmal nocturnal haemoglobinuria

Four patients with paroxysmal nocturnal haemoglobinuria (PNH) were treated with cyclosporine. The treatment with cyclosporine was based on the hypothesis that immune-mediated bone-marrow damage is the common pathogenetic mechanism of aplasia and PNH, with lack of GPI-linked ligands for an immune attack (i.e. LFA-3, CD58) rendering PNH cells a growth advantage over other bone marrow cells. In the first patient, presenting with a mixed AA/PNH syndrome, a gradual recovery from aplasia was seen after prolonged treatment with cyclosporine. In a second patient, with a mixed AA/PNH syndrome, no haematological improvement was noted during cyclosporine administration, but this patient became transfusion-independent with increasing neutrophil and platelet counts after a course of ATG in combination with androgen therapy. Both these patients showed an increment in the proportion of neutrophils with normal expression of GPI-linked proteins concurrently with the improvement of haematological characteristics. In the two other patients, presenting with typical PNH, cyclosporine treatment did not result in any change in haematological characteristics, nor in PNH parameters. No significant change in haemolytic parameters was seen in any of the patients. It is concluded that immunosuppressive therapy may be of benefit in patients with a mixed AA/PNH syndrome. This effect became apparent after prolonged treatment with cyclosporine in one patient, and after a subsequent course of ATG with concomitant androgen therapy in another.

Improved outcome of adult acute lymphoblastic leukaemia by moderately intensified chemotherapy which includes a 'pre-induction' course for rapid tumour reduction: preliminary results on 66 patients

Sixty‐six consecutive adult patients with acute lymphoblastic leukaemia (ALL) were treated with intensified chemotherapy which included a ‘pre‐induction’ course of cytarabine (AraC) and etoposide (VP16) when the white blood cell count (WBC) was ≥30 × 109/l (18 patients), and maintenance chemotherapy with regular intensifications for a total treatment duration of 3 years. Patients with a mediastinal mass (17) received consolidation courses with intermediate‐dose AraC and VP16 followed by mediastinal irradiation. 11 patients underwent allogeneic bone marrow transplantation in first complete remission (CR). 58 patients (87.9%, CI 77.5–94.6) attained CR; with a median follow‐up of 7 years, 35 of them (60.3%, CI 46.6–73.0) remain in CR. Toxicity was mild, although three patients died during remission induction, including two who were over 70 years of age. 23 patients (39.7%, CI 27.1–53.4) relapsed, seven of them primarily in the central nervous system (CNS), necessitating intensification of CNS‐directed therapy. Only one of 13 patients with WBC 30–100 × 109/l, but eight of nine with WBC >100 × 109/l, relapsed. The survival of older patients in CR did not differ from younger patients. The outcome of ALL in adult patients could thus be improved by slight intensification of treatment whilst keeping the toxicity within acceptable limits. ‘Pre‐induction’ with AraC and VP16 might improve the prognosis, especially in patients with WBC <100 × 109/l. Patients with WBC >100 × 109/l, however, almost always relapse, and the intensified chemotherapy might not be tolerated well by patients over 70 years of age.

Correction of neutropenia by GM-CSF in patients with a large granular lymphocyte proliferation.

SummaryThe in vivo and in vitro effects of GM-CSF were tested in four patients with large granular lymphocyte proliferation (LGLP) and severe granulocytopenia. All patients had an increased percentage of LGL cells (> 20%), whereas 3/4 patients demonstrated rearranged T-cell-receptor genes. An effect on the peripheral granulocyte counts was noticed in 3/4 patients after 14 days of GM-CSF administration (5Μg/kg/day, subcutaneously); 2.5, 7, and 0.45×109/1, respectively. These changes were associated with a two- to five-fold increase in monocytes and a strong increment in eosinophils. In one patient GM-CSF was not effective in increasing the granulocyte count. B lymphocytes showed a variable increase, ranging from 1.2-fold to 3.8-fold, while the number of NK cells remained almost constant during the GM-CSF treatment. No consistent effect of GM-CSF on T lymphocytes was observed. These data suggest that GM-CSF may be a therapeutic option in some patients with LGLP complicated by granulocytopenia and/or infection.

INTERLEUKIN-4 SUPPRESSES THE INTERLEUKIN-3 DEPENDENT ERYTHROID COLONY FORMATION FROM NORMAL HUMAN BONE-MARROW CELLS

Human recombinant interleukin 4 (IL‐4) was studied for its effects on the erythroid burst forming unit (BFU‐E) from human bone marrow cells. IL‐4 alone neither supports nor suppresses the erythropoietin (Epo)‐dependent colony formation. Different results were obtained when IL‐4 was combined with interleukin‐3 (IL‐3) in the presence of Epo. IL‐4 suppressed the IL‐3 supported erythroid colony formation in all cases (an increase of 58 ± 8% with IL‐3 versus an increase of 14 ± 7% with IL‐3 plus IL‐4, n= 8). This antagonizing effect was dependent on the continuous presence of IL‐4 in the culture medium, but was independent of adherent cells. B‐, T‐cells, or the presence of serum in the culture medium. Finally, the effects of IL‐4 and IL‐3 were studied on the ‘Epo‐independent’BFU‐E by adding Epo on day 3. A decline of the IL‐3 supported BFU‐E was observed in the presence of IL‐4 but the degree of reduction was equivalent to the results obtained when Epo was supplied at day 0. These findings indicate that IL‐4 acts as suppressive growth factor for the IL‐3 supported erythroid colony formation from human bone marrow cells.

K-CELL LYMPHOCYTOSIS NEUTROPENIA SYNDROME - THE NEUTROPENIA IS NOT CAUSED BY AUTOIMMUNITY

Summary. The role of humoral immune mechanisms in the pathogenesis of the neutropenia in five patients with chronic killer (K)‐cell lymphocytosis was studied. For the detection of neutrophil antibodies in the patients biood, immunofluorescence, cytotoxicity and agglutination tests and a sensitive antibody‐dependent cellular cytotoxicity (ADCC) assay were applied. An assay for bone‐marrow colony growth (CFU‐GM, BFU‐E) inhibition was applied as well. A Clq‐binding test was used to detect immune complexes. The lymphocytes of all five patients had the capacity to lyse alloantibody sensitized neutrophils. Neutrophil‐bound IgG was found only in one patient. Two patients had neutrophil‐reactive antibodies in their serum; in one patient these antibodies were only detectable in the ADCC using the patients serum to sensitize target cells. However, these antibodies reacted also with lymphocytes, were absorbable with platelets and thus probably were HLA antibodies. The serum of one of these two patients showed complement‐dependent CFU‐GM and BFU‐E inhibition, but the observed inhibition was probably also due to the anti‐HLA antibodies present in his serum, as the inhibiting effect disappeared after absorption of the serum with platelets. The serum of only one patient contained low amounts of immune complexes, as measured in the Clq‐binding test. Our data suggest that humoral autoimmune mechanisms, such as autoantibodies against neutrophils or neutrophil precursors or circulating immune complexes, do not seem to play an important role in the K‐cell lymphocytosis/neutropenia

Lymphocytes with parallel tubular structures: Morphologically a distinctive subpopulation

SummaryPeripheral blood lymphocytes were fractionated in T, B and Null cell enriched subsets by means of sheep red blood cell rosette (ESRBC) sedimentation and nylon wool adherence. The ultrastructural features of these subpopulations were investigated.The T cell fraction in which the sheep erythrocytes were removed from the ESRBC rosette-forming cells (ESRBC-RFC) by lysis with ammonium chloride, consisted mainly of two morphologically distinctive subsets. The majority of the cells (80%) displayed a smooth surface membrane and had a high nuclear to cytoplasmic ratio with few cytoplasmic organelles. The other cell type (18%) had a relatively rough surface membrane, a low nuclear to cytoplasmic ratio, often an indented nucleus and numerous cytoplasmic organelles such as characteristic amorphous granules and sometimes parallel tubular structures (p.t.s.). If the T cells were obtained after mechanical vibration of the ESRBC-RFC, the majority of these cells appeared morphologically identical to this latter cell type.Cells with p.t.s. and amorphous granules were also demonstrated within the Null and B cell enriched fractions (50% and 25% repectively), though in the B cell enriched fraction this cell type is probably due to a contamination of Null cells.Previous observations had already demonstrated that these cells in the three fractions represent the Fcγ receptor-bearing lymphocytes.The similarities suggest that the Fcγ receptor-bearing and p.t.s. containing lymphocytes form a morphologically distinct subpopulation.

In vitro evaluation of a high-efficiency leukocyte adherence filter

SummaryIn view of the currently available data, prevention of alloimmunization requires filters with higher efficiency to achieve a reduction in the number of leukocytes below 10 million per transfusion. Two versions (Pall PL-100 and PL-50) of the new generation leukocyte-depletion filters were studied. Single donor (SDPC)- and pooled multiple donor (MDPC) platelets were run in parallel.At a flow rate of 10 ml/min, the PL-100 filter was shown to effectively reduce the number of residual leukocytes to far below the critical immunogenic threshold of 10 million in all SDPC units and in 77% of MDPC units. Apheresis platelets appear not only to be better depleted than pooled multiple donor platelets, but also to have a better post-filtration platelet recovery (96% versus 84%).The efficiency of the smaller version of the filter (Pall-50) was higher than that of the Pall-100 filter for both single and pooled multiple donor platelet concentrates (PC). Leukocytes were absent in more than 92% of units in both types of concentrates. The maximal number of detected leukocytes was 2.2 million in a pool of 6 units. The outcome of filtration of 5-day-old pooled platelets was less favorable than filtration of 1- or 2-day-old pooled platelets, indicating that filtration soon after preparation is preferred to filtration after storage. Post-filtration platelet integrity, activation state, function, and morphology were all well preserved in both single and multiple PCs.

Parallel Tubular Structures in T, B and Null Lymphocyte Subpopulations

T, B and Null lymphocyte-enriched subpopulations were isolated by means of sheep red blood cell (E SRBC) sedimentation and nylon wool adherence. In these subsets the proportion of Fc receptor-bearing cells was determined by the antibody-coated human and ox erythrocyte rosette assays (EA Hu and Ox). In the T-cell fraction the proportion of Fc-bearing lymphocytes was dependent on the procedure by which the sheep erythrocytes were removed from the E SRBC rosette-forming cells. Mechanical vibration resulted in considerably higher percentages of EA rosette-forming cells (EA-RFC) than osmotic shock or lysis with ammonium chloride. In all three procedures the number of EA Hu-RFC was slightly higher than the number of EA Ox-RFC. In the B-cell fraction the proportion of EA Ox-RFC was higher than that of EA Hu-RFC, mean values 43 and 33%, respectively. In the Null cell fraction the reversed was seen: mean values 54% EA Hu-RFC and 45% EA Ox-RFC. In all three lymphocyte fractions the majority of the EA-RFC contained parallel tubular structures and/or associated amorphous granules. Non-Fc receptor-bearing lymphocytes only occasionally showed parallel tubular structures or the amorphous granules.