Bone morphogenic protein 6: a member of a novel class of prognostic factors expressed by normal and malignant plasma cells inhibiting proliferation and angiogenesis.

Pathogenesis of multiple myeloma is associated with an aberrant expression of pro-proliferative, pro-angiogenic and bone-metabolism-modifying factors by malignant plasma cells. Given the frequently long time span from diagnosis of early-stage plasma cell dyscrasias to overt myeloma and the mostly low proliferation rate of malignant plasma cells, we hypothesize these to similarly express a novel class of inhibitory factors of potential prognostic relevance. Bone morphogenic proteins (BMPs) represent possible candidates as they inhibit proliferation, stimulate bone formation and have an effect on the survival of cancer patients. We assessed the expression of BMPs and their receptors by Affymetrix DNA microarrays (n=779) including CD138-purified primary myeloma cell samples (n=635) of previously untreated patients. BMP6 is the only BMP expressed by malignant and normal plasma cells. Its expression is significantly lower in proliferating myeloma cells, myeloma cell lines or plasmablasts. BMP6 significantly inhibits the proliferation of myeloma cell lines, survival of primary myeloma cells and in vitro angiogenesis. A high BMP6 expression in primary myeloma cell samples delineates significantly superior overall survival for patients undergoing high-dose chemotherapy independent of conventional prognostic factors (International Staging System (ISS) stage, beta(2) microglobulin).

[Multiple myeloma. Diagnosis and therapy]. / Multiples Myelom. Diagnostik und Therapie.

Multiple myeloma is one of the 20 most frequent malignancies in Germany. Initial symptoms are usually non-specific. Assessment of bone marrow and laboratory data as well as imaging techniques are essential for diagnosis and prognostic evaluation. Data from molecular cytogenetics have led to a better understanding of the pathogenesis of multiple myeloma. Cytostatic therapy with alcylating agents and glucocorticoids prolongs the survival. High-dose therapy followed by transplantation of autologous hematopoietic stem cells improves prognosis for patients up to the age of 70. Currently, modifications of allogeneic hematopoietic stem cell transplantation, anti-angiogeneic and immunomodulatory drugs as well as proteasome inhibitors are evaluated in clinical trials. Supportive care has derived benefit from the introduction of new bisphosphonates.

[Predictive value of serum levels of basic fibroblast growth factor, vascular endothelial growth factor and matrix metalloproteinase-2 in advanced carcinomas of the head and neck]. / Prognostische Bedeutung von bFGF, VEGF und MMP-2 im Serum von Patienten mit fortgeschrittenen Kopf-Hals-Tumoren.

The objective of this trial was to analyse the predictive character of the angiogenic factors vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and matrix metalloproteinase-2 (MMP-2) in the sera of patients with advanced carcinomas of the head and neck treated by primary radiochemotherapy. From 1992 to 1995, 25 patients with UICC stage cancers and one patient with stage III disease were treated in the departments of otolaryngology and radio-oncology of the University of Heidelberg according to a protocol of accelerated concomitant boost radiochemotherapy with carboplatin. The serum levels of VEGF, bFGF and MMP-2 were measured by enzyme-linked radiosorbent assay and data were correlated with followup findings (median time of follow up: 60 months). Patients with serum levels above normal were detected for VEGF in 4 patients, MMP-2 in 7 patients and for bFGF in 13 patients. An increase in bFGF serum levels above the upper limit of normal controls was significantly associated with a shorter time of locoregional control (P=0.036). In a covariate analysis bFGF proved to be independent of other prognostic factors, such as age, site, total tumor volume and response to therapy. No prognostic relevance of VEGF and MMP2 serum levels could be determined. The present suggest that bFGF is an independent prognostic factor for tumor control in advanced head and neck cancer after primary radiochemotherapy.

Detection of clonally rearranged T-cell-receptor gamma chain genes from T-cell malignancies and acute inflammatory rheumatic disease using PCR amplification, PAGE, and automated analysis.

Clonal expansions of T cells carrying identical T-cell-receptor (TCR) genes are the hallmark of T-cell malignancies, but they can also result from a strong immune reaction to a dominant epitope. The basis for the molecular detection of clonal T cells is amplification of the V-(D)-N-J region of the TCR gene. We evaluated PCR amplification of the rearranged gamma TCR from genomic DNA extracted from peripheral blood and subsequent polyacrylamide gel electrophoresis (PAGE) in an automated DNA sequencer. We determined the sensitivity for the detection of clonal T cells and propose a standardized evaluation procedure for the electrophoretic profiles generated by the DNA sequencer. The sensitivity of our method was 0.6-1.25% of clonal T cells within a polyclonal background. Sixteen patients with T-cell malignancies, ten with acute inflammatory rheumatic diseases, and twelve healthy controls were examined. Among the systemic T-cell malignancies, all but one patient with T-PLL (8/ 9) revealed a clonal PCR signal. No clonal signal was detectable in any patient in clinical complete remission (5/5) or in either of the two patients with lymphomas limited to cutaneous sites. However, clonal T cells were detected in one patient with polymyalgia rheumatica and in one with reactive arthritis. A polyclonal signal was found in the remaining eight patients with acute inflammatory rheumatic diseases and in 12 healthy controls. Taking our results together, the PCR/PAGE assay is able to reliably distinguish clonal from polyclonal T-cell populations. However, although the sensitivity is limited to approximately 1%, clonal T cells can be found in the peripheral blood of some patients with autoimmune diseases and not only in T-cell malignancies.

Regulation of interleukin-8 mRNA expression and protein secretion in a melanoma cell line by tumour necrosis factor-alpha and interferon-gamma.

Interleukin-8 (IL-8) is a cytokine that is thought to promote melanoma tumour progression. We evaluated and adapted a non-radioactive, reverse transcriptase-polymerase chain reaction method for semiquantitative analysis of IL-8 mRNA expression. Using this technique we studied the regulation of IL-8 levels in the melanoma cell line Colo 38. Seeding of melanoma cells into culture dishes resulted in a significant increase of IL-8 expression, which could be attributed to adherence. A pronounced increase of IL-8 mRNA expression and protein production was induced by tumour necrosis factor-alpha (TNF alpha). Interferon-gamma (IFN gamma) partially inhibited TNF alpha-induced IL-8 secretion, whereas no influence on IL-8 mRNA levels was detected. The inhibitory affect of IFN gamma on melanoma cells is in contrast to its stimulatory effect on melanocytes.

T-cell receptor beta variable region diversity in melanoma metastases after interleukin 2-based immunotherapy.

Limited T-cell receptor (TCR) repertoire of tumor-infiltrating lymphocytes has been found in melanoma metastases and spontaneously regressing melanoma. Immunotherapy with INF-alpha/interleukin 2 can induce tumor regression in a proportion of patients with metastatic melanoma. We analyzed the gene expression of the TCR-beta variable (Vbeta) region of tumor-infiltrating lymphocytes from 16 melanoma metastases by subgroup-specific semiquantitative RNA PCR to investigate the influence of immunotherapy on the TCR pattern. In five progressing metastases before or after immunotherapy, no overexpression of Vbeta gene families was detectable, whereas in seven of seven metastases responding to IFN-alpha/interleukin 2 one to four Vbeta gene families were overexpressed. Preferential usage of certain Vbeta gene subgroups in patients sharing the same HLA class I molecules suggests a T-cell response to dominant public epitopes. Analysis of multiple specimens from the same patients gives evidence that this strong oligoclonal T-cell selection is induced or at least augmented by immunotherapy, supporting the functional relevance of this finding.

A polymerase chain reaction-based semiquantitative assessment of malignant melanoma cells in peripheral blood.

Malignant melanoma cells can be detected with high sensitivity in peripheral blood of patients using reverse transcription-PCR. The detection of tyrosinase mRNA that is actively expressed only in melanocytes and melanoma cells indicates the presence of melanoma cells in peripheral blood. As shown previously, tyrosinase transcripts can be found in a variety of patients with metastatic malignant melanoma. For semiquantitative analysis of these cells in peripheral blood and evaluation of possible influence of immunotherapy on the amount of circulating cells, we describe an assay combining reverse transcription-PCR and Southern blotting. In this system, the amount of circulating tumor cells was determined by interpolating the amplified tyrosinase signal strength of patient samples to an equivalent tyrosinase signal of diluted SK-mel 28 cells. We found that the amount of circulating tumor cells correlates with the tumor burden. Furthermore, in patients with regression of melanoma metastases after immunotherapy, a decrease of the amount of tumor cells in the peripheral blood was observed. Quantitative estimates of residual disease may be an accurate and sensitive predictor for the clinical course.

Addition of dacarbazine or cisplatin to interferon-alpha/interleukin-2 in metastatic melanoma: toxicity and immunological effects.

The combination of chemotherapy and immunotherapy seems to improve response rate in metastatic melanoma. We investigated the effects on toxicity and immunological effects of a single dose of dacarbacin (DTIC; 850 mg/m2) or cisplatin (CDDP; 100 mg/m2) added to subsequent immunotherapy with interferon-alpha (IFN-alpha) and interleukin-2 (IL-2). Twelve patients, who did not respond to IFN-alpha/IL-2 alone were studied. Six received DTIC and IFN-alpha/IL-2, and six received CDDP and IFN-alpha/IL-2. DTIC did not add significant toxicity except for nausea. Significant thrombocytopenia was observed in two patients after CDDP. Although CDDP led to grade 3 nephrotoxicity in two patients, the IL-2-induced fluid retention was less severe than with IFN-alpha/IL-2 alone. Pharmacokinetics of IL-2 were not altered by DTIC, but higher IL-2 serum levels were found in patients with grade 3 nephrotoxicity after CDDP. The IL-2-related induction of secondary mediators (interferon-gamma, tumour necrosis factor-alpha, soluble CD25) was not impaired by chemotherapy and the induction of neopterin was significantly higher after addition of CDDP. One partial response was observed after addition of DTIC to IFN-alpha/IL-2, and one after addition of CDDP. The addition of a single dose of DTIC or CDDP to IFN-alpha/IL-2 is fairly well tolerated and does not abolish induction of secondary mediators. Randomized trials are necessary to test the clinical efficacy.

Serum interleukin-8 (IL-8) is elevated in patients with metastatic melanoma and correlates with tumour load.

It was recently demonstrated that IL-8 is produced by melanoma cell lines and acts as an essential autocrine growth factor. We studied the constitutive production of IL-8 by melanoma cell lines and the serum concentrations in patients with metastatic melanoma. All of 10 melanoma cell lines investigated constitutively produced IL-8 (mean 315 +/- 58 pg/10(5) cells per 24 h. IL-8 was detectable (mean 159 +/- 13.1 pg/ml) in the serum of 21 out of 56 patients by an enzyme-linked immunosorbent assay (ELISA; detection limit < 100 pg/ml). There was a significant correlation with tumour load, whereas no correlation with metastatic sites was found. No increased IL-8 levels were seen in healthy controls or patients with metastatic renal cell carcinoma. These results suggest that IL-8 is constitutively produced by melanoma cells in vivo.

Restriction of T cell receptor V beta repertoire in melanoma metastasis responding to immunotherapy.

Restriction of the T cell receptor repertoire suggesting ongoing specific immune mechanisms has recently been described in melanoma tissue by several groups of investigators. The functional relevance for immunotherapy of melanoma, however, has not been established. We studied the T cell receptor repertoire in two melanoma metastases of a patient with a mixed response to immunotherapy. Expression of T cell receptor V beta regions was determined by subgroup-specific semiquantitative RNA polymerase chain reaction (PCR). In the regressing skin lesion a restricted expression of the T cell receptor repertoire and overexpression of three V beta subgroup genes was found; no restriction was present in the simultaneously progressing skin lesion of the same patient, compared with peripheral blood lymphocytes. Comparison of T cell receptor V beta gene expression in two metastatic lesions of a patient with simultaneously growing skin metastases, who did not receive immunotherapy, revealed only minor differences. These observations show for the first time an association between restricted T cell receptor repertoire and responsiveness of melanoma to immunotherapy and suggest a role of T cells using the overexpressed V beta genes for the cytokine-induced tumour regression.

Interleukin-2-based immunotherapy and chemoimmunotherapy in metastatic melanoma.

This report summarizes our experience in the treatment of advanced melanoma with immunotherapy and chemoimmunotherapy. A total of 45 patients initially received immunotherapy with interferon-alpha (IFN alpha) and a decrescendo regimen of high-dose interleukin-2 (IL-2). The objective response rate is 31% with an additional 36% of mixed response (MR) and stable disease (SD). A total of 18 patients failing immunotherapy with IFN-alpha/IL-2 received subsequent chemotherapy with dacarbacine (DTIC), followed by IFN-alpha. The response rate for this second-line regimen is 22%. A further 11 patients failing IFN-alpha/IL-2 received a single dose of DTIC or cisplatinum (CDDP) on day 1, followed by IFN-alpha/IL-2 according to the same protocol as previously, without chemotherapy. The addition of DTIC or CDDP was fairly well tolerated. Induction of secondary mediators was not inhibited, suggesting that the immunologic effects mediated by IL-2 are not impaired. A randomized clinical trial is now being performed to compare combined chemoimmunotherapy with immunotherapy alone.

Detection of residual tumor cells in patients with malignant melanoma responding to immunotherapy.

Recently, a highly sensitive assay combining reverse transcription and polymerase chain reaction (PCR) to assess for melanoma cells in peripheral blood has been developed. Detection of tyrosinase mRNA, a tissue-specific enzyme in melanocytes and melanoma cells, indicates the presence of melanoma cells in peripheral blood. We examined blood samples and bone marrow aspirates from 28 patients with metastatic malignant melanoma for presence of melanoma cells prior to and after therapy with interferon (IFN)-alpha and interleukin (IL)-2. Ten patients showed antitumor response to immunotherapy, including three complete (CR) and seven partial remissions (PR). Four patients (three PR, one stable disease) underwent subsequent resection of residual tumor lesions and had no clinical evidence of disease after surgery. Tyrosinase mRNA was detected in blood and bone marrow samples from all patients with malignant melanoma prior to and after immunotherapy, including those with no clinical evidence of disease (median disease-free survival 21 months, range 19-28 months). Tyrosinase transcripts were also detected in all patients with amelanotic melanoma. In contrast, no tyrosinase mRNA was detectable in any of 30 healthy persons or in six patients with other malignancies. The presence of residual melanoma cells may be an important indicator of occurrence of delayed relapse.

Hematogenous spread of malignant melanoma cells in different stages of disease.

Patients with malignant melanoma and distant metastases generally have an unfavorable prognosis, with a median survival of about 6 months. The mechanisms of hematogenous spread and implantation of melanoma cells are, however, poorly understood, because the standard diagnostic methods are not sensitive enough to detect oligocellular micrometastases. Recently a method using reverse transcription and polymerase chain reaction to determine tyrosinase mRNA in peripheral blood, which indicates the presence of circulating melanoma cells, has been developed. We utilized this assay to examine blood samples of 56 patients with malignant melanoma in different stages of disease. In one of 10 patients in stage I (localized disease) and in six of 17 patients with regional lymph nodes metastases (stage II) tyrosinase mRNA was detected. Tyrosinase transcripts were found in all 29 patients with distant metastases (stage III). Interestingly, tyrosinase mRNA was also detected in six patients with metastatic amelanotic malignant melanoma. In contrast, tyrosinase mRNA was not detectable in any of 39 healthy subjects or 17 patients with other malignancies. These findings may be helpful to define a patient group at high risk for systemic spread of disease.