Autologous bone marrow transplantation in acute myeloid leukemia in first remission: results of a Dutch prospective study.

Recent investigations have suggested a role for marrow ablative chemotherapy and radiotherapy given with autologous bone marrow transplantation (auto-BMT) in the treatment of acute myeloid leukemia (AML), but prospective studies have not been reported. We assessed the comparative values of auto-BMT and allogeneic marrow transplantation (allo-BMT) in 117 15- to 60-year-old consecutive patients (median, 43 years) with AML following remission-induction therapy. In 32 cases of the 90 (77%) complete responders, auto-BMT (nonpurged) was undertaken at a median of 3.8 months and in 23 eligible cases human leukocyte antigen (HLA)-matched allo-BMT occurred at 3.0 months after attainment of remission. Thus, nearly 60% of complete responders had access to transplantation, the others being withdrawn because of relapse, refusal, or other causes. Median time of regeneration to neutrophils 0.5 x 10(9)/L and platelets 20 x 10(9)/L were 39 and 63 days following auto-BMT versus 21 and 19 days after allo-BMT, respectively. AML relapse was the predominant cause of failure after auto-BMT (17 of 32) and procedure-related death was seen in three of 32 patients. The actuarial rates of relapse at 3 years are 60% (auto-BMT) and 34% (allo-BMT) (log-rank, P = .03). Patients treated with auto-BMT and allo-BMT have an overall survival of 37% and 66% at 3 years posttransplant, respectively (P = .05). Relapse-free 3-year survival rates are 35% and 51%, respectively (P = .12). Survival of the nongrafted complete responders is less than 10%. This study shows that allo-BMT in adult patients with AML in first complete remission (CR) results in more rapid hematopoietic reconstitution, is followed by fewer recurrences, and provides better survival than auto-BMT.

A population-based case-cohort study of drug-associated agranulocytosis.

BACKGROUND: Agranulocytosis is a life-threatening disorder, often caused by drugs. Incidences or risks of drug-induced agranulocytosis are not well known, since it is rare. METHODS: To determine the risk of drug-associated agranulocytosis as a reason for admission to Dutch hospitals, we performed a population-based case-cohort study. Hospital discharge data came from the Dutch Centre for Health Care Information, Utrecht, which contains data on all general and university hospitals in the Netherlands. The reference cohort consisted of all persons in the catchment area of the Pharmaco Morbidity Record Linkage System (PHARMO RLS) in the Netherlands, composing a population of approximately 220 000 to 484 000 persons from 1987 through 1990. All admissions during that period with agranulocytosis or related diagnoses were included in the study (n = 923). The potential causes of agranulocytosis were assessed in all cases classified as probable or possible agranulocytosis. RESULTS: Discharge summaries were received of 753 admissions, of which 678 contained enough information for analysis. Of the 678,108 were classified as "agranulocytosis probable" or as "agranulocytosis possible." In 75 of these 108 cases, agranulocytosis had been the reason for admission. Fifteen patients had used methimazole within 10 days before developing agranulocytosis; 2, carbimazole; 9, sulfasalazine; 8, sulfamethoxazole-trimethoprim; 4, clomipramine hydrochloride; and 2, dipyrone with analgesics, yielding adjusted relative risks of agranulocytosis of 114.8 (for thyroid inhibitors combined) (95% confidence interval [CI], 60.5-218.6), 74.6 (95% CI, 36.3-167.8), 25.1 (95% CI, 11.2-55.0),20.0 (95% CI, 6.1-57.6), and 26.4 (95% CI, 4.4-11.1), respectively. CONCLUSIONS: The highest relative risks were found for thyroid inhibitors, sulfamethoxazole-trimethoprim, sulfasalazine, clomipramine, and dipyrone combined with analgesics.

The problem of toxicity in the bioassay for erythropoietin using mouse fetal liver cells.

The use of neonatal instead of fetal calf serum, as a constituent of the culture medium, confronted the authors with the problem of toxicity in the fetal liver cell erythropoietin assay. Tested human sera were toxic at rather low concentrations. Heating the human sera for 30 min at 56 degrees C abolished the toxicity. Heating the Step I or Step III sheep plasma erythropoietin had very little influence. Fetal calf serum proved to be more suitable than neonatal calf serum for two reasons: The toxicity of human sera was less pronounced when fetal calf serum was used in the medium, and it gave a wider separation of unstimulated and maximally stimulated cultures.

The nature of toxicity of human serum in the bioassay for erythropoietin using mouse foetal liver cells.

Using several immunological techniques, it was possible to demonstrate that toxicity of human serum in the foetal mouse liver cell bioassay for erythropoietin was due to complement-dependent IgM hetero antibodies to mouse foetal liver cells. The titre of the antibodies in 50 normal human sera ranged between 2 and 64 as measured in an agglutination test with mouse erythrocytes. Specificity of the antibodies for the ABO-or Ii-blood group system could not be established. Inactivation of complement by heating a serum for 30 minutes at 56 degrees C abolished toxicity.

Congenital dyserythropoietic anemia type III. studies on erythroid differentiation of blood erythroid progenitor cells (BFUE) in vitro.

In order to investigate whether the morphological abnormalities observed in congenital dyserythropoietic anemia type III (CDA III) have a cellular or an environmental origin; BFUE from the blood of a patient exhibiting a CDA type III were grown in vitro. The progeny derived from these BFUE were subsequently studied at light and electron microscopic level. Giant multinuclear erythroblasts which represent the most prominent finding of CDA III in bone marrow were also found in culture. Nuclear clefts found in vivo were also observed by electron microscopic studies performed on the erythroblasts growing in vitro. In each erythroid colony, morphologically normal and giant multinuclear erythroblasts were intermingled. This finding indicates that the two populations of erythroblasts derive from the same defective stem cell. The studies by indirect immunofluorescence of i antigen was preferentially expressed in the immature erythroblasts as in culture from normal subjects but not in the giant mature erythroblasts. This finding suggests that the excess of i antigen expression of CDA III in vivo is rather the indirect consequence of a stimulation of erythropoiesis than result of the disease.

Effectiveness of low dose cyclosporine in acquired aplastic anaemia with severe neutropenia.

Six patients with acquired aplastic anaemia were treated with cyclosporine (5 mg/kg/day) either alone or in combination with corticosteroids. A favourable response was observed in 4, including 2 patients presenting with an absolute granulocyte count of less than 0.2 x 10(9)/l. The 6th patient showed no effect after 6 wk of therapy and was thereafter successfully treated with anti-thymocyte globulin (ATG). Side effects of cyclosporine therapy were minimal (maximum follow-up 20 months). Temporary discontinuation of the drug in 1 patient resulted in a relapse which responded to reinstitution of therapy. Our results indicate that cyclosporine may be an effective, well-tolerated agent in acquired aplastic anaemia even in previously untreated patients with severe neutropenia.

[Long-term treatment of patients with transfusion hemosiderosis using oral iron chelator 1,2-dimethyl-3-hydroxypyrid-4-one (L1)]. / Langdurige behandeling van patiënten met transfusiehemosiderose met de orale ijzerchelator 1,2-dimethyl-3-hydroxypyrid-4-one (L1).

A new oral iron chelator, L1, was given for 14 to 16 months to four patients with transfusion haemosiderosis. These patients could no longer be treated with deferoxamine because of allergic reactions or psychological problems. Serum ferritin values at the start of the treatment ranged from 2220 to 4530 microgram/l. L1 was given in a total daily dose of 3 g, at first in a single dose, later 3 times 1 g daily. The 24-hour urinary excretion of iron varied greatly from day to day. The mean urinary iron excretion of the four patients ranged from 19.3 to 45.7 mg/day. In two patients an important decrease of ferritin was found. These patients had been given no more or only sporadic transfusions. In one patient transient agranulocytosis was seen which was probably not caused by L1.

[Primary treatment of acute promyelocytic leukemia using all-trans-retinoic acid]. / Primaire behandeling van acute promyelocytenleukemie met all-trans-retinoïnezuur.

We describe the medical history of a 68-year-old woman with acute promyelocytic leukaemia. As primary treatment she received all-trans retinoic acid. For the major part this treatment could be given on an outpatient basis. After 60 days there was a complete remission of the leukaemia with disappearance of the characteristic cytogenetic abnormality t(15;17)(q22;q21).

Some aspects of the biology of multinucleate and giant mononucleate erythroblasts in a patient with CDA, type III.

Marrow cells of a patient with CDA, type III, were (1) incubated with 3H-thymidine for 0.5 h and studied using a combination of Feulgen microspectrophotometry and light microscope autoradiography and (2) incubated with 3H-thymidine, 3H-uridine or 3H-leucine for 1 h and studied using the technique of electron microscope autoradiography. The data revealed multiple abnormalities in the proliferation of erythroblasts but no abnormality in the distribution of neutrophil promyelocytes and myelocytes in the different stages of interphase. Some mononucleate erythroblasts had DNA contents of 4-20c and the multinucleate erythroblasts had total DNA contents of 2-40c. In about 40% of the multinucleate erythroblasts, only some of the nuclei within the same cell incorporated 3H-thymidine and the electron microscope autoradiographic studies revealed that the nuclei which failed to synthesize DNA virtually always showed abnormalities in the electron-density of the heterochromatin or euchromatin or a Swiss-cheese appearance of the heterochromatin. Furthermore, in some multinucleate cells but not in others, the ultrastructurally abnormal nuclei showed a marked depression of RNA synthesis when compared with the normal-looking nuclei within the same cell. An occasional binucleate, multinucleate and giant mononucleate erythroblast showed ultrastructural changes suggestive of advanced degeneration and such cells, which showed a marked depression of RNA and protein synthesis, appeared to be phagocytosed by macrophages.

Clinical and laboratory features of sickle cell disease in The Netherlands.

Out of about 200 patients with sickle cell disease (SCD) in the Netherlands, 6% are non-negroid patients from Turkey. 83 were assessed clinico-haematologically regarding the type of SCD, ethnic origin, concurrent alpha-thalassaemia (alpha-thal), and type of sickle cell gene (beta S-chromosome). 54 patients had homozygous sickle cell (SS), 1 sickle cell haemoglobin D (SD) Punjab, 5 sickle cell beta o-thalassaemia (S beta o-thal), 5 sickle cell beta +-thalassaemia (S beta +-thal) and 18 sickle cell haemoglobin C (SC) disease. 14% of the 83 patients were from Turkey, the others were of West Indian and African origin, most (73%) of whom were from Surinam. The Netherlands may be the only country in the world where non-negroid SCD patients are present in such a proportion to negroid SCD patients. alpha-thal was detected in 16 patients and in 14 of their relatives with sickle cell trait. Four main types of beta S-chromosomes were identified: Benin, Central African Republic, Senegal and Saudi Arabia types. SS and S beta o-thal disease ran a more severe course than S beta +-thal and SC disease. No clinical difference was ascribable to ethnic origin, alpha-thal or HbF-level but in each ethnic group there were some patients with a remarkably mild course of SS disease, which was related to the type of beta S-chromosome. These were the Senegal and Saudi Arabia beta S-chromosomes. Proper differentiation between genotypes is of prognostic and therapeutic relevance, especially in SC disease as it is sometimes discovered too late.(ABSTRACT TRUNCATED AT 250 WORDS)

A specific in vitro bioassay for measuring erythropoietin levels in human serum and plasma.

The accurate measurement of biologically active erythropoietin (Ep) in human serum and plasma using present in vivo and in vitro bioassays is difficult because of the presence of both inhibitors and non-Ep stimulators of erythropoiesis. We have developed a simple procedure to quantitatively purify Ep from serum and plasma for subsequent testing in the phenylhydrazine-treated mouse spleen cell assay. The method involves absorption of Ep to an immobilized high-affinity anti-Ep monoclonal antibody and acid elution of the antibody-bound material. After neutralization, the eluted EP is then tested directly in the in vitro bioassay without interference by other serum proteins. By using magnetic beads as a solid support for the antibody, washing and elution steps can be performed rapidly and efficiently. Recoveries of Ep after this procedure show very little sample-to-sample variation and are consistently between 45% and 55%, which is close to the maximum binding expected for the anti-Ep antibody. Coupled with the 7.4-fold concentration that this procedure affords, there is an overall increase in sensitivity of three- to fourfold, which makes this assay suitable for accurately measuring Ep levels in patients with below-average titers. Results with this magnetic bead assay indicate that accurate and reproducible estimates for Ep levels in the serum and plasma from healthy donors as well as from patients with hematologic disorders can be obtained. Titers of biologically active Ep in the sera from a group of patients with either leukemia or lymphoma were found to be elevated, and the values correlated well with titers of immunoreactive Ep measured in the Ep radioimmunoassay. Because of its specificity and high sensitivity, the magnetic bead assay is a valuable alternative to immunoassays for the measurement of elevated, normal, and even subnormal Ep levels in human serum and plasma.