Randomized comparison of 36-hour intermediate-dose versus 4-hour high-dose methotrexate infusions for remission induction in relapsed childhood acute lymphoblastic leukemia.

PURPOSE: Pharmacokinetics, toxicity, and therapeutic efficacy of two different methotrexate (MTX) infusions for remission induction of relapsed childhood acute lymphoblastic leukemia (ALL) were investigated in a randomized multicenter trial. PATIENTS AND METHODS: Sixty patients with early bone marrow relapse received a polychemotherapy induction protocol starting with either 12 g/m2 MTX as a 4-hour infusion (high-dose [HDM]) or 1 g/m2 as a 36-hour infusion (intermediate-dose [IDM]). In HDM, leucovorin (LCV) was administered orally (12 times, 15 mg/m2 every 6 hours), beginning at hour 24. In IDM, only two doses were administered at hours 48 and 54. RESULTS: Median serum MTX concentrations during infusion were 716 mumol/L in HDM and 7.2 mumol/L in IDM. In HDM, MTX serum levels at hour 24 (median, 2.8 mumol/L) were significantly less than steady-state levels of IDM. Concentrations greater than 1 mumol/L were maintained for 36 hours with HDM and 45 hours with IDM. General tolerance to treatment was better in the HDM group. Mucosal lesions occurred significantly more often and were more severe after IDM treatment. A median treatment delay of 3 days was required in the IDM group but not in the HDM group. At day 15, complete remission (CR) was documented in 45% of IDM- and 48% of HDM-treated patients. Persistent blasts (> 5%) appeared more frequently in HDM than in IDM (35% v 19% of patients; P = NS). After completion of induction therapy, 28 of 30 patients in each group achieved CR. CONCLUSION: Both regimens produced the same remission rates. The tendency to better antileukemic activity of IDM was accompanied by more severe side effects as a consequence of long-lasting cytotoxic MTX levels. Hence, long-term infusion of IDM followed by low-dose LCV is an effective treatment for recurrent ALL.

Relationship between cell density and prolidase activity in human skin fibroblasts: effects of ascorbate and fructose.

To evaluate the influence of cell density on the activity of fibroblast prolidase (EC 3.4.13.9), we determined this activity in sparse and dense cultures. We also investigated, the effects of different concentrations of beta-D (-) fructose and L (+) ascorbate, which both increased cell density at confluency. For a fructose concentration of 25 mM, we observed that in the absence of glucose, intracellular total proteins increased 1.5-fold and prolidase specific activity, 1.8-fold. For ascorbate, a broad optimum concentration was found (range 0.01 - 0.50 mM). Addition to cultures of 0.1 mM ascorbate increased total proteins 1.4-fold, and doubled prolidase activity. This investigation was prompted by our previous results [J. Metab. Dis. 1983, 6, 27-31], confirmed here, and suggesting that increased prolidase activity at confluency was due to a rise in cell density.

Extent of 14C incorporation into cholesterol of infant skin fibroblasts incubated with carboxyl-labeled oleic, -linoleic or -arachidonic acid.

In order to determine the incorporation of C1-14C derived from mono- and poly-unsaturated fatty acids into cholesterol of human cells cultured in exponential phase, infant skin fibroblasts (SF) were used at the 5th passage. On Day 6, the SF were preincubated 36 h in a medium containing 5 per cent lipoprotein-deficient serum, and thereafter [1-14C] oleic, -linoleic or -arachidonic acid-without (OL1, LI1 and AR1 group SF), or with the addition of 0.25 mM cold fatty acids (OL2), LI2 and AR2 group SF). Cholesterol specific radioactivity (SRA) peaked 1 h after, and leveled off afterwards in the OL1, LI1 and AR1 groups. Cholesterol-SRA was relatively low in the other groups, but increased progressively, giving a biphasic response: C1-14C derived from from linoleic and arachidonic acids was actively incorporated into cholesterol during the first hours, as compared to C1-14C derived from oleic acid, but stabilized between 6 and 12 h for the LI2 and AR2 group SF incubation. This result appears to be due to the stimulation of pyruvate decarboxylation, observed elsewhere, and consequently to the dilution of the radioactive units in a large pool of non-labeled acetyl-CoA units derived from glucose, when these SF were incubated with 0.25 mM polyunsaturated fatty acids.

Factor VIII procoagulant antigen in human tissues.

The localization of factor VIII procoagulant antigen (VIII:Ag) and factor VIII von Willebrand antigen (VWF:Ag) was investigated in human liver, lung, spleen, placenta and umbilical cord, by an immunoperoxidase technique using an avidin biotin complex (ABC). Positive staining for VIII:Ag was observed in the endothelial cells of liver sinusoids, veins and arteries, as well as in the endothelial cells of placenta, lung and spleen. VWF:Ag was detected in the vascular endothelial cells of all the organs explored. The staining intensity of both VIII:Ag and VWF:Ag varied in the different tissues and showed a distinctive pattern of distribution in the liver. VIII:Ag was also observed in the cytoplasm of dysplastic, foetal-like hepatocytes which infiltrated one liver specimen. Our results agree with the view that liver endothelial cells are a major site of Factor VIII (F VIII) storage and secondary release into the circulation. However, the bright staining intensity of VIII:Ag and VWF:Ag in the lung and placenta suggests that these two tissues might also be a substantial source of F VIII.

Mechanisms of resistance to methotrexate in childhood acute lymphoblastic leukemia: circumvention of thymidylate synthase inhibition.

PURPOSE: In about 25% of patients suffering from acute lymphoblastic leukemia (ALL) treatment failures occur that are most likely due to development of resistance to methotrexate (MTX). Blasts from patients with ALL were evaluated for MTX uptake, formation of long-chain MTX polyglutamates (MTX-Glu5+6), cytotoxicity and thymidylate synthase inhibition by MTX and compared to blasts from patients with acute myelogenous leukemia (AML). METHODS: Radioactively labeled MTX-Glu(n) were analyzed by means of HPLC. Thymidylate synthase activity was measured by a tritium-release assay. Cytotoxicity was determined by trypan blue exclusion. RESULTS: In most ALL blasts (n = 9) large amounts of MTX-Glu5+6 (1.06-7.03 pmol/10(7) cells) and high cytotoxicity (43.5% 92.7%) were found, while in others small amounts of MTX-Glu5+6 (0.0-0.39 pmol/10(7) cells) caused only weak cytotoxicity (6.0% 27.9%) (n = 5, 2 relapsed patients). Resistance to MTX in blasts from AML patients (n = 5) was also caused by reduced synthesis of MTX-Glu5s+6 (0.0-0.42 pmol/10(7) cells). In contrast, some ALL blasts (n = 7, 4 relapsed patients) were able to survive MTX treatment despite large amounts of MTX-Glu5+6 (1.5-5.05 pmol/10(7) cells) and extensive thymidylate synthase inhibition. CONCLUSIONS: Since the majority of ALL patients were examined at first diagnosis, an inherent mechanism of resistance seems most likely. We propose a mechanism based on the switch of thymidylate synthesis to the salvage pathway.

Fructose-induced enhanced mitogenicity of diploid human cells: possible relationship with cell differentiation.

Fructose strongly stimulates the growth of normal diploid human skin fibroblasts (SFs) and induces marked changes in their morphology and lipid accumulation. This mitogenic effect occurs despite very low fructose consumption and depends on the presence of glutamine. The cell kinetics of cultured fructose-fed human skin fibroblasts were different from those fed on glucose: in the presence of fructose a high proliferative index persisted at Day 14 of culture and the duration of the total cell cycle and of the G1 + 1/2 M and S phases was slightly shorter. The mitogenic effect of fructose on SF was largest in the presence of human serum: it was small or undetectable when fibroblasts were cultured in media supplemented with dialyzed human serum, fetal bovine serum, or serum substitutes. This suggests that serum growth factor(s) mediate the mitogenic effect of fructose. Only normal diploid human cells seem to be sensitive to this mitogenic effect of fructose: the long-term growth of normal human liver cells on fructose was slightly better or similar to that on glucose. In contrast, fructose could only support limited growth of hamster fibroblastic Nil cells and of a transformed human fibroblastic line, which grew better with glucose.

The time-pattern of rises and falls in proliferation fades with senescence of mortal lines and is perpetuated in immortal rat hepatoma Fao cell line.

Immortal cells perpetuate the rises and falls of proliferation that are progressively damped in mortal long-term cultured cells. For immortal rat hepatoma Fao cells, similar waves of proliferation occurred about every 3-4 wk. Under the same conditions, embryonic human fibroblasts and transformed but not immortalized embryonic fibroblasts display similarly recurring proliferation waves that progressively decrease in amplitude until senescence of the lines. In addition, strains of diploid normal human skin fibroblasts cultured under different culture conditions display a similar time-pattern of proliferation. Although the amplitude and baseline of these fluctuations are characteristic for each cell line, a common point was marked slow down in proliferation after every sequence of about 25 population doublings for all cells. Renewed proliferation waves of Fao cells allow about 22-23 additional population doublings each. Normal embryonic fibroblast culture and its transformed counterpart accumulate about 30 and 60 population doublings, respectively, before senescence. Normal fibroblast strains accumulate about 25 population doublings over their entire life spans. This halt in proliferation after every stretch of about 25 population doublings may correspond to a structural or functional stop following attrition of telomeric DNA. This putative stop may be bypassed once in transformed embryonic cells and repetitively in immortal cells. In support of this hypothesis, we observed rapid telomere shortening, in two steps, during divisions of mortal embryonic cells, and maintenance of long telomeres in immortal Fao cells, which may indicate episodic repair of telomeres. Alternatively, such maintenance of long telomeres may reflect survival and successive clonal growth of rare cells with long telomeres. We suggest that the balance between telomere attrition and repair processes regulates the waves of proliferation.

Effects of polyunsaturated fatty acids on human and rat cells. In vitro versus in vivo experiments.

Human infant skin fibroblasts and liver cells were subcultured with 250 microM PUFA (polyunsaturated fatty acid), and primary cultures of glial brain cells from new-born rats with 100 microM; oleic acid was added to controls. Minimum essential medium (MEM) supplemented with bovine serum was used as a reference. During the short-term experiment (18-24 h), control liver cells showed a regular increase in protein level, while protein increment was more rapid in linoleic and especially in arachidonic acid-treated cells, but only for the first 3 hours. During the long-term experiment (7 d), control skin fibroblasts showed a faster growth rate (increase in number of cells) than reference or fibroblasts cultured with the added PUFAs. Lipid droplets were seen in the PUFA-treated liver cells and skin fibroblasts, and ultrastructural modifications were observed in fibroblasts, but without growth rate alteration. During the long-term experiment (2 w), control glial brain cells showed faster protein increment (measuring growth rate) than PUFA-treated cells, particularly than arachidonic acid-treated cells. HMGR (3-hydroxy-3-methylglutaryl-CoA reductase) activity, determined after 6 h (liver cells) or 1 and 2 w (brain cells) of culture, was low in controls and reference, whilst higher in PUFA-treated-cells, and was especially high in arachidonic acid-treated brain cells. The present study indicates than the high HMGR activity may correspond to cultures of cells rapidly stopped in their protein increment, and to cultures of cells showing a slow rate of proliferation. This contrasts with results obtained from in vivo experiments; it also emphasizes the high mevalonate (MVA) level as a possible sign of nutritional medium imbalance.(ABSTRACT TRUNCATED AT 250 WORDS)

Neutropenia dynamics in a case of T-LGL lymphoproliferation illustrate rapid turnover of granulocyte progenitors.

OBJECTIVES: To elucidate the natural history of T-cell large granular lymphocyte (T-LGL) lymphoproliferation, we followed changes in associated fluctuating neutropenia for 3 years in an untreated patient presenting with the disease. MATERIALS AND METHODS: We report a nonlinear mathematical analysis of irregular neutrophil fluctuation, using iterative data maps, to detect long-term regulation of the neutrophil population. RESULTS: This geometric analysis indicated that variations of this sequence of neutrophil counts followed bounded deterministic dynamics around a fixed low level equilibrium, a situation similar to that previously observed for cultured mouse early bone marrow progenitor cells. CONCLUSION: These findings illustrate how the deleterious effect of T-LGL on neutrophils is balanced, over periods of years, by pulses of compensatory neutrophil production, potentially accounting for the commonly observed prolonged indolent course of the disease.

Prolonged perturbation of the oscillations of hepatoma Fao cell proliferation by a single small dose of methotrexate.

The proliferation rate of various cell types in vitro, including hepatoma Fao cells, displays aperiodic oscillations. The frequency of these oscillations is about one every 3-5 weeks, and there are variations in cell functions and polarity. Topological analysis has showed that these oscillations in growth rate are determined, and presumably chaotic. One characteristic of complex chaotic systems is that their dynamics can be persistently modified by a small external perturbation. We show that treatment with a single small dose of the anticancer drug methotrexate causes long-term stable alteration of the oscillatory dynamics of Fao cell proliferation. The oscillations of growth rate are shifted, and their mean level decreased according to a fractal pattern.

Clinical relevance of liver membrane antibody in chronic liver disease of children.

Antibody against liver membrane (LMA) was measured using suspensions of rabbit hepatocytes and FITC-conjugated F(ab')2 fragments of affinity-purified goat anti-human IgG. The sera of 43 children with chronic liver disease were examined. Significant titers of LMA were observed for all patients with untreated HBV-negative chronic active hepatitis (CAH). Follow-up studies during immunosuppressive therapy showed that the decrease in LMA titers was delayed as compared to that of non-organ-specific antibodies, and did not correlate with clinical, biochemical, and histological parameters. The detection of LMA is useful in the diagnosis of the CAH subtype which may benefit from immunosuppressive therapy. However, it is of no assistance in the clinical management of autoimmune CAH, since it failed to predict possible relapse after withdrawal of treatment. A pathogenic role for LMA remains thus questionable.

Insulin dependence of M2 pyruvate kinase in primary culture of human liver.

In the basal state, the presence of L pyruvate kinase (LPK) was constantly observed in primary human liver cell cultures initiated from explants, when cells were examined by immunofluorescence and double labelling. After short-term insulin incubation, M pyruvate kinase (MPK) appeared. Therefore, both LPK and MPK were located in the same cells. We previously obtained the same results in isolated rat hepatocytes in which we demonstrated that short-term regulation of M2PK by insulin was a function of dose and/or incubation time. The present work established that similar conditions govern the regulation of this isozyme in vitro in human hepatocytes.

Some metabolic differences between human skin and aponeurosis fibroblasts in culture.

Two types of human fibroblast strains were studied in culture. One was derived from abdomen skin and the other from abdominal muscle aponeurosis. Tissue-specific differences were found between these two cell strains. Skin fibroblasts had faster doubling time, smaller cell volume, and lower glucose consumption when compared to aponeurosis fibroblasts. Furthermore, extracellular amino acid variations showed some specific differences, in particular a lack of serine consumption in skin fibroblasts.

Pharmacokinetic study of methotrexate, folinic acid and their serum metabolites in children treated with high-dose methotrexate and leucovorin rescue.

The pharmacokinetics of methotrexate (MTX), 7-hydroxymethotrexate (7-OHMTX), 2,4-diaminomethylpteroic acid (APA), folinic acid, and 5-methyltetrahydrofolate (5-MTHF) have been studied during 21 high-dose MTX (HDMTX) infusions (5 g.m-2 in 24 h) with leucovorin (LCV) rescue, a component of the therapy of 5 children with acute lymphoblastic leukemia (ALL). The median steady-state concentration of MTX was 66 mumol.l-1. Three elimination half-lifes were determined for MTX: 1.8 h, 6.4 h and a terminal 15 h. The median systemic MTX clearance was 110 mg.m-2.min-1. The 7-OHMTX level increased during each infusion and a Cmax of 19 mumol.l-1 was achieved at the end. Its initial half-life was 5 h and the terminal half-life was 12 h. Thus, the peak serum concentration ratio of 7-OHMTX to MTX was reached 24 h after the end of the infusion at a median ratio of 8. The MTX metabolite APA was detected in concentrations less than 0.06 mumol.l-1. The median folinic acid level during rescue, 48 h after starting the infusion, was 7.0 mumol.l-1 and 18 h following the last dose of LCV it was 0.44 mumol.l-1, leading to ratios of folinic acid to MTX of 31 and 6, respectively. The median 5-MTHF level during rescue was 0.44 mumol.l-1 with a median ratio of 5-MTHF to MTX of 2. Twenty infusions with 48 h MTX levels of less than 0.5 mumol.l-1 were without marked toxicity. Only one patient with a 48 h MTX concentration of 5.5 mumol.l-1 and a ratio of 5-MTHF to MTX of 0.08 suffered from ulcerating mucositis and septicaemia despite increased and prolonged LCV rescue.

Permissive role of n-6 polyunsaturated fatty acids on carbohydrate oxidation in human infant skin fibroblasts: one possible mechanism of their intervention on coronary heart disease and diabetes.

UNLABELLED: Many publications indicate the beneficial effect of n-6 polyunsaturated fatty acids (n-6 PUFAs) in the control of coronary heart disease and diabetes, although the mechanism is not clear. Some of our previous results suggest that, in contrast to other lipids, n-6 PUFAs could have a permissive effect on carbohydrate oxidation. To check this hypothesis, we determined pyruvate dehydrogenase (PDH, decarboxylase: EC 1.2.4.1) activity in infant skin fibroblasts (ISF) incubated 6 hours in the presence of 0.25 mM linoleic (LI) or arachidonic (AR) acid, compared to oleic acid (OL) and control ISF incubated without addition of fatty acids. The four groups of cells were preincubated 36 hours either in the presence of fetal bovine serum (FBS), or in the presence of lipoprotein-deprived serum (LPDS). RESULTS: (1) When the ISF were maintained in the medium containing FBS, the two PUFAs had little inhibitory effect on PDH activity, in contrast with the effect of OL. (2) When the ISF were kept in the lipoprotein-deficient medium, PDH activity was low in controls and in the OL cells, but the addition of LI or AR increased the activity. This suggests the role of n-6 PUFAs in enhancing carbohydrate oxidation, under certain conditions.

Comparative use of fructose and glucose in human liver and fibroblastic cell cultures.

The effect of fructose as a substitute for glucose in cell culture media was investigated in human skin fibroblast and liver cell cultures. Cells were grown for between 2 and 10 days in identical flasks in four different media, containing 5.5 mmol X 1-1 and 27.5 mmol X 1-1 glucose and fructose, respectively. In the presence of fructose, cell growth was stimulated, but less in liver cells than fibroblasts. At Day 6, increases were observed in [3H]thymidine incorporation, protein levels, and amino acid consumption, and a reduction was noted in ATP levels. In media containing 5.5 mmol X 1-1 glucose or fructose, consumption of fructose was four times lower than that of glucose at Day 3 and did not rise until Day 6. In fructose media, the lactate production was very low (four to five times less than that of glucose) and the pH values were always higher. Some findings were different for the fibroblasts and liver cells, owing to the specific characteristics of these two cell types in culture; this applied especially to the effects of glucose and fructose concentrations of 27.5 mmol X 1-1. Several possible explanations for the stimulation of cell growth in fructose medium were discussed.

Respective effects of glucose and glutamine on the glutamine synthetase activity of human skin fibroblasts.

The activity of Glutamine Synthetase (GS) was measured during the growth of human diploid skin fibroblasts cultured for three weeks in the presence or absence of either glucose or glutamine or both. In medium free of both glucose and glutamine, a single late peak in GS activity was observed concomitantly with delayed small cell protein increment. In all media containing either glucose or glutamine or both. GS activity rose sharply during rapid cell growth, displayed a plateau, and then decreased once the cells had reached confluency. The variations in extracellular amino acid levels were also determined and were found to depend on the composition of the medium but not on the cell culture duration. These results demonstrate, for the first time as far as we know, that strong GS activity is present in rapidly growing skin fibroblasts. In contrast to many other mammalian cell types, GS activity in human skin fibroblasts appears not to be subject to regulation by extracellular glutamine. This difference may well be connected with cell differentiation.

Effect of interferon gamma and TNF alpha on the differentiation/activation of human glial cells: implication for the TNF alpha receptor 1.

This study focused on the activation/differentiation of human microglial cells and astrocytes, which is a prerequisite for HIV1 replication. In vitro, IFN gamma induced a differentiation-like morphological change in embryonic microglia and astrocytes, in both primary and in purified culture. This effect was enhanced by TNF alpha which in itself had no effect. IFN gamma did not increase the low level of endogenous TNF alpha, which is not secreted by embryonic cells, but stimulated the expression of TNF alpha R1, although to a relatively low extent. IFN gamma facilitated TNF alpha response through an increase in TNF alpha R1 expression, but probably also through interaction with different intracellular signal transduction pathways.

High-performance liquid chromatographic determination of methotrexate, 7-hydroxymethotrexate, 5-methyltetrahydrofolic acid and folinic acid in serum and cerebrospinal fluid.

A method for the simultaneous determination of the antifolates methotrexate and 7-hydroxymethotrexate as well as the folates 5-methyltetrahydrofolic acid and folinic acid (5-formyltetrahydrofolic acid) in serum and cerebrospinal fluid (CSF) is described. High-performance liquid chromatography with gradient elution and dual detection (ultraviolet absorption and fluorescence) was used to separate and quantitate the analytes. Serum samples containing high levels of the substances of interest and CSF samples were injected directly onto the HPLC column. For determination of low concentrations, serum samples were subjected to a solid-phase extraction method for clean-up and concentration purposes. The determination limits were 10 ng/ml for both antifolates, 100 ng/ml for folinic acid, and 0.1 ng/ml for the physiologically occurring methylated folate which is about 1/100 the serum concentration in healthy children. The suitability of the method for pharmacokinetic monitoring of high-dose methotrexate therapy combined with leucovorin rescue administered to children with acute lymphoblastic leukemia was demonstrated. Minimum values of the serum folate during treatment ranged from 0.2 to 3.1 ng/ml. Even those very low concentrations could be reliably measured.

Low efficiency of [14C]galactose incorporation by galactosemic skin fibroblasts: relationship with neurological sequelae.

The incorporation of radioactivity from [1-14C]-galactose into TCA-precipitable material was determined in skin fibroblasts derived from 11 galactosemic patients deficient in galactose 1-phosphate uridyl transferase (GALT-). "R" ratios (designated the R phenotype) were defined as the ratio between [14C]galactose incorporation and [3H]leucine incorporation. Results were expressed as a percentage of the controls. In the GALT-strains this ratio varied from strain to strain, presumably depending on the efficiency of the secondary route via the UDP-galactose pyrophosphorylase pathway. In 10 GALT-patients without late serious clinical manifestations, the R phenotype varied from 37 to 57% of the control value. In the 11th patient, the R phenotype was only 20% of the control. Thus, we obtained a significantly lower R phenotype in one patient who was distinguished from the others by having very severe delayed neurological complications, although compliance to galactose-free diet was good. We suggest that, in this patient, the development of the UDP-galactose pyrophosphorylase pathway was not sufficient to ensure the availability of enough galactose for the necessary synthesis of glycoproteins and glycolipids. Thus the R phenotype may be an indicator of the risk of late neurological complications. The determination of the R phenotype of GALT-patients may therefore be valuable. However, further investigations of galactosemic patients with neurological complications are required to confirm this relationship.