Biochemical mechanisms in the Killmann experiment: critique of the deoxyuridine suppression test.

The degree of inhibition of [3H]thymidine incorporation into DNA by exogenous deoxyuridine is assayed in a procedure known as the deoxyuridine suppression test. We report studies of the biochemical basis of this phenomenon in phytohemagglutinin-stimulated lymphocytes, which suggest that its mechanism has not been fully understood. Results show that inhibition by deoxyuridine is caused only in part by expansion of the intracellular pools of nonradioactive dTMP and dTTP, which dilutes the specific radioactivity of the [3H]dTMP and [3H]dTTP derived from [3H]thymidine. Increased dTTP levels also inhibit thymidine kinase. In addition, thymidine kinase is competitively inhibited by intracellular deoxyuridine. Inhibition of thymidine kinase activity by both mebolites further decreases the specific radioactivity of [3H]dTMP and [3H]dTTP. Deoxyuridine also inhibits the incorporation of [3H]deoxyadenosine and [3H]deoxyguanosine into DNA in these cells. Exogenous deoxyuridine still inhibits [3H]thymidine incorporation in cells whose de novo thymidylate synthesis has been strongly inhibited by 5-fluorodeoxyuridine or methotrexate. In such drug-treated cells, exposure to high concentrations of exogenous deoxyuridine can partially overcome the inhibition of thymidylate synthetase with resulting increase in the severely depleted dTTP pools. This increase is associated with enhanced DNA synthesis, as measured by incorporation into DNA of labeled deoxyribonucleosides other than [3H]thymidine. We conclude that exogenous deoxyuridine has multiple effects on [3H]thymidine incorporation, which must be considered in interpretations of deoxyurindine suppression test results.

Serine hydroxymethyltransferase activity and serine incorporation in leukocytes.

Studies of serine hydroxymethyltransferase activity in extracts of leukocytes from normal and leukemic subjects showed that the enzyme is present in lymphocytes and granulocytes but that activity is higher in lymphocytes. It is also higher than normal in lymphocytes from patients with chronic lymphocytic leukemia and to a lesser extent in the leukocytes of patients with acute myelocytic leukemia and acute lymphocytic leukemia. A striking increase in activity occurs in lymphocytes stimulated by phytohemagglutinin to divide in culture. Enzyme activity rises severalfold before cell number increases. Stimulated lymphocytes take up [3-14C]serine from the medium and incorporate its radioactivity into DNA, RNA, and other cell fractions. The rate of incorporation increases sharply before the rise in cell number. Thus, serine hydroxymethyltransferase activity and serine incorporation in vivo show a temporal correlation in stimulated lymphocytes. Inhibitors of DNA synthesis (e.g., fluorodeoxyuridine or high concentrations of adenosine or thymidine) block incorporation of serine radioactivity into DNA and other cell fractions. The results suggest that serine hydroxymethyltransferase activity and cellular uptake of serine have a significant role in proliferating cells.

Comparison between four and eight cycles of intensive chemotherapy in adult acute myeloid leukemia: a randomized trial of the Finnish Leukemia Group.

In acute myelogenous leukemia (AML) intensive postremission treatment is needed for an optimal result. However, it is not known how long the treatment should last and how many courses are necessary. The object of this prospective study was to compare four and eight intensive chemotherapy cycles in the treatment of adult de novo AML. In a multicenter study, 248 consecutive patients, aged from 16 to 65 years, were treated with intensive induction treatment. The patients in remission after two courses were randomized to receive either two (short arm) or six (long arm) additional intensive cycles of chemotherapy. The median follow-up time of the living patients is 68 months. Of the patients, 77% achieved complete remission, and 36% of all patients survived for 5 years. Seventy-three patients were randomized to the short arm and 66 to the long arm. There was no significant difference in the relapse-free survival (median 21 months vs 17 months) or overall survival (43 months vs 39 months) between the short and long arms, respectively. Treatment-related deaths occurred in 31 patients (13%), 11 of them in first remission. More than one-third of the patients survived for 5 years. It seems probable that the first few months after diagnosis are decisive for the prognosis if the chemotherapy is intensive, and further treatment cannot markedly influence the outcome.

Interaction between dopamine and phospholipids. Studies of the substantia nigra in Parkinson disease patients.

Interaction between dopamine and phospholipids was studied in the substantia nigra of ten patients with Parkinson disease and nine control subjects. There were no differences in the total content of phospholipids. However, in parkinsonian patients without previous levodopa treatment, the amount of sphingomyelin was increased and the amount of phosphatidylethanolamine and phosphatidylcholine decreased. Levodopa treatment corrected these values to the level of controls, whereas the amount of phosphatidylserine was decreased. It is concluded that changes in phospholipids are reflections of the deficiency of dopamine and loss of dopaminergic neurons in the substantia nigra of patients with Parkinson disease.

Factors stimulating collagen synthesis from the livers of hypercholesterolemic rats.

Hypercholesterolemia was induced in rats by feeding them a high cholesterol olive oil diet. The livers were homogenized in modified Krebs-Ringer medium and centrifuged at 35,000 x g. The supernatants from livers of both hypercholesterolemic and normal rats were found to stimulate collagen synthesis in freshly isolated embryonic chick-tendon fibroblasts. However, this was significantly greater in the supernatants from fatty livers. The stimulating principle proceed to be dialyzable, non-lipid and heat-stable. There were at least two factors involved, the more effective of which was trypsin-sensitive, with a molecular weight below 2,000. The results suggest that a mediator is formed in the livers of hypercholesterolemic rats which might be responsible for the enhanced collagen synthesis of fibrotic processes vivo, e.g., in atherosclerosis and liver cirrhosis.

Human recombinant GM-CSF selectively primes receptor mediated respiratory burst of neutrophils in vitro.

The influence of human recombinant granulocyte-macrophage colony-stimulating factor (rH GM-CSF) on respiratory burst response of isolated human neutrophils was examined. Preincubation of cells with rH GM-CSF significantly increased the respiratory burst in response to formyl-methionyl-leucyl-phenylalanine (FMLP), measured by luminol-dependent chemiluminescence (CL) assay. This priming effect of rH GM-CSF was independent of extracellular Ca2+ and Mg2+. On the other hand, the pretreatment of cells with rH GM-CSF could not enhance the neutrophil CL responses to unopsonized, serum complement-opsonized or immunoglobulin G (IgG)-opsonized zymosan particles. rH GM-CSF directly induced a weak CL signal in neutrophils. This signal, however, was abolished when extracellular Ca2+ and Mg2+ were removed. Exposure to rH GM-CSF caused a divalent cation-dependent up-regulation of complement receptors (CR1 and CR3) on neutrophil cell surface, while the expression of IgG Fc-receptors (FcRII and FcRIII) was not markedly changed by rH GM-CSF. The results indicate that rH GM-CSF primes FMLP-induced CL but not zymosan particle-induced respiratory burst in human neutrophils. It is hypothesized that the reason for the different sensitivity of FMLP-receptors and receptors to zymosan particles to rH GM-CSF priming may lie in differences in the signal-transduction pathways of these receptor types.

Intensive chemotherapy of poor prognosis myelodysplastic syndromes (MDS) and acute myeloid leukemia following MDS with idarubicin and cytarabine.

Forty patients with high risk myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) preceded by MDS were treated with intensive induction and consolidation chemotherapy in a prospective multicenter pilot study. They were given two cycles of cytarabine 100 mg/m with 12-h intervals on days 1-7 and idarubicin 12 mg/m2 on days 5-7, both intravenously. Patients who were in remission after these two cycles were given two further cycles of cytarabine on days 1-5 and idarubicin on day 5. No maintenance treatment was given. Eleven out of 19 MDS patients (58%) and 10 out of 21 AML patients (48%), in total 21 out of 40 patients (53%), entered remission. Eight patients underwent allogeneic bone marrow transplantation. The follow-up time was 13-48 (median 33) months. At the time of the analysis, seven patients survived, four patients with MDS all of whom had been treated with bone marrow transplantation (three in continuous remission), and three patients with AML treated with chemotherapy only (two in continuous remission). The median survival of the patients treated with chemotherapy only was 12 months, with the median progression-free survival being 8 months. In view of the poor prognostic factors of the patients, the remission rate was satisfactory, but the responses as well as the survival were short. The post-remission treatment needs to be improved.

Plasma cell leukemia 3 months after autologous blood cell transplantation for multiple myeloma.

We describe a patient with multiple myeloma who was treated with intensive therapy and autologous blood cell transplantation as her first-line treatment. The disease relapsed 3 months after the transplant as plasma cell leukemia and the patient succumbed in 4 weeks. We suggest that an aggressive plasma cell clone may be selected during the course of intensive treatment. Complex karyotypic findings are also presented.

Autologous blood cell transplantation in B-CLL: response to chemotherapy prior to mobilization predicts the stem cell yield.

Successful stem cell mobilization and collection is possible in B-CLL after a favorable response to preceding chemotherapy, and also after treatment with the new nucleoside analogues fludarabine and cladribine. A poor response, on the other hand, seemed to predict a mobilization failure. CD34+ cell selection resulted in a 2- to 3-log reduction of the CLL cells in the harvests. Engraftment with both unselected and selected progenitor cells was rapid, and need for hospitalization was short. High-dose therapy with stem cell rescue appears to be capable of inducing CRs of high quality, but so far the follow-up is too short to define whether this will be translated into prolonged disease-free survival.

The reappearance of 10 differentiation antigens on peripheral blood lymphocytes after allogeneic bone marrow transplantation.

Ten monoclonal antibodies and flow cytometry were applied to characterize the recovery of lymphocyte subsets in peripheral blood after allogeneic bone marrow transplantation (BMT). Ten patients were first followed for 150 days (short-term survey) and then analysed 2 years after BMT on average (long-term analysis). Eight of the 10 recipients showed increased relative and absolute numbers of CD8+ cells and reduced numbers of CD4+ cells resulting in an inverse helper/suppressor ratio. In these eight patients the CD8+ cell predominance was long-lasting and still detectable in the long-term analysis. Two patients had a normal helper/suppressor ratio throughout the study but otherwise a similar reconstitution. Despite the slow recovery of CD4+ cells, CD4+ Leu8- and CD4+ CD45RA- helper subsets were in a normal range already on day 30 and their proportions stayed higher than those of CD4+ Leu8+ and CD4+ CD45RA+ helper cells for the whole short-term survey. The number of activated suppressor cells (CD8+ HLA-DR+) increased markedly after BMT. Similarly, in eight patients high numbers of cytotoxic CD8+ CD57+ cells were found from day 50 onwards. An early and sharp rise of NK cells (CD16+, CD56+) was observed in all recipients, and seven recipients also showed an early increase in CD20+ B cells. Later on, normal or slightly elevated numbers of these cells occurred.

Low-dose or intermediate-dose cyclophosphamide plus granulocyte colony-stimulating factor for progenitor cell mobilisation in patients with multiple myeloma.

Cyclophosphamide (CY) combined with granulocyte colony-stimulating factor (G-CSF) is commonly used to mobilise blood progenitor cells to support high-dose therapy in patients with multiple myeloma (MM). The optimal dose of CY in this setting is unknown. We have retrospectively analysed mobilisation efficiency and need for supportive care in 57 patients with newly diagnosed myeloma previously treated with VAD+/-local radiotherapy. The patients were mobilised either with low-dose CY (LD-CY, 1.2-2 g/m(2)) (n=25) or intermediate-dose CY (ID-CY, 4 g/m(2)) (n=32) plus G-CSF. Both regimens proved to be effective in the progenitor cell mobilisation. At least 2 x 10(6)/kg CD34+ cells were collected from 88% and 84% of the patients with a single apheresis, respectively. Only one patient in the LD-CY group (4%) failed to mobilise vs none in the ID-CY group. Patients mobilised with LD-CY plus G-CSF had less toxicity: fewer hospital days during the mobilisation and apheresis procedures (5 vs 9 days, P<0.001), lower frequency of fever (20 vs 73%, P<0.001) and less need for supportive care including platelet transfusions (0 vs 24%, P=0.004) and days on parenteral antibiotics (0 vs 4 days, P<0.001). While these regimens seem to be equally effective in terms of progenitor cell mobilisation in newly diagnosed patients with MM, LD-CY+G-CSF is preferential because of more optimal resource utilisation and more favourable toxicity profile.

Allogeneic bone marrow transplantation in multiple myeloma: a report of four cases.

Allogeneic bone marrow transplantation offers a new and promising form for treatment of multiple myeloma incurable with chemotherapy. We present four cases of advanced multiple myeloma given bone marrow transplantation from HLA-identical and MLC-negative sibling donors. One patient had a recurrent plasmacytoma 8 months later and one died 12 days after the transplantation whereas the other two are in good clinical remission 15 and 19 months post-transplantation.

Neutrophils are responsible for the reappearance of chemiluminescence after allogeneic bone marrow transplantation.

The nature of the cells generating the early chemiluminescence (CL) response after allogeneic bone marrow transplantation (BMT) was studied in six patients; five transplanted for acute leukaemia and one for multiple myeloma. Peripheral blood was fractionated into 14 fractions with Percoll narrow range density gradient centrifugation on days +14, +17, +20, and +27 after BMT. The leucocytes were recovered in fractions 7-14 which were analysed for cell morphology and CL response. On days +14 to +20 after BMT the CL response was detected in the fractions containing morphologically mature neutrophils. In one of these fractions the CL response per phagocyte was significantly higher than in the neighbouring fractions although morphologically the cells were similar. The results suggest that the cells responsible for the early CL after BMT are neutrophils and possibly an active subpopulation of neutrophils produced by the marrow graft.

Flow cytometric DNA analysis and clinical correlations in multiple myeloma.

DNA content of both bone marrow and peripheral blood mononuclear cells was measured by flow cytometric analysis in 46 patients with untreated multiple myeloma and 15 patients with benign monoclonal gammopathy to clarify further the incidence and clinical correlations of DNA aneuploidy. Aneuploidy was detected in the bone marrow of 25 multiple myeloma patients (54%) but in only one benign monoclonal gammopathy patient (7%), who developed multiple myeloma 34 months later. Thus DNA aneuploidy is considered rare in benign monoclonal gammopathy. In two multiple myeloma patients, DNA aneuploidy was detected also in blood, indicating circulating myeloma cells. The light chain of the M component was more frequently lambda in the diploid and kappa in the aneuploid group. Most of the patients with only light chain secretion were DNA aneuploid. Multiple myeloma patients with DNA hypodiploidy (7%), biclonal aneuploidy (4%), or DNA aneuploidy detectable in blood (4%) did not respond to therapy with melphalan and prednisone. Survival was not influenced by DNA content. No DNA aneuploidy was detected in the bone marrow or the peripheral blood of 26 patients with chronic lymphocytic leukemia or two patients with Waldenström's macroglobulinemia.

VAD regimen in the treatment of resistant multiple myeloma: slow or fast infusion?

The VAD regimen is effective in the treatment of resistant and relapsing multiple myeloma. In the original VAD regimen, vincristine (V) and doxorubicin (A) are given as continuous infusions together with peroral dexamethasone (D). For practical reasons, we have shortened the infusion times: 8 hours for vincristine and 1 hour for doxorubicin. In this retrospective analysis, we have compared the efficacy and toxicity of the original and modified VAD protocols in the treatment of myeloma patients at our institution. Of the 31 consecutive patients with myeloma, primarily or secondarily resistant to alkylating agents, 16 were treated by the original and 15 by the modified VAD protocol. We found no significant difference in the response rates (good responses 31% and 20% respectively), survival times (17 and 9 months respectively) or toxicity between the two protocols. VAD may well be modified so as to consist of short infusions of V and A. The overall efficacy of the traditional and modified regimens is, however, rather unsatisfactory in patients with advanced myeloma.

Effects of alpha-interferon on serum beta-2-microglobulin.

Beta-2-microglobulin (B2M) forms the small invariable light chain subunit of class I HLA antigens on the cell membrane of all nucleated cells. During the continuous turnover of the HLA molecules, B2M is shed from the cell membrane into blood. Lymphocytes are the main source of serum free B2M. Serum B2M concentration is increased in renal diseases, various malignant diseases and some inflammatory and autoimmune disorders. In lymphatic malignancies serum B2M has significant prognostic value. Interferons (IFNs) have the ability to enhance the expression of class I and II histocompatibility antigens. Accordingly, IFNs cause a rise in formation and release of B2M. Currently, treatment with IFN alpha is used in diseases, like multiple myeloma, where serum B2M measurements are used to assess tumor burden. We have measured serum B2M levels during IFN alpha treatment in patients with both multiple myeloma and chronic myeloproliferative diseases, and IFN alpha caused a significant increase in serum B2M. It can be concluded that use of IFN alpha abolishes the value of serum B2M as an indicator of disease activity.

Long-term treatment with GM-CSF in patients with chronic lymphocytic leukemia and recurrent neutropenic infections.

In this prospective study we evaluated the multiple effects of long-term GM-CSF therapy on blood counts, granulocyte functions and disease progression in patients with chronic lymphocytic leukemia (CLL) with chronic neutropenia and recurrent bacterial infections. The treatment duration varied from 2 to 12 weeks. The neutrophil count was raised in all patients, by the median of 6.6-fold. The neutrophil level of 1.0 x 10(9)/l was usually reached after two weeks. The initial dose of GM-CSF was 5 microg/kg/day, and 1-7 microg/kg/day was required to maintain the neutrophil level above 1.0 x 10(9)/l. Granulocyte functions, i.e. chemiluminescence (CL), random migration, and fMLP-stimulated chemotaxis were initially depressed in all patients when compared to healthy controls. GM-CSF enhanced significantly CL even when given at small doses (less than 1 microg/kg/day), even lower than the dose required to promote granulopoiesis. We conclude that GM-CSF is effective in improving CLL associated chronic neutropenia and also enhances impaired granulocyte chemiluminescence. Thus, GM-CSF could be helpful for giving chemotherapy without neutropenic delays and for prophylaxis of infectious complications in CLL patients.

L-myc and N-myc in hematopoietic malignancies.

The myc proto-oncogenes encode nuclear DNA-binding phosphoproteins which regulate cell proliferation and differentiation. The c-myc gene is implicated in hematopoietic malignancies on the basis of its frequent deregulation in naturally occurring leukemias and lymphomas. Recent evidence suggests that also the N-myc and L-myc genes may have a role in normal and malignant hematopoiesis. N-myc and to a certain degree L-myc can substitute for c-myc in transformation assays in vitro, and their overexpression can block the differentiation of leukemia cell lines. Immunoglobulin heavy chain enhancer (IgH) -driven overexpression of N-myc or L-myc genes cause lymphatic and myeloid tumors, respectively, in transgenic mice. Furthermore, the L-myc and N-myc genes are expressed in several human leukemias and leukemia cell lines, L-myc predominantly in myeloid and N-myc both in myeloid and in some lymphoid leukemias. All N/L-myc positive leukemias and leukemia cell lines coexpress the c-myc gene, thus exemplifying a lack of negative cross-regulation between the different myc genes in leukemia cells. Taken together, these data suggest that L-myc and N-myc may participate in the growth regulation of hematopoietic cells.

Comparative analysis of minimal residual disease detection by multiparameter flow cytometry and enhanced ASO RQ-PCR in multiple myeloma.

Multiparameter flow cytometry (MFC) and allele-specific oligonucleotide real-time quantitative PCR (ASO RQ-PCR) are the two most sensitive methods to detect minimal residual disease (MRD) in multiple myeloma (MM). We compared these methods in 129 paired post-therapy samples from 22 unselected, consecutive MM patients in complete/near complete remission. Appropriate immunophenotypic and ASO RQ-PCR-MRD targets could be detected and MRD analyses constructed for all patients. The high PCR coverage could be achieved by gradual widening of the primer sets used for clonality detection. In addition, for 13 (55%) of the patients, reverse orientation of the ASO primer and individual design of the TaqMan probe improved the sensitivity and specificity of ASO RQ-PCR analysis. A significant nonlinear correlation prevailed between MFC-MRD and PCR-MRD when both were positive. Discordance between the methods was found in 32 (35%) paired samples, which were negative by MFC-MRD, but positive by ASO RQ-PCR. The findings suggest that with the described technique, ASO RQ-PCR can be constructed for all patients with MM. ASO RQ-PCR is slightly more sensitive in MRD detection than 6-10-color flow cytometry. Owing to technical demands ASO RQ-PCR could be reserved for patients in immunophenotypic remission, especially in efficacy comparisons between different drugs and treatment modalities.