A prospective observational study to evaluate G-CSF usage in patients with solid tumors receiving myelosuppressive chemotherapy in Italian clinical oncology practice.

Febrile neutropenia (FN) is a severe dose-limiting side effect of myelosuppressive chemotherapy in patients with solid tumors. Clinical practice guidelines recommend primary prophylaxis with G-CSF in patients with an overall ≥ 20 % risk of FN. AIOM Italian guidelines recommend starting G-CSF within 24-72 h after chemotherapy; for daily G-CSF, administration should continue until the absolute neutrophil count (ANC) is 1 × 10(9)/L post-nadir and should not be terminated after ANC increase in the early days of administration. The aim of this study was to assess guideline adherence in oncology practice in Italy. In this multicenter, prospective, observational study, patients were enrolled at the first G-CSF use in any cycle and were followed for two subsequent cycles (or until the end of chemotherapy if less than two additional cycles). Primary objective was to explore G-CSF use in Italian clinical practice; therefore, data were collected on the G-CSF type, timing of administration, and number of doses. 512 eligible patients were enrolled (median age, 62). The most common tumor types were breast (36 %), lung (18 %), and colorectal (13 %). A total of 1,164 G-CSF cycles (daily G-CSF, 718; pegfilgrastim, 446) were observed. Daily G-CSF was administered later than 72 h after chemotherapy in 42 % of cycles, and the median [range] number of doses was four [1, 10]. Pegfilgrastim was administered later than 72 h in 8 % of cycles. G-CSF prophylaxis in Italy is frequently administered in a manner which is not supported by evidence-based guidelines. As this practice may lead to poor outcomes, educational initiatives are recommended.

Influence of marrow CFU-GM content on engraftment and survival after allogeneic bone marrow transplantation.

The influence of the CFU-GM content of donor marrow on the outcome of allogeneic marrow transplantation (BMT) has been debated. We now report 38 patients (25 acute leukemias, 10 chronic myeloid leukemias, two myeloma; 24 in first CR/CP and 14 in more advanced phases of their disease) undergoing unmanipulated HLA-identical sibling BMT following conditioning with cyclophosphamide and total body irradiation (TBI). The median number of nucleated cells infused was 4.3 x 10(8)/kg (range 1.5-8.4); median CFU-GM numbers were 2.4 x 10(4)/kg (range 0.1-46). End-points of the study were (1) speed of neutrophil and platelet engraftment; (2) quality of engraftment beyond day +50 after BMT; and (3) transplant-related mortality in patients stratified according to whether they had received less than (n = 18) or more than (n = 20) 2.4 x 10(4)/kg CFU-GM. These two groups were comparable for diagnosis, disease status, donor sex, donor age, recipient sex, recipient age, CVHD prophylaxis, number of cells infused and CMV serology. Neutrophil counts were comparable at all time intervals. There was also no difference in platelet counts on days +7 to +50. However, patients who had received higher CFU-GM numbers had significantly higher platelet counts on day +80 (149 vs. 75 x 10(9)/L; P = 0.002), day +100 (153 vs. 77 x 10(9)/L; P = 0.0009) and day +150 (179 vs. 95 x 10(9)/L; P = 0.01). The 2-year actuarial transplant-related mortality was 5% vs. 53% (P = 0.007) in patients receiving high or low numbers of CFU-GM.(ABSTRACT TRUNCATED AT 250 WORDS)

Allogeneic bone marrow transplantation for acute myeloid leukemia in first complete remission: the effect of FAB classification and GVHD prophylaxis.

Ninety-one patients with de novo acute myeloid leukemia (AML) in first complete remission (CR) undergoing an HLA-identical sibling BMT and with a minimum follow-up of 12 months were analyzed for disease-related and transplant-related variables predicting survival and relapse. The overall actuarial 5 year survival is 53% and the relapse rate 29%, with a medium follow-up for surviving patients of 1552 days (range 365-4094 days). In univariate analysis the following variables were found to be associated with an increased risk of failure: high-dose cyclosporin (CsA), M4-M6 FAB subtype and a long interval (> or = 180 days) between diagnosis and BMT. Other disease-related variables at presentation were not significant, including WBC count > 50 x 10(9)/l, marrow blasts < 70%, time to enter remission > 40 days and > 2 courses to enter remission. Survival was 58% vs 43% for M1-M3 vs M4-M6 FAB subtypes (p = 0.03) and 71% vs 42% for low-dose vs high-dose CsA (p = 0.01). A multivariate analysis was then run separately on survival, relapse and transplant related mortality (TRM). Survival was negatively influenced by M4-M6 FAB subtypes (p = 0.009), high-dose CsA (p = 0.03) and a long interval between diagnosis and BMT (p = 0.04). Leukemia relapse was higher in patients receiving high-dose CsA (p = 0.003) and in females (p = 0.04). Transplant-related mortality was higher in FAB M4-M6 patients (p = 0.01) and patients grafted late after diagnosis (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Metastatic bone tumors. Nonsurgical treatment. Outcome and survival.

Of 683 (16.1%) consecutive patients investigated from October 1984 to December 1985, 110 had various malignant tumors and secondary bone involvement. In 82 of 110 patients (74.5%), the primary tumor was located in the breast, and the percentage of clinical and radiographic objective responses (OR) of their bone lesions (42.7% and 22.8%, respectively) was higher than for cancer in other sites (clinical OR, 21.4%; radiographic OR, 15.8%). The average survival time of 82 breast cancer patients was 87.4 months, or 38 months from the diagnosis of the bone metastases. Of the 110 patients with bone metastases, 60 patients (54.5%) had secondary spinal involvement. The clinical and radiographic OR (38.4% and 30.2%) were better in the patients with vertebral metastases than in the patients with bone metastases in other sites (clinical OR, 36%; radiographic OR, 9.1%). The average survival time of the patients with vertebral involvement was 99.4 months, or 40.4 months from the time of diagnosis of the bone metastases. From the results obtained, in terms of OR and survival for patients with bone metastases, early and aggressive treatment should be considered to improve the patients' life quality.

In vitro effect of stem cell factor on colony growth from acquired severe aplastic anemia.

In this study we review our present understanding of the effect of stem cell factor (SCF) on the in vitro growth of hemopoietic progenitors from patients with acquired severe aplastic anemia (SAA). We have run three separate sets of experiments. First, we have tested the expression of receptor mRNAs for granulocyte-macrophage colony stimulating factor/interleukin 3 (GM-CSF/IL-3) and for c-kit protein on bone marrow (BM) cells from SAA patients. Molecular analysis revealed the presence of normal transcripts for alpha and beta chains of GM-CSF/IL-3 receptor and for c-kit protein by Northern blot analysis. Second, we have tested the in vitro response to SCF of BM cells derived from 11 SAA patients: SCF induced a significant enhancement of erythroid burst forming unit (BFU-E) growth (8 to 29, p = 0.01) and allowed the formation of granulocyte/erythroid/macrophage/megakaryocyte (GEMM) colonies which were not scored in baseline culture conditions (0 to 8, p = 0.01). Granulocyte-macrophage colony forming unit (CFU-GM) growth was also enhanced (4 to 20, p = 0.3). This was true for patients both at diagnosis and after antilymphocyte globulin (ALG) treatment. We concluded that SCF can promote the in vitro growth of hemopoietic progenitors in patients with acquired SAA. Third, we have tested the response to SCF of peripheral blood (PB) hemopoietic progenitors collected from patients receiving in vivo long-term treatment with granulocyte CSF (G-CSF). When PB cells were plated directly in the presence of GM-CSF there was no colony formation.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone marrow harvest for marrow transplantation: effect of multiple small (2 ml) or large (20 ml) aspirates.

The aim of this study was to evaluate the yield of nucleated cells and CFU-GM and the T cell composition in bone marrow harvested by means of multiple small (2 ml) or large (20 ml) aspirations. Eleven marrow donors were studied: each donated 1000 ml of bone marrow in two aliquots of 500 ml for an HLA identical sibling transplant. In six cases the first 500 ml were harvested by means of multiple 2 ml aspirations (A) and the second 500 ml by means of 20 ml aspirations (B). In five cases the opposite was done: 20 ml aspirates first (C) and 2 ml afterwards (D). From each 500 ml aliquot a sample was taken for enumeration of nucleated cells and CD3+ lymphocytes and for CFU-GM growth. Small volume aspirations (groups A and D) yielded more nucleated cells (p = 0.02), more CFU-GM (p = 0.03) and fewer CD3+ cells (p = 0.1) when compared with large volume aspirations (groups B and C). This study shows that marrow harvesting by means of multiple small volume aspirations minimizes the dilution with peripheral blood and results in greater numbers of cells and hemopoietic progenitors.

Doxorubicin (or epidoxorubicin) combined with ifosfamide in the treatment of adult advanced soft tissue sarcomas.

The results of the association of doxorubicin plus ifosfamide in the treatment of locally advanced and/or metastatic adult soft tissue sarcomas as reported in the literature from 1986 up to the present time are reviewed. The data confirm the effectiveness of the association doxorubicin plus ifosfamide, with an objective response rate of 33.25% (range, 22% to 42%), with 9.3% of complete responses. The highest percentages were reported in studies using doses of doxorubicin of 60 mg/m2 or higher, with a suggested dose-response correlation. The pattern is generally well tolerated, with a prevalently haematological toxicity. Results being equal, the use of epidoxorubicin seems to allow a lower incidence of high grade leukopenia, and an higher dose-intensity of the drug administered. The two randomized studies by EORTC and ECOG indicate superiority of this combination compared to doxorubicin on its own or with other polychemotherapeutic regimens containing doxorubicin, without ifosfamide. However, the actual contribution of ifosfamide deserves further investigation. The impact on long-term disease-free survival is, however, poor and median survival time ranges from 8 to 12 months in responder patients. Future studies should be aimed at increasing the dosages of the drugs without a significant increase of toxicity, by administering them in continuous infusion or by the use of growth factors.

Concomitant radiation-doxorubicin administration in locally advanced and/or metastatic soft tissue sarcomas: preliminary results.

Doxorubicin was administered by continuous infusion at a dosage of 12 mg/sqm/day for 5 days concomitantly with radiation treatment (150 or 200 cGy/day for trunk or extremity lesions, respectively) for 5 days. The 5-day cycles were repeated every 3 weeks. Seventeen patients, 5 of whom were pretreated, entered the study; all were assessable for toxicity and 15 for response. The overall objective response rate was 46% (7/15): 1 complete and 6 partial responses. Response rate reached 54% in only non-pretreated patients (6/11) and 75% in patients with PS less than or = 2 (6/8). No disease progression was observed during treatment. The median duration of complete or partial responses was 28 weeks (range 5-86). Toxicity was low and treatment very well tolerated. In our preliminary analysis, the response rate obtained with this combined chemo-radiotherapic regimen was encouraging and the toxicity was acceptable.

Response of CFU-GM to increasing doses of rhGM-CSF in patients with aplastic anemia.

The aim of this study was to test whether large amounts of recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) are capable of promoting the growth of hemopoietic progenitors from patients with marrow failure. For this purpose 0.1, 100, 1000, 10,000 and 20,000 ng/ml of rhGM-CSF were added to 10(5) light-density (adherent cell-depleted) bone marrow cells from 9 normal controls and from 52 patients with aplastic anemia, 25 cases of which were transfusion-dependent (Tx-D) aplastic anemia (AA) and 27 of which were transfusion-independent (Tx-I) aplastic anemia (AA). A dose-dependent increase of granulocyte-macrophage colony-forming units (CFU-GM) was observed in healthy donors, from 81 to 247 colonies at 0.1 and 1000 ng/ml of rhGM-CSF, with a plateau thereafter. Tx-I AA patients showed the best increase of CFU-GM in response to colony-stimulating factor, from 0.1 to 32.7 mean colonies at 0.1 and 20,000 ng/ml of rhGM-CSF, and the increment was greater when compared to controls. The ratio of CFU-GM grown from these patients and controls was 1:810 at 0.1 ng/ml of rhGM-CSF and 1:7.9 at 20,000 ng/ml. Eleven patients were studied at diagnosis; there was no in vitro response to rhGM-CSF (0 and 1.8 mean colonies/10(5) cells at 0.1 and 10,000 ng/ml). Overall, Tx-D AA patients showed minimal increments of CFU-GM growth at very high doses of rhGM-CSF. Two suggestions come from this study: 1) maturation of CFU-GM from recovering AA patients appears to require larger doses of GM-CSF than normal controls, and 2) very high doses of rhGM-CSF have little or no effect on CFU-GM growth in AA patients. This may be relevant for clinical studies designed to improve hemopoiesis in patients with marrow failure.

In vitro response of T cells from aplastic anemia patients to antilymphocyte globulin and phytohemagglutinin: colony-stimulating activity and lymphokine production.

The aim of the present study was to compare the response of bone marrow (BM) lymphocytes from patients with aplastic anemia (AA) or normal controls to increasing doses of antilymphocyte globulin (ALG) or phytohemagglutinin (PHA). For this purpose BM T-enriched cells from 11 AA patients and 9 normal individuals were incubated with ALG (0-1000 micrograms/ml) or PHA (0%-10%) for 1 day, and the supernatants were tested for suppression/enhancement of granulocyte-macrophage colony-forming unit (CFU-GM) growth and for release of granulocyte-macrophage colony-stimulating factor (GM-CSF), tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma) assayed with the enzyme-amplified sensitivity immunoassay (EASI). The production of colony-stimulating activity (CSA) by T cells primed with ALG and tested in the absence of exogenous GM-CSF correlated with the dose of ALG in priming cultures up to 14% EG (100% EG = CFU-GM growth with 30 ng/ml of GM-CSF). The amount of GM-CSF in the supernatants paralleled their capacity to sustain CFU-GM growth (up to 3.5 ng/ml of GM-CSF). Production of CSA or GM-CSF from T cells primed with PHA was significantly lower. Supernatants of PHA-primed T cells, when added to normal BM cells in the presence of exogenous GM-CSF, produced a dose-dependent inhibition of CFU-GM growth (down to 13% +/- 10% EG). The same supernatants contained detectable amounts of IFN-gamma and TNF-alpha (21 +/- 6.7 IU/ml and 4.6 +/- 2.9 ng/ml, respectively). IFN-gamma production from severe AA (SAA) T cells in response to PHA was significantly superior to the IFN-gamma production from normal T cells (21 +/- 6.7 IU/ml vs 9.5 +/- 7.1 IU/ml, p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Increased risk of leukemia relapse with high-dose cyclosporine A after allogeneic marrow transplantation for acute leukemia.

Eighty-one patients with acute myeloid leukemia (ANLL, n = 44) or acute lymphoblastic leukemia (ALL, n = 37), aged 10 to 50 years were randomized to receive 1 mg/kg per day (n = 41, group A) or 5 mg/kg per day (n = 40, group B) of cyclosporine A (CyA) from day -1 to day +20 after bone marrow transplant (BMT). All patients received CyA orally thereafter. All patients were prepared with cyclophosphamide (CY) 120 mg/kg and fractionated total body irradiation (TBI), and received unfractionated BM from an HLA-identical sibling. The two groups were comparable for diagnosis, disease status, French-American-British (FAB) classification, WBC count at diagnosis, cytogenetic abnormalities, extramedullary disease before BMT, donor/recipient age and sex, number of cells infused, and number of days with intravenous (IV) CyA. Median follow-up for surviving patients in group A was 983 v 632 days in group B. Patients in group A had lower serum levels of CyA (295 v 686 ng/mL, P = .004), lower bilirubin levels (1.9 v 2.6 mg/dL, P = .07), lower creatinine levels (0.9 v 1.4 mg/dL, P = .06), and a lower proportion of CD8+ cells in the peripheral blood (PB) within day +21 (19% v 28%, P = .07). First day to 0.5 x 10(9)/L neutrophils was comparable in the two groups (13 v 14 days; P = .1). In a Cox model, the actuarial risk of acute graft-v-host disease (GVHD) grade II+, after stratification for age (less than 20 years greater than) was significantly lower in group B patients (0.54, P = .04). The actuarial risk of developing chronic GVHD was comparable (P = .9). Actuarial transplant-related mortality (TRM) at 240 days was 28% and 26% (P = .8) in group A and B: the major cause of death was GVHD in group A (P = .02) and multiorgan toxicity in group B (P = .07). The actuarial risk of relapse at 2 years overall was 20% in group A and 52% in group B (P = .001); it was 9% v 43%, respectively, for patients in first remission (P = .0001) and 48% v 63% for patients in non-first complete remission (CR) (P = .1). Actuarial 2-year disease-free survival (DFS) in group A and B was 58% v 32% (P = .02) for all patients, 71% v 35% (P = .01), in first remissions, and 30% v 23% (P = .2) in advanced disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Mixed chimerism after allogeneic marrow transplantation for leukaemia: correlation with dose of total body irradiation and graft-versus-host disease.

Fifty-four patients allografted for leukaemia were evaluated at various intervals after bone marrow transplantation for the presence of host haemopoiesis using red blood cell and cytogenetic markers. Out of 40 patients in remission, 10 showed functional host and donor haemopoiesis (mixed chimerism), whereas in the other 30 (complete chimerism) host haemopoiesis was never detected. Seven of the 14 evaluable patients who relapsed showed the reappearance of host haemopoiesis at the time of relapse. Analysis of the dose of total body irradiation (TBI) indicated that patients who achieved mixed chimerism, whether or not they relapsed, had received significantly lower doses than those with complete chimerism. However, some patients with complete chimerism had received a TBI dose equivalent to the dose received by those with mixed chimerism, suggesting that the TBI dose is not the only factor determining the reappearance of host haemopoiesis. The data on chimerism and relapse suggest that there is heterogeneity in radiosensitivity between normal marrow cells and leukaemic cells, and also within the different types of leukaemia. The incidence/severity of acute and chronic graft-versus-host-disease (GVHD) was significantly higher in patients with complete chimerism than in mixed chimeras, suggesting that mixed chimerism may play a role in the development of tolerance. Alternatively the absence of GVHD (i.e. tolerance) may be responsible for the persistence of host haemopoietic cells.

[Immunologic study of patients with chronic pharyngitis]. / Studio immunologico in pazienti affetti da faringite cronica.

The immunological status of 20 patients with chronic pharyngitis was studied. In 55% an increase of the T suppressor population was present while an inversion of T4/T8 ratio have a statistical significance compared with the control group (p = 0.029 and p = 0.003 respectively). The conclusion is drawn that an immunodeficiency is present in such patients and that treatment with immunostimulation drugs is justified.