Treatment Of Lymphoproliferative Disease Research Articles

Different Epstein-Barr Virus DNA Load and Immune Reconstitution Following Hematopoietic Stem Cell Transplantation Depending on Antithymocyte Globulin Preparation.

Epstein-Barr virus (EBV)-associated lymphoproliferative disease (LPD) is a serious complication following hematopoietic stem cell transplantation (HSCT). In 86 patients undergoing HSCT in a single center we prospectively performed a quantitative EBV-specific polymerase chain reaction in peripheral blood mononuclear cells (PBMC) weekly after HSCT. Cellular immune reconstitution was monitored by flow cytometric analysis on days 30 and 60 after transplantation. We observed an EBV reactivation (>103 EBV-genome copies/105 PBMC) only in patients who received antithymocyte globulin (ATG) for immunosuppression. 15 of 46 patients (33%) who received ATG experienced EBV reactivation. Interestingly, we found a similar incidence of EBV reactivation in 7 of 21 patients (33%) who received ATG (Fresenius) at a median total dose of 40 mg/kg and in 8 of 26 patients (31%) who received ATG (Sangstat) at a median total dose of 20 mg/kg. However, in patients with ATG (Fresenius) EBV reactivation was observed only in the range between 103 and 104 EBV-genome copies/105 PBMC and no EBV-associated LPD occurred. In contrast, in patients with ATG (Sangstat) EBV reactivation was always greater than 104 EBV-genome copies/105 PBMC. Median values for CD3+ cells were 157.7/μl versus 1.5/μl on day 30 and 327.0/μl versus 15.5/μl on day 60 in the group receiving ATG (Fresenius) or ATG (Sangstat), respectively. For CD3+CD4+ cells the corresponding numbers were 57.8/μl versus 0.5/μl on day 30 and 90.8/μl versus 10.0/μl on day 60. Median values for CD3+CD8+ cells were 89.4/μl versus 0.3/μl on day 30 and 237.3/μl versus 9.4/μl on day 60 in the group receiving ATG (Fresenius) or ATG (Sangstat), respectively. Patients with ATG (Sangstat) had significantly lower numbers of CD3+, CD3+CD4+, and CD3+CD8+ cells than patients with ATG (Fresenius) on day 30 (P <.001) and day 60 (P <.03). Four patients who received ATG (Sangstat) developed EBV-associated LPD at a median of 80 days after HSCT. The increase of EBV-genome copies occurred 1–5 weeks before the onset of LPD. After treatment of LPD 3 of 4 patients demonstrated a dramatic decrease of EBV-genome copies and survived, while the fourth patient died of lymphoma. All 4 patients with EBV-associated LPD presented with a high copy number (>104 EBV-genome copies/105 PBMC). In contrast, 79 patients who had a copy number lower than 104 EBV-genome copies/105 PBMC did not develop EBV-associated LPD (P <.001). This finding prompted us to start pre-emptive therapy in patients with a high copy number for prevention of EBV-associated LPD. Three patients developed a high viral load (>104 EBV-genome copies/105 PBMC). Pre-emptive therapy was performed with a single dose of rituximab (375 mg/m2) at a median of 52 days after HSCT. Following administration of rituximab a dramatic decrease of EBV-genome copies and B cells was observed. In all 3 patients no EBV-associated LPD occurred until 6 months after rituximab infusion. We conclude that in comparison to ATG (Fresenius) the use of ATG (Sangstat) as part of the conditioning regimen leads to a significant delay in T-cell reconstitution and to a significantly higher increase of EBV DNA load which predicts for EBV-associated LPD. Pre-emptive therapy with rituximab results in a dramatic decrease of EBV-genome copies and B cells and appears to be effective for preventing EBV-associated LPD.

A Novel N-Oxide Drug, AQ4N, Has In Vitro Activity in Lymphoma and Leukemia Cell Lines and Selectively Targets Lymphocytes and Lymphatic Tissues in Vivo.

An ideal treatment for lymphoma and leukemia is the use of highly selective compounds to eliminate diseased cells with minimal systemic toxicity to normal tissues (cf. imatinib mesylate; Gleevec). AQ4N (1,4 bis[[2-(dimethylamino)ethylamino}-5,8-hydroxyanthracene-9,10-dione bis N-oxide) is designed to have little or no toxicity until selectively activated by bioreduction in hypoxic cells to AQ4 (reduced AQ4N), a highly potent DNA topoisomerase II inhibitor. In a series of studies, AQ4 has been shown to have potent cytotoxicity on lymphoma and leukemia cell lines in vitro and AQ4N has selective activity in lymphatic tissues in vivo. The IC50 of AQ4, was 0.63, 12.0, 90.5 and 150 nM in Namalwa, Daudi, Ramos, and Raji human lymphoma cell lines and 1.0, 6.0, and 20 nM in HL-60, KG1a and K562 human leukemia cell lines. On several of the tumor lines the activity of AQ4 was more potent than doxorubicin (i.e. IC50 for Dox was 20.3 nM on Namalwa). AQ4N also had anti-proliferative activity at μM levels indicating a potential mechanism for activation by these cell lines. In repeat dose toxicology studies of AQ4N in pigmented rats and cynomolgus monkeys, the maximum tolerated doses (MTD; rats: 20 mg/kg/wk x 6; monkeys 6 mg/kg/wk x 6) resulted in lymphoid tissue atrophy. A decrease in lymphocyte levels and atrophy of the spleen, thymus, and mandibular and mesenteric lymph nodes were observed at terminal sacrifice of the animals. In contrast, there was an absence of myelosuppression and only mild neutropenia and minor bone marrow atrophy at the MTD. Administration of radiolabeled AQ4N (14C-benzene) to pigmented rats and cynomolgus monkeys indicated persistence of AQ4N radioactivity in lymphoid tissues for several weeks after a single dose (rats: 20 mg/kg (130–140 μCi/kg); monkeys: 10 mg/kg (135 μCi/kg)). For example, in rats the half-life of radioactive AQ4N in the spleen was 538 hrs with 0.9 μg AQ4N/g tissue (spleen) remaining one week after dosing. Monkeys demonstrated a similar effect with 76.5–86.8 μg AQ4N/g tissue observed in the spleen one week after treatment. Other tissues contained significantly less radioactive AQ4N with the exception of the liver (67.9–78.6 μg AQ4N/g tissue) and adrenal cortex (78.7–86.6 μg AQ4N/g tissue). While some hypertrophy and eosinophila was observed in the adrenal glands, liver toxicity was not observed at the MTD in the repeat dose cynomolgus monkey toxicology study. Overall, these initial findings indicate that AQ4N is active in vitro against human lymphoma and leukemia cell lines and selectively targets lymphoid tissues in vivo suggesting the potential benefit of AQ4N in the treatment of lymphoproliferative diseases.

Reconstitution of EBV-Specific T Cell Immunity in Solid Organ Transplant Recipients

EBV-specific autologous CTL were grown in vitro from three adults (two liver transplant recipients and one patient on hemodialysis awaiting kidney retransplant). All CTL lines were TCR alphabeta, CD8 positive cells, EBV specific, and MHC class I restricted. The CTL lines were expanded in vitro and infused in three escalating doses (5 x 10(7), 1 x 10(8), and 2 x 10(8) at monthly intervals. Weekly blood samples were collected following each infusion. EBV-specific CTL precursor cells in peripheral blood were quantitated by limiting dilution analysis, and their effect on EBV load in vivo was assessed by semiquantitative PCR. In all three patients, the numbers of CTL precursor cells increased during the weeks following the infusions and were highest after the third infusion. This level gradually declined but remained above the preinfusion levels for up to 3 mo. EBV genome copy number, on the other hand, dropped following the first infusion and became undetectable thereafter. The EBV DNA level remained lower than the pretransplant level in all patients for up to 3 mo after the last infusion. Our study shows that it is feasible to generate and expand EBV-specific CTL from pretransplant blood samples of solid organ transplant recipients, that these CTL can be stored and infused posttransplant, and that they remain cytotoxic and EBV specific in vivo. The aim of this study is to use these CTL for prevention and treatment of lymphoproliferative disease in solid organ transplant recipients.

Lymphoproliferative disorders and motor neuron disease: an update.

We studied 26 patients with both motor neuron disease and lymphoproliferative disease (LPD). Twenty-three patients had definite or probable upper motor neuron signs; none had electrophysiologic evidence of motor neuropathy. LPD syndromes comprised Waldenström's macroglobulinemia, multiple myeloma, chronic lymphocytic leukemia, follicular cell lymphoma, and Hodgkin's disease. In all but one patient, the cause of disability or death was neurologic. LPD was confined to bone marrow in 14 patients; eight of 14 had monoclonal paraproteinemia. One patient had LPD discovered at autopsy. Treatment of LPD in 20 patients resulted in neurologic improvement in 1 patient and arrest in another; both had progressive spinal muscular atrophy. Eleven patients were worse and 13 died. At least 30 cases have been reported from other centers, bringing the total to 56. Among the unusual reported concomitants were POEMS (polyneuropathy, organomegaly, endocrinopathy, myeloma, and skin changes) syndrome of myeloma and angiotropic lymphoma.

10 years of pediatric liver transplantation

Purpose: Pediatric liver transplantation is an accepted therapy for end-stage liver disease, but little long-term data exist. Methods: From October 1984 to October 1994, 202 patients underwent a total of 225 liver transplantations. There were 98 boys and 104 girls, the average age was 5.1 ± 4.9 (range, 0.2 to 19.1) years. Thirty (16%) were under 1 year of age. The diseases that required transplantation included biliary atresia (BA) (45%), metabolic liver disease (MLD) (9.9%), acute hepatic failure (6.9%), and Alagille's syndrome (AS) (5.4%). Originally the immunosuppression was cyclosporine- and steroid-based; the later regimens also included azathioprine and antilymphocyte preparations. All reported survival rates were derived from life-table analysis. Results: The patient survival rates at 1, 5, and 10 years were 76%, 70%, and 61%; the retransplantation rate was 11%. The respective graft survival rates were 71%, 63%, and 59%. There were 60 deaths; 48 (81%) occurred in the first year. These first-year deaths were from sepsis (20; 42%), central nervous system problems (5; 11%), intraoperative complications (4; 8%), lymphoproliferative disease (LPD) (2; 4%), rejection (2; 4%), primary nonfunction (2; 4%), and miscellaneous other causes (7; 15%). There were 12 deaths after the first year, from LPD (3; 25%), sepsis (1; 8%), rejection (2; 18%), cancer (1; 9%), secondary hepatic failure (1; 9%), cerebral vascular accident (1; 9%), or pre- or postoperative complications (3; 25%). Compared with the overall survival rate, patients with MLD had a better chance of survival (83%; P < .012) than did those with AS (45%; P < .001). The 5- and 10-year survival rates for patients with BA were 61% and 58%. Over the past 2 years, the survival rate has increased (87% v 72%; P < .05) as early septic deaths have decreased (from 2.6 to 1.0 per year). Conclusion: Liver transplantation is effective treatment for end-stage liver disease. Decreasing the number of early septic deaths has improved the chance of survival, and better diagnosis and treatment of LPD would improve the late survival rate.

Biologic response modifiers

Some biologic agents have proven effective in the treatment of lymphoproliferative diseases by stimulating host antitumor immunity or by applying active antitumor properties that specifically or nonspecifically effect tumor growth or tumor survival. These agents include interferons, which regulate cell gene expression, structure, and function; interleukin-2, which has several functions related to lymphoproliferation and mediation of lymphoid cell transport; anti-idiotype antibodies, which appear to cause a specific antiproliferative response against the patient's tumor; anti-idiotype vaccines, which produce cyclic complementary binding sites and idiotypes to induce specific immunity to tumors with resultant antitumor activity; radioisotope labeled monoclonal antibodies, which directly deliver tumoricidal doses of radiation to tumors, sparing normal tissue toxicity; and monoclonal antibody-immunotoxin conjugates, which directly deliver tumoricidal doses of radiation to tumors, sparing normal tissue toxicity. Encouraging results have been seen in clinical studies with these agents and much knowledge has been gained regarding the mechanisms involved. These findings dictate ongoing therapy modifications to produce continuing progress in the therapeutic applications of biologic agents in lymphoproliferative disease processes.

ANTI-IL-2 Receptor Antibody Treatment for Lymphoproliferative Disease: Transient Response in A Case of Ki-1+ Anaplastic Large Cell Lymphoma.

Most cases of Ki-1 + anaplastic large cell lymphomas (ALCL) express the CD25 antigen, and we have recently shown that IL-2 producing cells can also be detected in these lymphomas. The latter cells may thus constitute targets for anti-CD25 Mab treatment. In one patient with a chemoresistant disseminated Ki-1 + ALCL such a therapeutic approach was undertaken. We report the dramatic antitumoral effect of anti-CD25 Mab obtained in this patient. This confirms the observation, previously reported in adult T cell leukemia, showing that this therapeutic regimen is also efficient in CD25 + solid tumors.

On the potential role of cyclosporin in the treatment of lymphoproliferative diseases

Lymphomas and leukemias, as cancers of the immune system, may still retain some susceptibility to regulatory mechanisms which govern the proliferation of their cells of origin. According to this concept, an enhanced immune suppression as induced by irradiation and chemotherapy may contribute to their cytotoxic effect in inducing and maintaining a remission of the disease. Cyclosporin selectively and reversibly inhibits activation and proliferation of both normal and neoplastic T lymphocytes. In-vitro experiments and preliminary clinical data from small uncontrolled studies indicate that cyclosporin might be a promising agent in the treatment of mycosis fungoides, Hodgkin's disease, acute leukemia, and possibly other lymphoproliferative disorders, but the experience is still limited and no definitive conclusions may be made. In addition to its direct effect on lymphocytes, cyclosporin reverses the resistance of cancer cells to several antineoplastic agents and may thus find its place in combination with chemotherapy. It is hoped that a more systematic basic and clinical research will help define the role of this new therapeutic approach.

Deoxycoformycin-induced response in chronic lymphocytic leukaemia: deoxyadenosine toxicity in non-replicating lymphocytes

The occurrence of severe immunodeficiency disease in children with inherited adenosine deaminase deficiency, and reports of remission induction in T-cell acute lymphoblastic leukaemia with the adenosine deaminase inhibitor deoxycoformycin, prompted a study of the effects of deoxyadenosine on resting peripheral blood lymphocytes (PBL) and chronic lymphocytic leukaemic (CLL) lymphocytes in short-term culture. In the presence of an inhibitor of adenosine deaminase, micromolar concentrations of dAdo caused elevation of deoxyadenosine-5'-triphosphate (dATP) pools and in vitro lysis of non-dividing PBL and CLL lymphocytes. This death of non-replicating cells indicates a mechanism of deoxyadenosine toxicity independent of DNA replication and ribonucleotide reductase inhibition. Similar changes occurred in vivo in a patient with advanced CLL who responded to treatment with deoxycoformycin, 0.1 mg/kg, days 1-5, with a fall in the WCC from 102.0 x 10(9)/1 to 6.8 x 10(9)/l over 21 d. Therapeutic blockade of deoxyadenosine catabolism deserves further investigation both in the treatment of lymphoproliferative disease and as a method lympholytic immunosuppression.