Hepatocyte growth factor levels in bone marrow plasma of patients with leukaemia and its gene expression in leukaemic blast cells.

Hepatocyte growth factor (HGF) has been known as a multiple function factor, which also stimulates early haematopoiesis. In this study, we found that HGF was expressed at both the RNA and protein levels in acute myeloid leukaemia (AML) and chronic myeloid leukaemia (CML). In patients with AML (n = 20) and CML (n = 5), bone marrow plasma HGF concentrations were 20.44 +/- 6.26 (mean +/- s.e.) ng ml-1 and 7.17 +/- 0.53 ng ml-1 respectively. These were significantly higher (P < 0.01) than the value for normal subjects (n = 26): mean 0.92 +/- 0.09 ng ml-1. Constitutive HGF production was observed in freshly prepared leukaemic blast cells from three patients with high HGF levels of bone marrow plasma. Expression of HGF mRNA was correlated with bone marrow plasma HGF levels. After complete remission was obtained in six patients, bone marrow plasma HGF levels were significantly decreased. In contrast, the HGF mRNA was less abundantly expressed in acute lymphoid leukaemia (ALL). In patients with ALL (n = 5), bone marrow plasma HGF concentration (0.69 +/- 0.14 ng ml-1) remained low within the value for normal subjects. These results suggest that some populations of myeloid lineage cells have the ability to produce HGF.     

Clonality analysis suggests that early-onset acute lymphoblastic leukaemia is of single-cell origin and implies no major role for germ cell mutations in parents.

Childhood leukaemia presenting at a young age has been suspected of resulting from a leukaemogenic mutation in parental germ cells, either spontaneously or due to the exposure of a parent to leukaemogenic environmental hazards, particularly ionizing radiation. Mathematical modelling of leukaemogenesis suggests that any such patient would be especially prone to multiple independent leukaemogenic events leading to multiclonality in terms of cell of origin (analogous to bilaterality in familial retinoblastoma). To test this hypothesis we have carried out a search for multiclonal leukaemogenesis in infant and childhood acute lymphoblastic leukaemia (ALL). We used a polymerase chain reaction-based analysis of the X-linked monoamine oxidase A (MAOA) gene locus to study the clonality of marrow samples obtained from female paediatric ALL patients at the time of disease presentation. We obtained presentation samples from 102 patients of whom 72 were found to be informative at the MAOA locus. These included 20 infant leukaemias (< 1 year at diagnosis). Sixty-six samples were found to be unequivocally monoclonal while the remaining six could not, with certainty, be assigned a clonal origin. We also obtained bone marrow aspirates at first relapse as well as at presentation from eight patients. In each case the same pattern of X-linked allelic inactivation was observed at both time points of the course of the disease. No evidence was found for leukaemic multiclonality in any age group at presentation or for leukaemic 'clone-switching' in relapse. These findings suggest that both infant and childhood ALL is of single-cell origin and implies that leukaemic predisposition resulting from germ cell mutation is unlikely to have a major role in their pathogenesis.     

Inhibition of normal human in vitro colony forming cells by cells from leukaemic patients.

Co-culture in agar of normal bone marrow cells from different individuals gave granulocyte macrophage colony counts that were expected from counts made when the marrows were cultured separately. Co-culture of normal marrow with normal peripheral blood leucocytes (which did not themselves give rise to colonies) caused inhibition of colony growth only when the ratio of peripheral blood to bone marrow cells was of the order of 4 : 1. Peripheral blood or bone marrow cells from 7 of 9 patients with acute myelomonocytic leukaemia, which did not give rise to colonies, caused a marked reduction in the number of colonies obtained from normal marrow cells when cultured with them. This inhibitory effect of leukaemic cells was found when ratios of leukaemic to normal cells were as low as 1 : 4. Additional evidence that the inhibition of normal colony formation was related to the leukaemic process was obtained from follow-up studies on one of the patients whose cells lost the capacity to inhibit normal colony formation during remission and became inhibitory again on relapse.     

Prognostic Significance of Bone Marrow Trephine and Peripheral Blood Smears in 55 Patients with Mantle Cell Lymphoma

Bone marrow trephine and peripheral blood smears taken at diagnosis of 55 cases of well-documented mantle cell lymphomas were reviewed in order to analyse the leukaemic involvement in this non-Hodgkin's lymphoma: its incidence, morphological characteristics and prognostic significance. A median survival of 36 months was found. The median age was 61 and the male to female ratio was 4:1. Morphologically 7 cases presented with a mantle zone pattern, all the others had a diffuse pattern. Involvement of the bone marrow was found in 58% and a trend for prolonged survival in patients with a negative trephine was seen. An absolute lymphocytosis above 10,000 μ1 was found at diagnosis in 5 cases (10%) and had a statistically significant impact on survival. An additional 5 cases developed frank leukaemia during the course of the disease and died within 1 to 6 months of this evolution, suggesting that marked lymphocytosis is more a terminal event associated with an extremely poor prognosis than a presenting symptom. Finally we identified an additional parameter with statistically prognostic significance, namely, the presence of atypical cells in the peripheral blood even in the absence of an increased lymphocytosis.     

In vitro sensitivity of clonogenic cells in resisting and relapsing patients with acute myelogenous leukaemia.

The evolution of in vitro bone marrow clonogenic leukaemic cells (CFU-L) drug sensitivity was studied in 23 patients with acute myeloid leukaemia treated with anthracycline and cytosine arbinoside (ara-C). In 12 patients tested before and after first induction treatment failure (interval: 6 +/- 4 weeks), the sensitivity remained stable for daunorubicin and showed little variation for ara-C. Among eleven patients tested before treatment and at first relapse (interval: 13 +/- 7 months), in vitro CFU-L sensitivity revealed no correlation between the two measurements, and a trend in decreased sensitivity to daunorubicin and ara-C. These findings suggest that induction failures could be related to factors other than simple selection of a resistant CFU-L subclone.     

Studies on sensitivity of human GM-CFU and L-CFU to hyperthermic killing in vitro

The thermal sensitivity of normal myeloid and leukaemic cells was compared using morphology, cytochemistry and cultures of granulocyte-macrophage and leukaemic progenitor cells (GM-CFU and L-CFU). We have clearly demonstrated that blast cells from eight cases of acute nonlymphoblastic leukaemia (ANLL) showed greater morphological deterioration and loss of cytoplasmic enzymes with continuous heating at temperatures of 40-43 degrees C than normal marrow mononuclear cells obtained from ten controls. Survival of L-CFU also decreased exponentially with rising temperature whereas GM-CFU were not markedly affected, even at a temperature of 43 degrees C for 30 min. These results suggest that human L-CFU are more sensitive to hyperthermic killing than normal human GM-CFU and that hyperthermia might selectively purge residual leukaemic cells in vitro. Hyperthermia may have a role in clinical autologous bone marrow transplantation (ABMT) for acute leukaemia.     

Relation between leukaemic cell count and degree of maturation in acute myeloid leukaemia

In acute myeloid leukaemia the peripheral leukocyte count is known to be a prognostic factor. The preserved capacity of leukaemic cells to mature has also been suggested to be one. In a series of 179 cases of adult acute myeloid leukaemia peripheral leukaemic cell count and degree of maturation were found to be inversely correlated. As the degree of maturation of leukaemic cells in peripheral blood was lower than that in bone marrow in the majority of cases, blast cells appear to be released more easily from the marrow than cells that have matured to some extent in the direction of the larger promyelocytic or promonocytic cell type. In a series of 35 cases we found peripheral blast cells to be smaller than those in bone marrow. Moreover, central blast cell diameter and peripheral leukaemic cell count were inversely correlated. Therefore, leukaemic cell size or some factor related to it may contribute to the preferential egress of small immature cells from the marrow. Differences in proliferative activity could not account for the inverse correlation between degree of maturation and leukaemic cell count.     

Routine immunofluorescent and histochemical analysis of bone marrow involvement of lymphoma/leukaemia: the use of cryostat sections

Enzyme histochemical and immunohistological (immuno-fluorescence and -peroxidase) techniques have been routinely used for investigating over 70 normal and pathological bone marrow samples. This recently standardized diagnostic procedure is very quick and can be performed in a few hours. In 6 cases the clinical diagnosis of leukaemia/lymphoma has become apparent only after the immunohistological analysis of the bone marrow. In 6 other cases the information about the staging of B cell malignancies was superior in the frozen biopsies to the paraffin embedded preparations. Amongst many other features the monoclonality of B CLL/lymphomas, the special features of B CLL infiltrates (RFA-1+, Leu-1+, HLA-DR+, SmIg+), follicular lymphoma deposits (containing follicular dendritic cells) and non-T, non-B acute lymphoblastic leukaemic blasts (terminal transferase+, HLA-DR+) as well as the sometimes conspicuous presence of infiltrating normal T cells could be clearly and reproducibly demonstrated.     

Differential cytotoxicity of deoxyguanosine and 8-aminoguanosine for human leukemic cell lines and normal bone marrow progenitor cells

The inhibitory effect of deoxyguanosine (GdR) alone or in combination with the purine nucleoside phosphorylase (PNP) inhibitor, 8-aminoguanosine (AG) was tested on human T, B, cALL and myeloid leukaemia cell lines and on normal human bone marrow haemopoietic progenitor cells. GdR was found to be toxic to T-leukaemia cells. AG (100μm ) alone did not have any inhibitory effect, but when used with GdR (2·5 × 10^?5m ) a synergistic effect was seen towards T cells. Incubation with GdR and AG resulted in a marked decrease in cell viability (> 90 per cent in three and > 75 per cent in four of 5 T leukaemic cell lines tested at 72 h). This drug combination did not inhibit the growth of non-T leukaemic cells and was also non-toxic to normal bone marrow multipotent progenitor cells (CFU-GEMM) in vitro. Adenosine deaminase (ADA) acts consecutively with PNP in purine degradation. The addition of an ADA inhibitor, deoxycoformycin and deoxyadenosine, however, did not enhance the toxicity of GdR and AG for T cell leukaemia. The possibility of using GdR and AG for in vitro removal of residual T leukaemic blasts with the sparing of normal bone marrow cells, prior to autologous bone marrow transplantation should be further explored.     

Dysplastic eosinophils in three patients with acute promyelocytic leukaemia

Three cases of acute promyelocytic leukaemia (M3) with dysplastic eosinophils are reported. Promyelocytes from these cases showed classical features of hypergranular acute promyelocytic leukaemia. All the cases had minimal organomegaly and disturbances of coagulation were minimal. All the cases were associated with dysplastic eosinophils in the marrow but very few of these eosinophils were found in peripheral smear. One of the three patients presented with a mass in the vertebral column, a feature not uncommonly seen in a variant form of AML-M2 with eosinophilia. Dysplastic eosinophils appear to arise from leukaemic clone itself. These three cases probably represent hitherto undescribed morphological variant of acute promyelocytic leukaemia where leukaemic cells show limited differentiation capability to dysplastic eosinophils.     

The laminin-derived peptide YIGSR (Tyr-Ile-Gly-Ser-Arg) inhibits human pre-B leukaemic cell growth and dissemination to organs in SCID mice.

The YIGSR (Tyr-Ile-Gly-Ser-Arg) laminin beta1 chain sequence has an inhibitory effect on tumour growth and the metastasis of melanoma and fibrosarcoma cells. In the present study, we investigated whether the multimeric YIGSR peptide (Ac-Y16) has an antiproliferative effect and/or prevents the metastasis of human pre-B acute lymphoblastic leukaemia cells (NALM6) in severe combined immune deficient (SCID) mice. In in vitro studies, Ac-Y16 significantly inhibited leukaemic cell colony formation and the invasion of NALM6 cells in a Matrigel-based assay. The tumour growth and leukaemic infiltration in peripheral tissues were also analysed in SCID mice 9 weeks after NALM6, Matrigel and Ac-Y16 were subcutaneously co-injected. The weight of the subcutaneous tumours was significantly suppressed by Ac-Y16 in a dose-dependent manner. Flow cytometry analysis showed that the leukaemic infiltration was significantly inhibited in all organs with 1.5-2.0 mg of Ac-Y16. Leukaemic infiltrations in the brain were inhibited with 0.5 mg of Ac-Y16, and those in brain and bone marrow were also inhibited with 1.0 mg of Ac-Y16. With Ac-S16, a control-scrambled peptide, the only significant inhibition of the leukaemic infiltration was observed in bone marrow at a much higher dose. These data suggest that the multimeric YIGSR peptide can inhibit the tumour growth and metastasis of leukaemic cells and may be useful as a potential therapeutic reagent for leukaemic infiltrations.     

Eradication of leukaemic marrow and prevention of leukaemia relapse with total body irradiation and bone marrow transplantation.

A series of studies was carried out to determine the effect of allogeneic bone marrow transplantation (BMT) on leukaemia. The study aimed at two different, but strictly linked issues: (1) identification of the eradication capability of BMT, and (2) evaluation of the effect of BMT, both in preventing relapse and in producing long-term disease-free survival. 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. Among 40 patients in remission, 10 showed functional host and donor haemopoiesis (mixed chimerism), while in 30, host haemopoiesis was never detected (complete chimerism). Seven of the 14 evaluable patients who relapsed showed the reappearance of host haemopoiesis at the time of relapse. The records of received doses of TBI indicate that patients who achieved mixed chimerism, either relapsing or not, received significantly lower doses than complete chimeras. However, some patients with complete chimerism 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 further, within the different types of leukaemia. The incidence/severity of acute and chronic graft-vs-host disease (GvHD) was significantly higher in complete chimeras than in mixed chimeras suggesting that mixed chimerism may play a role in the development of tolerance; however, it could be the tolerance (i.e. absence of GvHD) which is responsible for the persistence of host haemopoietic cells. One-hundred-and-sixty-eight patients undergoing allogeneic bone marrow transplantation (BMT) for acute myeloid leukaemia (AML) and chronic myeloid leukaemia were analyzed for risk factor associated with relapse. All patients received marrow from an HLA identical sibling after preparation with cyclophosphamide 120 mg/kg and total body irradiation (TBI) of 330 cGy on days -3, -2, -1. There was a difference of +/- 18% between the nominal total dose of 990 cGy and the actual received dose as indicated by dosimetric recordings. While interstitial pneumonitis had minimal impact on survival there was a considerable difference in the incidence of relapses. The incidence of relapse was higher in patients receiving less, than in patients receiving more than 1000 cGy respectively and this had a major impact on survival. However, transplant-related mortality was slightly higher in the group of patients receiving higher doses of TBI.(ABSTRACT TRUNCATED AT 400 WORDS)     

Comparison of the distribution pattern of brown Norway myeloid leukaemia cells and L4415 lymphatic leukaemia cells in rat femoral bone marrow after I.V. infusion

The mechanism of myelosuppression during the course of leukaemia is still unknown. Mere replacement of normal marrow by leukaemic cells cannot completely explain this decrease. Evidence for a leukaemic factor suppressing normal haemopoieses is controversial. In this study, a preferential homing of infused myeloid leukaemia cells near the endosteum of the bone marrow was observed in the BNML rat model. In contrast to this, lymphatic leukaemia cells distribute randomly in the bone marrow of the L4415 rat model. In view of the optimum environment for normal haemopoiesis near the endosteal surface of the bone, the observations presented in this study might explain the severe decrease in haemopoiesis observed in AML as being a result of competition for specific sites in the bone marrow.     

Bone marrow biopsy during induction chemotherapy for acute myeloid leukaemia identifies only 50% of patients with resistant disease

A study was carried out to determine whether bone marrow biopsy performed on day 6 of induction therapy for acute myeloid leukaemia (AML) can identify those patients with resistant disease who would need an intensification of the first course of induction. Bone marrow biopsies were performed on day 6 of induction chemotherapy in 44 patients with AML treated with daunorubicin, cytosine arabinoside and thioguanine. Biopsies were assessed for blast count, trephine cellularity and leukaemic index. Discrimination between patients who went on to achieve remission and those with resistant disease was best achieved using the reduction in bone marrow cellularity from pretreatment marrow to day-6 marrow. However, this discriminator identified only 50% of the patients with resistant disease and included 13% of patients who achieved remission with the first course of chemotherapy. The other parameters of response were even less effective at discriminating between chemotherapy-resistant and chemotherapy-responsive disease.     

Eradication of leukaemic marrow and prevention of leukaemia relapse with total body irradiation and bone marrow transplantation

A series of studies was carried out to determine the effect of allogeneic bone marrow transplantation (BMT) on leukaemia. The study aimed at two different, but strictly linked issues: (1) identification of the eradication capability of BMT, and (2) evaluation of the effect of BMT, both in preventing relapse and in producing long-term disease-free survival. 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. Among 40 patients in remission, 10 showed functional host and donor haemopoiesis (mixed chimerism), while in 30, host haemopoiesis was never detected (complete chimerism). Seven of the 14 evaluable patients who relapsed showed the reappearance of host haemopoiesis at the time of relapse. The records of received doses of TBI indicate that patients who achieved mixed chimerism, either relapsing or not, received significantly lower doses than complete chimeras. However, some patients with complete chimerism 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 further, within the different types of leukaemia. The incidence/severity of acute and chronic graft-vs-host disease (GvHD) was significantly higher in complete chimeras than in mixed chimeras suggesting that mixed chimerism may play a role in the development of tolerance; however, it could be the tolerance (i.e. absence of GvHD) which is responsible for the persistence of host haemopoietic cells. One-hundred-and-sixty-eight patients undergoing allogeneic bone marrow transplantation (BMT) for acute myeloid leukaemia (AML) and chronic myeloid leukaemia were analyzed for risk factor associated with relapse. All patients received marrow from an HLA identical sibling after preparation with cyclophosphamide 120mg/kg and total body irradiation (TBI) of 330 cGy on days -3, -2, -1. There was a difference of ±18% between the nominal total dose of 990 cGy and the actual received dose as indicated by dosimetric recordings. While interstitial pneumonitis had minimal impact on survival there was a considerable difference in the incidence of relapses. The incidence of relapse was higher in patients receiving less, than in patients receiving more than 1000 cGy respectively and this had a major impact on survival. However, transplant-related mortality was slightly higher in the group of patients receiving higher doses of TBI. These results suggest that a higher dose of TBI, within this schedule, produced long-term disease-free survival in the majority of acute myeloid leukaemia and chronic myeloid leukaemia with minor radiobiological side-effects which, however, tended to be higher as the TBI dose increased. Moreover, a small reduction of the dose may significantly increase the risk of relapse. In addition, the disease status significantly influences the probability of relapse and this is mainly seen in chronic myeloid leukaemia. Moreover, the prevention of graft-vs-host disease plays a relevant role both in relapse as well as in the transplant-related mortality. It is therefore concluded that fine tuning of the conditioning protocol, and of the therapy for graft-vs-host prevention, is needed to improve the results in allogeneic bone marrow transplant.     

The antileukaemic activity of 5-Aza-2 deoxycytidine (Aza-dC) in patients with relapsed and resistant leukaemia.

In the present study we demonstrate that Aza-dC in combination with Amsacrine has major antileukaemic properties in patients who have not already received extensive Ara-C therapy. Eight out of 11 patients in their first relapse of acute leukaemia achieved complete remission. Cross resistance between Ara-C and Aza-dC was revealed by the lack of antileukaemic activity in five patients with with Ara-C resistant leukaemia. Combination therapy with Aza-dC/Ams-acrine induced a considerable period of a granulocytopenia (28-35 days), while the toxic effect on erythro- and megakaryopoiesis was comparable to that reported for high dose Ara-C/Amsacrine chemotherapy. Remarkable is the long disappearance time for leukaemic blast cells in bone marrow, i.e. 3-5 weeks in some cases. Analysis of cell membrane markers showed a loss of the early differentiation antigens CD34 and CD33 from leukaemic bone marrow cells after 7 days of Aza-dC treatment, which is suggestive of leukaemic cell differentiation. In the small group of patients tested for DNA hypomethylation no association existed between the degree of hypomethylation and clinical response. Non-haematologic side effects were considerable in patients receiving the highest dosages of Aza-dC and consisted of severe, although usually reversible, gastrointestinal and neurological complications. In comparison with Ara-C, Aza-dC causes less nausea and vomiting and is therefore better tolerated.     

Single-cell immunofluorescence assay for terminal transferase: Human leukaemic and non-leukaemic cells

The characteristics of a single-cell immunofluorescence assay for terminal deoxynucleotidyl transferase (terminal transferase, TdT) is described. The data indicate that the single-cell immunofluorescence assay is highly efficient and specific for the detection of cells containing TdT. Using this assay, we have examined 124 marrow or peripheral-blood samples from 104 patients with or without haematological malignancies. Results indicate that TdT⁺ cells from 6% to 100% were found in the following patients: 34/40 samples from patients with ALL at the time of diagnosis or during relapse; 2/3 patients with acute undifferentiated leukaemia; 2/3 patients with acute myelomonocytic leukaemia; 1/24 patients with acute myeloblastic leukaemia; 1/5 patients with chronic myelocytic leukaemia (CML) in blastic crisis; and 2/2 patients with diffuse lymphoblastic lymphoma. In contrast less than 1% of TdT⁺ cells were found in 20 marrow or peripheral-blood samples from ALL patients in complete remission; 8 patients with CML in chronic phase; 2 patients with myeloma; 1 sample from a patient with Hodgkin''s disease, peripheral-blood samples from 7 normal donors and marrow samples from 6 patients without haematological malignancies. TdT⁺ cells were also found in association with cells with lymphoblast morphology. The TdT⁺ cells in marrow were shown to be directly correlated with the percentage of morphological lymphoblasts, with a Spearman rank coefficient of 0·81, significant at a 0·001 level. In 2 longitudinal studies of 2 ALL patients with TdT⁺ cells at diagnosis, the percentage TdT⁺ cells also changed in parallel with the proportion of lymphoblasts. However, studies of 2 other patients with morphologically diagnosed ALL with < 1% TdT⁺ cells at diagnosis also showed < 1% TdT⁺ cells throughout the period studied, indicating a stable phenotype of blast cells in these patients. The single-cell immunofluorescence assay for TdT, which requires < 0·1% of the cells used in a conventional biochemical assay, is highly specific, and could provide a technically more efficient alternative for use in clinics as well as in experimental investigations of subpopulations of leukaemic and normal marrow cells.     

In vitro drug sensitivity of normal peripheral blood lymphocytes and childhood leukaemic cells from bone marrow and peripheral blood

In vitro drug sensitivity of leukaemic cells might be influenced by the contamination of such a sample with non-malignant cells and the sample source. To study this, sensitivity of normal peripheral blood (PB) lymphocytes to a number of cytostatic drugs was assessed with the MTT assay. We compared this sensitivity with the drug sensitivity of leukaemic cells of 38 children with acute lymphoblastic leukaemia. We also studied a possible differential sensitivity of leukaemic cells from bone marrow (BM) and PB. The following drugs were used: Prednisolone, dexamethasone, 6-mercaptopurine, 6-thioguanine, cytosine arabinoside, vincristine, vindesine, daunorubicin, doxorubicin, mafosfamide (Maf), 4-hydroperoxy-ifosfamide, teniposide, mitoxantrone, L-asparaginase, methotrexate and mustine. Normal PB lymphocytes were significantly more resistant to all drugs tested, except to Maf. Leukaemic BM and PB cells from 38 patients (unpaired samples) showed no significant differences in sensitivity to any of the drugs. Moreover, in 11 of 12 children with acute leukaemia of whom we investigated simultaneously obtained BM and PB (paired samples), their leukaemic BM and PB cells showed comparable drug sensitivity profiles. In one patient the BM cells were more sensitive to most drugs than those from the PB, but the actual differences in sensitivity were small. We conclude that the contamination of a leukaemic sample with normal PB lymphocytes will influence the results of the MTT assay. The source of the leukaemic sample, BM or PB, does not significantly influence the assay results.     

Effect of cyclophosphamide pretreatment on daunorubicin in rat acute leukaemia model

The total number of leukaemic cells at the time of therapy may affect the tissue and target cell distribution and antitumour efficacy of cytotoxic drugs. The effects of low dose cyclophosphamide pretreatment on daunorubicin concentrations in leukaemic bone marrow were investigated in rats. At day 12 after transplantation of the leukaemia, rats were injected intraperitoneally with cyclophosphamide (30 mg/kg). 2 days later the leukaemic rats received daunorubicin intravenously (7.5 mg/kg). Cyclophosphamide pretreatment led to a significant increase in daunorubicin concentration in the femoral bone marrow, by a factor of about 7. The log leukaemic stem cell kill (LCK) values, as estimated by a survival assay, were 1.8, 0.7, and 5.4 for the leukaemic rats injected with cyclophosphamide (day 12), with daunorubicin (day 14), or with cyclophosphamide (day 12) plus daunorubicin (day 14), respectively). The simultaneous administration of cyclophosphamide and daunorubicin at day 14, induced a LCK of 2.7, a value that was the sum of the LCKs of cyclophosphamide and daunorubicin alone. Low-dose cyclophosphamide pretreatment led to an increased daunorubicin accumulation in femoral bone marrow of leukaemic rats, and was synergistic with daunorubicin.     

Re-evaluation of refractory anemia with excess blasts in transformation

The category 'refractory anemia with excess blasts in transformation (RAEBt)' consists of two sub-sets; one group is categorized based on the percentage of blasts in the marrow (> or =20%) and other is based on the percentage of blasts in the peripheral blood (> or =5%). We separated RAEBt patients based on these two criteria and compared hematologic and clinical relevance to assess the reasonable basis for the new classification. All RAEBt patients showing peripheral blood (PB) blasts of > or =5% were re-classified as RAEB by the WHO classification. This subset of RAEBt patients had lower percentages of bone marrow (BM) blasts, and notably they showed frequent complex cytogenetic abnormalities, including -5/5q- and/or -7/7q-. Moreover, the RAEBt patients of this group had shorter survivals compared to RAEBt patients with BM blasts between 20 and 30%. We next assessed hematologic and clinical relevance between refractory anemia with excess blasts (RAEB) and RAEBt patients with PB blasts of > or =5%. Except for the percentage of blasts in the PB (P=0.0037) and BM (P=0.0073), there was no significant difference in hematologic or clinical features between RAEB patients with BM blasts of > or =11% and RAEBt patients with PB blasts of > or =5%. When MDS patients with PB blasts of > or =5% (RAEBt by the FAB classification) were included as RAEB-II based on the "MDS 2000 classification', there was a high frequency of patients with complex chromosome changes, involving 5q and 7q, with significant poorer outcome compared to those with RAEB-I. Although it is still controversial whether MDS patients with BM blasts 20% or more should be considered as acute leukemia, the utilization of the 'MDS 2000 classification' might be useful to designate MDS patients diagnosed based on the percentage of blasts in the peripheral blood.