Positive pregnancy test results occurred in a nongravid, premenopausal woman while she was receiving chemotherapy for multiple myeloma. We tested 2 hypotheses to account for this finding: (1) Heterophil antibodies caused positive interference in the immunoassays. (2) Genuine human chorionic gonadotropin (hCG) originated from a nonsyncytiotrophoblastic source. Paraprotein was eliminated as a source of positive interference because 3 different instruments with unique capture and signal antibodies gave similar results (83, 90, and 97 mIU/mL [83, 90, and 97 IU/L]). Human antimouse antibodies (HAMAs) were unlikely to cause positive interference because immunoreactivity was maintained after serum was treated to neutralize heterophil antibodies. Immunoassays performed after gel filtration of serum indicated that immunoreactivity was due to genuine hCG. The high-molecular-weight fraction (heterophil antibody) had 6 mIU/mL (6 IU/L) of hCG. The low-molecular-weight fraction (hCG) had 86 mIU/mL (86 IU/L) of hCG. Immunohistochemical stains revealed that myeloma cells expressed immunoreactive hCG. Hence, multiple myeloma caused positive pregnancy test results in a nongravid woman.

Primary plasma cell leukemia (PPCL) is a rare subtype of multiple myeloma that follows a rapid clinical course and responds poorly to conventional myeloma treatment. Recently it has been shown that melphalan doses up to 140 mg/m2 without HPC support can be given safely to myeloma patients. We report our experience with the use of HDM without HPC support in 3 patients with PPCL. All patients received HDM (140 mg/m2) as a single 40-minute IV infusion. Filgrastim (6 g/kg/day) was started 24 hours after HDM and continued until absolute neutrophil count (ANC) was> 500/L. There was complete clearance of plasma cells from the bone marrow and resolution of cytogenetic abnormalities. IgG level in patient 1 and M-protein level in patients 2 and 3 decreased by> 75% before thalidomide initiation and was maintained for> 6 weeks. One patient (case 1) had extramedullary disease progression evidenced on day 130 and expired despite further treatment with VAD, arsenic trioxide, methylprednisolone, and thalidomide. Patient 2 achieved CR after receiving allogeneic stem cell transplantation from a matched sibling donor at day 137 and remains in complete remission. There was no treatment-related mortality. Treatment of PPCL with HDM without HPC support was well tolerated. It resulted in prompt hematologic recovery and produced dramatic control of an otherwise rapidly fatal process. Such treatment may be a viable option when HPC transplantation is not feasible. Table 1Patient characteristicsAge (y)/SexWBC (1000/μl)/BM Involve-mentM-protein Level (g/dl)/Ig TypePrior Rx/ResponseCount Recovery (D 0+)Thalido-mide Started (D 0+)Best Documented Response/Day (D 0+)TTP/Survival (Days)50/M60.5/100%Not available/IgGHigh-dose cortico-steroids/progres-sive disease20NAPR/120130/423+45/F54.6/100%3.54/IgGHigh-dose cortico-steroids/Progres-sive disease2030PR/30NA/557+66/F17.3/75%4.5/IgGVAD/progres-sive disease36100PR/164NA/219+TTP: time to progression, NA: not applicable, PR: partial response. Open table in a new tab TTP: time to progression, NA: not applicable, PR: partial response.

Background: Tacrolimus (FK) is usually given as a continuous 24-hour infusion for acute graft-vs-host disease (GVH) prophylaxis in the setting of allogeneic hematopoietic stem cell transplantation (HSCT). Often, this schedule becomes logistically difficult and requires dedicated line and monitoring. We report our experience with the use of twice-daily intravenous (IV) bolus injection. Patients and Methods: Between 01/00–06/04, 59 patients (pts) with hematologic indication for allogeneic HSCT received twice-daily FK for GVH prophylaxis. Patients were given FK at initial dose of 0.015 mg/kg IV bolus over 3 hours on day T −1 then every 12 hours. First trough level was drawn before the seventh dose on day T +2 and then twice weekly unless clinically indicated otherwise. Doses were adjusted for a target level of 10 ng/ml (range 5–20 ng/ml). Patients were switched to oral form when were clinically able to tolerate it. Results: Median age was 49 years (range 19–64 y). Donors were transplanted for hematologic disorder indications. Donor compatibility status was as follows: matched-related 38 (64.4%), matched-unrelated 10 (17%), and mismatched-related 11 (18.6%). FK was used in 2 GVH prophylaxis protocols: with methotrexate or in combination with mycophenolate mofetil and daclizumab. Median first trough level was 9 ng/ml (range 2.6–22.5). Rate of grade I or II acute GVH was 16.9%. Only one pt developed grade III (1.7%) and no pt had grade IV. Significant nephrotoxicity (peak creatinine level ≥2× baseline or ≥2 mg/dl) occurred in 16 patients (27.1%). Five of these pts (31.25%) had at least 1 FK trough level ≥20 ng/ml whereas 15 of 44 patients with normal renal function (34.1%) had such elevated levels. Severe nephrotoxicity requiring dialysis occurred in 4 pts and only 1 of these had elevated FK level. One pt developed HUS/TTP and had all FK trough levels <20 ng/ml. There were no grade 3 or 4 seizures or tremors. Median discharge day was T +19 (range 12–34). Two pts relapsed, but were alive, by day 100. Day-100 relapse-free mortality was 18.6%. Conclusion: Results of twice-daily bolus tacrolimus compare favorably to historical safety and efficacy data of continuous infusion of FK in allogeneic HSCT. Bolus infusion was easy to administer and adjust and did not correlate with increased risk of nephrotoxicity. These results should be further investigated in a prospective clinical trial. Background: Tacrolimus (FK) is usually given as a continuous 24-hour infusion for acute graft-vs-host disease (GVH) prophylaxis in the setting of allogeneic hematopoietic stem cell transplantation (HSCT). Often, this schedule becomes logistically difficult and requires dedicated line and monitoring. We report our experience with the use of twice-daily intravenous (IV) bolus injection. Patients and Methods: Between 01/00–06/04, 59 patients (pts) with hematologic indication for allogeneic HSCT received twice-daily FK for GVH prophylaxis. Patients were given FK at initial dose of 0.015 mg/kg IV bolus over 3 hours on day T −1 then every 12 hours. First trough level was drawn before the seventh dose on day T +2 and then twice weekly unless clinically indicated otherwise. Doses were adjusted for a target level of 10 ng/ml (range 5–20 ng/ml). Patients were switched to oral form when were clinically able to tolerate it. Results: Median age was 49 years (range 19–64 y). Donors were transplanted for hematologic disorder indications. Donor compatibility status was as follows: matched-related 38 (64.4%), matched-unrelated 10 (17%), and mismatched-related 11 (18.6%). FK was used in 2 GVH prophylaxis protocols: with methotrexate or in combination with mycophenolate mofetil and daclizumab. Median first trough level was 9 ng/ml (range 2.6–22.5). Rate of grade I or II acute GVH was 16.9%. Only one pt developed grade III (1.7%) and no pt had grade IV. Significant nephrotoxicity (peak creatinine level ≥2× baseline or ≥2 mg/dl) occurred in 16 patients (27.1%). Five of these pts (31.25%) had at least 1 FK trough level ≥20 ng/ml whereas 15 of 44 patients with normal renal function (34.1%) had such elevated levels. Severe nephrotoxicity requiring dialysis occurred in 4 pts and only 1 of these had elevated FK level. One pt developed HUS/TTP and had all FK trough levels <20 ng/ml. There were no grade 3 or 4 seizures or tremors. Median discharge day was T +19 (range 12–34). Two pts relapsed, but were alive, by day 100. Day-100 relapse-free mortality was 18.6%. Conclusion: Results of twice-daily bolus tacrolimus compare favorably to historical safety and efficacy data of continuous infusion of FK in allogeneic HSCT. Bolus infusion was easy to administer and adjust and did not correlate with increased risk of nephrotoxicity. These results should be further investigated in a prospective clinical trial.

To determine the long-term results of high-dose chemotherapy and stem cell support in relapsed or primary refractory Hodgkin disease patients. One hundred and thirty-one patients with relapsed or primary refractory Hodgkin's disease were treated with a dose-intensive therapy protocol consisting of etoposide (2400 mg/m(2) continuous intravenous infusion) cyclophosphamide (7200 mg/m(2) intravenously), and carmustine (300-600 mg/m(2) intravenously) CBVi, All patients had previously failed conventional chemoradiotherapy. Severe toxicities were related to infectious, hepatic, and pulmonary complications. Fatal, regimen-related toxicity was 19%; liver and lung dysfunction, as well as infection, were the most frequent problems. Ninety-one (69%) of the patients achieved a complete response (CR) (95% CI = 59% to 75%) after CBVi and autologous stem cell infusion. With a median follow-up of 5.1 years (range 3.0 to 9.5 years), overall and event-free survival are 44% (95% CI = 33% to 47%) and 38% (95% CI = 28% to 46%) respectively. While univariate analysis did not reveal a statistically significant variable to predict a better response, responsiveness to therapy demonstrated a trend. We conclude that CBVi is an effective therapy for relapsed or refractory Hodgkin's disease, producing long-term, durable remissions.

There are experimental data which suggest that the primary immune effector cell responsible for maintaining immune surveillance against the outgrowth of EBV-transformed B cells in humans is the CTL, but in vivo proof of this is lacking. In this study we perform a series of cellular and molecular assays to characterize an autologous, endogenous immune response against a transplantation-associated, monoclonal, EBV+ posttransplant lymphoproliferative disorder (PTLD). Following allogeneic bone marrow transplantation, a patient developed a monoclonal PTLD of donor B cell origin. With a decrease in immune suppression, we document the emergence of endogenous, donor-derived CD3+CD8+ CTLs, followed by regression of the PTLD. The TCR Vbeta repertoire went from a polyclonal pattern prior to the development of PTLD to a restricted TCR Vbeta pattern during the outgrowth and regression of PTLD. Donor-derived CD3+CD8+ T lymphocytes displayed MHC class I-restricted cytolytic activity against the autologous EBV+ B cells ex vivo without additional in vitro sensitization. The striking temporal relationship between the endogenous expansion of a TCR Vbeta-restricted, CD3+CD8+ population of MHC class I-restricted CTL, and the regression of an autologous monoclonal PTLD, provides direct evidence in humans that endogenous CD3+CD8+ CTLs can be responsible for effective immune surveillance against malignant transformation of EBV+ B cells.

Approximately 45% of adults with acute myeloid leukemia (AML) have normal cytogenetics and therefore lack structural abnormalities that can assist in the localization and characterization of molecular defects. The partial tandem duplication of the ALL1 (MLL) gene has been found in several such cases of AML, yet its frequency and clinical significance are unclear. We performed Southern analysis of the ALL1 gene in pretreatment samples from 98 AML patients with normal cytogenetics. Eleven of 98 such patients (11%; 95% confidence interval, 6-19%) showed rearrangement of ALL1 at diagnosis. The partial tandem duplication of ALL1 was responsible for ALL1 rearrangement in all such cases examined, making it a frequent molecular defect in adult AML patients with normal cytogenetics. Furthermore, patients with ALL1 rearrangement had a significantly shorter duration of complete remission when compared to patients without ALL1 rearrangement (P = 0.01; median, 7.1 versus 23.2 months). This defect defines for the first time a subset of AML patients with normal cytogenetics who have short durations of complete remission and thus require new therapeutic approaches.

An observational study was conducted at 18 transplant centers in the United States and Canada to characterize the platelet recovery of patients receiving myeloablative therapy and stem cell transplantation and to determine the clinical variables influencing recovery, determine platelet utilization and cost, and incidence of hemorrhagic events. The study included 789 evaluable patients transplanted in 1995. Clinical, laboratory, and outcome data were obtained from the medical records. Variables associated with accelerated recovery in multivariate models included (1) higher CD34 count; (2) higher platelet count at the start of myeloablative therapy; (3) graft from an HLA-identical sibling donor; and (4) prior stem cell transplant. Variables associated with delayed recovery were (1) prior radiation therapy; (2) posttransplant fever; (3) hepatic veno-occlusive disease; and (4) use of posttransplant growth factors. Disease type also influenced recovery. Recipients of peripheral blood stem cells (PBSC) had faster recovery and fewer platelet transfusion days than recipients of bone marrow (BM). The estimated average 60-day platelet transfusion cost per patient was $4,000 for autologous PBSC and $11,000 for allogeneic BM transplants. It was found that 11% of all patients had a significant hemorrhagic event during the first 60 days posttransplant, contributing to death in 2% of patients. In conclusion, clinical variables influencing platelet recovery should be considered in the design and interpretation of clinical strategies to accelerate recovery. Enhancing platelet recovery is not likely to have a significant impact on 60-day mortality but could significantly decrease health care costs and potentially improve patient quality of life.

The receptor for megakaryocyte growth and development factor (MGDF), also known as thrombopoietin, has recently been cloned. MGDF stimulates platelet production and maturation both in vitro and in vivo. MGDF may thus have a role in attenuating the thrombocytopenia associated with acute myeloid leukemia (AML) and its therapy. However, there is concern that MGDF might induce AML blast proliferation and thereby increase the risk of treatment failure. To address this concern, we studied the expression of c-mpl mRNA and c-Mpl protein by blasts from AML patients. In addition we examined the in vitro effect of MGDF as well as the combined effect of MGDF and granulocyte colony-stimulating factor (G-CSF) or stem cell factor (SCF) on leukemic blast proliferation, recruitment into S-phase, induction of programmed cell death and activation of signal transducers and activators of transcription (STAT) proteins. Our results demonstrate that blasts from a substantial proportion of cases of AML express the receptor at either the mRNA or protein level. Moreover, the function of the MGDF receptor was demonstrated by activation of STAT proteins following exposure to MGDF. Nevertheless, blast proliferation in response to MGDF was rare, and the proliferative effect of MGDF was less than that of G-CSF or SCF. Furthermore, MGDF did not prevent programmed cell death induced by cytarabine. Finally, there appeared to be no correlation between receptor expression by AML blasts and functional response to MGDF. Based on these data, it would appear that clinical trials of MGDF may be undertaken safely in patients with AML.

PURPOSE:c-mpl, the human homolog of v-mpl, is the receptor for thrombopoietin. Given that c-mpl expression carries an adverse prognosis in myelodysplastic syndrome and given the prognostic significance of expression of other growth factor receptors in other diseases, we attempted to determine whether c-mp/mRNA expression is a prognostic factor in acute myeloid leukemia (AML).PATIENTS AND METHODS:We analyzed bone marrow samples from 45 newly diagnosed AML patients by reverse-transcription polymerase chain reaction.RESULTS:Samples from 27 patients (60%) expressed c-mpl mRNA (c-mpl+); their clinical and laboratory features were compared with those of the 18 patients without detectable levels of c-mpl(c-mpl-). No significant differences in age, sex, leukocyte count, French-American-British subtype, or karyotype group were found. c-mpl+ patients more commonly had secondary AML (41% v 11%; P = .046) and more commonly expressed CD34 (67% v 12%; P = .0004). There was no significant difference in complete remission (CR) rate. However, c-mpl+ patients had shorter CR durations (P = .008; median, 6.0 v > 17.0 months). This was true when only de novo AML patients were considered and when controlling for age, cytogenetics, or CD34 expression. There was a trend toward shorter survival in c-mpl+ patients (P = .058; median, 7.8 v 9.0 months).CONCLUSION:These data suggest that c-mpl expression is an adverse prognostic factor for treatment outcome in adult AML that must be considered in the analysis of clinical studies using thrombopoietin in AML.

Administration of growth factors prior to chemotherapy (priming) may reduce myelosuppression and provide an alternative to the use of stem cell support for the delivery of dose-intensive therapy. It is possible, however, that such priming may worsen aplasia, either by recruitment of progenitors into cell cycle and thereby increasing their sensitivity to chemotherapy or by depleting stem cell pools. We performed a Phase I/II trial of sequential interleukin 3 (IL-3)/granulocyte colony-stimulating factor (G-CSF) prior to and following high-dose etoposide and cyclophosphamide to determine the safety and efficacy of priming. IL-3 was given for 7 days, and then G-CSF was given until the WBC count reached a level of 100, 000/microliter or stopped rising. Chemotherapy was started 48 h after the last dose of G-CSF. Sequential administration of IL-3/G-CSF was repeated beginning 36 h after the last dose of chemotherapy. Twenty-five eligible patients with Hodgkin's disease, non-Hodgkin's lymphoma, or breast cancer were enrolled. Priming was generally well tolerated. The median maximum WBC count and absolute neutrophil count achieved was 66,400 and 57,600/microliter, respectively. Significant decreases in platelet counts were seen during priming with 15 patients having a >/=40% decrease from prepriming values. Hematological recovery of study patients was compared to that of an unprimed historical control group (n = 38) treated with the same chemotherapy followed by G-CSF alone. Neutrophil recovery to 500 and 1000/microliter and platelet recovery to >/=50,000/microliter was significantly faster in the study group compared to that of historical controls (P = 0.03, 0.05, and 0.01, respectively). Sequential IL-3/G-CSF given prior to and following high-dose etoposide and cyclophosphamide is safe and is a feasible strategy to compare in prospective randomized trials to patients treated with only postchemotherapy IL-3 and G-CSF and to patients treated with peripheral blood stem cell support.

Previous attempts to characterize harvested marrow and peripheral blood stem cell (PBSC) in order to predict time to and quality of engraftment post autologous bone marrow transplant (autoBMT) have included use of in vitro colony forming unit (CFU) assays. These assays are hampered by interlaboratory variability and are not uniformly predictive. CD34 quantification by flow cytometric technique has also been used to assess the quality of harvested marrow and PBSC. However, a lack of standardization has hampered direct comparison of published reports. We sought to characterize these early lineage-committed CD34+ progenitor cells from non-ficolled harvested marrow with six progenitor cell (PC) panels containing CD34 antibody plus two additional early lineage markers, using multiparameter flow cytometry. The specific gating technique including simultaneous CD34-PE vs. side scatter and forward vs. side scatter, was verified using morphologic analyses of sorted CD34+ cells. An ungated file was initially acquired to assess total CD34+ content. A second file using a CD34 threshold was then acquired to resolve lineage-committed subsets. The % CD34+ cells as well as cells/microliter of bone marrow was calculated using cell counts at the time of marrow harvest. Bone marrow (mean total cell dose = 3.8 x 10(5)/kg), obtained from 42 normal donors for allogeneic transplantation was first analyzed. CD34+ cells comprised a mean 1.3% of non-ficolled marrow, with 328 CD34+ cells/microliter, and mean CD34+ cells collected was 4.8 x 10(6)/kg. While no significant differences in total cells harvested nor proportion of CD34+ cells was found, a significant decrease in CD34 cells/microliter (= 233, P = .0012) was found in cancer patients. The percentage of CD19+ and CD38+ progenitor cells was significantly increased, while CD5+ and CD71+ cells were decreased. The proportions of all other early lineage-committed CD34 subsets were not different. Measurement of lineage-committed CD34 progenitor cells is a useful technique to characterize harvested marrow and PBSC, and may be applied to predict time and quality of engraftment post ablative conditioning regimens.