1197 The increase of prostacyclin-like activity in uraemic venous tissues may throw some light on the pathogenesis of bleeding in renal failure. Prostacyclin might be one of the -non-dialysable factors said to contribute to this haemorrhagic condition.7-9 It would be premature to speculate on the association we found between prolonged bleeding-time and increased prostacyclin-like activity in uraemic venous tissues. Indeed, it has long been recognised that aspirin and other non-steroid anti-inflammatory drugs which inhibit prostacyclin production (at least in vitro)" definitely prolong skin bleeding-time in man.12 Nevertheless, in some experiments the bleeding-time was shortened by administration of these drugs."-" In addition, aspirinlike drugs were reported to reduce significantly the excessive blood-loss in patients with menorrhagia. 16 It is thus possible that the contribution of prostacyclin to hamiostasis may differ in various experimental or clinical bleeding states. We therefore evaluated the effect of indomethacin on the bleeding-time of one of our patients (case 3). 2 hours after oral administration of 50 mg of this drug, skin bleeding-time8 was greatly prolonged (>30 min, compared with 21 min before indomethacin). In contrast, the duration of bleeding from a standard incision of a superficial vein of the forearm was reduced from 25 to 18 min. It would be unwise to draw any conclusion about treatment from these data until more is known about the role of prostacyclin and the factors influencing its formation in uraemic patients. The possibility that the metabolic pathways of prostaglandin endoperoxides can be modified in renal failure has been suggested. Morrison et al. 17 have indeed presented evidence that experimental obstruction of the ureters in the rabbit is accompanied by unmasking of the synthesis of thromboxane A2 in the kidney. We thank Dr C. Longhino, Dr A. Valsecchi, Dr E. Poletti, Dr V. Giorgianni, Dr A. Frontini, and Dr G. Mingardi for surgical assistance and advice. Judith Baggott, Gigliola Brambilla, Vanna Pistotti, and Vincenzo De Ceglie helped in preparing this manuscript. This work was supported in part by the Associazione Bergamasca per lo Studio delle Malattie Renali.

Requests for reprints should be addressed Ricerche

Farmacologiche. Milan, Italy.

"Mario

Negri",

to G. de G., Istituto di Via Eritrea 62, 20157

REFERENCES 1. Salzman, E. W., Neri, L. L. Thromb. Diath. hœmorrh. 1966, 2. Larsson, S. O. Scand. J. Hœmat. 1971, suppl. 15, p. 1. 3. Rabiner, S. F. Med. Clins. N. Am. 1972, 56, 221. 4. Eknoyan, G., Wacksman, S. J., Glueck, H. I., Will, J. J. New

15, 84.

Engl. J. Med. 1969, 280, 677. 5. Horowitz, H. I. Archs intern. Med. 1970, 126, 823. 6. Lindsay, R. M., Friesen, M., Koens, F., Linton, A. L., Oreopoulos, D., de Veber, G. Clin. Nephrol. 1976, 6, 335. 7. Kazatchkine, M., Sultan, Y., Caen, J. P., Bariety, J. Br. med. J. 1976, ii, 612. 8. Remuzzi, G., Livio, M., Marchiaro, G., Mecca, G., de Gaetano, G. Unpublished. 9. Remuzzi, G., Livio, M., Roncaglioni, M. C., Mecca, G., Donati, M. B., de Gaetano, G. Br. med. J. 1977, ii, 359. 10. Moncada, S., Gryglewski, R., Bunting, S., Vane, J. R. Nature, 1976, 263, 663. 11. Moncada, S., Higgs, E. A., Vane, J. R. Lancet, 1977, i, 18. 12. de Gaetano, G., Donati, M. B., Garattini, S. Thromb. Diath. hœmorrh.

1975, 34, 285. 13. Arfors, K. E., Bergqvist, D., Bygdeman, S., McKenzie, F. N., Svenjö, E. Scand. J. Hœmat. 1972, 9, 322. 14. Stella, L., Donati, M. B., de Gaetano, G. Thromb. Res. 1975, 7, 709. 15. Bergqvist, K. E., Arfors, K. E. Hœmostasis, 1976, 5, 74. 16. Anderson, A. B. M., Haynes, P. J., Guillebaud, J., Turnbull, A. C. Lancet, 1976, i, 774. 17. Morrison, A. R., Nishikawa, K., Needleman, P. Nature, 1977, 267, 259.

BONE-MARROW TRANSPLANTATION IN ACUTE LEUKÆMIA U.C.L.A. BONE-MARROW TRANSPLANTATION TEAM* Bone-marrow Transplantation Unit, University of California School of Medicine, Los Angeles, California 90024, U.S.A.

Survival in 33 patients with resistant leukæmia treated by marrow transplantation was compared with that of 37 matched patients treated by conventional and experimental chemotherapy; All patients in the transplant group were rendered free of detectable leukæmia for periods of from 36 days to more than 21/2 years, while only 6 patients in the chemotherapy group achieved a hæmatological remission. Overall survival in both groups was poor; however, 5 patients (15%) in the transplant group remain alive and in hæmatological remission 1-21/2 years after transplantation, while no patient in the chemotherapy group survived longer than 13 months. Bone-marrow transplantation appears to offer a small but distinct possibility of long-term survival in patients with acute leukæmia resistant to conventional therapy.

Summary

Introduction DESPITE advances in the treatment of acute leukeemost patients with acute myeloid leukaemia (A.M.L.) and more than half of all patients with acute lymphocytic leukaemia (A.L.L.) ultimately die from resistant disease. After initial relapse, some patients with A.L.L., but only a small proportion of patients with A.M.L., may achieve a second remission. Second and later remissions are generally brief and chances of prolonged survival

mia,

correspondingly poor. There is controversy over what is optimum therapy for patients with resistant leukaemia. Results of chemotherapy with conventional and experimental agents have been disappointing. Recent studies of bone-marrow transplantation 1-4 have indicated the possibility of long-term survival in a small proportion of patients, but there have been no reports of controlled trials of bonemarrow transplantation versus conventional therapy. In this study, we retrospectively compared survival of patients with resistant disease treated by bone-marrow transplantation with that of patients treated by chemotherapy alone. Most patients were treated at one centre by the same group of physicians. Our results indicate the possibility of achieving long-term disease-free survival in a small proportion of patients with resistant acute leukaemia treated by bone-marrow transplantation ; these results are better than those achieved with chemotherapy alone.

Patients and Methods

Study Design Two groups of

patients with drug-resistant

acute

leukaemia

*Members of the team: Dr ROBERT PETER GALE (a scholar of the Leukemia Society of America), Dr STEPHEN FEIG, Dr WINSTON G. Ho, Dr PETER FALK, Dr DREW WINSTON, Dr LOWELL S. YOUNG, Dr GERHARD OPELZ, Dr GERHARD OPELZ, Dr ALAN TESLER, Dr ROBERT SPARKES, Dr PETER R. GRAZE, Dr GREGORY SARNA, Dr DAVID W. GOLDE, Dr MARY C. TERRITO, Dr YVONNE BRYSON, Dr THOMAS GOSSETT, Dr FARAMARZ NAIEM, Dr FAWZY FAWZY, Dr CHARLES HASKELL, Dr JOHN L. FAHEY, and Dr MARTIN J. CLINE.

1198 studied-a transplant group consisting of 33 consecutive patients treated by bone-marrow transplantation, and a chemotherapy group of 37 patients treated by chemotherapy alone. Chemotherapy patients were selected from a group of 143 consecutive patients with acute leukaemia treated at or referred to were

U.C.L.A. from 1970 to 1977. Criteria were similar to those used for selection of transplant patients-namely, (1) diagnosis of acute leukaemia, (2) age 45 years or under, (3) patients with A.L.L. after a second relapse, and (4) patients with A.M.L. after a first relapse. Patients whose clinical status would have excluded them as transplant candidates (life-threatening infection or haemorrhage) were not included. The decision on marrow grafting was made on the basis of social and psychological factors, as well as on the availability of an HLA-identical donor. Clinical management of transplant patients is detailed below. The chemotherapy patients received both conventional and experimental drugs. Survival was measured from the time of transplantation or time chemotherapy was started for relapse, respectively. Details about the overall management of these patients, such as those on protective isolation, antibiotics, and platelet and granulocyte transfusions, have been pre-

viously described.2·s

tested. 31 donor/recipient pairs were ABO compatible and 2 were ABO mismatched. Plasma exchange was performed in mismatched recipients before transplantation to remove anti-ABO antibodies.6 was not

Transplantation were conditioned for transplantation with Scatu, chemoradiotherapy regimen consisting of 6-thioguanine, cyclophosphamide, ara-C, rubidomycin (daunorubicin), and total body irradiation (fig. 1). Details of doses, scheduling, and radiation dosimetry have been reported.2 Donor marrow was infused intravenously on day 0, within 24 hours

Recipients

Transplant Group (table I)

an

32 patients had active leukaemia at the time of transplant and were considered resistant to further chemotherapy by their physicians. 6 had active central-nervous-system (c.N.s.) disease. Only 1 patient, with A.M.L., was in remission. 9 patients had not responded to initial remission-induction chemotherapy, and the remainder had relapsed after one or more remissions.

Histocompatibility Testing HLA-A and HLA-B typing

Fig. I-SCARI schedule of chemoradiotherapy. 0= Day on which bone-marrow was infused.

carried out by standard techniques. donor-recipient pairs which included three identical twins, were HLA-A and HLA-B identical. 28 pairs were bidirectionally non-responsive in mixed lymphocyte culture (M.L.C.). 3 recipients were responsive against lymphocytes of their donor. 1 pair was bidirectionally responsive and 1 pair was

All

TABLE I-DETAILS OF PATIENTS PRIOR TO STUDY

intensive

of irradiation. The median dose of marrow cells infused was 2-87xl0*/kg (range 1-14-5.70). Methotrexate was given after grafting to modify graft-versus-host disease (G.v.H.D.). Criteria for diagnosis and staging of G.v.H.D. have been reported.’ Patients developing significant (grade n or more) G.v.H.D. received high-dose corticosteroids. Interstitial pneumonitis was diagnosed when patients had definite hypoxtmia (Pa0250 mm Hg at atmospheric conditions) and typical radiological abnormalities. Further investigations for interstitial pneumonitis included serological studies and cultures for cytomegalovirus (c.M.v.), echovirus, adenovirus, and other potential viral pathogens; bronchoscopy with lavage, and transbronchial or open lung-biopsy when indicated. Transplant recipients received co-trimoxazole as prophylaxis against

Pneumocystis cariniiinfection.88

0

Chemotherapy Group (table I) All patients in this group had received extensive chemotherapy before the trial. Their subsequent anti-leuktmic therapy was dictated by the agents available at the time of relapse (table 11). The basic objective in most cases was to attempt remission reinduction with conventional agents. If this was unsuccessful or if the patient relapsed again, experimental agents were considered. We did not attempt to standardise postrelapse chemotherapy. In 1 patient, low-dose total-body irradiation was used after treatment failure with chemotherapy.

Clinical Management Both groups of patients

cared for by a team ofhsematoexcept for 6 patients referred to U.C.L.A. for evaluation for marrow grafting but who were excluded from the transplant group because of the unavailability of a donor or for psychological factors. Patients excluded from transplantation for medical reasons were not included in the chemotherapy group. Both groups of patients received extensive red-cell, platelet, and granulocyte transfusions. Non-transplant patients usually received non-HLAmatched platelets; transplant patients received HLA-matched platelets whenever possible. Most patients in both groups received oral, non-absorbable antibiotics, and were treated with carbenicillin and an aminoglycoside antibiotic when infection was suspected or confirmed.

logists

*Median

(range).

tA.L.L.=acute lymphoblastic leukaemia; A.M.L.=acute myeloid leukwmia ; other=undifferentiated leukaemia (1) and lymphocytic lymphoma (1).

at

one

hospital,

were

1199 and tial

recurrent

leukaemia for 21%. The in 10

cause

of intersti-

(6), herpes

patients pneumonitis (1), Pneumacystis (1), unknown (2). 4 of the 5 long-term survivors have returned to full activity. The 5th patient’s activities are modestly restricted by chronic cutaneous G.v.H.D. but he is attending school regularly. was c.M.v.

zoster

TABLE I!——CHEMOTHERAPY OF NON-TRANSPLANT PATIENTS AFTER ENTRY INTO STUDY

.

Fig. 2-Actuarial survival

of bone-marrow

transplant

reci-

pients. Open circles represent patients still alive. Data Analysis

Comparisons between the study groups were analysed by Fisher’s exact t-test.9 Remission and survival were analysed by life-table analysis, program B.M.D. 11S of the U.C.L.A. Health Sciences Computing Facility. 10 Results

Transplant Group 5 patients in the transplant group are alive and in remission 1-2tyears after transplantation. 3 patients died of infection before day 14, with no evidence of residual leukxmia. Clinically detectable leukaemia was eradicated in the remaining 30. Only 3 relapses were observed: 1 in a patient with A.L.L. and 2 in patients with A.M.L. 2 relapses involved recipient cells; the third was in an identical twin. The actuarial relapse-rate was 24%. Overall, 2 years of disease-free survival was achieved by 15% (fig. 2); it was achieved by 20% of those aged 18 years or under and by 11% of those over 18 years. This difference is not

statistically significant.

Morphological type of leuksemia, number of previous remissions, ABO and sex matching, and dose of marrow had no significant effect on graft outcome. 28 patients died. 12 deaths (43%) were related to systemic fungal infections (Candida and Aspergillus), 2 (7%) to drugs and radiation toxicity, 10 (36%) to interstitial pneumonitis, 1 to G.v.H.D., and 3 (11%) to recurrent leukaemia. When early deaths (at day 40 or earlier) were excluded, interstitial pneumonitis accounted for 71% of deaths,

Chemotherapy Group The 37 patients in the chemotherapy group were treated with a variety of chemotherapeutic agents detailed in table 11. In addition, 1 patient received lowdose (less than 200 rad) total-body irradiation. 2 of.9 patients with A.L.L. achieved a 3rd remission. 4 of 28 patients with A.M.L. (14%) achieved a 2nd remission and 3rd remission. Late remissions were brief months). Actuarial survival of the chemotherapy group is given in fig. 3. Median survival was 4 months and no patient survived more than 13 months. Most patients died during attempts at reinduction, usually from infection and hxmorrhage, while 24 died without achieving remission. 31 had residual leukaemia at necropsy. 4 patients, 2 with A.L.L. and 2 with A.M.L., died from intractable c.N.s.leukaemia. 1 achieved (median 2

a

Discussion With intensive induction chemotherapy, hxmatological remission can be achieved in most patients with acute leukaemia. Prophylactic treatment of the c.N.s. and maintenance chemotherapy have prolonged remissions in A.L.L." The role of C.N.S. prophylaxis and maintenance chemotherapy in A.M.L. is controversial. Most haematologists feel that they contribute to prolongation of remission but results from controlled trials have been contradictory, and the brief duration of remissions in A.M.L. (median 10-13 months) indicates the relative ineffectiveness of this approach. Recently, there has been considerable evidence suggesting that immunotherapy, as currently administered, is ineffective in prolonging remissions in A.L.L.12 Results in A.M.L. have been contradictory, but some encouraging preliminary results have been reported. 13-16 Survival after leukaemic relapse is poor17 and there is controversy over the best treatment. Patients with A.L.L. may achieve a 2nd remission, particularly if the relapse occurs after the cessation of maintenance chemotherapy.18 Unfortunately, subsequent remissions, if achieved, are generally brief. The proportion of patients with A.M.L. achieving 2nd remissions is less than 25% in most series. 19-25 These remissions are likewise brief. ,

Fig.

3-Actuarial survival of treated by chemotherapy.

Survival for

A.M.L.

patients

patients

with resistant leukaemia

measured from lst

A.L.L. patients measured from 2nd relapse.

relapse; survival

for

1200 Recent data from the Medical Research Council leukeemia trials indicate a median survival of less than 26 weeks following relapse for A.M.L. patients aged 45 or

FETO-MATERNAL BIDIRECTIONAL MIXED LYMPHOCYTE REACTION AND SURVIVAL OF FETAL ALLOGRAFT

under.26 In view of the poor prognosis of leukaemia patients who either have failed to achieve an initial remission or have relapsed, we initiated a trial of allogeneic bonemarrow grafting in 1973 using an intensive conditioning regimen of "supralethal" doses of anti-leukaemic drugs and radiotherapy followed by marrow "rescue." This regimen was successful in eradicating disease with an actuarial 2-year relapse rate of 24%, which is superior to the 70-100% relapse rates, reported by others.1,3,4 As expected the incidence of early infectious complications, primarily fungal, was higher than that observed with less intensive conditioning regimens such as cyclophosphamide and total-body irradiation. Interstitial pneumonitis was a major problem in our series and those

reported by others. 1.2,77 Two trials of allogeneic marrow transplantation for resistant leukaemia, ours and a trial from Seattle,’ have reported 2-year disease-free survival rates of 14% and 15%. These results should be compared with results obtained in equivalent patients treated with standard forms of therapy. To provide data for such a comparison, we selected a retrospective control group of leukoemia patients who would have been transplanted had a suitable marrow donor been available. Transplant and non-transplant patients were matched for known prognostic factors and were cared for by a single group of physicians. Patients in the non-transplant group received what would be considered aggressive chemotherapy and intensive support in most leukxmia centres. The absence of long-term survivors confirms the experience of most clinicians. One must, however, be cautious in the interpretation of our results as this was not a prospective randomised trial. While the results of marrow grafting are far from ideal, they indicate the possibility of achieving longterm, disease-free survival in a small proportion (5 out of 33) of patients with resistant acute leukxmia. Unfortunately, intensive conditioning regimens such as SCARI are associated with a high incidence of early infections. Attempts to improve survival rates with improvement of antimicrobial support (e.g., sterile environments, "prophylactic" granulocyte transfusions, and earlier diagnosis and treatment of fungal disease) and earlier transplantation before development of resistant disease are now being studied. Bone-marrow transplantation must still be considered investigational but capable of achieving long-term survival in some patients with resistant leukaemia. This

study represents the teamwork of the nurses, staff, and physiof the U.C.L.A. Bone-marrow Transplant Team and the U.C.L.A. Acute Leukemia Study Group without whose dedicated efforts these studies would not have been possible. Nancy Lydanne, cians

Mindy Cahan, Jan Campiformio, Debbie Rose, Salpy Nicolescu, Michele Hamilton, Judy Lesch, Trudy Olins, Susan Mapes, Carma Rippee, Alice Wing, and Addy Olivier made important contributions to this study. This work was supported by grants CA 12800, CA 15688, and RR00865 from the National Cancer Institute and the U.S. Public Heatth Service.

Requests for reprints should be addressed to Dr Robert Peter Gale, U.C.L.A. Bone-marrow Transplant Unit, Center for the Health Sciences, Los Angeles, California 90024, U.S.A.

RONALD FINN J. C. DAVIS

C. A. ST. HILL L. J. HIPKIN

MARJORIE HARVEY Royal Southern Hospital, Liverpool and Departments of Medicine and Endocrine Pathology, University of Liverpool Maternal and fetal lymphocytes were tolerant of each other in the bidirectional mixed lymphocyte reaction. This seems to be the principal reason why the mother does not reject the fetal allograft. Tolerance between maternal and fetal cells must be largely due to a genetic mechanism, because the bidirectional mixed lymphocyte reaction between parents and older children was much reduced compared with that between randomly selected pairs of controls.

Summary

This weak reaction disappeared when immunosuppressive agents were given to one member of the parent/

D., Buckner, C. D., Banaji, M., Clift, R. A., Fefer, A., Flournoy, N., Goodell, B. W., Hickman, R. O., Lerner, K. G., Neiman, P. E., Sale, G. E., Sanders, J. E., Singer, J., Stevens, M., Storb, R., Weiden, P. L. Blood, 1977, 49, 511. 2. U.C.L.A. Bone-marrow Transplant Group. Ann. intern. Med. 1977, 86, 155. 3. Santos, G. W., Sensenbrenner, L. L., Anderson, P. N., Burke, P. J., Klein, D. L., Slavin, R. E., Schacter, B., Borgaonkar, D. S. Transpl. Proc. 1976, 1. Thomas, E.

4.

8, 607. Graw, R. G., Jr, Lohrman, H.-P., Bull, M. I., Decter, J., Herzig, G. P., Bull, J. M., Levanthal, B. G., Yankee, R. A., Herzig, R. H., Krueger, G. R. F., Bleyer, W. A., Buja, M. L., McGinniss, M. H., Alter, H. J., Whang-Peng, J., Gralnick H. R., Kirkpatrick, C. H., Henderson, E. S. ibid. 1974, 6,

349. 5. U.C.L.A. Bone-marrow Transplant Team. Lancet, 1976, 6. Gale, R. P., Feig, S. A., Ho, W., Falk, P., Rippee, C.,

ii, 921. Sparkes,

R. S. Blood,

1977, 50, 185. 7. Thomas, E. D., Storb, R., Clift, R. A., Fefer, A., Johnson, F. L., Neiman, P. E., Lerner, K. G., Glucksberg, H., Buckner, C. D. New Engl. J. Med. 1975, 292, 832, 895. 8. Lau, W. K., Young, L. S. ibid. 1977, 295, 716. 9. Goyette, D., Mickey, M. R. Technical Report no. 15, U.C.L.A. Health Science Computing Facility, 1975. 10. Dixon, W. J. (editor) B.M.D. Biochemical Computer Programs, X-series suppl., Berkeley, 1969. 11. Simone, J. Semin. Hemat. 1974, 11, 25. 12. Heyn, R. M., Joo, P., Karon, M., Nesbit, M., Shore, N., Breslow, N., Weiner, J., Reed, A., Hammond, D. Blood, 1975, 46, 431. 13. Powles, R. L., Russell, J., Lister, T. A., Oliver, T., Whitehouse, J. M., Malpas, J., Chapius, B., Crowther, D., Alexander, P. Br. J. Cancer, 1977, 35, 265. 14. Whittaker, J. A., Slater, A. J. Br. J. Hœmat. 1977, 35, 263. 15. Cuttner, J., Bekesi, J. G., Holland, J. F. Proc. Am. Ass. Cancer Res. 1976, 17, 196. 16. Gutterman, J. U., Rodriguez, V., Mavligit, G., Burgess, M. A., Gehan, E., Hersh, E. M., McCredick, B., Reed, R., Smith, T., Bodey, G. P., Sr, Freireich, E. J. Lancet, 1974, ii, 1405. 17. Wiernik, P. H., Serpick, A. A. Medicine, Baltimore, 1970, 49, 505. 18. Rivera, G., Pratt, C. B., Aur, R. J. A., Verzosa, M., Hustu, H. O. Cancer, 1976, 37, 1679. 19. Levi, J. A., Wiernik, P. H. ibid. 1976, 38, 36. 20. McCredie, K. B., Bodey, G. P., Burgess, M. A., Gutterman, J. U., Rodriguez, V., Sullivan, M. P., Freireich, E. J. Cancer Chemother. Rep. 1973, 57, 319. 21. Bodey, G. P., Hewlett, J. S., Coltman, C. A., Rodriguez, V., Freireich, J. Cancer, 1974, 33, 626. 22. Yakar, D., Holland, J. F., Ellison, R. R., Freeman, A. Cancer Res. 1973, 33, 972. 23. Land, V. J., Falletta, J. M., McMillion, C. W., Williams, T. E. Cancer Chemother. Rep. 1974, 58, 715. 24. Karon, M., Sieger, L., Leimbrock, S., Finkelstein, J. Z., Nesbitt, M. E.,

Swaney, J. J. Blood, 1972, 42, 359. Jacquillat, Cl., Weil, M., Gemon-Auclerc, M. F., Izrael, V., Boiron, M., Bernard, J. Cancer, 1976, 37, 653. 26. Medical Research Council Working Party. Br. J. Hœmat. 1974, 27, 373. 27. Neiman, P. E., Thomas, E. D., Reaves, W. C., Ray, C. G., Sale, G., Lerner, K. G., Buckner, C. D., Clift, R. A., Storb, R., Weiden, P. L., Fefer, A. Transpl. Proc. 1976, 8, 663. 25.