The aim of this study is to determine the safety and efficacy of Transfer Factor (TF) in accelerating the haematopoietic recovery in patients with acute leukaemias (AL), following intensive therapy to induce remission of the disease. Twenty-two patients with different types of AL (16 AML, three BC-CML and three ALL) were studied. The patients were divided in two groups. Group 1 (eight AML, two BC-CML and one ALL) received, after myelosuppression induced by chemotherapy, TF (1 unit daily, subcutaneous) until leucocyte count was > 2.5 x 10(9)/l and platelet count > 80 x 10(9)/l. Group 2 was considered the control group and did not receive TF. Treatment with TF accelerated the recovery of neutrophils, leucocytes, platelets (P < 0.001) and haemoglobin (P < 0.01). As a logical consequence, incidence and severity of infection and haemorrhage were lesser in the TF group than in the control group. There was no evidence that TF accelerated the re-growth of leukaemic cells. It seems that TF is safe in AL, accelerating haematopoietic recovery. However, it should be used with caution until results of additional trials become available.

Evidence has accumulated in mammals suggesting a positive role for epidermal growth factor (EGF) as an inducer of oocyte maturation. The potential use of EGF as inducer of cytoplasmic and nuclear maturation was tested in women with > 10 oocytes retrieved in in-vitro fertilization (IVF), since we have previously observed that such oocytes are immature. Oocytes from 17 high responders were randomly allocated to one of the three treatment groups upon retrieval: control receiving no EGF (n = 93), 1.0 ng/ml EGF (n = 92) and 10.0 ng/ml EGF (n = 77) for 6 h before insemination. The rates of fertilization were respectively 54.6, 59.0, and 46.1%, suggesting that EGF is not effective at this maturational stage after this length of exposure. Embryo development was further analysed by the appearance of the embryos under the dissecting microscope and the number of blastomeres developed 48 h after insemination. No difference between groups was observed considering the number of blastomeres developed. However, embryos derived from oocytes treated with 10 ng/ml EGF displayed a worse appearance under the microscope. It is concluded that a 6 h incubation with EGF does not seem to affect cytoplasmic maturation in oocytes obtained after gonadotrophin treatment, as ascertained by the rate of fertilization following oocyte insemination.

This study compared the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) alone or in combination with peripheral blood-derived hematopoietic progenitor cells (PBP) as support for patients receiving high-dose chemotherapy and assessed the adequacy of these strategies as alternatives to autologous bone marrow rescue.

One hundred and twenty-eight patients with non-Hodgkin's lymphoma (NHL), Hodgkin's disease (HD), and acute lymphoblastic leukemia (ALL) previously reported from a phase III trial of rhGM-CSF or placebo following autologous bone marrow transplantation (ABMT) were investigated for the development of late toxicities. Median follow-up is 36 months. No apparent long-term deleterious effects on BM function were observed. Moreover, disease-free survival and overall survival were similar for patients on both treatment arms, arguing for the long-term safety of recombinant human granulocyte macrophage-colony-stimulating factor (rhGM-CSF). The only factors predictive for both a high risk of relapse over time and mortality were having the diagnosis of ALL and/or undergoing ABMT in resistant relapse. We attempted to identify clinical variables before BM harvest, at the time of marrow infusion, or events within the first 100 days posttransplant, which might predict speed of neutrophil recovery in the setting of placebo or rhGM-CSF administration after ABMT. Only previous exposure to agents that deplete stem cells led to a significant delay in neutrophil recovery, suggesting their avoidance in patients who may undergo ABMT. Nevertheless, even those patients benefited from rhGM-CSF. For all patients, rhGM-CSF and agents that deplete stem cells were the strongest independent predictors for neutrophil engraftment. With the increasing use of newer hematopoietic growth factors both alone and in combination, long-term follow-up is essential to confirm the same safety that we report with rhGM-CSF.

From Dec 1986 to Dec 1990, 113 consecutive patients radically resected for renal cell carcinoma, have been randomized after surgery to observation or to Active Specific Immunotherapy (A.S.I.). 43 patients stage I-II and 13 p. stage III, according to TNM entered the treatment arm consisting of 10 autologous irradiated tumor cells injected intradermally, either mixed with BCG 10(7) (on days 28th and 35th after surgery) or alone (on day 42th). At randomization and 1, 6 and 12 months after treatment, patients were evaluated for the development of a DTCH to autologous tumor and to autologous normal cells, obtained by mechanical and enzymatic dissociation of the surgical specimens. Baseline DTCH were negative in all patients. One month after completing A.S.I. 36 out of 50 evaluable patients displayed a significant DTCH response to autologous tumor, which remained positive in 23/40 patients at 6 months. Our data clearly indicate that Active Specific Immunotherapy with autologous tumor cells mixed with BCG can elicit a specific immune response to autochthonous tumor as measured by DTCH.

Patients with cancer can now benefit from intensive drug dosage. Intensive drug dosage has become more effective because of the availability of better anti-emetics, hematopoietic growth factors such as granulocyte-macrophage colony-stimulating factor (GM-CSF), granulocyte CSF (G-CSF), erythropoietin, etc. and improvements in hematopoietic stem cell transplantation. We have evaluated the clinical and cost effectiveness of GM-CSF in patients undergoing autologous bone marrow transplantation (AuBMT) for Hodgkin's disease. Administration of GM-CSF after AuBMT enhances myeloid and platelet recovery and is cost effective in the treatment of patients with relapsed Hodgkin's disease who received intensive chemotherapy and AuBMT. We also describe the use of various new therapeutic approaches with emphasis on clinical and cost benefit. Further work is needed to improve the route and duration of growth factor(s) infusion and the timing of the various treatments.

High-dose chemotherapy and autologous bone marrow transplantation (ABMT) are commonly used to treat selected patients with high-risk breast cancer. A limitation of ABMT is that clonogenic cancer cells could be collected with the bone marrow and produce a relapse of diseases when reinfused into patients. Purging the marrow ex vivo may eliminate the tumor cells, but it can also delay engraftment. We employed two different purging methods whereby breast cancer cells were depleted without delaying engraftment. The addition of WR-2721 (amifostine) to 4-hydroperoxycyclophosphamide (4-HC) reduced the time to engraftment by 10 days compared with marrow purged with 4-HC alone (26 versus 37 days, respectively). The positive selection of CD34+ hematopoietic progenitors produced engraftment within 21 days. The use of granulocyte colony-stimulating factor (G-CSF) accelerated the engraftment time of CD34+ hematopoietic progenitors to 11 days.

A review of the published literature shows that treatment with high-dose carboplatin and etoposide with autologous bone marrow transplantation results in durable complete responses (3-42 months, continuous at time of report) in about 10%-20% of heavily pretreated patients with cisplatin-resistant germ cell tumors and represents a curative therapy in patients who would otherwise die of their disease. In a recent follow-up study of 40 patients with refractory germ cell tumors, 15% (six) were alive and free of disease more than 24 months after treatment with high-dose carboplatin and etoposide with autologous bone marrow transplantation. The several studies that incorporated an oxazaphosphorine (usually cyclophosphamide) in the regimen strongly suggest that the addition of this third drug to high doses of carboplatin and etoposide results in a higher proportion of complete responses (35%, 23% durable) than carboplatin and etoposide alone (26%, 12% durable). Early intervention with high-dose chemotherapy and autologous bone marrow transplantation appears to reduce hematologic toxicity. Its role in the treatment of less heavily pretreated patients will depend on the definition of "cisplatin-resistant," which may encompass those who failed to respond to the drug or those who are judged not likely to respond. Studies to improve treatment efficacy and to lessen the burden of supportive care during hematopoietic reconstitution are ongoing and include the use of peripheral blood-derived stem cells.

GM-CSF decreases the hematopoietic toxicity of both nonablative and marrow ablative intensive chemotherapy regimens. Data are limited at this time, particularly in regard to optimal schedules and GM-CSF dosing regimens with particular chemotherapy programs. The importance of GM-CSF scheduling in relationship to chemotherapy is becoming more clear. The dose-intensive regimens supported by GM-CSF produce a high complete remission rate in several types of malignancy. Evidence that these remissions will be durable is still lacking. Future directions will include filling some of these voids in our knowledge, as well as exploring various cytokine combinations for improved hematopoietic recovery and other chemotherapeutic regimens for improved antitumor effect. The near complete cytoreduction produced by these dose-intensive regimens may also create a better setting for attempts at therapeutic immunomodulation. Yet another, but more difficult, task will be to identify those situations where progenitor cell replacement is beneficial and appropriate.

GM-CSF represents an important advance in bone marrow transplantation. The drug can be given safely and does not appear to increase the risk of graft-versus-host disease or tumor relapse. This is a rare example of a new technology reducing the cost of health care. By shortening the duration of hospitalization, GM-CSF can significantly reduce the cost of a bone marrow transplant (Table 2). However, there are few data to support the conclusion that the reduction in the duration of neutropenia is associated with a superior survival. This attests to the excellent supportive care that has been developed for patients undergoing bone marrow transplantation. At present, GM-CSF has become a standard therapy in autologous bone marrow transplantation. However, the future will undoubtedly see the development of combinations of hematopoietic growth factors and/or new growth factors that will further improve our ability to perform bone marrow transplantation.

Standard or conventional treatment of chronic myeloid leukemia (CML) had little effect on the course and the duration of the disease. Treatment with human natural and recombinant alpha-interferon (IFN) was shown to induce hematologic responses, together with partial or complete repopulation of the marrow with Ph negative cells (karyotypic response). These findings prompted a prospective comparison of IFN and conventional treatment in CML.

To determine if a culture medium, designated CZB after the authors who first described it, which is supplemented with 0.11 mM ethylenediaminetetraacetic acid, 1.0 mM glutamine, 31.30 mM lactate, and 0.27 mM pyruvate and is lacking glucose for the initial stages of culture that overcomes the in vitro two-cell block of mouse embryos, can improve the rate of blastocyst formation of human embryos in long-term cultures and increase the pregnancy rate (PR) when used in a clinical in vitro fertilization (IVF) program.

To determine the hemopoietic effects of recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) in patients having autologous hemopoietic stem cell transplantation for Hodgkin or non-Hodgkin lymphoma.

The action of high-dose medroxyprogesterone acetate (MPA) was studied by analysing the behaviour of colony-forming-unit granulocyte-macrophage (CFU-GM) during chemotherapy. 21 non-pretreated men with locally advanced carcinoma of the head and neck were randomised into two arms: A (11 patients) received three alternating cycles of cisplatin, 5-fluorouracil (CF)/cisplatin, methotrexate, bleomycin, vincristine and then CF every 4 weeks and B (10 patients) were treated with the same schedule plus 1000 mg per day of MPA. MPA was administered 14 days before the start of chemotherapy (day 0) and continued daily up to the 90th day. Bone marrow was harvested in arm A on days 0, +14 and +90, and in B, also on day -14. There was diverse CFU-GM behaviour in the two arms on the 14th day. These data support the hypothesis that the myeloprotective effect of MPA is due to induction of a mitotic rest in the stem cells, which protects them from drug action.

After treatment of patients with intermediate or high grade non-Hodgkin lymphoma with chemotherapy plus G-CSF the numbers of haemopoietic progenitor cells in the circulation increased to a mean of 226-fold for mixed CFC (Mix-CFC), 278-fold for GM-CFC and 29-fold for erythroid burst forming unit (BFU-E). The mean increase was modest (7-12-fold) for patients treated with chemotherapy alone. Peripheral blood mononuclear cells harvested at the time of the peak in the numbers of progenitors, or 2-4 days before the peak, seeded onto irradiated marrow stroma in vitro, repopulated the stroma and generated active haemopoiesis at least as effectively as bone marrow cells on a cell per cell basis. This is in contrast to the poor repopulating capacity of pretreatment blood. The results indicate that not only the progenitor cells, but also the repopulating stem cells migrated into the blood after chemotherapy plus G-CSF in sufficient numbers to allow harvesting and successful grafting without the possible complication of late haemopoietic failure.

Seraspenide, a synthetic tetrapeptide, inhibits cell cycle entry of normal hematopoietic stem cells. In mice it protects hemopoiesis against the damage caused by cytarabine, cyclophosphamide and carboplatin. Seraspenide has been given to 53 cancer patients undergoing monochemotherapy with cytarabine and ifosfamide in a double-blind cross-over randomized study. A significant protection of peripheral blood cells has been observed. Seraspenide has been devoided of toxicity.

70% of patients with newly diagnosed and 50% of patients with relapsed acute myeloid leukemia (AML) can achieve a complete remission with intensive chemotherapy. However, the treatment-associated mortality can be as high as 30% increasing with age, previous chemotherapy and intensity of chemotherapy. GM-CSF was first applied in 36 patients with high risk AML after chemotherapy to reduce the time of critical neutropenia. The early death rate was significantly lower in the GM-CSF group compared to 56 patients of a historic control group with similar risk factors and identical chemotherapy (p less than 0.009). The rate of complete remissions was also significantly higher in the GM-CSF group (p less than 0.09). More recently, GM-CSF was used as a priming agent 24 h prior to start of chemotherapy. 25 patients have entered the study up to now. The cell biological effects of GM-CSF in vivo include an immediate increase of leukemic blasts and of normal myeloid cells in the peripheral blood with a median of 2.0, an increase of cells in the S-phase of the cell cycle in bone marrow biopsies, an increase in DNA polymerase activity, an increase in Ara-C cytotoxicity and immunophenotypic changes compatible with differentiation of leukemic blasts along the pathway of normal myeloid progenitors. GM-CSF has a dual effect on normal and leukemic myeloid cells. It can be safely applied in patients with AML. Prospective randomized trials have to be performed to establish its role in reducing treatment toxicity and in improving the overall treatment results.

To assess the risks and benefits of erythropoietin versus erythrocyte transfusion in the treatment of the anemia of prematurity, we randomly assigned 19 anemic preterm infants (birth weight 988 +/- 227 gm; gestational age 27.6 +/- 1.2 weeks; age 41 +/- 15 days; all values mean +/- SD) to receive either transfusion or subcutaneously administered erythropoietin (200 units/kg every other day for 10 doses). In the 10 erythropoietin recipients, corrected reticulocyte counts increased from 2% +/- 1% to 7% +/- 2% (p less than 0.001) and hematocrits increased from 27% +/- 2% to 30% +/- 4% (p less than 0.05). In the nine infants who underwent transfusion, reticulocyte counts did not increase, but hematocrits increased from 28% +/- 4% to 41% +/- 2% after initial transfusion (p less than 0.001) and had decreased to 34% +/- 5% by day 20. Signs attributed to anemia (tachycardia, apnea with bradycardia, and poor weight gain) declined in both the erythropoietin recipients and those who underwent transfusion. However, five of nine infants who underwent transfusion had symptoms within 10 to 14 days and were given further transfusions. Marrow aspiration performed after 7 to 10 days of treatment showed that infants receiving erythropoietin had greater percentages of erythropoietic precursors (p less than 0.01), greater concentrations of mature erythroid progenitors (p less than 0.001), and higher cycling rates of erythroid progenitors (p less than 0.001). The percentage of mature stored neutrophils in marrow was lower in the erythropoietin group than in the transfusion group, resulting in an inverse myeloid/erythroid ratio (0.5:1 vs 6.2:1; p less than 0.001). After 20 days, absolute blood neutrophil counts were lower in the erythropoietin recipients (1.8 +/- 0.9 x 10(3) cells/microliters) than in the infants who underwent transfusion (3.9 +/- 1.9 x 10(3) cells/microliters; p less than 0.05). Administration of erythropoietin thus stimulated erythropoiesis and relieved signs attributed to anemia; the significance of the relative neutropenia remains to be determined. We conclude that erythropoietin administration offers promise as an alternative to erythrocyte transfusion in neonates with symptomatic anemia of prematurity.

A randomized prospective trial was conducted to determine if the addition of cryopreserved autologous peripheral blood stem cells (PBSC) collected without mobilization techniques to autologous cryopreserved bone marrow for patients receiving an autologous bone marrow transplant (ABMT) affected the time to marrow function recovery. Thirty-five evaluable patients with various malignancies were studied. Sixteen received PBSC + ABMT and 19 received ABMT alone. The PBSC were collected with 4 h leukapheresis procedures on 3 consecutive days. No manipulations to increase the number of circulating stem cells were used during the collections. The median time to recover 0.5 x 10(9)/l circulating granulocytes was 20 days after transplantation in the ABMT group and 27 days in the PBSC + ABMT group (p = 0.12). The median time to recover 20 x 10(9)/l platelets was 22 days after transplantation in the ABMT group and more than 27 days in the PBSC + ABMT group (p = 0.29). The day of discharge from the hospital was earlier for the ABMT group (median 29 days) than the PBSC + ABMT group (median 35 days, p = 0.03). We did not find that the addition of non-mobilized PBSC to infused autologous marrow accelerates marrow recovery.