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Conjugate formation by natural killer (NK)-resistant and NK-sensitive leukaemic cell lines with fresh and IL-2-stimulated (lymphokine-activated killer, LAK) peripheral blood lymphocytes (PBL) was studied by a flow cytofluorometry method with double staining. A significant difference in binding of NK-resistant T-cell lymphoma (HuT 78) and NK-sensitive myeloid (K562) blasts to fresh PBL was observed (P < 0.01). Activation of lymphocytes with IL-2 resulted in a significant increase of binding and killing of both K562 and HuT 78. However, in the case of blasts from NK-resistant cell line Daudi a similar conjugate formation with fresh PBL and LAK effectors was observed, despite a significant increase in killing. Various subpopulations of LAK effectors (CD3, CD16 and CD56 positive) displayed similar binding activity towards myeloid (K562) and lymphoid (Raji) blasts, which shows that conjugate formation occurs not only with NK-cell-derived, but also with T-cell-derived LAK cells. The blocking of CD71 antigen (transferrin receptor) on K562 blasts inhibited binding of cytotoxic lymphocytes, which was mostly due to the blocking of binding of CD56+ subpopulation. Our results indicate that the resistance of leukaemic blasts to cell-mediated cytotoxicity may depend on different (and probably several) steps of this process.

By using a quantitative RNA-RNA solution hybridisation method, the average number of mdr1 RNA transcripts per cell was measured in total nucleic acid extracts of leukaemic cells from patients with acute leukaemia. The results in different types of leukaemia were (number of patients with detectable mdr1 RNA/total number of patients; median number of transcripts per cell in samples with detectable mdr1 RNA); de novo untreated acute myelocytic leukaemia (AML): 20/44; 0.7, secondary acute myelocytic leukaemia: 8/13; 1.1, acute lymphocytic (ALL) and undifferentiated leukaemia: 5/14; 0.6, relapsed leukaemia: 7/15; 0.7. Forty-six patients with de novo untreated acute leukaemia (AML: n = 34, ALL: n = 12) were evaluable for response to induction chemotherapy. Twelve of 18 patients (67%) with detectable mdr1 RNA levels achieved complete remission compared to 23 of 28 (82%) with undetectable levels (P = 0.40). The remission duration tended to be longer among patients with undetectable mdr1 RNA (P = 0.08). Leukaemic cells were analysed on consecutive occasions in 12 patients. The level of expression increased in four and decreased in two. In conclusion, expression of mdr1 RNA is common in acute untreated leukaemia. However, treatment with cytostatic drugs seems only rarely to increase the proportion of leukaemic cells that express mdr1 RNA. Expression of the mdr1 gene could be one of several equally important factors contributing to drug resistance in acute leukaemia.

Autotransplants in leukemia are controversial; their rationale and results have been questioned. Here we consider several issues central to this debate: (1) Are there convincing data to suggest that more intensive therapy increases cures? (2) Are results post-autotransplant a consequence of the transplant, or do they reflect subject-selection and time-to-treatment (time censoring) biases? (3) Does leukemia relapse after an autotransplant develop from persisting leukemia cells in the subject or the graft? (4) Do autotransplants using hematopoietic stem cells from different sources have distinct outcomes? (5) Are immune-mediated anti-leukemia mechanisms likely to prevent relapse after autotransplants? and (6) Can comparably intensive therapy be given without an autotransplant?

Results of five different methods (heme breakdown, mitotic indices, total marrow cellularity and different methods of labelling indices) to determine bone marrow cell growth are reviewed. Normal immature erythroblasts and myeloblasts have generation times of about 5-10 h. Erythroblasts in neoplastic conditions (the myelodysplastic syndrome and polycythemia vera) have generation times which are significantly prolonged, by 12-75 per cent, but this may not be true for myeloblasts, since total labelling indices are increased (from normal 3.9 to 11.2 per cent) in the myelodysplastic syndrome. In contrast, generation times in aplastic anemia are significantly shortened, by about 70-80 per cent. Normal mature erythroblasts and promyelocytes have generation times of about 24 h, and the malignant prolongation may be even greater.

The efficacy of platelet transfusions in pretransfused HL-1 sensitized patients has been doubtful, particularly where repeated platelet transfusions were required. The efficacy of one hundred and nine ABO-compatible, cross match negative platelet transfusions in 26 adult patients with acute leukemia was therefore studied. Although most of the patientswere old and pretransfused and although no HL-A typing could be made, a statistically significant average increase of about 11 000 platelets/mul was seen not only after the first but also after subsequent (up to 8) platelet transfusions. Moreover, significant reduction in temperature followed platelet transfusions. However, platelet recoveries were worse in severely infected patients.

The accumulation of vincristine in leukemic cells and normal mononuclear cells and the effect of verapamil on cellular drug accumulation were studied. Leukemic cells were isolated from 10 patients with chronic lymphocytic leukemia, immunocytoma and prolymphocytic leukemia. Normal mononuclear cells were collected from 3 healthy subjects. The cells were incubated with [3H]-vincristine and cellular drug accumulation was determined. The accumulation of vincristine differed nine-fold between patients. The presence of verapamil, 6.6 microM, during the incubation, increased drug accumulation by 150-550%. The effect increased with increasing verapamil concentrations up to 12-15 microM. The increased accumulation of vincristine caused by verapamil also led to increased in vitro cytotoxicity. However, neither the cellular accumulation of vincristine nor the effect of verapamil on drug accumulation was correlated with the clinical response to vincristine-containing treatment regimens. To study the clinical effect of verapamil on leukemic cell accumulation of vincristine, 4 patients were given verapamil, 120 mg three times orally. The plasma concentrations of verapamil after 3 days of treatment were lower than those required to enhance vincristine accumulation in vitro. In addition, norverapamil could also be detected in all patients. Before and at the end of the verapamil treatment period, blood from the patients was incubated with [3H]-vincristine and the leukemic cells then isolated. Verapamil treatment had no effect on the accumulation of vincristine in leukemic cells.

Forty-four adult patients under 60 years of age with acute nonlymphoblastic leukemia were randomized for induction treatment with one of the following three regimens: R 1 = courses of daunorubicin on day 1 + ARA-C on days 1--5; R 2 = courses of daunorubicin on days 1 and 2 + ARA-C on days 4--8; R 3 = courses of daunorubicin-DNA complex on days 1--2 + ARA-C on days 4--8. Out of 14 patients, 9 went into remission on R 1, 6 out of 14 on R 2, and 8 out of 16 on R 3. The preliminary results suggest that daunorubicin-DNA complex has the same efficacy for inducing remission as daunorubicin alone, if the same time intervals and dosages are used.

Leukemic cells isolated from peripheral blood from 6 patients with chronic lymphocytic leukemia, immunocytoma and prolymphocytic leukemia were incubated with vincristine (10 nM) with and without racemic verapamil and its L- and D-isomers (6.6 microM). Verapamil increased vincristine accumulation in all cells, the increase varying between 100 and 700%. Racemic verapamil and the L- and D-isomer increased cellular vincristine accumulation to the same extent. The verapamil effect could not be reversed by increasing the calcium concentration in the incubation medium (final concentration 2.5-5.0 mM). The results indicate that the mechanism behind the effect of verapamil on cellular accumulation of vincristine does not depend upon changes in calcium transport.

Sixty-six children with acute lymphatic leukemia (ALL), 26 adults with ALL and 47 adults with acute myeloid leukemia (AML) were subclassified according to the classifications French-American-British (FAB) and World-Health-Organization (WHO). Nine immunological markers and 6 cytochemical stains were also used. The reproducibility of the WHO classification of the smears performed independently twice by one observer was 93%, but that between two observers only 78%. Three patients considered ALL by A were called AML by B, but all three had the common acute leukemia antigen, CALLA. In the group of 87 patients considered ALL by B, only 74 were classified ALL by A, but of the 13 non-ALL B, none had the CALLA. Ten of these thirteen patients had myeloid markers such as Philadelphia chromosomes, peroxidase or Sudan Black B positive reactions, or Fc and C3 receptors. The remaining 3 patients were non-Hodgkin lymphoma with B-cell markers. None of the 47 cases classified as AML had CALLA. Seventeen of nineteen myeloblastic leukemias (M2, FAB) had a myeloid antigen (Mag) and 13 of 15 myelomonocytic leukemias (M4, FAB) had, in addition, Fc and C3 receptors.

In a questionnaire study 140 subjects answered 4200 questions in 1980 and 1986. They consisted of patients with myeloma, acute leukemia, lung carcinoma, and non-malignant disease and their relatives. In 22 additional cases the questionnaire was not answered. The results show that myeloma patients are less content with the general care than leukemia patients (P less than 0.05). Similarly, relatives of decreased myeloma patients are less satisfied with the information given to them than relatives of deceased leukemia patients (P less than 0.001). The information has improved with time, however, since the patients were more satisfied in 1986 than in 1980 (P less than 0.001) and relatives of myeloma patients still alive were more satisfied than relatives of patients who had died earlier (P less than 0.001). The opinions of patients were similar to those of their relatives. However, the relatives of leukemia patients were even more satisfied with the contact with the medical staff than the patients themselves (P less than 0.05). As many as 10-30% of the relatives never gave up hope for their relative's survival. Only two out of 27 deaths were considered not dignified. The lung carcinoma patients reported a less good quality of life (P less than 0.001), and less satisfaction with the information given (P less than 0.01), than the hematological patients from the same year. Similarly, their attitude to the medical care improved less (P less than 0.01), and they were less content with the general care than the leukemia group (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Sixteen patients who had died with leukemia were studied at autopsy between September 1975 and Februrary 1977. Special attention was given to degenerative changes in the heart. Five of the patients died of cardiac failure, all with no or only slight leukemic infiltration in various organs at autopsy. Five patients showed basophilic necroses in the myocardium, and two of these also showed necroses in the bone marrow. The myocardial lipofuscin was significantly (P less than 0.01) higher in the autopsies of leukemic patients (mean age 45 years) than in autopsies performed at the Department of Forensic Medicine in 18 cases of accidental death (mean age 36 years). No dose-response relationship could be found between the amount of myocardial lipofuscin and the total dose of rubidomycin. Eight of twelve patients with malignant lymphoma (mean age 45 years) also had increased amount of myocardial lipofuscin.

An attempt was made to see if new forms of treatment of fungal and bacterial septicemia, or new cytostatic combinations have changed the causes of death in leukemia and lymphoma. Autopsies were studied of 16 cases with acute leukemia, 2 with chronic granulocytic leukemia and 24 with lymphoma. 10 of the 18 patients with leukemia and 10/14 lymphoma patients died although they had no, or only slight, tumor infiltration in the bone marrow and parenchymatous organs; only 1/18 leukemias had extensive infiltration. There was a statistically significant correlation between the extent of marrow and organ infiltration. Cardiac failure (5/18 patients) was almost as common as the main cause of death as septicemia (7/18) in leukemia. The corresponding figures in lymphoma were 5/24 and 9/24, respectively. The present findings contrast with earlier ones, where more septicemia and tumor infiltration were found at autopsy, and less cardiac failure was observed. 15 of 16 cases with septicemia at autopsy had terminal fever. Bacteriological and histological signs of septicemia at autopsy agreed satisfactorily. There was a surprising absence of agreement between terminal granulocytopenia and septicemia; 13 of 16 patients with septicemia had over 0.1 x 10(9) and 10 over 0.5 x 10(9) granulocytes/liter blood.

Activity of terminal deoxynucleotidyl transferase (TdT), adenosine deaminase, and 5'nucleotidase and the cellular concentration of glucocorticoid (dexamethasone) receptor were determined in 25 patients with acute non-lymphocytic leukaemia. All patients were treated according to a common protocol. Increased activity of TdT (greater than 0.1 unit/microgram DNA) was found in 11 patients. This group of patients was shown to have higher remission and survival rates (p = 0.06) compared with patients with low activity of TdT. The glucocorticoid receptor concentration of the leukaemic blast cells ranged from 0 to 0.94 fmol/microgram DNA. Thirteen patients had blast cells with a glucocorticoid receptor concentration over 0.22 fmol/microgram DNA. These patients had significantly increased remission and survival rates (p = 0.006) compared with those with a low receptor concentration. This finding cannot be explained by a difference in sensitivity to glucocorticoids since these were not used as therapeutic agents. Adenosine deaminase and 5'nucleotidase activities both varied within two orders of magnitude. No correlation could be found between activities of these enzymes and remission or survival rate. These results show that measurements of TdT activity and the glucocorticoid receptor concentration yield valuable prognostic information in acute non-lymphocytic leukaemia.

Earlier studies show that immunotherapy (IT) improves prognosis in acute nonlymphatic leukemia (ANLL), and that ANLL cells probably have tumor-associated antigens, for autologous lymphocytes can react to them. Also, IT seems to immunize against allogeneic ANLL cells, but there is no cross-immunity to autologous ones. Moreover, patients immunized against their ANLL cells have no better prognosis than patients not having lymphocytes reacting to their ANLL cells. It has also been suggested that IT causes nonspecific immunostimulation, but IT patient's lymphocytes actually react less than those of patients not given IT. The current hypothesis is macrophage activation: Lymphocyte suppression in IT could be explained by suppressor macrophages. Colony-stimulating activity, produced by bone marrow macrophages, decreases during remission in patients not given IT, but not in IT patients. Numerically, blood cells from patients given IT form more colonies than those from patients not given IT. Three of eight patients given IT had more colonies than the upper normal limit.

Out of 38 leukaemic cases only 16 had extensive leukaemic infiltration at death. 15 patients had slight or moderate and 7 no infiltration at all. 12 of the 15, and 5 of the 7 died with septicaemia. The latter patients must have died of complications rather than of the leukaemia itself. Although it has been possible to reduce the incidence of septicaemia during life, terminal septicaemia does not yet seem to be preventable. Septicaemia was revealed at autopsy in 27 of 38 patients; 25 of these also had clinical signs of septicaemia before death. Necrotizing gastrointestinal lesions may cause endogenous infection. In the present material, almost every second patient had fungal septicaemia. Out of 7 patients having oral candidiasis in vivo 5 had systemic candidiasis at autopsy, but only half of the patients with systemic candidiasis had visible oral growth. Modern treatment of leukaemia seems to be able to prevent intracranial haemorrhage in 90% of the cases. On the other hand, vacuolization of muscle and liver tissue was a frequent finding in leukaemia. It is suggested as being caused by fatty degeneration. Vacuolization of myocardial cells was found in 7 out of 13 cases. Among these 7, 4 had had intermittent hypokalaemia.

Although every second patient with leukemia or a solid tumor has lymphocytes which can recognize or can be induced to recognize autologous tumor cells, it has been difficult to demonstrate that this recognition is, in man, due to tumor specific antigens. Other immunological abnormalities, such as lineage infidelity or maturation asynchrony, are more likely explanations. Moreover, immunological heterogeneity is pronounced among human tumor cells. For these reasons, antibody independent tumor surveillance is receiving increased attention. It is mediated by cytotoxic macrophages, NK-cells and the so called NK-like, pre-induced cytotoxic T-cells. NK-cells, probably a T-cell subpopulation sharing a marker with macrophages, have a cytotoxic effect mainly on certain cell-lines, but hardly on viable human tumor cells. In contrast, different degrees of pre-stimulation with allogeneic lymphocytes, lectins or interleukin 2 can induce, in human T-cells, both HLA-restricted and non-restricted cytotoxicity against viable human tumor cells. This indication is active even in T-cell populations that are either monoclonal or pre-depleted of NK cells.

The frequency of fever days was measured in 67 patients with acute leukemia in the initial phase until remission was obtained or the patient died. A total of 3411 hospital days were studied. Three antibiotic schedules were examined between 1970 and 1975. There were 50% fever days when penicillin and streptomycin were combined as initial antibiotics, 37% when cephalosporin and gentamycin were used, and 31% when, in addition, semi-isolation was used prophylactically and granulocytes were given in a therapeutic attempt (0.05 greater than p greater than 0.01). The corresponding frequencies of early death were 9/21 (43%), 6/23 (26%) and 5/23 (22%). Early death occurred on an average 14, 23 and 21 days after admission. The frequencies of remission (complete and partial) were 8/21 (38%), 12/23 (52%), and 13/23 (57%). A randomized subgroup (12 patients) with intestinal sterilization was studied separately. It had 28% fever days, which is significantly less (p less than 0.01) than in the 13 patients given the same systemic antibiotics without intestinal sterilization. Fever was significantly lower (0.05 greater than p greater than 0.01) on the day after a series of granulocyte transfusions than before, although only 10(9) granulocytes were given. However, this fever reduction may have been due to concomitant antibiotics.

Peripheral blood and bone marrow mononuclear cells from 12 patients with acute myeloid leukemia (AML), 2 patients with acute lymphatic leukemia, and 1 patient with chronic myeloid leukemia in blastic crisis were taken at diagnosis or in relapse. Cells were immunophenotyped with a panel of monoclonal antibodies (Moab) (OKIa, Leu M1, Leu M2, Leu M3, Leu M4, B1, Okt 11, J5) and the same antibodies were used in an in vitro cytotoxicity test. Of the 14 patients, 10 had antibody-binding cells, and the percentage of lysed cells was almost equal to that of blasts. The other 4 patients had few binding cells and little lysis. Acute leukemia with and without preceding myelodysplastic features did not differ in immunophenotype. Mean spontaneous release of 51Cr was 12.7% and complement alone caused an additional average release of 11.8%. Four single antibodies together with complement showed a mean 51Cr release of 0.7-32.4% above that found with complement alone. Combinations of Moabs resulted in 51Cr release at least 10% above the single most efficient Moab in 8 out of 12 patients. Not all blast cells showed antibody binding, nor were all antibody-binding cells susceptible to cytotoxicity. Normal bone marrow growth in vitro seemed to be stimulated by factors in complement and in the Moab. When this stimulation was compensated for by adding fetal calf serum, cytotoxicity tests prior to CFUc assays resulted in a mean decrease of 46% of colonies and 25% of clusters in normal bone marrow. CFUc are thus sensitive to the cytotoxicity, although CFU may also be resistant.

Growth of bone marrow and mononuclear white blood cells (MWBC) in soft-agar cultures was studied in 26 patients with untreated acute non-lymphocytic leukaemia (ANLL). Marrow and MWBC from 30 healthy volunteers served as controls. All ANLL patients revealed an abnormal growth in vitro. Patients with an increased number of clones in marrow cultures and large cluster predominance ('excessive growth') responded poorly to therapy with only one of 10 patients entering remission. On the contrary, only two of the 15 patients with a decreased clone number ('low growth') failed to achieve remission. The number of colonies and clusters in both bone marrow and blood cultures was significantly lower at presentation in patients who later entered remission than in those who did not. The correlations between the number of colonies and clusters in the blood and the marrow cultures were statistically significant. No significant correlations were found between prognosis or colony formation, on one hand, and the production of colony stimulating activity (CS)bA), by bone marrow and blood cells of ANLL patients, on the other. Nor could such correlations be found between prognosis, blood cell counts, and age. It is concluded that the growth pattero cytostatic drugs and particularly in selecting patients with a high probability to respond poorly to current cytostatic regimes.

After 24-72 h of PHA-stimulation, T-cells expressed the transferrin receptor. This receptor facilitates zinc uptake. Zinc transferrin stimulated DNA synthesis in pre-activated or activated, but not in resting T-cells. The regulatory nuclear protein matrix fraction increased from 5 to 40% of the total nuclear protein material in lymphocytes simultaneously with the initiation of DNA synthesis. In contrast, optimal concentration (0.1-0.4 mM) of zinc salts induced a mitogenic response in transferrin-receptor negative resting, but not in PHA-activated or leukemic T-cells. Higher concentrations were toxic. These findings can explain earlier reports on the effect of zinc on immunocompetence in zinc deficient mice and enteropathic acrodermatitis as well as present findings of a normalization of the T-suppressor-cell number in immunosuppressed patients.