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Eight patients with stage III aggressive multiple myeloma, refractory to current chemotherapy in six cases, were treated by high-dose chemotherapy (nitrosourea, etoposide, and melphalan) (HDC) and total body irradiation (TBI), followed by autografting with blood stem cells. These cells were previously collected by leukapheresis performed during hematologic recovery following cytotoxic drug-induced bone marrow aplasia. Seven patients were alive 9 to 17 months after HDC-TBI and graft. One died at day 40 from cerebral bleeding. All living patients achieved a 90% or greater reduction in tumor mass. In two cases, a complete remission (CR) has persisted at a follow-up of 15 and 16 months. Three patients have been well and off therapy with stable minimal residual disease (RD) since 10, 11, and 17 months, respectively. A patient in apparent CR and another with RD have relapsed 9 to 12 months posttreatment. Autologous blood-derived hematopoietic stem cells induced successful and sustained engraftment in all living patients. These results, although still preliminary, indicate that HDC and TBI, followed by blood stem cells autograft, which has both practical and theoretical interest over allogeneic or autologous bone marrow transplantation, deserve consideration in selected patients with multiple myeloma.

Fifty-three hairy cell leukemia patients were treated with low dose recombinant and natural alpha-interferon for 7 or 13 months with a marked improvement in peripheral blood and bone marrow findings. Our results suggest that daily injections have no advantage over three weekly injections, but longer treatment (12-13 months) is better than shorter treatment (6-7 months). The possibility of a relapse raises the issue of the place of splenectomy in the treatment strategy. Since the definition of remission and of relapse is based on the histological changes in the bone marrow, the necessity for the quantification of the hairy cell infiltration on bone marrow sections is stressed.

alpha-Interferon (IFN) is effective in the treatment of hairy-cell leukemia (HCL), but the treatment is sometimes over a long period. Biological changes such as the increase of tumorigenicity can occur rapidly in vivo as a result of beginning this treatment; an increase in c-Ki-ras oncogene expression has also been observed. In order to determine whether the findings observed in vitro would be duplicated in an in vivo system, we decided to analyze the Ki-ras RNA and protein levels in the lymphocytes of three HCL patients, compared with these levels in seven normal donors and one non-treated HCL patients. Ki-ras was not activated by IFN, at least not in lymphocytes. Therefore, the data suggest that the drug could be used for long-term therapy with relatively low risk to the patients.

To investigate the platelet contribution to the development of myelofibrosis in hairy cell leukaemia (HCL), we have studied two platelet alpha granule components in 15 patients with HCL before chemotherapy: mitogenic activity was measured by 3H thymidine incorporation in BALB/C 3T3 cells and beta thromboglobulin (beta TG) assayed by radioimmunoassay (RIA). Platelet mitogenic activity and beta TG content were significantly decreased in the patients as compared to the control subjects. The nine patients who were treated with recombinant human interferon (IFN alpha A) were restudied after 4 months of therapy. The levels of both mitogenic activity and beta TG platelet content were significantly increased after IFN alpha-treatment with a complete response in five of the nine treated patients, a partial response in two and no response in the two others. HCL seemed therefore to be responsible for an acquired platelet alpha granule defect. As in the grey platelet syndrome a relationship between this abnormal platelet granule storage and the development of myelofibrosis is suggested in HCL.

Between May 84 and December 85, 61 patients were treated for hairy cell leukemia by (recombinant or natural) alpha-IFN in a single institution. The responses obtained after 7 or 12 months of treatment are presented and the follow-up of the 39 patients for whom the treatment had been stopped for more than 12 months is evaluated. Neither clinical or histological parameters at presentation nor the type of timing of the interferon used allowed to predict the quality of response. The median time-lapse before the occurrence of neutropenia below 1.10(9)/l in patients with normal blood counts at the end of treatment was 12 months. However early relapses after the treatment stop were observed more frequently in patients with initially severe neutropenia or hyperleucocytosis. The therapeutic strategy in hairy cell leukemia is discussed.

Interferons (IFNs) initiate their effects by interacting with specific high-affinity cell surface receptors, but little is known about the physiology of IFN receptor interaction in vivo. Treatment of patients suffering from hairy cell leukemia (HCL) with human recombinant alpha IFN results in significant tumor regression, with clinical improvement in a high percentage of cases. To investigate a possible relevance of binding parameters as response markers, IFN receptor interaction on tumor cells responsive to IFN in vivo was studied. Binding of human alpha 2 IFN to circulating hairy cells was analyzed before and during IFN therapy in ten patients selected on the basis of high numbers of peripheral hairy cells. Binding experiments were carried out on Ficoll-Paque fractionated peripheral cell samples containing a majority of hairy cells. All patients reacted to recombinant alpha IFN treatment with a striking decrease in binding capacity within 12 hours after the first injection. As demonstrated by using a monoclonal antibody able to recognize alpha 2 IFN bound to its receptor, this decreased binding capacity was not due to blocking by circulating IFN but rather to a decrease in receptor number. This receptor "down-regulation" was partially reversible after the first IFN injection. However, upon prolonged IFN therapy, all patients displayed a stable state of decreased receptor expression. Down-regulation of IFN receptors can be regarded as a response marker to IFN treatment. This response marker, however, was not correlated with the clinical response within the first months of IFN therapy.

This report presents the results of a clinical trial on 53 patients with hairy cell leukaemia using low-dose alpha-interferon as therapy. Improvement of cytopenia and/or bone marrow hairy cell infiltration occurred in all but one patient. Often, blood and bone marrow improvements were dissociated and, after 7 or 13 months of therapy, complete remission was only observed in about 40% of patients. Recurrence of the disease was observed in some cases after cessation of therapy. A summary of the following results is presented: alpha-interferon receptor analysis, oncogene expression, study of the sensitivity of hairy cells to natural killer cells, and the effects of interferon on T-cell receptor gene rearrangement and on the function of T-cell clones. Results are also presented which show that myelofibrosis may be due to a release of platelet derived growth factor. The immunological findings and oncogene expression in 2 patients with a variant form of hairy cell leukaemia for which resistance to therapy was observed are also described. All the results show that interferon acts on hairy cells and are consistent with a direct effect by interferon in the treatment of hairy cell leukaemia.

TCR gamma delta expressing T cell clones are able to exhibit in vitro strong cytolytic activity against cultured tumor cell lines as the myeloid K562 or the Burkitt's lymphoma Daudi cell line. We investigate the possibility of developing TCR gamma delta bearing T cell lines from peripheral blood of 2 leukemic patients in complete remission in order to study their ability to kill autologous leukemic cells. T lymphocyte clones are obtained by limiting dilution of lymphocytes from the blood of patients with an acute lymphoblastic leukemia (ALL). The T cell clones are first selected for their CD8- CD4-phenotype and then for their ability to react with the monoclonal antibody anti-CD3 without presenting reactivity with a monoclonal antibody directed against the TCR alpha beta. Further biochemical studies have indicated that the CD3 associated structure expressed on the cell membrane of these T cell clones is a gamma delta heterodimer. Functional analysis have indicated that these cloned cells are able to kill in a classical cell mediated lysis assay the autologous leukemic cells only when also LAK activity is observed. Thanks to this clonal expansion 10(10) cells/week indefinitely only 1 sample of peripheral blood will be necessary. Would these results be found with other leukemic patients, we propose to use this procedure for a possible application of killer cells for maintenance therapy of leukemia.

Thirty patients older than 65 years of age with acute nonlymphocytic leukemia were treated with low-dose cytosine arabinoside (10 mg/m2 subcutaneously every 12 hours for 15 to 21 days). Fifteen achieved complete remission and five had partial remission. Treatment was more effective when initial bone marrow cellularity was low (P = 0.007). Four of six patients with secondary leukemia entered complete or partial remission. Therapy was well tolerated with reduced myelosuppression and few number of early deaths. Sixteen patients followed the whole treatment as outpatients. Six of 12 patients who achieved complete remission showed no evidence of post-therapeutic bone marrow aplasia. These data are consistent with the view that low-dose cytosine arabinoside acts on leukemic cells as a differentiating agent.

Seven patients with hairy cell leukemia were treated by intensive chemotherapy because they were considered to have a progressive disease and a poor short-term prognosis. The mean age was 47 years (range, 36 to 58). Six of seven patients had prior splenectomies with minor or transient hematologic responses. One patient had no spleen enlargement. The seven patients had never received any cytotoxic drugs and had prolonged granulocytopenia (less than 300/microL) with recurrent, severe infectious episodes. Chemotherapy included Rubidazone (zorubicine hydrochloride) 450 mg/m2 on day 1, arabinosyl cytosine 200 mg/m2/d from day 1 to day 5, and cyclophosphamide, 2,000 mg/m2 on day 5. Responses were assessed through examination of repeat bone marrow biopsy specimens and blood counts. A complete response was defined as normal blood counts associated with the disappearance of hairy cell infiltration and fibrosis on the bone marrow biopsy specimens. A partial response was defined as normal blood counts with persistence of leukemic cells in the bone marrow. Three patients achieved a complete response, and one patient had a partial response. Three patients died of infectious complications during induction chemotherapy. For the responding patients, the mean duration of aplasia was 37 +/- 5 days. Follow-up for the responding patients has been 44+, 24, 32+, and 23+ months. One patient with a complete response died while on maintenance therapy. We conclude that complete and prolonged histologic remission of hairy cell leukemia can be obtained with intensive chemotherapy. The toxicity of chemotherapy is such, however, that progressive disease after splenectomy needs to be more clearly defined.

Based on the in vitro experiments which showed the capacity of Aracytine (AraC) to induce differentiation of leukemic cells, low dose AraC treatment of patients with acute myeloid leukaemia (AML) or myelodysplastic syndromes (MDS) has been available since 1980. Many studies involving only small numbers of patients have demonstrated contradictory results regarding the efficacy or the mechanism of action of this regimen. A retrospective clinical study is presented, including 159 patients treated in 11 French institutions and 1 German institution (AML: 99 patients; MDS: 38 patients). The study confirms the efficacy of low dose AraC, especially in elderly patients with hypoplastic AML. Although, less severe than with high dose chemotherapy, toxicity needs regular monitoring. The mechanism of action cannot be ascertained by this clinical study, however half of the complete remissions were obtained with no bone marrow aplasia. Studies with low dose AraC and/or other in vitro differentiating agents need to be continued.

In the case of three patients an acute respiratory failure with alveolar hypoventilation is related to bilateral diaphragmatic paralysis apparently isolated from any other neurologic abnormalities. The current initial diagnosis of pulmonary embolism leading to admission in an intensive respiratory care unit, because of the severity of the acute respiratory failure, has to be rectified then. Bilateral diaphragmatic paralysis is suspected on account of the absence of any patent etiology, on increasing dyspnea in supine position and paradoxic movements of the upper abdomen (whether spontaneously or in attempted weaning of ventilation support). Bilateral diaphragmatic paralysis is asserted by electromyogram with measurement of nerve conduction velocities of the two phrenic nerves. In the first case, it appears early in the course of an amyotrophic lateral sclerosis; in the second case, it occurs before the presence of a herpes-zoster becomes patent. In the third case, paralysis seems to be idiopathic. Evolution is promising in the last two cases, owing to the reversibility of the lesions. The difficulty of diagnosis, the varying nature of etiology and prognosis encountered in these three cases are also apparent in the 15 cases published in medical literature. The small number of cases published up to now, contrasting with the cases we have witnessed over the last 3 years, leads us to think that this disease must exist more often and may remain unknown to us.

Low-dose interferon-alpha (IFN-alpha) therapy is consistently effective in the treatment of hairy cell leukemia (HCL). In two cases of resistance to IFN-alpha administration, we diagnosed variant HCL, a form of HCL with intermediate features between typical HCL and B cell prolymphocytic leukemia. We tried to distinguish variant and typical hairy cells (HCs) by Northern blot analysis of the oncogenes expressed in vivo. We report that variant HCs contain c-myc transcripts in contrast to typical HCs, whereas c-fos transcripts are detected in both cell types. We also report that the mRNA levels of c-myc are not modified in variant HCs by IFN-alpha treatment, whereas the level of c-fos mRNA is modulated in both types of HCs. Our findings suggest that the failure to modulate c-myc expression in vivo might indicate the limits of low-dose IFN-alpha therapy.

Since vimentin intermediate filament (IF) expression in hemopoietic cells varies with the cell lineage as well as the state of differentiation of the cells, we studied the vimentin cytoskeleton by direct immunofluorescence and electron microscopy in 50 cases of acute nonlymphocytic leukemias. We found that malignant cells tend to reproduce the vimentin organization characteristic of their normal cellular counterpart. Thus, in M2 and M3 leukemias (French-American-British classification), vimentin was often reduced to a juxtanuclear bundle of filaments contrasting with the rich filamentous network expressed by M4 or M5 leukemias. In erythroblastic leukemias (M6) and megakaryoblastic leukemias, both identified by the expression of lineage-specific antigens, the absence of vimentin IFs could be correlated with the level of differentiation reached by the blasts. M1 leukemias displayed an abnormal pattern of vimentin organization with aggregated filaments giving a ring-like structure. However, no abnormality of the vimentin polypeptide could be detected by two-dimensional electrophoresis. These results show that the expression of the vimentin IF cytoskeleton may be a useful marker of differentiation in the study of leukemic cells.

Acute febrile neutrophilic dermatosis, so called Sweet's Syndrome is a distinct dermatological disease defined by constant clinical and histological features: Eruption of painful, tender, raised erythematous plaques of face and neck with fever. Dense dermal infiltration with mature neutrophil polymorphs. Sweet's Syndrome may occur during the course of chronic or acute haematological diseases such as chronic myelogenous leukemia or acute non lymphoblastic leukemia. In all cases, the counts of Neutrophil Polymorphs were normal or above normal limits. We report a case of Sweet's Syndrome occurring during the aplastic period induced by the treatment of an acute myelo monocytic leukemia, and discuss the responsibility of white blood cells transfusion in genesis of typical histological aspect.

This presentation reports on patients with 13 B - acute lymphoblastic leukemia (ALL), treated with intensive chemotherapy. To date 5 patients are alive, in complete remission (greater than 24 months), 4 of them had CNS disease at diagnosis; 7 patients relapsed, 2 to 4 months after complete remission, 6 of them having CNS relapse, isolated or with bone marrow involvement. The improvement in prognosis of B-ALL results from intensive chemotherapy, but the prognosis remains poor because of early relapses, especially CNS relapses (survival rate is less than 50%). The authors propose new therapeutic approaches.