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Notes: Summary Seventeen patients with relapsed, acute leukemia were grafted with bone marrow from HLA-identical siblings by the ‘Munich Cooperative Group for Bone Marrow Transplantation’ during the period from August 1975 to June 1980. The antileukemic and immunosuppressive conditioning treatment consisted of high doses of Bischlorethyl nitrosourea, Cytosine-Arabinoside and Cyclophosphamide, as well as, total body irradiation of about 9 Gy (midline body dose) from dual60Cobalt sources. Methotrexate was given to all patients for prophylaxis of graft-versus-host disease (GvHD). Nine patients received marrow that was treated with anti-T-cell globulin (ATCG) “in vitro”. — Crossreacting antibodies against hemopoietic stem cells were removed by absorption. Two of 5 evaluable patients given untreated marrow developed chronic GvHD, while patients given ATCG-treated marrow did not show unequivocal symptoms of GvHD. Six patients are in complete remission one to 33 months following bone marrow transplantation (b.m.t.) Five patients died with relapses of leukemia between 3 1/2 and 24 months following b.m.t., 3 patients died with interstitial pneumonia within 3 months of b.m.t. and 3 patients died with insufficient graft function within 4 weeks of b.m.t. Four of thirteen patients that were grafted more than 6 months ago are presently alive and in continuous complete remission at 11, 14, 29 and 33 months following b.m.t. Our results confirm that longterm remissions can be obtained with b.m.t. in patients with acute leukemia in advanced stage.

Notes: Summary In 23 children with mild iron-deficiency anemia, 22 children with latent iron-deficiency, and in 46 healthy controls the3H-thymidine incorporation in blood lymphocytes after stimulation with phytohemagglutinin, concanavalin A, pokeweed mitogen, and serum against thymocytic cells was measured. In 11 of the children with iron-deficiency anemia, in 13 of the children with latent iron-deficiency, and in 20 controls the lymphotoxin secretion after phytohemagglutinin stimulation was also performed. All patients studied were without intercurrent infections and were well nourished. No alteration of the lymphocyte function in the patients was found. The concentrations of immunoglobulins and the components C3 and C4 of complement system were also found to be normal. It is suggested that lymphocyte functions are eventually only altered in more severe states of iron-deficiency anemia.

Notes: Summary From March 1975 until May 1980 twelve patients with severe aplastic anemia were grafted with bone marrow from HLA-identical siblings by the Munich Cooperative Group for Bone Marrow Transplantation. Six patients are alive between 10 months and more than 5 years after grafting with normal blood values and marrow. One patient is treated as an out patient for chronic localized graft-versus-host disease (GvHD), five patients are well and without treatment. Six patients have died, one patient with a cerebral hemorrhage the day before transplantation, three patients following rejection of grafts 32, 40 and 55 days after grafting, one patient with severe GvHD 85 days after grafting and one patient, probably with interstitial pneumonia, following cerebral hemorrhage. Three of 6 patients who were conditioned with Cyclophosphamide (CY) only died following rejection of the graft. Two adults who were conditioned with CY and “total lymphoid irradiation” and three children, who were given unirradiated leukocyte concentrates from the marrow donor after grafting, did not reject their grafts. The results of the Munich-Cooperative Group for Bone Marrow Transplantation are comparable to those of large, specialized centers for bone marrow transplantation, they indicate possibilities of cure of severe aplastic anemia by marrow grafts from HLA-identical siblings. They confirm that better results are obtained with earlier transplantation in the course of the disease.

Notes: Summary A boy with severe Aplastic Anemia (AA) and a girl with Acute Lymphoblastic Leukemia (ALL) in relapse have been grafted with marrow from HL-A identical, mixed leukocyte culture (MLC) negative siblings after appropriate immunosuppressive and antileukemic therapy. Both of them are well 7 and 2 months after transplantation respectively. Bone marrow transplantation should be considered in children with AA and ALL in relapse, if HL-A identical, MLC negative sibling are available.

Notes: Summary The lymphoblasts from 100 patients with acute lymphocytic leukaemia were investigated for the expression of receptors for sheep erythrocytes (E) and of a specific heterologous T cell antigen (T). In 17 cases, both T cell markers were expressed simultaneously on the leukaemic cells. In 13 cases only T antigens could be demonstrated on the lymphoblasts. A quantitative analysis of T antigens by immunoautoradiography revealed that the T expression of E−T+-lymphoblasts was in general like that of E+T+-lymphocytes in the blood of normal persons, in several cases even higher. Therefore, the failure of E-rosette formation cannot be correlated to a decrease of the other T cell differentiation marker. In 7 out of 9 tested cases, a strong acid phosphatase reaction product located paranuclearly could be demonstrated. Complement-receptors were expressed in 3 of 5 cases which were also demonstrated in some cases of the E+T+-ALL group. The latter group was characterized by a T antigen expression like that of thymocytes. 4 cases of the E−T+ALL group were adults. Since the leukaemia cells of 2 cases were negative for acid phosphatase, PAS and all surface markers including cALL antigen, the T antigen can classify undifferentiated and otherwise unclassificable leukaemias. The clinical significance of the E−T+-ALL seems to be important since 5 out of 9 children with this type of ALL died soon after diagnosis.

Notes: Summary A case of acute lymphoblastic leukaemia of null cell type in infancy showed the specific reciprocal translocation t(4; 11) (q21; q23) reported 16 times so far in the world literature. The proportions of abnormal and normal metaphases throughout the course of the illness correlated well with the clinical picture, but even during the short term remission metaphases expressing the translocation were still identifiable in appreciable numbers. Comparison between cytogenetic analyses of cultured and native bone marrow, PHA-stimulated and non-stimulated peripheral blood demonstrated the gradual conquest of the periphery by the abnormal clone. The importance of chromosomal changes and their interpretation for diagnosis, classification and prognostic judgment in haemotologic neoplasms is discussed in the light of the reported case.

Notes: Summary Anti-human-thymocyte globulin (AHTZG) was applied to prevent GvHD in clinical bone marrow transplantation. AHTZG produced by absorption with several cell preparations reacted specifically with T-lymphocyte populations and was no longer inhibitory to human CFUc and bone marrow growth in diffusion chambers. Marrow grafts of 14 patients with ALL were incubated in vitro with AHTZG and transferred to the recipients conditioned with antileukemic chemotherapy and total body irradiation of 1000 rad. Ten patients were transplanted after relaps, four patients during remission. The patients tolerated the marrow without side effects and a hemopoietic engraftment was seen in 12 cases. Three patients showed signs of GvHD on the skin, two of them showed later on also manifestations in the liver. In the other cases no GvHD could be detected. Five out of 14 patients are still alive between 144 and 964 days post transplantation in remission.

Notes: Abstract The intestinal absorption of 59Fe from a diagnostic 10 μmole (0.56 mg) 59Fe2+ test dose and 5 mg Fe equivalents of 59Fe-labeled pork, hog liver and hemoglobin was measured with a 4 π geometry whole-body radioactivity detector with liquid organic scintillator and the results compared with the stainable amounts of diffuse cytoplasmatic (non-heme) storage iron in the bone marrow macrophages, serum iron concentrations and total iron-binding capacity, erythropoietic activity and other hematological parameters. Children with mild hypochromic, microcytic anemia due to heterozygous β-thalassemia absorbed normal amounts of 59Fe from the diagnostic dose of 59Fe2+ if their bone marrow macrophages contained normal or mildly increased amounts of diffuse cytoplasmatic storage iron. Depleted iron stores also caused increased absorption of diagnostic 59Fe in children with heterozygous β-thalassemia, so that prelatent iron deficiency can be diagnosed by measurement of increased iron absorption. The diagnostic 59Fe2+ absorption was increased to 70–100% in children with homozygous β-thalassemia when it was measured 64–300 days after the last blood transfusion. Since all these children contained normal to increased amounts of diffuse cytoplasmatic storage iron in the bone marrow macrophages, the high intestinal iron absorption was not caused, as is usual, by depleted iron stores but coincided with considerable hyperplasia of ineffective erythropoiesis demonstrated by the increased numbers of normoblasts in the bone marrow and peripheral blood during a period of severe anemia. Blood transfusions which elevate the hemoglobin levels from 4–5 g/100 ml to 8.5–9.9 g/100 ml and suppress the erythroblastic hyperplasia in the bone marrow also reduce the increased absorption of inorganic and food iron to normal values. Interruption of blood transfusions always results in the next erythroblastic hyperplasia and a simultaneous increase of intestinal iron absorption. Mild hyperplasia of the erythropoietic system such as is observed in megaloblastic anemia due to vitamin-B12 deficiency or in hereditary spherocytosis is not sufficient to increase iron absorption. Anemia per se does not increase iron absorption, as is borne out by the observation that patients with severe aregenerative anemia or megaloblastic anemia absorb 59Fe2+ according to their normal iron stores within the normal range. The messenger which signalizes depleted iron stores or erythropoietic hyperplasia to the duodenal and jejunal mucosa so that intestinal iron absorption is increased is not yet known. The food iron absorption from 59Fe-labeled pork and hog liver was increased to 2–4 times the normal average when measured in homozygous β-thalassemia with severe anemia and erythroblastic hyperplasia 28–42 days after the last blood transfusion. This increased food iron absorption was normalized by blood transfusion which suppressed the erythropoietic hyperplasia and raised the hemoglobin levels to 9.7–10.4 g/100 ml. The development of hemosiderosis either from blood transfusions or from increased food-iron absorption seems to be unavoidable in patients with homozygous β-thalassemia. Regular transfusion of 2–8 l blood per year is necessary to keep the hemoglobin at a level of at least 9 g/100 ml, which does not induce erythrocytopoietic hyperplasia and increased food-iron absorption. After 18 years on such a transfusion schedule, between 18 and 73 g iron have been incorporated into the body and produced transfusion hemosiderosis. Patients with homozygous β-thalassemia who survive without blood transfusions and have low hemoglobin levels (〈8 g/100 ml) absorb 3 times more iron from a mixed diet and after 18 years have accumulated about 19 g iron from increased food-iron absorption, which is also enough to produce hemosiderosis.

Notes: Abstract A high negative correlation (coefficient ∼ 0.9) between increased 59Fe absorption from a diagnostic 0.56 mg 59Fe2+ dose and the depletion of available storage iron was observed in menstruating and pregnant women, fullterm and premature infants, blood donors, patients with infections, inflammations, tumors, hepatic cirrhosis, gastric surgery, increased urogenital or gastrointestinal blood loss. The increased diagnostic 59Fe2+ absorption is a reliable and sensitive indicator of at least depleted iron stores or prelatent iron deficiency as caused by iron malnutrition or maldigestion, increased iron requirement in pregnancy, infancy, urogenital or gastrointestinal blood loss. Although the messenger system which signalyzes the depletion of iron stores to the iron absorbing enterocytes of the duodenal and jejunal mucosa is not yet known available storage iron seems to control intestinal iron absorption under normal and the great majority of pathological conditions in humans. Anemia per se or high erythropoietin levels in blood do not influence iron absorption since patients with even severe erythroblastic hypoplasia, aplastic anemia and megaloblastic anemia due to vitamin B12 deficiency absorb iron according to their iron stores. An only mild hyperplasia of the erythropoietic system in the bone marrow does also not effect iron absorption which was still under the control of available storage iron in patients with hereditary spherocytosis, nonspherocytic congenital hemolytic anemia due to glucose-6-phosphate dehydrogenase deficiency, acquired hemolytic anemia and vitamin B12 deficiency induced megaloblastic anemia. An exception from the general rule that depleted iron stores do cause increased iron absorption, which can be used therefore for the reliable diagnosis of depleted iron stores or prelatent iron deficiency, was observed only in anemic children with hereditary nonspherocytic enzymopenic hemolytic anemia due to pyruvate kinase deficiency. In these cases a strong normoblastic hyperplasia correlated well with the increased iron absorption in the presence of normal amounts of available storage iron. Blood transfusions which suppress the normoblastic hyperplasia do also reduce the increased iron absorption to normal levels. A similar iron absorption increasing effect of hyperplastic ineffective erythrocytopoiesis was also observed in adults with sideroblastic anemia and children with severe homozygous β-thalassemia although the iron stores of these patients were normal or increased. The messenger system which is used by the body for signalyzing severe normoblastic hyperplasia to the iron absorbing intestinal mucosa and induces a useless and even dangerous augmented iron absorption is not yet known. Since the diseases with severe normoblastic hyperplasia are extremely rare and easily to diagnose the increased intestinal iron absorption from the diagnostic 0.56 mg 59Fe2+ dose is a very useful, reliable and sensitive indicator of already the earliest stage of iron deficiency.

Notes: Abstract Small amounts of milk do inhibit ferrous iron absorption from a 5 mg 59Fe2+ dose in 1- to 18-month-old infants. Only 50 ml of 2/3 cow milk reduced the absorption from 18±3% (Xa ± S.E.) to 3.8 ± 1.2% in infants with normal iron stores (inhibition index 0.21) and from 26±3% to 8.5±1.4% in infants with depleted iron stores (inhibition index 0.33%). Milk does not inhibit the biovailability of hemoglobin iron. From a 5 mg dose of hemoglobin-59Fe added to 50 ml of 2/3 cow milk 4.8±1.0% were absorbed by infants with normal iron stores and 8.3±0.8% by infants with depleted iron stores. The low iron content of milk (50 μg Fe/100 ml) and its poor biovailability (∼5% in infants with normal iron stores) would require a daily consumption of 32 l of unfortified milk to cover infants daily iron requirement of 0.8 mg/day. The supplementation of 2–3 milk meals per day with 5 mg hemoglobin iron each meets the whole iron requirement of infants with depleted and normal iron stores respectively and can be used for iron prophylaxis in infancy during the first and second year. Prophylaxis with inorganic iron requires an empty stomach and duodenum for optimal bioavailability. A daily dose of only 5 mg ferrous sulfate iron is enough to cover the total iron requirement of infants.