S cancer (SCLC) results in a high remission rate, but

Transcription

1 Smll Cell Lung Cner nd the Influene of Chemotherpy on CF,s in Bone Mrrow P. E. POSTMS, MD,' N. H. MLDER, MD,t E. G. E. DE RIES, MD,t M. AN LYN,* AND M. R. HALIE, MDS To determine the optiml moment for the hrvesting of bone mrrow for utologous trnsplnttion, the uthors did serilly olony forming units in ulture (CF,) ounts in group of 42 ptients with smll ell lung ner (SCLC) before nd fter remission indution hemotherpy nd subsequent mintenne hemotherpy. Disese stge did not influene the CF, ount exept in ptients with bone mrrow metstses; this resulted in either bnormlly low or bnormlly high CF, ounts, probbly dependent on the degree of invsion. After 2 ourses of indution hemotherpy, the number of CF,s ws 3.1 fold higher thn before therpy. After 4 ourses, the CF,s number ws omprble to the pretretment vlue. An inverse orreltion ws found between the degree of hemtologi toxiity (expressed s leuoytes ount) nd the inrese of CF,s fter indution hemotherpy. The number of CF,s deresed during prolonged hemotherpy to low levels fter 1 yer. Hrvesting of bone mrrow is probbly done best shortly fter indution hemotherpy. Cner 53:3964, TANDARD DOSE CHEMOTHERAPY for smll ell lung S ner (SCLC) results in high remission rte, but only in few ptients in longterm disesefree survivl.' These observtions hve led to serh for more promising therpeuti mesures. One of the observtions tht ould be importnt in this respet is the dose dependeny of the tumor response in SCLC.' Therefore it is worthwhile to evlute the effiy of highdose hemotherpy. Beuse of the side effets on bone mrrow funtion, suh tretment must be followed by resue with bone mrrow ells, usully from utologous mrr~w.~ Two problems re ritil when utologous mrrow is used in this sitution: (1) the problem of tumor involvement of bone mrrow; nd (2) the bility of the reinfused mrrow to reonstitute the Both re diretly influened by the moment hosen to proure mrrow. Although other ssys of stem ell funtion hve been desribed reently, the determintion of CF,s is s yet the most widely used.6") Therefore we studied the number of CF,s in bone mrrow of ptients with SCLC before nd fter remission indution hemotherpy nd subsequent mintenne hemotherpy. Furthermore, the reltion ws nlyzed between these numbers of CF,s From the *Deprtments of Pulmonry Diseses, tmedi1 Onology, nd $Hemtology, niversity Hospitl, Groningen, The Netherlnds. Address for reprints: P. E. Postmus, MD, Deprtment of Pulmonry Diseses, niversity Hospitl, Oostersingel59,97 I3 EZ Groningen, The Netherlnds. Aepted for publition November 19, nd the effets of hemotherpy on peripherl blood leuoytes. Mterils nd Methods From June 198 through Deember 1981, 42 onseutive previously untreted ptients with histologilly proven dignosis of SCLC were investigted. All ptients underwent routine stging proedures: history, physil exmintion, hemtologi evlution, liver funtion, hest X ry, fiberopti or rigid bronhosopy, isotope sns of bone nd liver, neurologi evlution, nd in some ptients, liver biopsy. An unilterl posterior ili rest bone mrrow biopsy with Ymshidi needle ws performed in ll ptients. On tht osion bone mrrow ws lso spirted for smerpreprtion nd for ulturing purposes. Ptients with tumor limited to one hemithorx, medistinl nd/or suprlviulr lymph nodes, were designted s to hve limited disese (LD); lt other ptients hd extensive disese (ED), inluding those with bone mrrow involvement. All ptients reeived intensive indution hemotherpy with ispltin, 75 mg/m2 intrvenously (I) dy I; ylophosphmide, 75 mg/m2 1 dy I : nd P mg/m2 I dys 2, 5, 8 (CC) for 2 ourses t 3 week intervls without dose redution for hemtologi toxiity. This ws followed by 2 ourses onsisting of vinristine. 1.4 mg/m2 1 dys 1 nd 8; Adrimyin, 6 mg/m2 I dy I; nd prorbzine, 1 mg/m2 orlly dys

2 No. 3 SCLC AND CHEMOTHERAPY IN BONE MARROW PStmu.S 397 (AP), t 3week intervls. Response ws evluted fter 6 nd 12 weeks. In most ptients this inluded lso bone mrrow investigtion s desribed erlier. In responding ptients, mintenne therpy ws initited t week 14: CCN 8 mg/m2 orlly dy 1 nd hexmethylmelmine 15 mg/m2 orlly dys 17 nd 2228, whih ws repeted every 6 weeks until 1 yer from the strt of tretment. Aording to the stging proedure, 23 ptients were shown to hve LD nd 19 ED, inluding 6 ptients with bone mrrow metstses. CF,s were mesured in 37 ptients before therpy (1 8 LD, 19 ED), in 2 fter 2 ourses of CC ( 1 LD, 1 ED) nd in 23 fter 2 ourses of both CC nd AP (1 5 LD, 8 ED). In five ptients, CF, ount ws done fter bout 6 months, nd in 6 ptients t the end of tretment t 1 yer. Bone Mrrow Culture Proedures (CF,.) Approximtely 2 ml of the spirted bone mrrow ws pled into tissue tube ontining 2 ml of Hnks blned slt solution nd 2 heprine. The ulture proedure ws s desribed by Pike nd Robinson." The leukoytes from norml helthy volunteers served s soure of olony stimulting ftor. Throughout this u1, D LD ED ED with bone mrrow involvement under nd upper limits in helthy volunteers +I men 9 FIG. 1. CF, vlues before, during nd fter remission indution. 6 3 e e _. 9 3t A s o& I n 8 8 e 8 Q before p<1 p<o 1 I N S I 8 I I I I fter 2CC fter 2CC+2AP fter Gmonths fter lyer

3 398 CANCER Februry I I984 ol J D J : 12 3 C rn. + 9 LL v J J "I, of initil vlue 6 3 before. fter'2cc fter ZCC+ ZAP O = LD o = ED LO 5 5 CF,/lO nuleted ells before therpy FIG. 2. The reltion between CF, vlues before therpy nd fter 2 ourses of ytostti hemotherpy. study, the sme donor pool hs been used. Alternting donors from this pool did not influene CF, ounts in ontrol experiments beyond the rnge of duplite determintions. A totl of 1 X 1' leukoytes per plte ws used in the feederlyer nd employed within 6 dys. The overlyer ontined 1 X lo5 nuleted bone mrrow ells per plte. Cultures were sored t dy 1 throughout this study, but were lso exmined on dy 14. A disseting mirosope t X 1 mgnifition ws h LD ED ED with bone mrrow involvement FIG. 3. CRJ, vlues in 9 ptients before therpy, fter the first 2 ourses of hemotherpy nd t the end of indution therpy. used. Only groups of more thn 4 ells were sored s olonies. Norml vlues hve in our lbortory been determined in helthy volunteers. The rnge is 1 to 5 olonies per 1' ells (N = 1 1). This rnge is lso found in ptients without bone mrrow relted disese. All determintions hve been performed in triplite (SD = 2.1: N = 148). Stutisfiy Differenes in men vlues were ssessed with Student's t test. The sttistil signifine of the differenes in CF, ounts in ptients who were evluted both before nd fter therpy, ws ssessed by Wiloxon rnk sum test on pired smples. Correltion oeffiients were determined nd regression lines were lulted on the stter digrms of Figures 2 nd 4. Putint C'hrterislis Results The medin ge of the 42 ptients studied is 56 yers (LD, 57 yers; ED, 54 yers). Thirteen ptients hd Krnofsky performne sttus < 6. Pretretment of CF,. L~vels The pretretment CF, vlues (Fig. I) show no differene between LD nd ED ptients (men 17.6 v'rsus 2.1 per 1' ells). There is no reltion between pretretment CF, ount nd ge, sex nd performne sttus. In 12 ptients, the CF, ount ws bnormlly low (less thn 1 per 1' ells). Four of these ptients hd histologilly proven bone mrrow involvement; in the smer of this spirte there ws substntil number of tumor ells, t lest 5%. As tumor ells were inluded in the plted ell numbers, these low CF, ounts ould be due to lk of hemopoeti ells. In two ptients, bnormlly high CF, ounts were found (bove 5 per lo5 ells); in the smers of these spirtes smll lumps of tumor ells were found, but less thn 5% of the totl ell ount. CF, Coirnt After Two Cour.m of C'C'I' In the 2 ptients (1 LD, 1 ED), there is no differene in CF, ounts between LD nd ED (men 58.2 nd 54.4 olonies per 1' ells). In 17 of these 2 ptients, pretretment vlue is known; in 15 ptients (88.2%). the CF, vlue is inresed fter therpy. The inrese in this group is signifint (Wiloxon rnk sum test, P <.1). Also, the inrese in the mens of CF, vlues before (men, 18) nd fter 2 ourses (men, 55) is signifint (P <. I).

4 No. 3 SCLC AND CHEMOTHERAPY IN BONE MARROW * fostmlls 399 The three ptients in this group with pretretment bone mrrow invsion hd vrying effets of hemotherpy on CF, ount: from 74 to 15 fter, from 66 before to 3 fter, nd from I to, respetively. There were no signs of metstses in the bone mrrow biopsy speimen or spirte in ny of the 2 ptients fter 2 ourses of CC. In 14 ptients without proven bone mrrow involvement, we found orreltion between the pretretment CF, vlue nd the inrese of the number of CF,s fter 2 ourses of hemotherpy (YO of initil vlue): r =.715; y = 459e""""; P <.25 (Fig. 2). CF,. Counts After Two Courses of AP (23 Ptients) Agin there is no differene between LD ( 15 ptients) nd ED (8 ptients) (men, CF, 15.7 nd 15.9 per 1' ells, respetively). These vlues re little lower thn the pretretment vlues; the differene, however, is not signifint (men, 15.7 versus 18.9). The derese between the vlues found fter 2 nd 4 hemotherpy ourses is signifint (men, 56.3 versus 15.7; P <.1). CF, ounts in 15 ptients in whom ultures were performed both before nd fter these hemotherpy ourses lso showed signifint derese ( P <. 1, Wiloxon rnk sum test on pired smples). In nine ptients, CF, ounts were performed sequentilly during indution therpy (Fig. 3). In these 9 ptients, vlues fter 2 ourses of CC differ signifintly (P <.1) from the vlues before nd fter 2 ourses of CC + 2 ourses of AP. Before nd fter hemotherpy, the CF, ounts do not differ signifintly (Wiloxon rnk sum test on pired smples). CF, Count During Mintenne Therpy In five ptients, fter 6 months of hemotherpy, vlues in the norml rnge were found ( per I O5 ells); in 5 of 6 ptients, n bnormlly low vlue ws found fter 12 months of tretment (15 per 1' ells). Hemtologi Toxiity nd Rtdtion with CF,. Count While no differene ws found in men CF, ount before therpy in ptients with ED nd LD, leukoytes ounts in LD (men, 7.1 X 19/1) were lower thn in ED (men, 1.7 X 19/1) ( P <.25). Grnuloytes ounts in LD (men 4.6 X 1y/l) were lso lower thn in ED (men, 8.4 X 19/1) (P <.25). Hemoglobin levels, g/l in LD nd 135. g/1 in ED, nd pltelets X 1y/l nd X 1y/l, were similr. There were no differenes in leukoyte ndir (men, 1. X 1y/l in LD nd 1.36 X 1y/l in ED) nd pltelet ndir (men 84. X 1y/l nd 82.4 X 1y/l, respetively). A low leukoyte ndir during the first ourse of CC is relted to high ' 1 hl L 5 J.+ ul l 1 J 5 3 C Ln?. o=ld o=ed LL 3I ndir leuoytes FIG. 4. Reltion between leukoyte ndir during the first ourse of hemotherpy nd the CF, ount fter 2 ourses. CF, ounts fter 2 CC ourses (r =.544; y = 81.45e.32'" P <.5) (Fig. 4). Disussion In SCLC, highdose hemotherpy with utologous bone mrrow s primry therpy hs led to high number of remissions." Also, ptients with refrtory disese hve shown responses of this form of tretment.".i4 Current studies re underwy in our nd other institutes onerning the potentil of this tretment form for ptients who hve rehed omplete remi~sion.'~.'~ The moment tht is hosen to hrvest the mrrow might influene the outome of the proedure. Hrvesting bone mrrow before therpy hs strted would hve the dvntge tht stem ell numbers re not ommitted by ytosttis. However, SCLC is often, t the strt of tretment, lredy metstsized, with high risk of ontmintion with mlignnt ells if the mrrow is then ryopreserved. ' ' This study shows tht fter 2 ourses of hemotherpy, the men CF, ount is 3.1fold higher thn before ther py in 88% of the ptients. Our results re omprble to those of Abrms el 1.l' in omprble group of SCLC ptients where the number of irulting CF,s ws 6.7fold higher fter I ourse of indution hemotherpy in the mjority of the ptients. CF, determintions only mesure prt of the bone mrrow funtion nd other prmeters ould dd worthwhile informtion. Erythroid preursors seem to be more suseptible to unfvourble storge onditions" nd my therefore be of vlue in the qulity ontrol of preserved mrrow. Potentilly, ssys tht give rise to mixed olonies should more losely mirror the presene of stem ells.2

5 4 CANCER Februry ol. 53 Spitzer et /.9 found good orreltion between the number of CF,s infused nd the time to hemopoieti reovery in leukemi nd solid tumor ptients treted by mrrow bltive therpy. Ekert et /. ould not find this orreltion, but s their ptients reeived prophylti otrimoxzole, it is possible tht this hs used dely of hemtopoieti reovery.2 In this study, substntil inrese ws found in CF, ounts following severe hemotherpyindued leukopeni, the inrese being relted to the degree of leukopeni. This inrese seems to be more overt when the pretretment CF, ounts re low. In our mteril, invsion of the bone mrrow with tumor ells ould led to both bnormlly low or bnormlly high CF, ounts, probbly dependent on the degree of invsion. The inrese in CF, ount in ptients with disrete mrrow involvement ould be due to prodution or stimultion of olony stimulting ftor by tumor ells.22 Interestingly, leukopeni due to hemotherpy in these ptients did not led to further inrese in CF, ount. The bnorml growth pttern reported by MCrthy nd oworkers,23 in two ptients with SCLC ws not seen in ny of our ptients. It n be onluded from our study tht soon fter n ttempt t remission indution might be n optiml moment to ollet mrrow if trnsplnttion is onsidered. The min problem remins to exlude the possibility tht tumor ells re lso preserved. However, it n resonbly be ssumed tht the number of these ells is t ndir shortly fter suessful remission indution. REFERENCES I. Minn J, Lihter A, Brereton H ei (11. Smll ell lung ner: Long term potentilly ured survivors in Ntionl Cner Institute trils. Clin Re.7 198; 28:419A. 2. Cohen MH, Creven PJ. Fossiek BE ei l. Intensive hemotherpy of smll ell bronhogeni rinom. ( uner Triwf Rep 1977; 6 l: Deisseroth A, Abrms RA. The role of utologous stem ell reonstitution in intensive therpy for resistnt neoplsms. Cner Trei Rep 1979; 63: I. 4. Deisseroth A, Abrms RA. Bode ei ul. Current sttus of utologous bone mrrow trnsplnttion. In: Gle RP, Fox CF, eds. Biology of Bone Mrrow Trnsplnttion: ICNCLA Symposi on Moleulr nd Cellulr Biology, vol. XII New York: Ademi Press, 198; 145 I Shefer W, Nowrousin MR. Oh1 S et /. Autologous bone mrrow trnsplnttion: The influene of prolonged ytotoxi hemotherpy. Herniol Bluitrn.$u.~ I98 I : 25: Hrtmn DW, Robinson WA, Morton NJ, Mnglik A, Glode LM. High dose nitrogen mustrd (NH2) with utologous non frozen bone mrrow trnsplnttion in dvnd mlignnt melnom. Blut I98 1 ; 42: Appelbum FR, Herzig GP. Ziegler JL, Grw RG, Levine AS. Deisseroth AB. Suessful engrftment of ryopreserved utologous bone mrrow in ptients with mlignnt lymphom. Blood 1978: 52: MElwin TJ, Hedley DW, Burton G el /. Mrrow utotrnsplnttion elertes hemtologil reovery in ptients with mlignnt melnom treted with high dose melphln. Br J Cner 1979; 4: Spitzer G, ern DS. Fisher R et l. The myeloid progenitor ell: Its vlue in prediting hemtopoieti reovery fter utologous bone mrrow trnsplnttion. Blood 198: 55: Ekert H. Ellis M, Wters KD. Turog P. Autologous bone mrrow resue in the tretment of dvned tumors of hildhood. Cner 1982; 49:6369. I I. Pike BL, Robinson WA. Humn bone mrrow olony growth in grgel. J Cell Physiol 197: 76: Souhmi RL, Hrper PG, Linh D el l. High dose ylophosphmide with utologous mrrow trnsplnttion s initil tretment of smll ell rinom of the bronhus. Cner C hemofher Phrmuol 1982; Spitzer G, Dike KA, Litm J et /. High dose ombintion hemotherpy with utologous bone mrrow trnsplnttion in dult solid tumors. Cner 198: 45: Stevenson RD, Bnhm SW, Burnett AK el /. Lte dosge intensifition with utologous bone mrrow resue in smll ell lung ner (Abstr). Eur J Re.yp Dis 1982: 63: Prignot J, Bosly A, Symnn M ef l. Lte intensifition hemotherpy nd utologous bone mrrow trnsplnttion in smll ell lung ner (Abstr). Eur J Resp Di : 63: Klstersky J, Niise C, Longevl E, Strykmns P, the EORTC Lung Cner Working Prty. Cispltin, drimyin nd etoposide (CA) for remission indution of smll ell bronhogeni rinom. 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