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Expansion
of the
Myeloma
Growth
With
Fraction
Alkylating
By Sydney
a
continued
that the
between
otherapy
T
high
LI:
plateau
resulted
the cytoreductive
and expansion
HUS
FAR,
human
the
this
suggests
from a balance
effects of chemof the growth
development
tumors
has
tinued
treatment.
In
body
burden
pled
serially
experimental
of tumor
from
eloma
cells and
of tumor
cells
From
the
the
bone
studies2
of from
animal
tumor
kinetics
Section
Additionally,
marrow
for
defined
the
approximately
indicated
present,
for
disseminated
Although
many
growth
of Hematology
this
form
of
aad
the
tumor
cells
immunologic
Oncology.
can
and
be readily
cytokinetic
Department
between
survival
of myeloma
and
of
Internal
Medicine.
the
National
Cancer
samstudies.
of myeloma
as associated
to approximately
5 x
regression
College of Medicine,
Tucson,
Ariz. 85724.
Submitted
April 19, 1974; accepted
July 19. 1974.
Supported by USPHS Grants CA -14102 and CA -14087
drug
man,
agent
impor-
a “model
tumor.”
Specifically,
(the M-component,
a monoclonal
can be used
to calculate
the total
was a proportionality
of disease,
and
patient
and
In
of
clinical
range
2 x 10”
that there
symptoms
of the
systems,
single
toxicity
to
despite
con-
in terms
of cell cycle
kinetic
principles.
typically
observed
with
single
alkylating
Multiple
myeloma
has been
of signal
cells.’
the
chemotherapy
challenge.
it has many
characteristics
secrete
a characteristic
marker
measurements
of which
Our previous
body
burden
analyzed
a difficult
activity
within
the range
of acceptable
only partial
regression
of the tumor
resistance
can be understood
such
apparent
resistance
is
therapy
for multiple
myeloma.
tance
because
myeloma
cells
immunoglobulin),
fraction
(GF)
of the tumor.
Preliminary
attempts
to capitalize
therapeutically
on
this expansion
of the GF in several
patients
included
administration
of the
cycle-active
agents vincnstine
and cytosine
arabinoside.
Vincnistine
appeared
to induce a further
reduction
in tumor in several patients,
although
cytosine
arabinoside appeared
to be ineffective
despite
clear evidence
of its inhibition
of DNA
synthesis
in myeloma
cells in vivo. Further
clinical
studies
of the effects
of cycleactive
drugs on myeloma
appear
to be
warranted;
however,
successful
exploitation of the dynamic
change
in myeloma
cell kinetics
with
chemotherapy
will
require the use of cycle-active
agents
with
marked
selective
toxicity
for myeloma
cells.
of effective
been
agents
have marked
oncolytic
the host,
they usually
induce
Agents
E. Salmon
Patients
with
lgG
multiple
myeloma
underwent
serial
studies
of tumor
cell
kinetics
including
(1)
estimation
of the
total body myeloma
cell number
(TBMC),
(2) measurement
of the myeloma
cell tntiated thymidine
labeling
index (LI), and
(3) calculation
of the total number
of myeloma cells undergoing
DNA synthesis.
Intermittent
courses of chemotherapy
with
cycle-non-specifIc
agents
such
as melphalan
resulted
in a marked
increase
in
the LI of myeloma
cells in patients
who
had a 75%
reduction
in TBMC.
The long
“plateau”
phase
of partial
remission
of
myeloma
in these patients
was associated
with
in Multiple
l012
the
with a
my-
number
time.
We
found
that
University
of
Arizona
National
Institutes
NCI-C-73-7313
© 1975
of Health,
from
Department
the Division
of Cancer
by Grune
& Stratton,
Inc.
Blood, Vol. 45, No.
i (January),
1975
of Health,
Treatment.
from
Education,
and
Welfare.
and
Institute
by Contract
(NC!),
NIH-
NC!.
119
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120
SYDNEY
the tumor
intriguing
grows
“plateau”
in
accord
with
phenomenon
of intermittent
or continuous
had determined
that both
therapy
tumor
we
scribed
with
and
Gompertzian
drug-induced
growth
fraction
(GF)
In order
to test this
with
cell number
thymidine
and
labeling
the
percentage
assessing
index
of cells
accepted
as a direct
cologic
determine
“manipulations”
whether
duced
with
an
be
an
going
through
GF.4)
measured
(The LI
DNA
of the
GF
on
a group
total
synthesis
cases,
tumor.
in
body
the
tumor
the in vitro
tritiated
is a useful
indicator
of
and
is generally
preliminary
in vivo with
to cycle-active
of the
shifts
studies
the
as
de-
of growth
dynamic
serial
In a few
carried
out
susceptibility
increased
expansion
we
cells.
Inasmuch
can be
retardation
to
scheduled
of the
were
both
to calculating
tumor
kinetics,
(LI) of myeloma
correlate
that
agent.2’3
regression
we performed
In addition
often
displaying
an
with a fixed schedule
alkylating
and tumor
attributable
tumor.
hypothesis,
myeloma.
kinetics,
regression
we reasoned
might
ofthe
latter
IgG
with
growth
kinetics,
regression
ofpatients
Gompertzian
after
initial
E. SALMON
pharma-
cycle-active
agents
Our
agents
could
be
observations
to
in-
provide
evidence
that alkylating
agent
of this proliferative
compartment
“plateau”
phenomenon2’3
of
therapy
can expand
the tumor’s
GF.
Expansion
may at least
partially
explain
the important
partial
remission
in patients
with
myeloma.
addition,
support
for
of
nonproliferating
the
attack
the
time
active
the
studies
provide
overwhelming
of diagnosis,
drugs
in the
residual
mass
as well
“plateau”
myeloma
cell
untreated
The clinical
and
have
Bone
AND
patients
with
immunologic
been
marrow
described
for
least
were
of
The
the
1251-labeled
collected
albumin
from
scribed
previously.1’2
its
in
prior
obtained
rates
out
for
for
and
empirical
attempt
with
heparin
the
trials
of cycleto further
reduce
Electric
equations,
and
Particularly
tumor
nature
relevant
background
ISB
staging
selected
for
of disease
serum,
260
the
which
plasma
digital
was
study.
in these
present
was
and
the
written
via
N.Y.).
have
the
The
been
is an
to
and
tumor
Mark
theoretical
detailed
additional
calculate
this
the
were
III
studies
deand
were
“pulse”
occasionally
done
routinely.
synthetic
were
time-sharing
background,
cal-
studies
M-component
kinetic
the
was
melphalan
LI
not
careful
as
to subsequent
was
for
syn-
with
weight
of
aspirates
data
GE
body
in vitro
prior
cycle,
by
3 mo
M-component
courses
marrow
turnover
determined
the
for
immediately
curve-fitting
study
4-day
tissue
Newly
technique.5’6
were performed
every
the
aspirates
treatment
computer
used
short-term
protein.5
was
and
with
marrow
metabolic
Schenectady,
serum
volume,
Although
in
and
number,
the
for
of chemotherapy
cell
Div.,
in
rate
studied
of
studies;
synthetic
Bone
times
myeloma
measured
patients
at other
LI
of
was
4-6
therapy.
vitro
volume
the
wk.
in
“sandwich”
radioimmunoassay
studies of serum proteins
every
of the programs
to
body
computation
Electric
Co.,
were
and
synthesis
Plasma
total
the
for
cellular
of the
course
studies
a General
(General
in
all
records,
body
myeloma
diagnosis
M-component
agent-prednisone
in vitro
total
of
The
once
to the initial
alkylating
of
patterns.
concentration
of patient
theoretical
concentration
administered
of
studies
technique.
chemotherapy
prednisone,
for
electrophoretic
culated
Storage
prepared
monthly.
analysis
multiple
the
M-component
was measured
with the
acetate electrophoretic
and densitometric
courses
to
at
present
METHODS
diagnosed
used
thesized
Cellulose
obtained
for
in an
usually
in detail.1
aspirates
also
newly
criteria
were
Initial
cells
In
drugs
mass.
cultures
at
of cycle-nonspecific
Studies
Previously
patients
use
as a strong
rationale
phase
of myeloma
MATERIALS
Patient
the
carried
service
mathematical
previously.2
computer
theoretical
program
proliferative
based
on
fraction
this
at
From www.bloodjournal.org by guest on June 16, 2017. For personal use only.
GROWTH
any
FRACTION
given
IN MULTIPLE MYELOMA
tumor
size.
The
equation
121
for
calculation
of
the
theoretical
proliferative
fraction
(p)is
Pi
Aj’tg%
where A, is the slope of the line tangent
to the growth
curve
at time
t,
and tg, the theoreticaL
doubling
(generation)
time, is assumed to be constant.
Development
of this concept
is detailed
in reference 2.
Remission
of myeloma
was defined as a reduction
in the total body tumor cell number
of at
least
50%,
and
significant
Calculation
Total
ofthe
Myeloma
regression
was defined
Body
Cell Number
as an approximate
M-Component
1 log reduction.
Synthetic
Rate
and
Total
Body
(TBMC)
The total body synthetic rate for the M-component
was calculated
from the fractional
rate (f) for the specific immunoglobulin,
its concentration
in the serum, plasma volume,
weight.
was
In
used
IgG
myeloma
as described
cases,
in our
the
equation
previous
kinetic
of Waldmann
Strober’
TBMC
total M-component
synthetic
rate and the measured
myeloma cell in vitro, as described previously.13
Myeloma
and
analysis.2
was
cellular
for
the
derived
calculation
from
M-component
catabolic
and body
the
synthetic
of
f
calculated
rate
per
Cell LI Studies
A 1-3-mI specimen ofbone marrow was aspirated
aseptically
into a syringe
containing
heparin.
One-quarter
volume of 3% dextran was added to the sample in order to sediment
the red cells.
The supernatant
plasma, which contained
the marrow
cells, was transferred
to a sterile centrifuge
tube and diluted to 45 ml with Hanks’ Balanced Salt solution
with 10% fetal calf serum (HBSSFCS) and centrifuged
for 10 mm at 600 g at room temperature.
The cell button
was then resuspended in HBSS-FCS,
and the centrifugation
and cell washing
procedure
was repeated
two times.
A 2-mi aliquot of the washed cell suspension
was placed
in a sterile
plastic
tissue culture
tube and
warmed to 37’C in a waterbath.
One microCurie
of tritiated
thymidine
(specific
activity,
18 Ci/
mmole) was added to the cell suspension.
After
1 hr of incubation,
the suspension
was washed
free of the unincorporated
tritiated
thymidine
by two additional
centrifugations
and washes with
HBSS-FCS.
The cell preparations
were free of clumping,
and, at the completion
of the incubation,
viability
was
from
98%
to
100%.
Slides
for
radioautography
and
microscopic
examination
were prepared with the Shandon
cytocentrifuge.
After methanol
fixation,
radioautographs
were
prepared for exposure by dipping in Kodak NTB-3
emulsion
and then exposed for 7 days at 2’C.
Standard
developing
techniques
were used, and the slides were stained with acid Giemsa stain.
Radioautographs
prepared
in this fashion
were of exceedingly
high quality
with a background
median grain count of less than 35 grains per 100 cells.
All marrow cells which were morphologically
in the lymphoid-plasma
cell series were defined
as myeloma
cells. Special care was taken in staining and microscopic
examination
to assure that
plasma
cells could
be distinguished
morphologically
from early red cell precursors.
Cells contaming
at
least
five
counted in order
sure the accuracy
in the bone
marrow
sured
this
with
siderations
grains
over
the
nucleus
to determine
the myeloma
of the counting
procedure,
were
not
LI technique
regarding
analyzed.
The
were
considered
median
grain
was in the class of >50
threshold
grain
counts
labeled.
One
thousand
cells
were
cell LI, which was expressed as a percentage.
To enslides on patients with less than 8% myeloma
cells
and
relation
count
grains
to
of
per
labeled
cell
background
myeloma
nucleus.
were
cells
Statistical
as
described
mea-
conby
Clarkson
et al.8
A simple extrapolation
total number
of labeled
from the LI and tumor cell number
data was the calculation
of the
myeloma
cells in the body (the size of the compartment
of DNA-
synthesizing
TBLMC.
tumor
cells),
TBLMC
RESULTS
Proliferative
Kinetics
Patient
R.D.,
when electrophoresis
in a Previously
a 43-yr-old
man,
was performed
equals
AND
TBMC
x LI.
DISCUSSION
Untreated
Patient
was discovered
to
as part
of a health
with
Myeloma
have
an
screening
M-component
program.
He
From www.bloodjournal.org by guest on June 16, 2017. For personal use only.
SYDNEY
122
was
entirely
asymptomatic,
peripheral
blood
serum
identified
concentrate
aspirate
tient’s
and
showed
contained
physician
no
20%
evidence
plasma
considered
studies
total
to have
of the
tumor
TBMC
cell
Within
and
mass,
the
skeletal
Jones
proteinuria.
of which
were
a benign
synthesis
measurements.
doubling
examination,
x-rays,
a halving
total
and
that
of the
number
gammopathy,
volume,
there
LI.
of
marrow
The pabut
synthesis
and
cell kinetics.
period
with serial
bone
mar-
plasma
time
and
of the
of a urine
A bone
binucleate.
monoclonal
of immunoglobulin
times over a 136-day
ofimmunoglobulin
electrophoretic
physical
were normal.
Immunoelectrophoresis
as IgG kappa.
Electrophoresis
of Bence
cells, some
him
referred
him
for evaluation
The patient
was studied
four
row
his
laboratory
values
the M-component
E. SALMON
hematologic,
was
Thus,
slightly
despite
myeloma
cells
(TBLMC)
remained
essentially
unchanged
at approximately
diagnosis
of multiple
myeloma
was considered
established,
was begun.
Studies
of the patient’s
kinetic
measurements
and
more
the
than
a
increase
synthesizing
in
DNA
1 x 10” cells.
A
and chemotherapy
listed in Table
I.
are
It is clear
from
these
measurements
that
only
a small
fraction
of myeloma
cells were undergoing
DNA
synthesis
during
the phase
of tumor
growth
with
>
myeloma
cells and a tumor
doubling
time of6 mo. Back calculation
from
this patient’s
time) of about
surement
of the
niques,
been
time
growth
3 days.
curve
would
Confirmation
myeloma
although
this
published.9”0
in vivo are
cell
suggest
an initial
of this estimate
generation
estimate
time
is in general
Additional
clearly
needed
measurements
to develop
doubling
time
(generation
would
require
precise
mea-
with
accord
labeled
with
thymidine
the
few
data
techthat
have
of the myeloma
cell generation
knowledge
of the range
of Tc in
firm
myeloma.
Effects
oflntermittent
Eight
Chemotherapy
patients
with
75% tumor
(at least
of diagnosis.
good
responses
regression)
Labeling
was
in the
sion,
plasma
cells
took
most
group
studied.
LI rose
or “small”
in larger
up
label
In contrast,
progressively
Table 1. Serial
Day
(g/lOOml)
1
serial
agent-prednisone
LI studies
observed
cells
cells.
therapy
initiated
in cells
myeloma
myeloma
at the
which
time
would
be
(< 18,u in diameter),
Binucleate
or multi-
only
infrequently,
but when
they did, all
patterns
were
observed:
Prior
to interthe LI was low, ranging
from
2% to 7%
LI
in association
with
a series
with
significant
of courses
lgG Multiple
Total No. of
Myeloma
Cells
(x 102)
tumor
of chemotherapy
Studies of Tumor Kinetics in an Untreated
with
IgG
M-component
alkylating
frequently
were
tagged.
Characteristic
alkylating
agent
chemotherapy,
the
to
underwent
classified
as either
plasmablasts
but it was occasionally
observed
nucleate
nuclei
mittent
on the LI
until
Patient
Myeloma
labeling
Index
(%)
3.4
1.7
47
4.6
2.5
-
107
136
5.0
2.8
-
6.2
3.6
3.1
6.0
regres-
Total No. of
Myelama
Cells
Synthesizing
DNA
(x
10’)
0.10
-
0.11
a
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GROWTH
FRACTION
IN MULTIPLE MYELOMA
123
50
I
40
.1
LI
#{176}
PERCENT
20
10
Fig.
Myeloma
cell tnitiat.d
labeling
indices prior to
alkylating
agent chemo-
1.
thymidine
and after
therapy.
has
a time
course
are
summarized
value
was
obtained
the
of minutes
in Fig.
at a time
“plateau”
phase
of alkylating
agent
Serial
Observations
on Chemotherapy
patients
having
who
therapy.
Patient
of treatment
at
injury).
not
tumor
time
AFTER
THERAPY
and
the
tumor
observa-
the
highest
persisted
dur-
remained
con-
These
data
compartment
were
as a
and
two
rapid
a brisk
courses
and
responses
clear
to alkylating
of therapy
cell
were
of melphalan;
it would
appear
expanded
chemotherapy.
regression
drug
enough
An
be administered
failed
to promptly
counterbalance
resistance
did
not
appear
(data
not
increase
to have
kill
there
his
was
a 150-day
cytoreductive
in
virtually
cells
and
to melphalan.
R.K.
represents
cell mass occurred
the
course
course
myeloma
during
this
proliferative
of
with
each
each
sensitive
over
Two
cycle-active
with
after
B.D.,
between
however,
the LI rose markedly
that in this latter
patient,
the
additional
patient
to have
a significant
cell
unusually
of
untreated
patients
meiphalan-prednisone
number
In patient
agents
which
could
LI.
to respond.
trials
of
of tumor
in tumor
in the
failing
received
previously
courses
evidence
rebound
precursors,
others
also
of remission.
data
on three
received
pulse
increase
in sensitivity
hematopoietic
response
serial
TBMC
and LI studies.
for this analysis
varied,
with
cause
of limiting
bone
marrow
hypoplasia.
Patient
phenomenon:
Only minimal
regression
in myeloma
patient,
LI
instances,
Cycle-nonspecific
myeloma
underwent
in the patients
chosen
showed
had
with
difference
had
These
all)
regression
which
With
excellent
H.S.
but
association
normal
after
(but
of the cycles
of chemotherapy.
of the tumor’s
proliferative
excellent
had
drugs
in the “plateau”
phase
Figure
2 shows
the serial
relatively
difficult
cases
who
doses
fore,
VALUE
OF
chemotherapy.
patients
with IgG
to chemotherapy
patients
Only
HIGHEST
Agents
Seven
Response
no
most
of myeloma,
result
the
In
of maximum
in size despite
repetition
as evidence
of expansion
Cycle-specific
to hours
1.
stant
taken
some
TO THERAPY
was obtained
(in the range
of I 5%-40%).
Inasmuch
as each LI
4-6 wk after the previous
course
of chemotherapy,
the LI results
to reflect
prereplicative
DNA
synthesis
rather
than
DNA
repair
tions
ing
#{149}
PRIOR
ONSET
maximal
value
was measured
would
appear
(which
.
period
an
be-
unusual
with full
period.
Therecompartment
effects
shown)
who
in LI with
did not have
treatment.
a cytokinetic
basis.
of
tumor
In this
From www.bloodjournal.org by guest on June 16, 2017. For personal use only.
B.D.
124
SYDNEY
R.K.
H.S.
92
Kg
53
3.0
/
i
OLO-20
1-
I
1.0
/
:
.8
io12
30
/
MYELOMA
CELL NUMBER
40
.
85Kg
-,
2.0
x
Kg
: 10
I,
I
‘.5
0
______________________
_________________________
I
I
I
I
I
1
1
I
I
0 50
50 100150
0
50 100150
DAYS
Effects of treatment
difficult
Patient
myeloma
E.M.
PERCENT
4
.2
Fig. 2.
1.1.
8
6
.4
in three
E. SALMON
on myeloma
cases (patients
(Figs.
3 and
AFTER
ONSET
I
B.D.,
and
4), a 75-yr-old
I
I
2
OF THERAPY
cell number (a
H.S.,
I
100150200250300
o) and
labeling
index
(.---e)
R.K.).
man,
had
severe
anemia
and
osteo-
porosis
when
first examined.
He had a presenting
TBMC
of 2.9 x l012 tumor
cells and an LI of 3.6%.
Intermittent
courses
of meiphalan
and prednisone
resulted
in a 72% reduction
in TBMC
within
100 days.
By that time,
the patient
had achieved
a “plateau”
stage
of remission,
with
a stable,
residual
myeloma
cell mass
“plateau”
of9
x 10” myeloma
cell mass persisted
cells. With
at this level
further
for an
pulse
courses
of therapy,
additional
250 days.
By
time,
the LI had increased
to 22%,
and the TBLMC
number
had
doubled
(from
8.7 x 1010 to 2.0 x 10” cells),
despite
a 72% reduction
In an attempt
to perturb
vincristine
were
added
tumor
then
peared
to plateau
regressed
the tumor
with a cycle-active
agent,
to the cycles
of melphalan-prednisone
an
again
additional
at 5.5
x
39%
10”
from
myeloma
the
cells
first
1-mg
level
a total
ft
more
than
in TBMC.
injections
therapy.
plateau
(i.e.,
-
40
30
MYELOMA
CELL
PERCENT
1012
DAYS
AFTER
ONSET
Fig. 3. Effects of treatment on myeloma cell number
in a responsive
myeloma
patient
(patient
E.M.).
OF
(o
THERAPY
o) and
labeling
index
of
The
ap-
regres-
LI.
NUMBER
x
and
tumor
-
the
this
(.---.)
From www.bloodjournal.org by guest on June 16, 2017. For personal use only.
GROWTH
FRACTION
IN
MULTIPLE
MYELOMA
125
EM,
105Kg
gG
.
Fig. 4.
.
of
.
of addition
Effects
patient
EM.
(Kinetic
data
this patient are shown
3.)
lgG
M-component
centration
plasma
(g/100
volume
decrease
in
.
.
.
.
P9=54
(
“
029
-s
--
3
is
P
05
io
I I
MEL
200
I I
I
300
I
I
the
400
I
I
500
I
I
I
I
I
I
600
PRED
VCR
the addition
of vincnstine
to
the regimen.)
PRED, prednisone; MEL, melphalan.
from
CURVE
O37
..
vol-
of the
( Note
values
identical
of 81%
#{149} ...
#{149} .
response
constant
NUMBER
OOMPERTZ
e.022
for alpha
were seen during
primary
regression
and with
sion
CELL
FIT
‘,
CELLS
(Note
equation.
almost
to12
Alpha
the retardation
that
PV,
plasma
with
chemotherapy.)
Gompertz
MYELOMA
ml).
TUMOR
.
‘REST
2.0
in Fig.
con-
(liters).
ume associated
to
on
in
for
number
MYELOMA
3
-
(VCR)
cell
K MULTIPLE
gG:8O
.
vincnstin.
myeloma
the
3.0
.
DAYS
TBMC
at presentation).
The
total
effective
cell
kill
was
2.35 x 1012 myeloma
cells. Six weeks
after the third
vincristine
injection,
the LI
had increased
to 42% and the TBLMC
compartment
had a further
increase
to
2.3 x 10” cells. Several
days after the LI of42%
had been obtained,
the patient
was treated
with cytosine
arabinoside
administered
as a continuous
intravenous
infusion
at a dose
tion ofthe
infusion,
that
cytosine
their
DNA
of 100 mg/sq
m/day
for 5 days.
Twelve
a repeat
LI was less than 0.1%.
This
arabinoside
entered
synthesis.
rebound
to a level
of 5 x
suggests
that
the
out
being
time
either
lethal
of the
a transient
lOll
cells
cytosine
or that
infusion
additional
were
1406 days.
Patient
and
The
to
L.W.
a TBMC
prompt
(Fig.
of
regression
period
of
of
x
l0
88%
therapy,
melphalan
and
the patient
(administered
persisted
with
a concomitant
several
the
level
and
followup
when
with
tumor
very
could
the
be
patient
case
marked
first
bone
inhibited
observed,
This
in the
LI of residual
result
with-
synthesis
at
rapidly.
the
Despite
maintained
with
has
remained
July
pain
for
1, 1974
and
is
anemia
treatment.
melphalan-prednisone
received
daily
maintenance
A “plateau”
phase
in excess
increase
and
synthesis
as of
referred
terminaindicates
was
weeks.
DNA
DNA
in this
had
cells
occurred
then
orally).
within
the
woman,
tumor
cells
undergoing
plateau
therapy,
5), a 58-yr-old
8.5
not
after
result
in tumor
inhibited
repopulate
the
total
occurred
cells
able
myeloma
regression
arabinoside
this
rebound
phenomenon,
melphalan-prednisone-vincristine
asymptomatic.
proliferating
Although
hours
latter
A
combination
treatment
of 800 days
myeloma
with
then
cells.
In-
jections
of vincristine
were
administered
intermittently.
Repeated
2-mg
injections caused
a prompt
fall in the residual
myeloma
cell mass;
however,
sporadic
injections
of 0.5 mg had much
less effect.
No other
cycle-active
drugs
have been
tried
in this patient,
although
periodic
injections
of vincristine
have been
used
to reinforce
the
as of July
1, 1974
effects
remaining
in an excellent
of alkylating
is 2302
days
from
remission.
agents.
the
time
The
total
followup
of presentation,
in this
with
the
patient
patient
From www.bloodjournal.org by guest on June 16, 2017. For personal use only.
SYDNEY
126
E. SALMON
lx io12,_
.8
.6
50Kg
LW
.4
.2
MYELOMA
CELL NUMBER
1x1011
.8
.6
V222
55
55
5
:
I
200
0
I
400
I
600
I
800
I
1000
I
1200
I
1400
DAYS
Fig. 5.
Effects
Arrows indicate
of addition
of vincristine
in
The
clinical
to
explorations
success
man.
Many
tumor
kinetic
systems
events
“plateau”
time at which doses were administered.
GENERAL
relative
the
and
of
these
in
in the
features
had
in animals”’4;
in myeloma
of myeloma
levels (in milligrams)
Dose
this
paper
treatment
already
of
been
provide
they
observed
on
cell
DNA
ascertained
labeling
are
in
ticipated
tinct
LI”
with perhaps
in this patient’s
from
calculation
In a sense,
such
comparisons
taneous
cell death
As detailed
in
treatment
with
follows
LI (and
a “reverse
undoubtedly
the
of
compatible
the
fraction.
time
kylating
of our
agent
can
dosage
theoretical
original
therapy,’6
kinetic
rise
report
on
proliferative
the difference
of the tumor’s
be used
schedule
Gompertzian
the GF)
with
analysis,2
the
confirmatory
the
myeloma
change
present
during
in the
observations
One
size
dis-
“theoretical
death
rate.
of the
regression
of a cycle-nonspecific
curve.”
The
progressively
cell death.
The
would
be an-
between
the
spontaneous
to approximate
effects
repair.
in Patient
RD.
phase
during
the
the fraction
of
the LI probably
expansion
of the
than
compartment.
our
previous
a fixed
of the same
on
human
some
increase
in spontaneous
case were significantly
larger
possibility
to explain
this is that
and the measured
LI is a function
in
experimental
evidence
that
the
synthesis,
rather
and hydroxyurea
on scheduled
DNA
synthesis,
as opposed
to unscheduled
DNA
The serial
measurements
of the LI, TBMC,
and TBLMC
(Table
1) provide
evidence
that the approach
to “plateau”
growth
of a monoclone
is associated
with
a reduction
of
myeloma
cells undergoing
DNA
synthesis.
This
decrease
in
reflects
a reduction
in the growth
fraction
and a reciprocal
G0 compartment,
measured
LIs
insights
neoplasms
our studies
confirm
the occurrence
in man.
Very
recent
observations
myeloma
LW.
are indicated.
some
disseminated
myeloma
cells by Alberts
and
Golde’5
provide
additional
measured
LI of myeloma
cells
reflects
prereplicative
DNA
than DNA
repair.
The in vitro
effects
of cytosine
arabinoside
that
in patient
COMMENTS
described
failure
phase
sponduring
alkylating
studies
tumor
myeloma
have
show
regression.
cell
been
LI
agent
that
with
made
the
Since
alby
From www.bloodjournal.org by guest on June 16, 2017. For personal use only.
GROWTH
FRACTION
Drewinko
recently
IN
MYELOMA
increase
with
this
expansion
sult
from
in the size
chemotherapy.
in the
after
Our
one
potential
comparison
Fig. 6. The
with the
theoretical
size that the
at any given
OF would
have
tumor
size. The
those
size
often
of
the
effects
occur
the
cell
further
worthy
of refor
it may
well
of
growth
the
LI,
as that
the
for the tumor’s
in the OF will
is an index
course
clearly
The
death
of
fractions
by
this
adding
the
with
cycle-active
approach
with
the
already
as shown
the minimum
kinetic
always
the
of S-phase
tumor
during
remission,
attempts
to
once
the
cells
appear
agents
and
that
in
treatment
in which
these
increase
the
LI
in
behavior
be greater
death
over
alterations
drugs
of
been
It is of interest
anticipated
on
the rate of cell
of these
dynamic
agents
cycle-active
logjam”
of partial
regression
and
myeloma
cells
may
display
with
a resultant
narrow
therapeutic
cells into
still be es-
chemotherapy,
of
re-
proof
effect
agent
of partial
cycle-active
only
alkylating
increase
result
of a “plateau”
death
has
proliferative
fraction
is a projection
of
to be to account
per cent of cells
of treatment
spontaneously.
and
interferon,
myeloma
cells in vitro.’9
what
would
have
been
theoretical
fraction
During
growth
explorations
of trial,
“break
elements
agents,
candidate,
kinetic
forces
are in a delicate
balance.
of the results
of our
preliminary
In view
analysis
in the triggering
of myeloma
an inhibitor
or chalone
must
by human
exceeded
of the
proliferative
with
in cycle.
development
opposing
favoring
plot
enumerated
the cytotoxic
which
would
induction
responsible
obscure,
detailed
have
a dy-
myeloma
suggested
that
a simple
feedback
inhibitor
cells (e.g.,
a chalone3)
could
account
for the retardation
prior
to therapy,
whereas
release
from the inhibitory
although
of all cells
observations
indicate
that
follows
the
mechanism
remains
system.
demonstrated
to be produced
that the measured
LIs always
than
Golde.’5
Similar
These
studies
all
chemotherapy
regulatory
antitumor
therapy)
could
result
The biochemical
nature
of such
tablished,
the
and
of the OF of tumor
cells
Although
the precise
OF
a feedback
and regression
of
duced
by myeloma
growth
of myeloma
not
127
et al.,’7 as well as by Alberts
been
made
in acute
leukemia.’8
namic
mission
(after
cycle.
MULTIPLE
has
is
two
forces
increased,
warranted.
will
not
Although
necessarily
myeloma.
Normal
hematopoietic
similar
sensitivity
to cycle-active
index.
Indeed,
studies
by Ogawa
iol2.
#{149}
e
.
e
1010.
-
e
io8
.
-
106’
Myeloma
I
io
Cell
Fig.
of the theoretical
proliferative
fraction
(theoretical
growth
fraction) to tumor cell number
values projected
for
a
growth
3days).
6.
Relation
patient
constants
with
(a
typical
=
0.008;
Gompertzian
generation
I
io2
I
Number
I 11111111
1
1 II
10
time,
Prolif.
Fraction
%
From www.bloodjournal.org by guest on June 16, 2017. For personal use only.
SYDNEY
128
and
Bergsagel#{176} which
mouse
myeloma
shown
in this
no differential
perspective,
have
cells
suitable
markers
as those
marked
which
selective
(as
shown
a marked
compared
sensitivity
to the
optimal
chemotherapy
of tumor
we
burden
have
toxicity
increase
in
to hematopoietic
cycle-active
requires
and
observed,
but
for myeloma
of
the
to
sensitivity
of
melphalan
have
drug
5-fluorouracil.
Viewed
not only the availability
of
exploitation
also
cells.
the
cells)
E. SALMON
kinetic
availability
alterations
of new
such
drugs
with
a
ACKNOWLEDGMENT
I would
clinical
and
like
to
thank
suggestions,
Dr.
puter
Peter
Dr.
Ms.
W.
David
Beth
Sullivan
Alberts,
A.
for
Smith
Dr.
for
assistance
superb
in kinetic
Brian
Dune,
technical
and
Dr.
Raymond
assistance,
formulation
and
and
Alexanian
Dr.
Hugo
development
for
Martinez
of
useful
H #{228}moblastosen
mit
com-
programs.
REFERENCES
I.
Salmon
synthesis
IgG
SE,
and
Smith
total
multiple
BA:
body
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proteinamischen
Immunoglobulin
tumor
cell
J Clin
number
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in
49: 1 14,
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PW,
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SE:
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in
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of
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BA:
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TA,
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leukemic
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with
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given
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Killmann
VP:
SA,
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of
design
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Rep
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following
synthesis
cell
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Induction
cycleVol
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54:431,
(Nov
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chemo-
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for
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RW:
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(abstn.).
Clin
in
Res
1972
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tersuchung
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multiple
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in two
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solid
for
1969
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1969
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Fried
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The
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HH:
1967
Bond
in:
in planning
1970
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of
growth
tumor
Metabolism
Ota
by
autoradio-
Wochenschr
Dynamics
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syn-
1969
Allergy
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tnitiated
charac-
human
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Estimation
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103:129,
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para-
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radioimmunoassay
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104:665,
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growth
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immunoglobulins
SE,
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of
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forms
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Thymidine
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leu[Cell
haemoblastosis
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of
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proteinaemic
2.
the
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labelling
index
B, Brown
BW,
Effect
of
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Cooper
Humphrey
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R,
on
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Cancer
LE,
Groth
the
34:
526, 1974
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Vogler
DP:
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FRACTION
Correlation
of
increment
blast
in
cells
33:603,
1974
19.
Epstein
of
interferon
IN
cytosine
growth
with
clinical
MULTIPLE
129
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arabinoside-induced
fraction
of
patients
leukemic
response.
Cancer
20.
EA:
LB.
by
Salmon
malignant
SE:
The
plasma
production
cells
from
with
112:1131,
titative
vivo.
multiple
myeloma.
i
Immunol
1974
Ogawa
M,
Chemotherapy
cell
Blood
Bergsagel
of
cultures
41:7,
mouse
predictive
1973
DE,
McCulloch
myeloma:
of
response
quanin
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1975 45: 119-129
Expansion of the growth fraction in multiple myeloma with alkylating
agents
SE Salmon
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