EXTRACORPOREAL IRRADIATION IN THE TREATMENT OF ACUTE LEUKAEMIA

13

EXTRACORPOREAL IRRADIATION IN THE TREATMENT OF ACUTE LEUKAEMIA R. S. SOUHAMI

J. S. CLIFTON E. W. EMERY J. N. GODLEE T. A. J. PRANKERD J. L. PROVAN Departments of Clinical Hœmatology and Radiotherapy, University College Hospital, London W.C.1

Extracorporeal irradiation of the blood (E.C.I.) has been used in the treatment of five patients with acute leukæmia. Treatment was with a high dosage administered over a short period of time. The main effect of E.C.I. was to produce a short-lived reduction in the numbers of circulating blast cells. Temporary clinical improvement was seen in one patient. Chemotherapy after E.C.I. did not seem to be more effective than when given beforehand. Sum ary

Introduction

EXTRACORPOREAL irradiation (E.C.I.) of the blood has been used in the treatment of acute leukaemia 1-3 and of chronic myeloid and chronic lymphatic leukæmia.3 44 The treatment is based on two theoretical possibilities. The first is that leukaemic cells are exchanged between bone-marrow and blood, in which case a reduction of the mass of circulating leukxmic cells might produce improvement by diminishing the total leukaemic-cell population. The second possibility is that a high peripheral white-blood-cell count might inhibit the release ofleukaemic cells from the marrow; in this event a fall in peripheral count might lessen the degree of leukxmic infiltration in the marrow. Because leukaemic cells are more sensitive to irradiation than are mature cells, it should be possible to deplete the blood of leukaemic cells without injury to the normal elements. Initial reports of the results of treatment in acute leukaemia have been encouraging, and we describe here the response to E.C.I. in five patients with acute leukaemia. Technique of Irradiation An arteriovenous shunt was made, using’Teflon ’ tubing, between a forearm vein and the ulnar artery. Blood was passed from the arterial end of the shunt through a polyethylene coil which was in the radiation zone. Physiological saline with heparin was run slowly into the arterial side of the coil during irradiation to prevent clotting. The irradiation was from a four-bladed source containing 24 Ci of strontium-90. The blades are arranged in pairs, with the active faces of each pair opposed leaving space for the coil to pass between. The design is similar to that

5.

6. 7. 8.

9.

10. 11.

12. 13.

Hunt, A. H., Parr, R. M., Taylor, D. M., Trott, N. G. Br. med. J. 1963, ii, 1498. Hunt, A. H. Portal Hypertension. Edinburgh, 1958. Baggenstoss, A. H., Foulk, W. T., Butt, H. R., Bahn, R. C. Am. J. clin. Path. 1964, 42, 259. Goudie, R. B., MacSween, R. N. M., Goldberg, D. M. J. clin. Path. 1966, 19, 527. Doniach, D., Roitt, I. M., Walker, J. G., Sherlock, S. Clin. exp. Immun. 1966, 1, 237. Smallwood, R. A., Williams, H. A., Rosenoer, V. M., Sherlock, S. Lancet, 1968, ii, 1310. Ahrens, E. H., Payne, M. A., Kunkel, H. G., Eisenmenger, W. J., Blondheim, S. H. Medicine, Baltimore, 1950, 29, 299. Sherlock, S. Diseases of the Liver and Biliary System. Oxford, 1968. Sherlock, S., Datta, D. V., Walker, J. G. Revue int. Hepat. 1966,

16, 217.

by Lajtha et al.1 Our apparatus (unpublished) is fully protected, self-contained mobile unit. The dose administered will depend on the number of

described

designed

as a

turns in the coil:

The dosage is independent of flow-rate, but it is assumed that the duration of treatment results in an adequate distribution of irradiation to the whole blood.

Case-reports Case 1 (51, F, Acute Myeloblastic Leukæmia) Presented with severe vaginal bleeding. There was purpura, and enlargement of the liver and spleen. Initial blood-count: Hb 5-8 g. per 100 ml., w.B.c. 73,100 per c.mm. (blast cells 93%, neutrophils 5%, lymphocytes 2%), platelets 25,000 per c.mm. Sternal marrow showed numerous blast cells. Peroxidase reaction positive. She was treated with rubidomycin (120 mg.), and total w.B.c. fell rapidly to 2000 per c.mm. with almost complete disappearance of blast cells (fig. 1). However, over the next 10 days the count rose to 10,000 per c.mm. with 90% blast cells. Treatment with 6-mercaptopurine (6-M.P.) (150 mg. per day) and prednisone (40 mg. per day) was begun and a further dose of rubidomycin (120 mg.) produced only a transient fall in w.B.c. followed by a rapid rise to 50,000

anaemia,

per

c.mm.

started, a dose of 10,000 rads being given over 30 hours. This produced only a modest fall in W.B.C., and a further dose of 40,000 rads was given over 96 hours which was followed by a fall in total count to 3000 per c.mm. of which 90% were blast cells. Lymphocytes and platelets completely disappeared from the circulating blood. 6 days later the W.B.c. had risen to over 50,000 per c.mm. A further two infusions of rubidomycin were given, and these were followed by a rapid fall of w.B.c., but the response was as short-lived as after the previous injections. After E.C.I. widespread cutaneous leuk2emic deposits had developed and there was troublesome haemorrhage. A further dose of rubidomycin produced only a transient effect and she died 2 weeks later. Necropsy showed widespread leukxmic infiltration in the spleen, lymph-glands, bone-marrow, pharynx, vocal cord, and breast. There were infiltrative masses of leukaemic tissue in the upper respiratory tract, and occlusion of a large bronchus by leukaemic deposits. Comment.—E.C.I. produced only a temporary fall in total W.B.C. followed by a rise to high levels. Rubidomycin was no more effective when given immediately after E.C.I. than when given beforehand. There was striking dissemination of leukasmia after E.C.I. during life, and widespread E.C.I. was

infiltration

was seen

at necropsy.

Case 2 (26, F, Acute Myeloblastic Leukæmia) This patient’s illness began with malaise and sore throat, and when first seen she had gingival infection, enlargement of liver and spleen, and sternal tenderness. Blood-count: Hb 8-2 g. per 100 ml., w.B.c. 31,000 per c.mm. (blast cells 89%, neutrophils 3%), platelets 200,000 per c.mm. Bonemarrow showed numerous blast cells, with a positive reaction. started (fig. 2) but the shunt did not work well and only a small dose of 1000 rads was given over 4 hours which produced a transient fall in w.B.c. 4 days later a total dose of 10,000 rads was given over 48 hours without any improvement in w.B.c. Rubidomycin was administered the day after E.C.I. (320 mg. total over 4 days), and this produced a fall in total count to 1300 per c.mm. with almost complete disappearance of primitive cells. A partial remission was achieved and she received additional treatment with

peroxidase

E.C.I. was

14

Fig. 1-Case 1 (54-year-old female with acute myeloid leukaemia): hwmatological picture in relation The ordinate shows cells per c.mm. on a log scale.

prednisone and vincristine. 8 weeks later there was relapse with widespread skin infiltration. A further dose of rubidomycin (120 mg.) produced only a transient response and her disease spread rapidly.

to

therapy.

Comment.-In this patient

E.C.I. was the first line of There was little response to this manoeuvre, but a partial remission was achieved with rubidomycin. Relapse soon occurred with widespread leuksemic infiltration.

treatment.

Case 3 (22, F, Acute Myeloblastic Leukcemia) Acute myeloblastic leukaemia was diagnosed in 1963. A complete remission was produced with prednisone and 6-M.p. A relapse 3 years later was treated with prednisone, 6-M.P., and cvclophosphamide with complete remission in blood and bone-marrow. Meningeal

Fig. 2-Case 2 (29-year-old female with picture in relation to therapy.

acute

myeloid leukaemia): haematologicsl

deposits developed in 1967 and were treated with intrathecal methotrexate She relapsed in with good result. February, 1968, with recurrence of meningeal involvement, and with blast cells in the peripheral blood. An improvement in her condition was obtained with prednisone, 6-M.P., and intrathecal methotrexate, but 3 months later she developed faucial infection, Bloodpurpura, and splenomegaly. count : Hb 8-8 g. per 100 ml., w.B.c. 640 per c.mm. (mainly blast cells), platelets less than 20,000 per c.mm. Two treatments with E.C.I, were given in 5 days with a dose of 10,000 rads in 36 hours on each occasion. The first treatment was followed by an increase in w.B.c. (fig. 3), largely in immature cells. The second treatment produced no clinical or hxmatological effect, and she died 2 weeks later. Necropsy.-Very extensive infiltration in bone-marrow, liver, spinal cord, brain, and spleen, much of which was of

15 a

chronic

nature.

There

was

also very extensive visceral

haemorrhage. Comment.-E.C.I. was used here as the last treatment after the failure of chemotherapy. Unlike the other patients she had a low peripheral W.B.C., and irradiation produced a rise in total count, mainly in immature cells.

Case 4 (18, M, Acute Lymphoblastic Leukaemia) Acute lymphoblastic leukaemia had been diagnosed in Cyprus, and he had been treated with prednisone. On admission to this hospital there was anaemia and slight hepatic enlargement. Blood-count: Hb 6-7 g. per 100 ml., W.B.C. 1100 per c.mm. (neutrophils 29%, immature cells 6%). Bone-marrow showed numerous blast cells. He was treated with rubidomycin, 6-M.P., and prednisone. After the initial rapid fall in W.B.C. (fig. 4) there was a return to normal levels with few immature cells. Relapse soon followed with meningeal involvement treated with intrathecal methotrexate. Subsequently, his W.B.C. rose with numerous blast cells present. He was treated with B.c.1., 8000 rads being given in 36 hours. The w.B.c. count fell from 105,000 (40% immature cells) to 8200 per c.mm. with 20% immature cells. The platelet-count fell from 150,000 to less than 40,000 per c.mm. and there was troublesome bleeding. For 7 days after irradiation he. felt rather better and was able to go home for 2 days. He deteriorated rapidly, with further bleeding, and died 4 days later. Necropsy.-There were very extensive haemorrhages especially in the brain, and there was some leukaemic infiltration in the meninges. Comment.-In this patient with widespread disease, E.C.I. produced both hsematological and clinical improvement. This was not so striking as that produced by rubidomycin,

Fig. 4-Case

4

(18-year-old male with

acute

Fig 3-Case 3 (22-year-old female with acute myeloid le11kaemia); haematological picture in relation to therapy.

lymphatic leukaemia): haematological picture in relation

to

therapy.

16 and was short-lived. There infiltration at necropsy.

was

widespread

leukasmic

Case 5 (71, M, Acute Lymphatic Leukcemia) This patient had a short illness with purpura and large painful ulcers over the face and neck with leukasmic infiltration in the skin. The liver and spleen were enlarged and there was generalised glandular enlargement. Bloodcount : Hb 9-8 g. per 100 ml., w.B.c. 93,000 per c.mm. (neutrophils 5%, blast cells 80%, lymphocytes 10%), platelets 54,000 per c.mm. Sternal marrow showed heavy infiltration with blast cells and lymphocytes. E.C.I. was given in a dose of 7800 rads over 36 hours. There was a rise in the total count with an increase in the number of blast cells. Irradiation was stopped, but treatment with rubidomycin and prednisone produced no improvement and he died 2 days later. Comment.-This gravely ill patient was treated with E.C.I. as a first treatment. There was deterioration in his clinical and hxmatological state with no response to chemotherapy

subsequently. Discussion

might be effective in the treatment of acute leukaemia in two ways. Firstly, there might be a free interchange of leukaemic cells between the bonemarrow and the blood, when E.C.I. might be effective in depleting the total mass of leukasmic tissue. Secondly, it is possible that the liberation of blast cells from the bone-marrow is inhibited by the high peripheral w.B.c.-count and that a reduction in the count would lessen bone-marrow infiltration by allowing leukxmic cells to leave the bone-marrow. In the cases described here, E.C.I, produced a fall in the total w.B.c.-count, especially in the blast cells, but this effect was short-lived and was usually followed by a rise in the number of primitive cells to a level higher than before E.c.i. Two patients who had a reduction in the number of blast cells after the first course of irradiation showed no response to a second and similar dose (cases 2 and 3). One patient (case 1) had no response to an initial dose of 10,000 rads, but the w.B.c.-count fell rapidly after a second dose of 40,000 rads, but even this larger dose was only transient in its effect. As far as can be judged from this small number of cases the effect of E.C.I. on the peripheral W.B.c.-count was no different whether the irradiation was undertaken as an initial treatment or as the last manoeuvre in patients who had had intensive chemotherapy on previous occasions. One patient (case 4) showed a rapid fall in count after a relatively small dose of irradiation. He had previously been treated with many antileuksemic drugs. Another patient (case 2) was given E.C.I. as a first treatment without any effect. The size of the dose of irradiation may clearly be of importance in determining the response. Lajtha et al.5 gave between 10,000 and 20,000 rads continuously over a short period (1-5 days). In one patient they achieved a partial remission of 5 weeks, but in others the response to E.C.I. was as short-lived as in the cases reported here. Schiffer et al. treated patients with acute myeloblastic leukxmia with E.C.I. over several weeks for 3-4 hours each day. Some of their patients showed clinical and haematological improvement while on E.c.i. and one patient had a remission of her disease. They noted a better outcome in patients who were treated with a transit dose of over 340 rads, E.C.I.

but because of the small number of cases reported it is whether the response to a high total dose over a short time is different from a lower dose given regularly over a period of several weeks. Although there has occasionally been sustained improvement after E.C.I., with both forms of treatment the w.B.c.count has normally risen as soon as E.C.I. has been not clear

discontinued.

rapid rise in peripheral w.B.c.-counts after stopping E.C.I. is remarkable. It was also observed by Lajtha et al.,5 and in our patients the peripheral count has shown a doubling-time of as little as 1-5 days. This might be accounted for by increased replication of cells in the marrow or by a stimulation of their release from the marrow. Since something of the order of 1010 cells may appear in the blood in one day it seems unlikely that the increased cell production would account for The

this alone. Chan et al.noted that the mitotic activity of the cells in the bone-marrow increased after E.C.I. when the peripheral W.B.c.-count had been lowered, and he suggested that the fall in peripheral count was a cause of the increased mitotic activity in the marrow. However, in case 3 reported here, irradiation was given even when the peripheral count was low, and this was followed by a rise in the peripheral count to higher levels than before treatment. Thus, although E.C.I. may have provoked mitotic activity in the marrow, something other than the level of the peripheral W.B.c.-count must have been the operative factor. In the patients reported here, and also by Lajtha et al.,5 no diminution in blast-cell infiltration of the marrow has been observed after E.C.I. Such evidence as there is suggests, therefore, that neither of the two mechanisms, through which E.C.I. might be effective, obtains. Although the procedure was usually well tolerated by patients, bleeding at the site of the shunt was sometimes a problem, as was clotting in the coil. Only one patient felt improved as a result of the irradiation, and he was the patient whose W.B.C. fell rapidly after a small dose (case 4). In the main, the irradiation produced no effect, one way or the other, in the patient’s well-being. It is our impression, however, that dissemination of the disease may possibly have been accelerated by the procedure. Two patients showed striking and extensive leukaemic infiltration of the skin about 1 week after irradiation was discontinued. This was also observed in two of the patients described by Schiffer et al. In the four patients where necropsy was done there was widespread leukaemic infiltration, but not necessarily of greater extent than is commonly seen in patients dying of this disease. Chan et al.have suggested that patients who have had E.C.I. may be more responsive to chemotherapy subsequently because of the increased mitotic activity observed in the bone-marrow. Our experience with these few cases does not support this idea. In case 1 (fig. 1), the patient was initially treated with rubidomycin with a temporary reduction in number of circulating blast cells. After E.C.I., rubidomycin was again administered, but on this occasion the effect was even less pronounced. The drug was given 6 days after E.C.I. and the timing of chemotherapy after irradiation may clearly be of importance. Case 2 (fig. 2) also

17

received rubidomycin after E.C.I. and although the response to this drug was rapid, and a partial remission was achieved, this response was in no way different from that seen in many other patients treated with rubidomycin in this hospital. Rubidomycin was also given immediately after E.C.I. in case 5, but the drug was entirely without effect. Our experience with the cases presented here does not therefore support the suggestion that chemotherapy might be particularly effective after E.C.I., though clearly this needs further

investigation. We thank Prof. J. F. Smith for necropsy details. Requests for reprints should be addressed to T. A.

J. P.

REFERENCES

Lajtha, L. G., Lewis, C. L., Oliver, R., Gunning, A. J., Sharp, A. A., Callender, S. Lancet, 1962, i, 353. 2. Schiffer, L. M., Atkins, H. L., Chanana, A. D., Cronkite, E. P., Greenberg, M. L., Stryckmans, P. A. Blood, 1968, 31, 17. 3. Schiffer, L. M., Chanana, A. D., Cronkite, E. P., Greenberg, M. L., Joel, D. D., Schnappauf, H., Stryckmans, P. A. Sem. Hœmat. 1966, 3, 154. 4. Thomas, E. D., Epstein, R. B., Eschbach, J. W., Prager, D., Buckner, C. D., Marsaglia, G. New Engl. J. Med. 1965, 273, 6. 5. Lajtha, L. G., Garrett, J. V., Turner, L., Gilbert, C. W., Halnan, K. E., Easson, E. C., Nuttall, P. M., Watson Williams, E. J., Keidan, S. E. Br. J. Hœmat. 1969, 16, 39. 6. Chan, B. W. B., Hayhoe, F. G. J., Bullimore, J. A. Nature, Lond. 1969, 221, 972. 1.

THE INFLUENCE OF GENETIC AND ACQUIRED LIVER DEFECTS ON RADIOCOPPER TURNOVER IN WILSON’S DISEASE

S. B. OSBORN

Department of Medical Physics, King’s College Hospital, London

J. M. WALSHE Department of Investigative Medicine, University of Cambridge Studies with radiocopper have been made in patients with untreated Wilson’s disease in the presymptomatic (6), hepatic (6), and neurological (13) stages of the illness; these have been compared with similar studies made in patients with chronic liver disease. Control observations have been made on individuals heterozygous for Wilson’s disease and normal individuals. Estimation of the ratio of radioactivity in the plasma at 24 hours compared with that at 2 hours will separate the patients with Wilson’s disease from patients with liver disease and from the control groups. Uptake of radiocopper by the liver was only rarely severely depressed in patients with chronic liver damage but was always very severely depressed in patients with untreated neurological Wilson’s disease. It was not possible to show any correlation between the degree of liver damage measured either histologically or biochemically and the reduced uptake of radiocopper by the liver in the latter group of patients.

Sum ary

Introduction As the site of synthesis of the serum-copper-protein caeruloplasmin and as the main site of excretion of copper via the bile the normal liver plays a key role in the homoeostasis of this metal. In patients with Wilson’s disease both functions are impaired with

consequent accumulation of copper in the body, principally the brain, liver, and kidneys. Copper is a powerful enzyme poison not only in vitro but also in vivo,! and in consequence tissue damage follows its excess deposition. The first pathological changes in patients with Wilson’s disease are probably in the liverand this organ is eventually the site of cellular necrosis, fibrosis, and postnecrotic cirrhosis. The liver thus plays a dual role in the pathogenesis of Wilson’s disease.3 The earliest studies with radiocopper in patients with Wilson’s disease led to the finding of delayed or absent incorporation of the radioisotope into caeruloplasmin 4 ; later studies at various centres also showed abnormal handling of radiocopper by the liver. As a result of our own studies on patients with Wilson’s disease we were able to show a sequence of events in which the liver progressively lost its ability to concentrate copper from the plasma as the illness progressed; later this function was regained after the excess metal was mobilised with penicillamine. We concluded that the changes we reported were a direct consequence of saturation of the hepatic binding sites for copper following failure of excretion of the metal. 56 Alternatively these findings could be explained in terms of non-specific liver damage. Thus the dual role of the liver in Wilson’s disease makes interpretation of findings with radiocopper difficult. In this communication we have attempted to separate the effects of non-specific liver damage on the handling of radiocopper from those due to the genetic defect of Wilson’s disease. Methods of uptake radiocopper by the liver, the liver/thigh (L/T) ratio, and the plasma radioactivity were all measured by methods previously described.’-il The studies were made on 18 normal controls, 18 patients with chronic hepatic disease, 14 heterozygotes for Wilson’s disease, and 25 patients with untreated Wilson’s disease. The dose of radiocopper (64CU or 67CU) given to patients and controls was within the range recommended by the Radioisotopes Advisory Panel of the Medical Research Council. Liver damage was assessed both clinically and by biochemical determinations which included serum transaminases (serum - glutamic - oxaloacetic - transaminase [s.G.o.T.], and serum - glutamic - pyruvic - transaminase [s.G.P.T.]), thymol turbidity (T.T.), and serum bilirubin and proteins; these estimations were made on blood taken at the time of the radiochemical study. The results are shown in table i. Clinical assessment of the patients with chronic liver disease showed that the degree of liver injury varied from fairly mild to very severe. By comparison only 4 of the 13 patients with advanced neurological Wilson’s disease had any clinical evidence of liver damage (splenomegaly), and in only 1 case did the liver-function tests suggest that this was at all active. Results The

The

for plasma-radioactivity, expressed as of the dose of radiocopper injected per percentage litre of plasma at 2 hours and 24 hours, is shown in table 11. The ratio, radioactivity-at-24 hours/radioactivity-at-2-hours, is also shown, since this is an index of incorporation of copper into cmruloplasrnin. 12 These results show that the plasma-radioactivity in patients with neurological Wilson’s disease is significantly raised at 2 hours compared with the patients with hepatic disease, confirming the slow rate of removal of copper a

findings