Scientific and Ethical Discipline in Clinical Trials on Acute Leukemia G. MATHE Institut de Cancerologie ct d'Immunogenetique "', Hi'ipital Paul-Brousse "."", Villejuif/France Clinical research is still in an evolutionary stage. Although scientific technology was readily accepted and applied, scientific methodology has been accepted much more slowly and is very rarely properly applied. There are three reasons why this is so. First, medical ethics frequently limits the applicability of clinical research, for doctors have to be more than scientists. They must also remain moral philosophers, as they were before medicine became a science. Second, the heterogeneity of the material on which clinical researchers work in studying human diseases makes the application of scientific methodology difficult. Third, researchers must publish. This means that they must obtain publishable results, and too often this means results in accordance with established concepts, easily accepted by the editors of established journals, which are read by the establishment. It is the privilege of too many people to be able to accept "truth" and recipes from other people and confirm their truth and results. It is the mission of a very few others to accept nothing as "truth" and to consider no recipe ideal, either in concept or detail.

Volume therapy or infusion therapy is used worldwide for the treatment of hypovolemia caused by surgical blood and plasma losses, trauma, burns, or infections. Interestingly, significant differences exist between countries regarding the use of plasma substitutes. In the United States, crystalloids and albumin are more popular, whereas in Europe artificial colloids such as hydroxyethyl starch are preferred. From an international perspective, it is notable that volume therapy using hydroxyethyl starch is an established therapy for the treatment of cerebral, retinal, otogenic, and peripheral circulation disorders in Germany. In other countries, crys talloids are mostly used to treat dehydration or hypovolemia, for example in brain stroke. In recent years, new data made it possible to overcome national differences and agree on an evidence-based, international con sensus. The efficacy of different plasma substitutes for a volume therapy last ing several days has not been sufficiently studied in the past. Long-term volume therapy of patients with cerebral perfusion disorders is an excel lent model for studying the effects of artificial colloids in detail, because of the high doses of colloids that are administered. Through a compari son of commonly used plasma substitutes, we were able to show that sig nificant differences exist between different colloids, for example in their effect on coagulation. After repeated infusion, hydroxyethyl starches that are difficult to degrade lead to an accumulation of large molecules that are difficult to eliminate. These large molecules impair factor VIII/von Willebrand factor."

This book is an edited verbatim account of the proceedings of the Second London Workshop on Red Cell Filtration and Deformability, organised jointly by the Royal Society of Medicine and the Groupe de Travail sur la Filtration Erythrocytaire. The first such London Workshop was held on the occasion of the Second European Conference on Clinical Haemorheology in 1981 and its con clusions were published in an abbreviated form. The interest in blood filtration as a technique for assessing red cell deformability has continued to increase and there are now several hundred centres around the world using some form of filtration. It was, therefore, felt that the informal detailed discussions held by a small invited group of experts from many countries would be of more general interest and therefore worth publishing. This has been made possible by the continued interest and generous support of Hoechst. Spontaneous open discussion rather than formal presentations has been the hallmark of these workshops, with precirculation of all scientific data to the participants. We have attempted to preserve this flavour in editing the transcript of the proceedings. This, together with our anxiety for rapid publication, may have resulted in a less than finely polished text which may contain some in accuracies. The topics discussed were loosely structured into eight sessions, outlined in the accompanying programme."

In the last few years a good deal of information related to the biology and treatment of malignant lymphomas has been accumulated and published in journals and monographs. There is, however, no book that gives a concise and objective update of this information or presents a general survey of the subject. The contributors to this book are international authorities, and on the basis of their personal experience and data from the literature they have written a high-level update on malignant lymphomas which will be of interest to both specialists and nonspecialists.

Recent experimental and clinical progress in the evaluation of cytokines in treatment concepts for cancer patients is the central theme of this book in the ESO Monographs series. The discussion revolves on the experimental basis as well as current clinical experience with the use of human recombinant cytokines. It gives the state of the art and, as such, puts into perspective potential areas of growth and future research.

Major epidemiologists from the UK, USA and Europe contribute to the first ever, much needed comprehensive review of the epidemiology of peripheral vascular disease in the lower limbs.

Through numerous discussions with colleagues it became apparent that the time was right to begin a series of workshop-like meetings on myeloid tumorigenesis. Myeloid tumors are the nonlymphocytic tumors of the hematopoietic system which include tumors of the neutrophilic, monocytic, erythrocytic, basophilic (mast cell) and megakaryocytic lineages. Pioneering studies in myeloid tumorigenesis were initially made in chickens with the discovery of retroviruses that induce various kinds of myeloid tumors acutely (myelocytomatosis, myeloblastosis, and erythroblastosis). These avian retroviruses were subsequently shown to contain the oncogenes v-myb, v-~, v-~, v-erbA, or v-erbB. There have been dramatic advances in studying the pathogenesis of hematopoietic tumors in genetically defined mammalian systems. Many of the well developed model systems in inbred mice, have focused on T- and B-1ymphoma development. Although myeloid tumors have been found in mice, they have not been studied as intensively as lymphoid tumors. Possibly this is because myeloid tumors are less common than lymphoid tumors. Recently, there has been renewed interest in murine myeloid tumor systems. This focus has resulted from 1) the discovery of inbred strains of mice (e. g. BXH-2, AKXD- 23, SJL/J) that are highly susceptible to spontaneous or induced myeloid tumorigenesis; 2) establishment of transplantable murine myeloid tumors (e.

The biology of solid tumor metastasis has been the subject of significant scientific and clinical interest for years and while experimental evidence reveals that metastasis is not solely a random event, very little is known about the biology of metastasis originating from prostate cancer. This is in spite of the fact that the majority of prostate cancer patients die with metastatic lesions to the bone. Progress in understanding this most important aspect of prostate cancer has been hampered by the lack of suitable animal models and an inability to accurately quantify bone metastases and their responses to therapy. Over the past decade, scientists in Japan and the United States have steadily advanced our understanding of the cellular, molecular and immunologic biology of primary and disseminated prostate cancer. It is this body of new information, combined with advances in imaging techniques and prostate cancer tumor markers, that prompted the need for an in-depth assessment of bone metastasis of prostate cancer. Accordingly, on December 12, 1990, a group of basic and clinical investigators from Japan and the United States convened in Gotenba, Japan, to hold the first conference devoted solely to the basic biology and clinical aspects of bone metastases originating from prostate cancer. The cross-fertilization of ideas that was fostered through in-depth discussion of technological advances among various basic and clinical disciplines not only further advanced our understanding of prostate metastases to the bone, but suggested approaches for precise quantitative assessment of these lesions and their treatment.

The publication of Platelet-Vessel Wall Interactions, the second monograph in the Bloomsbury Series in Clinical Science, is particu larly welcome as its appearance signifies the further development of the Series and its potential for the future. The theme of this monograph is the pathophysiology of atherosclerosis, a topic that symbolises the aim of the Series, namely to highlight the important interfaces between basic medical science and clinical practice. Our congratulations to the Editors and contributors. London, December 1987 lack Tinker Preface In the Western world, atherosclerosis causes more illness and death than any other disease. Despite its devastating effects, the pathogenesis of the disease remains a matter for hypothesis and con jecture. This monograph owes its conception to a programme of work directed towards understanding the basic pathophysiology of atherosclerosis. The circulatory system is lined by vascular endothelium which has a central role in maintaining the integrity of the vessel wall and prevent ing thrombosis. The natural equilibrium existing between normal en dothelium which supports blood flow, and platelets which serve to re pair damaged endothelium, is explored in the first two chapters. Atherosclerosis developing as a response to endothelial injury is one hypothesis which has stimulated widespread interest, and re search has largely been directed towards finding the injurious agent."

Written by a team of world-leading experts in the field, who have published extensively

For primary care physicians, haematologists, surgeons and other healthcare professionals with an interest in thromboprophylaxis

Discusses both medical and surgical thromboprophylaxis and includes all relevant guidelines for thromboprophylaxis in pregnancy

Thoroughly revised and updated new edition

This second edition of the Handbook of Thromboprophylaxis expands upon the role of anticoagulants in clinical practice. In addition, it summarises key papers in the field and provides evidence-based guidelines for the use of anticoagulants in routine day-to-day practice.

"

While the enzyme cascade that allows coagulation is well known physiologically, its elegant practical examples are vividly demonstrable in the clinical application of blood and components for the treatment of bleeding problems in surgery, trauma or in congenital deficiency in patients. This volume provides the fundamental and recent understanding relating to coagulation pathways, recombinant technology and other methods for coagulation factor production, up to date laboratory assay, preservation of cellular and plasma components, and their clinical use in surgery and medicine, including the immuno response to repeated challenge to contaminating protein in coagulation factor concentrates. The interrelated but multi-disciplinary chapters have been integrated in four sections: Principles and Fundamentals: Mechanism of thrombin formation; structure -- function relationship of coagulation proteins, role of calcium and anticoagulant: blood collection on haemostatic potential of plasma proteins and platelets; Factor VIII yields from anticoagulant exchanged plasma. Preservation Aspects: Platelet function preservation, platelet interaction with vessel wall; trends in the use of coagulation factor concentrate; immuno purification of Factor VIII; structural and fundamental properties of recombinant coagulation factors. Laboratory Aspects: Platelets counting and function testing; platelet crossmatch predictive value; clinical efficacy of platelet concentrate; protein C and protein S; principle of coagulation factor assay; standardisation of clotting factor assays; clinical efficacy of clotting factor concentrates. Clinical Consequences

Between 1950 and 1960, remarkable advances were made in the develQpment Qf antihypertensive drugs, but since then, prQgress has been less rapid. This dQes nQt mean that no. new drugs have been intrQduced: Qn the cQntrary, their number has increased sharply; but since the advent Qf the beta-adrenergic blQckers no. new pharmacQdynamic principle has been discQvered that CQuid be applied widely as an antihypertensive. This has nQt been fQr want Qf effQrts, because many attempts have been made to. find new ways and means Qf influencing blQQd- pressure regulatiQn Qr the mechanisms invQlved in the pathQgenesis Qf hypertensiQn. HQwever, the results Qf these endeavQrs have mQstly been disapPQinting. Even thQugh high blQQd pressure can be treated mQre satisfactQrily tQday than many Qther diseases, the success achieved in cQmbating Qne Qf man's mQst frequent ailments shQuld nQt induce cQmplacency, but rather stimulate research tQwards further imprQvements. The present standstill affQrds an QPPQrtunity to. review the field Qf antihy- pertensive agents, fQr it is unlikely that fundamentally new drugs will appear in the near future. AlthQugh greater knQwledge has been gained Qf the mechanisms Qf blQQd-pressure regulatiQn and Qf the pathQgenesis Qf hypertensiQn, these ad- vances have had no. direct cQnsequences in the search fQr new therapeutics.

J.J. Van Loghem Previously to this symposium, five others have taken place in Groningen. The first one in 1976. This yearly scientific happening has continued. It has greatly stimulated the in terest in blood transfusion and all allied disciplines in our country. It is clear that these meetings are organized not only by a good scientist, but at the same time by a gifted or ganizer who, as director of the Red Cross Blood Bank Gro ningen-Drenthe, has shown that the heavy load of daily routine work can very well be combined with a large amount of experimental and clinical research in blood component therapy, coagulation disorders, blood group genetics and serology, the latter in cooperation with the Blood Group laboratory of the University Hospital Groningen under the directorship of Dr. Van Dijk. All these activities show how much a well-organized blood bank can contribute to a national blood transfusion orga nization."

1 2 D. FITZGERALDI, I. PASTAN , and J. ROBERTUS Introduction . . . . . . . . . . . . . I 2 Toxin Structure-Function Properties 2 2. 1 Functions. . . . . . . . . . . . . . . . . . . . . . . . 2 2. 2 Binding. . . . . . . . . . . . . . . . . . . . . . . . . 3 3 Intracellular Processing - Cleavage and Reduction . . . . . . 4 3. 1 Cytosolic Activity . . . . . . . . . . . . . . . . 5 4 Immunotoxin Design and Testing. 6 5 Conclusion. . 8 References. . . . . 8 1 Introduction While various treatment approaches for cancer include reversal of the transformed phenotype, stimulation of immune responses, inhibition of metastatic spread and deprivation of key nutrients, the goal of immunotoxin treatment is the direct killing of malignant cells. Because they are enzymatic proteins that act catalytically to kill cells, bacterial and plant toxins are often employed as the cell-killing component of immunotoxins. Here we provide background information into the structure-func tion relationships of toxins and discuss how they can be combined with cell-binding antibodies or other ligands to generate immunotoxins. Bacterial and plant toxins (e. g. , diphtheria toxin, Pseudomonas exotoxin and ricin) are among the most toxic substances known. However, because they bind to cell surface receptors that are present on most normal cells, unmodified toxins are generally useless as anti-cancer agents. To convert toxins into more selective agents, their binding domains are either eliminated or disabled and replaceq with cell binding antibodies that are tumor-selective.

Due to the topology and structure of the lymph nodes, their role in the pathogenesis and development of diseases is a very special one. Each organ and even each organ-related region of the body has its own group of lymph nodes, specific topological reactions, such as in circumscribed inflammation or in the metastatic spread of malignant tumors. On the other hand, all the lymph nodes of an organism join in a uniform function effected by highly differentiated structures. Volume 84 of Current Topics in Pathology presents our current knowledge about the structure and reaction patterns of this "sec ondary" lymphoid organ. Despite our original intention to publish all the contributions in one book, it became necessary to divide them: Part 1 focuses on the involved nodal compartments, cell types, and functions, while Part 2 describes their reactions in inflammatory, neo plastic, and immune-deficient diseases. Even with the cooperation of more than 30 authors, the coverage cannot be exhaustive. The scope of both parts is limited to those reactions that can be described by direct and indirect morphological methods, including modern tech niques such as immune electron microscopy."

Contents: Introduction and Overview Lymphopoietic Growth Factors: Pathophysiology of T-Cell Mediated Shock Induced by Bacterial Superantigens - Natural Killer Cells and Interleukin-2-Activated Killer Cells - TumourImmunogenicity Induced by Exogenous Interleukins - Cytokine Gene Therapy of Cancer - Analysis of T-Cell Receptor Variability in Tumour Infiltrating Lymphocytes - Clinical Studies with Interleukin-2: An Overview - Clinical Trials with Local Administration of Lymphopoietic Growth Factors - Clinical Trials with Interlaukin-2. The Rome Experience. Haematopoietic Growth Factors: Lymphohaematopoietic Growth Factor Use in Lung Cancer Patients - Clinical Trials with Haematopoietic Growth Factors and Peripheral Blood Stem Cells

Since 1952, postgraduate courses for practising physicians and speci alists have been given by the Medical Faculty of the University of Leiden in the Boerhaave Quarter, in which most of its clinics and laboratories are located. During these years, recent advances in a wide variety of m dical fields and subjects have been discussed by distin guished speakers from many countries. The steadily increasing atten dance has shown that, as could be expected from the rapid progress of modern medicine, there is a widely felt need for this form of postgra duate study. In 1957, therefore, the Leiden Medical Faculty appointed a permanent committee for the organization of postgraduate medical education. Of the courses given since then, certain material proved to have sufficient immediate scientific value to justify publication, and it now gives the Committee great pleasure to announce that in collaboration with the Leiden University Press it will publish the Boerhaave Series for Postgraduate Medical Education. The first volume of this new series is the product of the course on Human Blood Coagulation given in Novem ber 1968. It is our hope that this book will prove valuable not only to those who participated in the course but also to many others working in this and associated fields."

Much of the attention presently paid to leukemia is the result of recent progress in understanding and treatment. Chemotherapy of leukemia started in the late 1940s, and combination therapy evolved in the late 1950s. It was at that time that the clonality of leukemia was realized, after the discovery of chromosomal and then biochemical and immunological markers. And now we have the new data on retroviral and cellular oncogenes and the reports on human T -cell lymphoma/ leukemia viruses. Many more steps forward could be enumerated in a field which is so rapidly making the hematological textbooks outdated. In this volume, thirteen in-depth reviews from large multicenter trials in the Federal Republic of Germany summarize the current state of diagnosis and management of leukemias. Childhood ALL and AML adult ALL and AUL were investigated. While cure appears to be achievable for more and more patients with acute leukemia, we still pursue the aim of optimal palliation in chronic leukemias. The management of patients with leukemia therefore varies to a large extent in aggressiveness of therapy. In some situations, rescue from an otherwise lethal disease is provided by bone marrow transplanta tion, which is discussed in two chapters."

The European School of Oncology came into existence to respond to a need for informa tion, education and training in the field of the diagnosis and treatment of cancer. There are two main reasons why such an initiative was considered necessary. Firstly, the teaching of oncology requires a rigorously multidisciplinary approach which is difficult for the Universi ties to put into practice since their system is mainly disciplinary orientated. Secondly, the rate of technological development that impinges on the diagnosis and treatment of cancer has been so rapid that it is not an easy task for medical faculties to adapt their curricula flexibly. With its residential courses for organ pathologies and the seminars on new techniques (laser, monoclonal antibodies, imaging techniques etc.) or on the principal therapeutic controversies (conservative or mutilating surgery, primary or adjuvant chemotherapy, radiotherapy alone or integrated), it is the ambition of the European School of Oncology to fill a cultural and scientific gap and, thereby, create a bridge between the University and Industry and between these two and daily medical practice.

One of the most fascinating tools at the disposal of the molecular biologist is the medical clinic. The responsibilities of those who provide health care do not stop when they give optimal care to the individual patient and train their successors adequately. They also are under the obligation to obtain maximal information from every case they treat in order to reach a better understanding of the underlying illness in order to improve therapeutic results in the next patient. Fundamental research in pathological material is therefore a medical must as well as an opportunity for scientific work. The scientist working in this field can profit from nature's unasked for experiments, which are encountered by his medical colleagues in their clinical material. There are many examples of subjects of study - for instance hemoglobins and immunoglobulins - which started in a medical context and gradually developed into a field of prime interest for the molecular biologist. The study of blood coagulation is one of the younger areas of this kind.

This book has been written from two points of view: firstly, from the viewpoint of those who are involved in the diagnosis and treatment of lymphoid malignancies, who must meet the challenge of integrating the new biological insights into their knowledge of these diseases; and secondly, from the viewpoint of those who are involved in basic biological approaches to malignancy and immunology, who wish to know more about the function of the lymphoid tissues and their malignant diseases. Neoplasia of lymphocytes is a focus for considering many of the most important biological advances impinging on cancer in the past two or three decades, because malignant lymphoproliferative diseases offer unequalled opportunities for studying many aspects of cancer. We probably know more about lymphocytes than other normal cells because of the ease with which they can be obtained. For the same reason we probably know more about malignant lymphocytes. One or other aspect of most of the momentous advances in biology of the past two or three decades has implications for lymphoid malignancies: hybridoma technology and the use of monoclonal antibodies, gene technology, the understanding of oncogenes and growth factors in the control of growth and differentiation, insights into causation of cancer by potent tumour promoters such as the phorbol esters and by viruses, and knowledge of the control of growth function of lymphocytes themselves. Conversely, many of the advances in understanding lym phocytic leukaemias and lymphomas have implications for other cancers."

I am honored to be invited to prepare a foreword for the proceedings of the Second International Lubeck Conference on Erythropoietin (Epo). I congratulate Wolfgang Jelkmann, Horst Pagel and Christoph Weiss for their organization of an excellent program for this conference which updated all of us on the advances made in erythropoietin research during the past few years since the first conference in June of 1988. I am sure that Professor Paul Carnot, had he been present at this conference, would be very pleased and proud of the advances made in the field of erythropoietin since his and Madame DeFlandre's seminal finding in 1906 (1) that rabbits produced a humoral substance following bleeding which controls red blood cell production. The reports by Hjort in 1936 (2) and by Erslev in 1953 (3) that large volumes of plasma or serum from rabbits following a bleeding stimulus, when injected into normal donor rabbits, produced a reticulocytosis, were very significant in confirming the existence of a humoral factor which controls erythropoiesis. Reissmann's parabiotic rat experiments in 1950 (4) reawakened interest in erythropoietin when he proved that hypoxia stimulated the production of a factor which regulates red cell produc tion. The studies of several investigators such as Jacobson et al. (5), Fisher and Birdwell (6), Kuratowska et al. (7) and Nathan et al."

Knowledge of mechanisms involved in the pathogenesis of occlusive arterial dis eases is fundamental for the design of prevention and treatment. A series of studies based on in vitro investigations, the experimental animal and the human being have slowly increased our understanding of cardiovascular diseases and unveiled their secrets to us. Over the last 60 years it has been generally assumed that dietary fats and lipids and the occurrence of atherosclerosis are closely related. Yet, even if epidemiological studies clearly indicate the existence of an association between the amount of composition of dietary lipids and morbidity and mortality of cardio vascular disease, our basic knowledge on cause and effect is still hidden in a cloud of uncertainty. The present book discusses the relation between dietary lipids and arterial throm bosis, which latter process has been observed in the coronary arteries in up to 90% of subjects with acute myocardial infaction. In this volume Dr. Hornstra, who has occupied himself with thrombosis research with never-failing enthusiasm, great skill and critical approach for the last fifteen years, tries to establish possible links between lipid metabolism and thrombosis. His literature studies are comprehensive and his investigations are impressive in that they give a new dimension and a new methodology to research of lipids and thrombosis."

xi List of first authors xiii Acknowledgements xv INTRODUCTICN Approaches to radiolabelling blood d-c cells: past, present and future M. L. Thakur 3 CELL LABELLllJG TEDlNIQUES 2 Labelling techniques of granulocytes and platelets 17 with 111 In-oxinate M. R. Hardeman, E. G. J. Eitjes-van Overbeek, A. J. M. van Velzen, M. H. Rovekarnp 111rndium-labelling of human washed platelets; kinetics 3 29 and in vivo sequestration sites M. Eber, J. P. Cazenave, J. C. Grob, J. Abecassis, G. !o1ethlin 111Indium loss from platelets by in vitro and ex 4 44 vivo manipulation R. J. Hawker, C. E. Hall, H. C-oldman, C. N. McCollum PIATELEl'S: KrnETIC STUDIES 5 The maturation of megakaryocytes and their precursors 65 J. H. Paulus 6 !o1egakaryocytic precursors 74 J. Breton-Gorius, W. Vainchenker 7 !-1ethods of quantification of platelet production 86 in man. A critical analysis Y. Najean vi 8 Platelet production rate deteDmination with (75se)_ seleno-m:thionine R. Cardinaud, E. Dassin 96 9 Platelet kinetics: the state of the art A. duP Heyns 110 10 Platelet kinetics A. M. Peters 130 Evaluation of models to deteDmine platelet life 11 span and survival curve shape M. G. LOtter, C. P. Herbst, P. N. Badenhorst, A. duP Heyns, P. Wessels, P. C. Minnaar 139 12 Canparison of three m:thods evaluating platelet survival tim: in patients with prosthetic heart valve J. Schbath, D. Ville, B. Hathy, B. Sanchini, E. Benveniste, J. Belleville, M. Dechavanne, J. P. Boissel, J.