1254 and
v) fell by about 30%, and this is significant both statistically, and, probably, in practice. Ampicillin is one of the most widely prescribed antibiotics both in hospital and general practice. The drug was not used in this hospital for the prophylaxis of wound sepsis in either 1971
Letters to the Editor SURVIVAL IN ACUTE MYELOID LEUKÆMIA
1974, and the decline in sensitive strains is attribu-
or
increasing therapeutic use of this antibiotic. Our policy of administering a single, intra-incisional dose of cephaloridine for the prophylaxis of wound .sepsis has not encouraged the emergence of either resistant strains of previously sensitive bacteria or of inherently resistant bacteria. On the other hand, the widespread therapeutic use of ampicillin both in hospital and general practice has resulted in a higher proportion of ampicillin-resistant strains in 1974 than in 1971. Should the cephalosporins become as widely prescribed in the future as ampicillin is now, a similar pattern could well table
to
the
emerge for them. We thank Dr K. Froome and his staff in the
Department of Patho-
logy. The following have given generously of their advice: Dr E. J. L. Lowbury (Birmingham), Dr J. D. Anderson (York), Dr C. H. Dash and Dr R. B. Sykes (Glaxo Laboratories), and Mr J. A. Lewis (LC.L, Pharmaceuticals Division). Requests for reprints should be addressed to A. V. P.
SIR,-In their
paper Dr
Burge and his colleagues (Oct. 4,
p. 621) were critical of the intensive treatment of acute myelogenous leukaemia (A.M.L.). They now seem (Nov. 29, p. 1091)
have modified their views in a rather confusing manner. They remain critical of the M.R.C. leukaemia regimens, and state that, because there is no "cure" for A.M.L., special-centre treatment is "inhuman". However, they end their letter by stating that "Undoubtedly centres are needed which aim to improve the treatment of acute myeloid leukaemia" and this must leave the reader wondering just what they do mean. So far two major points have been emphasised—namely, that trials from major centres have advanced knowledge of the disease and that secondly the contention that the quality of life suffers during aggressive treatment is an oversimplification. A detailed comparative analysis of the paper by Dr Burge and his colleagues is needed to place their results in perspective. to
Adults with A.M.L. had a median survival of 2 months in the 1940s.4 The advent of chemotherapeutic agents and better supportive care have resulted in increased frequency of remission and length of survival. In many studies, but not all (table I), the link between remission and survival has been estabTABLE I-EFFECTS OF CHEMOTHERAPY IN A.M.L.
REFERENCES
1. 2. 3. 4. 5.
Evans, C., Pollock, A. V. Br. J. Surg. 1973, 60, 434. Pollock, A. V., Rosenberg, I. L. Br. med. J. 1974, ii, 558. Evans, C., Pollock, A. V., Rosenberg, I. L. Br. J. Surg. 1974, 61, 133. Pollock, A. V., Evans, M. ibid. 1975, 62, 292. Pollock, A. V., Evans, M. J. antimicrob. Chemother. 1975, suppl. 1, p. 71. 6. Lowbury, E. J. L., Ayliffe, G. A. J. Drug Resistance in Antimicrobial Therapy. Springfield, Illinois, 1974. 7. Alder, V. G., Gillespie, W. A. Lancet, 1967, ii, 1062. 8. Richmond, M. H., Sykes, R. B. Adv. microb. Physiol. 1973, 9, 31. 9. Lacey, R. W. J. antimicrob. Chemother. 1975, 1, 25.
’Median survival of those
achievmg complete remission was 104 weeks.
Ara C = cytarabine
Christmas Quiz
lished; therefore ANYONE READ THE LANCET? How well have you read The Lancet in the past 1. 2. 3. 4.
year? Copenhagen?
What drew the men to market in Where lies the wamie? Who wrote an unexpected French best-seller? What medical classic survived three fires, to become
an
octogenarian? 5. What is keh shih ping? 6. Howard, David, Renato-what’s the connection? 7. Lock last July, who next? 8. Erasmus and Paracelsus are well-known Baslers-who’s the fictional third? 9. Plunge the face in cold water-to treat what? 10. Who sniffed at the Thames and stole away? 11. What was New, died, yet ended much alive and Free? 12. They set out from Tokyo but never made Paris-what went
to induce complete remission, a state defined of clinical and haematological normality, is not merely a laboratory achievement, but crucial to the patient’s life prospects. The inference that one continues with aggressive treatment until the patient is either dead or in complete remission is nonsense. Table t clearly documents the increased survival due to chemotherapy, and the results should be related to the median survival (untreated) of 2 months reported by Tivey.4 Aggressive treatment of A.M.L. acknowledges the risk of marrow aplasia. Improvements in supportive care have reduced the numbers of patients who die. However, there are still patients who are either unresponsive to treatment, or who experience profound aplasia, and who die early during the induction phase. Dr Burge and his colleagues proposed an approach which, they suggest, is better in terms of quality of life and which provides an alternative philosophy for the treatment of A.M.L. It is important to examine their treatment programme in some detail.
in
wrong?
13. Forget the Curies, but remember whom? 14. What got the tadpoles swimming again? 15. When Christmas and Eastbourne met in Canada what was the result? A prize, a copy of the book Words (based on a B.B.C. Radio 3 series), will be awarded for the three most nearly correct solutions. Incomplete entries are eligible. Entries, which should be marked Christmas Competition and sent to the London office of The Lancet, will be held unopened until Monday, Feb. 2, to allow overseas readers to enter.
terms
Initial Treatment Protocol
They gave 6-mercaptopurine (6-M.P.) 150 mg daily together 1. Clink, H.MacD., Douglas, I. D. C. Lancet, 1975, ii, 988. 2. Baccarini, M. ibid p. 989. 3. Jacobs, P., Dubovsky, D, ibid. p. 1041. 4. Tivey, H. Ann. N.Y. Acad. Sci. 1954, 60, 322. 5. M.R.C. Leukæmia in Adults Working Party First Report. Br.
med. J. 1963, i, 7. 6. Gee, T. S., Yu, K. P., Clarkson, B. D. Cancer, 1969, 23, 1019. 7. Crowther, D., and others, Br. med. J. 1973, i, 131. 8. Gluckman, E., Basch, A., Varet, B., Dreyfus, B. Cancer, 1973, 31, 487. 9. Clarkson, B. D., Dowling, M. D., Gee, T. S., Cunningham, I. B., Burchenal, J. H. ibid. 1975, 36, suppl. p. 775.
1255 TABLE II—COMPARISON OF U.C.H. STUDY WITH BARTS TRIAL V
Intensive treatment of the younger patients in a major centre is the treatment of choice. It is in such centres that advances will be made. S. A. N.
Departments of Hæmatology and Medical Oncology, St Bartholomew’s Hospital, London EC1A 7BE.
JOHNSON
M. E. J. BEARD T. A. LISTER P. F. M. WRIGLEY J. M. A. WHITEHOUSE
HLA-D ON SPERM IS HAPLOID, ENABLING USE OF SPERM FOR HLA-D TYPING
SiR,—The HLA specificities of the HLA-A and HLA-B loci
characteristically expressed on the head and circumference of human spermatozoa in a haploid manner. 1-3 We have found that the HLA-D determinants which stimulate mixed-lymphocyte reactions and which are an integral part of the HLA haplotype are also expressed on spermatozoa in haploid form. This finding has enabled us to use spermatozoa as typing cells for the HLA-D determinants. HLA-D determinants are currently identified by mixed lymphocyte culture (M.L.C.) testing of people with irradiated or mitomycin-C-treated HLA-D homozygous lymphocytes-usually obtained from the children of first cousins. These cells are rare, since there is only 1/16 probability of HLA-D homozygosity among children of first-cousin marriages, and even when we do find them their HLA-D determinants are often of very low frequency in the population, and so far only 60% of the total gene frequency has been accounted for.4 Levis et al. reported that human spermatozoa stimulated lymphocytes in culture.’ We have confirmed this finding and modified the method as follows to type for HLA-D determinants. The sperm were prepared by first washing in tissueculture medium 199 (TC 199 Wellcome) divided into two parts, one being treated with one kind of anti HLA-B antiserum and the other with another anti-HLA-B antiserum corresponding to the two identified HLA-B antigens of the donor. There were two stages-both at room temperature. The sperm were incubated first with antiserum, for 30 min, centrifuged to remove supernatant, and then resuspended in rabbit complement (final dilution 1/10 in TC 199) for the second incubation, also for 30 min. Dead sperm were removed by passing the suspensions through a nylon wool column in 2 ml syringes. The live sperm were concentrated and prepared for culture at 106/ml in TC 199 containing 10% heat-inactivated human AB serum. 50 1 suspensions of sperm were mixed with 50 p.1 suspensions of lymphocytes, in Linbro tissue-culture plates in quadruplicate; controls with sperm and lymphocytes alone were also set up, including autologous sperm/lymphocyte cultures (s.L.c.s). After 6 days in culture 14C-thymidine was added for 16 h, and the cells were harvested in a semiautomatic machine and counted in a liquid scintillation counter. In the experiment shown in the table seven individuals who had at least one known HLA-D determinant were tested in S.L.C. with the sperm of one of them (A). Lymphocytes from individuals who were DW1failed to respond to sperm treated with anti-BW40-i.e., the c.p.m. was not significantly above the background (A’s lymphocytes plus A’s sperm}-and only DW3 lymphocytes were not activated by sperm treated with anti-BW22 and the sperm and lymphocytes alone incorporated a negligible amount of 14C-thymidine. Similar results were obtained in an experiment with F’s sperm stimulating. These experiments provide further evidence for the haploid expression of HLA antigens on spermatozoa and a new way of typing for HLA-D determinants. This method is much are
*Half of these patients
were
infected before
treatment.
with allopurinol, a drug which may increase considerably the effective dose of 6-M.p. If blast cells were present in the blood one week later, daunorubicin, sometimes followed by cytarabine, was given. Three patients under 60 were given 6-M.p. only, so 90% of patients in this age-group received daunorubicin and cytarabine.
Supportive Care Prednisolone 40 mg daily and platelet transfusion were given for purpura or bleeding, respectively. "Reverse barrier" nursing, prophylactic antibiotics when neutropenia was present, and granulocyte transfusions were all used. These precautions were obviously considered necessary despite the "gentleness" of the treatment. Although the above anti-infective procedures may be worth while, their value has not been
proved. C.N.S. Prophylaxis Although indicated in childhood A.M.L. the value of this procedure, even in young adults with A.M.L., is dubious. Maintenance Treatment 6-M.P. twice weekly, prednisolone to stimulate the marrow, and one of the following--cytarabine, vincristine, methotrexate, daunorubicin-every 3 weeks were used. This is intensive therapy by any standards. No immunotherapy was given despite its proven value. 10 " The survival of the U.C.H. patients should be compared with that of other studies (table i) or with a recent trial at St Bartholomew’s Hospital (Barts trial v, table
II). With these considerations in mind, conclusions:
(1) ment
we
draw the
following
The chemotherapy used is often similar to "aggressive" treatschedules. To give it less frequently gives no guarantee that mar-
suppression will not occur. (2) Supportive care required
row
is similar
to
aggressive
treatment
schedules.
(3) Complications of the sort considered to lower the "quality of are fairly frequent. (4) Time spent in hospital is shorter during remission induction but longer during maintenance treatment. (5) Early deaths are fewer, but survivals are shorter. life"
The virtues of the U.C.H. scheme may be most obvious for who are known to tolerate intensive chemoFor younger patients intensive chemotherapy offers the best chance of complete remission and return to normal life. Whenever cytotoxic drugs are used considerable supportive care is essential, as the U.C.H. team have demonstrated. What they have failed to do in this uncontrolled study is advance or improve treatment of A.M.L. The choice of management of A.M.L. lies with the referring physician; conservative management of the elderly group of patients will often produce acceptable results in terms of comfort and survival.
elderly patients therapy poorly.
10. 11.
Powles, R. L., and others, Br. J. Cancer, 1973, 28,
365.
Gutterman, J. U., and others. Lancet, 1974, ii, 1405.
1. 2. 3. 4.
Fellous, M., Dausset, U. Nature, 1970, 225, 191. Halim, A., Abbasi, K., Festenstein, H. Tissue Antigens, 1974, 4, 1. Halim, A. PH.D thesis, University of London, 1975. Joint Report in Proceedings of the Sixth International Histocompatibility Workshop Conference. Copenhagen (in the press). 5. Levis, W. R., Whalen, J. J., Sherins, R. J. Lancet, 1974, ii, 954.
v) fell by about 30%, and this is significant both statistically, and, probably, in practice. Ampicillin is one of the most widely prescribed antibiotics both in hospital and general practice. The drug was not used in this hospital for the prophylaxis of wound sepsis in either 1971
Letters to the Editor SURVIVAL IN ACUTE MYELOID LEUKÆMIA
1974, and the decline in sensitive strains is attribu-
or
increasing therapeutic use of this antibiotic. Our policy of administering a single, intra-incisional dose of cephaloridine for the prophylaxis of wound .sepsis has not encouraged the emergence of either resistant strains of previously sensitive bacteria or of inherently resistant bacteria. On the other hand, the widespread therapeutic use of ampicillin both in hospital and general practice has resulted in a higher proportion of ampicillin-resistant strains in 1974 than in 1971. Should the cephalosporins become as widely prescribed in the future as ampicillin is now, a similar pattern could well table
to
the
emerge for them. We thank Dr K. Froome and his staff in the
Department of Patho-
logy. The following have given generously of their advice: Dr E. J. L. Lowbury (Birmingham), Dr J. D. Anderson (York), Dr C. H. Dash and Dr R. B. Sykes (Glaxo Laboratories), and Mr J. A. Lewis (LC.L, Pharmaceuticals Division). Requests for reprints should be addressed to A. V. P.
SIR,-In their
paper Dr
Burge and his colleagues (Oct. 4,
p. 621) were critical of the intensive treatment of acute myelogenous leukaemia (A.M.L.). They now seem (Nov. 29, p. 1091)
have modified their views in a rather confusing manner. They remain critical of the M.R.C. leukaemia regimens, and state that, because there is no "cure" for A.M.L., special-centre treatment is "inhuman". However, they end their letter by stating that "Undoubtedly centres are needed which aim to improve the treatment of acute myeloid leukaemia" and this must leave the reader wondering just what they do mean. So far two major points have been emphasised—namely, that trials from major centres have advanced knowledge of the disease and that secondly the contention that the quality of life suffers during aggressive treatment is an oversimplification. A detailed comparative analysis of the paper by Dr Burge and his colleagues is needed to place their results in perspective. to
Adults with A.M.L. had a median survival of 2 months in the 1940s.4 The advent of chemotherapeutic agents and better supportive care have resulted in increased frequency of remission and length of survival. In many studies, but not all (table I), the link between remission and survival has been estabTABLE I-EFFECTS OF CHEMOTHERAPY IN A.M.L.
REFERENCES
1. 2. 3. 4. 5.
Evans, C., Pollock, A. V. Br. J. Surg. 1973, 60, 434. Pollock, A. V., Rosenberg, I. L. Br. med. J. 1974, ii, 558. Evans, C., Pollock, A. V., Rosenberg, I. L. Br. J. Surg. 1974, 61, 133. Pollock, A. V., Evans, M. ibid. 1975, 62, 292. Pollock, A. V., Evans, M. J. antimicrob. Chemother. 1975, suppl. 1, p. 71. 6. Lowbury, E. J. L., Ayliffe, G. A. J. Drug Resistance in Antimicrobial Therapy. Springfield, Illinois, 1974. 7. Alder, V. G., Gillespie, W. A. Lancet, 1967, ii, 1062. 8. Richmond, M. H., Sykes, R. B. Adv. microb. Physiol. 1973, 9, 31. 9. Lacey, R. W. J. antimicrob. Chemother. 1975, 1, 25.
’Median survival of those
achievmg complete remission was 104 weeks.
Ara C = cytarabine
Christmas Quiz
lished; therefore ANYONE READ THE LANCET? How well have you read The Lancet in the past 1. 2. 3. 4.
year? Copenhagen?
What drew the men to market in Where lies the wamie? Who wrote an unexpected French best-seller? What medical classic survived three fires, to become
an
octogenarian? 5. What is keh shih ping? 6. Howard, David, Renato-what’s the connection? 7. Lock last July, who next? 8. Erasmus and Paracelsus are well-known Baslers-who’s the fictional third? 9. Plunge the face in cold water-to treat what? 10. Who sniffed at the Thames and stole away? 11. What was New, died, yet ended much alive and Free? 12. They set out from Tokyo but never made Paris-what went
to induce complete remission, a state defined of clinical and haematological normality, is not merely a laboratory achievement, but crucial to the patient’s life prospects. The inference that one continues with aggressive treatment until the patient is either dead or in complete remission is nonsense. Table t clearly documents the increased survival due to chemotherapy, and the results should be related to the median survival (untreated) of 2 months reported by Tivey.4 Aggressive treatment of A.M.L. acknowledges the risk of marrow aplasia. Improvements in supportive care have reduced the numbers of patients who die. However, there are still patients who are either unresponsive to treatment, or who experience profound aplasia, and who die early during the induction phase. Dr Burge and his colleagues proposed an approach which, they suggest, is better in terms of quality of life and which provides an alternative philosophy for the treatment of A.M.L. It is important to examine their treatment programme in some detail.
in
wrong?
13. Forget the Curies, but remember whom? 14. What got the tadpoles swimming again? 15. When Christmas and Eastbourne met in Canada what was the result? A prize, a copy of the book Words (based on a B.B.C. Radio 3 series), will be awarded for the three most nearly correct solutions. Incomplete entries are eligible. Entries, which should be marked Christmas Competition and sent to the London office of The Lancet, will be held unopened until Monday, Feb. 2, to allow overseas readers to enter.
terms
Initial Treatment Protocol
They gave 6-mercaptopurine (6-M.P.) 150 mg daily together 1. Clink, H.MacD., Douglas, I. D. C. Lancet, 1975, ii, 988. 2. Baccarini, M. ibid p. 989. 3. Jacobs, P., Dubovsky, D, ibid. p. 1041. 4. Tivey, H. Ann. N.Y. Acad. Sci. 1954, 60, 322. 5. M.R.C. Leukæmia in Adults Working Party First Report. Br.
med. J. 1963, i, 7. 6. Gee, T. S., Yu, K. P., Clarkson, B. D. Cancer, 1969, 23, 1019. 7. Crowther, D., and others, Br. med. J. 1973, i, 131. 8. Gluckman, E., Basch, A., Varet, B., Dreyfus, B. Cancer, 1973, 31, 487. 9. Clarkson, B. D., Dowling, M. D., Gee, T. S., Cunningham, I. B., Burchenal, J. H. ibid. 1975, 36, suppl. p. 775.
1255 TABLE II—COMPARISON OF U.C.H. STUDY WITH BARTS TRIAL V
Intensive treatment of the younger patients in a major centre is the treatment of choice. It is in such centres that advances will be made. S. A. N.
Departments of Hæmatology and Medical Oncology, St Bartholomew’s Hospital, London EC1A 7BE.
JOHNSON
M. E. J. BEARD T. A. LISTER P. F. M. WRIGLEY J. M. A. WHITEHOUSE
HLA-D ON SPERM IS HAPLOID, ENABLING USE OF SPERM FOR HLA-D TYPING
SiR,—The HLA specificities of the HLA-A and HLA-B loci
characteristically expressed on the head and circumference of human spermatozoa in a haploid manner. 1-3 We have found that the HLA-D determinants which stimulate mixed-lymphocyte reactions and which are an integral part of the HLA haplotype are also expressed on spermatozoa in haploid form. This finding has enabled us to use spermatozoa as typing cells for the HLA-D determinants. HLA-D determinants are currently identified by mixed lymphocyte culture (M.L.C.) testing of people with irradiated or mitomycin-C-treated HLA-D homozygous lymphocytes-usually obtained from the children of first cousins. These cells are rare, since there is only 1/16 probability of HLA-D homozygosity among children of first-cousin marriages, and even when we do find them their HLA-D determinants are often of very low frequency in the population, and so far only 60% of the total gene frequency has been accounted for.4 Levis et al. reported that human spermatozoa stimulated lymphocytes in culture.’ We have confirmed this finding and modified the method as follows to type for HLA-D determinants. The sperm were prepared by first washing in tissueculture medium 199 (TC 199 Wellcome) divided into two parts, one being treated with one kind of anti HLA-B antiserum and the other with another anti-HLA-B antiserum corresponding to the two identified HLA-B antigens of the donor. There were two stages-both at room temperature. The sperm were incubated first with antiserum, for 30 min, centrifuged to remove supernatant, and then resuspended in rabbit complement (final dilution 1/10 in TC 199) for the second incubation, also for 30 min. Dead sperm were removed by passing the suspensions through a nylon wool column in 2 ml syringes. The live sperm were concentrated and prepared for culture at 106/ml in TC 199 containing 10% heat-inactivated human AB serum. 50 1 suspensions of sperm were mixed with 50 p.1 suspensions of lymphocytes, in Linbro tissue-culture plates in quadruplicate; controls with sperm and lymphocytes alone were also set up, including autologous sperm/lymphocyte cultures (s.L.c.s). After 6 days in culture 14C-thymidine was added for 16 h, and the cells were harvested in a semiautomatic machine and counted in a liquid scintillation counter. In the experiment shown in the table seven individuals who had at least one known HLA-D determinant were tested in S.L.C. with the sperm of one of them (A). Lymphocytes from individuals who were DW1failed to respond to sperm treated with anti-BW40-i.e., the c.p.m. was not significantly above the background (A’s lymphocytes plus A’s sperm}-and only DW3 lymphocytes were not activated by sperm treated with anti-BW22 and the sperm and lymphocytes alone incorporated a negligible amount of 14C-thymidine. Similar results were obtained in an experiment with F’s sperm stimulating. These experiments provide further evidence for the haploid expression of HLA antigens on spermatozoa and a new way of typing for HLA-D determinants. This method is much are
*Half of these patients
were
infected before
treatment.
with allopurinol, a drug which may increase considerably the effective dose of 6-M.p. If blast cells were present in the blood one week later, daunorubicin, sometimes followed by cytarabine, was given. Three patients under 60 were given 6-M.p. only, so 90% of patients in this age-group received daunorubicin and cytarabine.
Supportive Care Prednisolone 40 mg daily and platelet transfusion were given for purpura or bleeding, respectively. "Reverse barrier" nursing, prophylactic antibiotics when neutropenia was present, and granulocyte transfusions were all used. These precautions were obviously considered necessary despite the "gentleness" of the treatment. Although the above anti-infective procedures may be worth while, their value has not been
proved. C.N.S. Prophylaxis Although indicated in childhood A.M.L. the value of this procedure, even in young adults with A.M.L., is dubious. Maintenance Treatment 6-M.P. twice weekly, prednisolone to stimulate the marrow, and one of the following--cytarabine, vincristine, methotrexate, daunorubicin-every 3 weeks were used. This is intensive therapy by any standards. No immunotherapy was given despite its proven value. 10 " The survival of the U.C.H. patients should be compared with that of other studies (table i) or with a recent trial at St Bartholomew’s Hospital (Barts trial v, table
II). With these considerations in mind, conclusions:
(1) ment
we
draw the
following
The chemotherapy used is often similar to "aggressive" treatschedules. To give it less frequently gives no guarantee that mar-
suppression will not occur. (2) Supportive care required
row
is similar
to
aggressive
treatment
schedules.
(3) Complications of the sort considered to lower the "quality of are fairly frequent. (4) Time spent in hospital is shorter during remission induction but longer during maintenance treatment. (5) Early deaths are fewer, but survivals are shorter. life"
The virtues of the U.C.H. scheme may be most obvious for who are known to tolerate intensive chemoFor younger patients intensive chemotherapy offers the best chance of complete remission and return to normal life. Whenever cytotoxic drugs are used considerable supportive care is essential, as the U.C.H. team have demonstrated. What they have failed to do in this uncontrolled study is advance or improve treatment of A.M.L. The choice of management of A.M.L. lies with the referring physician; conservative management of the elderly group of patients will often produce acceptable results in terms of comfort and survival.
elderly patients therapy poorly.
10. 11.
Powles, R. L., and others, Br. J. Cancer, 1973, 28,
365.
Gutterman, J. U., and others. Lancet, 1974, ii, 1405.
1. 2. 3. 4.
Fellous, M., Dausset, U. Nature, 1970, 225, 191. Halim, A., Abbasi, K., Festenstein, H. Tissue Antigens, 1974, 4, 1. Halim, A. PH.D thesis, University of London, 1975. Joint Report in Proceedings of the Sixth International Histocompatibility Workshop Conference. Copenhagen (in the press). 5. Levis, W. R., Whalen, J. J., Sherins, R. J. Lancet, 1974, ii, 954.
