The Therapeutic Effects of Total Body Irradiation Followed by Infusion of Autologous Marrow in Humans. (Draft 2)

Page 1

Chai man, Comnl t t t e on ..ascar&, Clncl nnat 1 General Hospl tal PROTOCOL: The Therapeutic Effect of fob1 Body Irradiation F oll ~ dby Infusion of Autologous ChrrPw I n Hunanr 1. To investigate the use o f whole and partial body Irradiation i n the palliation and prophylaxis of certain f om of cancer as compated t o other nethods of tre a tmnt or t o no tre a tmnt. 2. To develop biological Indicators t o determine effects of radiation so as to predict consequences of high dose and dose rate and large volume therapy. To develop and evaluate therapeutic methods t o increase marvns o f safety from the radiation effects. Hast form of widespread mta st a tlc cancer i n man are not amenable to conventional chemtherapy with a few notable exceptions such as carcinoma I ofthe breast and.prostate. Curative radiotherapy requires Qses of radiation * generally i n excess o f 3500 rads, and such large amaunts of irradiation cannot ; adiL i yay sr nd. Table 1 sumarlzcr the nunber of patients and type5 o f irrad-

Page 2

dose of rad la tion required to kill 63% ofa msmnallan cell populrtlon) lles between 100-180 rads for all cell types studjed (6).Thus, even though lam masses of tumor i n vivo my not always be conparable t o these I n vltm doseresponse assays, saw proportlon o f tunor cells it radiated should always be killed. This i n turn should frequently relieve synptoms secondary t o tunor pressure within or on an organ and, by lowering the number of tunor cells present, possibly prolong life. an effect on prolonging life(7).4 iResults of these studies will be analyzed by means o f the lffe table 8 technique, i.e. percent surviving each year of those at risk for that year as compared'to the survival figures of several papers which have examined the natural history of various carcinomas with liver o r osseous metastb\es (8-9) and data from the Tunor Registry atthe Clncinnati General Hospival. To further evaluate the efficacy of lw dose-wide field radiotherapy. a protocol i s under consideration randomizing patients with adenoLarc1rraa , o f the colon metastatic to the liver into groups receiving 5-fluomuracil 15 mg. per kg. (10) o r 300 rads cobalt gamna-irradlation toa wide field from xiphbid to feet. by T.L. Wright, M.D. and appended to this protocol. We are cooperating wlth Quality of survival will be measured by crit er j a revised Frank Hendrickson o f Presbyterfan-St. Luke's Hospital, Chicago, and William Rider, M.D. o f Princess Margaret Hospital, Toronto i n sharing data on survival7 o f whole body irradiated children with Ening's tunor. The 3children w hm we * for patients receiving rad la tion doses I n excess o f - 3 cyto peni a. Provision o f " sterile " en vi rome nts(11.12).platelet(13) and

Page 3

,- leukocyte (14)transfusions, and radioprotective chemlcrls (15) hrve beet enployed by others; we are using marrow ru to trans pl & nt atl on to avoid thes T h e patient has marrow removed fmm 0800 to 1000 hours i n the opera mom, i s irradiated a t about 1300-1400 hours and receives his Mrmw (sto ' a t 4" C.) intravenously from 1430 t o 1600 hours, dose calculation can be found elsewhere (16). The mthod of radiation: 1 lavender top Vacutainer tube, labeled with patient ' s name and number, 1 red toy Vacutainer tube, labeled with pat lent ' s nam and nunber for the . blood bank, plus a blood bank form 200 cc. heparin solution cor,taining 50 units heparin per cc..-f This is made by putting one cc. o f preservative-free heparin, 10,000 units per cc., i n 199 cc. ofnom1saline. An extra vial of this heparin i s brought tothe operating room. TC-199 culture medim, 100 CC. buffered with sodium bic a hon ate to oH 1 7.3 - 7.4 dnd ddd ed to a fermal pack. 150 12 cc.sterile syriil.,r; t: 30 obtained by the operating room. I Sipdmotor pump with tubing attach m nts.

Page 4

Sterilized doubie filter system with two mesh filter openings of 297, and 149 micra diameter respectively. o 2 Fenwal Blood Pack Units No. TA-10, 1000 cc. 1 thioglycolate culture tube 1 box sterile microscope slides I + Abbott Venopak adapter Normal saline for injection, 1- 30 CC. vial + 3 Abbott blood administration sets with filter opening measuring 150 by 2 50 cc. syringes with 18 gauge needles I 2 10 cc. syringes with 18 gauge needles Formalin tube for Pathology Department study o f marrow aspirate. ? Blood bank request form , The patient is premedicated with 0.6 milligrams atropine and 100 mg. Seconal intramuscularly, at6 a.m. The patient goes t o the operating mom a t approximately 7 a.m. where, after induction with Pentothal , endotracheal intubation i s performed, and the patient is given general anesthesia with oFenwal Laboratories Div. o f Travenol Laboratories, Inc., Morton Grove , 111.60053'

Page 5

preparation of the patient ' s Ilia c crest area, bone mrmw a spl rat lon may At this tine. prior to aspiratlon, blood for peripheral white Cell count and differential is obtained and 5 cc. o f blood are sent t o the blood bank for typing and crossmatching of2units of whole blood. As an alt ernst, 500 cc. of blood may be obtained 1 week before the transplant and refnfused during the marrow aspirstions, so as t o elimfnate arte factual results from heterogeneous cell populations. Bone marrow aspirations are performed using the BIennan needles for the sternvn, and Kurnick needles for the ilia c crests. No mre than 3 cc. are obtained with the needle bevel i n one position. The bevel i s rotated through four- quadrants for each aspiration. Aspi ration 4 s perfornvd witha syringe which has been filled with one cc. o f the heparin solution containing 50 units per cc. An Abbott VenODak adapter connects a sterile bottle containing 200 cc. o f heparin solution, 50 units per CC., toa twoway stopcock adapter i n which each syringe i s placed t o fill it with one i s a closed system between aspirations. This stopcock Is also turned so that the heparin solution The syrinqe with aspirated qarmw is inverted several t it WS to drstribute the heparin and handed t o an assistant. She injects it thmugh abo - ' ; way stopcock addpter into the Ferwal DaCk which contains TC 199. syringe is left place but the stopcock handle i s turned each time so as to close off the fenwal pack system. After each aspiration another assistant j

Page 6

ilia c crests and the sternum. After 500 cc. of marruu u k ' collected, the bag i s inverted 5-10 times and then a sanple is ob tt in ed for nucleated cell The areas to be aspirated will be posterior and anterior count and differential, In fu si on : For infusion we employ the Sigmarator p ' r p and Infusion set, alcohol sponges, hemostat, 10 cc. syringe fitted wit na 20-gauge needle, u sterile bottle of 30 cc. o f 0.9% saline for injection,sc is son and the double filter system noted above. After the marrow has been collected and stored inthe blood bank a t 4' C. for several hours while the patient recefves whole body irradiation, i t is then taken t o the patient ' s ward where the Fcnwrl pack holding the mrrw Is inverted several t fm s to insure homogeneous d is tri but lon of cells and then fitted to the Sigmamotor Infusion system. dOwnStredf5 from the pump at a rate of 60 t o 90 dmps (4-6 cc.) per arlnuw Al'iQhots are collected imnediately after the punp i s turned on for the determination of cell viability, nucleated cell count and differential Three Abbott blood infusion sets an present for cmr - and the marrow passes through the double f i 1t e r system as well as blood culture. I f there i s evidence o f malfunction o f the filter system, as shown i ~ i c hthe marrow has been infused "piggyback" I s restarted. The Fenwal

Page 7

aininq the mrrw i s then connected to a standard Abbott blood set which is attached to the bottle containing this SrllIW SolutlOn n fusion bequn aqain. After the infusion has been completed, sterile noi*md\ saline i s flushed through the filter set which has been disconnected from the punp. The marrow infusion 15 Egularly f o l l o w 4 by chills 'and fever unless 10 grains of aspirin aw given orally o r rectally during the procedure. Blood cultures a w mutineiy obtained and have always been sterile. To Cdlculdtr the a c t u a l nunber of mdrm cells adninistered, we count .I f i l t e r e d specimer using Kurnick's technique ( 1 7 ) and obtain the nucleated cell count p e r single hemocytometer square by counting eight squares and dividing thr totai by eiqht. count per mn ) x (40. dilution factor in counting) x (1000, nd cr of i n the Fenwal pack) x (fraction o f marl ,w made up o f erythroid dnd nye ln id precursors, in cli i ding stab cells).This sirrglifies t o (cell count per (fraction of mdrmu cel Is.). Then we rmltiply this nunber by (lO,-to c)et Intravenous in fur ion of bone marrow has been known t o repopulate the niarrow spdce (18-2.') o f .inimdls and there I s nw ample experience with bunan subjects as well i 2 3 ) . The marmw transplant technique developed inobr

Page 8

A t brcsent UP arc cor:tinuing the niarrow. ilur earl * s i r c,tudies 011 marrow transfused after storage a t -83' C infused with irl I' tiout'\ o f aspiration; this storage techn:que will re qu l rc imL?*ovemnt, I t *iI I thrrl be possible t o consider cvalubtion o f transfusion dt intervals bet wcw 'be onqet of irradiation and 21 days especially if necessary micrnenvirrlnment (25) as soon as possible t o avoid any delay in until the cell count-, have fallen to clinically danqemus levels in the fourth weeh, one must still allow 5to 10 days for the preclirsors Ofcir - cula ting leukocytes (26) and probably the same tim for platelets (27) t o not then tell if the marrow transplant has been efficacious, whereas if t h mbrrow i s given on the day o f radiotherapy the severe cytopenia durtng the expected nadir af peripheral blood cell counts docs not occur, indicating td in in q)viability of 20-502 compared t o 95-99s If Ue wish to return un l rrs dirt ed marrow toits I f one delays gf vln g marm By this time the patient Is either seriously 111 orre - Our pdtients receive daily white blood cell counts and differential .w hite counts, platt-let and ret icu lo cyte counts. and a check o f the hematocrit and herrogloSin levels. They are sent h m two days post - irradiation and tire degree of(vt ni w nia observed post - ir rb di atl on in our patients has not

Page 9

As s rss nw nt of the effects of large field lm dose I rrr dirt lon Is mdcr way fat tne follcwing parameters: 1 Psyrholoqqc per fo mn ce dccrerrnt. periphcrrl blood cells. Radiation-Induced alteration In Imu nola glc response t o & Stt of phages, ,covered under a separate protocol o f HMO, 11&ln, e t rl . These form, containing I n lay lingurge an t xp lr rut lon of the pmctdurct described above have been fomrrded t o your Cou aft tte. The patient 1 s told that the radiotherapy t o be given I s nat acue but that it mdy ml f eve pain (sham rrdlatlon doer not have this pl r ch effect i n our cancer patients) and that Its efficacy I n prolonging life It mder study.

Page 11

ELAPSED TLKE TO DEATH POLLDUINC rOTAL AND PMIAL BODY RADIATION Ref. 7. Frm "Effects o f Total a d Partial Body fhorapoutic Lnternational Synpoalrr in tha B1010~icr1 Lncrrpracation of lhae f toa Acc dera tO t ?rodwad Rdiatloa. Jamarc. Radiation Labor8tory. Ikrhley, blif., March 13-16,

Page 12

have new performance statu ratlngr are8q gert ad by tha fact that lo tho grwg * of patient * In Phase 1 o! the study, tha por f oma aca rating. according to the apt a of ICamofeky (1951) seemed t o bunch aromd 70 and thou fall prc c ip it owl y Vhm clinical l uta static disease supervened. These modlflcationo, i t 18 hopod, will provia. a gte8t.r range inthe upprr performance ratings and aascruhat more obj oct ivo crito ria far my 8lven rating. Th1.r nev system ignoroo coarplotoly object l vo 8ign8 of dio or umd fa concerned entf rely with Ierfonnancs. Impaired A cgi vit y Wlnor Care Problem do not interforo withp8t1.nt18act i viti a8. only minimally ir pair ad. Capable of full - Not capable of full-time vork but r tr : l able to porforr pmt - tima work. Not capable of part - time work but able t o car. complarely for 8alf at harn. Soma 88riotrrca roqulrad but thir is vanan; meu M Louger doing minor howehold taak,). Spando 1.08 thaa 4 hour. l a bed at h m par day. leaving how r our i8tad. 40% Dl mb lod.Sw dow re than 4 hour. i n bed at hor per dry.Hoop it aliz ation u y be re qui rod If DO uri rta ace available Sevorely dioabled. kjor care pro b lr la tho haw.by bo hor pital it ad althouqb patiant urd fmily may alrct tora ah loop it al it at Lao aacarsary for tmrrrinal can or for acrlve 8upportivo tte at unt. bquirar full and eoapfetv nurriny care.

Page 13

tat ions and Therapeutic Efforts, Ocfense Atomic Support Agency Report WO. Johnson, R.E. Total Body Irradiation of Chmnlc Lymphocytic Leukemla: Incidence and Ouration o f Remission, Cancer 2 : 5 2 3 - 5 3 0 , 1969. Johnson, R.E. Total Body Irradiation with Fractionated Dosage Scheduler, Front. Radiation Ther. Onc. -3:152-162, 1968. Collins,V.P., Loeffler, R.K. and Hyman, G.A. Comparative Effects o f Total Body Pddiation, Nitrogen Mustard and Trlcthylene Melamine on the Hematopoietic System o f Tenninal Cancer Pat lent s, Science =:161-163, 1963. Miller, L.S., Fletcher, G.H. and Gerstner, H.C. Systemic and Cllnlcal Effects Inluccd i n 263 Cancer Patients by Whole Body X-irradlatlon wlth Nominal Air Doses of 15 t o 200 R. Cellular Effects of Ionizing Radlatlon, New Eng. 3 . Hed. inkn,in Proc. 1st International Synposiun on the Blolosical Interpretation a_f Gose from Accelerator Produced Radlatlon, Lawrence Radiation Laboratory, Berkerey, California, March 13- 16s …