Advances in Cancer Research, Volume 10

ADVANCES I N CANCER RESEARCH VOLUME 10

Contributors to This Volume J. M.

Barnes

J. S. Harington

Daniel E. Bergsagel

A. Haut

H. V.

W. Eugene Knox

Gelboin

A. Clark Griffin

P. N. Magee

K. M. Griffith

W. J. Stuckey, Jr.

ADVANCES IN CANCER RESEARCH Edited by ALEXANDER HADDOW Chester Beatty Research Institute Institute of Cancer Research Royal Cancer Hospital, London, England

SIDNEY WEINHOUSE Fels Research Institute Temple University Medical School Philadelphia, Pennsylvania

Volume 70

@ ACADEMIC PRESS

1967

NEW YORK AND LONDON

COPYRIGHT @ 1967, BY ACADEMIC PRESS INC. ALL RIGHTS RESERVED. NO PART OF T H I S BOOK MAY BE REPRODUCED I N ANY FORM,

BY PHOTOSTAT, MICROFILM, OR ANY OTHER MEANS, WITIIOCIT WRITTEN PERMISSION FROM T H E PUBLISHERS.

ACADEMIC PRESS INC. 111 Fifth Avenue, New York, New York 10003

United Kingdom Edition published by ACADEMIC PRESS INC. (LONDON) LTD. Berkeley Square House, London W . l

LIBRARY O F CONGRESS CATALOG CARD

NUMBER: 52-13360

PRINTED I N T H E UNITED STATES OF AMERICA

CONTRIBUTORS TO VOLUME 10 Numbers in parentheses rcfer to the pages on which the authors’ contributions begin.

J. M. BARNES, Toxicology Research Unit, Medical Research Council Laboratories, Carshalton, Surrey, England (163)

DAKIEL E. BERGSAGEL,* University of Texas M . I). Anderson Hospital and Tumor Institute, Houston, Texas (311)

H. V. GELBOIN,National Cancer Institute, National Institutes of Health, Departrnent of Health, Education and Welfare, Bethesda, Maryland (1) A. CLARK GRIFFIN,T h e University of Texas M . D . Anderson Hospital and Tumor Institute, Houston, Texas (83)

K. M. GRIFFITH,Department of Biomathematics, University of Texas M . D . Anderson Hospital and Tumor Institute, Houston, Texas (311) J. S.HARINGTON,? Chester Beatty Research Institute, Institute of Cancer Research, Royal Cancer Hospital, London, England (247) A. HAW, University of ilrkarisas School of Medicine, Little Rock, Arkansas (311)

W. EUGENE KNOX,Department of Biological Chemistry, Harvard Medical School and the Cancer Research Institute, N e w England Deaconess Hospital, Boston, Massachusetts (117) P. N. MAGEE,Toxicology Research Unit, Medical Research Council Laboratories, Carshalton, Surrey, England (163)

\V. ,J. STUCICEY, JR.,Tulane lrniversit y School of Medicine, N e w Orleans, LOU~S~U (311) WL

* Present, Address: t PreserLl

Princess Margaret Hospital, Toronto, Ontario, Canada.

Atlclress: Canwr Rcsearch Unit of the National Cancer Association of

South Africa, South African Institute for Medicaal Research, P. 0. Box 1038 Johannesburg, South Africa. V

This Page Intentionally Left Blank

CONTENTS CONTHIBUTORS T O VOLU\lE 10 . CONTENTS OF PRIWIOUS Vor.u\ifi>s

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ix

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1 5 23 26 28 29

Carcinogens. Enzyme Induction. and Gene Action

H . V . GBLBOIN I . Introduction

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I1. Polycyclic Hydrocarbons and Enzyme Induction . . . . . I11. Tlie Effect of Drugs and Insecticides on Liver Microsomal Enzymes

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IF’. The Nature of the Microsomal Drug-Metabolizing Enzyme Systems . . . . . . V . Effect o f Oncogrnic Viruses on Enzyme Intlnction V I . Enzyme Induction in Rat Hepatoma . . . . . . . . . VII . Pharmacological and Physiological Significance of Polycyclic Hydro. . . . . carbons and Drug-Induced Enzyme Activity . VIII . The Mechanism of Polycyclic Hydrocarbon and Drug-Induced Increase . . . . . . . . . . . . in Enzyme Activity . . . . . . . . . IX . Carcinogenesis and Gcne Action . References . . . . . . . . . . . . . . .

36 51 66 76

In V i k o Studies on Protein Synthesis by Malignant Cells

A . CLARKGRIFFIN

I . Introduction . . . . . . . . . . . . . . . I1. Current Concepts of Protein Biosynthesis . . . . . . . . I11. Protein Synthesis by in Vitro Systems Derived from TLUIIO~ Cells . . I V . Comparison of Protein Gynt.licsis in Tiimor with Microbial and Normal Mammalian Systems . V . Summary and Conclusions References . . . .

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83 84 92 97 111 113

The Enzymic Pattern of Neoplastic Tissue

W . EUGENE KNOX I . Gencral Ideas about Ncoplasia . . . . . . . . . . I1. The Measurement of Enzymes in Tissues and the Prediction of

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. . . . 111. Glycolysis and the Enzymrs of Glycolysis I V . G l y c e r o l ~ ~ l i o s p l ~Dcliydrogcmm at~~ Levels and Glycolysis .

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Metnbolir Behavior

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V . The Enzymes of the Pentosc Pathway . . . . . . . . VI . Enzymes of Gluconrogcnesis and Glycogen Formation . . . . . V I I . Tentativcb Formilltition of the Pat.tern of Enzymes in Neoplastic Tissues VIII . Discussion . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . .

vii

117 123 125 133 134 137 143 155 158

...

CONTENTS

Vlll

Carcinogenic Nitroso Compounds

P. N . MACEEA N D J . M . BARNES I . Introduction . . . . . . . . . I1. Chemistry . . . . . . . . . 111. Acute Toxic Effccts . . . . . . . IV . Neoplastic Changes . . . . . . . V . Some Special Features of Nitroso Compounds as VI . Mutagenic Action . . . . . . . VII . Metabolism of Nitroso Carcinogens . . . VIII . Biochemical Effects . . . . . . . . . . I X . Reactions with Cell Constituents X . Possible Mechanisms of Action . . . . X I . Public Health Aspects . . . . . . References . . . . . . . . .

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. . . Carcinogens . . . . . . . . .

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164 165 171 175 191 193 202 209 220 227 234 238

The Sulfhydryl Group and Carcinogenesis

J . S. HARINGTON

I . Introduction . . . . . . . . . . . . . . . 248 . . . . 249 I1. The SH Group and Normal Cell Division and Growth 111. The Stimulation of Cell Division by SH Groups . . . . . . 250 IV . SH-SS Cycles in Cell Division . . . . . . . . . . 252 . . 255 V . Growth Inhibition and Stimulation by Carcinogenic Substances VI . The Interaction of Carcinogens with SH Groups . . . . . . 259 VII . The Interaction of SH-Reactive Substances of Unknown Carcinogenic Activity or without Carcinogenic Activity . . . . . . . 277 VIII . The SH Group in Carcinogenesis . . . . . . . . . . 280 I X . SH Metabolic Systems Possibly Involved in Carcinogenesis . . . 285 X . Other SH Systems and Carcinogens . . . . . . . . . 289 X I . Discussion . . . . . . . . . . . . . . . 292 References . . . . . . . . . . . . . . . 300

The Treatment of Plasma Cell Myeloma

DANIELE . BERGSAGEL. K . M . GRIFFITH. A . HAUT.A N D

I . Introduction . . . . . . . . . . I1. Plasma Ccll Neoplasms . . . . . . . 111. Antineoplastic Treatment of Plasma Cell Myeloma IV . Summary . . . . . . . . . . References . . . . . . . . . . AUTHOR INDEX .

SUBJECTINDEX

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w. J . STUCKEY. JR. . .

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311 312 329 353 354

361

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38 1

CONTENTS OF PREVIOUS VOLUMES Volume 1

Electronic Configuration and Carcinogcnesis C . A. Coulson Epidermal Carcinogenesis E . V . Cowdry The Milk Agent in the Origin of Mammary Tumors in Mice L. Dmochowski Hormonal Asprcts of Experimental Tumorigenesis 7'. U . Ga h e r Prolwrtics of the Agent of Rous NO. 1 Sarcoma it. J. C . Harris Applications of Radioisotoprs to Studies of Carcinogcnesis and Tumor Me tab olism Charles Heidelberger The Carcinogenic Aminoazo Dyes James A . M i l l e r wid Elizabelh C . Miller The Chemistry of Cytotoxic Alkylating Agents M . C . J . Ross Kutrition in Relation to Cancer Albert Taiznenbaitm and Herbert Silverstone Plasma Proteins in Cancer Iiicliartl J . W i n d e r A U T l I O I I INDEX-SUBJECT

INDEX

Volume 2

The Reactions of Carcinogens with Macromolecules Peter A l e x a d e r Chmiical Constitution and Carcinogenic Activity G . M . Badger

Carcinogenesis and Tumor Pathogenesis I . Berenblum Ionizing Radiations and Cancer Austin M . Brues Survival and Preservation of Tumors in the Frozen State James Craigie Energy and Nitrogen Metabolism in Cancer Leonard D . Fenninger and G. Burroughs Mider Some Aspects of the Clinical Use of Nitrogen Mustards Calvin T . Klopp and Jeanne C. Bateman Genetic Studies in Experimental Cancer L. W . Law Tlir Role of Viruses in the Production of Cancer C . Oberling and M . Gueiin Experimental Cancer Chemotherapy C . Chester Stock AUTHOR INDEX-SUBJECT

INDEX

Volume 3

Etiology of Lung Cancer Richard Doll The Exprrimental Development and Metabolism of Thyroid Gland Tumors IIarold P. Morris Electronic Structure and Carcinogenic Activity and Aromatic Molecules: New Developments A . Pullman and B. Pullman Some Aspects of Carcinogenesis P. i2 ondoni Pulmonary Tumors in Experimental Animals Michael B. Shimkin

ix

x

CONTENTS O F PREVIOUS VOLUMES

Oxidative Met,abolism of Neoplastic Tissues Sidney Weinhouse AUTHOR INDEX-SUBJECT

INDEX

Volume 4

Advances in Chemotherapy of Cancer in Man Sidney Farber, Rudolf Toch, Edward Manwing Sears, and Donald Pinkel The Use of Myleran and Similar Agents in Chronic Leukemias D. A . G. Gallon The Employment of Methods of Inhibition Analysis in the Normal and Tumor-Bearing Mammalian Organism Abraham Goldin Some Recent Work on Tumor Immunity P. A . Gorer Inductive Tissue Interaction in Development Clifjord Grobstein Lipids in Cancer Fmncss L. Haven and IY. R. Bloor The Relation between Carcinogenic Activity and the Physical and Chemical Properties of Angular Benzacridines A . Lacassagne, N . P. Buu-Hoi, R . Daudel, and F . Zajdela The Hormonal Genesis of Mammary Cancer 0. Miihlbock AUTHOR INDEX-SUBJECT

INDEX

Volume 5

Tumor-Host Relations R . W . Begg Primary Carcinoma of the Liver Charles Berman Protein Synthesis with Spccial Reference to Growth Processes both Normal and Abnormal P. N . Campbell

The Keuer Concept, of Cancer Toxin Waro Nalcahara and Fumako Fukuoka Chemically Induced Tumors of Fowls P. K. Peacock Anemia in Cancer Vincent E . Price and Robert E . Greenfie Id Specific Tumor Antigrns L. A . Zilber Chemistry, Carcinogenicity, and Metabolism of 2-Fluorenamine and Related Compounds Elizabeth I also prevented the MC-induced increase in rat liver DAB reductase activity and in the phenobarbitalinduced increase in the niicrosomal content of CO-binding pigment (.Jervell et al., 1965; Orrenius e t al., 1965). There h a r e been no reports of failure of nctinomycin D to prevent induction of microuomal enzymes hy methylcholantlirenc or by phenobarbital. Jervell et nl. (1965), however, reported that actinomycin failed to prevent the increake in DAB rcductase activity induced by starvation. This suggests that there niay be ii second nicch:inisni by which microsomal enzymes can be induced which

56

H. V. GELBOIN

is independent of DNA-dependent RNA synthesis. This may be similar to thc actinomycin D-insensitive enzyme synthesis reported by Grcengard e t al. (1963) for tryptophan pyrrolase induced in rat liver by tryptophan. This has been shown to be due to a stabilization by the substrate of tlic rapidly turning over tryptophan pyrrolasc (Berlin and Scliimkc, 196.5). The stiriiulatory cffcct of polycyclic hydrocarbons arid drugs on certain liver niicrosonial enzymes appears not to be mediated through the endocrine system, since the stimulation is observed in gonadectomizcd, adrcnalcctoiiiized, hypophyscctomizcd, or thyroidectoinized rats. Conricy (1965) reported that M C increases azo dye N-demcthylase in either hypopliy~ectomized~ or adrcnalectoinized rats.

B. STIMULATORY EFFECT O F P O L Y C Y C L I C HYDROCARBONS AND DRUGS ON PROTEIN SYNTHESIS Arcos et al. (1961) showed that many polycyclic hydrocarbons increase liver size, with a proportionate incrcase in total liver protcin. Within 4 days after the administration of MC, naphthacene, or anthantlirenc there was a 20 to 30% increase in liver protein contcnt. Although M C increased total protein content of the liver, it did not change the amount of protein per grain of liver. On the other hand, the adniinistration of phenobarbital and relatcd drugs caused an increase in both the total liver protein and in the amount of protein per gram of wet weight of liver. Conney et al. (1960) and Conney and Gilnian (1963) have found that phenobarbital, chlorcyclizinc, orphenadrine, or phenylbutazonc caused increases in microsoinal protcin per gram of wet liver ranging from 22 to 39%. Orrenius et al. (1965) rcportcd an increase in both protcin and RNA content of the microsomes of liver treated with phcnobarbital for a 120-liour period. T h e latter investigators fractionated the microsomes and reported an increase in both the agranular and granular endoplasmic reticulum 120 hours after the rats were treated with phenobarbital. The phenobarbital effect was considerably greater in the agranular endoplasmic reticulum where a 2-fold increase was observed ; the granular endoplasmic reticuluni increased only 20% upon Phenobarbital treatment. These results are consistent with the reports from several laboratories of a proliferative effect of phenobarbital on the agranular endoplasmic reticulum. Thus, Remmer and Merker (1963) and Fouts and Rogers (1965) have demonstrated by electron niicroscopy an increased content of the agranular endoplasinic reticulum of liver after rats or rabbits were treated with phenobarbital. The studies demonstrating a n increased protein content, a proliferation of the agranular endoplasmic reticulum, and an induction of a variety of microsoinal enzymes raise the question as to the effect of poly-

57

CARCINOGENS, ENZYME INDUCTION, AND GENE ACTION

cyclic hydrocarbons and drugs on the protein-synthesizing systems of the microsomes. Kato et al. (1965) studied the effect of phenobarbital on the in vivo incorporation of Cl4-leucine into the various subcellular fractions of rat liver. Table XI1 (Kato et al., 1965) shows that phenobarbital affected only the labeling of the inicrosomal fractions. The proteins from a highly purified nuclear fraction, iiiitochondria, or the soluble fraction of the cell sap were labeled equally in control and in phenobarbital-treated rats. Microsomes, however, froiii phenobarbital-tre:ted rats showed approximately a 25% increase in the incorporation of leucineC14. This increase was observed both in thc deoxycholate (DOC) -soluble TABLE XI1 THEEFFECTS OF

P H E N O B A R B I T l L ON T H E I N C O R P O R 4 T I O N

L-LEUCINE-C'4

I N S U B C E L L U L k R F R A C T I O N S O F RAT

in

VtUO OF

LIVER"' *

Specific activity (c.p.m./mg. protein) Fraction Nuclei Mitochondria Microsomes Ribosomes DOC-soluble microsnies Supernatant

PB

Control

69 121 216 84 239 55

f. 8 f. 14 f 21 f. 6 f 36

f. 4

71 115 265 104 290 57

f4 k 11 k 10 f0 12 7

* *

%

1'

+3 -5 +23 +24 +21 +3

>0.05 >0.05 11 0 mg. %/total (%) Uremia: no. BUNc > 30 mg. %/total (%) Hemoglobin (g.%) mhen melphalan started: mean median Melphalan dose rates (mg./kg./month) : mean median Early deaths: deaths in 3 weeks/total no. (%) followed

MDAH

Other institutions

65 60.1 60 45 20 (13/52) 16.4 11.0 6/30 (20%) 8/37 (22%) 10.6 10.6 0.73 0.56 1/65 (2%)

179 58.4 60 37 47 (82/91) 16.0 8.3 18/114 (16%) 47/127 (37%) 9.6 9.3 0.90 0.48 20/173 (1170)

AkSDERSON

n m

Significance

8m E

t

=

0 . 8 9 (N. S . ) b

1 . 0 8 (N. S.) t = 4.38 ( p < 0.01) t = 0 . 1 2 (N. S.)

t

=

t = 0.52

(N.S.)

t

< 0.1) = 1 . 9 7 ( p < 0.05)

t

=

t = 1.92 ( p

1.25 (N.

t = 3.43 ( p

S.)

< 0.01)

The data in this table were analyzed a t a later date than the material in Tables IV, VII, and VIII, and for this reason the number of patients differs. b i Y . S.: not significant. BUN: blood urea nitrogen.

P

c

E 7

2;

7 5:

! w +

;P

C

e ;P 2,

t,

z

35 *ia

TABLE X CLINICAL

.3

z

PATTERNh: PL.4hM4 CELL ;?;EOPLASRlS

m 1

s

Pathological protein Clinical features J,ymphadenopathy Spleiiomegaly Osteolytic lesions Survival from onset of symptoms

Type I< Type L light chain protein light chain protein S o n e (0/12)0 Xone (0/12)" Common 1T months (median).

Sone (O/9)a Sone (0/9)" Common 17 months (median)c

G- and hmyeloma protein Pncwmmon (l/i'O)a I~ncommorr(4/70). Common 17 months (median)

3

+-

2 &I-macroglobulin

Hy-chain protein

Common Common Uncommon 38-40 monthsd

Common ( 5 / 5 ) b Common ( 5 / 5 ) b None (O/5)b 4-36 monthsb

+

0 "! CJ

P

%

*2 3

Patients studied by the SIVCCSG (Bergsagel et nl., 1965). The figires in parentheses refer to the numbers of patients producing the indicated pathological protein, who manifested lymphadenopathy or splenomegaly, and the total numbers of patients in this group. b Patients with Hy-chain disease reported by Franklin et al. (1964) and Osserman and Takatsuki (1964). The survival figures indicate the range observed for 5 patients. c Median survival est,imated for 600 patients with plasma cell myeloma treated prior t,o the use of alkylat,ing agents (Oagood, 1960). Average survival (Kappeler et al., 1958). a

m

F

zI:

mr

2P

350

BERGSAGEL, GRIFFITH, I-IAUT, AND STUCICEY, JR.

survival for 600 myeloma patients producing all protein types collected from the literature prior to the use of alkylating agents; the median survival of the total group was 17 months. The survival of patients with M-macroglobulineniia and Hy-chain disease is not known with as great accuracy as for plasma cell myclomn. However it is the clinical imprcssion of many investigators that M-macroglobulinemia is a more benign disease than myeloma, and many patients are known to survive for long periods of time. The average survival of patients with M-niacroglohulinemia has bccii reported to be 38-40 months (Kappeler et al., 1958). The average survival noted for M-macroglohulinemia cannot be cornparcd directly with the median survival reported for myeloma patients, but this figure does suggest that the prognosis of M-macroglohulinemia is better than for myeloma. The proteins produced by 91 patients with plasma cell myeloma treated with rnclphalan by nicmbers of the SWCCSG, were availahlc for antigenic typing. This material provided the unique opportunity for determining whether the tumors which produced different types of myeloma protein differed in their response to nielphalan (Bergsagel et al., 1965). The data obtained from this study are summarized in Table XI. The data available on the response of patients with Mmacroglobulinemia and Hy-chain disease to mclphalan therapy are inadequate for this comparison. Patients were classified as being objectively improved (responders) by melphalan therapy if one, or more, of the following criteria were satisfied: (1) a decrease in the myeloma serum protein to 50% or lcss, of the prestudy value; (2) a decrease in the amount of urinary protein excreted per 24 hours to 50% or less of the prestudy value; (3) an increase of 2.0 g.% or more in hemoglobin; (4) shrinkage of palpable TABLE kI EFFECT OF MELPHALAN ON PLASMA CELL TUMORS 'PRODUCING OF MYELOMA PROTEINSQ

VARIOUS

TYPES

Melphalan response

Responder

Myeloma protein type

TypeK light chain proteins

G-and Amyeloma proteins

11/11

30/65

0/9

68 43-109 4/12

55 45-67 25/70

23 18-31 6/9

No. objectively improved/no. evaluable Survival from onset of symptoms Median (months) 95% confidence interval (months) No. deadjtotal no.

Intermediate Nonresponder

Patients studied by the 8WCCSG (Bergsagel et al., 1965).

TypeL light chain proteins

T H E TREATMENT OF PLASMA CELL MYELOMA

35 1

plasmacytomas of 50% or more; and ( 5 ) a decrease in serum calcium from more than 6.0 to 5.0 meq./liter or less. These criteria were selected arbitrarily with the helief that the changes arc clinically significant. The effect of melphalan therapy was not evaluated if the changes in the myeloma proteins in serum or urine were not determined, or if the patient died or wits otherwise lost in less than 3 weeks. The patients can be divided into threc groups on the basis of the response to melphalan therapy (Table XI). All of the evaluable patients producing only type K light chain proteins responded ; these patients are listed as the responder group. I n the group of patients producing G- or A-myeloma proteins, 30 of G5 were objectively improved; these patients are listed as an intermediate group. None of the patients producing only type L light chain proteins were objectively improved; these patients are listed as nonresponders. The estimates of survival are significantly different ( t test) for the comparison of the survival of the nonresponders with the intermediate group (from onset of symptoms, p < 0.02; from diagnosis, p < 0.01 ; froin start of mclphalan, p < 0.05). With the sample size available for comparing the survival of the responders and nonresponders, the differences are not significant, although for the survival from the onset of symptoms the difference is close to significance a t p = 0.05. The differences between the survival of the responder and intermediate group are not significantly different. Since less than 50% of the patients are dead in the responder and intermediate groups, these estimates of survival are unstable, and, in view of the small sample size of the responder and nonrcsponder groups, the estimates should not be interpretated a s being well established. Other investigators (Osserman, 1965; Lee et al., 1965) have reported that objective improvement occurred in 5 of 10 patients producing only type L light chain proteins, and 3 of 6 patients producing only type K light chain proteins failed to improve following melphalan therapy. These observations clearly indicate t h a t the correlation of melphalan response to the type of protien produced by the tumor is not absolute, but the data are inadequate to disprove the thesis t h a t paticnts producing only type K light chain proteins respond more frequently than those producing only typc L light chain proteins. Since the difference.: in the frequency of response to melphalan observed in these three series may be due to many factors, it is difficult to compare them. Two important differences are the dosage schedules employed and the selection of evaluable patients. Ossermm (1965) only evaluated the response of patients treated for 6 months or more, and Lee et nl. (1965) report on “adequately treated” patients (27 of 40) observed on therapy for a minimum of 3 months. The SWCCSG

352

BERGSAGEL, GRIFFITII, HAUT, AND STUCKEY, JR.

evaluated the response of all patients followed for a t least 3 weeks; it was found that 3 to 9 months of treatment were required for optimum improvement, but in most cases it was possible to rate the response within 3 weeks after the first dose of the drug. I n the SWCCSG series, 14 of the total group of 91 (15%) [2 of 12 patients (17%) producing only type K light chain proteins, and 3 of 9 patients (33%) producing only type L light chain proteins] died within the first 6 months. The elimination of patients who die early would probably result in the loss of more nonrespontlers than responders from the series of Osserman and of Lee e t al.; this malies their series quite different from the SWCCSG series. If i t is assumed that the different melphalan dosage schedules employed did not influence the results, and also assumed t h a t there were no early deaths in the Osserman or Lee e t al. series, there is still convincing evidence t h a t patients producing only typc K light chain proteins respond more frequently (14 of 17) than those producing only type L light chain proteins (5 of 19) when the results of the three series are combined. Further studies of the response of patients producing different types of myeloma protein to melphalan therapy are required. Thew observations suggest t h a t the classification of plasma cell malignancies on the basis of the type of protein produced is useful for grouping patients with similar clinical manifestations, prognosis, and melphalan rrsponsiveness. Why should plasma cell tumors producing only type K light chain proteins respond inore frequently to melphalan therapy than those producing only type L light chain proteins? It is possible that an extracellular factor, such as the myeloma protein, may react with the alkylating agent and inactivate it. If the type L light chain proteins could be shown to react more readily than type K light chain proteins, it would be possible to explain the different response rates. This possihility was checked in two ways. First, the rate a t which melphalan reacts in vitro with type K and type L light chain proteins was checked (Fig. 7) and no differences in the reaction rate could be demonstrated. Second, if type L light chain proteins inactivate melphalan more readily than type K light chain proteins, one would expect to find less severe hematological toxicity in the patients producing only type L light chain proteins. The heniatological toxicity observcd in patients producing either type K or type L light chain proteins was checked carefully, and no difference in the severity of the hcmatological toxicity could be demonstrated (Bergsagel, 1966; Bergsagel et al., 1965). Thus, it seems unlikely that the different response rates can be explained on the basis of an extracellular factor.

THE TRWl'MEST OF PLASMA CELL MYELOMA

353

It s e e m more likely that inelphalan responsiveness is determined by an intracellular factor related to the stage of differentiation of the malignant plasma cell or to the growth characteristics of the tumor. Dr. Bruce and his absociates a t the Ontario Cancer Institute have shown that dividing cells are much inore sensitive to iiiaiiy types of chemotherapeutic agents than are cells in the resting ( Go ) phase of the ccll cycle (Bruce and Alccltcr, 1965; Bruce et nl., 1966). It is possible that tumors I)roducitig only typc I< light cliain proteins 1i:ir.e a larger

r

b

50t

"

I

I

I

1 (Patient) 4 5 0 mg. (W.R.H

450mg.(C.N.1 300mg.(M.O. ) 3 0 0 m g . (J.C.W.)

0

1

2

3

4

5

Time (hrs.)

FIG.7 . Reaction of melplialan with types I< and L Bcnce-Jones Iwoteins. Type

B and 1, Bence-Jones proteins were precipitated from urine samples by 50% saturation with ammonium sulfate. Tlic protein precipitates were dissolved in distillrtl wat,rr, dialyzctl against distillrtl \vatcar f o r 4 days, :ind tlrrn lyopliilizcd. Weighed samples were incubated at 37°C. with 20 mg. mrlphalan in 0.15M NnCl ;it, pI5 7.0. A t t l i c tinics int1ir:rttd om IIir almc L, tlic llrotrin was precipitatcd with ethanol. Free melphalan, including the adsorbed drug released from the prot,rin in the conrse of c~thanol privipi(:ttion, \\:is inrnsurrd sprctrol,lroinctrirally. The reaction of melpli:ilan with Bencc-Jones protcins wzs studied by Dr. J. H. Iinford and Miss Jennie Hmi:itle, Department of Medicine, University of Manit.oba, Winnipeg. Canada, using mctliotls dcvelopcd in his laboratory (Israels anti Idinford, 1963).

proportion of tlivicling t*c~Ilsth:w 1)labiiin ccll tumors produciiig only type I, light c11:tiits, and this inci.casccl proportion of divicling cells may make the tumor more sensitive to the effects of inelphalan. Unfortunately, there is no direct evidence that the proportion of dividing cells in plasma cell tuniors producing only type K light chain proteins is greater than in tuinorb producing only type I, light rh:iin proteins. IV. Summary

A plasnin cell tumor develops when a ccll, destined to produce an is affected hy a inalignant traiisfoi-mation, antI the ininiunoglo~~uiin, ncoplastic daughter cells successfully establish a tumor clone. The genetic constitution, antigenic stiniulation, and exposure to );-irradiation

354

BERGSAGEL, GRIFFITH, HAUT, AND STUCKEY, J R .

appear to be of sonie importance in the etiology of plasma cell neoplasms of animals and man; there is no direct evidence that the malignant transformation of plasma cells is caused by a virus. The tumor protein synthesis pattern reflects the stage of differentiation of the majority of the tumor cells; the classification of plasma cell tumors on the basis of the typc of protein produced is useful for grouping patients with similar clinical manifestations, prognosis, and melphalan responsiveness. The diagnosis of a plasma cell neoplasm requires the demonstration of a neoplastic (i.e., uncontrolled) proliferation of plasma cells evidenced by the formation of a tumor, destructive tissue invasion (e.g., osteolytic lesions), or a progressive increase in the pathological protein. The prognosis of patients with apparently solitary lesions is better than that of patients with generalized disease, and the development of heniatological or rcnal failure indicates a shortened life expectancy. Infections lead the list of factors contributing to the death of patients with plasma cell myeloma. Supportive care directed a t preventing or relicving the major complications of infections, hypercalcemia, pathological fractures, renal failure, and the hyperviscosity syndrome is of great importance in the management of patients. Alkylating agents (melphalan and cyclophosphamide) are the only antineoplastic drugs capable of producing objective improvement in direct manifestations of plasma cell tumors, and also prolonging survival significantly. Melphalan and cyclophosphamide appear to be equally effective in producing objective improvement and prolonging survival.

REFERENCES Adams, W. S., and Skoog, W. A. 1957. J. Chronic Diseases 6, 4 4 M 5 6 . Adams, W. S., Alling, E. L., and Lawrence, J. S. 1949. Am. J . M e d . 6, 141-161. Aherne, W. A. 1958. J. Clin. Palhol. 11, 326329. Alwall, N. 1947. Lancet 11, 388-389. Alwall, N. 1952. Acta M e d . Scand. 144, 116118. A. M. A. Council on Drugs. 1965. J. Am. M e d . Assoc. 191, 547-549. ;Inderson, J., Emery, E. W., McAlister, J. M., and Osborn, S. B. 1956. Clir'. Sci 15, 567-585. Anderson, J., Farmer, F. T., Haggith, J. W., and Hill, M. 1960. Brit. J. Radiol. 33, 374-378. Anderson, R. E., and Ishida, K. 1964. A n n . Internal Med. 61, 853-862. Austin, C., Bergsagel, D. E., and Sprague, C. C. 1962. Cancer Chemotherapy R e p t . 21, 107-112. Barnett, E. V., Stone, G., Swisher, s. N., and Vaughan, J. H. 1963. Am. J. Med. 35, 113-122. Bentzel, C. J., Carbone, P. P., and Rosenberg, L. 1964. J. Clin. Invest. 43, 21322145. Bergel, F., and Stock, J. A. 1954. J. C h e m . SOC.2409-2417.

T H E TREATMENT O F PLASMA CELL MYELOMA

355

Bergsagel, D. E. 1962. Cancer Chemotherapy R e p t . 16, 261-266. Bergsagel, D. E. 1966. In “Recent Advances in the Diagnosis of Cancer” (R. L. Clark and R.W. Cuiiiley, c d s . ) , pp, 170-179. Year Book Publ., Cliicago, Illinois. 13ergsage1, D. E., and Levin, W. C. 1960. Cancer Chemotherapy Kept. 8, 120-134. Uergsugel, D. E., Ross, S. W., and Baker, D. T. 1962a. Cuncer Chemotherapy R e p t . 21, 101-106. Bergsagel, I).E., Ross, S.W.,and Davis, P. 1962b. Cancer Chemotherapy R e p t . 21, 75-80.

Bergsagel, D. E., Sprague, C. C., Austin, C., and Griffith, K. M. 1962c. Cancer Chemotherapy R e p t . 21, 87-99. Bergsagel, D. E., Sprague, C. C., and Ross, S. W. 1962d. Cancer Chemotherapy Ir‘ept. 21, 6S74. Bergsagel, D. E., Migliore, P. J., and Griffith, K. M. 1965. Science 148, 376377. Bernard, J., Seligmann, M., and Danon, F. 1962. Nouvelle R e v . Franc. Hematol. 2, 611-616.

Bernhard, W. 1958. Cancer I h . 18, 491-509. Bernier, G. M., and Putnam, F. W. 1964. Biochim. Biophys. Acta 86, 295-308. Bethell, F. H., Louis, J., Robbins, A,, Donnelly, W. J., Dessel, B. H., Battle, J. D., Jr., Pisciotta, A . V., Well, J., and Clifford, G. 0. 1960. Cancer Chemotherapy R e p t . 8, 112-115. Brccher, G., T~litkil,Y., Malmgrcn, 13. A,, and I”ahey, J. L. 1964. A m . N . Y . Acad. Sci. 113, 64Z653. Brittin, G. M., Tannka, Y., and Breckcr, G. 1963. Blood 21, 335-351. Brock, N. 1958. ArztLeiniittel-Forsch. 8, 1-9. Brook, J., Bateinan, J . R., and Stc~infcltl,J . 1,. 1964. Cancer Chemotherapy Rept. 36, 25-34. Brown, C. L., Bergsagel, D. E., and Lcvin, W. C. 1962. Cancer Chemotherapy Rept. 21, 81-85. 13ruce, W. R., and Meeker, B. E. 1965. J. Null. Cancer Inst. 34, 849-856. 13ruce, W. R., Meeker, B. E., and Valeriote, F. 9.1966. J. Natl. Cancer Inst. 37, 233-245.

Carbone, P., Frei, E., 111, Owens, A . H., Jr., Olson, I x ~ I1,. ~ PJ.,~269, , 304 Hcatl, M. -4., 273, 308 Hcnth, D. F., 166, 167, 168, 169, 170, 172, 173, 178, 202, 203, 204, 205, 206, 207, 214, 226, 228, 241 Hrath, J. C., 271, 304 Hrftrr, R. W., 51, 81 Hcgycli, A,, 291, 304 Ilc~itirlbcrgrr,C., 70, 71, 76, i s , 80, 156, 160, 231, 232, $41, 244, 261, 304 Hrilhrunn, L. V., 295, 309 Hcintz, It,. 84, 116' Hcisr, E., 217, 741 Hckhuis, G. L., 146, 150, 1 6 s Hrlgrbostad, A,, 236, 2.f0 Hrlldrom, I., 29, SO Helmus, C., 321, 356 Heniberg, T., 265, 270, 304 Hcmingway, J . T., 264, 289, $04

368

AUTHOR INDEX

Hendrrson, E., 264, 308 Henderson, J. F., 5, 10, 14, 78, 156, 159 Hendry, J . A,, 230, 246 Hengy, H., 170, 244 Henke, H., 197, 199,241 Henriques, 0. B., 263, 264, 304 Henriques, S. B., 263, 264, 304 Henry, M. C., 141,161 Henwhler, D., 237, 241, 246 Henson, J . B., 315, 356 Heredia, C. F., 91, 114 Hermnns, J. F., 320, 356 Herrrll, W. E., 312, 356 Herrmann, A,, 236, 242 Herrold, K. M., 177, 186, 187, 238, 24.8 Hersulto, A,, 287, 305 HPSS,W. C., 264, SO4 Hmvett, C. L., 263, 302 Hintt, H. H., 5 , 76 Hickey M. D., 289, 308 Hickinhottom, W. J., 165, 242 Higa, H. H., 168, 243 Hill, I