THE LANCET
`
`No 8625
`
`BOSTON, MASS. AND LONDON· SATURDAY DECEMBER 17 1988
`
`VOL II FOR 1988
`
`ORIGINAL ARTICLES
`Ocular Fundus Lesions in Divers
`P. ]. Polkinghome, FRACP, Kulwant SehnU, FRPS, M. R. Cross, MB,
`Darwin Minassian, FRCS, Prof A. C. Bird, FRCS
`
`Allele Loss on Short Arm of Chromosome 17 In Breast Cancers
`]. Mackay, FRCS, C. M. St«I, MRCPE, P.A. Elder, HNC,
`Sir Patrick Forrest, FRCS, ProfH. J. Evans, PHO
`
`Support for Adrenaline-hypertension Hypothesis: 18 hour Pressor Effect
`after 6 hours Adrenaline Infusion
`P. J. Blankestijn, MD, A. J. Man in't Veld, MD, Joke Tulen, B SC,
`A.H. ven den Meiracker, PH o, Frans Boomsma, PH o, Peter Moleman, PH o,
`H.J. Ritscrna van Eck, MD, F. H. M. Derlcx, MD, Paul Mulder, PH o,
`S. ]. Lambens, MD, M.A. D. H. Schalelwnp, MD
`
`Simultaneous Isolation of HIV-I and HIV-2 from an AIDS Patient
`L. A. Evans, PH o, Jacques Moreau, MD, Koudou Odehouri, MD, Deborah Seto, BA,
`Graeme Thomson-Honnebier, MD, Harold Legg, BA, Ashley Barboza, BA,
`Cecilia Oleng-Mayer, PH D, Prof J. A. Levy, MD
`
`Improvement of Hepatic Encephalopathy Treated with Flumazenil
`Georg Grinun, MD, Peter Fercnci, MD, Regina Katzenschlager, Olristian Madi,
`Bruno Schneeweiss, MD, A. N. Laggner, MD, Kun Lenz, MD, Prof Alfred Gangl, MD
`
`1381
`
`1384
`
`1386
`
`1389
`
`1392
`
`PRELIMINARY COMMUNICATION
`Remission Induction in
`Non-Hodgkin Lymphoma with
`Reshaped Human Monoclonal
`AntibodyCAMPATil-IH
`G. Hale, PH o,
`M. J. S. Dyer, MRCP,
`M. R. Oark, PH o,
`]. M. Phillips, PH D,
`R. Marcus, MRC PATH,
`L. Riechmann, PH o,
`G. Winter, PHO,
`H. Waldmann,MtD
`
`1394
`
`REVIEWS
`Notices of Books
`
`GENERAL PRAcnCE
`EvaluadonofaStructured
`Treatment and Teaching
`Programme on
`Non-insulin-dependent Diabetes
`Peter Kronsbein, PH o,
`Viktor Jorgens, MD,
`Ingrid Miihlhauser, MD,
`Vera Scholz, PH D,
`Annene Venhaus, MS,
`Prof Michael Berger, MD
`
`1399
`
`1407
`
`THERAPEUTICS
`Reversible Ceftriaxone(cid:173)
`associated Biliary Pseudolithiasis
`in Children
`U. B. Schaad, MD,
`Joanna Wedgwood-Krucko, .\\0,
`Heinz Tschaeppeli;r, MD
`
`1411
`
`HOSPITAL PRAGnCE
`Nasal Continuous Positive
`Airway Pressure In
`- ~
`Pneumocystis carinii Pneumonia 1414
`Steven Kesten, FRcrc,
`A. S. Rebuck, FRCPC
`
`ROUND TIIE WORLD
`India
`
`IN ENGLAND NOW
`
`1415
`
`1416
`
`XamoteroI: Stabilising the
`Cardiac Beta Receptor?
`Shackled, Shameful, and
`Shoddy
`Valproate, Spina Bifida, and
`Binh Defect Registries
`Diurnal Variation in Platelet
`Aggregation Responses
`Recurrent Respiratory
`Papillomatosis
`
`1403
`
`1404
`
`1406
`
`1407
`
`1408
`
`1417
`
`1418
`
`1418
`
`1419
`
`1419
`
`1420
`
`1421
`
`LETIERS TO TIIE EDITOR
`Reversed Polarity of Vasculocutaneous
`Potential and Neonatal Nccrotislnc
`Enterocolltls
`Dr M . R. Millar and others
`Haemodllution In Renal
`Transplantation in Patients on
`Erythropoietln
`Dr Jan Wahlberg and others
`Treatments for Neurotic Dborders
`Prof D. F. Klein
`Ucensing Synthetic lntracervlcal Tents 1418
`Mr Nicholas JohnS<lCl, MRCX>G
`Birthwdght and Neonatal Monallty
`Dr Alfredo Pisacanc
`Food Intolerance and Rheumatoid
`Arthritis
`Dr Pekka Kurki and others;
`Prof L. Corbec:I and others
`Changes In Body Wdght between
`Consecutive Pregnancies
`Dr J. S. Samra and others
`Salmonella -teritidi• Phage Type 4
`and Hens' Eggs
`Dr John Paul,
`Dr Barry Batchelor
`O.olinergic Side-elTecu of
`Tetrabydroaminoacridinc
`ProfR2ymond Uvy
`Peripheral Facial Paralysis Indicating
`HIV lnrection
`Dr Laurent &lee and Olhers
`HIV, Glue Ear, and Adenoidal
`Hypertrophy
`Mr J. W. Fairley, FRCS, and others
`Cat Scratch Disease, Bartonellosls,
`and Kaposi Sarcoma
`Dr S. Dcaller
`Inhibition of O.olinesterasn by
`Pentarnldinc
`Dr T. A. Alston
`
`1421
`
`1421
`
`1422
`
`1422
`
`1423
`
`Italian Epidemic orW•terbornc
`Tulancmi8
`Dr E. Mignani and others
`Home lntravmous lmmunoglobulin
`Therapy
`Dr H. M. O>apcl,
`Sister V. M. Brennan
`Is Inactivated Poliovacclne more
`Expensive?
`Dr J.P. Moulia-Pdat and others
`Heat-suable vcnus Heat-labile
`Vaccines
`Dr C. P. Muller,
`Prof Giinthcr Jung
`Marlagmimt of Dysentery by
`Community Health Worken
`Dr Manin Kirl<patrick
`Antibody Responses to Human
`Herpcsvirus 6 and other
`Herpcsvlruses
`Dr D. ] . Morris and others;
`Dr Martin Andre,
`Dr lkrtfncd Matz
`Parvovlrus-associated
`Thrombocytopenic Purpura
`Dr N. K. Foreman and others
`Clinical Trial Numben and
`Confidence Intervals of
`Pre-specified Sitt
`Mr S. J. Day, FSS
`Danish Exp.rim« of Suatutory Right
`or Patients to Access to Hospital
`Records
`Dr T eis Andcnen
`Dr Georg Jergmsm
`Better Surgeons get Better Results
`Mr Richard Novell, FRCS, and othcn
`Paying for Extended Medicare
`Dr Brian Potter
`ICRF Appeals
`Dr L. A. l'lia:
`Graves' DiseaK: the Thyroid not the
`Pancras
`Prof]. G. Scadding
`Specific Detection of r.,,;,, MJ6inata
`Eggs by DNA Hybridisation
`Dr A. Flisscr and others
`Non-$urglcal Lefi-atrial Aonic Bypass
`Dr U. U. Babic and others
`Screening for Aortic Aneurysm
`Mr Jack Collin, FRCS
`Pelvic Irradiation and Tamoxlfm as
`Risk Facton for Carcinoma or
`Corpus Uteri
`Dr l..amart Hardell
`Erythromycln-raistant Streptococcw
`tm-monitM
`Dr J. Vttha<gm and Olhers;
`Dr R. E. Wanm and others
`Naevus of Jamaica
`Dr Ncjat Akar
`
`1423
`
`1423
`
`1424
`
`1424
`
`1425
`
`1425
`
`1426
`
`1427
`
`1428
`
`1428
`
`1429
`
`1429
`
`1429
`
`1429
`
`1430
`
`1431
`
`1432
`
`1432
`
`1433
`
`MEDICINE AND 1llE LAW
`O>smetic Surgery: Greater Duty to
`Warn of Risks
`Doctors and Advertising
`
`NOTES AND NEWS
`MRC Activities-Official
`Spare a Thought for the Victim
`Help for Sick Doctors
`After the Olrisanas Pany
`C.ancer Incidence World Wide
`Women's Health Concern
`Healers, Quacks, and Lady Doctors
`Postgraduate Education
`Training Courses for HIV/AIDS
`Counsellors
`
`CORREGnON
`Fetal Obstructi~e Uropathy
`
`1434
`1434
`
`1435
`1435
`1435
`1435
`1435
`1436
`1436
`1436
`
`1436
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`1436
`
`uarc, London WCIB 3SL, England. Tel:
`Editorial Offi«: 46 Bedford
`01-436 4981. The Lan=, North American Edition ISSN 0099-5355
`published wttltly by Llnlc, Brown and Company, 34 Beacon St., Boston,
`Mass. 02108. Annual individual subscription in U.S. 185.00, in Canada
`S95.00; resident and intern rate (U.S. and Canada) $48.50; Single copy $7.00.
`Second class postage paid at Boston, Ma .. ., and"' additional mailing offices.
`!) The Lancet Lld., 17 Dcconber 1988. Postmaster: Send address changes
`to The Lan=, 34 Beacon St, Boston, Mass. 02108 (617) 227-0730, ext 516.
`lliE WHOLEOFTilE 1..llCRARY .\\ATJCR IN THE LANCET IS COPYRIGHT
`
`0189 1289LI SC IP 0400~~ °'f8
`SCRIPPS C~INIC hfS FDTH:'\)".W. l
`·i~~~~LT5R~·~R INES DEC:::~ 1988
`LA J3LLA
`CA
`92037
`DO NOT REMOV~j
`
`1 of 7
`
`BI Exhibit 1132
`
`

`

`1394
`
`Discussion
`This study is the largest experience to date with the
`bcnzodiazcpine antagenist flwnazcnil in the treatment of
`HE. The effects of the drug were assessed clinically and by
`SEP recordings. The late components of cortical SEPs
`(peaks X3 and P3) appear to be highly sensitive indicators of
`cortical dysfuiiction in HE.11 The results indicate that
`Oumazcnil may improve the HE that complicates both acute
`and chronic liver failure. Flumazenil treatment was
`IS30ciated with improvement in neurological status in 60%
`of episodes of HE; with one exception improvement
`occurred within a few minutes to an hour of drug
`administration. The speed of these responses contrasts with
`the interval of several hours that is typically necessary before
`HE improves after conventional therapies. The response co
`flumazcnil in bcmodiazcpine intoxication is also very
`rapid.19
`The 60% improvement rate may even underesr.imate the
`potential efficacy of flumazeni.I in the treatment of HE since
`most of the patients in this study had been cncephalopathic
`for many days before flumazenil treatment and had not
`responded to conventional therapy. Furthermore all 5
`patients with clinical evidence of increased intracranial
`pressure due to brain oedema did not respond to flwnazerul.
`l of these patients improved after treatment with mannitol.
`The remaining 4 died within 3 days of flumazcnil
`administration.
`In 8 of the 12 episodes rcponding to flumaz.cnil there was
`an exacerbation of HE 0·5-4 h after stopping treatment,
`This transient effect of the drug is consistent with its
`phannacokinctics.'°.z1 To achieve a sustained response
`continuous administration of the dn:~ over lonecr period~
`may be necessary. Although these 12 episodes unproved, no
`patient regained normal brain function at the end of
`treatment. The possibility that larger doses or a longer
`duration of treatment would have achieved complete
`improvement seems unlikely since, in bcnzodiazcpine
`intoxication, much lower doses are sufficient for recovery. 11
`In addition an increased GABA-crgic tone may be only one
`of many abnormalities of brain function in patients with
`liver failure and correction of this particular abnormality
`may therefore induce incomplete improvement.
`The mechanism by which flwnazcnil improves HE is
`uncertain. One possibility is displaccmcnt of an endogenous
`bcnzodiazcpinc-like
`from
`substance
`the GABA"(cid:173)
`bcnzodiazcpine receptor. The prcscncc of such a substance
`was suggested in the brains of animals with HE and in
`cerebrospinal fluid of patients dying with HE. 21
`This srudy was supponed by the Fonds zur FOrdcnina der wwcn·
`schaftlichcn Fonchung (P 6169 M). Flwnaunil was provided by Hoffmann(cid:173)
`La Roche, Basel, Swilzerland.
`Corttspondcnce should be oddttsscd to G. G., 1st Oepanmmt of
`Medicine, Uruvcniry of Vimn11, A-1090 Vimnll, Ausma.
`
`REFERENCES
`I. Scllafcr OF,P-SC, llndy LE,Jacol>I R,JonaEA. v...i~pounuab ona
`nbbol modd o( ._ mcephalopolhy I. _ . . . -..... Ind mmponsara
`wilh dtuc lnduc.d ........ ~ 1984;"' 540-45.
`2 Basil< AS, Ganvnal SH, Mullen KD, Jones EA, SkoWd< P. DilTcr<naal
`mponlivmcss o( ocr<bdlu: Pur!Onj< ncun>n> to GABA and bcnzodiazopu><
`r«<pcor bpnds in m orurnal modd olbcpobc: mcopbolopolhy. JN- 1988;1:
`2414--21.
`3. Scharer OF, Jones EA H<poac mcq>halopodly and 1h< y~...ad
`ncwocnnsrrumr ,,_.., ~ 11182; ii: 1&-.:IO.
`4. Paul SM, Ma..,..,. PJ, Skolnd P. Tbt ~-<hloride ionophote
`r«<pcor complct: ......-lite oCnunor innquilliza ection. Biol l'rycJr 1981; 16:
`213-29
`
`THEu.NCET,DECEMBER 17, 1988
`
`Preliminary Communication
`
`REMISSION INDUCTION IN NON-HODGKIN
`LYMPHOMA WI1H RESHAPED HUMAN
`MONOO..ONAL ANTIBODY CAMPA Til-lH
`
`G. HALE'
`M. R. ()JJu{I
`R MARcus2
`G. WrNTER1
`
`M. J. S. DYER2
`J.M. PHILLIPS'
`L. RIElliMA.NN1
`H. WALDMANN'
`
`/Rparrmnus of Palho/ogy1 and Haanarology,' Unn.'C'siry of
`Cambridge, and Labortllory of Mokcu/ar Biology,> Cambridge
`
`Summary
`
`A genetically reshaped human IgG l
`monoclonal antibody (CAMPATI-1-lH.
`was used
`to treat two patients with non-Hodgkin
`lymphoma. Doses of 1-20 mg daily were given
`intravenously for up to 43 days. In both patients lymphoma
`cells were cleared from the blood and bone marrow and
`splenomegaly resolved. One patient had lymphadenopathy
`which also resolved. These effects were achieved without
`myelosuppression, and normal haemopocisis was restored
`during the course of treaonent, partially in one patient and
`complctdy in the other. No antiglobulin response was
`detected in either patient. CAMPATI-1-lH is a potent
`lympholytic antibody which might have an important use in
`the
`treatment of lymphoprolifcrative disorders and
`additionally as an immunosuppressive agent.
`
`G. GRIMM AND OTHERS; REFERENa;.s....coruinwd
`
`5. Banldi M, Zenaoti ML, VaalW'll E, n al. Supmcnsiliviry o( bauodilzq>ane
`m:ep«>n in hq>oac aaaphalopelhy due to fulnunan1 bepotic failure in 1h< n1.
`r<venoJ by • bauodiaz<pine -
`Clut So 1984; 67: 167-~.
`6 BauettML.Mullm KD,Skolrud<P,nal~o(hq>oacmcephalopolhyby
`phumoo:)lopc .,_...,. oC 1h< GABA•~ re<:<J*lr canplot., a
`rabbttmoddofl\olminomhq>ouc faalutt. a.,,,_,,.oloo 1987;'3: 1069-77.
`7. 8ansky G, Mdcr PJ, Ziegler WH, Walser H, Sdvrud M, Huber M. Rev<nal of
`hepoDc coma by bcnzodiazepu>e Wlaiconi>t (Ro I 5rl788~ U..:n 1985; i• I 32+-25
`8 BanslyG,MacrPJ,RiedeftrE,nal Ell'<aola~-nbepooc
`mcephalopolhy.,--. H'PO'olao 1987; 7: 1103
`9. S<olJo.t....vw.n G, Suwvnonn E. Revenal ol hq>ooc coma by -_ , .
`anusonist (Ro 15rl788). lanu1 1985; i: 1324.
`10. Bwte DA, Milchdl KW, Al Mardini H, R<a>rd CO Rev<na1 o(hepobc coma Wldl
`Oumazmil .,........,..,...,,., an V>IUll ~ pocmaals. lanul 1988; ii:~
`11 Su!herbnd LR, M....ia GY. Ro 15rl788 and hepobc ~A- I"''"' Mal 1988,
`IOI: 158.
`12 Gnmm G, L<ni K, KJe.nberl<f G, n al. Ro I Sri 788 unprovcs coma on ~ out of 5
`peomts with fulmananl hcpabC Ca.turc": vcnficaoon by b\a; latency auditory and
`soma1osauory po<mtiab. J H•paUJ/ 1987; 4 (suppl I): S21.
`tl Mt... R, Gyr K. Traanen1o(hepoo< <ne<phalopotlay (HE) Wllh the btluodmepone
`.._.,. fNmazcrul: a plo< S<Udy. £w J A_,,ltnoo/ 1988; suppl 2 t l9-46
`14 T.....W. G, Jmnm B Assesvnaat o( 1X1ma and tmpaaml a>nsc:IOU>ll<SS a pncoaJ
`scale. lanut 1974; u: 81-1!4.
`15. Conn HO, Liebenhal M. Tbt hepotic 1X1ma syndromn and lactuloK. Baltimo«:
`Vlllilms & Wil<inl, 1979: 6.
`16. Cnao RQ, Bodlf.Wolner I, <do. Fronlim o( dinocal """"*"""' Voll evoked
`poc- New Yon:: Alm R. Lm, 1966.
`17. ) - HH. Tbt tal/twa>ty ekarodc .,....... oC 1h< I~ Fcdcnoon.
`~ClatN~1958; 10:371-75.
`18. Olu NS, Yq SS. Ponal-symnuc cnaphalopolhy: ahcrations in~ and
`bninsccm audnory evoked pocentials. J Nnmll So 1988; 14: 41-'°
`19 l'n5dU F, Donner A, Grimm G, t1 al Value o( flumazaul ., bauodiaupone
`ldf-poiooralns. M.J T.....i 1988;): 334-)9.
`:10 L>staR,Gr.<nl>llnD,AbemoihyD,nall'bam-....oc""'1ia..,ROl5rt788,a
`bcNodiueptne ._ lipnd, in tbebninol,._ B,.,,Ro 1984;J90l ls:Hl6.
`21. Roncanli G,ZiqlcrWH,GumienTW. --oltbencwbauodiaupine
`°"' ~ 19961ll:421-:IS.
`._m Ro 15rl788 in,,_ followinc inlrwv<nousand onl ldminio<nDan. Br J
`22. Mullen KD, M1r1111 JV, -WB ,n al Could., mdopnoul bcnmdiaz<pln<
`........ """"-., bepotic cna:pbalopodry? Lanut 1988; i: 457-59.
`
`2 of 7
`
`BI Exhibit 1132
`
`

`

`THE U..-.:CET,DECEMBER 17, 1988
`
`1395
`
`a
`UllHot•• , ........ ,
`lttMU Ntu+IN ON I
`
`A
`
`... -· ...
`
`i
`l
`
`Fag 1-Efrttt ofCAMPATil-IG (A) and CAMPATil-IH (8)- blood counts in poitleat I.
`4 - lymphocytes; D. • ncucrophils.
`
`INTRODUCTION
`T U.\\OUR treaanem by passive serotherapy has had a long
`and largely unsuccessful history .1 The advent of monoclonal
`antibodies gave fresh impetus to this approach, but results
`with unmodified antibodies are generally unremarkable.
`Efforts to enhance activity in vivo are now largely focused on
`the conjugation of antibodies to toxins or radionuclides.
`However, we are convinced that physiological effector
`mechanisms are still among the most potent and have tried
`to find the optimwn combinations of antibody specificity
`and isocype to exploit them fuJJy.
`One possible specificity is the CAMPATH-1 antigen.' It
`does not readily undergo modulation and is abundantly
`expressed on virtually all lymphoid cells and monocyces, but
`not on other cell cypes.u These properties make it a
`potential target for treaanent of lymphoid malignant
`disorders and for immunosuppression. Several rat lgM and
`lgG antibodies to this antigen have been produced.•.s The
`lgM CAMPATH-IM) is intensely lytic with hwnan
`complement and is widely used for depletion ofT cells from
`bone marrow to prevent graft-versus-host disease."' The
`lgG2b (CAMPATH-lG) is the most potent for cell
`depletion in vivo,• probably because it binds to hwnan Fe
`receptors and can activate the complement system.• Patients
`with
`lymphoid malignant disorders
`treated with
`CAMPATH- lG (25-50 mg/day for 10 days) showed
`pronounced reduction in lymphoid infiltration of blood and
`bone marrow and
`improvement of splenomegaly.•
`However, treaanent with rat antibody is likely to be limited
`by an antiglobulin response. This problem should be
`reduced or eliminated by use of a hwnan antibody. A
`reshaped hwnan antibody (CAMPATH-lH) has been
`constructed-the hypervariable regions of the rat antibody
`were transplanted into nonnaf hwnan immunoglobulin
`genes.• Hwnan IgG l was chosen since it had greater activity
`than other hwnan isocypes both in complement lysis and in
`cell-mediated killing .... "
`Here we describe the use of CAMP A TH-lH to treat two
`patients with non-Hodgkin lymphoma. Although it was
`possible to continue treaanent for up to 6 weeks without the
`development of a neutralising antiglobulin response, the
`main point of this report is to describe the efficacy of the
`antibody in clearing large masses of nunout cells. This is the
`first report of treaanent with a fulJy reshaped hwnan
`monoclonal antibody.
`
`PATIENTS ANO MEniODS
`Approval for the use of monoclonal antibodies was given by the
`ethical comminec of Addcnbrooke's Hospital and wrincn consent
`was obwncd from both paticnrs.
`Antibodies were obtained from culrure supernatant of cells
`growing in a hollow fibre biorcactor (' Acusyst-Jr', Endorronics).
`CAMPATii-IG was purified by precipitation with ammonium
`sulphate; CAMPATH-IH was
`purified
`by
`affinity
`chromatography on prolClll-A-• Scpharosc'. They were dissolved in
`phosphate-buffered saline, sterile filtered, and tested for pyrogcn
`and sterility. Patients were prchydrated overnight and antibody,
`diluted in 500 ml saline, was inflHcd over 2-4 h
`CAMPA TH-I expression on rumour cells was measured by flow
`and
`cytomctry
`complement-mediated
`Scrum
`lysis.u•
`ooncent12tions of CAMPATii-IH were measured by
`invnWlOOuorescmce with normal lympbocytcs.' Southern bk><
`analysis with an imnnmoglobulin J" probe was used to detect
`residual rumour cdls in DNA extracted from mononuclear
`fractions of bone marrow.• Antiglobulin responses were sought by
`two techniques. Tbc first was a solid-phase cnzymc-linked assay
`using microtittt plates coated with CAMPATH-IH. After
`incubation with patients' scrum samples, the assay was devdopcd
`with biotin-labelled CAMPATH-IH foUowcd by Stttptavidin(cid:173)
`pcroxidasc. A mixture of monoclonal mouse antibodies against
`human JgG was used as a positive control and 500 ng/ml of this
`mixture oould be detected. In the second assay, patienrs' scrum
`samples were mixed with rcdcdlsoouplcd with CAMPATH-IH.11
`Agglutination by 5 ng/ml of the control mixture could be detected.
`Inummoglobulin allotypcs were dctcrmincd by means of standard
`reagents and techniques from the Central Labomory of the
`Netherlands Red Cross blood U20Sfusion service.
`
`RESULTS
`
`PaLien1 I
`A 69-year-old woman presented in I 983 with acute
`appendicitis. Massive splenomegaly was found (table) and
`the bone marrow was heavily infiltrated with lymphocytes,
`some of which had clefted nuclei and a single nucleolus.
`There was weak membrane expression of IgM-kappa.
`Computed tomography scan showed splenomegaly but no
`lymphadenopathy. Grade I, stage IVA non-Hodgkin
`lymphoma in leukaemic phase was diagnosed. Between
`1983 and 1987 the patient received oral and intravenous
`chemotherapy with combinations of cyclophosphamide,
`vincristine, prednisolone, and chlorambucil, which induced
`partial responses, the minimwn level of marrow infiltration
`being 40%. Two courses of splenic radiotherapy were given,
`
`3 of 7
`
`BI Exhibit 1132
`
`

`

`1396
`
`THE LANCET, DECEMBER 17, 1988
`
`but the second (in April 1987) was cunailed since the spleen
`grew larger during the course.
`In September 1987 the disease progressed with increases
`in blood lymphocytes (24 x 109 cells/I) and spleen size. The
`patient was treated with CAMPATH-IG for 8 days (fig
`IA). This treatment completely cleared lymphoma cells
`from blood and marrow but only partially reduced spleen
`size. CAMP A TH-1 G induced fever, nausea, and vomiting,
`and the treatment was stopped on day 8 when it resulted in
`severe bronchospasm. (Such severe reactions have not been
`seen in twenty-one other patients who have received similar
`doses.) Reappearance of lymphoma cells in the blood was
`initially slow and the spleen size did not change for 5 months
`but there was little recovery of normal haemopoiesis. In
`March 1988 the patient began to lose weight and
`experienced drenching night sweats. The spleen enlarged
`and lymphoma cells reaccumulated in the blood. They
`had
`similar phenotype and
`identical
`rearranged
`immunoglobulin J" fragments
`to those seen before
`treatment. Marrow aspirate and trephine showed complete
`replacement of normal marrow by lymphoma cells (fig 2A);
`the patient became dependent on red-cell transfusions and
`was absolutely neutropenic.
`The patient's serum did not block binding of
`CAMPATH-IH or CAMPATH-IG
`to
`normal
`lymphocytes and the tumour cells were still sensitive to these
`antibodies in vitro, so we decided to treat her with
`CAMPATH-IH. The starting dose was 1 mg daily and,
`since it was well tolerated, the dose was increased to a
`maximum of 20 mg/day, though the usual dose was 4
`mg/day owing to the small amount available. In all the
`patient received 126 mg over 30 days. The response was
`prompt; in 6 days the night sweats had abated, by day 10
`there was pronounced reduction in splenomegaly and
`recovery of blood neutrophils, and by day 18 lymphoma
`cells were cleared from the blood (fig IB). On day 28 a bone
`marrow aspirate and trephine were hypocellular but showed
`active myelopoiesis and erythropoiesis and no lymphoid
`cells (fig 2B). No CAMPATH-1-positive cells could be
`detected by flow cytometry. DNA from the mononuclear
`marrow cells was germline when probed with an
`immunoglobulin t probe under conditions where clonal
`rearrangements could be detected in 0·2% of cells. Thus, we
`conclude that lymphoma cells were cleared from the
`marrow. The spleen volume was reduced about eight-fold
`(fig 3A, B), although it was still slightly larger than normal.
`Other than fever occurring about I h after the end of
`antibody infusions there were no adverse effects of antibody
`treatment until the 5th week, when severe rigors occurred
`after each infusion. No antiglobulin response could be
`detected and the rate of clearance of antibody from the
`serum was unchanged. For the next 3 weeks the patient
`continued to experience occasional fever and rigors. She was
`given oral cotrimoxazOfe because of her lymphopenia, but
`no infective cause of these symptoms could be found.
`In the next 4 months lymphocytes, which appeared
`morphologically normal, slowly reappeared in the blood (up
`to 0·2 x 109/1). They did not show the characteristic
`rearranged immunoglobulin fragments, and both CD3-
`positive and CDI9-positive cells were present (table).
`Serum immunoglobulin levels, which had been very low
`since presentation, have risen towards normal (table). A
`marrow aspirate and trephine taken 50 days after the end of
`treatment were again hypocellular but had no
`lymphomatous infiltration. This rnai:ow sample contained
`
`PATIENT OiARACfERISTICS BEFORE AND AFTER TREATMENT
`WITH CAMPATH-IH
`
`Patient 1
`
`Patient 2
`
`-
`Splern nu (m/Jt
`Lymphadmoparlryt
`
`~marrow
`% lymphoma cells
`Southern blot analysis
`lg JH fragment
`Pm/>heral blood
`Haemoglobin (g/dl)
`Rcticulocytcs ( x 109/1)
`Platelets ( x 109/1)
`Lymphocytes ( x 109/1)
`Neu<rophils ( x 109/1)
`Monocytcs ( x 109/1)
`Blood lymplwcyte
`phmctype I % J
`CD19
`CD3
`CAMPATH-lM
`CAMPATii-lH
`Serwn immunctlobulins
`lg/I)
`JgM
`lgA
`JgG
`Brna-Jtm£j
`
`Before
`
`After•
`
`lld0tt
`
`4460
`None
`
`590
`None
`
`2600
`
`paraortic
`
`99
`
`0
`
`R/R
`
`G/G
`
`8·7
`31
`37
`60
`0
`O·
`
`97
`0
`96
`98
`
`<0·3
`<0·5
`5·8
`None
`
`10·6
`135
`50
`0
`2-0
`0-04
`
`46
`32
`ND
`ND
`
`1·2
`<0·5
`8·2
`None
`
`72
`
`R/R
`
`11·2
`ND
`110
`37
`4·6
`1·5
`
`93
`8
`95
`97
`
`<0·3
`<0·5
`n
`++
`
`After•
`
`440
`None
`
`0
`
`G/G
`
`.12-0
`ND
`453
`0
`7-3
`0·5
`
`<5
`80
`ND
`ND
`
`0·7
`0·5
`4·7
`None
`
`*Made shonly after end of antibody treatment, except for lymphocyte
`phcnotyping and senun inununoglobulins, which wae assessed 6 weeks
`later.
`tBy computed tomognphy.
`ND- not done.
`
`4% CAMPATH-1-positive cells and showed some
`oligoclonal rearrangements of immunoglobulin genes.
`However, by day 100, lymphoma cells were again detected
`in the blood and the spleen size had started to increase. A
`second course of 12 days' therapy with CAMPATH-IH
`was completed with similar therapeutic benefit to the first
`and no adverse effects. Since the main reservoir of disease in
`this patient appeared to be the spleen, splenectomy was
`carried out at the end of this second course of treatment. At
`that time no rumour cells could be detected in blood or
`marrow. The patient is now well 37 days after the
`splenectomy. The lymphocyte count is low but she has
`normal neutrophil, platelet, and red-cell counts.
`
`Pazient 2
`A 67-year-old man presented in April 1988 with splenic
`pain; there was 12 cm splenomegaly, and computed
`tomography scan of thorax and abdomen revealed
`retrocrural and para-aortic lymphadenopathy, the largest
`node measuring 3 cm in diameter (fig 3C). A blood count
`revealed 36·6 x 109 lymphocytes/ml, the majority being
`lymphoplasmacytoid cells which expressed surface IgG(cid:173)
`kappa and were characterised by large cytoplasmic periodic(cid:173)
`acid-Schiff-positive vacuoles which could be intensely
`stained by anti-IgG. A marrow aspirate contained 72%
`lymphomatous cells
`(fig 2C). DNA
`from blood
`mononuclear cells showed biallelic rearrangement of
`immunoglobulin J" genes but was germline with various
`T -cell receptor and oncogene probes. The lymphoma cells
`expressed
`the CAMPATH-1 antigen
`in amounts
`comparable with normal lymphocytes but were more
`resistant to complement-mediated lysis. Stage IV A grade I
`
`4 of 7
`
`BI Exhibit 1132
`
`

`

`THE LJ\NCET, DECEMBER 17, 1988
`
`1397
`
`.. ~··
`,
`~'= ... ·~~··-...: .. ,
`• !
`. . ... ·.
`•...
`... ..
`·--
`.. ":.
`
`•·,~
`
`..
`"·
`
`. --
`
`-· ... ·~
`..A~
`... ·
`..:· .......... ·
`,
`• • ~ . . . . . . ... "t~ . . .
`
`Fig 2.-Cytology of hone ma.rrnw cells.
`
`A~ patient I trcphine before trcaancnt with CAMPATH-IH; B • patient I trcphine on day 43 (ie, 16 days after trcaanent); C~ patient 2 aspirate before
`treatment with CAMPATH·IH; D - patient 2 aspirate on day 78 (ie, 35 days after trcauncnt). Rcdu<:<d by 58% from x IOO (A,B), x 1000 (C), x 400 (D).
`
`A
`
`B
`
`c
`
`D
`
`Fag 3--Computed tomography scans showing affected splttDS and lymphnode.
`A•patient I before trcaoncnt with CAMPATH·IH; B •patient I on day 57; C - paticnt 2 before trcaancnt with CAMPATH-IH (tttr()CJ"llra] node
`arrowed); D •patient 2 on day 51.
`
`5 of 7
`
`BI Exhibit 1132
`
`

`

`1398
`
`THE LANCET, DECEMBER 17, 1988
`
`CAMH.TH · tH
`llllfltUUUUH I
`
`ISMt totel
`f
`I
`I
`I
`I
`
`100
`
`t
`
`t
`
`10
`
`c
`e
`
`0 · 5
`
`•
`
`i
`l
`
`0
`
`10
`
`20
`
`30
`
`•o
`
`so
`
`10
`
`10
`
`10
`
`to
`
`Days since start of antJbody therapy
`
`Fig -Effect of CAMPA TH-IH on blood counts in patient 2.
`
`• = lymphocytes; D. = neutrophils.
`
`non-Hodgkin
`
`lymphoma was
`
`lymphoplasmacytoid
`diagnosed.
`The patient was offered CAMPATH-lH as primary
`therapy and received a total of 85 mg over 43 days. This
`resulted in clearance of the lymphoma cells and normal
`lymphocytes from blood (fig 4) and marrow (fig 20),
`resolution of splenomegaly, and improvement in the
`lymphadenopathy. A computed tomography scan taken 8
`days after the end of antibody treaunent was normal (fig
`30). A bone marrow aspirate taken at the same time showed
`active haemopoiesis but no lymphoma cells, and no
`CAMPATH-1-positive cells could be detected by flow
`cytometry. DNA from the mononuclear fraction of this
`marrow showed only germline configuration when probed
`imrnunoglobulin J H probe. By day 78
`with
`the
`morphologically normal blood lymph0cytes began to
`reappear and none of the vacuolated cells could be seen. The
`patient remains well and off therapy.
`Some toxic effects of CAMPATH-lH were observed.
`The first dose was stopped after 3 mg had been given
`because of hypotension, possibly caused by tumour lysis.
`This problem was subsequently avoided by giving smaller
`doses at a slower rate and when lymphoma cells had been
`cleared from the blood, the dose was increased to a
`maximum of 8 mg over 4 h without any effect on blood
`pressure. Nevertheless, all doses induced fever (up to
`38·5°C), and malaise for up to 36 h, but these were not severe
`enough to stop antibody treaunent which, after the first
`week, was given on an outpatient basis. Treaunent was
`stopped after 43 days because of the development of an
`urticaria! rash after two successive antibody infusions.
`
`Half-life of CAMPATH-IH
`The concentration of CAMP A TH-1 H was measured in
`serum samples taken before and after antibody infusions and
`at other rimes throughout treaunent. In theory, a dose of 4-<i
`mg corresponds to about 1 µg/ml in the plasma. In fact we
`could not detect free antibody till day 4-<i, presumably
`because of rapid uptake by the tumour mass. After that, the
`rate of clearance was
`roughly constant, with
`the
`concentration being about 30-70% of the theoretical level
`
`Lack of Antiglcbulin Response
`TheallotypeofCAMPATH-lH is Glm(l,2,17),Krn(3).
`Patient 1 was Glm(l,3,17),Krn(3) and patient 2 was
`G lm(3),Krn(3), so both could theoretically have made an
`anti-allotype response as well as a response to the
`hypervariable regions. However, we failed to detect any
`antiglobulin to CAMPATH-lH either by the solid-phase
`the more
`sensmve
`enzyme-linked assay or by
`haemagglutination assay. In addition, the rate of clearance of
`CAMPA TH-IH did not change and free antibody could be
`detected for up to 8 days after the last dose had been given. It
`is possible that the reactions experienced at the end of the
`course of treaunent could have been provoked by
`contaminating non-human proteins
`in
`the antibody
`preparation.
`
`DISCUSSION
`The remissions achieved in these two patients show that it
`is possible to clear large numbers of rumour cells with small
`amounts of an unmodified monoclonal antibody. The
`effects in the first patient were far superior to the results of
`previous chemotherapy and radiotherapy. The selective
`lysis of lymphoma cells with recovery of normal
`haemopoiesis during the course of treaunent was an
`important advantage, which allowed treaunent to be given
`largely on an outpatient basis. We believe the· choice of
`antibody specificity and isotype is important; indeed, it may
`be why we had more success than previous effons with other
`monoclonal antibodies.1 ... 16 The CAMPATH-1 antigen
`seems to be a good target because it is widely distributed and
`abundant, and does not
`suffer
`from antigenic
`modulation.2.>"·11 This study shows that, as predicted,
`human IgGl can bring about cell lysis in vivo, though we
`cannot yet assess the relative importance of humoral or
`cellular mechanisms. There was no change in serum
`complement levels (CH50, C3, or C4 components) during
`antibody treatment (data not shown), but this does not
`exclude a role for C3 in cell clearance.
`Although the two patients did not make any serologically
`detectable antiglobulin response, it would be premature to
`draw general conclusions about the imrnunogenicity of
`human monoclonal antibodies, since CAMPATH-IH itself
`is probably imrnunosuppressive and the patients were
`already immunosuppresscd as a result of their disease.
`Nevertheless, it was encouraging that two courses of
`antibody treaunent could be given, even in the patient who
`· had previously had unusually severe reactions to the original
`rat antibody.
`The long-term benefit of treaunent with CAMPATH-
`1 H can only be assessed in a much larger trial when it would
`conventional
`probably be combined with more
`chemotherapy and radiotherapy. It may have wider
`an
`imrnunosuppressive agent
`for
`applications as
`transplantation and possibly autoimmi,me disease, since we
`already know that the rat antibody CAMPATH-IG is a
`potent imrnunosuppressant in the shon-term.
`
`We thank the patients and families, nursing sWT, medical collcaguc:s, and
`Prof F. G . J. Hayhoe for their coopcT3tion, encouragement and support; and
`Dr D. Gilmore, Dr H. S. Kruger-Gray, Prof R. R. A. Ox>rnbs, Mart.
`
`6 of 7
`
`BI Exhibit 1132
`
`

`

`THE LANCET, DECEMBER 17, 1988
`
`Frcwin, ond Caroline McHarg for their help. Thn won was Npported by !he
`Medical R~ Uiunal, Wellcome Bioccdl Lid, Ind St John's Collqe
`Cambrid~ (Meres studcntslup to M. J. S. D.). 'CAMPA Tif' 1$ a trade mart;
`ofWelkxxne Foundaoon.
`
`Correspondence should be addressed 10 H. W., Department of Pathology,
`Uruvcmty ofCamb~, Tennis Coun ROid, Cambrid~ CB2 IQP.
`
`REFERENO!S
`I. Cumc GA. Ech'l' yean o< immunoch<npy: 1 ttVICW olimmunoloplll m<lhods used
`(or treatment album.. canar. B' J c.-tr 1972; Mc 141-S).
`2. !Uk G, 11nabt S, Olumblcy G, ct oL R..._.t ol T odl from ban< monow (or
`cnrupbntation: a monodMal .-itilymphocytc antibody that fuccs human
`compl<mau. Blood 1983; 62: 87>-82.
`3. Hole G, Swinl<y O, Waldmann H, 0 - LC Rcoctivity ol r11 mon