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Bone Marrow Transplantation (2007) 39, 115–120 & 2007 Nature Publishing Group All rights reserved 0268-3369/07 $30.00

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ORIGINAL ARTICLE

Use of physiological doses of human growth hormone in haematological patients receiving intensive chemotherapy promotes haematopoietic recovery: a double-blind randomized, placebo-controlled study B Sirohi1, R Powles1, G Morgan1, J Treleaven1, S Kulkarni1, C Horton1, R Saso1, D Rolfe1, G Cook1, C Shaw1 and J Wass2 1

Haemato-Oncology Unit, Royal Marsden Hospital and Institute of Cancer Research, Sutton, Surrey, UK and 2Department of Endocrinology, Churchill Hospital, Oxford, UK

In vivo and in vitro studies suggest human growth hormone (hGH) receptors on bone marrow stem cells may be biologically active and could be exploited to promote haemopoetic recovery after intensive chemotherapy. Patients with haematological malignancies receiving intensive chemotherapy and requiring hospitalization were randomized in a double-blind, placebo-controlled singlecentre trial. Patients were randomly assigned to receive either hGH 500 lg/day or placebo, for 6 weeks. There was no significant difference in patient characteristics at baseline between the placebo and treatment arms. Patients treated with hGH showed significantly faster recovery of platelets to 25 109/l (median of 16 versus 19 days; P ¼ 0.03) compared to the placebo-controlled arm (hazard ratio 1.47 favouring hGH, 95% confidence interval (CI), 1.03–2.08). Time to relapse did not differ significantly between arms. There was no change in the anthropometric parameters at the start and end of hGH/placebo therapy. The study drug was well tolerated. Treatment with hGH in physiological doses improves platelet recovery, but is not associated with a lower relapse rate or improved anthropometric parameters in patients receiving intensive chemotherapy. Bone Marrow Transplantation (2007) 39, 115–120. doi:10.1038/sj.bmt.1705545; published online 4 December 2006 Keywords: hGH; haemopoietic recovery; intensive chemotherapy

Introduction Growth hormone receptors are known to exist on normal bone marrow haemopoetic stem cells. These are biologi-

Correspondence: Professor R Powles, Parkside Oncology Clinic, 49, Parkside, Wimbledon, SW19 5NB, UK. E-mail: [email protected] Received 11 August 2006; revised and accepted 23 October 2006; published online 4 December 2006

cally active as seen in models in which exposure to recombinant human growth hormone (hGH) in vitro increases the colony-forming capacity of human myeloid and erythroid precursor cells and increases the colonyforming units in the spleen of inoculated mice.1–4 hGH produces better mobilization of marrow stem cells in mice and man, and hGH-treated mice recover more quickly after syngeneic transplantation of marrow cells.4,5 In a double-blind, placebo-controlled randomized trial, we explore the possibilities that hGH may be used in vivo to enhance bone marrow recovery after intensive treatment with cytotoxic chemotherapy and may also attenuate morbidity by reducing muscle loss, as seen in AIDS patients.6–8 We also explore whether there is any direct or indirect anti-tumour effect on the malignant cells leading to prolongation of remission duration and survival because of the presence of receptors on these cells allowing increased apoptosis. Also, enhanced marrow recovery may permit optimization of chemotherapy scheduling.9

Methods Study design The study was designed as a prospective, randomized, double-blind, placebo-controlled trial. Patients were randomized (1:1) to receive hGH or placebo. Enrolment took place between July 2002 and September 2003 at the Royal Marsden Hospital. The trial design was such that patients would receive the study drug intravenously while they were admitted for a period of 2–4 weeks and were receiving other intravenous medication as part of their routine management. After the first 20 patients, it was apparent that the study drug was well tolerated and the patients were receptive to the idea of administering it subcutaneously on discharge. Hence, the trial duration was extended to 6 weeks after ethical approval. Patients started hGH/placebo when they commenced chemotherapy with or without total body irradiation as part of conditioning for their stem cell transplant (on day 1). The study was approved by local research and ethics committee and individual patient consent was obtained (Local number 2128; NCT00300664).

hGH and haemopoietic recovery after intensive chemotherapy B Sirohi et al

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Patients Patients were eligible for randomization if they fulfilled the following criteria: a diagnosis of haematological malignancy, above 18 years of age and undergoing in-patient myelosuppressive chemotherapy and/or radiotherapy, no history of allergy to hGH, no history of hypertrophic cardiomyopathy or severe heart failure and serum creatinine below 150 mmol/l. The first 20 patients enrolled in the study received the study drug (hGH/placebo) only during their hospitalization (median of 24 days, range 9–42 days), but all subsequent patients were planned to receive it for 6 weeks (intravenously or subcutaneously depending upon the intravenous access). Patients were allowed to participate in the trial for the second or third time if they were still eligible and were being hospitalized for chemotherapy. Procedures The randomization code was computer generated by the statistical division of the Institute of Cancer Research and held by the pharmacy department independently. The nurses and physicians involved in the study were not aware of the randomization. Patients were randomized to receive either hGH or placebo in a 1:1 ratio. Pre-filled syringes (0.5 ml) labelled hGH/placebo were made in the chemotherapy division of the pharmacy for each patient and kept on the ward. Each patient had syringes prepared regularly for a week at a time. All patients had routine full blood count and biochemistry tested daily until discharged from the hospital and then with every out-patient visit (usually twice a week to begin with and then weekly). Patients had the following investigations performed at the time of study entry and at the end of 6 weeks therapy: height, weight, triceps skin fold thickness (TFT) in mm, mid-arm circumference (MAC) in cm, serum IGF-1 levels, mannan binding lectin (MBL)

Table 2

levels and muscle strength in the quadriceps group of muscles. Dual-energy X-ray absorptiometry (DEXA) scans for total body composition on study entry and at 6 weeks was undertaken in the last 33 patients. Body mass index (BMI) was calculated as weight/(height)2 (kg/m2) and mid-arm muscle circumference (MAMC) was calculated as MAC (3.14 TFT in cm) cm2 at baseline and at 6 weeks. Serious adverse events during the trial were reported to the trials office. Data on MBL levels and muscle strength will be presented elsewhere.

Statistical analysis and justification The end points of the study were to assess BMI, MAC, TFT, MAMC at the start and end of therapy with hGH/ placebo, to assess tolerability of hGh/placebo, IGF-1 levels, albumin levels, recovery of neutrophils, platelets, days in hospital and overall and relapse-free survival. No estimates of the within-patient variation in these parameters in this group of patients were available on which to base sample size calculations. The literature suggests that as many as 90% patients will have significant weight loss and reduction in muscle mass during intensive therapy for haematological malignancies.10–13 If the percentage of patients losing weight and muscle mass is reduced by 20%, the study would have 80% power to detect the difference as Table 1 Trial profile of 119 patients receiving 150 courses (treatment protocols for these patients are shown in Table 2) Study drug

Once only

Twice

Thrice

Total

hGH Placebo hGH and placebo

48 47 0

5 5 7

1 0 6

54 52 13

Total

95

17

7

119

Patient characteristics of 150 courses and 106 non-cross over patients hGH (n ¼ 75)

Placebo (n ¼ 75)

Non-cross-over hGH (n ¼ 54)

Non-cross-over placebo (n ¼ 52)

P

Sex, male/female

47/28

51/24

0.5

34/20

36/16

0.5

Age (years) Median (range)

50 (18–74)

52 (19–77)

0.4

55 (18–74)

54 (20–77)

0.9

Diagnosis Acute leukaemia Myeloma Other

43 (57%) 30 2

49 (65%) 23 3

0.5

24 29 1

29 20 3

0.2

Treatment Chemotherapy Autotransplant Allotransplant Received TBI

29 39 7 12 (16%)

32 36 7 15 (20%)

0.9

17 33 4 6 (11%)

20 28 4 7 (13%)

0.7

Disease stage* Newly diagnosed Complete remission Partial remission Relapse/progressive disease

18 25 (33%) 17 15

11 42 (56%) 8 14

12 13 (24%) 17 12

9 21 (40%) 8 14

Patient characteristics

Abbreviation: hGH ¼ humam growth hormone. *P-value for complete remission versus rest.

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P

0.5

0.005

0.7

0.07


Abbreviations: BMI ¼ body mass index; IGF ¼ insulin-like growth factor; MAC ¼ mid-arm circumference; MAMC ¼ mid-arm muscle circumference; TFT ¼ triceps skin fold thickness.

3.6 (17.3 to +16.2) 0 1.3 (6.2 to +3.2) 0.15 (1.8 to +0.9) 1.16 (5.34 to +5.11) 1.05 (7.77 to +5.37) 0 (16 to +12) 15 (339 to +446) (45.4–116.4) (1.46–2.00) (18.8–43.4) (0.9–4.7) (16.54–38.01) (14.13–30.21) (20–50) (4–642) 71.8 1.72 29.2 2.6 24.26 21.12 34 280 (46.3–106) (1.5–1.89) (21–37.4) (1.4–4.6) (16.91–39.06) (12.96–29.49) (19–45) (17–697) 73.4 1.7 30 2.53 24.63 21.57 35.5 411 0.38 0.65 0.41 0.33 0.15 0.088 0.69 0.47 (47.7–117.6) (1.46–2) (20.9–43.1) (0.9–5.2) (17.46–39.16) (13.99–29.58) (21–43) (40–597) 75 1.72 30.9 2.55 25.09 22.39 35.5 313.5 (50.9–116.7) (1.50–1.89) (25.0–40.2) (1.4–5.8) (20.13–40.35) (15.25–30.59) (24–46) (74–661) 77.4 170 32 2.6 26.43 22.68 35.5 286

GH, at 6 weeks P, baseline Placebo, baseline GH, baseline

0.53 0.65 0.67 0.64 0.28 0.94 0.26 o0.0005

3.5 (18.6 to +2.4) 0 1.5 (9.0 to +2.7) 0.1 (1.9 to +1.2) 1.23 (5.58 to +0.97) 1.21 (8.33 to +6.71) 0 (17 to +11) 101.5 (254 to +454)

P Change placebo, baseline to 6 weeks Change GH, baseline to 6 weeks

Weight (kg) Height (m) MAC (cm) TFT (mm) BMI (kg/m2) MAMC (cm2) Albumin (g/dl) IGF-1 (ng/ml)

Anthropometric data There were no significant differences in the baseline anthropometric parameters between the hGH and placebo arm (Table 3). At the end of 6 weeks of therapy, there was no difference in anthropometric measurements between the two groups.

Parameter

Non-cross-over patients Of the 119 patients, 13 were crossed over between hGH or placebo, and hence 106 non-cross-over patients were exposed to either hGH (n ¼ 54; five twice and one thrice) or placebo (n ¼ 52; five twice) alone. These patient data were used for outcome analysis. Demography of the 106 patients is shown in Table 2.

Table 3

Patients A total of 150 courses of hGH/placebo were administered to 119 patients. Other than a significantly higher number of patients in complete remission (CR) in the placebo arm (P ¼ 0.005), baseline characteristics were well balanced between both the arms. Ninety-five patients were randomized once, 17 were randomized twice and seven on three occasions (Table 1). Four patients withdrew from the study owing to personal reasons. The chemotherapy regimens received by the patients in the two arms were not significantly different and are shown in Table 2. Various chemotherapy regimens (described in detail elsewhere) received by the patients were BF1214 (11 hGH, 10 placebo), MACE14,15 (seven hGH, 10 placebo), DAT/DAM15 (mylotarg with DA three hGH, eight placebo), UKALL XII/ German ALL induction/consolidation16 (four hGH, two placebo) and others (four hGH, two placebo).

Anthropometry at baseline and at 6 weeks (medians and range given in parentheses)

Results

Placebo, at 6 weeks

P, at 6 weeks

Drug doses and duration of treatment Patients were randomized to receive 250 mg intravenously twice daily (500 mg/day), of hGH or placebo on the day of starting chemotherapy. When the platelet counts increased above 20 109/l, the study drug was administered at a dose of 500 mg subcutaneously once a day. The total duration of therapy was 6 weeks.

0.47 1 0.65 0.94 0.45 0.56 0.41 o0.0005

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significant at a two-sided alpha level of 0.05, if 150 courses are completed in a 1:1 ratio (75 in each arm). The Mann–Whitney test for equality of medians was used to compare continuous variables and the w2 test was used to compare frequencies. Time to haematological recovery, discharge from hospital and survival were estimated using the Kaplan–Meier method and comparisons between groups were made using log–rank method. The trial profile is shown in Table 1. All 150 courses (Table 2) were used for the assessment of anthropometric data, hospital stay and haematological recovery. Data on 106 non-crossed-over patients (Table 2) were used for assessment of survival and relapse. Non-cross-over patients were defined as those who received either hGH or placebo alone (once, twice or thrice) throughout their treatment.

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118 Recovery of neutrophils to 0.5 × 109/l 100 Median 17 days for hGH (n =75)

80 % Prob

DEXA scans Whole-body DEXA scans were performed at baseline in 33 patients and at 6 weeks in 28 patients (15 hGH and 13 placebo) to measure lean body mass, total fat and total bone mineral content. Lean body mass reduced by a mean of 5.4% in both groups. Total fat reduced by 7.3% in the hGH group and 8.2% in the placebo group and bone mineral content by 0.8% in the hGH group and 0.4% in the placebo group. No statistically significant differences were found between the two arms.

60 40 P = 0.41 20 0

Tolerability of the study drug hGH/placebo was well tolerated and no serious adverse events were attributable to the study drug. Patients received hGH for a median of 41 days (range, 2–42) and placebo for a median of 42 days (range, 10–42) (P ¼ 0.3). Five (7%) patients died during the study period at a median of 21 days (range, 10–40) in the hGH arm compared to four (5%) patients in the placebo arm (P ¼ 0.5).

0

2

1

3

4

5

6

8

7

9

Months since end chemo

Figure 1 Log-rank comparison for recovery of neutrophils to 0.5 109/l between hGH (n ¼ 75) and placebo (n ¼ 75) arm.

Recovery of platelets to 25 × 109/l 100

Median 16 days for hGH

80 % Prob

IGF-1 levels IGF-1 levels (mg/l) were comparable between the two arms at baseline. At the end of 6 weeks of therapy with hGH, there was a significant rise in the levels of IGF-1 with hGH compared with placebo (Po0.0005). The median IGF-I level at baseline in the hGH arm was 286 (range, 74–661) compared to 313.5 (range, 40–597) in the placebo arm (P ¼ 0.47). At the end of the study period, IGF-1 levels were available for 138 courses, median of 411 (range, 17–697) in the hGH arm compared to 280 (range, 4–642) in the placebo arm (Po0.0005).

Median 18 days for placebo (n =75)

Median 19 days for Placebo (n =75)

60 40

P = 0.028

20 0

0

1

2

3

4

5

6

7

Months since end chemo

Figure 2 Log-rank comparison for recovery of platelets to 25 109/l between hGH (n ¼ 75) and placebo (n ¼ 75) arm.

Changes in glucose levels Blood glucose levels (mmol/l) were available at the end of 6 weeks in 110 patients. For these, the median glucose at baseline was 6.1 (range, 4.5–18) in the hGH arm compared with 6.3 (range, 3.8–15) in the placebo arm (P ¼ 0.7). The level of glucose at the end of treatment was 5.9 (range, 3.5– 15) in the hGH arm compared with 5.9 (3.9–15.4) in the placebo arm (P ¼ 0.4). The median change from baseline to the end of treatment was 2 in the hGH arm and 0.35 in the placebo arm (P ¼ 0.9). Eight patients received insulin in the hGH arm (two diabetic) compared with five patients (one diabetic) in the placebo arm (P ¼ 0.76). Haematological recovery Time to haematological recovery was estimated from the last day of chemotherapy. There was no difference in the time to neutrophil recovery above 0.5 109/l (Figure 1). The time to platelet recovery above 25 109/l was significantly faster in the hGH arm (median of 16 versus 19 days in hGH and placebo arm, P ¼ 0.028; Figure 2). The median number of packed red cells transfused was four (range, 0–22) in hGH arm versus five (range, 0–46) in the placebo arm (P ¼ 0.5). The median number of platelets transfused in the hGH arm was three (range, 0–44) compared with five (range, 0–42) in the placebo arm (P ¼ 0.22). The incidence of documented infections was not significantly different between the two arms (hGH arm: 12 Bone Marrow Transplantation

bacterial, one fungal and two viral compared with 12 bacterial, two fungal and one viral in the placebo arm). There was no significant difference in time to discharge from hospital and the need for supportive care.

Overall survival In the non-cross-over group of 106 patients, 54 are alive at a median of 805 days (range, 238–1006) and there was no difference in the overall survival (OS) between the two groups (hGH 32/54 alive, placebo 22/52 alive, P ¼ 0.12; Figure 3). There were 29 myeloma patients in the hGH arm and 21 in the placebo arm and there was no difference in their OS (HR ¼ 1.68, 95% CI 0.64–4.43, P ¼ 0.28). Relapse Fifty-two of the 106 non-cross-over patients relapsed. Twelve patients were considered not evaluable for relapse as they were in relapse at the time of treatment and the response was not assessable (five in the hGH arm and seven in the placebo arm). Twenty-six of the 54 patients in the hGH arm and 26 of the 52 patients in the placebo arm relapsed (P ¼ 0.22; Figure 4). Of the 29 myeloma patients in the hGH arm and 21 in the placebo arm, there were no significant differences in relapse rate (HR ¼ 1.48, 95% CI 0.68–3.22; P ¼ 0.3)


119 Overall survival in 106 non-cross over patients 100 P = 0.12

80 % Prob

hGH: 32 of 54 patients alive

60

40

Placebo: 22 of 52 patients alive

20

0 1

0

2

3

Years since 1st date chemo-end

Figure 3 Log-rank comparison for OS in non-cross-over patients between hGH (n ¼ 54) and placebo (n ¼ 52) arm.

Probability of relapse in non-cross over patients 100

P = 0.22

% Prob

80 Placebo: 26 of 52 relapsed; 7 non-evaluable

60 40

hGH: 26 of 54 relapsed; 5 nonevaluable

20 0

0

1

2

3

Years since 1st date chemo-end

Figure 4 Log-rank comparison for relapse-free survival in non-cross-over patients between hGH (n ¼ 54) and placebo (n ¼ 52) arm.

Discussion This is the first study in man to show faster haemopoietic recovery (platelets) in man by the use of hGH after intensive chemotherapy and supports the observation in mice that showed faster recovery after syngeneic transplant.4 The only other study in man that indirectly supports this observation is that by Carlo-Stella et al.5 which has shown that combining hGH with granulocyte-colony stimulating factor (G-CSF) leads to a significantly better collection of haemopoetic stem cells than with G-CSF alone. We did not see a significant effect on neutrophil recovery and days of hospitalization with hGH and this may be due to the small number of patients studied, or it is possible that hGH was acting as a co-factor for in vivo thrombopoietin. We were mindful that hGH might be toxic when given to patients receiving intensive chemotherapy as it has been shown that there was increased mortality and morbidity with its use in supraphysiological doses in critically ill patients.17 In the critically ill patients, those treated with hGH required insulin more frequently than in the placebo group. The dose of hGH used in our study was equivalent to 7 mg/kg, which is the upper end of the physiological dose required by an adult; this was much lower than that used in

the study by Takala et al.,17 where patients received up to 5.3–8 mg/day of hGH. We knew before embarking on our study that blood glucose control would be important because, firstly hGH does not work well in the presence of a high blood glucose and secondly our patients often have high blood glucose levels due to the use of steroids as part of their anticancer treatment, anti-emetics or for treatment of graft-versus-host disease. In our study, treatment-related mortality was similar in both the arms and we were reassured to find few side effects in this population of patients who are frequently very ill due to a combination of active disease, bone marrow failure and the side effects of treatment. Despite the low dose of hGH in this pilot study, we clearly demonstrated a significant effect on platelet reconstitution and feel that further studies may warrant increasing the dose of hGh to maximize haemopoetic effect. In the present study, hGH was given intraveneously to our thrombocytopenic patients because during this period subcutaneous injections cause unacceptable bruising, pain and morbidity and this does not affect bioavailability. Intravenous administration of hGH is probably not equivalent to subcutaneous administration, as the plasma half-life of growth hormone is only 15–20 min. It has previously been used intravenously in various studies without any concern relating to tolerability and toxicity.18 In these intensively treated patients, there was a significant rise in IGF-1 levels at the end of hGH therapy, suggesting that resistance to growth hormone described previously in patients with severe systemic illness was not present.19,20 We also looked at the outcome of myeloma patients separately owing to the potential role of IGF-1 in supporting myeloma cell growth21 and found no difference in relapse rate between the two arms. In 1996, growth hormone was approved by the Food and Drug Administration (FDA) for the treatment of wasting and cachexia in patients with AIDS. This approval was based on evidence that growth hormone increases lean body mass and decreases fat mass in patients with AIDS, and a survival benefit was observed.22–24 Cancer patients lose weight and muscle mass during chemotherapy.10,11 In this study, we hoped to see a possible protection in preventing muscle and protein loss during the immediate period after intensive chemotherapy. As this study period was too short to see muscle mass gain, the study was designed to assess prevention of muscle loss. We did not see any such benefit, possibly because the dose of hGH used may have been insufficient to elicit the responses shown in the patients with AIDS where higher pharmacologic doses were used (1.4–6 mg/day).6,7 The reason for not seeing an effect in our study was possibly because our patients had additional acute metabolic shutdown associated with intensive chemotherapy with or without sepsis. We also had the technical difficulty of accurate anthropometric assessment in this group of patients who have tremendous fluctuations in weight owing to changes in fluid balance. There has been considerable concern for many years that hGH might either induce cancer or accelerate pre-existing, early or pre-cancerous states.23–26 In this study, we carefully looked for increased relapse rate, but could not find any. We therefore felt we were justified in embarking on this Bone Marrow Transplantation


120

present study, particularly to look for possible direct growth inhibition effect on tumour cells not previously looked for, within the background of an adjuvant effect with chemotherapy. Recent studies have shown an effect of hGH on cell survival by regulating nuclear factor-kappa B activity, leading to apoptosis in leukaemia cell lines.9 Also, Cherbonnier et al.9,27 showed that hGH-transfected tumour cells engrafted in nude mice responded in vivo to chemotherapy with non-toxic doses of daunorubicin, whereas, under the same conditions, control tumour cells remained insensitive. We show that it is safe to use hGH in this group of patients treated intensively with chemotherapy and/or stem cell transplantation, and that it does not increase relapse rate and improves platelet reconstitution. Future studies to confirm and assess its other effects are warranted.

References 1 Golde DW, Bersch N, Li CH. Growth hormone: speciesspecific stimulation of erythropoiesis in vitro. Science 1977; 196: 1112–1113. 2 Merchav S, Tatarsky I, Hochberg Z. Enhancement of erythropoiesis in vitro by human growth hormone is mediated by insulin-like growth factor I. Br J Haematol 1988; 70: 267–271. 3 Murphy WJ, Tsarfaty G, Longo DL. Growth hormone exerts hematopoietic growth-promoting effects in vivo and partially counteracts the myelosuppressive effects of azidothymidine. Blood 1992; 80: 1443–1447. 4 Tian ZG, Woody MA, Sun R, Welniak LA, Raziuddin A, Funakoshi S et al. Recombinant human growth hormone promotes hematopoietic reconstitution after syngeneic bone marrow transplantation in mice. Stem Cells 1998; 16: 193–199. 5 Carlo-Stella C, Di Nicola M, Milani R, Guidetti A, Magni M, Milanesi M et al. Use of recombinant human growth hormone (rhGH) plus recombinant human granulocyte colony-stimulating factor (rhG-CSF) for the mobilization collection of CD34+ cells in poor mobilizers. Blood 2004; 103: 3287–3295. 6 Schambelan M, Mulligan K, Grunfeld C, Daar ES, LaMarca A, Kotler DP et al. Recombinant human growth hormone in patients with HIV-associated wasting. A randomized, placebocontrolled trial. Serostim Study Group. Ann Intern Med 1996; 125: 873–882. 7 Waters D, Danska J, Hardy K, Koster F, Qualls C, Nickell D et al. Recombinant human growth hormone, insulin-like growth factor I and combination therapy in AIDS associated wasting: a randomised double-blind placebo-controlled trial. Ann Intern Med 1996; 125: 865–872. 8 Paton N, Newton P, Sharpstone D, Ross HM, Cotton J, Calder AG et al. Short-term growth hormone administration at the time of opportunistic infections in HIV-positive people. AIDS 1999; 13: 195–202. 9 Cherbonnier C, Deás O, Carvalho G, Vassal G, Durrbach A, Haeffner A et al. Potentiation of tumour apoptosis by human growth hormone via glutathione production and decreased NF-kB activity. Br J Cancer 2003; 89: 1108–1115. 10 Lerebours E, Tilly H, Rimbert A, Delarue J, Piguet H, Colin R. Changes in energy and protein status during chemotherapy in patients with acute leukaemia. Cancer 1988; 61: 2412–2417. 11 Couto-Silva AC, Trivin C, Esperou H, Michon J, Fischer A, Brauner R. Changes in height, weight and plasma leptin after Bone Marrow Transplantation

12

13

14

15

16

17

18

19

20

21

22 23

24

25

26

27

bone marrow transplantation. Bone Marrow Transplant 2000; 26: 1205–1210. Osoba D, Murray N, Gelmon K, Karsai H, Knowling M, Shah A et al. Quality of life, appetite and weight change in patients receiving dose-intensive chemotherapy. Oncology (Williston Park) 1994; 8: 61–65. Kumar R, Marwaha RK, Bhalla AK, Gulati M. Protein energy malnutrition and skeletal muscle wasting in childhood acute lymphoblastic leukaemia. Indian Paediatr 2000; 37: 720–726. Mehta J, Powles R, Treleaven J, Swansbury GJ, Kulkarni S, Saso R et al. The impact of karyotyping on remission rates in adult patients with de novo acute myeloid leukemia receiving high-dose cytarabine-based induction chemotherapy. Leuk Lymph 1999; 34: 553–560. Kell WJ, Burnett AK, Chopra R, Yin JA, Clark RE, Rohatiner A et al. A feasibility study of simultaneous administration of gemtuzumab ozogamicin with intensive chemotherapy in induction and consolidation in younger patients with acute myeloid leukemia. Blood 2003; 102: 4277–4283. Powles R, Sirohi B, Treleaven J, Kulkarni S, Tait D, Singhal S et al. The role of posttransplantation maintenance chemotherapy in improving the outcome of autotransplantation in adult acute lymphoblastic leukaemia. Blood 2002; 100: 1641–1647. Takala J, Ruokonen E, Webster NR, Nielsen MS, Zandstra DF, Vundelinckx G et al. Increased mortality associated with growth hormone treatment in critically ill adults. Ne Engl J Med 1999; 341: 785–792. Laursen T, Mller J, Jorgensen JO, Orskov H, Christiansen JS. Bioavailability and bioactivity of intravenous vs subcutaneous infusion of growth hormone in GH-deficient patients. Clin Endocrin 1996; 45: 333–339. Bentham J, Rodriguez-Arnao J, Ross RJ. Acquired growth hormone resistance in patients with hypercatabolism. Horm Res 1993; 40: 87–91. Timmins AC, Cotterill AM, Hughes SC, Holly JM, Ross RJ, Blum W et al. Critical illness is associated with low circulating concentration of insulin-like growth factors-I and -II. Alterations in insulin-like growth factor binding proteins, and induction of an insulin-like growth factor binding protein 3 protease. Crit Care Med 1996; 24: 1460–1466. Ge NL, Rudikoff S. Insulin-like growth factor I is a dual effector of multiple myeloma cell growth. Blood 2000; 96: 2856–2861. Gilden D. Human growth hormone available for AIDS wasting. GMHC Treat Issues 1995; 9: 9–11. Renehan AG, Zwahlen M, Minder C, O’Dwyer ST, Shalet SM, Egger M. Insulin-like growth factor (IGF-1), IGF binding protein-3, and cancer risk: systematic review and metaregression analysis. Lancet 2004; 363: 1346–1353. Swerdlow AJ, Higgins CD, Adlard P, Preece MA. Risk of cancer in patients treated with human pituitary growth hormone in the UK, 1959–85: a cohort study. Lancet 2002; 360: 273–277. Fiebig HH, Dengler W, Hendricks HR. No evidence of tumour growth stimulation in human tumours in vitro following treatment with recombinant human growth hormone. Anticancer Drugs 2000; 11: 659–664. Sklar CA, Mertens AC, Mitby P, Occhiogrosso G, Qin J, Heller G et al. Risk of disease recurrence and second neoplasms in survivors of childhood cancer treated with growth hormone: a report from the childhood cancer survivor study. J Clin Endocrinol Metab 2002; 87: 3136–3141. Cherbonnier C, Deas O, Vassal G, Merlin JL, Haeffner A, Senik A et al. Human growth hormone gene transfer into tumor cells may improve cancer chemotherapy. Cancer Gene Ther 2002; 9: 497–504.