Is age an independent risk factor for chemically induced acute myelogenous leukemia in children?

Secondary or therapy-related acute myelogenous leukemia (t-AML) is a rare but unfortunate consequence of treatment with certain classes of cytotoxic chemotherapeutic agents or chronic exposure to high concentrations of benzene. Drugs known to produce AML following chemotherapy of primary malignancy are usually alkylating agents or topoisomerase II inhibitors. Both children and adults develop AML following treatment with these classes of antineoplastic drugs. In this review, the effect of age at treatment on a child's susceptibility to developing therapy related AML was investigated. The clinical literature describing pediatric cancer patients treated with cytotoxic chemotherapeutic agents was used to characterize risk factors associated with chemical leukemogenesis in children. As demonstrated in the published literature, the risk of developing AML following chemotherapy is not reliably correlated with the age of the pediatric patient. There is no consistent evidence that indicates that younger children will be at increased risk; in fact, some studies suggest that younger children might actually display a decreased susceptibility. The age dependency of treatment-related malignancies (all types) in children appears to vary considerably with the type of secondary neoplasm in question. For example, secondary solid tumors such as breast, central nervous system (CNS), bone, and thyroid cancer are highly dependent on the age of the patient at time of diagnosis and treatment; in contrast, an age dependency for t-AML risk was not observed in these same patient populations. Predictably, the induction of t-AML in children follows a rational dose-response relationship, with increasing doses of chemotherapy resulting in greater risk. Recent U.S. Environmental Protection Agency (EPA) cancer risk assessment guidance recommends a default assumption that children are inherently up to 10-fold more sensitive than adults to carcinogen exposures. Available scientific and medical literature does not support the hypothesis that children necessarily possess an increased risk of developing AML following leukemogenic chemical exposure.

Acute myeloid leukemia after adjuvant breast cancer therapy in older women: understanding risk

PURPOSE

The purpose of this study was to determine the risk of developing acute myeloid leukemia (AML) after adjuvant chemotherapy for breast cancer in older women.

PATIENTS AND METHODS

Data from the Surveillance, Epidemiology, and End Results-Medicare linked database were used for women diagnosed with nonmetastatic breast cancer from 1992 to 2002. The primary end point was a claim with an inpatient or outpatient diagnosis of AML (International Classification of Diseases ninth revision, codes 205 to 208), comparing patients treated with and without adjuvant chemotherapy, and by differing chemotherapy regimens. The cumulative hazard of AML was estimated using the Kaplan-Meier method. Cox proportional hazards models were used to determine factors independently associated with the development of AML.

RESULTS

In this observational study, there were 64,715 patients: 10,130 received adjuvant chemotherapy and 54,585 did not. The median patient age was 75.6 years (range, 66 to 104 years). The mean follow-up was 54.8 months (range, 13 to 144 months). The absolute risk of developing AML at 10 years after any adjuvant chemotherapy for breast cancer was 1.8% versus 1.2% for women who had not received chemotherapy. The adjusted hazard ratio for AML with adjuvant chemotherapy versus none was 1.53 (95% CI, 1.14 to 2.06). Granulocyte colony-stimulating factor (G-CSF) within the first year of diagnosis did not convey a significantly increased risk of AML (hazard ratio, 1.14; 95% CI, 0.67 to 1.92).

CONCLUSION

There is a small but real increase in AML after adjuvant chemotherapy for breast cancer in older women. This study may underestimate the true incidence because myelodysplastic syndrome cannot be identified through claims. G-CSF use within the first year of diagnosis does not convey an increased risk of AML in older women.

Maternal alcohol and coffee drinking, parental smoking and childhood leukaemia: a French population-based case-control study

We investigated the role of maternal alcohol and coffee drinking during pregnancy and that of parental smoking in the aetiology of childhood leukaemia. A French, population-based, case-control study was conducted, comparing 472 [407 acute lymphoblastic leukaemia (ALL) and 62 acute myeloblastic leukaemia] cases of childhood acute leukaemia (AL) and 567 population controls, frequency-matched with cases on age, gender and region of residence. Both case and control mothers filled in a comprehensive self-administered standardised questionnaire, eliciting detailed data on maternal alcohol and coffee consumption during pregnancy and parental smoking before, during and after pregnancy. Maternal alcohol consumption of more than 1 drink per day was related to ALL (OR = 2.8 [95% CI 1.8, 5.9]). While maternal coffee consumption was not significantly related to AL (OR = 1.4 [95% CI 0.9, 2.3]), highest intake of coffee (more than 3 cups per day) during pregnancy was associated with AL in children whose mothers were non-smokers (OR = 1.9 [95% CI 1.0, 3.5]). No association with parental smoking, either maternal or paternal, was observed with AL. The present results suggest a possible role of the highest consumption of alcohol by the mother during pregnancy in the aetiology of childhood AL.

AML1-ETO positive AML: first report from India

Translocation (8;21) is associated with few typical morphological features and favorable prognosis. All patients of AML and MDS with increased blasts (N = 35) according to FAB criteria, presenting (between Jan 2004 to June 2005) to the Department of Hematology, AIIMS were studied. RT-PCR was done for the AML1-ETO fusion transcript in all cases. Overall incidence of AML1-ETO was 28.57% and no correlation was found between AML1-ETO positivity and clinical or hematological parameters except for a direct correlation with absolute blast count (ABC) (a lower ABC in the AML1-ETO positive cases). Interestingly, 1/3 MDS cases were positive for the same fusion transcript and thus, it appears worthwhile to look for AML1-ETO in all cases of MDS with increased blasts. Objective morphological evaluation using a scoring system based on morphological features was not helpful in predicting positivity for AML1-ETO. The effect of this translocation on long-term survival could not be determined by the present study.

Leukemia as a second malignancy

To study the occurrence of leukemia as a second malignancy following various primary solid and hematological malignancies. Total 11 cases of leukemia presenting as a second malignancy were studied over a period of 15 years from 1990 to 2005. The primary malignancies included carcinoma breast (4), multiple myeloma (3) and one each of Hodgkin's lymphoma, mediastinal germ cell tumor, papillary carcinoma thyroid and myxopapillary ependymoma. Ten patients had received chemotherapy with combination radiotherapy in six patients. The commonest type of leukemia was AML-M2. The cyogenetic test results were available in three cases. The secondary leukemia showed aggressive behaviour and all patients on follow-up died within a period of one month. The risk benefit ratio of chemotherapy and radiotherapy should be considered before starting the patients on treatment. A high degree of suspicion and follow up with hematological parameters is required for therapy related complications.

Family history of cancer in children with acute leukemia, Hodgkin's lymphoma or non-Hodgkin's lymphoma: the ESCALE study (SFCE)

The role of a family history of cancer in the etiology of childhood hematopoietic malignancies was investigated using the data from the ESCALE study. ESCALE, a population-based case-control study, was carried out in France over the period, 2003-2004. A total of 773 cases of acute leukemia (AL), 130 of Hodgkin's lymphoma (HL), 163 of non-Hodgkin's lymphoma (NHL) and 1,681 population-based controls were included. The controls were randomly selected from the French population and were frequency matched with the cases on age and gender. Cancer history in first- and second-degree relatives was reported by the mothers in a structured telephone questionnaire that was the same for the cases and controls. Odds ratios (ORs) were estimated using an unconditional regression model taking into account the stratification variables and potential confounders. A family history of cancer was associated with an increased risk of HL (OR = 1.5 [1.0-2.2]) and NHL (OR = 1.8 [1.3-2.5]), but not AL (OR = 1.0 [0.9-1.2]). The ORs were higher when at least 2 relatives had a history of cancer or when 1 case occurred before age 46 years. Only HL was significantly associated with a family history of hematopoietic malignancies (OR = 2.0 [1.0-3.8]), mainly because of a significant association with a history of HL (OR = 5.4 [1.3-22]). In conclusion, the study findings support the hypothesis of familial susceptibility to childhood lymphoma, but do not suggest familial susceptibility to childhood AL.

HLA class II allele and haplotype frequencies in iranian patients with acute myelogenous leukemia and control group

Previous studies have demonstrated some significant differences in HLA allele frequencies in leukemic patients and normal subjects. We have analyzed HLA class II alleles and haplotypes in 60 Iranian patients with acute myelogenous leukemia (AML) and 180 unrelated normal subjects. Blood samples were collected after obtaining informed consents. From the patients and control DNA extraction and HLA typing were performed using PCR-SSP method. Significant positive association with the disease was found for HLA-DRB1*11 allele (35% vs. 24.7%, p=0.033). Two alleles including HLA-DRB4 and -DQB1*0303 were found to be significantly decreased in patients compared to controls. Regarding haplotype analysis, no significant association was found between case and control groups. It is suggested that HLA-DRB1*11 allele plays as a presumptive predisposing factor while the HLA-DRB4 and -DQB1*0303 alleles are suggested as protective genetic factors against acute myelogenous leukemia. Larger studies are needed to confirm and establish the role of these associations with acute myelogenous leukemia.

The homeobox gene CDX2 is aberrantly expressed in most cases of acute myeloid leukemia and promotes leukemogenesis

The homeobox transcription factor CDX2 plays an important role in embryonic development and regulates the proliferation and differentiation of intestinal epithelial cells in the adult. We have found that CDX2 is expressed in leukemic cells of 90% of patients with acute myeloid leukemia (AML) but not in hematopoietic stem and progenitor cells derived from normal individuals. Stable knockdown of CDX2 expression by RNA interference inhibited the proliferation of various human AML cell lines and strongly reduced their clonogenic potential in vitro. Primary murine hematopoietic progenitor cells transduced with Cdx2 acquired serial replating activity, were able to be continuously propagated in liquid culture, generated fully penetrant and transplantable AML in BM transplant recipients, and displayed dysregulated expression of Hox family members in vitro and in vivo. These results demonstrate that aberrant expression of the developmental regulatory gene CDX2 in the adult hematopoietic compartment is a frequent event in the pathogenesis of AML; suggest a role for CDX2 as part of a common effector pathway that promotes the proliferative capacity and self-renewal potential of myeloid progenitor cells; and support the hypothesis that CDX2 is responsible, in part, for the altered HOX gene expression that is observed in most cases of AML.

Acute Myeloid Leukemia: A Classification and Treatment Update

Approximately 11,000 Americans will be diagnosed with acute myeloid leukemia (AML) in 2003, and about 75% ultimately will die from the disease. Despite significant advances in understanding biologic, molecular, and cytogenetic aspects of this malignancy, several other areas remain poorly understood. During the 1990s, significant advances in the characterization of this condition have shown that AML affects elderly patients more frequently. Treatment of patients in this age group poses a greater challenge partly because of increased tumor resistance and the presence of multiple medical comorbidities that may contraindicate therapy. New therapeutic approaches are promising and have renewed enthusiasm and optimism among patients and healthcare providers. Future treatment strategies for patients with AML most likely will include combinations of biologic agents with defined molecular targets (e.g., monoclonal antibodies, retinoids, hypomethylating agents, tyrosine kinase inhibitors).

Vaccination and the risk of childhood acute leukaemia: the ESCALE study (SFCE)

BACKGROUND

In 2002, a poster alerted the French health authorities to the possibility that the risk of childhood leukaemia might be increased by hepatitis B vaccination. Elucidating the role of vaccination in the aetiology of childhood acute leukaemia (AL) was therefore included in the objectives of an ongoing national study.

METHODS

The ESCALE study was a French national population-based case-control study conducted in France in 2003 and 2004 in order to investigate the role of infectious, environmental and genetic factors in four childhood neoplastic diseases (leukaemia, lymphoma, neuroblastoma and brain tumour). The controls were randomly selected from the French population and age and gender frequency matched with the cases. A total of 776 cases of AL (91% of the eligible cases) and 1681 controls (71% of the eligible controls) were included. In a specific standardized telephone interview, which was the same for both the cases and controls, each mother was asked to read out her child's complete vaccination record.

RESULTS

No association between vaccination and the risk of childhood AL: acute lymphoblastic leukaemia or acute myeloblastic leukaemia was observed. No relationship between the risk of leukaemia and the type of vaccine, number of doses of each vaccine, total number of injections, total number of vaccine doses or number of early vaccinations was evidenced. No confounding factor was observed.

CONCLUSION

The study did not show any evidence of a role of vaccination in the aetiology of childhood leukaemia.

[Acute myeloid leukemia]

The annual incident rate of pediatric acute myeloid leukemia (AML) is now 10 per million in Japan, against 5 to 9 per million in the USA and Europe. Overall long-term survival has now been achieved for more than 50% of pediatric patients with AML in the USA and in Europe. The prognostic factors of pediatric AML were analyzed,and patients with AML were classified according to prognostic factors. The t(15;17), inv(16) and t(8;21) have emerged as predictors of good prognosis in children with AML. Monosomy 7, monosomy 5 and del (5 q) abnormalities showed a poor prognosis. In addition to chromosomal deletions, FLT 3/ITD identifies pediatric patients with a particularly poor prognosis. Clinical trials of AML feature intensive chemotherapy with or without subsequent stem cell transplantation. Risk group stratification is becoming increasingly important in planning AML therapy. APL can be distinguished from other subtypes of AML by virtue of its excellent response and overall outcome as a result of differentiation therapy with ATRA. Children with Down syndrome and AML have been shown to have a superior prognosis to AML therapy compared to other children with AML. The results of the Japan Cooperative Study Group protocol ANLL 91 was one of the best previously reported in the literature. With the consideration of quality of life (QOL), risk-adapted therapy was introduced in the AML 99 trial conducted by the Japanese Childhood AML Cooperative Study Group. A high survival rate of 79% at 3 years was achieved for childhood de novo AML in the AML 99 trial. To evaluate the efficacy and safety of the treatment strategy according to risk stratification based on leukemia cell biology and response to the initial induction therapy in children with AML, the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) has organized multi-center phase II trials in children with newly diagnosed AML.

Acute myeloid leukemia in the elderly: current therapeutic results and perspectives for clinical research

More than half of acute myeloid leukemia (AML) diagnoses are currently made in patients older than 60 years. Furthermore, even if the age-specific incidence remains stable in the coming years, the incidence of AML in elderly people is expected to consistently increase, given the progressive ageing of the general population. Consequently, the treatment of the disease in aged individuals represents a daily challenge in clinical hematology. Several studies have shown that, in current practice, a high fraction of patients older than 60 years is negatively selected for inclusion in clinical trials that are based on intensive chemotherapy. Apart from performance status and comorbidity at diagnosis, other non-clinical factors can significantly affect therapeutic choice including the distance from hematologic institution, presence of a carer, physician's and patient's attitude, and the scientific interest of the physician in a given therapeutic programme. In daily practice, a combination of these factors results in relevant selection of patients for clinical trials. Clearly, preselection of patients with AML leads to misleading overly optimistic results in some studies. Treatment of AML in the elderly is difficult and well-controlled trials in this group of patients are uncommon. Frequently, higly selected patients are recruited to relatively small phase II unrandomised trials with complete remission (CR) rates ranging from 25 to 70 %. These figures may turn unrealistic in the current practice. The present article reviews results of most relevant studies addressing therapeutic results in elderly patients with AML. Questions to be addressed will include potential selection biases, results with conventional chemotherapy, the therapeutic potential of autologous and allogeneic stem cell transplantation and a critical review of results achieved with newly developed drugs.

Acute childhood leukemias and exposure to magnetic fields generated by high voltage overhead power lines - a risk factor in Iran

Many investigators have studied the effects of Extremely Low Frequency-Magnetic Fields generated by ordinary and domestic power lines, as a risk factor in acute leukaemias of children, but there are limited information available regarding very high voltage overhead power lines. Children in developing countries sometimes live very close to such structures and we have registered several patients with acute leukaemias appearing in clusters. In the present study we have analyzed 60 consecutively diagnosed patients with acute leukaemias, and 59 matched controls in a provincial capital city in North-Western Iran. After provision of consent, a detailed form was filled in, and a visit to the present (or previous) residential areas of both groups was arranged. The locations of the very high voltage power lines (123, 230, 400 kilo volts), were noted in each area, if present, and their distances from the houses under study were detected. The expected intensities of the Magnetic Fields (B) were calculated having the mean intensity of the electrical current and other line characteristics, by means of relevant equations. Fourteen patients in the case group (23.5%) were living near the high voltage power lines in distances < or = 500 meters. (Mean B = 0.6 microTeslas, microT). In the control group at the same distance, the figure was 2 children (3.3%) (Mean B = 0.35 microT). Statistically, the likelihood of leukaemia was increased considerably in this distance (Odds ratio (OR) = 8.67, 95% Confidence Interval (CI) = 1.74- 58.4, P value= 0.001). On the other hand 15 pts (25 %) in the leukaemia group were experiencing Magnetic fields above 0.45 microT in comparison to 5 in the control group ( 8.5% )(OR = 3.60, 95% CI = 1.11-12.39, P = 0.01). More children in developing countries like Iran live close to very high voltage lines, and they experience relatively more harmful effects from the Magnetic Fields, in comparison with children in developed countries. Residence near very high voltage overhead power lines, in distances < or = 500 meters, and Magnetic Fields >0.45 microT, should be considered a risk factor for the pathogenesis of acute leukaemias in children.

[Incidence of hepatitis B virus infection in patients with blood disease]

AIM

To define incidence of HBV infection in patients with blood diseases caused by blood components transfusion; correlation between infection rate and blood disease nosological entity, intensity of hemoreplacement therapy, time of hepatitis B incubation period in patients with hematological malignancies after the diagnosis and initiation of polychemotherapy (PCT).

MATERIAL AND METHODS

In 2000-2007 a prospective clinicoepidemiological trial was made to detect markers of HBV infection among 303 patients 15 to 76 years of age treated in the department of acute leukemia chemotherapy of N.N. Burdenko Military Hospital for acute lymphoid and myeloblastic leukemia, chronic myeloid leukemia in a blastic crisis, myelodysplastic syndrome in blast transformation, lymphoproliferative diseases with bone marrow affection. Statistic processing was performed with standard methods.

RESULTS

HBV infection markers were detected in 30 (9.9%) of 303 examinees. Among the infected patients there were 16 (53.4%) patients with different variants of acute myeloblastic leukemia, 12 (40.0%) with different immunophenotypes of acute lymphoblastic leukemia, 1 (3.3%) patient with acute biphenotypical leukemia and 1 (3.3%) with lymphoma/leukemia. HBV infection was registered in patients 2 to 32 months after the beginning of the treatment. Most of the patients - 23 (74%) of 30 - were infected with HBV within the first year after hematological diagnosis and PCT induction course. HBV was diagnosed within treatment year two in 5 (16%) patients and within year three after PCT in 3 (10%).

CONCLUSION

High incidence of HBV infection in patients with hematological malignancies points to a high epidemiological risk of hemoreplacement therapy, unsatisfactory quality of donor blood testing and necessity of updating methods of donor infection detection. To lower the risk of HBV infection in patients with hematological malignancies it is necessary to perform vaccine prophylaxis of hepatitis B before PCT.

Investigating childhood leukemia in Churchill County, Nevada

BACKGROUND

Sixteen children diagnosed with acute leukemia between 1997 and 2002 lived in Churchill County, Nevada, at the time of or before their illness. Considering the county population and statewide cancer rate, fewer than two cases would be expected.

OBJECTIVES

In March 2001, the Centers for Disease Control and Prevention led federal, state, and local agencies in a cross-sectional, case-comparison study to determine if ongoing environmental exposures posed a health risk to residents and to compare levels of contaminants in environmental and biologic samples collected from participating families.

METHODS

Surveys with more than 500 variables were administered to 205 people in 69 families. Blood, urine, and cheek cell samples were collected and analyzed for 139 chemicals, eight viral markers, and several genetic polymorphisms. Air, water, soil, and dust samples were collected from almost 80 homes to measure more than 200 chemicals.

RESULTS

The scope of this cancer cluster investigation exceeded any previous study of pediatric leukemia. Nonetheless, no exposure consistent with leukemia risk was identified. Overall, tungsten and arsenic levels in urine and water samples were significantly higher than national comparison values; however, levels were similar among case and comparison groups.

CONCLUSIONS

Although the cases in this cancer cluster may in fact have a common etiology, their small number and the length of time between diagnosis and our exposure assessment lessen the ability to find an association between leukemia and environmental exposures. Given the limitations of individual cancer cluster investigations, it may prove more efficient to pool laboratory and questionnaire data from similar leukemia clusters.

Outcomes and charges of elderly patients with acute myeloid leukemia

A retrospective database analysis was conducted to evaluate hospitalization outcomes and charges among elderly acute myeloid leukemia (AML) patients. The data source was a longitudinal (2000-2003) inpatient database from 28 US hospitals. Data on 275 AML patients aged 60 and older were analyzed for demographic and treatment characteristics, hospital mortality, length of stay (LOS), overall days of stay (DOS), and charges across multiple admissions. Multivariate modeling was performed to determine factors that influenced outcomes. Overall, 115 (41.8%) patients received inpatient chemotherapy (CT); most (90.4%) received it on the first admission. Of all initial CT regimens 40.9% consisted of a single agent. The mean LOS for initial hospitalization was 23.0 (SD 21.8) days for patients who received CT and 6.7 (SD 7.5) days for those who did not. One quarter (25.3%) of initial hospitalizations resulted in death. On initial hospitalization, mean total charges were $113,118 (SD $220,417) for patients who received CT and $43,999 (SD $190,533) for those who did not; for both groups mean charges were higher than respective subsequent admission charges. Overall, in-hospital mortality did not differ significantly between on-CT and off-CT groups (43.5 and 38.8%, respectively). In multivariate modeling, CT was significantly associated (P < 0.0001) with increased charges and LOS. Elderly patients with AML incurred substantial hospital charges and inpatient mortality. The highest charges and a substantial number of deaths occurred during first admission. Although treatment with CT was associated with increased charges and days in-hospital, inpatient mortality in the two groups was found to be similar.

Treatment decision-making for older patients with high-risk myelodysplastic syndrome or acute myeloid leukemia: problems and approaches

BACKGROUND AND OBJECTIVES

High-risk myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) are mainly diseases of patients over the age of 60 years. In these patients, intensive chemotherapy and/or allogeneic blood stem cell transplantation are the only curative treatment approaches, while non-curative options include low-dose chemotherapy or best supportive care alone. The basis for treatment decision-making in this clinically and biologically heterogeneous group is not well defined.

DESIGN AND METHODS

In order to investigate treatment stratification patterns and outcomes in this population, we performed a systematic literature search in MedLine for relevant clinical reports published between 1989 and 2006. Only large population-based investigations and publications of clinical trials with more than 40 patients were analyzed.

RESULTS

In 36 AML studies involving a total of 12,370 patients (median age 70 years) median overall survival approached 30 weeks for intensively treated patients. In patients receiving best supportive care alone, or best supportive care plus non-intensive treatment, median overall survival was 7.5 and 12 weeks, respectively. The complete remission rate after induction was 44%, and in those patients who achieved complete remission age no longer influenced prognosis. In 18 large studies approximately 50% of AML patients received induction therapy, 30% non-intensive chemotherapy and 20% supportive care only.

INTERPRETATION AND CONCLUSIONS

Due to the scarcity of randomized AML/MDS trials in which older patients are assigned to either induction or less intense therapy, predictors to identify older patients most likely to benefit from intensive therapy and novel tools to optimize (or even standardize) recommendations are needed. We propose that in this patient population in the future, geriatric assessment instruments and comorbidity scoring are implemented in treatment decision-making.

The risk of bleeding in thrombocytopenic patients with acute myeloid leukemia

BACKGROUND AND OBJECTIVES

Patients with acute myeloid leukemia are at risk of bleeding. The risk factors for different severities of bleeding are poorly studied.

DESIGN AND METHODS

Data from Rebulla et al. were analyzed in an exploratory analysis using multivariate Cox regression analyses for time-to-first bleed with time-depend- ent covariates reflecting measures of clinical and laboratory variables on the previous day. The relationships of the variables with three bleeding categories were studied: mild bleeding (WHO grades 1 and 2) clinically significant (bleeding grades 2, 3 and 4) and severe (bleeding grades 3 and 4).

RESULTS

Bleeding of any severity occurred in 149 (58.4%) of 255 patients. There were 743 days of bleeding over 7335 patient-days of observation. Risk factors for mild bleeding included increased body temperature and decreased platelet count; the risk was decreased with administration of antifungal medication or platelet transfusion on the previous day. Risk factors for clinically significant bleeding included grade 1 bleeding on the previous day, decreased platelet count and elevated body temperature. Decreased platelet count and mild bleeding on the previous day were risk factors for severe bleeding. Higher hemoglobin values were associated with a delay in the time-to-first clinically significant bleed.

INTERPRETATION AND CONCLUSIONS

These results support clinical guidelines for increasing the platelet transfusion threshold in the presence of fever and support the use of milder bleeding symptoms as an outcome in clinical trials. The suggestion that hemo- globin concentration maybe predictive of bleeding risk supports the hypothesis that this maybe a valuable intervention in anemic thrombocytopenic patients at high risk of bleeding.

Long-term survival in patients with acute leukemia and chronic disseminated candidiasis despite minimal antileukemic therapy

Infections may require discontinuation of antineoplastic chemotherapy, which, in turn, renders patients vulnerable to disease progression or relapse. We identified six patients with acute leukemia in whom antineoplastic treatment had to be discontinued because of chronic disseminated candidiasis (CDC). However, despite minimal antileukemic treatment, all patients remained in complete remission. Immunologic mechanisms associated with CDC might have had an antileukemic effect.