Allogeneic bone marrow transplantation for acute lymphoblastic leukemia in remission: prolonged survival associated with acute graft-versus-host disease

Forty remission patients with high-risk acute lymphoblastic leukemia (ALL) underwent matched allogenic bone marrow transplantation (BMT) following preparation with cyclophosphamide and fractionated total body irradiation (TBI). As of March 1987, the median follow-up is more than 3 1/2 years. Thirteen patients are alive (11 relapse free) between 2 and 4 1/2 years post-BMT. Neither age, sex, remission number, prior extramedullary leukemia, nor WBC at diagnosis of ALL was statistically significant as a predictor of relapse-free survival. The development of acute graft-v-host disease (GVHD) in 17 patients was found, with time-dependent Cox regression analysis, to be associated with a significant reduction in post-BMT relapse risk (P = .04) and improved disease-free survival (P = .11). A prospective, randomized trial of maintenance chemotherapy with oral methotrexate and mercaptopurine did not demonstrate improvement in relapse risk or survival for those assigned maintenance chemotherapy (P = .7). These results suggest that allogeneic BMT can result in extended relapse-free survival for some patients with high-risk ALL. More effective preparative chemoradiotherapy and exploitation of the apparent graft-v-leukemia effect may be useful in future trials.

The effect of naproxen on fever in children with malignancies

Naproxen was used as an antipyretic agent in febrile pediatric cancer patients with evidence of active malignant disease. Sixteen children with leukemia and lymphoma who had fever for more than 72 hours were given naproxen to control fever. Their ages ranged from 16 months to 17 years. There were ten female and six male patients. Their temperature was greater than 38.3 degrees C and the leukocyte count ranged from 400/microliters to 33.3 X 10(3)/microliters, with an absolute neutrophil count (ANC) from 0 to 4514/microliters. The children had no evidence of infection by clinical or laboratory evaluations. All patients were receiving triple antibiotics when naproxen was started. Fourteen patients responded to naproxen with complete lysis of fever within 6 hours of initiation of treatment. Two patients did not respond to naproxen, but proved to have culture-positive infections. There were no side effects from the drug. Naproxen is an effective antipyretic in patients with cancer. It may be useful as a means of differentiating fever secondary to active malignant disease from that due to infection.

Malignant lymphoma of the skin in children

The clinical and histopathologic findings in eight cases of malignant lymphoma of the skin in children are presented. All patients had skin lesions as a primary manifestation of the disorder. Three patients had simultaneous regional lymph node involvement documented by the findings of subsequent biopsies. The majority (five patients) had solitary nodules involving the skin of the head and neck region. Three of the skin biopsy specimens were classified as lymphoblastic lymphoma, two large cell lymphoma, two mixed small and large cell lymphoma, and one small cleaved cell lymphoma. Disseminated disease subsequently developed in four patients in an interval that ranged from 4 to 30 months after diagnosis. The follow-up period ranged from 8 to 56 months, and median survival was 56 months. A literature review of 33 previously reported patients and our eight patients indicate that: skin of the head and the neck region is the most common site of involvement (56%); the majority of lymphomas are diffuse (93%); lymphoblastic lymphoma is the predominant type (53%), with a high proportion showing a non-T-cell phenotype; Burkitt's lymphoma and Hodgkin's disease of the skin are extremely rare; and most patients presented in an early clinical stage (Stage IE 56%, Stage IIE 21%), and prolonged disease-free survival was seen mostly in Stage I patients. The cumulative probability of survival for Stage I patients at 24 months was 0.71; while for Stages II to IV patients combined, it was 0.33 at 26 months.

Ewing's sarcoma of a lower extremity in an infant. A therapeutic dilemma

A 5.5-month-old infant with Ewing's sarcoma of the left femur is described. The clinical and the pathologic features in this infant are presented in detail, and the dilemma faced in diagnosis and therapy of Ewing's sarcoma in infants is discussed. It is suggested that Ewing's sarcoma in an infant with a lower extremity lesion may be adequately managed without primary amputation.

Use of VP-16-213 in the treatment of familial erythrophagocytic lymphohistiocytosis

Five patients with familial erythrophagocytic lymphohistiocytosis (FEL), aged 6 weeks to 3 years, were treated with VP-16-213. The drug dosage ranged from 100 to 200 mg/m2 administered biweekly until remission was achieved, and then at 1- to 3-week intervals as maintenance therapy. Intrathecal methotrexate was given to two patients with central nervous system involvement. All patients attained remission. Systemic relapses often ensued in all patients when VP-16-213 was delayed because of myelosuppression, or after attempts to lengthen the treatment interval, but they initially responded again to a more intensive chemotherapy schedule. To date, four of the patients died from disseminated disease and terminal infections 15 to 20 months from the time of diagnosis. One child is alive and well 20 months from diagnosis. Three of the dead children had become refractory to the drug. Our observations show that VP-16-213 induces remissions and prolongs survival in FEL. However, since the patients eventually become refractory to the drug and die of the disease, additional forms of therapy are required to improve the outlook of affected children.

Sequential testicular biopsies in childhood acute lymphocytic leukemia

Between August 1978 and November 1981, 33 boys with acute lymphocytic leukemia (ALL) (26 non-T, 7 T-cell) younger than 16 years underwent bilateral wedge testicular biopsies at the time of initial diagnosis. Seven (4 non-T, 3 T-cell) demonstrated focal leukemic infiltrates. Rebiopsy after successful induction therapy without testicular irradiation showed eradication of leukemic infiltrates in five, persistent focal infiltrates in one, and a diffuse infiltrate in one. The two patients who had persistent leukemic involvement had a T-cell phenotype, and in one of them overt testicular disease developed 2 years later. All 33 patients were followed prospectively for a minimum of 3 years. Fifteen (14 non-T, 1 T-cell) remained in remission for 3 years and underwent another testicular biopsy before the cessation of therapy. Two patients, both non-T and both of whom were free of testicular involvement at diagnosis, showed testicular infiltrates at that time. Of the seven boys with positive specimens at diagnosis, only two remained disease-free for 3 years and showed no testicular involvement upon the completion of chemotherapy. In this study, microscopic testicular involvement by lymphoblasts occurred in 21% of newly diagnosed boys with ALL; this occurred only if the leukocyte count exceeded 25,000/microliter. These patients in general had a poor prognosis, probably reflecting the overall heavy tumor burden. However, it was not possible to predict accurately those patients who would have leukemic testicular infiltrates at the cessation of chemotherapy by performing biopsy of the testes at the time of initial diagnosis or after induction therapy.

The incidence of second neoplasms following megavoltage radiation for pediatric tumors

From 1953 to 1975, 330 children received megavoltage for benign or malignant tumors. Fourteen subsequently developed second neoplasms. The 30-year cumulative incidence of second neoplasms was 9.6%. The incidence of second malignant neoplasms may be lower following megavoltage radiation than following orthovoltage radiation.

Interstitial pneumonitis following total body irradiation for bone marrow transplantation using two different dose rates

A total of 22 patients with leukemia (10 ALL, 11 AML, 1 CML) have undergone allogeneic bone marrow transplantation (BMT) by the Quebec Co-operative Group for Marrow Transplantation from 1980 to 1982. All patients received 900 cGy total body irradiation (TBI), in a single fraction, on the day preceding BMT. The first 11 patients were treated on a cobalt unit at a constant dose rate of 4.7 to 6.3 cGy/min. Six of these patients developed interstitial pneumonitis (IP). The clinical course of three patients, two with idiopathic and one with drug-induced pneumonitis, was mild and recovery was complete in all. The other three patients developed severe infectious IP and two died. The next 11 patients were treated with a sweeping beam technique on a 4 MV linear accelerator delivering a total tumor dose of 900 cGy at an average dose rate of 6.0 to 6.5 cGy/min but an instantaneous dose rate of 21.0 to 23.5 cGy/min. Eight patients developed severe IP. Five of these were idiopathic and four died. Three were infectious and all died. The fatality of interstitial pneumonitis appeared to be greater in the group treated with the sweeping beam technique.

Recurrence of Wilms tumor after apparent cure

The recurrence of Wilms tumor after a 5-year disease-free interval is rare. We present two patients who had recurrent disease after a disease-free interval of greater than 7 years. Three additional patients, registered with the National Wilms Tumor Study who had a recurrence after 5 years, are also described. Of these three patients, two had nephroblastomatosis. Because more patients are achieving long-term survival, careful surveillance after apparent "cure" is recommended, particularly if nephroblastomatosis is identified in the original nephrectomy specimen.

Leukemia cutis treated with total skin irradiation

An infant with acute monoblastic leukemia who presented with an extramedullary mass and involvement of the bone marrow, cerebrospinal fluid, and skin is described. After achieving remission, she later developed a relapse that was isolated in the skin. Superficial electron beam irradiation to the total skin surface was administered as therapy for the relapse. She remains in remission 12 months following this treatment. The isolated nature of the skin relapse, in addition to the fact that the relapse did not involve a previously irradiated field, suggests that the skin may have harbored the leukemic cells since the time of diagnosis. Cytogenetic data is presented that lends further support to this hypothesis.

Intraocular retinoblastoma group V: an analysis of prognostic factors

A retrospective analysis of the University of Minnesota (Minneapolis) experience with retinoblastoma is presented. Seventy-five patients were diagnosed with retinoblastoma between 1958 and 1983, of which 53 (71%) had at least one Reese-Ellsworth group V eye. Nineteen group V patients and one group II patient developed extraocular disease recurrence. The cumulative actuarial rate of recurrence at 12 years was 36% for patients with group V disease. The median time from diagnosis to recurrence for unilateral patients was seven months and for bilateral patients 28 months (P = .001). Patients developing extraocular disease had a 10-year actuarial survival rate postrecurrence of 34%. The four long-term survivors of extraocular recurrences had had isolated orbital or local soft tissue recurrences only. Features of group V patients associated with extraocular recurrences were identified by univariate life table analyses. Clinical poor-risk factors included the nongenetic form of the disease (P = .03) and male sex (P = .02). Pathologic poor risk factors included rubeosis (P = .01), undifferentiated histology (P = .03), large tumor size (P = .05), and intraocular extension to the anterior segment (P = .02), retinal pigment epithelium (P = .03), choroid (P less than .001), and optic nerve beyond the lamina cribrosa (P = .02). Treatment-associated poor-risk factors included an optic nerve length of less than 5 mm removed at enucleation (P = .003). Multivariate life table analyses demonstrated the following parameters to be independent poor-prognostic factors: optic nerve length of less than 5 mm removed at enucleation (P = .001), optic nerve involvement (P = .004), and large tumor size (P = .01). These results will help to identify patients with retinoblastoma who are at greatest risk for extraocular recurrence.

Effect of fractionation and rate of radiation dose on human leukemic cells, HL-60

The capacity of HL-60 cells, human acute promyelocytic leukemic cells established in culture, to repair sublethal radiation damage was estimated from the response of the cells to fractionated irradiation or to a single irradiation at different dose rates. The HL-60 cells grown as a suspension culture in RPMI 1640 medium supplemented with 10% calf serum and antibiotics showed a cloning efficiency of about 0.46 in an agar culture bed. After exposure of cells to a single dose of X rays at a dose rate of 78 rad/min, the survival curve was characterized by n = 2.5, Dq = 80 rad, and D0 = 83.2 rad. Split-dose studies demonstrated that the cells were able to repair a substantial portion of sublethal radiation damage in 2 hr. The response of the cells to irradiation at different dose rates decreased with a decrease in the dose rates, which could be attributed to repair of sublethal radiation damage. The radiation response of leukemic cells is only one of the many factors which affect the clinical outcome of total-body irradiation (TBI) followed by bone marrow transplantation. Nevertheless, the possibility that some of the malignant hemopoietic cells, if not all, may possess a substantial capacity to repair sublethal radiation damage should not be underestimated in planning total-body irradiation followed by bone marrow transplantation.

Wilms tumor arising in horseshoe kidney

Tumors originating in horseshoe kidneys are rare; only 21 cases of Wilms tumor reported in horseshoe kidneys. A seven-month-old girl with Wilms tumor arising from the isthmus of a horseshoe kidney is reported. The literature is reviewed, and surgical considerations are discussed.

Plasma dopa and catecholamines in the diagnosis and follow-up of children with neuroblastoma

Plasma dopa and the catecholamines--dopamine, norepinephrine, and epinephrine--were assayed by a radioenzymatic method in 15 children with active neuroblastoma and in eight others without evidence of disease to assess the value of these determinations in the diagnosis and management of the tumor. Thirty-four children with solid tumors and hemopoietic malignancies served as our controls. Elevated plasma dopa levels were observed in 13 children with active neuroblastoma (87%); dopamine and norepinephrine were elevated in 1/4 of these patients. In the group of children with neuroblastoma without evidence of disease, dopa and catecholamine levels were within the range observed in the controls. Total urinary catecholamines, homovanillic acid (HVA) and/or vanilmandelic acid (MVA) were elevated in 11 of the 15 (73%) neuroblastoma patients with active disease. While serial plasma dopa determinations correlated with the course of the disease in practically all patients and thus were useful in their follow-up, the catecholamines were of limited value in assessing tumor status. Our results suggest that plasma dopa, assayed by a radioenzymatic method, may be more reliable than the traditional urinary catecholamine determinations in the diagnosis of neuroblastoma, and it appears useful in the management of this disease.

Correlation of chromosome abnormalities with patient characteristics, histologic subtype, and induction success in children with acute nonlymphocytic leukemia

Cytogenetic analyses of bone marrow cells were performed in 195 children with acute nonlymphocytic leukemia (ANLL) at diagnosis, as part of Childrens Cancer Study Group Study No. 251. Ninety-six patients (49%) exhibited clonal abnormalities, including trisomy 8 in 18 patients, t(8;21) in 11, t(15;17) in seven, loss of a sex chromosome in seven, monosomy 7 in seven, and the Philadelphia chromosome in four. Clonal abnormalities were found significantly more often in younger patients. Furthermore, recurring cytogenetic abnormalities tended to correlate with specific ages. For example, t(8;21) was associated significantly with children over four years of age, while -7 associated with overall loss of genetic material from the long arm of chromosome 7 (7q) and 11q- were associated significantly with younger children. Recurring chromosome abnormalities also correlated with specific ANLL histologic subtypes, such as t(8;21) with acute myelogenous leukemia and t(15;17) with acute promyelocytic leukemia. Presence or absence of cytogenetic abnormalities was compared with the ability of patients to achieve remission. Individuals exhibiting clonal abnormalities in bone marrow cells had an equally likely chance of achieving remission (74%) as those individuals with normal karyotypes (75%). Nonrandom chromosome abnormalities associated with a high induction success rate included +8 with a 94% induction success rate (P = .13) and t(8;21) with a 91% success rate (P = .46). Patients exhibiting the -7 abnormality associated with overall loss of 7q had a significantly less successful induction outcome, with only 28% achieving remission (P = .02); three of seven patients with t(15;17) died during induction therapy.

Unilateral radiation nephropathy--the long-term significance

Eighteen patients with gastrointestinal and retroperitoneal non-Hodgkin's lymphoma received abdominal radiotherapy as their primary treatment. Each patient received a total tumor dose of 2200 to 4500 cGy in 5 to 9 weeks to the whole or half of one kidney. Nine patients developed unilateral radiation nephropathy demonstrable on post-treatment evaluation with 99m Tc glucoheptonate blood flow, delayed static scan, and an I-131 radio-hippurate renal perfusion study. The tests were periodically repeated over periods ranging from 5 to 8 years. Six patients with nephropathy and 4 patients without nephropathy were followed 5 years or longer. The minimum nephro-pathogenic irradiation dose was 2200 cGy delivered in 59 days. The incidence of nephropathy is higher with increase in the total dose. Short term recovery in function was observed in 3 patients and long-term complete recovery was observed in one patient. Atrophic renal change was irreversible and progressive in 3 patients over a 6 to 7 year follow-up period. In this group of patients, an abnormal creatinine clearance and serum beta-2 microglobulin level was indicative of vascular damage. Elevated arterial blood pressure was seen in 5 patients. All were controlled medically, without nephrectomy. There was no other clinically significant problem resulting from the unilateral nephropathy in this group of patients.

Serial thyroid function measurements in children with Hodgkin disease

Thyroid function was measured serially in 28 children with Hodgkin disease diagnosed from 1971 to 1978. The patients' ages ranged from 4 to 16 years at diagnosis, and treatment consisted of chemotherapy only (four patients), radiation alone (15), or radiation plus chemotherapy (nine). None of the four children given chemotherapy only developed thyroid hypofunction, in contrast to 21 (88%) of the 24 children given high doses of radiation (P less than 0.001). Thyroid function in three patients with compensated hypothyroidism and in one child with primary hypothyroidism reverted to normal without thyroid replacement. One child given chemotherapy only and one child given radiation only became transiently hyperthyroid. These results indicate that patients given combined modality therapy for Hodgkin disease are at high risk for thyroid abnormalities. The results of long-term follow-up of thyroid function demonstrate, however, that all such thyroid abnormalities may not necessarily be permanent.

Clinical aspects of a rotational total skin electron irradiation

A simple rotational total skin electron irradiation technique utilising a single large field electron beam is presented. Clinical and technical aspects of the technique are discussed and treatment results for the first 10 patients treated for widespread mycosis fungoides reported. The technique is simple and well tolerated by patients, and can easily be implemented in centres utilising electron beam radiotherapy.

Testicular function following bone marrow transplantation performed during or after puberty

Testicular function was assessed in eight males who had undergone bone marrow transplantation (BMT) during or shortly after puberty. Their ages ranged between 10 years, 10 months and 17 years, 3 months (median, 13 years, 7 months) at the time of BMT, and they were followed 13 to 77 months (median, 36 months) posttransplantation. Therapy for BMT consisted of high-dose, short-term chemotherapy either alone (Group I) or in combination with single-dose irradiation, total lymphoid (Group II) or total body (Group III). Subjects in Group III had all received combination chemotherapy prior to BMT. Hormonal and clinical evidence of germ-cell dysfunction was common in that 6 patients manifested elevated plasma levels of follicle-stimulating hormone (FSH), and four subjects were found to have a subnormal testicular volume. Of the six patients with abnormal FSH values, four were followed serially, and all showed normalization over time. Leydig cell function was less impaired in that seven of the eight patients produced normal adult male levels of testosterone, including three subjects with elevated luteinizing hormone (LH) levels. All eight developed normal adult male secondary sexual characteristics. It is concluded that the therapy utilized for BMT causes damage primarily to germinal epithelium which appears amenable to recovery. This may be due, in part, to the use of single dose rather than fractionated radiation.

Changes in acidity of mouse tumor by hyperthermia

The intratissue pH of SCK tumor and leg muscle of unanesthetized mice were determined before, during and after hyperthermia with the use of bulb type pH microelectrodes having pH-sensitive hemisphere 20-40 micron in outer radius. Intratumor pH was heterogeneous throughout tumor (range, 6.60-7.38; average, 6.96), and was more acidic than the intramuscle pH of mouse leg (average, 7.46). Hyperthermia at 43.5 degrees C for 30 min induced a further increase in acidity (decrease in pH of about 0.2 units) in tumor but not in muscle. The heat-induced acidity in tumor lasted for 12 hr following hyperthermia and then recovered to almost control pH value 24 hr after heating. The cause of the increase in acidity in the heated tumors is not clear, but it appears to result from an increase in the contents of acidic metabolites and a sluggish drainage of them due to induced vascular damage. The increased acidity in the heated tumors may inhibit the repair of thermal damage and sensitizes the tumor cells to subsequent heating.

Intracranial ependymomas and ependymoblastomas

Nineteen cases of intracranial ependymal tumors were reviewed to examine the prognostic factors influencing survival of the patients with this disease. The two most important predictive factors in relation to survival status were a histologic grade of tumors and a presence of hydrocephalus. The clinicopathological correlation in this study has supported the view of two distinct ependymal tumors; more curable ependymomas and highly malignant ependymoblastomas .

A simple isocentric technique for irradiation of the breast, chest wall and peripheral lymphatics

The major problem with the standard technique for irradiation of the breast or chest wall and peripheral lymphatics is field matching at the junction between the supraclavicular and tangential fields. Overdosing or under-dosing across the junctions is unavoidable because of beam divergence. Various techniques using a half-blocked supraclavicular field in conjunction with special tangential fields have been introduced recently to eliminate the junction problem; they are, however, complicated, involving couch motions and machine isocentre repositioning when changing from the supraclavicular to the tangential fields. The breast treatment technique which we have used over the past twelve months utilises a supraclavicular half-blocked field, two tangential half-blocked fields and an optional posterior axillary field. The technique is simple and easy to set up since the same machine isocentre is used for all treatment fields and no couch movement or patient repositioning is required. The same half-block collimator which is used to define the caudad border of the supraclavicular field is used to define the cephalad edges of the two tangential fields. The margin of error of treatment is reduced and the dose measurements demonstrate excellent dose homogeneity through the entire treatment volume with no overdose or underdose at the field junction.

Impact of the timing of triple intrathecal therapy on remission induction in childhood acute lymphoblastic leukemia: a Pediatric Oncology Group study

Five weekly doses of triple intrathecal (IT) chemotherapy (methotrexate, hydrocortisone, cytosine arabinoside) starting on day 1 of treatment were added to systemic induction therapy in a regimen (Arm 3) that was compared to three other regimens (Arms 1, 2, and 4) in which central nervous system (CNS) prophylaxis was initiated after complete marrow remission (CR) was attained. The CR rate for Arm 3 was only 83% as compared to 91-92% for other Arms. The lower CR rate was the result of a significantly higher death rate during induction for patients receiving early CNS prophylaxis (10.6 vs 0.9-3.5%). These differences were only observed in high risk patients as defined in the study. The early death rate was especially high (30%) in Arm 3 for children who were less than 2 years of age. Infection was the primary cause of morbidity and mortality. Severe infection following the initiation of induction therapy was found in 16.7% of patients on Arm 3 vs 1.8-6% on other regimens. Immediate triple IT chemoprophylaxis during induction therapy of acute lymphoblastic leukemia as used in this study appears to be associated with increased susceptibility to infection and this form of CNS prophylaxis has increased hazards of morbidity and mortality in infants and other high risk patients.

Total lymphoid irradiation and cyclophosphamide conditioning prior to bone marrow transplantation for patients with severe aplastic anemia

A preparative regimen, consisting of total lymphoid irradiation and cyclophosphamide, was utilized in 40 patients with severe aplastic anemia undergoing allogeneic marrow transplantation. This regimen was successful in decreasing rejection in these previously transfused patients, as only one patient rejected the marrow graft. Twenty-nine of the 40 transplanted patients are surviving from 1.5 to 59 mo, with a median follow-up of 24 mo. The actuarial survival rate for these heavily transfused patients with aplastic anemia is 72% at 2 yr. This preparative regimen is extremely effective in decreasing rejection following transplantation for severe aplastic anemia. Future efforts in this area must be aimed at the elimination of graft-versus-host disease and control of fatal infections.

Acute megakaryoblastic leukemia in early childhood

Two girls, each less than 2 yr of age, developed acute megakaryoblastic leukemia (malignant myelosclerosis). Both presented with anemia, severe thrombocytopenia, and a low percentage of blasts in their peripheral blood. Their marrow showed marked reticulin fibrosis with an increase in blasts and immature megakaryocytes. The blasts stained negatively for myeloperoxidase and Sudan Black B, but showed acid phosphatase (ACP) and alpha-naphthyl acetate esterase (ANAE) activity inhibitable by sodium fluoride. They were identified as megakaryoblasts by the platelet peroxidase reaction. Cytogenetic studies showed multiple chromosomal abnormalities in both cases. Chemotherapy with vincristine, prednisone, and L-asparaginase was without effect, while daunorubicin and cytosine arabinoside induced a complete remission in one case. The second case responded to a combination of cytosine arabinoside, daunorubicin, and 6-thioguanine. This article documents that acute megakaryoblastic leukemia occurs in early childhood and describes its clinical, pathologic, and cytogenetic features. Previous reports of childhood "myelofibrosis" are reviewed, and their possible relationship with acute megakaryoblastic leukemia is discussed.

Intensive therapy followed by bone marrow transplantation for patients with acute lymphocytic leukemia in second or subsequent remission: determination of prognostic factors (a report from the University of Minnesota Bone Marrow Transplantation Team)

Fifteen patients with acute lymphocytic leukemia (ALL) in second or subsequent remission received intensive therapy with cyclophosphamide and single dose, rapid rate (26 cGy/min) total body irradiation (TBI) followed by bone marrow transplantation (BMT) from a histocompatible sibling match. Outcome was compared to that of 23 conventionally treated control patients in second ALL remission who presented to the same institution during the same time period but had no available transplant donor. The 15 BMT patients and 23 control patients had similar characteristics, with the exception that the BMT patients were significantly older at the time of ALL diagnosis (12.6 yr versus 5.7 yr, p = 0.01). BMT patients had a significantly increased chance of remaining disease-free for 36 mo from time on study (43% actuarial versus 5%, p = 0.004) and a greater overall survival rate at 48 mo (47% actuarial versus 9%, p = 0.27) than the conventionally treated patients. In all, 5 of the bone marrow transplant patients (33%) remain alive and free of disease 24-48 + mo from transplantation. Several pre- and posttransplant characteristics were analyzed to determine predictive factors for a successful BMT outcome for patients with ALL in second or subsequent remission. Significant risk factors for predicting leukemic relapse included initial white blood count (WBC) greater than 50,000/microliters at ALL diagnosis (100% relapse rate versus 37% for patients with lower WBCs, p = 0.001) and presence of any extramedullary disease pre-BMT (100% relapse rate versus 37% for patients without extramedullary disease, p = 0.03). All 5 disease-free BMT survivors had initial WBCs less than 50,000/microliters and no evidence of extramedullary disease pretransplantation. Maintenance chemotherapy with 6-mercaptopurine (6MP) and methotrexate was given to four patients starting 100 days after bone marrow transplantation. Use of maintenance chemotherapy was associated with a significantly increased chance of remaining disease free (100% of patients surviving leukemia-free versus 17% for patients not receiving maintenance chemotherapy, p = 0.02). Presence of graft-versus-host disease (GVHD) did not influence leukemia-free survival. These results confirm that intensive therapy followed by bone marrow transplantation is the treatment of choice for patients with ALL in second or subsequent remission who have a histocompatible sibling match. Furthermore, the data suggest that a controlled trial to evaluate the efficacy of maintenance chemotherapy post-BMT for ALL patients is warranted.

Malignant histiocytosis after lymphoblastic lymphoma

Malignant histiocytosis developed in a 19-year-old boy 3 1/2 years after the initial diagnosis of lymphoblastic lymphoma of T-cell origin. The experience with this young adult suggests that a close surveillance of the survivors of lymphoma is mandatory, and a prompt biopsy of enlarged lymph nodes in patients treated for lymphoma should be a routine procedure.

Total lymphoid irradiation

Total lymphoid irradiation by itself can produce sufficient immunosuppression to prolong the survival of a variety of organ allografts in experimental animals. The degree of prolongation is dose-dependent and is limited by the toxicity that occurs with higher doses. Total lymphoid irradiation is more effective before transplantation than after, but when used after transplantation can be combined with pharmacologic immunosuppression to achieve a positive effect. In some animal models, total lymphoid irradiation induces an environment in which fully allogeneic bone marrow will engraft and induce permanent chimerism in the recipients who are then tolerant to organ allografts from the donor strain. If total lymphoid irradiation is ever to have clinical applicability on a large scale, it would seem that it would have to be under circumstances in which tolerance can be induced. However, in some animal models graft-versus-host disease occurs following bone marrow transplantation, and methods to obviate its occurrence probably will be needed if this approach is to be applied clinically. In recent years, patient and graft survival rates in renal allograft recipients treated with conventional immunosuppression have improved considerably, and thus the impetus to utilize total lymphoid irradiation for its immunosuppressive effect alone is less compelling. For example, in our institution, the current one-year patient and graft survival rates in recipients of kidneys from cadaver donors are 91 and 84 per cent in those treated with cyclosporine and 94 and 80 per cent in those treated with conventional immunosuppression. Similar results might also be achieved by protocols that use total lymphoid irradiation as an immunosuppressant, but it will be difficult to improve over the current results with cyclosporine or conventional immunosuppression, at least for primary transplantation. The future of total lymphoid irradiation probably lies in devising protocols in which maintenance immunosuppression can be eliminated, or nearly eliminated, altogether. Such protocols are effective in rodents. Whether they can be applied to clinical transplantation remains to be seen.

Bone marrow transplantation for non-Hodgkin's lymphoma in children and young adults. A pilot study

Allogeneic bone marrow transplantation was performed in 10 patients with disseminated Burkitt's lymphoma or poor-prognosis T-cell lymphoblastic lymphoma. All patients received a cytoreduction regimen consisting of cyclophosphamide, cytosine arabinoside, bis-chloro-nitroso-urea, and total-body irradiation. Eight patients received marrow from HLA-matched sibling donors. One patient received marrow from a parent donor and one patient died during initial cytoreduction and did not undergo total-body irradiation or marrow infusion. Six patients had Burkitt's lymphoma stages III and IV at diagnosis, and three of the six are alive at 18, 28, and 73 months. Four patients had T-cell lymphoblastic lymphoma, stages III and IV at diagnosis, and two of the four are alive at 29 and 49 months. Overall survival in the nine patients who underwent transplantation is 56 percent by life-table analysis. Follow up for the surviving patients ranges from 18 to 73 months (median 29 months). All five survivors are at home with unmaintained remissions.

Uptake of carbon monoxide by C3H mice following X irradiation of lung only or total-body irradiation with 60Co

Carbon monoxide uptake (Vco) and ventilation rate (VR) of C3H mice were determined at 14 weeks following either X irradiation of lungs only or total-body irradiation with 60Co at different dose rates. Following localized X irradiation of lung at 97 cGy/min there was a reduction in Vco, which was inversely related to radiation dose, with a small reduction below control levels being detected at 7 Gy, the lowest dose tested. An increase in VR could be detected only at doses of 11 Gy, or more. Another group of animals received 11.5 Gy total-body irradiation at either 26.2 or 4.85 cGy/min followed by transplantation with syngeneic bone marrow. Following total-body irradiation, Vco was significantly reduced by about 37% at the higher dose rate and 23% at the lower dose rate. In contrast, a trend toward elevated VR was detected only at the higher dose rate. The results indicate that Vco is a sensitive indicator of radiation-induced lung injury and that under the experimental conditions used Vco is a more sensitive indicator of radiation-induced lung injury in C3H mice than VR.

Ovarian function after successful bone marrow transplantation in postmenarcheal females

Ovarian function was followed serially in a group of six postmenarcheal females after successful bone marrow transplantation (BMT). The patients were between 13 9/12 and 22 6/12 (median 16 5/12) years of age at the time of BMT and were followed a median of 20 months (range 17-45 months) posttransplantation. Two subjects received short-term high-dose cyclophosphamide combined with single-dose total lymphoid irradiation (Group I), whereas the remaining four were treated with short-term, high-dose chemotherapy plus single-dose total body irradiation (Group II). Group II subjects also received combination chemotherapy prior to BMT. One subject from Group I continues to have regular menses and normal gonadotropin levels, 36 months post-BMT. The remaining five patients have demonstrated persistently elevated plasma concentrations of LH and FSH over a 17- to 45-month period of time. None of the four patients in Group II has menstruated since undergoing BMT. We conclude that single-dose radiation combined with short-term, high-dose chemotherapy results in profound ovarian damage in the majority of young women undergoing BMT.

Non-Hodgkin's lymphoma in couples

The occurrence of identical non-Hodgkin lymphomas in three couples related only by marriage, is reported. The couples had lived together for 25 years or longer and there was a five to eight year delay in onset of the lymphoma between each of the members of the couple. The pathologic finding in two of the three couples was a nodular poorly differentiated lymphocytic (NPDL) type in the third a diffuse histiocytic (DHL) type (Rappaport's classification). All cases are believed to be of B-cell origin. The unusual clustering in their cases suggests an infections agent and/or environmental factor may be playing a role in the etiologic causes of some non-Hodgkin's lymphomas.

Emperipolesis of neutrophils by dysmorphic megakaryocytes

Neutrophil engulfment by megakaryocytes was observed within 20 to 30% of megakaryocytes from two children: one with metastatic rhabdomyosarcoma, the other with fever of unknown origin. Other cell types and neutrophil precursors were not observed within megakaryocytes. Only late megakaryocytes were involved in the process, and often these cells appeared vacuolated or degenerating at the light and electron microscope level. Ultrastructurally the engulfed neutrophils were intact and were within the open canalicular system of the megakaryocyte cytoplasm. No evidence of neutrophil granule exocytosis could be demonstrated in ultrastructural morphologic and peroxidase preparations; however, many neutrophils appeared to be endocytosing portions of the megakaryocyte cytoplasm. The phenomenon could not be transferred to normal marrow incubated with patient serum or plasma. Thus, our patients differ from previous observations of emperipolesis in: 1) the extreme frequency of the observation; 2) the selective involvement of neutrophils; and 3) the association of the anomaly with dysmorphic and/or disrupted megakaryocytes. These observations are consistent with a neutrophil response to altered and/or injured megakaryocytes.

Two new acute lymphoblastic leukemia cell lines with early B-cell phenotypes

Two leukemic cell lines (697 and 207) were established from bone marrow cells obtained from children with ALL in relapse. These cell lines were positive for the common-ALL antigen (CALLA), the HLA-DR (i.e., Ia-like) antigen, and for cytoplasmic and surface IgM heavy chains. The lines were negative for other immunoglobulin heavy chains and light chains. The lines had elevated levels of terminal deoxynucleotidyl transferase enzyme and expressed surface antigens found on normal myeloid-macrophage cells (MMA) and on natural killer cells (HNK-1). A minority of cells in line 207 expressed the T-1, T-6, and Leu-1 antigens as detected by monoclonal antibodies. Line 697 was positive for Epstein-Barr virus (EBV), while line 207 did not possess EBV. Line 697 carried a marker chromosome (identified as a translocation between chromosomes 7 and 19), which was also patient's fresh leukemic cells. The leukemic origin of the cell lines was further indicated by their morphological, cytochemical, and immunologic similarity to the patients' leukemic cells. Phenotypically, both cell lines appear to be arrested in a transitional stage of development between pre-B and B cells and express surface antigens usually found on normal and fresh leukemic cells of non-B-cell lineages.

Thyroid dysfunction among long-term survivors of bone marrow transplantation

Thyroid function studies were followed serially in 27 long-term survivors (median 33 months) of bone marrow transplantation. There were 15 men and 12 women (median age 13 1/12 years, range 11/12 to 22 6/12 years). Aplastic anemia (14 patients) and acute nonlymphocytic leukemia (eight patients) were the major reasons for bone marrow transplantation. Pretransplant conditioning consisted of single-dose irradiation combined with high-dose, short-term chemotherapy in 23 patients, while four patients received a bone marrow transplantation without any radiation therapy. Thyroid dysfunction occurred in 10 of 23 (43 percent) irradiated patients; compensated hypothyroidism (elevated thyroid-stimulating hormone levels only) developed in eight subjects, and two patients had primary thyroid failure (elevated thyroid-stimulating hormone levels and low T4 index). The abnormal thyroid studies were detected a median of 13 months after bone marrow transplantation. The four subjects who underwent transplantation without radiation therapy have remained euthyroid (median follow-up two years). The only variable that appeared to correlate with the subsequent development of impaired thyroid function was the type of graft-versus-host disease prophylaxis employed; the irradiated subjects treated with methotrexate alone had a higher incidence of thyroid dysfunction compared to those treated with methotrexate combined with antithymocyte globulin and prednisone (eight of 12 versus two of 11, p less than 0.05). The high incidence and subtle nature of impaired thyroid function following single-dose irradiation for bone marrow transplantation are discussed.

Reversal of severe bone marrow fibrosis and osteosclerosis following allogeneic bone marrow transplantation for chronic granulocytic leukaemia

Severe marrow fibrosis and osteosclerosis gradually disappeared after a 33-year-old woman received an allogeneic bone marrow transplantation (BMT) as experimental treatment for chronic granulocytic leukaemia. Serial biopsies demonstrate gradual resolution of dense reticulin fibrosis, collagen fibrosis and osteosclerosis, and restoration of normal marrow architecture after transplantation. These changes correspond with histological and cytogenetic evidence of normal marrow engraftment and sustained complete remission from chronic granulocytic leukaemia. In this case severe marrow infiltration with reticulin and collagen fibrosis as well as severe derangement of marrow architecture and obliteration of the medullary cavity by osteosclerosis was an entirely reversible process after allogeneic bone marrow transplantation, and did not prevent successful engraftment, haemopoietic and cytogenetic reconstitution and complete remission from chronic granulocytic leukaemia.

Successful allogeneic bone-marrow transplantation for patients in the accelerated phase of chronic granulocytic leukaemia

Nine patients underwent allogeneic bone-marrow transplantation as treatment for chronic granulocytic leukaemia (CGL) during the accelerated phase, a point in the course of the disease when it has progressed beyond the stable chronic phase but before the onset of blast crisis. After bone-marrow transplantation, haematological and cytogenetic studies showed ablation of all evidence of leukaemia, successful engraftment, and persistence of normal haemopoiesis in all patients. In one patient severe myelofibrosis and osteosclerosis disappeared after bone-marrow transplantation. Two patients have died of complications related to graft-versus-host disease (GvHD) but with no evidence of CGL. In one patient haematological and cytogenetic evidence of recurrent disease developed after bone-marrow transplantation, and she survives in chronic phase. Six patients are free of disability, do not require transfusions, possess normal marrow chromosomes, and have persistent clinical and haematological evidence of complete remission from CGL. Intervention with allogeneic bone-marrow transplantation during the accelerated phase of CGL can eradicate the disease and can provide normal haemopoiesis with acceptably low early morbidity and mortality. The long-term efficacy of bone-marrow transplantation as treatment for CGL, and the most effective timing of the transplantation with regard to the course of disease have yet to be determined.

A randomized study of the prevention of acute graft-versus-host disease

Acute graft-versus-host disease is a major problem in allogeneic bone-marrow transplantation. We performed a randomized study to compare the effectiveness of two regimens in the prevention of acute graft-versus-host disease. Thirty-five patients received methotrexate alone, and 32 received methotrexate, antithymocyte globulin, and prednisone. Of the patients who received methotrexate alone, 48 per cent had acute graft-versus-host disease, as compared with 21 per cent of those who received methotrexate, antithymocyte globulin, and prednisone (P = 0.01). The age of the recipient was a significant factor in the development of acute graft-versus-host disease: Older patients had a higher incidence of the disease (P = 0.001). We conclude that the combination of methotrexate, antithymocyte globulin, and prednisone significantly decreased the incidence of acute graft-versus-host disease and should be used to prevent this disorder in patients receiving allogeneic marrow transplants.

Pretreatment testicular biopsy in childhood acute lymphocytic leukaemia

Between August, 1978, and March, 1981, 24 boys with acute lymphocytic leukaemia (ALL) (14 non-B-cell non-T-cell, 6 pre-B-cell, and 4 T-cell) underwent bilateral wedge testicular biopsy at initial diagnosis. All testes were of normal size. Histological analysis was performed independently by three pathologists, 4 (3 non-B non-T, and 1 pre-B) of 20 patients with non-T-cell ALL demonstrated testicular focal lymphoblastic involvement. Successful induction chemotherapy without concomitant testicular irradiation completely eradicated testicular infiltrates in all 4 patients. Only 1 of the 4 T-cell patients had pre-treatment testicular infiltrates. Unlike boys with non-B non-T leukaemia, attainment of bone-marrow remission in this patient was associated with persistent testicular disease. These preliminary data indicate that in patients with ALL of non-T-cell type, systemic induction chemotherapy eradicates the small testicular infiltrates of lymphoblasts. Prophylactic testicular irradiation in this group of patients does not seem to be warranted.

Limited surgery with or without radiotherapy for early breast carcinoma

Between January 1971 and December 1978, 117 consecutive patients with unilateral early stage carcinoma of the breast were treated with limited surgery, with or without the addition of postoperative radiotherapy. Local excision alone was found to be inadequate treatment for T1 and T2 carcinoma of the breast. Local recurrence rates were also high in patients with T1 and T2 lesions treated by local excision plus relatively low dose radiotherapy. Local recurrence was, however, infrequent after partial mastectomy, and no local failures were observed after partial mastectomy plus postoperative radiotherapy to a dose of 5000 rad in 5 weeks. Morbidity with such treatment is minimal and cosmetic results are generally excellent.