Effect of chlorambucil on bone mineral density in the course of chronic lymphoid leukemia

The purpose of this work was to study the effects of chronic lymphoid leukemia (CLL) and its treatments on bone mineral density (BMD). Lumbar and femoral BMD was measured by X-ray absorptiometry in 50 (32 M, 18 F, median age 65, range age: 47-87 yr) CLL patients. In order to gauge the respective effects of CLL and corticoids on bone mass, 31 CLL patients under treatment were compared with 31 controls on cortisone. Nineteen untreated patients with CLL were compared with controls devoid of osteopenia risk factor. There was no significant difference regarding lumbar and femoral BMD between the untreated patients with CLL and the healthy controls. An increase in lumbar and femoral BMD was noted in the treated CLL group compared with the controls on cortisone (lum BMD: 1.018 vs. 0.861 g/cm2, p=6.10(-4); fem BMD: 0.773 vs. 0.699 g/cm2, p=0.037). This increase was observed only in patients who had received chlorambucil (lum BMD: 1.066 vs. 0.861 g/cm2, p=0.10(-4); fem BMD: 0.806 vs. 0.699 g/cm2, p=4.10(-3)), whereas there was no difference between the CLL patients treated without chlorambucil and the controls on cortisone. Multiple linear regression analysis confirmed the marked effect of chlorambucil (r=0.3715, p<10(-3)) on BMD increase in the course of CLL.

Doxorubicin-containing regimen with or without interferon alfa-2b for advanced follicular lymphomas: final analysis of survival and toxicity in the Groupe d'Etude des Lymphomes Folliculaires 86 Trial

PURPOSE

To compare progression-free survival (PFS), overall survival (OS), and toxicity of a doxorubicin-containing regimen administered alone or in combination with interferon alfa-2b (IFNalpha) in patients with low-grade follicular lymphoma (FL) and poor prognostic factors.

PATIENTS AND METHODS

Two hundred sixty-eight patients with advanced-stage FL received cyclophosphamide, doxorubicin, teniposide, and prednisone (CHVP) monthly for 6 months, then every 2 months for 12 months. After randomization, 242 patients were evaluated for efficacy: 119 received CHVP alone, and 123 also received IFNalpha at a dose of 5 million units three times weekly for 18 months.

RESULTS

After a 6-year median follow-up, the patients treated with CHVP + IFNalpha showed significantly longer median PFS than those who received CHVP alone (2.9 years v 1.5 years, respectively; P = .0002) and significantly longer median OS (not reached v 5.6 years, respectively; P = .008). Although some side effects, which included neutropenia, asthenia, fever, elevated serum transaminase levels, flu-like symptoms, and thrombocytopenia, were more frequently observed in patients who received the combination regimen, these reactions were moderate. IFNalpha was withdrawn because of toxicity in 10% of the patients, and a dosage reduction or temporary suspension was required in 28%.

CONCLUSION

With long-term follow-up of 6 years, these results confirm that the addition of IFNalpha to a doxorubicin-containing regimen for patients with advanced-stage and clinically aggressive FL not only increased PFS, as in most other similar trials, but also prolonged OS. Toxicity was moderate. The beneficial effects of this combined chemotherapy and IFNalpha regimen on OS probably reflect the selection of FL patients with poor prognostic factors.

[Characterization of specific IgG, IgM, IgA and IgE isotypes in profound candidiasis]

Enzyme-linked immunofiltration assay technique (Elisa) has been applied to the characterization of G, M, A and E anti-Candida antibodies isotypes specific to cell wall mannans in 201 sera from 126 patients. These sera were studied at the same time using Co-immunoelectrodiffusion and indirect immunofluorescence. In 18 of 21 patients with systemic candidiasis, Elisa demonstrated the presence of antimannan IgG antibodies in sera contemporary of Candida positive blood culture. These IgG were associated with antimannan IgM, A and E in 15 patients. In 37 patients colonized with Candida, used as negative controls, antimannan IgG were detected in 3 cases, and in 2 were associated with specific IgMs. The sensitivity and specificity of Elisa IgM and IgA in the diagnosis of systemic Candidiasis were 85.7% and 81%, respectively. The kinetic study shows that the different isotypes appeared most of the time simultaneously. The evolution of the 4 isotypes beyond the acute episode was variable and without correlation with the clinical status. The decrease of IgG was slower than the one of IgM, IgA or IgE. The systematic research, in at risk patients, of antimannan antibodies using Elisa required simple technology. A simple method should allow to aim at other functional antigens which could be used in a quantitative manner to determine the efficacy of the medical treatment.

A placebo-controlled study of recombinant human granulocyte-macrophage colony-stimulating factor administered during and after induction treatment for de novo acute myelogenous leukemia in elderly patients. Groupe Ouest Est Leucémies Aiguës Myéloblastiques (GOELAM)

The complete remission (CR) rate after intensive chemotherapy for acute myelogenous leukemia (AML) remains low in elderly patients, mainly because of a higher infectious mortality rate related to neutropenia and an increased incidence of adverse prognostic factors. Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been shown to potentially recruit leukemic blasts into cell cycle and improve cytotoxic effects when given during chemotherapy, and to shorten the duration of neutropenia when administered after chemotherapy. Two hundred forty patients aged 55 to 75 years who had newly diagnosed AML were randomly assigned to receive placebo or Escherichia coli-derived GM-CSF (5 micrograms/kg/d by 6-hour intravenous infusion) starting during induction chemotherapy on day 1 and continued through and after chemotherapy until recovery of neutrophils, or evidence of regrowth of leukemia, or up to day 28. Induction chemotherapy consisted of idarubicin (8 mg/m2/d on days 1 to 5) and cytarabine (100 mg/m2/d on days 1 to 7). The study drug was not administered subsequent to the induction course. Patients who achieved a CR received continuous maintenance therapy for 1 year with four quarterly reinduction courses; in the 55- to 64-year age subgroup, patients were randomly assigned to receive or not a consolidation course before maintenance therapy. The CR rate was similar in the GM-CSF and placebo groups (63% and 60.5%, respectively; P = .79). The mortality, rate of resistant disease, and rate of regrowth of leukemia were also similar in both groups. The time to neutrophil recovery was shorter in patients who received GM-CSF (24 v 29 days; P = .0001), but the incidence and characteristics of infectious events were not different. The 2-year disease-free survival (DFS) rate was significantly improved in the GM-CSF group (48% v 21% in the placebo group; P = .003). This effect was highly significant in the cohort of patients aged 55 to 64, but only marginal in patients >/=65 years of age. There was a trend toward a longer overall survival (OS) in the GM-CSF group (P = .082). In summary, the administration of GM-CSF, concomitantly with chemotherapy and thereafter during induction course in AML, shortened the time to neutrophil recovery, but did not improve the CR rate in patients aged 55 to 75. Nonetheless, DFS and OS were significantly prolonged in patients aged 55 to 64 treated with GM-CSF. These results are promising and further evaluation of myeloid growth factors in AML is warranted.

Comparison of autologous bone marrow transplantation and intensive chemotherapy as postremission therapy in adult acute myeloid leukemia. The Groupe Ouest Est Leucémies Aiguës Myéloblastiques (GOELAM)

Three intensive consolidation strategies are currently proposed to younger adults with acute myeloid leukemia (AML) in first complete remission (CR): allogeneic or autologous bone marrow transplantation (BMT) and intensive consolidation chemotherapy (ICC). Patients aged 15 to 50 years with de novo AML received an induction treatment with 7 days of cytarabine and either idarubicin or rubidazone. After achievement of a CR, patients up to the age of 40 and having an HLA-identical sibling were assigned to undergo an allogeneic BMT. All the other patients received a first course of ICC with high-dose cytarabine and the same anthracycline as for induction. They were then randomly assigned to either receive a second course of ICC with amsacrine and etoposide or a combination of busulfan and cyclosphosphamide followed by an unpurged autologous BMT. Of 517 eligible patients, 367 had a CR, but only 219 (59.5%) actually received the planned intensive postremission treatment (73 allogeneic BMT, 75 autologous BMT, and 71 ICC). With a median follow-up of 62 months, the 4-year disease-free survival (DFS) of the 367 patients in CR was 39.5%. The 4-year overall survival (OS) of the 517 eligible patients was 40.5%. In multivariate analysis, DFS and OS were influenced only by the initial white blood cell count and by the French-American-British classification. The type of postremission therapy had no significant impact on the outcome. There was no difference in the 4-year DFS and OS between 88 patients for whom an allogeneic BMT was scheduled (respectively, 44% and 53%) and 134 patients of the same age category and without an HLA-identical sibling (respectively, 38% and 53%). Similarly, there was no difference in the outcome between autologous BMT and ICC. The 4-year DFS was 44% for the 86 patients randomly assigned to autologous BMT and 40% for the 78 patients assigned to ICC (P = .41). The 4-year OS was similar in the two groups (50% v 54.5%, P = .72). The median duration of hospitalization and thrombocytopenia were longer after autologous BMT (39 v 32 days, P = .006, and 109.5 v 18.5 days, P = .0001, respectively). After a first course of ICC, a second course of chemotherapy is less myelotoxic than an unpurged autologous BMT but yields comparable DFS and OS rates.

Avascular necrosis of the femoral head as a complication of chronic myelogenous leukaemia

A 17-year-old male patient complaining of intense pain in his right hip was found to be suffering from chronic myelogenous leukaemia. Preliminary X-rays and bone scintigraphy did not suggest avascular necrosis of the femoral head. Magnetic resonance imaging (MRI) did, however, reveal leukaemic infiltration of the femoral neck and generalised ischeamia in the femoral head. Further, MRI carried out 4 months later disclosed typical signs of osteonecrosis, despite previous indications of an improvement under chemotherapy. Flattening of the head of the femur appeared in radiographs taken in the 9th month. In the 12th month, recurrence of pain made it necessary to perform a total hip arthroplasty. Anatomo-pathological investigation confirmed both the necrosis and the leukaemic invasion.

Treatment of acute myeloblastic leukemia in adults. The GOELAM experience

The GOELAM group conducted 2 consecutive trials on the treatment of de novo acute myeloblastic leukemia (AML) in adults. In the GOELAM1 protocol 786 patients aged 15-65 were randomized between two induction treatments (ARA-C 200 mg/m2/day for 7 days plus either Idarubicin 8 mg/m2/day for 5 days or Rubidazone 200 mg/m2/day for 4 days). Out of 731 evaluable patients, 521 (71%) achieved complete remission (CR) without significant difference between the 2 anthracyclines. For patients aged 51-65, the CR rate was significantly higher with Idarubicin (75%) than with Rubidazone (61%) (p = 0.03). In this group of patients the post-remission therapy consisted in only one course of high dose ARA-C plus m-Amsa and the 6 year disease free survival (DFS) was 24% (intention to treat analysis). For patients aged 15-50 years, the post remission therapy was either allogeneic bone marrow transplantation (BMT) (patients up to 40 years of age with an HLA identical sibling) or a first course of intensive consolidation chemotherapy (ICC) followed by a randomization between autologous unpurged bone marrow transplantation (ABMT) and a second course of ICC. There was no significant difference in the 4 year DFS between allogeneic BMT (42%) and the other types of intensive post remission-therapy (40%). The 4 year DFS was 42% for ABMT and 38% for ICC (p = 0.46) (intention to treat analysis). However the median duration of thrombocytopenia was much longer after ABMT (109.5 days versus 18.5 days p = 0.0001). The GOELAM SA3 randomized placebo-controlled protocol tested the impact of GM-CSF given during and after induction treatment for elderly patients (55-75 years). In this study, 232 evaluable patients received induction chemotherapy (Idarubicin 8 mg/m2/day for 5 days plus ARA-C 100 mg/m2/day for 7 days) plus placebo or GM-CSF 5 micrograms/kg/day from day 1 until the end of neutropenia. The CR rate was 61.5%. The median duration of neutropenia was shorter in the GM-CSF arm (22 days versus 27 days p = 0.0001). There was no overall significant advantage for the GM-CSF arm, in terms of CR rate and survival. However for patients age 55-64 the 2 year DFS was significantly higher in the GM-CSF arm (43% vs 17% p = 0.0013).

Combination of quinine as a potential reversing agent with mitoxantrone and cytarabine for the treatment of acute leukemias: a randomized multicenter study

A phase III prospective randomized multicenter study was performed to determine whether quinine could improve the response rate of poor-risk acute leukemias (ALs) to standard chemotherapy including a multidrug resistance (MDR)-related cytotoxic agent. The rationale of the study was based on the negative prognostic value of MDR phenotype in ALs and the ability of quinine to reverse this phenotype both in vitro and ex vivo. Three hundred fifteen patients (median age, 49 years; range, 16 to 65) with relapsed (n = 108) or refractory (n = 32) acute myeloblastic leukemia (AML), relapsed (n = 27) or refractory (n = 9) acute lymphoblastic leukemia (ALL), secondary AL (n = 22) or blastic transformation of myelodysplastic syndrome ([MDS] n = 74) or myeloproliferative syndrome ([MPS] n = 43) were randomly assigned to receive mitoxantrone ([MXN] 12 mg/m2/d, days 2 to 5) and cytarabine ([Ara-C] 1 g/m2/12 h, days 1 to 5) alone or in combination with quinine (30 mg/kg/d, days 1 to 5; continuous intravenous infusion beginning 24 hours before MXN infusion). Side effects of quinine were observed in 56 of 161 quinine-treated patients and disappeared in all but four cases after one or two 20% dose decreases. Sera from quinine-treated patients showed increased MXN uptake in an MDR-positive cell line compared with matched sera obtained before quinine infusion. Quinine induced a significant increase in the incidence of nausea, vomiting, mucositis, and cardiac toxicity. A complete response (CR) was observed in 85 of 161 patients (52.8%) from the quinine-treated group versus 70 of 154 patients (45.5%) in the control group (P = .19). The most important differences between quinine and control group CR rates were observed in patients with refractory AMLs and blastic transformation of MDS and MPS. The CR rate was higher in P-glycoprotein-positive cases, although the difference was not significant. Failure of the regimen due to blastic persistence or blast number increase was higher in the control group (61 of 154 patients) than in the quinine group (45 of 161, P = .04). Early death was observed in eight cases (four in each arm) and death in aplasia in 27 cases (20 in quinine group v seven in control group, P = .01). The significant increase of toxicity in the quinine arm could have masked the clinical benefit of MDR reversion in poor-risk ALs.

Treatment of acute myelogenous leukaemia in patients aged 50-65: idarubicin is more effective than zorubicin for remission induction and prolonged disease-free survival can be obtained using a unique consolidation course. The Goelam Group

From December 1987 to June 1992, 251 patients aged 50-65 with de novo acute myelogenous leukaemia (AML) were recruited to a multi-institutional randomized clinical trial. Induction therapy consisted of Ara-C (200 mg/ m2, continuous infusion, days 1-7) with either zorubicin (ZRB) (200 mg/m2, i.v., days 1-4) or idarubicin (IDR) (8 mg/ m2, i.v., days 1-5). Consolidation therapy consisted of a single course of intensive chemotherapy with high-dose Ara-C (3 g/m2, 3 h infusion, q 12 h, days 1-4) and m-Amsa (100 mg/m2/d, i.v., days 5-7). The complete remission (CR) rate was (73%) with Ara-C/ IDR versus (60%) with Ara-C/ZRB (P = 0.033). In multivariate analysis, factors found to be significant in predicting CR were normal karyotype and treatment with IDR. With a median follow-up of 73 months, the median disease-free survival (DFS) duration of all CR patients and the probability of CR at 6 years were 17 months and 29%. In multivariate analysis the only factor associated with an increased DFS duration was a normal karyotype. The median event-free survival (EFS) duration for all evaluable patients and the median overall survival duration for all eligible patients were respectively 7 and 12 months without any difference between induction arms. The study shows that in patients aged 50-65 idarabicin is more effective than zorubicin for remission induction. However, the type of anthracycline did not influence overall survival duration. Using a unique consolidation course, we observed a prolonged DFS which compares favourably with results obtained with more prolonged consolidation therapy or maintenance treatment.

Characterization of specific anti-Candida IgM, IgA and IgE: diagnostic value in deep-seated infections

The proposed serological diagnosis of systemic Candida infections is based on a microplate immunocapture technique detecting IgM, IgA and IgE anti-Candida antibodies. Activity is revealed with a suspension of human erythrocytes sensitized with somatic antigen of Candida albicans, and is quantified on an automated plate reader. The sera were obtained from patients with deep-seated (n = 56) and superficial (n = 193) candidosis. We compared this immunological method with a combination of indirect immunofluorescence and co-immunoelectrodiffusion. The immunocapture method was more sensitive (80.4% vs. 48.2% with indirect immunofluorescence and 58.9% with co-immunoelectrodiffusion), and often provided the diagnosis at an earlier stage, with clear therapeutic advantages. The IgA isotype was a particularly valuable marker of deep-seated Candida infections.

[Lymphocytic ascites revealing systemic mastocytosis]

Systemic mastocytosis is a chronic disease with proliferation of mastocytes in organs separate from skin. We report the case of a systemic mastocytosis revealed by a lymphocytic ascites in the absence of cutaneous involvement. The diagnosis was established by the ultrastructural examination of the bone marrow. Identification of few mastocytes in ascites suggested a mast cell infiltration of the peritoneum. A treatment by alpha-2b interferon was unsuccessful, and death rapidly occurred.

In vitro study of THP-doxorubicin retention in human leukemic cells using confocal laser microspectrofluorometry

Microspectrofluorometry allows the analysis of fluorescent molecules such as anthracyclines in the nucleus of isolated living cells. Using this technique, we confirmed that the amount of doxorubicin or THP-doxorubicin incorporated into the nucleus was related to the resistant or sensitive character of K562 cells. It was then extended to the study of fresh leukemic cells and kinetic studies were performed allowing the calculation of the retention rate (RR) of anthracycline (THP-doxorubicin) into the cell nucleus. A reproducibility study confirmed the accuracy of the method. Blast cells collected in patients with acute myeloid (n = 22) or lymphoid (n = 8) leukemia, at diagnosis (n = 26), or in relapse (n = 4) have been studied. RR varied from 8 to 98% independently of the type of leukemia or the clinical status. RR did not correlate either with P-glycoprotein or with CD34 expression although this latter result should be confirmed on a higher number of subjects. Among 18 patients presenting with AML at diagnosis, 14 have been treated with intensive chemotherapy including anthracyclines; the only one who had resistant disease had the lowest RR value. In conclusion, the results obtained here show that microspectrofluorometry allows the performance of kinetic studies on fresh leukemic cells in order to quantify chemo-resistance phenomena related to drug transport.

[Acute febrile pustular and bullous neutrophilic dermatosis (Sweet syndrome) disclosing acute myeloblastic leukemia]

We report a patient with Sweet's syndrome (acute febrile neutrophilic dermatosis) revealing an acute myelogenous leukemia. About 10% of Sweet's syndromes are associated with a malignant disease that they can reveal. Among those, hemopathies are the most frequent, and 42% are myelogenous leukemia. These observations emphasize the particular clinical aspects of the Sweet's syndrome associated with an hemopathy.

Erythrocyte aggregation--determination of normal values. Influence of age, sex, hormonal state, oestroprogestative treatment, haematological parameters and cigarette smoking

Erythrocyte aggregation is a physiological phenomenon and constitutes one of the most important factors accounting for the non-Newtonian properties of normal human blood. Pathological aspects have also been described and therapy aimed at reducing hyperaggregability has been proposed. The object of this study was to establish normal values of erythrocyte aggregation parameters as measured by laser light backscattering and to study the influence of various physiological factors. Normal values were determined from a reference population. Sex and age induce variations in erythrocyte aggregation which are neither fibrinogen nor haematocrit dependent and there is a general trend towards stronger aggregation in women, although neither hormonal state nor oestroprogestative treatment appear to influence the female aggregation parameters. In elderly people stronger aggregation is also observed but this effect is of lower magnitude. In vivo, the plasma fibrinogen level is the most important factor influencing erythrocyte aggregation, while variations in haematocrit play a lesser role and mean corpuscular volume, red cell distribution width and white blood cell and platelet counts have no effect. Finally, no difference is noted in cigarette smokers.

Approach to erythrocyte aggregation through erythrocyte sedimentation rate: application of a statistical model in pathology

Erythrocyte sedimentation rate (ESR) is mainly used in clinical practice as a screening test for inflammatory diseases and sometimes in the follow-up of patients. However, ESR is highly dependent on erythrocyte aggregation. In this study, using a Sediscan (Becton) automatic device measuring the kinetics of ESR, these results are compared with the measurement of erythrocyte aggregation as determined by laser light backscattering (Erythroaggregometer Affibio). A series of 188 samples from in-patients were tested. Statistical analysis of 13 parameters indicates that 82% of ESR variance may be explained by fibrinogen level, haematocrit and a parameter characterizing erythrocyte aggregation: the aggregation index at 10 s. This correlation was then validated prospectively in 128 other patients and seems to be independent of the underlying disease. Thus ESR in combination with fibrinogen assay and haematocrit may be considered as a simple and economic method to assess erythrocyte aggregation.

[Prognostic factors and monitoring of myeloma]

An improved knowledge of the initial prognostic factors of multiple myeloma and regular monitoring of the disease should result in the choice of the most effective treatment. The conventional prognostic factors have been divided into three stages by Durie and Salmon. These stages are based on the proportion and type of the monoclonal component, on haemoglobin, calcium and creatinine blood levels and on the extent of bone lesions. However, this widely used classification has certain disadvantages: the size of the tumoral mass is evaluated mainly from the proportion of monoclonal gammopathy, the bone lesions are difficult to determine and the kinetics of cell proliferation are not taken into account. Parameters with high prognostic value have recently been demonstrated; they include beta 2-microglobulin, LDH, interleukin-6, C-reactive protein, serum albumin and kinetic of cell proliferation. When associated, these data allow to establish prognostic staying that are at least as relevant as those of the Durie-Salmon's classification. Monitoring of patients with multiple myeloma by means of a time-related curve of either the tumoral mass or the amount of monoclonal gammopathy leads to the best possible treatment.

Intranuclear concentration measurements of doxorubicin in living leucocytes from patients treated for a lympho-proliferative disorder

The accumulation of doxorubicin (DOX) in white blood cells of treated patients has been studied by quantitative microspectrofluorometry. From blood samples of treated patients, leucocyte subpopulations were separated by the gradient method. Emission fluorescence spectra from a microvolume of a single living cell nucleus were analysed in terms of spectral shape and fluorescence yield between free and DNA-bound doxorubicin. With this non-destructive analysis technique, intranuclear doxorubicin concentrations were determined within +/- 10%. Doxorubicin concentrations were measured in patients treated with bolus injection. After an accumulation of DOX in leucocytes during the first 30 min, intranuclear doxorubicin concentration did not vary significantly for 24 h, whereas its concentration in plasma decreased. Despite large differences between patients, monocytes accumulated significantly more doxorubicin than granulocytes or lymphocytes did.

[Value and limitations of anti-mannan antibodies research by co-immunoelectrodiffusion in the diagnosis of deep candidiasis]

Several groups have evaluated detection of antibodies against Candida, with somewhat conflicting results. In this study, co-counterimmunoelectrodiffusion was used to detect antimannan antibodies specific of components of the Candida membrane. Study patients were divided into two groups according to whether their history for Candida infection was negative (population A, n = 102) or positive (population B). Different antigen levels were used in order to differentiate low and high antimannan antibody levels. Among the 102 sera in population A, 42 were positive for antimannan antibodies; the antimannan antibody titer was low in 40 cases and high in 2 cases. In population B (53 patients), antimannan antibodies were found in 97 of the 98 sera studied; titers were high in 95 cases. Use of an antigen level that detects only high titers of antimannan antibodies thus provides a sensitive and specific tool for the diagnosis of deep candidiasis. The simplicity and rapidity of this test are particularly valuable in situations where emergency treatment is needed.