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.

Kidney allograft survival in dogs treated with total lymphoid irradiation

Total lymphoid irradiation (TLI) is immunosuppressive and, in rodent, can induce a state where transplantation of allogeneic bone marrow results in chimerism and permanent acceptance of organ allografts from the donor strain. We attempted to apply this treatment to a large animal model. Twelve splenectomized dogs were treated with TLI (150 rads per fraction, total dose 1950-3000 rads) before bilateral nephrectomy and renal allotransplantation. Eight dogs received bone marrow from the kidney donor. In 13 untreated control dogs renal allografts functioned (serum creatinine level less than 2.0 mg/dl) for a mean +/- (SE) of 4.7 +/- 0.3 days. In the four TLI treated dogs who did not receive bone marrow the renal allografts functioned for 15-76 days (two dogs died with functioning grafts). In the eight TLI treated dogs who received donor bone marrow, two died immediately after transplantation, two rejected at 3 and 13 days, one died at 13 days with a functioning graft, and two have had the grafts function for longer than 500 days. Chimerism was not detected in the one dog tested. The response of peripheral blood lymphocytes to stimulation with phytohemagglutinin and in mixed lymphocyte culture was suppressed for at least on month after TLI. The results confirm the immunosuppressive effect of TLI. The absence of kidney rejection in two recipients of donor bone marrow show the potential of this approach to induce long-term immunologic unresponsiveness as to an organ allograft, but the outcome is unpredictable and further experiments are needed to define the optimal conditions for administration of TLI and bone marrow to the recipients.

Successful bone-marrow transplantation for infantile malignant osteopetrosis

A five-month-old girl with autosomal-recessive osteopetrosis received a bone-marrow transplant from her five-year-old HLA-MLC-identical brother after preparation with cyclophosphamide and modified total-body irradiation. Engraftment was documented by chromosomal analysis. Anemia, thrombocytopenia, and leukoerythroblastosis corrected within 12 weeks of transplantation. Low serum calcium and elevated serum alkaline and acid phosphatase levels became normal. Serial x-ray studies revealed bony remodeling and new nonsclerotic bone formation. A pretransplantation bone biopsy revealed small marrow spaces, rare marrow elements, increased osteoclasts, and no bony resorption. After transplantation, osteoclasts were actively resorbing bone, and medullary cavities contained normal bone marrow. Fluorescent Y-body analysis after transplantation revealed donor (male) osteoclasts and recipient (female) osteoblasts. Monocyte bactericidal activity, markedly decreased before transplantation, became normal. Vision, hearing, growth, and development were progressively improving 16 months after transplantation. Allogeneic bone-marrow transplantation appears to be the treatment of choice in this fatal disorder.

Oligodendrogliomas. I. A clinical study of cerebral oligodendrogliomas

Fifty-four patients with oligodendroglioma presented in the past 15 years. In contrast to some widely taught concepts, oligodendrogliomas occured largely in the frontotemporal area of both cerebral hemispheres with two peaks of age incidence: one small peak in childhood, and the highest incidence in the middle-aged adult. Seizures, either major and/or minor, were the most common clinical manifestations (average 87%). Cerebral angiography and pneumography were the most reliable and useful diagnostic procedures, as well as the promising CAT scan. All 24 patients who underwent combined modalities of treatment with radical surgery and postoperative radiation therapy survived at least five years, and 2 out of 11 patients treated by surgery alone failed to survive the five-year follow-up period in addition to two recurrences. Postoperative radiation treatment is considered quite effective and indicated in most cases because complete removal of the tumor is not always possible.

Essential thrombocythemia in a child: platelet ultrastructure and function

A nine-year-old black girl with essential thrombocythemia developed hemoptysis. Only two other cases in the English literature have been described. Ultrastructure and functional characteristics of this patient's platelets were studied. Twenty-six percent of the patient's platelets were very large (megathrombocytes). Spontaneous aggregated from the patient's platelets were not compact, and the pseudopods did not interdigitate. Both qualitative and quantitative defects in platelet organelles were detected. The microtubular system was faulty in organization. Furthermore, the number of granules (especially alpha granules) was reduced. Platelet aggregation studies demonstrated subnormal aggregation in response to ADP, epinephrine, and collagen, but aggregation with ristocetin was normal. It is postulated that a platelet membrane abnormality may be the cause of their defective platelet aggregation.

Fatal veno-occlusive disease of the liver following high dose chemotherapy, irradiation and bone marrow transplantation

In two patients fatal veno-occlusive disease of the liver developed after bone marrow transplantation for underlying malignancies. Both had received significant pretransplant chemotherapy, including cystosine arabinoside, and total body irradiation. The diagnosis of veno-occlusive disease should be considered in patients in whom hepatomegaly, ascites and deteriorating liver function tests develop after they have received cancer chemotherapy.

Transient respiratory depression of the newborn. Its occurrence after succinylcholine administration to the mother

A baby born after a cesarean section experienced transient respiratory depression. The mother had a postsuccinylcholine apnea caused by homozygosity for the atypical allele for serum pseudocholinesterase; the baby was heterozygous for this allele and the usual allele for serum pseudocholinesterase. The possible relationship between the genotype of the baby and the respiratory difficulty at birth is raised.

Cranial irradiation of young rats impairs later learning and growth

Young rats (26 days) were exposed to ionizing radiation of the head of 0, 1200, 2400, or 3000 rads total in 200 rads/day doses. The subsequent growth of irradiated rats was permanently impaired: such impairment was positively related to amount of irradiation. Beginning in adolescence, rats were trained on a horizontal/vertical visual discrimination in a runway task, and although all four groups mastered the discrimination, they differed in their patterns of acquisition. These results indicate long term effects are associated with a cranial irradiation regimen similar to that given to children suffering acute lymphocytic leukemia (ALL).

Preservation of mycobacteria at -70 degrees C: survival of unfrozen suspensions in transit

Mycobacteria stored at -70 degrees C retain 100% viability and maintain their definitive taxonomic, serologic, immunologic, and pathogenic properties. When shipped at ambient temperatures, however, suspensions of all mycobacteria lose viability in transit, with those species having a narrow temperature range for growth (Mycobacterium tuberculosis and M. bovis) being most severely affected. In spite of these losses, all strains retain their definitive taxonomic properties. If care is taken in pre-testing and post-testing the microbial populations being preserved, mycobacteria are probably best shipped in the lyophilized state, and this procedure has been successfully used for several international studies.

High-viability lyophilized Bacille Calmette-Guérin vaccine produced by deep-culture technique

Evidence suggests that Bacille Calmette-Guérin (BCG) vaccine for use in cancer immunotherapy should have the following characteristics: high viability which is maintained on storage; high ratio of live to dead cells; high proportion of single cells; and low content of soluble antigen. The production of a vaccine with these characteristics was accomplished by use of a deep-culture technique. The medium was modified Proskauer and Beck medium containing Tween 80 and glucose. The mass culture was grown in a Wheaton double-side-arm bottle (6 liters of medium in an 8-liter container), aerated by means of an aquarium aerator and mixed by a magnetic stirrer. The culture was incubated 7 to 9 days at 37 degrees C, concentrated 11 to 15 times by ultrafiltration, diluted with equal parts of 25% lactose, and then lyophilized. The lyophilized ampoules, stored at -70 degrees C, were cultured at intervals ranging from 3 days to 450 days, and no loss in viability was observed. The mean number of viable BCG per ml of reconstituted vaccine was 8.75 log10. The viable count was 90% of the total bacterial count. Moreover, 85% of the cells were present as single bacilli.