Proceedings: Splenectomy and chemotherapy in acute myelocytic leukemia of childhood

Quantitative tumor burden imaging parameters of the spleen at MRI for predicting treatment response in patients with acute leukemia

Objectives

To study the value of standardized volume and intravoxel incoherent motion (IVIM) parameters of the spleen based on tumor burden for predicting treatment response in newly diagnosed acute leukemia (AL).

Methods

Patients with newly diagnosed AL were recruited and underwent abdominal IVIM diffusion-weighted imaging within one week before the first induction chemotherapy. Quantitative parameters of magnetic resonance imaging (MRI) included the standardized volume (representing volumetric tumor burden) and IVIM parameters (standard apparent diffusion coefficient [sADC]; pure diffusion coefficient [D]; pseudo-diffusion coefficient [D∗]; and pseudo-perfusion fraction [f], representing functional tumor burden) of the spleen. Clinical biomarkers of tumor burden were collected. Patients were divided into complete remission (CR) and non-CR groups according to the treatment response after the first standardized induction chemotherapy, and the MRI and clinical parameters were compared between the two groups. The correlations of MRI parameters with clinical biomarkers were analyzed. Multivariate logistic regression was performed to determine the independent predictors for treatment response. Receiver operating characteristic curves were used to analyze the predicted performance.

Results

76 AL patients (CR: n = 43; non-CR: n = 33) were evaluated. Standardized spleen volume, sADC, D, f, white blood cell counts, and lactate dehydrogenase were significantly different between CR and non-CR groups (all p < 0.05). Standardized spleen volume, sADC, and D were correlated with white blood cell and lactate dehydrogenase, and f was correlated with lactate dehydrogenase (all p < 0.05). Standardized spleen volume (hazard ratio = 4.055, p = 0.042), D (hazard ratio = 0.991, p = 0.027), and f (hazard ratio = 1.142, p = 0.008) were independent predictors for treatment response, and the combination of standardized spleen volume, D, and f showed more favorable discrimination (area under the curve = 0.856) than individual predictors.

Conclusion

Standardized volume, D, and f of the spleen could be used to predict treatment response in newly diagnosed AL, and the combination of morphological and functional parameters would further improve the predicted performance. IVIM parameters of the spleen may be viable indicators for evaluating functional tumor burden in AL.

Second malignancy after treatment of childhood acute myeloid leukemia

To investigate the cumulative incidence of second malignancy and the competing risk of death due to any other cause in patients who were treated for childhood acute myeloid leukemia (AML), we analyzed the outcomes in a cohort of 501 patients who were treated at St Jude Children's Research Hospital between 1970 and 1996. Five patients developed a second cancer (two carcinomas of the parotid gland, one non-Hodgkin's lymphoma, one supratentorial primitive neuroectodermal tumor, one acute lymphoblastic leukemia) as compared with 0.47 expected in the general population (standardized incidence ratio, 10.64; 95% confidence interval, 3.28 to 22.34). A third neoplasm (meningioma) developed in one patient. At 15 years after the diagnosis of AML, the estimated cumulative incidence of second malignancy was 1.34% +/- 0.61%, whereas the cumulative incidence of death due to any other cause was 72.96% +/- 2.14%. We concluded that although a more than 10-fold increased risk of development of cancer was found in survivors of childhood AML as compared to the general population, the risk of this late complication is small when compared to the much larger risk of death because of the primary leukemia or the early complications of its treatment. Future studies should focus on improving treatments for primary AML while preventing second malignancies.

Experiences with the Ommaya reservoir for prophylaxis and treatment of the central nervous system in adult acute myelocytic leukemia

Intraventricular chemotherapy was administered to adult AML patients via an Ommaya reservoir. Twenty-eight patients received central nervous system (CNS) prophylaxis and seven patients were treated for meningeal leukemia (ML). A treatment course lasted at least 6 months. Asymptomatic ML developed in two patients (7%) of the prophylaxis group concomitantly with bone marrow relapse. One of these patients had not completed the standard course. CNS remission could be obtained in all evaluable patients with ML. The easy entrance to the cerebrospinal fluid (CSF) offers the advantage of frequent investigations of the CSF, early diagnosis and treatment of CNS relapses without radiotherapy, and caused little patient discomfort. CNS prophylaxis in this small study seemed to prolong first remission duration slightly. In M4 and M5 subtypes CNS prophylaxis can be valuable.

Long-term survival of children with acute non-lymphoblastic leukemia

Results of a pilot protocol employing chemoimmunotherapy for treatment of 23 children with acute non-lymphoblastic leukemia consecutively diagnosed between 1975 and 1979 are reported. Twenty-two children achieved remission, ten of whom are surviving 6.5-9.5 years after completion of primary systemic therapy (median 7.8 years). Treatment consisted of intermittent courses of Daunomycin, Cytosine Arabinoside, 6-Thioguanine, VP-16, with or without Decadron, Connaught BCG applied between courses of chemotherapy for the first 8 months of treatment, and cranial irradiation/intrathecal Cytosine Arabinoside in early first remission. Five patients with leukemic cells in spinal fluid at diagnosis had myelomonoblastic or monoblastic subtypes and a median diagnostic white blood cell count (WBC) of 149,000/mm3 compared with a median WBC of 12,000/mm3 for the other 18 patients (P = .007).

Results of a pilot study for the treatment of childhood acute nonlymphoblastic leukemia

Eighteen children with acute nonlymphoblastic leukemia were entered on a pilot protocol. The drugs used were vincristine, daunorubicin, cytosine arabinoside, and prednisolone for remission induction, high-dose cyclophosphamide together with vincristine and mercaptopurine for consolidation, and cycles of vincristine, prednisolone, mercaptopurine, methotrexate, and daunorubicin for maintenance therapy. Prophylactic central nervous system therapy (cranial radiotherapy 2400 rad and intrathecal methotrexate 10 mg/m2 for five doses) was given once remission had been achieved. Fourteen of the 18 children (78%) achieved complete remission (CR) and 50% of those achieving CR remain in CR for 35+ to 87+ months. Survival for all children ranges from 2 to 88+ months with 50% remaining alive for 36+ to 88+ months. The protocol was well tolerated with minimal side effects. These results together with those of other recently reported studies indicate an improving prognosis for acute nonlymphoblastic leukemia in childhood.

Chemotherapy and wound healing

This paper provides a review of common chemotherapeutic agents and the experimental evidence supporting their effects on wound healing. Correlation with clinical studies is used to establish relevance, and therapeutic guidelines are developed.

Treatment of acute myeloid leukemia with a combination of intensive induction chemotherapy, early consolidation, splenectomy and long-term maintenance chemotherapy

The authors developed a therapeutic regimen in which 33 patients aged 11 to 61 years (mean +/- SE, 35.9 +/- 2.3 years) with acute myeloid leukemia (AML) were given intensive induction chemotherapy with Adriamycin (doxorubicin) (ADM), vincristine (VCR) and cytosine arabinoside (ARA-C). Twenty-nine of these patients (88%) attained a complete remission (CR) after 1, 2, or 3 courses and were then subjected to an early consolidation course of chemotherapy, identical to that for induction. After consolidation, all patients in CR received a long-term continuous maintenance therapy in which 6-mercaptopurine (6-MP) and methotrexate (MTX) were alternated, associated with periodic reinforcements with daunorubicin (DNR) and VCR. Twenty-five of the 29 patients who achieved a CR were splenectomized soon after the consolidation course. Histologic sections of the spleens, liver biopsy specimens, and lymph nodes, stained routinely and with the naphthol AS-D chloroacetate esterase (NCA) method, showed mature granulocytes and a few NCA positive mononuclear cells, but no proved leukemic infiltrates. For the 25 splenectomized patients, the probability of remaining in CR at 36 and 54 months was 75% and 66%, respectively; the probability of survival at 36 and 54 months was 85% and 75%, respectively. Age older than 40 years and evidence of extramedullary involvement at presentation appeared to carry a bad prognosis for disease-free survival.

Mode of action of 1-beta-D-arabinofuranosylcytosine in human lymphoblasts: differential effects of the drug on chromosomal replication

This paper describes a novel biochemical effect of 1-beta-D-arabinofuranosylcytosine (Ara-C), a potent antitumor agent, on the process of DNA replication in cultures of human lymphoblasts (CCRF-CEM). By using short incubation periods of five minutes with 3H-thymidine and analyzing the nascent DNA by velocity sedimentation in alkaline sucrose gradients, it was found that the initial effect on DNA replication by the addition of 5 nM Ara-C is inhibition of initiation of new replicating units in DNA. A second effect of Ara-C, which is evident 30 minutes after drug addition, is a reduction in the process of elongation of these units. A model is presented to explain the mechanism by which Ara-C may cause a differential effect on DNA chain initiation and elongation in CCRF-CEM cells.

Determination of cytarabine and uracil arabinoside in human plasma and cerebrospinal fluid by high-performance liquid chromatography

A high-performance liquid chromatographic method for the determination of the antineoplastic agent cytarabine and its main metabolite uracil arabinoside in human plasma and cerebrospinal fluid is described. Complete separation from endogenous constituents was achieved by isocratic reversed-phase chromatography using phosphate buffer (0.05 M, pH 7.0) as the eluent. The limit of detection was 50 ng/ml. Day-to-day coefficients of variation were below 10%. The applicability of this rapid, simple and specific method for pharmacokinetic studies and monitoring of therapy was demonstrated.

Natural history of central nervous system acute leukemia in adults

Central nervous system (CNS) involvement occurred in 45 of 222 (20.3%) leukemic adults achieving bone marrow (BM) complete remission (CR), including 12 of 23 (52%) acute undifferentiated leukemia (AUL), 12 of 32 (39%) lymphoma leukemia, 5 of 26 (19%) acute lymphoblastic leukemia, and 16 of 142 (11%) acute myelogenous leukemia. Risk factors for CNS disease were lactic dehydrogenase (LDH) greater than or equal to 25,000/mm3. AUL morphology, age less than 20 years, and extramedullary involvement were most significant. Pattern of CNS involvement varied with morphology. Survival after CNS relapse depended most on BM status and symptoms. Duration of CNS CR was longest for asymptomatic patients with low CSF cell counts. Also important were duration of first BM CR, ease of achievement of initial BM CR, and leukocyte count (original and at most closely antecedent BM involvement), reflecting the common origin of BM and CNS leukemic cells. Central nervous system relapse generally did not shorten BM CR or survival, although early primary CNS relapse was associated with early BM relapse.

67Ga scintigraphy in granulocytic sarcoma

Several granulocytic sarcomas (chloromas) developed in a patient with acute myelogenous leukemia while in hematologic remission. A positive diagnosis of the symptomatic lesion was made by means of open biopsy examination. The other lesions, which were unsuspected, were detected with a 67Ga-citrate scan. Subsequent 67Ga-citrate scans indicated a favorable response to treatment. The incidence and significance of silent granulocytic sarcomas in patients in hematologic remission is not known. Documentation of such lesions might prove valuable for diagnosing extramedullary relapse or for delivering intensive local therapy.

Acute nonlymphocytic leukemia

The discovery of cytosine arabinoside, and then the anthrocycline antibiotics, 6-thioguanine, vincristine, cyclophosphamide, and other drugs, has added to the armamentarium of known effective agents. The use of combination chemotherapy, the recognition of the need during induction for virtual marrow aplasia to obtain a remission, and recognition of the predilection of the disease for the central nervous system requiring prophylaxis constitute major advances. The impediment to long-term survival is the lack of effective maintenance therapy.

Central nervous system involvement at presentation in acute granulocytic leukemia. A prospective cytocentrifuge study

We have undertaken a perspective study of the prevelance of the central nervous disease in acute granulocytic leukemia (AGL). Thirty-nine newly diagnosed patients with AGL underwent cytocentrifuge examination of cerebral spinal fluid. Seven of the 39 patients had blast cells in their cerebral spinal fluid. All seven of these patients had acute myelomonocytic leukemia (AMML). No patients with other variants of AGL demonstrated blast cells in their cerebral spinal fluid. Other high risk factors associated with meningeal infiltration were elevated serum lysozyme levels, high peripheral white blood cell count, low age, splemomegaly and the presence of infiltration in other organs. The admission rates for patients with meningeal leukemia were lower and the survival time was shorter than in both the 32 noninvolved patients and the noninvolved patients with AMML. We believe that a lumbar puncture is indicated in all patients with newly diagnosed AMML.

Mode of action of 9-beta-D-arabinosyladenine and 1-beta-D-arabinosylcytosine on DNA synthesis in human lymphoblasts

The effects of 9-beta-D-arabinosyladenine (AraAde), 1-beta-D-arabinosylcytosine (AraCyt) and 2'-deoxyadenosine on DNA replication in cultured human lymphoblasts (CCRF-CEM line) were studied by pulse-labeling cells with [3H]thymidine and analyzing the nascent DNA by velocity sedimentation in alkaline sucrose gradients. At doses that reduced the overall rate of DNA synthesis to 50--70% of control values, both AraAde and AraCyt profoundly inhibited the formation of new replicons, with secondary effects on chain elongation contributing to the total inhibition of DNA synthesis. In contrast, the suppression of DNA synthesis by 2'-deoxyadenosine stemmed mainly from an inhibition of chain elongation. These studies also disclosed that about 100 times more AraAde than AraCyt was required to produce a similar inhibition of DNA replication in CCRF-CEM cells. Determination of intracellular concentrations of the nucleoside triphosphates (AraCTP and AraATP) indicated to 90% inhibition of DNA synthesis was achieved at 1.6 and 25 pmol/1 . 10(6) cells, respectively. Studies with cell lysates revealed that the replicative machinery in CCRF-CEM cells is more sensitive to AraCTP than to AraATP. This finding contrasts with earlier research, in which the inhibtion of purified DNA polymerase by either AraATP of AraCTP yielded essentially the same Ki value. The difference in sensitivity of the cell lysate to these arabinonucleotides may reflect either a target enzyme other than DNA polymerase or, more plausibly, some subtle interaction of the polymerase with other components of the replicative process.

Preventive central nervous system irradiation in children with acute nonlymphocytic leukemia

In this study of children with acute nonlymphocytic leukemia an attempt was made to prevent central nervous system relapse and to determine whether this therapy, coupled with multiagent chemotherapy, would be successful in prolonging durations of complete remission. Central nervous system relapses were prevented by irradiation, although patients who received this therapy did no better than those who did not receive irradiation. A small group of patients received irradiation to the liver and spleen, but this modality also failed to improve the duration of remission. Control of extramedullary leukemia, in this study, failed to improve remission duration because bone marrow relapse was not prevented or delayed. It is unlikely that focal therapy will have a significant impact in acute nonlymphocytic leukemia until longer marrow remissions are achieved.

The central nervous system in childhood leukemia. III. Mineralizing microangiopathy and dystrophic calcification

We determined the prevalence, histopathologic features, and clinical correlations of a distinctive vascular lesion within the central nervous system (CNS) of children who died with acute lymphoblastic leukemia (ALL). Of 163 brains examined at autopsy, 28 (17%) had a noninflammatory mineralizing microangiopathy, usually accompanied by varying amounts of necrosis and calcification in adjacent neural tissue. The lesion always involved the lenticular nucleus with or without additional involvement of cerebral cortex. It was not the cause of death in any patient. An analysis of clinical features common to patients with microangiopathy indicated that cranial irradiation, in doses as low as 1500 rad, had induced the degenerative process. Survival beyond 10 months from the time of irradiation and multiple postirradiation CNS leukemic relapses, both had significant influences on the development of the lesion. Chemotherapy, particularly systemic or intrathecal methotrexate, might have contributed to the disease process, but apparently was not the instigating factor. Patients at greatest risk for developing microangiopathy are those under 10 years of age at the time of cranial irradiation, who then live more than 10 months and develop multiple CNS leukemic relapses.

Central nervous system involvement at presentation in the chronic phase of chronic myelogenous leukemia in childhood

With the advent of more effective chemotherapy an increasing incidence of central nervous system involvement in acute lymphocyte (ALL) and myelocytic leukemias (AML) and chronic myelocytic leukemia (CML) in blast crisis has become evident. Meningeal involvement in the chronic phase of CML is rare. We report two children whose initial presentation of Ph1 CML was in the central nervous system as documented by cytocentrifugation. Aggressive combination chemotherapy and cranial irradiation has resulted in prolonged survival without blastic transformation or further meningeal disease. An approach to children with CML is suggested.

Increased survival in childhood acute nonlymphocytic leukemia after treatment with prednisone, cytosine arabinoside, 6-thioguanine, cyclophosphamide, and oncovin (PATCO) combination chemotherapy

One hundred-sixty-three children with acute nonlymphocytic leukemia (ANLL) were treated with a multiple-drug induction program (PATCO) consisting of prednisone (PDN), cytosine arabinoside ((Ara-C), 6-thioguanine (6-TG), cyclophosphamide (CPM), and Oncovin (VCR). Ninety-six, 59%, obtained a remission. Remission was maintained with daily 6-TG and four-day pulses of Ara-C and CPM with a single dose of VCR every 28 days. The median duration of remission was 11.5 months. Certain prognostic factors affected induction rate and remission duration. Initial white blood count (WBC) was a significant factor in achieving a remission, whereas age, sex, and type of ANLL had no effect. Initial WBC, age, and sex had a significant effect on remission duration, but type of ANLL had no effect. Relapsing patients were treated with daunomycin and 5-azacytidine. The reinduction rate was 53% with a median second remission duration of 190 days. Overall survival for the 163 patients is 55.4% at 12 months, 31.5% at 24 months, 21.4% at 36 months, and 19% at 48 months.

Treatment of acute nonlymphoblastic leukemia in children with a multiple-drug protocol

Twenty-one children with acute nonlymphoblastic leukemia (ANLL) were treated with a combination regimen consisting of arabinosyl cytosine (Ara-C), 6-thioguanine (TG), and Adriamycin, The incidence of complete remission was 74%. For consolidation, addition courses of Ara-C and TG were given, followed by L-asparaginase. The maintenance program was the same as that for the lymphoblastic type (L-2) including intrathecal methotrexate for prophylaxis of meningeal leukemia. Of the 16 who were evaluable for the duration of complete remission, six developed bone marrow relapse, one meningeal leukemia within 3-14 months after entering complete remission and one was lost to follow-up. Eight remain in complete remission for 9-72 months. In five of eight, chemotherapy has been terminated after 3 years, and all continue in remission for 11-32 months post-treatment. Although the results do not compare well to those of the lymphoblastic morphology, long-term disease-free survival can be achieved with multiple-drug intensive treatment in childhood ANLL.

Marrow transplantation in treatment of children with aplastic anaemia or acute leukaemia

Seventy-six patients, aged 2 to 17 years, were treated with bone marrow transplantation for severe aplastic anaemia or acute leukaemia refractory to conventional therapy. 16 of the 22 patients (73%) who received marrow transplantations for aplastic anaemia are surviving, 12 of these for over one year. In acute leukaemia, using preparation with cyclophosphamide and total body irradiation, 8 of 33 patients (24%) receiving allogeneic and 5 of 8 (63%) receiving syngeneic transplantations are continuing in remission from 3 months to beyond 2 years. The longest continuing remission off therapy is now over 4 1/2 years after preparation with total body irradiation. The major causes of failure remain graft-versus-host disease, infection, graft rejection (aplastic anaemia), and leukaemic relapse.

Acute nonlymphocytic leukemia in 171 children

The initial features, response to therapy, complications, cause of death, and prognostic factors of 171 consecutive children with ANLL are described and compated to historical data for adults with ANLL and for children with ALL. Major differences between children and adults with ANLL include a higher frequency of CNS leukemia and a lower frequency of early deaths in the children. The most important differences between children with ANLL and ALL are the absence of a peak age of incidence in ANLL and the far better response to therapy in ALL. Among features present at 100,000/mm3 or above, and no palpable hepatomegaly had significantly longer survivals, while patients with platelet counts below 10,000/mm3 had significantly shorter survivals. The frequency and duration of remission were significantly better with three protocols used since 1968 than previously. However, even with these protocols, the results were far from satisfactory, with a complete remission frequency of 66%, a median duration of hematological remission of 6 months, and a median duration of survival of 10 months. The striking contrast of these results in childhood ANLL with current results in childhood ALL underscores the need for novel, imaginative therapeutic approaches for ANLL.

Remission induction with L-asparaginase, vincristine, and prednisone in children with acute nonlymphoblastic leukemia

Forty-five children with acute nonlymphoblastic leukemia in relapse received a total of 56 courses of L-asparaginase combined with vincristine and prednisone. The complete remission rate of 40% (12 of 30 trials) in patients resistant to vincristine and prednisone was almost identical to that in children still sensitive to vincristine and prednisone (42%, 11 of 26 trials). The complete remission rate of 38% (14 of 37 exposures) in those children who had not received L-asparaginase previously compared favorably with the complete remission rate in those children who had received prior L-asparaginase (47%, 9 of 19 exposures). Forty-seven of the 56 induction trials were in children with 1 or more remissions and 14 of these were in children with 3 or more prior remissions. Toxicity was minimal.

Meningeal leukemia after blastic transformation of chronic myeloid leukemia

In two patients with blastic transformation of chronic myeloid leukemia complete remission was induced, but meningeal leukemia subsequently developed. The recognition of blast cell crisis as the presenting feature of chronic myeloid leukemia is discussed, together with treatment of this condition and its rare complication, meningeal leukemia. The development of meningeal leukemia in this disease is almost certainly due to the increased survival that has been produced by advances in therapy for blastic transformation.