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Clarke RT, Van den Bruel A, Bankhead C, Mitchell CD, Phillips B, Thompson MJ. Clinical presentation of childhood leukaemia: a systematic review and meta-analysis. Arch Dis Child 2016; 101:894-901. [PMID: 27647842 DOI: 10.1136/archdischild-2016-311251] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 07/17/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Leukaemia is the most common cancer of childhood, accounting for a third of cases. In order to assist clinicians in its early detection, we systematically reviewed all existing data on its clinical presentation and estimated the frequency of signs and symptoms presenting at or prior to diagnosis. DESIGN We searched MEDLINE and EMBASE for all studies describing presenting features of leukaemia in children (0-18 years) without date or language restriction, and, when appropriate, meta-analysed data from the included studies. RESULTS We screened 12 303 abstracts for eligibility and included 33 studies (n=3084) in the analysis. All were cohort studies without control groups. 95 presenting signs and symptoms were identified and ranked according to frequency. Five features were present in >50% of children: hepatomegaly (64%), splenomegaly (61%), pallor (54%), fever (53%) and bruising (52%). An additional eight features were present in a third to a half of children: recurrent infections (49%), fatigue (46%), limb pain (43%), hepatosplenomegaly (42%), bruising/petechiae (42%), lymphadenopathy (41%), bleeding tendency (38%) and rash (35%). 6% of children were asymptomatic on diagnosis. CONCLUSIONS Over 50% of children with leukaemia have palpable livers, palpable spleens, pallor, fever or bruising on diagnosis. Abdominal symptoms such as anorexia, weight loss, abdominal pain and abdominal distension are common. Musculoskeletal symptoms such as limp and joint pain also feature prominently. Children with unexplained illness require a thorough history and focused clinical examination, which should include abdominal palpation, palpation for lymphadenopathy and careful scrutiny of the skin. Occurrence of multiple symptoms and signs should alert clinicians to possible leukaemia.
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Affiliation(s)
- Rachel T Clarke
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ann Van den Bruel
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bankhead
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher D Mitchell
- Department of Paediatric Oncology/Haematology, Children's Hospital, John Radcliffe, Oxford, UK
| | - Bob Phillips
- Department of Paediatric Oncology/Haematology, Leeds General Infirmary, Leeds, UK
| | - Matthew J Thompson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK Department of Family Medicine, University of Washington, Seattle, USA
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2
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Hudson MM, Neglia JP, Woods WG, Sandlund JT, Pui CH, Kun LE, Robison LL, Green DM. Lessons from the past: opportunities to improve childhood cancer survivor care through outcomes investigations of historical therapeutic approaches for pediatric hematological malignancies. Pediatr Blood Cancer 2012; 58:334-43. [PMID: 22038641 PMCID: PMC3256299 DOI: 10.1002/pbc.23385] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 09/12/2011] [Indexed: 12/21/2022]
Abstract
Investigations of long-term outcomes have been instrumental in designing safer and more effective contemporary therapies for pediatric hematological malignancies. Despite the significant therapeutic changes that have occurred over the last five decades, therapy modifications largely represent refinements of treatment protocols using agents and modalities that have been available for more than 30 years. This review summarizes major trends in the evolution of treatment of pediatric hematological malignancies since 1960 to support the relevance of the study of late effects of historical therapeutic approaches to the design and evaluation of contemporary treatment protocols and the follow-up of present-day survivors.
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Affiliation(s)
- Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, 332 N. Lauderdale, Memphis, TN 38105, USA.
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3
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Cheng H, Yang Y, Dai W, Tang C, Shi M, Feng G, Kang T, Su X, Zhao G. Acute leukemia presenting with blasts first found in the cerebrospinal fluid but not in the peripheral blood. J Clin Neurosci 2010; 17:1252-5. [PMID: 20605098 DOI: 10.1016/j.jocn.2010.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 01/19/2010] [Accepted: 02/07/2010] [Indexed: 11/28/2022]
Abstract
Acute leukemia presenting with central nervous system (CNS) signs and symptoms is uncommon and prone to be misdiagnosed. Here, we report nine patients with acute leukemia, including five patients with acute lymphoblastic leukemia (ALL) and four patients with acute myeloid leukemia (AML). These patients presented with symptoms suggestive of involvement of multiple cranial nerves, the spinal cord, and meningeal involvement. Moreover, we found that all these patients unexpectedly showed the presence of blasts in the cerebrospinal fluid (CSF) but not in the peripheral blood despite repeated examinations. Bone marrow examination confirmed the presence of acute leukemia in these patients. Seven patients died within 18months of diagnosis and two patients developed stable disease. Our findings show a novel presenting feature of acute leukemia and highlight the importance of CSF cytology in the diagnosis of acute leukemia.
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Affiliation(s)
- Haoran Cheng
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
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4
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Abstract
Childhood cancer is uncommon but remains the leading cause of disease-related death in children. Symptoms are often vague or insidious; they may suggest a more common alternative diagnosis, and they are quite different from those associated with adult malignancy. The skilled office practitioner must consider cancer as a diagnosis when symptoms/signs persist or when multiple symptoms point toward a possible diagnosis of malignancy. Early diagnosis is critical, as survival rates have increased dramatically over the past decades. Prolonged delay in diagnosis is common, especially for brain tumors and certain lymphomas (Hodgkin disease). When one encounters symptoms suspicious for a childhood malignancy, it is imperative that the child be referred to a pediatric cancer center. These centers possess not only the ability to further evaluate and manage children with malignancy, but also are able to provide support for patients and their families. This evaluation may include further imaging, but often involves obtaining tissue for histologic review. This will require appropriate tumor or bone marrow biopsy, preferably before the start of treatment. Depending upon the type of suspected malignancy, direct tumor biopsy can be facilitated by imaging-guided biopsy (ultrasound, CT, or MRI), which spares the patient additional surgery. This optimally is performed by a skilled team: hematologist/oncologist, surgeon, radiologist, and pathologist. Best results depend upon early referral by the thoughtful practitioner.
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Affiliation(s)
- Christopher P Raab
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA.
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5
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Ustün C, Kalla A, Bollag RJ, Manaloo E, Kulharya A, Jillella A. Relapsed acute myelogenous leukemia occurring after 18 years with recurrent novel chromosomal abnormality t(18;22)(q23;q11.2). ACTA ACUST UNITED AC 2007; 177:135-8. [PMID: 17854669 DOI: 10.1016/j.cancergencyto.2007.05.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Revised: 04/18/2007] [Accepted: 05/11/2007] [Indexed: 10/22/2022]
Abstract
A 22-year-old woman presented with lymphadenopathy in a similar manner as she had presented at age 4. At age 4, she was diagnosed with acute myelogenous leukemia (AML) with t(18;22)(q23;q11.2) and received chemotherapy until age 6 under a pediatric study protocol. At age 22, a lymph node biopsy confirmed granulocytic sarcoma, and a bone marrow aspirate showed increased myeloblasts with no dysplasia. Cytogenetic analyses of the lymph node and the bone marrow were positive for t(18;22)(q23;q11.2). The patient was treated for relapsed AML and at writing had been disease-free for 9 months. Translocation between chromosomes 18 and 22 has been reported in indolent lymphoproliferative disorders, but not in AML. Although we do not know the precise molecular etiology of this leukemia, the uncommon presentation for AML and late relapse with the same chromosomal abnormality may indicate a causal relationship between this novel chromosomal abnormality and the AML. This observation also suggests the possible presence of dormant stem cells containing the chromosomal abnormality in this particular patient.
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MESH Headings
- Adolescent
- Child, Preschool
- Chromosome Aberrations
- Chromosomes, Human, Pair 18/genetics
- Chromosomes, Human, Pair 22/genetics
- Female
- Humans
- In Situ Hybridization, Fluorescence
- Karyotyping
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
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Affiliation(s)
- Celalettin Ustün
- Section of Hematology/Oncology, Medical College of Georgia, 1120 15th Street, BAA 5407, Augusta, GA 30912, USA.
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6
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Ribeiro RC, Razzouk BI, Pounds S, Hijiya N, Pui CH, Rubnitz JE. Successive clinical trials for childhood acute myeloid leukemia at St Jude Children's Research Hospital, from 1980 to 2000. Leukemia 2006; 19:2125-9. [PMID: 16281077 DOI: 10.1038/sj.leu.2403872] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite substantial progress in the management of childhood acute myeloid leukemia (AML), only about 50% of patients are cured by intensive chemotherapy. The long-term results of clinical trials may reveal principles that can guide the development of future therapy. From 1980 to 2000, 251 patients <15 years of age with newly diagnosed AML were enrolled on one of the five consecutive St Jude AML studies. The median age of the 128 boys and 123 girls was 6.2 years; 193 were white, 45 black, and 13 of other racial groups. With the exception of one protocol (AML-83), outcomes improved in general over the two decades. The estimated 5-year event-free survival (+/-s.e.) was 30.8+/-5.6% for AML-80; 11.1+/-4.3% for AML-83; 35.9+/-7.4% for AML-87; 43.5+/-6.2% for AML-91; and 45.0+/-11.1% for AML-97. Resistant or relapsed AML caused the great majority of treatment failures. Increasing the intensity of chemotherapy (AML-87) did not improve outcome, partially because of toxicity, nor did prolonging postremission therapy by adding sequential myeloablative (AML-80) or nonmyeloablative (AML-83) chemotherapy cycles. We conclude that subtype-specific therapies are needed to replace the 'one size fits all' strategy of the past two decades.
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Affiliation(s)
- R C Ribeiro
- Department of Hematology-Oncology, St Jude Children's Research Hospital, Memphis, TN 38105-2794, USA.
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7
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MESH Headings
- Adult
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bone Marrow Transplantation
- Child
- Child, Preschool
- Cytogenetics
- Disease-Free Survival
- Down Syndrome/complications
- Forecasting
- Humans
- Immunophenotyping
- Infant
- Infant, Newborn
- Leukemia, Myeloid, Acute/classification
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/therapy
- Leukemia, Promyelocytic, Acute/therapy
- Prognosis
- Randomized Controlled Trials as Topic
- Recurrence
- Remission Induction
- Risk Factors
- Time Factors
- Tumor Lysis Syndrome
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Affiliation(s)
- Victor M Aquino
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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8
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Abstract
Acute myelogenous leukemia (AML) accounts for about 20% of the acute leukemias seen in children. In contrast to childhood acute lymphoblastic leukemia (ALL), there has only been a modest improvement in the cure rate of children with AML during the past two decades. Approximately 40% of children treated with chemotherapy alone are long-term survivors. The outcome is somewhat better for those children who are given bone marrow transplants from histocompatible sibling donors early in the first remission. During the last decade, however, new insights into the molecular basis of AML has increased our understanding of the pathogenesis and biology of this group of leukemias and are beginning to provide us with new therapeutic strategies.
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Affiliation(s)
- D H Ebb
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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9
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Maher-Wiese VL, Wenner NP, Grant-Kels JM. Metastatic cutaneous lesions in children and adolescents with a case report of metastatic neuroblastoma. J Am Acad Dermatol 1992; 26:620-8. [PMID: 1597549 DOI: 10.1016/0190-9622(92)70091-s] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A child with neuroblastoma metastatic to the skin is reported. A review of the literature revealed that neuroblastoma and leukemia are the neoplasms most frequently associated with cutaneous metastases in children and adolescents. The low incidence of these lesions and their high malignant potential are two important factors that emphasize the pivotal role the dermatologist plays in prompt diagnosis and early referral.
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Affiliation(s)
- V L Maher-Wiese
- Department of Dermatology, Brown University, Providence, Rhode Island
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10
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Barrios N, Tebbi CK, Freeman AI. Central Nervous System (CNS) Involvement in Acute Nonlymphocytic Leukemia (ANLL). Leuk Lymphoma 1990; 2:47-50. [PMID: 27456570 DOI: 10.3109/10428199009042513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The incidence of central nervous system (CNS) involvement and effects of therapy were reviewed in 42 consecutive pediatric patients with acute nonlymphocytic leukemia (ANLL). The morphology of ileukemic cells was considered M1 in 13, M2 in 7, M3 in 5, M4 in 8, and M5 in 9. Two patients with M5 morphology presented with CNS disease at diagnosis. Systemic Ara-C treatment was included as a mainstay of remission induction and maintenance program for all patients. With the exception of the M5 group, none of the patients received direct CNS prophylactic therapy. There was a 0% incidence of CNS relapse: in this group of patients. Median duration of remission for all patients (excluding the M5 group) was 33 months. This experience may indicate that systemic treatment with Ara-C may provide some degree of CNS prophylaxis in ANLIL.
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Affiliation(s)
- N Barrios
- a Department of Pediatric Hematology/Oncology, Tulane University Medical Center, New Orleans, LA, 70112, USA
| | - C K Tebbi
- b Department of Pediatrics and Adolescent Unit, Roswell Park Memorial Institute, Buffalo, NY, 14263, USA
| | - A I Freeman
- c Department of Pediatrics, The Children's Mercy Hospital, Kansas City, MO, 64108, USA
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11
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Suttorp M, Polchau H, Kühn B, Löffler H, Rister M. Acute megakaryoblastic leukemia (FAB-M7) in an infant presenting with orbital chloroma and meningeal involvement. HAEMATOLOGY AND BLOOD TRANSFUSION 1990; 33:368-73. [PMID: 2323644 DOI: 10.1007/978-3-642-74643-7_70] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- M Suttorp
- Dept. of Pediatrics, University of Kiel, FRG
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12
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Windebank KP, Tefferi A, Smithson WA, Li CY, Solberg LA, Priest JR, Elliott SC, de Alarcon PA, Weinblatt ME, Burgert EO. Acute megakaryocytic leukemia (M7) in children. Mayo Clin Proc 1989; 64:1339-51. [PMID: 2531821 DOI: 10.1016/s0025-6196(12)65376-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We analyzed the clinical and laboratory features of eight children (median age, 20 months; range, 13 months to 11 years) with acute megakaryocytic leukemia (M7) and compared the findings with those reported in the literature. The diagnosis was supported by ultrastructural examination for platelet peroxidase or immunophenotyping for glycoprotein IIb/IIIa or the von Willebrand factor protein. Two patients had Down's syndrome. Initial findings included anemia (in all patients), thrombocytopenia (in six), myelofibrosis (in three), lytic bone lesions (in two), and pronounced leukocytosis (in one). Stem cell culture studies of peripheral blood specimens revealed an aberrant phenotype of the megakaryocytes in one patient and reversal to a normal pattern after successful therapy. Remission was achieved in seven of the eight patients after aggressive chemotherapy, and four patients remained in remission 27 to 57 months after diagnosis. Three of these four patients underwent allogeneic bone marrow transplantation. M7 leukemia is not infrequent in children younger than 3 years of age, especially in those with Down's syndrome. The availability of monoclonal antibodies specific to restricted antigens of the megakaryocytic lineage has made the diagnosis of M7 leukemia both possible and practical.
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Affiliation(s)
- K P Windebank
- Section of Pediatric Hematology/Oncology, Children's Hospital, St. Paul, Minnesota
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13
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Abstract
A 12-year-old boy with acute myelogenous leukemia developed acute weakness and paresthesias of the lower extremities after lumbar puncture. Computed tomography and magnetic resonance imaging revealed 2 large paraspinal masses (granulocytic sarcoma) causing spinal cord compression. Treatment with corticosteroids, radiation therapy, and chemotherapy caused complete resolution of symptoms; there was no evidence of tumor on subsequent magnetic resonance imaging or at autopsy. Granulocytic sarcomas (chloromas) rarely involve the nervous system in patients with acute myelogenous leukemia, although with increased survival it is apparent that the incidence may be greater than previously believed. Central nervous system prophylaxis was not administered to our patient but may be recommended for future patients if systemic disease can be controlled. General features of central nervous system complications of acute myelogenous leukemia, characteristics of granulocytic sarcoma, and review of current radiographic techniques used in the evaluation of these tumors are discussed.
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Affiliation(s)
- L M Brown
- Department of Neurology, University of Texas Medical Branch, Galveston 77550
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14
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Haaxma-Reiche H, Daenen S, Witteveen RJ. Experiences with the Ommaya reservoir for prophylaxis and treatment of the central nervous system in adult acute myelocytic leukemia. BLUT 1988; 57:351-5. [PMID: 3207892 DOI: 10.1007/bf00320756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- H Haaxma-Reiche
- Department of Neurology, University Hospital, Groningen, The Netherlands
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15
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Lampkin BC, Lange B, Bernstein I, Woods W, Odom L, Wells R, Ruymann F, Feig S, Miller L, Chard R. Biologic characteristics and treatment of acute nonlymphocytic leukemia in children. Report of the ANLL Strategy Group of the Childrens Cancer Study Group. Pediatr Clin North Am 1988; 35:743-64. [PMID: 3047652 DOI: 10.1016/s0031-3955(16)36508-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Today approximately 75 per cent of children with ANLL can be induced into a complete remission and approximately 40 per cent will have an event-free survival for more than 3 years, irrespective of whether they received a bone marrow transplantation or chemotherapy after induction. In order to achieve these results very intensive therapy is required. The morbidity and mortality of treatment are high. The length of therapy needed after induction of remission is not known. Whether or not maintenance therapy is required is perhaps related most directly to the intensity of the therapy employed. Similarly, the role of bone marrow transplantation in patients in first remission, treatment of CNS leukemia, and treatment of chloromas are controversial. There is general agreement that WBCs over 100,000, acute monoblastic leukemia in infants less than 2 years of age, and certain chromosomal abnormalities are associated with a poor prognosis. Although there has been a dramatic improvement in the treatment of ANLL over the past 15 years, stratification of therapy based on biologic parameters, and alteration of treatment based on the early responses to treatment may be required before further advances will be made.
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Affiliation(s)
- B C Lampkin
- University of Southern California, Comprehensive Cancer Center, Los Angeles
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16
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Hooijkaas H, Adriaansen HJ, van Dongen JJ. Detection of central nervous system involvement in patients with leukemia or non-Hodgkin's lymphoma by immunological marker analysis of cerebrospinal fluid cells. Cancer Treat Res 1988; 38:149-71. [PMID: 2908594 DOI: 10.1007/978-1-4613-1713-5_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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17
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Abstract
Nine children with acute promyelocytic leukemia (APL) are presented. This series of children represents 7% of all acute leukemias and 21% of acute myelogenous leukemias seen during the same period at the Red Cross War Memorial Children's Hospital. These figures are much higher than the incidence quoted in other series of childhood leukemia. In addition, most of those children came from a confined geographic area. Two of the patients were younger than 2 years of age. The youngest patient with APL previously reported in the literature was 24 months.
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18
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Abstract
The authors review the advances of the last decade in bone marrow culture cytogenetics and immunology that have aided in understanding the pathophysiology of acute nonlymphocytic leukemia and they also discuss the major strides in treatment that have occurred.
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19
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Abstract
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.
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20
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Ritter J, Creutzig U, Riehm HJ, Schellong G. Acute myelogenous leukemia: current status of therapy in children. Recent Results Cancer Res 1984; 93:204-15. [PMID: 6382480 DOI: 10.1007/978-3-642-82249-0_8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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21
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Chak LY, Sapozink MD, Cox RS. Extramedullary lesions in non-lymphocytic leukemia: results of radiation therapy. Int J Radiat Oncol Biol Phys 1983; 9:1173-6. [PMID: 6575971 DOI: 10.1016/0360-3016(83)90176-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Fifty-four courses of radiotherapy were given to 33 patients with symptomatic extramedullary involvement by non-lymphocytic leukemia. Among them were 23 cases of granulocytic sarcoma. Analysis of the treatment response showed that age, hematopathologic type and quality of irradiation did not influence the radiation response. However, a dose response relationship could be demonstrated with a statistically significant difference in response among the four groups of patients treated to total doses of less than 1000 rad, 1000-1999 rad, 2000-2999 rad, and greater than or equal to 3000 rad (p = 0.003). We suggest irradiating all extramedullary lesions to at least 1100 ret.
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22
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Abstract
Acute non-lymphoid leukemia is a group of hematologic neoplasms which have been the subject of intensive basic and clinical research. These studies have led to a better understanding of the genetic basis of leukemia and may ultimately help establish the molecular mechanisms of malignant transformation. They also have increased our understanding of myeloid differentiation. As a result of clinical trials, we can now induce a clinical remission in a large majority of patients with acute non-lymphoid leukemia. Future studies will attempt to lessen toxicity and to maximize the response rate. Many of these advances will come from improvements in supportive care given during the periods of therapy-related marrow aplasia. The role of intensive chemotherapy to prolong remission duration and to increase the usefulness of allogenic bone marrow transplantation will be clarified during the next several years.
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23
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Carr R, Innes EM. Prolonged remission in Di Guglielmo's syndrome. Postgrad Med J 1983; 59:34-7. [PMID: 6575374 PMCID: PMC2417354 DOI: 10.1136/pgmj.59.687.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A case is reported of a 12-year-old boy with Di Guglielmo's syndrome who achieved complete remission for over three years before developing a central nervous system relapse. The poor results of treatment in this disease are reviewed and the arguments for routine central nervous system prophylaxis discussed.
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24
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25
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26
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Amadori S, Petti MC, Pacilli L, Papa G, Mandelli F. Therapy of Acute Nonlymphocytic Leukemia in Children: A Review of 73 Patients. TUMORI JOURNAL 1981; 67:209-14. [PMID: 7025401 DOI: 10.1177/030089168106700308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since 1969, 73 children with acute nonlymphocytic leukemia have been admitted for evaluation and treatment at the Institute of Hematology of the University of Rome. Various drug regimens, basically including daunomycin and/or cytosine arabinoside, were employed both for induction and maintenance treatment. Overall, the incidence of complete remission was 63 %. The availability of intensive supportive measures starting in 1974 appears to be the most likely explanation for the higher response rate observed since then. Duration of remission and overall survival were disappointingly short owing to the high frequency of bone marrow relapse. Carefully controlled clinical studies will in the future be necessary to explore better methods of preventing leukemic relapse.
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27
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Steinhorn SC, Myers MH. Progress in the treatment of childhood acute leukemia: a review. MEDICAL AND PEDIATRIC ONCOLOGY 1981; 9:333-46. [PMID: 7266426 DOI: 10.1002/mpo.2950090405] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The dramatic improvements in the survival experience for children diagnosed with acute leukemia are analyzed using data collected through hospitals participating in the National Cancer Institute's End Results Group Program between 1950 and 1973. Children under 15 years of age who were diagnosed with both acute lymphocytic leukemia (ALL) and acute nonlymphocytic leukemia (ANLL) showed moderate improvements in the 1950s, but beginning in the 1960s those with ALL did far better. Statistically significant differences at the 0.05 level were noted between their three-year survival rates for all cohorts analyzed between 1960 and 1973. For the 1970-1973 cohort, three-year survival rates were 49% and 20% for ALL and ANLL, respectively, and five-year survival rates were 34% and 12%. Between 1950 and 1976 the age-adjusted incidence rate for all childhood leukemias remained relatively stable in a sample of five geographic areas, changing from 4.6 per 100,000 children under 15 years of age to 4.3 per 100,000. In contrast, the corresponding age-adjusted mortality rate fell approximately 45% over the same period, from 4.4 per 100,000 to 2.4 per 100,000.
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Madanat FF, Sullivan MP. Improved survival in young children with acute granulocytic leukemia treated with combination therapy using cyclophosphamide, oncovin, cytosine arabinoside, and prednisone. Cancer 1979; 44:819-23. [PMID: 289434 DOI: 10.1002/1097-0142(197909)44:3<819::aid-cncr2820440305>3.0.co;2-c] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Seven of 17 children (41%) under 5 years of age with acute granulocytic leukemia (AGL) treated with either cytosine arabinoside-cytoxan (CA-CYT) or Mini-COAP (CA-CYT with vincristine sulfate [VCR] and prednisone) have been in continuous complete remission 4 years or more. CA and CYT were each given in the dosage of 120 mg/m2 intravenously, daily in 3 divided doses, for 4 days. Induction consisted of two courses given at intervals of 2 weeks; during maintenance the courses were repeated at intervals of 4 weeks. In the Mini-COAP regimen, standard 28-day VCR-prednisone therapy was superimposed on CA-CYT induction and 4-day VCR-prednisone pulses were superimposed on CA-CYT maintenance. Transient moderate to severe myelosuppression was frequent; other manifestations of toxicity were mild. Administration of drugs at home was feasible in many instances. Mini-COAP was proved to be an effective therapeutic regimen for young children with AGL and should be considered as initial therapy.
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Baehner RL, Bernstein ID, Sather H, Higgins G, McCreadie S, Chard RL, Hammond D. Improved remission induction rate with D-ZAPO but unimproved remission duration with addition of immunotherapy to chemotherapy in previously untreated children with ANLL. MEDICAL AND PEDIATRIC ONCOLOGY 1979; 7:127-39. [PMID: 291771 DOI: 10.1002/mpo.2950070206] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In 163 children with acute nonlymphocytic leukemia (ANLL), a D-ZAPO induction program consisting of daunomycin, 5-azacytidine, cytosine arabinoside, prednisone, and vincristine resulted in a remission rate of 71.8%. Immunologic therapy was employed during maintenance with the aim of prolonging remission and improving survival. The administration of immunotherapy consisting of a mixture of bacillus Calmette-Guérin (BCG) and allogenic acute myelomonocytic leukemic cells injected intradermally on day 14 of each of the first three monthly cycles of 6-thioguanine for ten days, 5-azacytidine and cytosine arabinoside for four days, and vincristine for one day did not improve remission duration or survival compared to that due to chemotherapy alone. Important prognostic factors identified in this study included a remission induction rate significantly better for females than males (P = 0.04), for children between the ages of 5 and 10 years compared to those greater than this age group (P = 0.01), and a prolonged remission duration (P = 0.04), and survival (P less than 0.01) for patients with initial white blood counts of less than 20 x 10(9)/liter.
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Abstract
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.
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Abstract
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.
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Abstract
A study was conducted in metropolitan Baltimore to examine changes in survival of white and black children with acute leukemia from 1960 through 1975. Two-hundred eighty-seven cases were identified, of which 77% were acute lymphocytic leukemia (ALL). Eighty-three percent of all cases occurred in white children. In white children with ALL, two-year survival rates increased from 32% in 1960--64 to 47% in 1965--69, and to 79% in 1970--75 (p less than .005). In the small sample of black children with ALL, two-year survival rates increased from 25% in 1960--64 to 59% in 1965--69 (p less than .01), with no further increase in 1970--75. For acute nonlymphocytic leukemia (ANLL), survivorship was analyzed in white children, among whom one-year survival rates increased from 42% in 1965--69 to 71% in 1970--75 (p less than .005). The increasingly better survival over time of white children with acute leukemia probably reflects the increasing efficacy of new therapeutic approaches.
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Abstract
As can be seen, there are many problems yet to be solved in the development of optimal therapy for acute leukaemia in children. For patients with ALL we must be able to identify clearly the standard and the varieties of high risk patients. For the patient with standard risk features life expectancy is long and therapy regimens must be designed to provide optimal control of the disease with minimal short and long-term toxicity. For patients with the high risk features of those varieties of ALL associated with poor prognosis methods must be found to circumvent the problem of early acquisition of drug resistance by the leukaemic lymphoblasts. For children with AML the results of remission induction regimens must still be improved to match those obtained in ALL. The major problem awaiting solution, however, is the maintenance of remission once obtained. As disease-free survival in AML is improved then consideration of CNS prophylaxis and the timing of cessation of therapy must be considered.
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Abstract
Twelve new cases of childhood leukemia and neurofibromatosis were ascertained and evaluated in conjunction with 17 previously well-documented cases. The ratio of ALL:nonlymphocytic leukemia was 9:20, markedly different from the 4:1 ratio in children without NF. Rarer subtypes predominated: 8 CML and 8 AMML. The peculiar distribution of leukemia by cell type and the number of cases observed in the United States indicate that the risk of childhood leukemia in NF is increased. Two possible variants were noted: NF with "transient leukemia," and multiple skin xanthomas with nonlymphocytic leukemia.
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Amadori S, Petti MC, De Francesco A, Chierichini A, Mastrovincenzo C, Testa MG, Mandelli F. Lack of prognostic significance of the pretreatment labeling and mitotic indices of marrow blasts in acute nonlymphocytic leukemia (ANLL). Cancer 1978; 41:1154-60. [PMID: 638960 DOI: 10.1002/1097-0142(197803)41:3<1154::aid-cncr2820410353>3.0.co;2-e] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The prognostic significance of the pretreatment growth characteristics of marrow blasts was examined in 37 patients with acute nonlymphocytic leukemia (ANLL) treated with a similar therapeutic regimen. Initial mitotic index (MI) and in vitro 3H-thymidine labeling index (LI) were broadly distributed showing no correlation to other initial variables, such as age or absolute blast count. No relationship whatsoever was observed between the pretreatment LI, MI and either the likelihood of achieving a complete remission or the remission and survival length. We conclude that the initial growth characteristics of marrow blasts do not play a significant role in predicting the therapeutic response in ANLL; age, modality of therapy and, possibly, the dynamic perturbations of the proliferative activity of the blast cells induced by treatment should be regarded as more reliable prognostic indicators in ANLL.
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Oliff A, Poplack D. Characteristics of long-term survivors in AML. MEDICAL AND PEDIATRIC ONCOLOGY 1978; 5:219-23. [PMID: 284169 DOI: 10.1002/mpo.2950050130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We examined the records of all patients with a diagnosis of acute myelogenous leukemia or acute myelo-monocytic leukemia seen between 1963--1975. Of 211 patients, 12 are alive and in complete remission from 179--48 months since diagnosis. Life table analysis reveals a survival plateau of 4--5% after five years. Three of the survivors have suffered relapses but still survive without evidence of disease. The clinical and laboratory characteristics of all the survivors are presented. The survivors have a significantly younger age at diagnosis than the nonsurvivors (P less than 0.005). However, no other factors could be identified as characteristic of the survivors' group.
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Chard RL, Finklestein JZ, Sonley MJ, Nesbit M, McCreadie S, Weiner J, Sather H, Hammond GD. Increased survival in childhood acute nonlymphocytic leukemia after treatment with prednisone, cytosine arabinoside, 6-thioguanine, cyclophosphamide, and oncovin (PATCO) combination chemotherapy. MEDICAL AND PEDIATRIC ONCOLOGY 1978; 4:263-73. [PMID: 355821 DOI: 10.1002/mpo.2950040310] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Mandelli F, De Lipsis E, Grignani F, Martelli M, Liso V, Amadori S. Daunomycin, cytosine arabinoside and 6-thioguanine (DAT) vs vincristine, cytosine arabinoside and 6-thioguanine (VAT) in the induction treatment of acute nonlymphocyte leukemia: a randomized collaborative study. MEDICAL AND PEDIATRIC ONCOLOGY 1978; 4:231-40. [PMID: 277749 DOI: 10.1002/mpo.2950040306] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
One hundred patients were entered in a cooperative study comparing the efficacy of two different regimens in the induction treatment of acute nonlymphocytic leukemia (ANLL). Patients were randomly allocated to receive either the DAT or VAT combination; half of the patients were also randomized to receive CNS prophylaxis including intrathecal methotrexate + prednisone and cranial irradiation. Consolidation and maintenance therapy were uniform in responding patients. Out of 82 evaluable patients 41 (50%) attained complete remission (CR) with no significant difference between the two regimens. Median remission duration was slightly longer in the DAT group (32.5 vs 22 weeks); median survival was 34 weeks for all evaluable patients with no difference between the two schedules. Meningeal relapse occurred only in two patients after 19 and 99 weeks of continuous remission. Fourteen patients are still alive after 61 to greater than or equal to 155 weeks, of whom seven are in their initial remission (six in the DAT and one in the VAT group). We conclude that 1) DAT and VAT are equally effective in inducing CR in a high proportion of ANLL patients; 2) until marrow remission can be prolonged significantly, preventing CNS leukemia will not have any significant impact of the course of ANLL.
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Abstract
Treatment for the child with cancer has increasingly been on a rational rather than an empiric basis. An understanding has developed of the importance for determining clinical and laboratory features present at diagnosis as an aid not only to establish a prognosis but also to design specific treatment regimens. A system has been developed for bringing new chemotherapeutic agents into clinical trials as effectively as possible. Through both clinical and laboratory studies, an increasing understanding of the biology of cancer is being developed. This understanding will provide the basis for more rational treatment programs in the future. Physicians of different specialty interests have learned to work together to develop coordinated programs of treatment so important to optimal care. By far the most important lesson learned, however, is that cancer in children is not of necessity a fatal disease, even when dissemination has occurred. For the furture, it will be necessary to develop even more effective methods of treatment, and research must provide a better understanding of this disease that may offer the opportunity for prevention, which, after all, is the number one interest of the pediatrician.
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Abstract
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.
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Abstract
Twenty children with acute myeloblastic leukemia were given induction and maintenance regimens combining cytosine arabinoside (ARA-C) and 6-thioguanine (TG). Two died before completing induction therapy and were considered unevaluable. Of the 18 remaining patients, 3 died shortly after induction, 2 had no response, 1 had a partial response and 12 (66%) had a complete remission (CR) lasting 4 to 68 months. Six still survive: two in their initial CR and four who relapsed but were reinduced to CR. Although no prophylactic central nervous system (CNS) therapy was given, only one patient has developed CNS involvement after diagnosis. Two girls became pregnant while on maintenance therapy. One delivered a normal, full-term infant; both she and the child are well 24 months later.
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Mauer AM. Leukemias of childhood. Curr Probl Cancer 1977; 2:1-46. [PMID: 269035 DOI: 10.1016/s0147-0272(77)80063-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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