Rates of inclusion of teenagers and young adults in England into National Cancer Research Network clinical trials: report from the National Cancer Research Institute (NCRI) Teenage and Young Adult Clinical Studies Development Group

Poor inclusion rates into clinical trials for teenagers and young adults (TYA; aged 13-24 years) have been assumed but not systematically investigated in England. We analysed accrual rates (AR) from 1 April 2005 up to 31 March 2007 to National Cancer Research Network (NCRN) Phase III trials for the commonest tumour types occurring in TYA and children: leukaemia, lymphoma, brain and central nervous system, bone sarcomas and male germ cell tumours. AR for 2005-2007 were 43.2% for patients aged 10-14 years, 25.2% for patients aged 15-19 years, and 13.1% for patients aged 20-24 years in the tumour types analysed. Compared with accrual from 1 April 2005 to 31 March 2006, AR between 1 April 2006 and 31 March 2007 increased for those aged 10-14 and 15-19 years, but fell for those aged 20-24 years. AR varied considerably among cancer types. Despite four trials being available, patients over 16 years with central nervous system tumours were not recruited. Rates of participation in clinical trials in England from 2005 to 2007 were much lower for TYA older than 15 years compared with children and younger teenagers. The variations in open trials, trial age eligibility criteria and extent of trial activation in treatment centres in part explain this observation. Other possible influences, such as difficulties associated with the consent of TYA require further evaluation. Closer dialogue between those involved in planning and running trials for children and for adults is necessary to improve trial availability and recruitment. Further research is required to identify trends in trial availability and accrual for those tumours constituting the remaining 26% of TYA cancers.

Highly purified CD38+ and CD38- sub-clones derived from the same chronic lymphocytic leukemia patient have distinct gene expression signatures despite their monoclonal origin

CD38 expression is an important prognostic marker in chronic lymphocytic leukemia (CLL) with high levels of CD38 associated with shorter overall survival. In this study, we used gene expression profiling and protein analysis of highly purified cell-sorted CD38(+) and CD38(-) chronic lymphocytic leukemia cells to elucidate a molecular basis for the association between CD38 expression and inferior clinical outcome. Paired CD38(+) and CD38(-) CLL cells derived from the same patient were shown to be monoclonal by V(H) gene sequencing but despite this, CD38(+) CLL cells possessed a distinct gene expression profile when compared with their CD38(-) sub-clones. Importantly, CD38(+) CLL cells relatively over expressed vascular endothelial growth factor (VEGF) and appeared to preferentially utilize an internal autocrine VEGF survival loop. Elevated VEGF expression was associated with increased expression of the anti-apoptotic protein Mcl-1. Inhibition of VEGF receptor signaling also resulted in a reduction in cell viability. In contrast, exogenous VEGF caused a significant increase in CD38(-) CLL cell viability and a marked induction of Mcl-1; both effects were less obvious in CD38(+) CLL cells. Taken together, our data provide a biological rationale for the poor prognosis of CD38(+) CLL and indicate that both VEGF and Mcl-1 may prove to be useful therapeutic targets.

Deletion analysis of chromosome 13q14.3 and characterisation of an alternative splice form of LEU1 in B cell chronic lymphocytic leukemia

Heterozygous and homozygous deletions of chromosome 13q14.3 are found in 50% of patients with B cell CLL, suggesting the presence of one or more tumour suppressor genes within the deleted region. To identify candidate genes from the region, we constructed a map of 13q14.3 using a combination of genomic and cDNA library screening. The incidence of deletions in CLL patients was 51.5% encompassing a 265 kb region of minimal deletion (RMD) telomeric to markers D13S319. Two CpG islands were identified within the RMD, the telomeric of which is fully methylated whilst the more centromeric is unmethylated. A novel transcript was identified within the RMD that represents an alternative splice version of Leu1. The nine exons of this transcript span a genomic of 436 kb with exon 1 of Leu1 being the common first exon. The remaining exons were shown to be more frequently deleted than Leu1 itself. All splice forms of this transcript were detectable by RT-PCR but Leu1 detected the most abundant message on Northern blotting. Sequence analysis failed to reveal inactivating mutations in patients with heterozygous deletion of 13q14.3, although a polymorphic T to A variant was identified within exon 1 of Leu1 in leukemic and normal controls. As no mutations have been detected for Leu1 or any other transcript so far described, we cannot exclude the existence of control elements within the RMD that may regulate expression of genes lying in this region.

Acute myeloid leukemia: therapeutic indications

The main issue for younger patients with acute myeloid leukemia is the prevention of relapse. About 55% of patients relapse and the risk can partially be predicted by prognostic factors, particularly cytogenetics. A number of strategies can attempt to reduce the relapse risk. Intensification of induction therapy has been attempted but there is as yet no convincing evidence that survival is improved. Transplantation of either allogeneic or autologous stem cells does not seem to offer major survival advantage overall or within risk groups. Improved understanding of resistance mechanisms and the identification of new risk factors may enable the development of a more targeted approach to therapy.

Role of allogeneic and autologous hematopoietic stem cell transplantation in acute myeloid leukemia

Most younger patients with acute myeloid leukemia will enter remission of disease. Prevention of relapse is now the central therapeutic issue. A number of factors predict the risk of relapse, the most powerful of which is cytogenetics. Both allogeneic and autologous transplantation have been extensively used as remission consolidation, but intensive chemotherapy has also provided improved results such that the choice of consolidation treatment is not clear. Recent prospective trials of allogeneic and autologous transplantation with careful analysis have not always shown a survival benefit, although both approaches have significantly reduced relapse risk. In analysis where relapse risk is taken into account based on cytogenetics, there is little evidence of the benefit of transplantation in good-risk patients, partly because patients in this group who relapse can then undergo successful salvage therapy. The results are still uncertain in standard-risk patients, so transplantation should continue to be used in the context of a trial. Poor-risk patients have a higher failure rate after transplantation, and for these patients novel approaches are required.

Lack of clonal BCRA2 gene deletion on chromosome 13 in chronic lymphocytic leukaemia

Chromosome 13q deletion is among the most common cytogenetic abnormalities in chronic lymphocytic leukaemia (CLL). We investigated the 13q14.3 deletion in 44 CLL patients by Southern blotting following purification of clonal B CLL cells to >90%. Two sets of probes were used to investigate the site of clonal deletion, the D13S25 and D13S319 markers (at 13q14.3) and probes for exons 11 and 26-27 of the BRCA2 gene (at 13q12). Homozygous and heterozygous deletion at the 13q14.3 region was found in five and 17 patients, respectively. Despite the recent report of the BRCA2 gene involvement in >80% of CLL patients, we failed to detect a single case of homozygous or heterozygous deletion involving the 13q12 region. Our data support previous findings that the 13q14.3, and not the 13q12 region, is the major site of candidate tumour suppressor gene(s) in CLL.

Diagnostic utility of bone marrow sampling in HIV positive patients

OBJECTIVE

To evaluate the diagnostic utility of bone marrow (BM) sampling in HIV positive patients.

DESIGN

Retrospective cohort analysis.

SETTING

Specialist HIV/AIDS service in London.

SUBJECTS

215 consecutive HIV infected patients undergoing 246 BM samplings for investigation of pyrexia without localising signs, haematological abnormalities, or staging/investigation of lymphoma.

MAIN OUTCOME MEASURE

Diagnostic yield from (and impact on management of) BM sampling.

RESULTS

Of 122 BM samples taken to investigate pyrexia, 33 (27%) revealed the cause on microscopy: unexpected lymphoma in seven (6%), mycobacteriosis in 25 (20%), and toxoplasmosis in one (1%). Marrow infiltration was confirmed in 11 of 38 BM samples taken for staging/investigation of lymphoma/leukaemia. In afebrile patients, of 22 with pancytopenia, BM samples showed HIV associated changes in 17 and specific diagnoses in five (mycobacterial infection in three, haemophagocytic syndrome in one, and megaloblastic change due to vitamin B-12 deficiency in one); of 21 with isolated thrombocytopenia, 20 (95%) BM samples showed immune thrombocytopenic purpura to be the cause and the remaining patient had BM changes of aplasia; of 29 with isolated anaemia, 28 had BM changes of HIV associated dysplasia/erythroid dysplasia and one had unsuspected iron deficiency; all 10 with isolated leucopenia/neutropenia had BM changes ascribed to HIV infection exacerbated by concurrent sepsis or medication; of four BM samples taken for other reasons, one showed mycobacterial infection.

CONCLUSIONS

BM sampling has diagnostic utility in HIV infected patients with pyrexia without localising signs, pancytopenia, and staging/investigation of lymphoma; this test has little value in the investigation of afebrile patients with isolated thrombocytopenia, anaemia, or leucopenia as HIV is usually the underlying cause.

Bone pain as the presenting manifestation of secondary syphilis

A 31 year old fireman presented with acute pain and tenderness in both shins and forearms. Radiographs were normal but bone scintigraphy showed widespread increased isotope uptake. Serology was consistent with a diagnosis of secondary syphilis, and the patient's symptoms resolved completely six weeks after a course of penicillin.

DISCUSSION ON THE COMPLICATIONS OF OPERATIONS FOR PILES: President's Address

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Case of Ununited Fracture of the Humerus treated by the Insertion of a Segment of Fibula into the Medullary Cavity

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