Epidemiology of malignant neoplasms in soft tissue during childhood

Employing the data of the Hokkaido Children's Cancer Registry, incidences of malignant neoplasms in soft tissue during childhood were estimated. During 25 years (1975--1999), a total of 110 such cases (0-14 years of age) were registered. The average incidence was 0.40 per 100,000 population aged 0-14 years. The incidence of rhabdomyosarcoma (RMS) was 0.24, accounting for 60% of all malignant neoplasms in soft tissue. 30% of the malignant neoplasms in soft tissue were found in the head/face/neck. The share of RMS in the upper limbs was 76%, while that in the chest was 25%. Mortality due to malignant neoplasms in soft tissue was estimated using the data of vital statistics of all Japan. The average mortality of all malignant neoplasms in soft tissue was about 0.15 per 100,000 population aged 0-14 years, which was almost constant throughout the 25 years. Both the mortality at 5-9 years of age and that at age 10-14 years increased, while that at 0-4 years had a tendency to decrease. The prolongation of the survival period in the 0-4-year age group due to the progress in therapy may have brought about a shift of the age at death to older age groups, leading to a decrease in the mortality at 0-4 years of age.

Is the mass screening for neuroblastoma ineffective?

Though a recent study (Schilling et al. 2002) concluded that the mass screening for neuroblastoma targeting children age 12 months was ineffective, we pointed out several serious problems and reestimated its effectiveness using their data. They employed the subjects in the "control area" as controls, not the "non-participants" whose biases are fewer because their area is the same as that of the participants. The incidence of neuroblastoma among the subjects in the "control area" was about 25% smaller than that of the "non-participants". This leads to underestimation of the effectiveness of the mass screening. They combined false negatives with true positives to calculate the incidence of the "screened group". But since many spontaneous regression cases are included in the true positives, this method inflates the incidence of the "screened group", leading to underestimation of the effectiveness of the mass screening. When the false negatives are compared with the non-participants, the incidence of the cases in stage 4 among the latter is about 40% of that of the former, and the mortality is less than two-thirds. The percentage of spontaneous regression cases among the true positives is estimated to be about 40%. These results are better than those of the Japanese screening programs (targeting infants age 6 months), supporting the effectiveness of mass screening for neuroblastoma.

Contribution of HPLC mass screening for neuroblastoma to a decrease in mortality

The aim of this study is the estimation of the contribution of HPLC mass screening for neuroblastoma to the decrease in deaths due to this disease. The mortality rates of malignant neoplasms of the adrenal glands (ICD 9, 1940; ICD 10, C74; virtually all the cases of these codes are neuroblastoma during childhood) at 1-4 years of age in cohorts born in 1979-1984, 1985-1988, and 1989-1992 in the whole of Japan were calculated, using data obtained from the Ministry of Health and Welfare. The numbers of infants screened by HPLC in the cohorts were estimated through the reports of the Ministry of Health and Welfare and the database of the Japanese Society for Mass-screening. The mortality of the cohort born in 1989-1992, in which 77.8% of the live births were screened by HPLC, was 1.73 per 100,000 live births. This is about half of that (3.26) of the cohort born in 1979-1984, in which few infants were screened. On the assumption that cases of the 1985-1988 and 1989-1992 cohorts died according to the mortality rate of the 1979-1984 cohort, the expected numbers of deaths were estimated; that for the 1985-1988 cohort was 178.51 (of them, that for the infants screened by HPLC was 39.65), and that for the 1989-1992 cohort was 159.78 (of them, that for the infants screened by HPLC was 124.33). The observed numbers of deaths were 145 and 85, respectively. Assuming that non-HPLC methods have no effects and using 2 unknown quantities x (contribution of HPLC) and y (other factors), simultaneous equations (1) 178.51 - 39.65x - 178.51y = 145 and (2) 159.78 - 124.33x - 159.78y = 85 were made. Solving them, x = 0.5041 and y = 0.0757 were obtained. In conclusion HPLC screening targeting infants aged 6 months reduces death of adrenal neuroblastomas at 1-4 years of age by about 50%.

Mutations/deletions of the WT1 gene, loss of heterozygosity on chromosome arms 11p and 11q, chromosome ploidy and histology in Wilms' tumors in Japan

Incidence rates of Wilms' tumor (WT) markedly differ in East Asian and Caucasian children. In the present study, we examined WT1 deletions/mutations and loss of heterozygosity (LOH) on 11p and 11q in a large number of WTs and compared our findings with those from 4 series of Caucasian WTs. Incidence rates of the subtle WT1 mutation in 3 of the 5 series of sporadic and unilateral WTs including ours were 4.3-6.2% and similar. However, gross homozygous WT1 deletion was more frequent in our series than in some others. In addition, our series tended to show a higher incidence of LOH limited to 11p13 and a lower incidence of LOH including 11p15 than the Caucasian one. These findings indicate some genetic differences in WT between the 2 regions. One of the 4 Caucasian series reported a correlation of germinal WT1 mutation with the predominantly stromal histology. The present study not only confirms the correlation of germinal WT1 deletion/mutation with predominant stromal histology but also establishes a correlation with somatic WT1 deletion/mutations with predominant stromal histology. While WTs with WT1 abnormalities usually showed pseudodiploidy and predominant stromal histology, those without WT1 abnormalities showed various chromosome numbers and histologic subtypes.

Development of acute myeloid leukemia after chemotherapy for osteosarcoma

The current study describes two patients with osteosarcoma who had acute myeloid leukemia develop after treatment with multiagent chemotherapy. The incidence density for the chemotherapy protocol was 129.8 per 10,000 person-year of followup. Karyotype analysis of 16 reported patients (including the current two patients) indicated that most leukemias after treatment of osteosarcoma correlated with the use of topoisomerase II inhibitors, such as doxorubicin. The deoxyribonucleic acid-damaging activity of doxorubicin reinforced by the use of alkylating agents is highly suspected as a causative event in the development of leukemia after treatment of osteosarcoma. As the next step in the development of treatment for patients with osteosarcoma, the type and intensity of treatment must be evaluated to minimize possible leukemogenic effects without compromising the potential for cure.

Frequent increase of DNA copy number in the 2q24 chromosomal region and its association with a poor clinical outcome in hepatoblastoma: cytogenetic and comparative genomic hybridization analysis

In a cytogenetic and comparative genomic hybridization (CGH) study of 38 hepatoblastomas, we found gain of 1q in 17 tumors (44.7%), that of 2 / 2q in 14 (36.8%), that of 20 / 20q in 9 (23.7%) and that of 8 / 8q in 8 (21.0%), loss of 4q in 4 (10.5%) and no DNA copy changes with normal karyotype or no mitotic cells in 11 (28.9%). Eleven tumors with 2 / 2q gain detected by CGH had a total chromosome 2 gain, a partial 2q gain, or a total chromosome 2 gain with an augmented partial 2q region; the common region for DNA copy gain was 2q24. Two-color fluorescence in situ hybridization (FISH) analyses using probes covering the centromere of chromosome 2 or HOXD13 (2q31) confirmed the CGH findings, and showed that the common region for gain in 2q was centromeric to HOXD13. Event-free survival (EFS) +/- standard error (SE) at 5 years was lowest in patients with 2q gain [37 +/- 15%], highest in those with no DNA copy changes [82 +/- 12%], and intermediate in those with DNA copy changes other than 2q gain [74 +/- 13%] (P = 0.0549). Multivariate analysis showed that 2q gain was an independent factor predicting a poor outcome. These findings suggest the presence of a growth-promoting gene or an oncogene in the 2q24 chromosome band, and a tumor suppressor gene in terminal 4q, which have important roles in the development and progression of hepatoblastoma.

Prognostic impact of CD45 antigen expression in high-risk, childhood B-cell precursor acute lymphoblastic leukemia

To evaluate the clinical implications of CD45 expression in acute childhood lymphoblastic leukemia (ALL), we measured the CD45 expression of blast cells from 133 untreated patients with childhood B-precursor ALL (n = 118) or T-ALL (n = 15). CD45 expression (> or = 20%) was detected in all 15 cases (100%) of T-ALL, and 101 cases (86%) of B-precursor ALL. In 122 cases, the fluorescence intensity of the CD45 expression was measured as a relative value; the ratio of average linear values (RALV) of CD45 on the blasts to that on CD3-positive T-lymphocytes from the same specimen. The expression was more intense in the T-ALL cases than in the B-precursor ALL cases (RALV, mean +/- SE: T-ALL 0.230 +/- 0.04 vs. pro-B ALL 0.150 +/- 0.012/pre-B ALL 0.153 +/- 0.019, p < 0.05). However, the intensity of the CD10, CD19, CD20 and CD34 antigen immunoreactivity did not correlate with the CD45 expression. Patients with hyperdiploidy (chromosome number > 50) showed significantly lower levels of CD45 expression than patients with t(1;19) or normal karyotypes (RALV, mean +/- SE: 0.081 +/- 0.022 vs. 0.133 +/- 0.03/0.143 +/- 0.019, p < 0.05). Other clinical features such as age, gender and WBC count did not correlate with CD45 expression. The prognostic implications of CD45 expression were studied in non-high-risk (low-risk + intermediate-risk) (n = 60) and high-risk patients (n = 52) with B-precursor ALL who had been treated with the risk-directed protocol of ALL-941 trial. Although CD45 expression did not correlate with the event-free survival (EFS) of the non-high-risk patients, there was a significant correlation between the expression levels and the EFS of the high-risk patients: the 3-year EFS rate of the CD45low group (n = 26, RALV = 0.017-0.132) was 88 +/- 7% versus the CD45high group (n = 26, RALV = 0.133-0.450) at 34 +/- 24% (p < 0.05). These results show that the levels of expression of the CD45 antigen on leukemic lymphoblasts are significantly correlated with the clinical features and prognosis of childhood ALL.

Monitoring of minimal residual disease in children with acute promyelocytic leukemia by RT-PCR detecting PML/RARalpha chimeric gene: a retrospective study of clinical feasibility

We studied retrospectively the clinical feasibility of minimal residual disease (MRD) monitoring by reverse transcription-polymerase chain reaction (RT-PCR) detecting the PML/retinoic acid receptor alpha (RARalpha) chimeric gene in children with acute promyelocytic leukemia (APL). MRD monitoring of APL was performed with standard and nested RT-PCR for PML/RARalpha gene, the sensitivity of which was 1 leukemic cell in 10(3)-10(4) and 1 in 10(4)-10(5) cells, respectively. Patients were nine children with APL (average age: 8.3 year; average period of follow-up: 69.2 months) who, after achieving remission with all-trans retinoic acid (ATRA), received treatment either with multidrug chemotherapy or with a combination of chemotherapy and ATRA. Out of six patients treated with multidrug-combined chemotherapy, two patients exhibited PCR positivity after six months of post- remission therapy, which shifted from the detectable range of the nested PCR to that of the standard PCR. These two patients subsequently relapsed and, together with two of the other patients receiving multidrug-combined chemotherapy, underwent allogeneic bone marrow transplantation. No MRD was detected in these patients after transplantation. In the remaining three patients who underwent cyclic treatment with alternative chemotherapy and ATRA, two showed positive RT-PCR at the nested or standard level, respectively, after six months of combined therapy, and one of them relapsed. Overall, three of four patients with MRD detected in post-remission period ultimately relapsed, while all of five patients without detectable MRD had a good prognosis. These findings suggest that impending relapse may be predicted by the detection of preceding PCR positivity with an increasing quantity of the PML/RARalpha mRNA that appears beyond six months of post-remission chemotherapy, with or without combined ATRA therapy.

Congenital malformations and childhood cancer

BACKGROUND

We investigated the epidemiology of congenital malformations and childhood cancer.

PROCEDURE

By employing the cases of the Registry of Childhood Malignancies in Hokkaido Prefecture, Japan, from 1969 to 1996, the numbers of malignancies in cases (diagnosis at 0-14 years of age) with Down syndrome (DS), mental retardation (MR) excluding DS, luxatio coxae congenita (LCC), congenital heart disease (CHD) excluding DS, undescended testicle (UT), and cleft palate-lip (CPL) were calculated. Using the percentages of malignancies in the 2,349 cases without malformation, expected numbers of malignancies in the cases with the malformations were calculated. The observed numbers were statistically compared to expected ones.

RESULTS

In the DS cases, leukemia developed with a significantly high frequency, but no UT cases developed leukemia. No brain tumor was preceded by DS. This could not be explained only by early death from coexisting diseases such as CHD, insofar as the CHD cases without DS developed brain tumors more frequently than expected. The ratio of acute lymphoblastic leukemia (ALL) to acute nonlymphoblastic leukemia (ANLL) was different among the malformations. The MR cases developed ANLL more frequently than expected, whereas the CPL cases developed ALL more frequently. The distribution of the age at diagnosis for Wilms' tumor was different according to the underlying malformation.

CONCLUSIONS

Malformations might have some factors that inhibit or delay as well as promote the development of certain malignancies.

Epidemiology of childhood brain tumors in Japan

Using the vital statistics issued annually by the Japanese Government from 1960 to 1994, the mortality of brain tumors during childhood (0-14 years of age) in Japan was estimated. Since there are few nationwide registries of childhood cancers with a sufficiently high registration rate, the incidence of brain tumors was calculated using the Registry of Childhood Malignancies in Hokkaido Prefecture from 1969 to 1996. Though the mortality due to malignant diseases as a whole during childhood has been decreasing, and though there should be progress in therapeutic methods, the mortality due to brain tumors in children has been increasing. The incidence of brain tumors in Hokkaido Prefecture has been increasing as well. There was no tendency for the incidence of medulloblastoma to decrease. The incidence of childhood brain tumors has been increasing in Japan, though the cause is unknown. The period of the present study corresponded to a period of high economic growth. Thus, a study on environmental factors would be interesting.

Correlation of chromosome abnormalities with presence or absence of WT1 deletions/mutations in Wilms tumor

Of 40 Wilms tumors with chromosome abnormalities, 6 were hypodiploid, 10 were pseudodiploid, 7 were hyperdiploid with 47 to 49 chromosomes, and 17 were hyperdiploid with 50 or more chromosomes, mostly including +12. WT1 deletions/mutations were found in one hypodiploid, eight pseudodiploid, and one hyperdiploid (47-49 chromosomes) tumor, but in none of the hyperdiploid (> or =50 chromosomes) tumors. Of the 10 tumors with WT1 abnormalities, 6 had a homozygous WT1 deletion, 1 had a nonsense WT1 mutation and loss of heterozygosity at 11p, 1 had an intragenic hemizygous WT1 deletion without detectable WT1 mutation, and 2, which occurred in Wilms tumor-aniridia-genitourinary abnormalities-mental retardation syndrome patients, had a hemizygous deletion and a missense or frameshift mutation of WT1. Six of the nine tumors with homozygous or hemizygous WT1 deletions had chromosome aberrations involving chromosome band 11p13 in one of the two chromosomes 11. While one hypodiploid and one pseudodiploid patient died of the disease, and one hyperdiploid (47-49 chromosomes) patient was alive in nonremission, all hyperdiploid (> or =50 chromosomes) patients had no evidence of disease at the last follow-up. Our data show that chromosome aberrations are closely correlated to WT1 abnormalities and suggest that hyperdiploid (> or =50 chromosomes) Wilms tumors may be characterized by the absence of WT1 abnormalities and possibly also by a favorable prognosis.

Improvement in CNS protective treatment in non-high-risk childhood acute lymphoblastic leukemia: report from the Japanese Children's Cancer and Leukemia Study Group

BACKGROUND

Prevention of central nervous system (CNS) leukemia by early introduction of therapy to this sanctuary site is an essential component of modern treatment strategy for acute lymphoblastic leukemia (ALL). However, the optimal form of preventive CNS therapy remains debatable.

PROCEDURE

To address this issue, we evaluated the efficacy of CNS preventive therapy for 572 children with ALL who achieved complete remission in the Children's Cancer and Leukemia Study Group (CCLSG) ALL874 (1987-1990) and ALL911 (1991-1993) studies. They received risk-directed therapy based on age and leukocyte count. In the ALL 874 study, the non-high-risk (low-risk [LR] + intermediate risk [IR]) patients were randomly assigned to the conventional cranial irradiation (CRT) regimen (L874A and I874A) and the high-dose methotrexate (HDMTX) regimen without CRT (L874B and I874B). The former patients received 18-Gy CRT plus 3 doses of intrathecal (i.t.) MTX and the latter patients received 3 courses of HDMTX at 2 g/m2 plus 13 doses of ITMTX (L874B) or 4 courses of HDMTX at 4.5 g/m2 plus 1 dose of ITMTX (I874B).

RESULTS

The 7-year probabilities (+/- SE) of CNS relapse-free survival were 97.3% +/- 2.6% (L874A, n = 41) vs. 90.3% +/- 5.3% (L874B, n = 39) (P = 0.25) in the LR patients, and 100% (I874A, n = 55) vs. 78.5% +/- 6.5% (I874B, n = 54) (P = 0.002) in the IR patients. The corresponding disease-free survival (DFS) rates were 79.4% +/- 6.5% vs. 74.4% +/- 7.3% (P = 0.62) in the LR group and 63.3% +/- 6.8% vs. 58.3% +/- 7.2% (P = 0.66) in the IR group. Thus, the HDMTX regimen could not provide better protection of CNS relapse as compared with the CRT regimen, although their overall efficacy was not significantly different. In the ALL 911 study, intensive systemic chemotherapy with extended i,t, injections of MTX plus cytarabine achieved a high CNS relapse-free survival (98% +/- 1.9% at 7 years) and a favorable DFS (85.5% +/- 5% at 7 years) in the IR patients. The patients in the high-risk (HR) group in both ALL874 and ALL911 studies received the 18-Gy or 24-Gy CRT with intensive systemic chemotherapy. Their 7-year probabilities of CNS relapse-free survival ranged from 88% to 95%, among which the T-ALL patients had a risk of CNS leukemia, which was 3-4 times higher compared with B-precursor ALL patients.

CONCLUSIONS

These results indicate that long-term intrathecal CNS prophylaxis as well as appropriate systemic therapy for the non-high-risk patients can provide protection against CNS relapse equivalent to that provided by cranial irradiation.

[Studies of childhood non-Hodgkin's lymphoma--treatment results with the CCLSG NHL 960 protocol. Children's Cancer and Leukemia Study Group (CCLSG)]

We report here on the preliminary treatment findings of a CCLSG NHL 960 study that was initiated in March 1996. In this study, 37 patients with non-Hodgkin's lymphoma were assigned to 4 different treatment groups according to disease stage and histology: (1) localized disease; (2) advanced disease, lymphoblastic type; (3) advanced disease, large cell type; and (4) advanced disease, Burkitt type. The first three groups received the modified protocols of the NHL 890 study. Groups 1 and 3 received COPADM induction therapy (CPM, VCR, PRD, ADR, and MTX). After achieving remission, Group 1 received only maintenance therapy consisting of alternate administration of 7 drugs, while Group 3 received additional intensification therapy with combination chemotherapy consisting of MTX and Ara-C, followed by a maintenance phase involving the administration of 9 drugs. Group 2 received COPADL induction therapy (CPM, VCR, PRD, ADR, and LASP) and consolidation/intensification therapies followed by a maintenance phase. Group 4 received short-term intensive COPADM polychemotherapy. Twelve patients with localized with localized disease (stage I-II) and 25 patients with advanced disease (stage III-IV) were enrolled in this study. Except for 2 patients in the advanced disease stages who died earlier in the course of the study, all patients remained in remission.

Mass screening for neuroblastoma by HPLC and by non-HPLC: a review

There have been a number of contradictory views concerning the efficacy of mass screening for neuroblastoma. Three Japanese and one cohort study from Quebec, and three Japanese cross-sectional studies were reviewed. The four cohort studies revealed that mass screening using high performance liquid chromatography (HPLC) reduced the incidence of this disease by about half in children aged from 1 to 4 years while little reduction was noted in screening utilizing non-HPLC methods. There is a large difference in the efficacy of mass screening depending on the method used. In the three cross-sectional studies, there was no discrimination between screened and unscreened cases, or between subjects screened by HPLC and non-HPLC methods. The percentage of children in the cross-sectional studies screened by HPLC was low. Cross-sectional studies seem inappropriate in assessing the effectiveness of current HPLC mass screening.

Long survivors with Ki-1 lymphoma having t(2;5) (p23;q35). Does the presence or absence of t(2;5) influence the prognosis of patients with Ki-1 lymphoma?

We experienced three patients with CD30+ diffuse large cell lymphoma having chromosomal abnormalities. The first patient was an 8-year-old girl with bilateral cervical lymphadenopathy. A biopsy of a cervical lymph node revealed diffuse large cell lymphoma (stage III), positive for CD30 and a chromosomal abnormality, t(2;5). She attained a remission and is now in complete remission 108 months after diagnosis, despite frequent relapses. The second patient was a 13-year-old boy with right axillar and supraclavicular lymph-node adenopathy. A biopsy of a cervical lymph node revealed diffuse large cell lymphoma (stage III), positive for CD30 and a chromosomal abnormality, t(2;5). He attained remission and was in continuous first remission 112 months after diagnosis. The third patient was an 11-year-old boy with fever and bilateral cervical lymph node revealed diffuse large cell lymphoma (stage III), positive for CD30 and chromosomal abnormality without t(2;5). He showed a very aggressive clinical course. Only the patients with Ki-1 lymphoma having t(2;5) survived over 100 months from the diagnosis, despite the advanced stage of the disease. These findings and a review of the literature showed that the presence or absence of t(2;5) may influence the outcome of Ki-1 lymphoma.

[Bone marrow relapse in high-risk pediatric patients with acute lymphoblastic leukemia: a comparison of relapse times and initial clinical features of patients on different protocols. Children's Cancer and Leukemia Study group (CCLSG)]

To clarify the efficacy of modern intensive chemotherapy for ALL patients with unfavorable features, we compared the time to failure and initial clinical features of children who relapsed in the bone marrow or combined sites, as documented by early CCLSG studies (H811 and H851; 1981-1987) and later studies (H874 and H/HH911; 1987-1993) concerning high-risk ALL patients. In the later studies patients outcomes with new intensive regimens employing early intensification and reinduction therapy were apparently better than those of patients in the early studies with conventional regimens. When we compared the number of relapsed patients based on duration of first remission, we found that the improved outcomes for patients in the later studies were due to a decrease in the number who relapsed 7-36 months after the start of treatment (intermediate relapse), and that the percentage of those who relapsed within the first 6 months of therapy (early relapse) was higher. Patients with high initial WBC counts tended to relapse much earlier than those with low initial WBC counts. However, in the later studies, patients with high WBC counts often relapsed after the termination of therapy (late relapse). These results suggest that the intensive chemotherapy regimens used in the later studies can prevent the development of drug resistant leukemic clones, except in extremely high-risk patients likely to relapse within the first 6 months of therapy.

Mutations in the E-domain of RAR portion of the PML/RAR chimeric gene may confer clinical resistance to all-trans retinoic acid in acute promyelocytic leukemia

The binding of all-trans retinoic acid (ATRA) to the ligand-binding region in the E-domain of retinoic acid receptor-alpha modifies the transcriptional activity of RARalpha protein. ATRA probably induces differentiation of acute promyelocytic leukemia (APL) cells by binding to the E-domain of the RARalpha portion (RARalpha /E-domain) of PML/RARalpha chimeric protein. Therefore, molecular alteration in the RARalpha /E-domain of the chimeric gene is one mechanism by which patients with APL may acquire resistance to ATRA therapy. In this study using reverse transcription-polymerase chain reaction and single-strand conformation polymorphism, DNA segments amplified from the RARalpha /E-domain in fresh APL cells of 23 APL patients (8 males and 15 females from 4 to 76 years of age) were screened for mutations. Of those patients, 3 patients (1 with de novo and 2 with relapse) had clinical resistance to ATRA therapy. We found mutations in the RARalpha /E-domain of PML/RARalpha chimeric gene exclusively in the 2 patients who exhibited ATRA-resistance at relapse, whereas the mutations were not detected at their initial onset. Interestingly, these patients received a prolonged or intermittent administration of ATRA before relapse with ATRA-resistance. The mutations lead to the change of amino acid in the ligand-binding region of RARalpha /E-domain, Arg272Gln, or Met297Leu according to the amino acid sequence of RARalpha, respectively. Further study demonstrated that the in vitro ligand-dependent transcriptional activity of the mutant PML/RARalpha protein was significantly decreased as compared with that of wild-type PML/RARalpha. These findings suggest that mutations in the RARalpha /E-domain of the PML/RARalpha chimeric gene may confer clinical resistance to ATRA therapy in patients with APL.

[Treatment of children with non-Hodgkin's lymphoma with CCLSG NHL 855/890 protocols long-term outcome and incidence of secondary malignancies]

We report here on treatment results of consecutive CCLSG NHL studies (NHL855, 1985-1989; NHL890, 1989-1996). The NHL855 protocol consisted of an induction phase of five drugs (VCR, PRD, CPM, DXR, and high-dose MTX) and a maintenance phase of 7 drugs. The probabilities of EFS at 7 years were 78% (SE, 10%) for the patients with localized disease, and 38% (SE, 7%) for those with advanced disease. In the NHL 890 protocol, the patients were assigned to two different treatment groups according to their histology and received different consolidation therapy; non-lymphoblastic subtype was treated almost identically to NHL855 while LASP and VP-16 were newly added for the lymphoblastic subtype. The 7-year EFS improved to 91% (SE, 6%) for localized disease, and 61% (SE, 6%) for advanced disease. A remarkable improvement was particularly evident for lymphoblastic type with mediastinal mass. Optional trial of high-dose sequential chemotherapy and peripheral blood progenitor cell auto grafting resulted in an unfavorable outcome. The 7-year EFS according to main histological subgroups were as follows: 84% (10%) for large cell type, 67% (11%) for Burkitt's-type, 58% (10%) for lymphoblastic type. Secondary cancer occurred in two of the 163 patients studied. Both patients were AML (M0/M4) and MLL rearrangement was detected in the M4 case.

[Prognostic implication of DNA contents on long-term outcome of childhood acute lymphoblastic leukemia]

Prognostic value of cellular DNA content was evaluated in 189 children with acute lymphoblastic leukemia. Treatment outcome of the three different DNA index (DI) groups (Group A, DI = 1.0 vs. Group B, DI 1.01-1.15 vs. Group C, DI > or = 1.16) was compared between the two treatment risk groups (standard-risk and high-risk groups) stratified by the initial leukocyte count and age. In the standard-risk group, these groups had 10-year event free survival (EFS) rate (SE) of 62% (6%), 40% (21%) and 87% (6%), respectively (p < 0.05). In the high risk group, they had 10-year EFS rate of 30% (5%), 33% (27%) and 60% (19%), respectively (p < 0.01). Use of the DI, leukocyte count and age may be sufficient to distinguish the patients with an extremely low risk of failing to the standard ALL therapy from the patients with a relatively high-risk of treatment failure.

[Childhood acute promyelocytic leukemia treated with all-trans retinoic acid]

We treated two children with acute promyelocytic leukemia (APL) in whom complete remission was successfully induced by oral administration of all-trans retinoic acid (ATRA). We followed these patients with conventional chemotherapy. The first patient has remained in continuous complete remission. However, the other patient relapsed during the maintenance therapy and died of progressive disease in spite of a second treatment with ATRA and chemotherapy. From a clinical point of view, the latter case had a hyperleukocytosis on admission. Also morphologically speaking, this patient had a different M3 variant than the first case. There are two major isoforms of PML/RAR alpha transcripts, so called short and long type transcripts, according to the breakpoints in the PML genes. In the first case the "long type' isoform was detected by reverse transcriptase polymerase chain reaction (RT/PCR) amplification. On the other hand the "short type' isoform was observed in the latter case. Also the second case became PCR positive at relapse, although the detectable isoform was negative during remission. The "short type' isoform may be related to the poor prognosis and RT/PCR analyses may be a powerful to detect early relapse.

Hyperplastic callus formation in both femurs in osteogenesis imperfecta

A 3-year-old boy with osteogenesis imperfecta had hyperplastic callus formation in the right femur, without preceding trauma or fracture. Radiologically, this bony mass in the femoral shaft mimicked osteosarcoma. Open biopsy showed that it was benign and suggested hyperplastic callus formation. Seven months after the biopsy, the hyperplastic callus had practically vanished. A similar process developed in the left femur 1 year later, also without fracture.

[A clinical study of fluconazole in the treatment of systemic mycosis associated with immunocompromised children]

Efficacies of fluconazole (FLCZ) were evaluated in 8 cases of systemic mycosis (1 case each of candidemia, candiduria, 4 cases of pulmonary candidiasis, and 2 cases of suspected fungemia) complicated in immunocompromised children. Enrolled in the study were 3 patients with acute leukemia, 1 with malignant lymphoma, 2 with congenital immunodeficiency syndrome, 2 with other disorders. The clinical efficacies were good in 6 out of 7 cases. No side effects were observed. FLCZ is a very good and safe agent for the treatment of systemic mycosis complicated with immunocompromised children.

Acute lymphoblastic leukemia and non-Hodgkin's lymphoma with mediastinal mass--a study of 23 children; different disorders or different stages?

Mediastinal tumor was found in both acute lymphoblastic leukemia (ALL) and non-Hodgkin's lymphoma (NHL). Most cases showed the T-cell phenotype. We query whether these two diseases are in fact different disorders or merely different stages of the same disease. Twelve ALL patients with a mediastinal mass and eleven NHL patients with a mediastinal mass under 15 years of age were studied with respect to cytogenetics, immunophenotype, genotype and clinical features. Clonal chromosome abnormalities were found in 75% (9/12) of the ALL patients and 100% (11/11) of the NHL patients. Of the 20 patients with chromosome abnormalities, 12 (60%) had translocations involving 14q11-13 and 7q35 (8 ALL, 4 NHL). t(9;17)(q34;q23) was found only in 3 patients with NHL. All showed the T-cell phenotype except two, who had none of the chromosomal abnormalities frequently detected in T cell ALL/NHL. In T-cell patients, immunophenotypical staging of ALL showed a predominance of early and common thymocyte phenotypes while that of NHL showed a predominance of common thymocyte phenotypes. All 7 of the T-cell patients examined showed rearrangements of the T-cell receptor beta chain gene. On the other hand, two non-T-cell, non-B-cell patients showed no rearrangement. There were no apparent clinical differences between ALL and NHL patients in age (median 8.6 vs 8.9 years), sex ratio (F/M 9/3 vs 7/4) or in the rate of complete remission (90% vs 100%). Our study demonstrated no relevant clinical, prognostic, or immunophenotypic differences between ALL and NHL with mediastinal mass.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary myelofibrosis in an infant--a case report and review of the literature]

Primary myelofibrosis (PMF) is regarded as a chronic myeloproliferative disorder. It is characterized by marrow fibrosis, leukoerythroblastosis, tear drop erythrocytes and extramedullary hematopoiesis. Most patients are in their late 50s when first diagnosed. Pediatric PMF is said to be quite rare. Here describe a female infant with PMF. The patient was born on Aug. 7, 1991. The pregnancy and delivery were uneventful. Hepatomegaly was noted soon after birth. Combined blood counts showed polycythemia and leukocytosis. It was thought to be extramedullary hematopoiesis due to intrauterine infection. She was followed up in another hospital, but since her condition was unchanged she was admitted to our hospital for further medical examinations at age 7 months. On the peripheral blood smear, there were tear drop erythrocytes, normoblasts and early myeloid elements. Repeated bone marrow aspirations were dry taps. This case presented the classical findings of fibrosis of the bone marrow on bone marrow biopsy. She is in good health without any therapy until now. A review of 7 cases of PMF, including our case, in Japanese children was made and discussed in comparison to adult cases.

[A clinical study of fluconazole-granules and -injectable in pediatric patients with deep-seated mycoses]

Fluconazole (FLCZ) is an antifungal agent of triazole class developed by Pfizer, Inc. Its oral and injectable forms have been available on the market since June 1989 in Japan. FLCZ exhibits potent antifungal activities against Candida spp., Aspergillus spp. and Cryptococcus spp. and, as orally or intravenously administered, is widely distributed into organs and tissues. For its low protein binding rate of about 10 per cent and long serum half life of about thirty hours in adults, FLCZ has been proved highly effective and useful in the treatment of deep-seated mycosis in adult patients. In the present study, we have investigated the clinical effectiveness and antifungal activities of FLCZ granules, a new dosage form of the drug, and of intravenous form in pediatric patients with deep mycosis. A total of 72 patients were treated either with granules orally or with intravenous injection and 47 patients among them were evaluable on the clinical efficacy of the drug. Also, a study on the pharmacokinetics of pediatric patients including premature/new born babies was conducted employing multiple dose regimens in a total of 27 patients. The clinical efficacy rates were 79.5% (35 patients out of 44) in candidiasis and 100.0% (3 of 3) in aspergillosis. The safety of the drug was assessed in 63 patients. No side effects were observed. Clinical laboratory test abnormalities were observed in some patients with an incidence of 9.7% (6 patients out of 62) but most of the abnormalities were only mild and transient. The pharmacokinetics at repeated doses indicated that a steady-state is reached in 4 days after the initial administration of either granules or intravenous form. From these results, it may be concluded that FLCZ is a very useful medication in the treatment of deep mycosis in pediatric patients.

[A multi-institutional study on the efficacy and toxicity of imipenem/cilastatin sodium in severe infections complicating hematological diseases and cancers in children. Study Group of Infectious Diseases in Pediatric Hematology/Oncology in Hokkaido]

A multi-institutional study was conducted between September 1990 and April 1992 to evaluate the efficacy and toxicity of imipenem/cilastatin sodium (IPM/CS) in severe infections in cases of granulocytopenia in children with hematological diseases and cancers. A total of 60 episodes of infection were treated with the drug, and an overall efficacy rate of 80% (48/60) was obtained. The efficacy rate in patients who were positive for Endospecy test was 90.0%. A group of patients who had previously received other antibiotics showed an efficacy rate of 79.2%, while the patients who had not received previous antibiotic treatment showed an efficacy rate of 80.6%. The difference between the 2 groups was statistically insignificant, however. Granulocyte counts appeared to have influence on the efficacy of the drug, but the influence was not strong. Three patients had nausea, vomiting and/or diarrhea, and 2 other patients showed abnormal liver function test parameters though they recovered soon after the cessation of the drug treatment. From these results, we have concluded that IPM/CS is an effective antibiotic for treatment of severe infections with hematological diseases and cancers in children.

Cytogenetic characteristics of childhood non-Hodgkin lymphoma

Cytogenetic studies were performed successfully on 24 patients with non-Hodgkin lymphoma (NHL) who were younger than 15 years of age. Of these, 22 patients (92%) had abnormal clones. With respect to histologic findings, 3 (25%) of the 12 patients with lymphoblastic lymphoma had 14q11 translocations and 2 (17%) had t(9;17) (q34;q23). Four (80%) of the five patients with small non-cleaved cell lymphoma had t(8;14)(q24;q32). With respect to immunologic findings, four (44%) of the nine patients with T-cell lymphoma had abnormalities consisting of 14q11 and 7q36 translocations, in which the T-cell receptor genes resided. Three (33%) of the patients with T-cell lymphoma had t(9;17)(q34;q23). However, three (43%) of the seven patients with B-cell lymphoma had t(8;14) (q23;q32), and two (29%) of the patients with B-cell lymphoma had an extra i(11q) chromosome with a resultant 11q tetrasomy. Non-T-cell non-B-cell lymphomas, which occurred in 21% of all patients, showed various chromosomal abnormalities. This study demonstrated that, in childhood NHL, karyotype correlates closely with immunophenotype, clinical features, and histologic findings.

[Clinical evaluation of severe toxicity in two patients with acute lymphoblastic leukemia receiving outpatient methotrexate therapy]

Methotrexate (MTX) is now widely used for the treatment of acute leukemia and non-Hodgkin lymphoma in the pediatric oncology field and is thought to be one of the key drugs for this treatment. A regimen utilizing high dose MTX (HD-MTX) with leucovorin rescue is being investigated as effective chemotherapy in the patients with these kinds of cancer. Relatively large amounts of MTX (225 mg/m2) are given to such outpatients by intravenous push as a course of maintenance therapy. It is said that those amounts will infuse safely. However, we experienced two serious cases-patients T.H. and M.Y.--which developed into severe side effects after this treatment. Both patients showed acute renal failure, severe myelosuppression, erosion around the oral and anal region, and continuous diarrhea. Judging from the serum concentration of MTX, patient T. H. was exposed to more than the maximum allowance serum MTX level for 9.6 days, patient M. Y. for 6.5 days. This suggests physicians must pay attention to the clinical symptoms even after treatment using MTX without HD-MTX.

[Cytogenetic studies on 53 childhood acute nonlymphocytic leukemia]

Cytogenetic study in 53 children (aged less than 15 years) with acute non-lymphocytic leukemia (ANLL) were studied. The cytogenetic findings were compared with those of ANLL patients (136 aged less than 19 years and 747 aged over 20 years) in the Fourth International Workshop on Chromosomes in Leukemia (IV IWCL) and also with those of childhood acute lymphoblastic leukemia (ALL) cases (previously reported as our 124 ALL case). Of the ANLL patients, 77.4% had acquired chromosomal clonal abnormalities. As abnormalities, t(15;17), all cases which were seen in M3 or M3V cases, t(8;21), which was seen in M1 or M2, and rearrangements of 11q23, which were seen in M5, were more frequently seen than was reported at the IV IWCL (20.8%, 17.0% and 7.5% vs 6.3%, 6.3% and 3.2% respectively). 5q-, monosomy 7, t(6;9) and t(9;22), which have been noted previously in this disease, were not seen. Besides structural abnormalities, some cytogenetic differences in numerical abnormality between ALL and ANLL were observed as follows: 1) Hyperdiploidy of greater than 51 chromosomes noted in ALL was not found in ANLL. 2) Isolated trisomy 8 was frequently found in ANLL, but not in ALL. 3) Loss of a sex chromosome was frequently found in ANLL, but not in ALL. Our study revealed a different frequency of non-random chromosome abnormality in children with ANLL as compared with that of adults, and clarified the differences in numerical abnormalities, as well as structural abnormalities, between ALL and ANLL.

Distinctive glycolipid patterns in Wilms' tumor and renal cell carcinoma

Glycolipid patterns were analysed chromatographically in Wilms' tumor and renal cell carcinoma tissues and compared with those of uninvolved tissue. Ganglioside GM3 was found to be increased in both cancer tissues, whereas sulfatides accumulated only in renal cell carcinoma, as reported earlier. Neolactotetraosylceramide was detected in both cancer tissues, but not in the uninvolved kidney tissues. In four cases of Wilms' tumors, only a low level of sulfotransferase towards galactosylceramide was found in one case, while no activity was detected in the three other cases. Present results show that the increased sulfatide(s) in the renal cell carcinoma and the deficiency of the sulfatides in Wilms' tumors appear to be biochemical characteristics of histologically different carcinomas.

[Significance of the 14q32 translocations in childhood acute lymphoblastic leukemia]

To assess the frequency and significance of 14q32 translocation abnormalities in childhood acute lymphoblastic leukemia (ALL) and the differences between the clinical and cytogenetic features of patients with the 8; 14 translocation and those of patients with other 14q32 translocations, we analyzed our experience with 124 consecutive cases with completely banded karyotype. Eight cases (6.5%) with 14q32 translocation were identified :5 with the 8; 14 translocation and 3 with other 14q32 translocations. As compared with ALL children lacking 14q32 translocations, these 8 cases had a higher serum lactic dehydrogenase (LDH) level, more L3 (FAB classification), and a poorer outcome. On the other hand, in comparison with ALL patients with other 14q32 translocations, patients with the 8:14 translocation were likely to be younger (median age 4.5 years vs 10.4 years), to have a higher serum LDH level (median 5832 IU/l vs 504 IU/l), to have more L3 (3/5 vs 0/3), to have a higher induction failure rate (4/5 vs 1/3), and to have more partial duplication of the long arm of chromosome 1 (4/5 vs 0/3). These results helped clarify the characteristic features of ALL children with 14q32 translocations and showed that ALL children with the 8 ; 14 translocation have different clinical and cytogenetic findings from those of ALL children with other 14q32 translocations.

[Transient abnormal myelopoiesis followed by acute leukemia in children with Down syndrome]

This report describes three cases with Down's syndrome. These cases initially had transient abnormal myelopoiesis (TAM), from which they recovered spontaneously. They finally developed into overt acute leukemia characterized by an increase of blasts, hepatosplenomegaly, and elevated lactic dehydrogenase. Of these three cases, one was thought to have ANLL, which broke out 5 months after spontaneous remission. The other two had ALL, each occurring 8 and 9 years later. Chromosomal abnormality, in addition to trisomy 21, was detected in blast cells from one of the patients with acute leukemia. All three patients with acute leukemia experienced complete remission. However, two of the three patients relapsed and died. It is noted in the literature that remission is permanent in most cases of TAM, and is rarely terminated by leukemic relapse. In view of our observations, the importance of following up on such patients who evidence apparent remission of their leukemia-like disorder is emphasized.

[Septicemia in children with malignant disease]

Severe infection is a major cause of morbidity and mortality in patients with malignancy. In this study, 34 episodes of septicemia occurred in 1,468 childhood patients with malignancy who admitted and were treated at National Sapporo Hospital between 1979 and 1988. The occurrence of septicemia and its mortality rate were higher in malignant hematologic disease than in malignant solid tumor. Most cases of septicemia occurred in relapse. The most frequent organism causing septicemia were Klebsiella pneumoniae (16.3%) and Staphylococcus epidermidis (16.3%). Septicemia due to Gram-negative organism was more frequent than that of Gram-positive organism or fungus. Polymicrobic septicemia occurred 3 times and multiple episodes 6 times. They had a high mortality rate. Neutropenia was strongly associated with episode of septicemia. In our series, absolute neutrophil count under 500 per microliter developed septicemia. Especially, children with less than 100 granulocytes per microliter had a major risk factor for the development of infection and death. No children with granulocyte count greater than 1000 per microliter died in connection with septicemia.

[Evaluation of the role of surgery in 25 patients with metastatic neuroblastoma]

The role of surgery was evaluated using a recently proposed TNM staging system in metastatic neuroblastomas. Of twenty-five patients, twenty-four were over 1 year, 1 case was 3 months old, nine were boys, sixteen were girls, and all were stage IV using Evans-D'Angio staging system (excluding IV-s). They were retrospectively assigned a TNM clinical stage (CS) preoperatively and a pathologic stage (PS) postoperatively. All twenty-five patients were CS 4 using this TNM staging system. The role of surgery was evaluated by analyzing survival according to the postoperative PS. PS 1-2-3A were regarded as satisfactory resections, since all macroscopic tumor was removed, while PS 3B-3C-4-5 were regarded as unsatisfactory resections. With Kaplan-Meier analysis, there was a slight survival advantage when satisfactory resection of the primary tumor was achieved in the cases with any evidence of metastasis at the time of operation. However, in the cases with no evidence of metastasis at operation, there was a survival advantage when satisfactory resection of the primary tumor was done (p = 0.05). If metastatic disease is controlled prior to operation, total resection improves prognosis of metastatic neuroblastoma.

Karyotypic changes from initial diagnosis to relapse in childhood acute leukemia

Cytogenetic study was performed at both diagnosis and relapse in 31 children with acute leukemia who had initially abnormal karyotypes, 21 with acute lymphocytic leukemia (ALL) and 10 with acute nonlymphocytic leukemia (ANLL). Seventy percent of the patients showed karyotypic changes between diagnosis and relapse. The ALL patients showed karyotypic changes more often than the ANLL patients (76 vs. 40%)(chi-square test, p less than 0.05). All the initially abnormal patients with karyotypic changes exhibited structural changes, most frequently chromosome 1 abnormalities, especially in ANLL, and 6q-, 7p-, 9p- in ALL. Half of the patients, with structural karyotypic change had two or more clonally related cell lines at relapse. On the other hand, only 20% of the patients with karyotypic changes showed numerical changes. All but one of the initially abnormal patients showed karyotypic changes involving the original cytogenetically abnormal clone. Our study demonstrated that sequential cytogenetic studies may provide a better understanding of the nature of leukemia relapse.

[Clinical and cytogenetic features in childhood acute lymphoblastic leukemia with 1; 19 translocation]

We studied the clinical and cytogenetic features of 14 acute lymphoblastic leukemia (ALL) patients with 1; 19 translocation. Ten patients had poor prognostic factors such as age over 10 years, hyperleukocytosis over 5 X 10(4)/microliters or high serum lactic dehydrogenase levels over 5,000 IU/l. Two patients had relapsed within 12 months after the onset, but their 5-year survival rate was 84.6%. Cytogenetically, 6 of 14 patients had multiple subclones. Two had the clones with hyperdiploidy greater than 50 chromosomes, which was known to be one of the favorable prognostic factors in childhood ALL. These findings show ALL children with 1; 19 translocation have a more favorable outcome in spite of some high-risk features than hitherto been thought.

[Hyperdiploidy (greater than 50 chromosomes) has the most favorable prognosis among the major karyotypic subgroups of childhood acute lymphoblastic leukemia]

Thirty-four children, including nine relapsed cases with acute lymphoblastic leukemia (ALL) having hyperdiploidy (greater than 50 chromosomes) were studied on clinical and cytogenetic characteristics. The majority of children initially with hyperdiploidy (greater than 50 chromosomes), who showed favorable prognostic features such as lower leukocyte counts, lower serum lactic dehydrogenase levels, ages between 2 and 10 years, or the presence of common ALL antigen, had the most favorable outcome among childhood ALL (5-year survival rate was 100%). Even nine children, who showed poor prognostic features such as ages over 10 years, leukocyte counts over 2 X 10(4)/mm3 or lymphomatous signs, had also the same favorable outcome. There were no differences in clinical features between 6 patients with additional chromosomal structural abnormalities and 19 patients without them. Duplication of the long arm of chromosome 1 was frequently observed as additional chromosomal structural abnormalities. Patients with hyperdiploidy (greater than 50 chromosomes) observed at relapse, who had the same favorable clinical features as those at diagnosis, had a poorer prognosis. These findings show that initial hyperdiploidy (greater than 50 chromosomes) is an independent favorable prognostic sign in childhood ALL and additional chromosomal structural abnormalities may not indicate a poor prognosis among childhood ALL with hyperdiploidy (greater than 50 chromosomes). On the other hand, relapsed children with hyperdiploidy (greater than 50 chromosomes) have not a favorable outcome after the onset of relapse.

[Clinical and laboratory studies in seven patients with pre-B cell leukemia in children]

We have experienced and treated seven patients of pre-B cell leukemia in childhood. Clinical, cytological and ultrastructural characteristics of them were studied. Most of them had higher counts of white blood cells, hepatosplenomegaly, high value of lactic dehydrogenase and various karyotype abnormalities at onset. The chromosomal translocation t (1; 19) that is supposed to be specific to pre-B cell ALL was found in four of seven of our cases. In the seven patients, survival was studied in comparison to that of 27 common ALL patients at our hospital that are common in childhood acute leukemia. Although no difference in remission duration and survival time between pre-B cell ALL patients and common ALL group, there have been seen the tendency that remission and survival were of shorter duration for patients with pre-B cell ALL.

[Cutaneous malignant lymphoma in childhood]

Two cases of malignant lymphoma in childhood were studied. The first case was a Japanese girl aged 8, in whom the primary site was skin of the right temple. The second case was a 4-year-old Japanese boy, who had metastases to the abdominal skin. Histochemical findings indicated B-cell lineage in both cases. Primary cutaneous lymphoma is extremely rare in childhood. Fourteen such cases that have been reported in Japan and our case added to them, were reviewed. The relationship between their morphologic, immunohistochemical and clinical findings were summarized and discussed. Although the prognosis of lymphoma confined to skin in childhood has been reported not to be bad as compared with other types of lymphoma, our first such case was fatal. This suggests that appropriate initial treatment is very important. Recent advances in science may clarify the clinical and biologic characteristics of this tumor in the near future.

Japanese experience of screening

In Sapporo City, the mass-screening for neuroblastoma concerning the urine of infants at about 6 months of age, started in 1981. After 1984, the quantitative determination of VMA, HVA in the urine was carried out using high performance liquid chromatography from the first step. About 104,000 babies have received the screening during the last 7 years, and 19 patients were found (incidence of detection 1:5,500). Except for one, who died of the duodenal perforation shortly after the surgery, all other patients are surviving free from disease. Among 10,000 neonates, we determined urinary concentration of VMA, HVA, and no positive cases were found. However, from this group, 2 patients we detected by the mass-screening at 6 months of age (1:5,000). After the start of mass-screening, the number of the patients with this tumor in much earlier stages and younger ages increased, clarifying that the main cause for improvement of the survival rates of neuroblastoma in Sapporo.

[BCR rearrangement and cytogenetic findings in Philadelphia-positive chronic myelocytic leukemia in children]

Eight children with Philadelphia (Ph1) chromosome positive chronic myelocytic leukemia (CML) were available for cytogenetic studies and breakpoint cluster region (bcr) rearrangement analysis as compared to the features of adults with Ph1-positive CML. In chronic phase additional abnormalities other than Ph1 chromosome were found in none of our cases. On the other hand, in blastic crisis all of 6 cases had additional chromosomal abnormalities like as i(17q), double Ph1 and +8. The frequency of the appearance of additional chromosomal abnormalities, especially i(17q), is higher in children than in adult cases. In the DNA of 7 of 7 examined patients, rearrangement of bcr could be demonstrated by Southern blot analysis. These findings were similar to those observed in adults. An analysis of the location of the bcr breakpoint indicated that 5' breakpoints were found in four cases who were long-term survivors, and two of the other cases had blastic crisis from the onset of the disease. These findings showed the cytogenetic findings of children with Ph1+CML were different from those of the adult cases in the frequency of the appearance of the additional chromosomal abnormalities, and the location of the bcr breakpoint in children cases might be different from that in the adult cases and influence its prognosis.

[BH-AC.AMP protocol in the treatment of refractory childhood acute leukemia]

Sixteen children with refractory hematological malignancies were treated with a combination of BH.AC, aclacinomycin-A, 6-MP and predonisolone (BH-AC.AMP protocol). They were ALL(6), ANLL(8), CML(1) and NHL(1). The CR ratio was 17% in ALL, 50% in ANLL, and blast crisis of CML was treated successfully but NHL failed in the induction remission. Major complications were vomiting, nausea, gastrointestinal bleeding, hematuria and hemorrhagic cystitis. More than 10 days or 120 mg/m2 administration of aclacinomycin-A was thought to induce more severe side effects.

Dimerization of neurokinin A and B COOH-terminal heptapeptide fragments enhanced the selectivity for tachykinin receptor subtypes

We have synthesized dimeric analogues of neurokinin A and B COOH-terminal heptapeptide fragments and evaluated their biological activities to contract isolated smooth muscle preparations of the guinea-pig ileum and rat vas deferens. The dimers were fairly active and showed two-fold increased selectivity for receptors in the guinea-pig ileum as compared with monomers. Extremely slow dissociation indicated a possible bivalent interaction between dimer and receptor.

[Therapy of advanced neuroblastoma by the protocol of the Welfare Ministry used by the Sawaguchi Group]

Five patients with advanced neuroblastoma were treated with the protocol of the Welfare Ministry used by the Sawaguchi group. This protocol consists of cyclophosphamide (CPM), vincristine (VCR), 4'-O-tetrahydropyranyladriamycin (THP-ADM) and cisplatinum (CDDP). Two patients treated with this protocol as the first therapy obtained partial remission. Two patients who had obtained complete remission before the treatment with this protocol remained in complete remission after the treatment. One patient who had shown poor response to the therapy given before treatment with this protocol also showed poor response to the protocol. The most significant side effect with this protocol was myelosuppression, the severity of which was closely related to the dose of THP-ADM. Damage to the liver, kidney and heart was not very significant. We advocate that patients with advanced neuroblastoma can obtain complete remission with the aid of surgery and radiotherapy, etc., if they are treated with the present protocol as the first therapy.

[Intra-arterial chemotherapy of soft tissue sarcoma in children]

As to the treatment of soft tissue tumor in children, we have performed intraarterial infusion chemotherapy in 3 children, two of whom had rhabdomyosarcoma and one of whom had infantile fibrosarcoma, at Sapporo National Hospital. The former two patients had large and unresectable solid tumor. In the latter case, an uncommon disease of childhood, local excision was considered while sacrificing a significant degree of function in the affected part. We describe here these three cases and the effectiveness of this therapy. Intraarterial chemotherapy reduced the tumor remarkably and facilitated second-look surgery. Although transient hematuria, slight articular contracture and vasculitis were observed in each case as side effects during the therapy, they were only minimal and tolerable. Unfortunately, one patient relapsed 6 months after surgery, but two patients are still in good health without recurrence. According to the results of our study, we believe that this method can be effective for controlling unresectable primary malignant soft tissue tumor.