A distinct cognitive profile in individuals with 3q29 deletion syndrome

BACKGROUND

3q29 deletion syndrome is associated with mild to moderate intellectual disability as well as comorbid psychopathology such as ADHD, anxiety, ASD and schizophrenia. A greater understanding of specific profiles that could increase risk for psychopathology is necessary in order to best understand and support individuals with 3q29 deletion syndrome. The goal of this study was to thus carefully outline the strengths and weaknesses of these individuals. A second goal was to ask whether the cognitive impact of the deletion predicted psychopathology in other domains.

METHODS

We systematically evaluated cognitive ability, adaptive behaviour and psychopathology in 32 individuals with the canonical 3q29 deletion using gold-standard instruments and a standardised phenotyping protocol.

RESULTS

Mean full scale IQ was 73 (range 40-99). Verbal subtest score (mean 80, range 31-106) was slightly higher and had a greater range than non-verbal subtest score (mean 75, range 53-98). Spatial ability was evaluated in a subset (n = 24) and was lower than verbal and non-verbal ability (mean 71, range 34-108). There was an average 14-point difference between verbal and non-verbal subset scores; 60% of the time the verbal subset score was higher than the non-verbal subset score. Study subjects with a verbal ability subtest score lower than the non-verbal subtest score were four times more likely to have a diagnosis of intellectual disability (suggestive, P value 0.07). The age at which a child first spoke two-word phrases was strongly associated with measures of verbal ability (P value 2.56e-07). Cognitive ability was correlated with adaptive behaviour measures (correlation 0.42, P value 0.02). However, although group means found equivalent scores, there was, on average, a 10-point gap between these skills (range -33 to 33), in either direction, in about 50% of the sample, suggesting that cognitive measures only partially inform adaptive ability. Cognitive ability scores did not have any significant relationship to cumulative burden of psychopathology nor to individual neurodevelopmental or psychiatric diagnoses.

CONCLUSIONS

Individuals with 3q29 deletion syndrome have a complex pattern of cognitive disability. Two-thirds of individuals with the deletion will exhibit significant strength in verbal ability; this may mask deficits in non-verbal reasoning, leading to an overestimation of overall ability. Deficits in verbal ability may be the driver of intellectual disability diagnosis. Cognitive ability is not a strong indicator of other neurodevelopmental or psychiatric impairment; thus, individuals with 3q29 deletion syndrome who exhibit IQ scores within the normal range should receive all recommended behavioural evaluations.

Long-term outcome of allogeneic or autologous haemopoietic cell transplantation for acute lymphoblastic leukaemia in second remission in children. GETMON experience 1983–1998

We present a retrospective study of long-term outcome and predictive factors of survival and relapse in 219 paediatric patients with acute lymphoblastic leukaemia (ALL) in second remission. They received allogeneic (allo) or autologous (auto) haemopoietic cell transplantation (HCT) depending on the availability of a matched sibling donor. The probability of event-free survival (EFS) for the total patient group was 0.35+0.03 at 14 years. No significant differences were observed for EFS between allo- and auto-HCT: 0.39+0.05 vs 0.32+0.04 (P=0.43). A better EFS was seen in patients with a late relapse (LR) (P=0.06 and 0.02, for allogeneic and autologous respectively). Significantly better EFS was observed in allo-HCT patients under 10 years of age and in auto-HCT patients with leukocytes at diagnosis below 25 x 109/l and late relapse. Predictive factors of failure in both groups were early relapse (ER), medullary relapse and age over 10 years. The probability of relapse (RP) for the total group of patients was 0.57+0.03, and it was significantly higher in auto-HCT patients: 0.65+0.04 vs 0.42+0.06 (P=0.002). Factors predictive for relapse were medullary and early relapse, auto-HCT and WBC >25 x 109/l at diagnosis.

Long-term results of high-dose chemotherapy and autologous stem cell rescue for high-risk neuroblastoma patients: a report of the Spanish working party for BMT in children (Getmon)

The authors retrospectively analyzed the long-term outcome of 67 patients over 1 year of age at diagnosis with high-risk neuroblastoma (stage 4 or stage 3 with N-myc amplification) who were treated with megatherapy and stem cell rescue from 1984 to 1998. Median age at transplant was 4 years (range 1.6-15 years). The source of cells was peripheral stem cells in 29 and bone marrow in 38 patients. In 12 patients, an in vitro purging of bone marrow harvest was performed. Most patients were conditioned with melphalan, BCNU, and VM-26. After transplant 19 patients received complementary treatment with IL-2 (16) or 13-cis-retinoic acid (3). Six patients (8%) died from transplant-related toxicity and 39 from disease progression. Three patients were alive with active disease at the time of analysis. Nineteen patients are alive and disease-free at a median follow-up of 104 months. Five-year event-free survival is 0.30. Survival of patients who received a purged graft was not significantly better than the rest. Post-transplant complementary treatment significantly improved overall and event-free survival (p = .01 and p = .04, respectively).

Matched-pair analysis comparing allogeneic PBPCT and BMT from HLA-identical relatives in childhood acute lymphoblastic leukemia

This multicenter study was designed to evaluate whether allo-PBPCT provides some advantages, if any, over BMT in terms of engraftment kinetics, acute and chronic GVHD incidence, TRM, relapse incidence and survival in acute lymphoblastic leukemia patients (ALL). From January 1995 to December 1999, 67 ALL patients (34 in the PBPCT group and 33 in the BMT group) were included in this study. Median age for both groups was 8 years (range, 1-18). There were 24 patients in first or second CR in the PBPCT group and 28 such patients in the BMT group. Preparatory regimens were TBI-based in 26/34 in the PBPC group and 25/33 in the BMT group. GVHD prophylaxis was CsA alone in 38 patients (18 PBPCT vs 20 BMT) and CsA plus short Mtx in 29 (16 PBPCT vs 13 BMT). Engraftment was achieved in all cases. Median days to neutrophil recovery was 10 (range, 7-18) after PBPCT vs 14 (range, 9-21) after BMT (P < 0.0001). Platelet engraftment (>50 x 10(9)/l) was also faster for PBPCT patients (median 13 days, range, 9-40 vs 23 days, range, 15-165) (P < 0.0001). Acute GVHD grade II-IV incidence was similar in both groups (46.4 +/- 8.8% vs 42.7 +/- 8.6%) (P = 0.45). Probability of chronic GVHD was 50.6 +/- 12.2% after PBPCT vs 27.8 +/- 9.2% after BMT (P = 0.1). Probability of relapse was similar (28.7 +/- 9.2% for PBPCT vs 27.1 +/- 8.2% for BMT) (P = 0.89). There were eight patients who died from transplant-related complications after PBPCT vs 5 after BMT (P, NS). With a median follow-up of 25 months the event-free survival probability was 53 +/- 8.9% for PBPCT vs 54.9 +/- 9.7% for BMT (P = 0.54). Using PBPC for allogeneic transplantation in childhood ALL results in faster hematopoietic recovery compared to BM, with a similar incidence of aGVHD, TRM, relapse and disease-free survival. However, the issue of cGVHD remains unresolved.

High survival rate in infant acute leukemia treated with early high-dose chemotherapy and stem-cell support. Groupo Español de Trasplante de Médula Osea en Niños

PURPOSE

Infants with acute leukemia have a poor prognosis when treated with conventional chemotherapy. It is still unknown if stem-cell transplantation (SCT) can improve the outcome of these patients. In the present study, we review our experience with SCT in infant acute leukemia to clarify this issue.

PATIENTS AND METHODS

We report the results of 26 infants who were submitted to a SCT for acute leukemia. There were 15 cases of acute myeloid leukemia and 10 cases of acute lymphoid leukemia. One patient had a bilineal leukemia. Twenty-two patients were in their first complete response (CR1), three were in their second CR, and one was in relapse. Eight patients were submitted to allogeneic SCT, and 18 underwent autologous SCT.

RESULTS

With a median follow-up of 67 months, the 5-year overall survival and disease-free survival (DFS) are 64% (SE = 9%) and 63% (SE = 10%), respectively. Autologous and allogeneic SCT offered similar outcome. There was not any transplant-related mortality, and all deaths were caused by relapse in the first 6 months after SCT. In multivariate analysis, the single factor associated with better DFS was an interval between CR1 and SCT of less than 4 months (P: <.025).

CONCLUSION

SCT is a valid option in the treatment of infant acute leukemia, and it may overcome the high risk of relapse with conventional chemotherapy showing very reduced toxicity. This study suggests that SCT should be performed in CR1 in the early phase of the disease.

[Evaluation of the quality of life of infants and very young children: validation of a questionnaire. Multicenter European study]

In the last few years, evaluating quality of life in children has become possible using specific instruments; nevertheless, there is still an unsolved issue concerning the earliest ages, when the child is not able to give his/her own opinion. QUALIN, a new instrument designed to assess an infant's quality of life (between the ages of three months and three years) was developed from the study of spontaneous criteria used by parents or caregivers (paediatricians or nurses) when they think about the quality of life of a baby (preliminary survey including 800 open-ended questionnaires).

PATIENTS AND METHODS

One thousand four hundred and twelve children under the age of three were included in this validation study. QUALIN questionnaire is a 34-item scale and can be completed by parents or caregivers. Two forms are available: one form is designed for children under the age of one and the other is designed for children between the ages of one and three. The QUALIN questionnaire was translated into English, Italian and Spanish, and a European multicentric validation study was conducted in Belgium, France, Italy, Luxembourg, Spain and Switzerland. Data were collected with QUALIN questionnaires from children's parents and paediatricians.

RESULTS

The psychometric properties of the scale are satisfactory (acceptability 90%, Cronbach's coefficient alpha over 0.75, correlations between two raters over 0.50, construct validity with principal component analysis showed emerging factors in agreement with the hypotheses linked to the questionnaire construction). The results are interesting, showing significant differences according to the health status of the children and their country of origin.

CONCLUSION

The QUALIN questionnaire can be used for studies concerning the quality of life of children less than three years of age.

Autologous stem cell transplantation for advanced Hodgkin's disease in children. Spanish group for BMT in children (GETMON), Spain

This study evaluates the outcome of myeloablative chemo-radiotherapy and autologous stem cell transplantation (ASCT) in children with Hodgkin's disease (HD). Twenty children aged 5 to 18 years (median 10.8 years) at diagnosis, with relapsed, refractory or very poor prognosis HD, underwent ASCT in eight hospitals of our country. Status at transplant was: second complete remission (CR2): n = 12; further CR (CR >2): n = 3, partial remission (PR): n = 2, relapse: n = 2 and first CR (CR1): n = 1. Eighteen patients received chemotherapy-based conditioning regimens: cyclophosphamide, carmustine and etoposide (CBV): 11 (55%), carmustine, etoposide, cytarabine and melphalan (BEAM): 5, other: 2; and two patients were conditioned with TBI/Cy. Peripheral blood (PB) was the source of progenitor cells in 12 patients, BM in seven, and BM plus PB, in one. All patients engrafted. One patient died of sepsis and multiorgan failure at day 28 after transplantation. All four patients with measurable disease (PR or relapse) at transplantation attained complete remission. Five patients relapsed 5-34 months after transplant (median: 11 months). Eighteen children remain alive with a median survival time of 40 months. The projected 5-year overall survival and event-free survival (EFS) rates were 0.95 and 0.62. High-dose therapy with stem cell rescue can lead to durable remissions in children with advanced HD. Bone Marrow Transplantation (2000) 25, 31-34.

Genetics of two mu opioid receptor gene (OPRM1) exon I polymorphisms: population studies, and allele frequencies in alcohol- and drug-dependent subjects

The gene encoding the mu opioid receptor, OPRM1, contains at least two polymorphisms affecting protein sequence in exon 1, Ala6Val and Asp40Asn. In previous studies, each variant has been reported to be associated with some form of drug dependence. Although past reports have not been consistent, they have also not considered comparable populations. The goals of the present study were to delineate allele and haplotype frequencies of these variants in a range of populations, and in drug- or alcohol-dependent subjects deriving from some of those populations. We developed new PCR-RFLP methods to detect both of these polymorphisms and studied them in control and substance-dependent populations of African American (AA), European American (EA) and Hispanic origin, and in a series of populations differing in geographic origin (Japanese, Ethiopians, Bedouins, and Ashkenazi Jews), 891 subjects overall. We designed primers flanking the DNA segment containing both polymorphisms, each primer creating a different artificial restriction site, such that a single PCR reaction can be completed, then divided, and the PCR product digested with either of two enzymes to reveal both polymorphisms. We found that allele frequencies for both polymorphic systems were significantly different between AA and EA subjects, and there was significant heterogeneity among the more extensive set of populations. Furthermore, there were no significant differences in allele frequency by diagnosis; that is, neither polymorphism appears to be a direct risk factor for substance dependence. Finally, we demonstrated linkage disequilibrium between the two exon 1 markers, and a previously described short tandem repeat (STR) marker.

Comparison of the classic Glucksberg criteria and the IBMTR Severity Index for grading acute graft-versus-host disease following HLA-identical sibling stem cell transplantation. International Bone Marrow Transplant Registry

Acute graft-versus-host disease (AGVHD) severity is usually graded (grades 0-IV) by the pattern of organ involvement using the classic Glucksberg-Seattle criteria (GSC). Recently, the International Bone Marrow Transplant Registry (IBMTR) developed a new Severity Index by regrouping the patterns of organ involvement into five Indexes (0-D) that appeared more predictive of transplant-related mortality (TRM) and transplant failure (TF, relapse or TRM). We studied the predictive value of both grading systems of TRM, TF and GVHD-related mortality (GTRM) in a series of 114 consecutive patients > or = 12 years old allografted from a histocompatible sibling at our institution, 100 of whom were evaluable for AGVHD. The IBMTR Severity Index showed better incremental prediction of TRM (relative risks (RR) of 1, 1.5, 1.4, 2 and 2.5 for Indexes 0, A, B, C and D), TF (RRs of 1, 1.6, 1.6, 2 and 2.3, respectively) and GTRM (RRs of 1, 2.2 and 4.8 for Indexes B, C and D) than the GSC. With the GSC different outcomes for TRM and TF were found only from grade 0 to I-II and 0 to IV or I-III to IV, but not from I-II to III. The GSC also appeared less predictive of GTRM (RRs of 1, 0.4 and 2.9 for grades II, III and IV). In our relatively small patient sample, the new IBMTR Severity Index appeared more predictive of transplant outcome than the GSC, especially between no AGVHD, early Indexes (A-B) and advanced Indexes (C-D).

Autologous bone marrow transplantation with monoclonal antibody purged marrow for children with acute lymphoblastic leukemia in second remission. Spanish Working Party for BMT in Children

The purpose of this study was to evaluate the outcome of children with acute lymphoid leukemia (ALL) in second remission who have undergone high-dose chemotherapy and radiotherapy and autologous bone marrow transplantation (ABMT) with monoclonal antibody purged marrow, and to determine the main prognostic factors. From 1987 to 1992, 55 children with ALL in second remission underwent ABMT. The conditioning regimen consisted of total body irradiation (TBI) plus cyclophosphamide in 21 patients and TBI plus cyclophosphamide plus cytarabine or VP-16 in 28 patients; the remaining six patients were treated with chemotherapy alone (cyclophosphamide and busulfan, and/or VP-16). The marrow was purged using monoclonal antibodies and complement or magnetic microspheres in all cases. All patients engrafted. Three patients (5%) died early post transplant from infections. Twenty-six patients (47%) relapsed (median 150 days); 26 patients (47%) are alive and in complete remission (CR) at a median of 36 months. The Kaplan-Meier estimation showed a probability of event-free survival (EFS) of 46 +/- 0.007%. In the univariate analysis, first CR length and conditioning with TBI plus two or more cytotoxic drugs were found to be the most significant predictors of EFS. ABMT with purged marrow is a treatment modality which offers a chance of cure in children with ALL after relapse, including children who relapse early.

Recombinant human erythropoietin (rh-Epo) administration to normal child bone marrow donors

We have evaluated the efficacy of administering recombinant human erythropoietin (rh-Epo) to 11 healthy bone marrow donors weighing less than 30 kg. Three weeks before harvesting, the donors received 100 units/kg/day rh-Epo subcutaneously and oral iron supplementation (2.5 mg/kg twice daily). Six children with hematocrit values below the normal ranges for their ages after bone marrow harvesting received 150 units/kg rh-Epo three times a week for 2 weeks and oral iron supplementation at the same dose. No rh-Epo side-effects were observed. Hematocrit values before harvesting increased to between 5.7 and 18.5 (mean 10.6 +/- 1.2) above the baseline values (P = 0.0001). Hematocrit after harvesting decreased to between 4 and 19.5% (mean, 11.1) below the day 0 pre-harvest values. On day + 15 all but one patient had a hematocrit value > or = baseline value. No patient required transfusion during or after bone marrow harvest. Our results show that rh-Epo administration can avoid transfusion and has no side-effects in low weight child bone marrow donors.

Quality of life in young adults having received a BMT during childhood: a GETMON study. Grupo Español de Trasplante de Médula Osea en el Niño

A quality-of-life questionnaire study was administered in a group of 98 disease-free survivors more than 3 years after BMT. All participants were over the age of 17 years at the time of the survey. The transplants were performed between 1981 and 1993 in eight Spanish hospitals. Eighty-three percent of patients had undergone BMT for neoplastic disease. Seventy-three per cent received an allogeneic bone marrow transplantation. A modified version of a questionnaire applied in Stanford Hospital to evaluate quality of life in adults after BMT was used. A single investigator was responsible for interviewing all subjects by telephone. We compare these results with the same questionnaire applied in a control group of 58 healthy subjects of similar age. The most significant results were: BMT patients valued their quality of life more highly than the control group. The mean score for global quality of life was 8.19+/-0.17 in BMT group as compared to 7.54+/-0.13 in control group (P=0.0013). Studies were cited as the major concern in both groups: 24% in BMT group and in 69% in control group (C.I. 95%=0.59 to 0.30). The patients in the BMT group considered they had fewer problems in comparison with the control group regarding interpersonal relationships with family members and friends, sleep, depression and leisure possibilities. However, they considered they had more problems concerning their physical appearance, studies and work possibilities than their peers. Considerations regarding weight, height, sexual functioning, anxiety, tendency to suffer illness and problems with insurance were similar in both groups.

Mutational analysis of p53 in 16 cases of acute lymphoblastic leukemia and Burkitt's lymphoma

BACKGROUND AND OBJECTIVE

Improvements in therapy for patients with B-cell acute lymphoblastic leukemia (ALL) and Burkitt's lymphoma (BL) depend on the identification of subsets of patients who require more intensive therapy. Abnormalities of the p53 gene are the most common molecular lesions in human cancer, and may be of prognostic significance in hematologic malignancies. In this study, we examined the p53 gene status in a group of patients with ALL/BL to determine whether some types of mutants were more frequent in this selected group of patients.

METHODS

We selected a group of 16 patients with acute lymphoblastic leukemia (ALL) and Burkitt's lymphoma (BL) in order to investigate the presence of p53 mutations. DNA obtained from affected organs (bone marrow, lymph node and a renal mass) was used for the molecular studies. Single-strand conformation polymorphism (SSCP) analysis of exons 5 to 9 of the gene was used to detect p53 mutants. After detecting an abnormal migration pattern on the SSCP, mutations were determined by direct sequencing.

RESULTS

Point mutations were found in eight patients; a misense mutation in seven cases and a non-sense mutation in one case. The normal allele was also identified in 7 mutated samples. The same mutation at codon 282 was identified in three different patients, in whom an identical conformer was detected after SSCP analysis. Mutation at codon 282 was present in an extramedular relapse (renal) appearing after a BMT. No such alteration was present in the bone marrow analyzed at the same time.

INTERPRETATION AND CONCLUSIONS

Our findings suggest that p53 mutations are quite frequent in recognized clinical groups. The criteria chosen in this study allowed us to identify a high percentage of the samples with mutation. Different malignant phenotypes could be determined by functional heterogeneity of p53 mutants.

Immunomagnetic bone marrow purging in children with acute lymphoblastic leukemia

Autologous bone marrow transplantation (ABMT) offers a therapeutic alternative for children with poor prognosis acute lymphoblastic leukemia (ALL) who lack an HLA-matched sibling donor. The most common cause of treatment failure after ABMT in these patients is leukemia relapse. We have developed an ex vivo autologous marrow purging program for children with ALL using an immunomagnetic method. BM purging has been performed in 37 children with ALL (31 B-lineage ALL and 6 T-lineage ALL) following an indirect method, using panels of mouse monoclonal antibodies (MAbs) directed against B or T cell antigens, Dynabeads M-450 (Dynal) coated with sheep antimouse (SAM) antibodies, and the MaxSep Magnetic Cell Separator (Baxter). Purging efficiency has been assessed by flow cytometry. Considering the limit of detection of target cells 0.1%, the median depletion was 2.0 log (range 0.8- > 2.8 log) for the B-lineage ALL and 2.7 (range 2.2- > 2, 9 log) for the T-lineage ALL patients. Twenty-seven patients have been autografted (6 in first complete remission, CR, 13 in second CR, and 8 in third or subsequent CR). Engraftment has been satisfactory in all of them, reaching levels of 500 neutrophils/mm3 and 20,000 platelets/mm3 after a median of 17 (range 12-39) and 30 (range 13-96) days post-ABMT, respectively. In summary, our results show that this immunomagnetic procedure achieves high levels of target cell depletion and can be safely applied to bone marrow purging in childhood ALL patients.

High-dose systemic interleukin-2 therapy in stage IV neuroblastoma for one year after autologous bone marrow transplantation: pilot study

Despite intensified chemotherapy protocols, including autologous bone marrow transplantation (ABMT), stage IV neuroblastoma has a poor prognosis, and modern therapeutic trends are aimed at the eradication of minimal residual disease, which is though to be the main factor leading to relapse. In this pilot study, we report the systemic administration of high doses of interleukin-2 after ABMT in four patients. Five day cycles of IL-2 at a dose of 18 x 10(6) IU/m2/day were administered at variable time intervals as frequent as it was necessary to maintain the levels of natural killer (NK) cytotoxic activity higher than the median control value (40 LU/ml blood) throughout 1 year from the start of first IL-2 treatment. After IL-2 infusion, NK and LAK activities increased significantly (median 742 x 10(-3) LU/ml blood and 186.8 x 10(-3) LU/ml blood, respectively). Toxicities were transient and no life-threatening complications were observed. Fever, anorexia, skin rash and enlarged liver were always present. Anaemia, thrombocytopenia, leukocytosis, lymphocytosis and and eosinophilia occurred following most of the IL-2 courses. Although the small number of patients does not allow an estimation of the immunomodulatory-antineoplasic effects of IL-2, the results seem promising for the management of neuroblastoma patients.

Interleukin-2 in neuroblastoma: clinical perspectives based on biological studies

Stage IV neuroblastoma (NB) is a disease with a poor prognosis. Chemotherapeutical intensification and hematological rescue with autologous bone marrow transplantation (ABMT) achieve some complete remissions (CR), but most patients relapse during the first year. Immunotherapy could be an alternative in this situation of high risk of relapse due to residual disease and ABMT-related immunodepression. Ten stage IV NB patients in CR or very good partial remission have been treated with recurrent 5-day cycles of high doses of Interleukin-2 (IL2) after ABMT throughout one year (usually 5-6 cycles). Natural killer (NK) and lymphokine-activated killer (LAK) cytotoxic activities, as well as phenotype and number of circulating NK cells were determined, before and after each course of IL2 treatment. The effects promoted by IL2 varied during treatment: early cycles of IL2 induced a great extent of cell expansion, mainly on CD3-/CD16-/CD56+bright and CD8+dim cell phenotypes; conversely, late courses of IL2 promoted higher NK cytotoxic activity but a lesser increase on circulating NK cells. The induction of LAK activity did not significantly differ from early and late IL2 treatments. Clinical results are still inconclusive due to the small number of patients. The median follow-up of patients treated with IL2 is 24 months and the disease free survival (DFS) probability is 0.80 +/- 0.12 vs 0.16 +/- 0.15 from a historical control with identical treatment, but in the absence of IL2 treatment (p < 0.005). IL2 treatment-related toxicity was mild and no interruption of the treatment was required. Extremely accurate hydric control was carried out to avoid, as much as possible, the consequences of vascular leak syndrome, one of the most important toxic effects of IL2 treatment. The results presented here suggest an evolution of NK activity during IL2 treatment after ABMT, which should be taken into account for the designing of new immunotherapeutical protocols and opens a promising perspective in treatment of stage IV neuroblastoma.

[Allogenic bone marrow transplantation versus autograft in acute lymphoblastic leukemia, in second remission in 113 children. Results of the Grupo Español de Transplante de Medula Niños (GETMON)]

PURPOSE

Using the data from the GETMON ("Grupo Español de Trasplante de Medula Osea en Niños") we carried out a retrospective analysis of the results of allogeneic bone marrow transplantation (alloBMT) compared to autologous bone marrow transplantation (ABMT) in 113 paediatric patients with acute lymphoblastic leukaemia (ALL) in second remission. Transplants were performed by the following centers, from April 1983 to December 1991: H. Vall d'Hebrón and H. Sant Pau from Barcelona, H. Ramón y Cajal and H. Niño Jesús from Madrid and H. Marqués de Valdecilla from Santander.

PATIENTS AND METHODS

The study included 113 patients between the ages of two and 16 years with ALL in second remission at marrow transplant. Fifty-six underwent alloBMT and 57 ABMT. Both groups were homogeneous with respect to age, sex, immunophenotype, duration of first remission, risk at diagnosis, percentage of early and late relapses, percentage with marrow or extramedullary relapse prior to transplant, time interval from attainment of second remission to transplant, and conditioning regimens applied for marrow transplant, with predominance of chemoradiotherapy in both.

RESULTS

Haematologic recovery was observed to be faster in alloBMT than in ABMT. A granulocyte count > 0.5 x 10(9)/l was reached in alloBMT patients in a median of 19 days and in ABMT patients in a median of 25 days (p < 0.001). Early procedure-related death after ABMT occurred only in one patient (1.75%) and was caused by hepatic veno-occlusive disease. In the alloBMT group, the incidence was 25%. GVHD and infection were the most common causes. Actuarial DFS for alloBMT was 38.8 +/- 6.7% at 8.5 years versus 29.2 +/- 6.5% at 4.5 years for ABMT, p = NS. No significant differences of actuarial DFS were found between alloBMT or ABMT in patients according to leukocyte count and risk at diagnosis, neither with first remission duration, nor with remission duration at transplant. A separate analysis of actuarial DFS for each group shows that in ABMT group DFS was significantly greater in patients who had presented a late relapse (> 30 months) 61.1 +/- 13.8%, than those who had presented an early relapse (< 30 months) 18.3 +/- 6.5% (p < 0.005). Probability of relapse was significantly greater in ABMT (70%) compared to alloBMT (46%) (p < 0.025). Transplant offers a better DFS in extramedullary relapses compared to isolated or combined bone marrow relapses: 71.4 +/- 17.1% with alloBMT and 38.1 +/- 14.7% with ABMT (p = NS).

CONCLUSIONS

In our experience we observed a better DFS with alloBMT compared with ABMT, overcoat in early relapses, but without significant difference. A higher relapse rate in ABMT group is partially compensated by more early deaths in alloBMT offers a few survival possibilities in patients with medullary relapses whose first remission lasted less than 30 months.

Feasibility and results of bone marrow transplantation after remission induction and intensification chemotherapy in de novo acute myeloid leukemia. Catalan Group for Bone Marrow Transplantation

PURPOSE

To evaluate prospectively the feasibility and results of bone marrow transplantation (BMT) after induction and intensification chemotherapy (CT) in patients with de novo acute myeloid leukemia (AML).

PATIENTS AND METHODS

A total of 159 patients less than 51 years of age were treated. Induction CT consisted of daunorubicin 60 mg/m2 for 3 days, cytarabine (ARA-C) 100mg/m2 for 7 days, and etoposide 100 mg/m2 for 3 days. The first intensification therapy included mitoxantrone 10 mg/m2 for 3 days and ARA-C 1.2 g/m2 every 12 hours for 4 days. Amsacrine (100 or 150 mg/m2 for 3 days) and ARA-C (1.2 g/m2 every 12 hours for 2 or 4 days) were given as the second intensification therapy. Depending on the availability of a human leukocyte antigen (HLA)-identical sibling, the intention of treatment after CT was allogeneic BMT (allo-BMT) or autologous BMT (ABMT).

RESULTS

Complete remission (CR) was obtained in 120 patients (75%) and partial remission (PR) in 11 (7%), while 15 patients (10%) were refractory and 13 (8%) died during induction. There was a trend for better leukemia-free survival (LFS) at 4 years for patients assigned to the ABMT group (50% +/- 6%) compared with the allo-BMT group (31% +/- 7%) (P = .08). This difference in LFS reached statistical significance when considering only transplanted patients (63% +/- 3% at 4 years after ABMT and 38% +/- 11% after allo-BMT, P = .02). The favorable results in patients who received ABMT (no toxic deaths and 37% +/- 7% probability of relapse at 4 years) contrast with the poor outcome of allografted patients (11 patients with transplant-related mortality).

CONCLUSION

Our study reflects the difficulties in the completion of a therapeutic strategy that include BMT and suggests that intensification before BMT may be useful in the setting of ABMT, but this approach was associated with a high mortality rate in allo-BMT patients.

Progression of natural immunity during one-year treatment of residual disease in neuroblastoma patients with high doses of interleukin-2 after autologous bone marrow transplantation

The aim of this work was to monitor the functional and phenotypic variations of natural killer (NK) cells in seven children with stage IV neuroblastoma (NB) treated with recurrent 5-day cycles of interleukin-2 (IL-2) at a dose of 18 x 10(6) IU/m2/d by continuous intravenous infusion. All patients who entered the study had no detectable disease after hematologic recovery from intensive chemotherapy and autologous bone marrow transplantation (ABMT). To evaluate the effect of this treatment on tumor relapse, IL-2 immunotherapy was adjusted to maintain levels of NK activity above those of age-matched controls (threshold of 40 lytic units [LU]/10(9) mononuclear cells) during a 1-year period since hematologic recovery of ABMT. The levels of NK and endogenous lymphokine-activated killer (eLAK) cell cytotoxic activities, as well as phenotype-differentiated lymphocyte counts, were determined from patients' freshly isolated peripheral blood mononuclear cells (MNC). Data were analyzed at different points between each cycle of IL-2, and before and 36 hours after each infusion. NK and eLAK activities significantly increased in response to IL-2. Both cytotoxic parameters correlated with the serum levels of the soluble IL-2 receptor (sIL-2R). IL-2 increased the amounts of NK and T cell subsets but not of B cells. The effects of IL-2 were time-dependent. Early cycles of IL-2 preferentially increased cell numbers, especially of cells bearing a CD3-/CD16-/CD56+bright and CD8+dim phenotype. Conversely, late courses promoted higher cytotoxic effects but with a smaller increase in NK and T cell counts; the main NK subset became CD16+, and CD8+dim cells remained a minor subset. It is worthy to note that the patient who relapsed after completing immunotherapy showed only a slight increase of the NK subset in response to IL-2. These results show the feasibility of sustaining an increased NK activity during 1 year after ABMT in children with advanced neuroblastoma and suggest the occurrence of changes in the functional and phenotypic characteristics of the NK cells generated throughout the 1-year treatment.

High-dose busulfan and melphalan before bone marrow transplantation for acute nonlymphoblastic leukemia

Fourteen patients with acute nonlymphoblastic leukemia (ANLL) (n = 13) or juvenile chronic myelomonocytic leukemia (n = 1) were transplanted after conditioning with high-dose busulfan (4 mg/kg daily on days -7 to -4) and melphalan (180 mg/m2 on day -2). This protocol was designed for patients considered unable to receive standard conditioning regimens with cyclophosphamide and/or TBI. Five patients (4 children and 1 adult) received a second allogeneic BMT in untreated early marrow relapse after a first BMT. There were 3 procedure-related deaths (PRD), 2 during aplasia and 1 from acute GVHD. Two patients survived the procedure; 1 relapsed at 6 months and 1 is alive at 43+ months. Nine subjects (8 children and 1 adult) received an autologous BMT, 7 in first and 2 in second complete remission (CR). Of the 7 patients grafted in first CR, there was 1 PRD, 2 relapses at 3 and 15 months, and four are alive at 38 to 82+ months. One patient grafted in second CR relapsed at 7 months and 1 is alive at 67+ months. Toxicities were mild or moderate in autologous BMT recipients, mainly affecting the gastrointestinal tract. In the allogeneic BMT group, there were more moderate to severe toxicities, including 3 cases of moderate-severe renal toxicity; no cases of such toxicity were seen in ABMT recipients. Two cases of HVOD occurred, 1 in each group. These results are encouraging, although the small patient group does not allow any firm conclusions.

Bone marrow transplantation in 46 pediatric patients with non-Hodgkin's lymphoma. Spanish Working Party for Bone Marrow Transplantation in Children

We report a retrospective analysis on 46 pediatric patients (median age 9 years, range 1-17 years) with non-Hodgkin's lymphoma (NHL), transplanted in six Spanish centers. Fourteen patients underwent allogeneic bone marrow transplantation (BMT) and 32 autologous BMT. Most patients were boys (36 of 46). Twenty one cases were of lymphoblastic lymphoma, 19 Burkitt's lymphoma and six diffuse large cell lymphoma. Maximal Murphy's stage any time before BMT was stage III in 17 cases and stage IV in 29 cases. At BMT, 13 cases were in first CR, 21 in second CR, seven in third CR, four with sensitive active disease and one with refractory disease. All patients transplanted in CRl were considered candidates for BMT because of delayed CR (two cases), failure of the first-line therapy (seven cases) or central nervous system (CNS) or BM infiltration at diagnosis (four cases). Conditioning therapy included TBI in 33 patients and 13 cases were conditioned with chemotherapy alone. Toxic mortality was 13% (three of 14 in the allogeneic BMT group and three of 32 in the autologous group). No toxic deaths were registered in 13 patients undergoing BMT in CR1 (three allogeneic BMT and ten autologous BMT). Twelve patients relapsed 1-7 months after BMT. Overall event-free survival (EFS) was 58% (42-73%; confidence interval (CI) 95%), with a median follow-up of 33 months. EFS was similar for allogeneic BMT and autologous patients. Disease status at BMT was the only predictive factor for EFS (P < 0.01). There were no significant differences between patients in CR1 (82.5%) and CR2 (68%).(ABSTRACT TRUNCATED AT 250 WORDS)

Second bone marrow transplantation for leukemia in untreated relapse

Seven patients with relapsed acute leukemia (4 ANLL, 3 ALL) and one with juvenile chronic myelomonocytic leukemia (JCMML) received a second BMT (BMT2). Patients were conditioned with CY/TBI (n = 7) or BU/CY (n = 1) for the first BMT (BMT1), with adequate recovery in all and without the appearance of acute GVHD (n = 3) or with mild forms (grade I, n = 2; grade II, n = 3). Relapse after BMT1 occurred in < 6 months (n = 2), between 6 and 12 months (n = 5) and > 12 months (n = 1), and the interval from BMT1 to BMT2 was < 6 months (n = 1), from 6 to 12 months (n = 5) or > 12 months (n = 2). Conditioning for BMT2 was done in untreated relapse and included combinations of BU/CY (n = 2), CY/TBI (n = 1) or BU 1 mg/kg at intervals of 6 h by mouth on days -7 to -4 and melphalan 180 mg/m2 i.v. on day -2, with the addition of VP-16 in the patient with JCMML. Two patients died on day +11 with no evidence of residual leukemia at autopsy. Six patients engrafted, one of whom had an uneventful BMT2, but he relapsed 6 months later. The other five developed severe acute GVHD (grades III-IV), with a fatal outcome in three cases, while two responded to treatment and are currently alive in continuous CR at 12 and 36 months. All patients had received conventional prophylaxis against acute GVHD.(ABSTRACT TRUNCATED AT 250 WORDS)

Hematological recovery after autologous bone marrow transplantation in acute leukemia: predictive factors

The kinetics of hematological recovery after autologous marrow transplantation have been studied in 70 patients with acute leukemia (38 acute nonlymphoblastic leukemia [ANNL] and 32 acute lymphoblastic leukemia [ALL]). The incidence of graft failure in this group was 3.2%, and a persistent severe thrombocytopenia was observed in 24% of the cases. Variables influencing engraftment have been studied using univariate and multivariate statistical analysis. Analysis of the entire group showed a correlation between graft colony-forming unit granulocyte-macrophage (CFU-GM) content and granulocyte recovery (p < 0.001). Marrow purging was associated with a delayed engraftment (p < 0.001). In ANLL patients, we found that high cummulated AraC doses before marrow cryopreservation correlated with poor granulocyte recovery after marrow infusion (p < 0.002). Platelet recovery was essentially affected by age, with shorter thrombocytopenia periods in younger patients (p < 0.001). Finally, excluding autotransplants with purged marrows, ALL patients showed better platelet recoveries than ANLL patients (p < 0.005). These findings will be useful to evaluate the risk of delayed engraftment after autologous bone marrow transplantation (ABMT) in patients with acute leukemia.

[Genitourinary rhabdomyosarcoma in childhood]

We present the result obtained by GICOP in the treatment of 12 genitourinary rhabdomyosarcoma, located in vagina-uterus (5), bladder-prostate (4) and paratesticular (3). The age of the patients ranging from 1 to 15 years. Embryonal rhabdomyosarcoma was the most common histologic type (58 for 100) being the major number of cases in stadium II. The treatment was based in the combination of chemotherapy protocolised with vincristine, d-actinomycin, cyclophosphamide (VAC), vincristine, adriamycin (VAC-VAD) and/or iphosphamide, vincristine, d-actinomycin (IVA), use of radiotherapy, marrow auto-transplantation and radical surgery avoidance. Complete remission was achieved in 11 out of 12 cases (92 for 100), relapsing in 5 cases (38 for 100) of which 4 (80 for 100) achieved a second remission. An 82 for 100 disease free survival was achieved in a 5 year period.

[Effectiveness of rectal metromidazole in acute infantile appendicitis]

Thirty two consecutive children who underwent surgery for suspected acute appendicitis, were treated with prophylactic metronidazole suppositories. A serum sample was taken at surgery to determine the serum concentration of the drug. After a preoperative dose of 15-20 mg/kg the minimal bactericidal concentration was achieved in almost all cases at the time of anesthetic induction. This drug showed an optimal biodisponibility when used rectally and no side-effects was noted. Neither a wound-infection, nor a wound-sepsis was reported and a satisfactory outcome was registered. We conclude that rectal dosing with metronidazole is effective for prophylactic wound infection in acute appendicitis.

Testicular pseudolymphoma

Pseudolymphomas are reactive processes which by their morphology can be confused with lymphomas. They have been described in non-lymphoid organs (gastrointestinal tract, lung, breast, etc.), although cases have also been reported in the spleen. In this article we present the case of a 3-year-old child in whom the location was in the testes. It is the 4th case reported in the literature and the first in a child. The main criteria for establishing such a diagnosis are the delimitation of the lesion, the presence of mature lymphocytes intermingled with other cells which are mainly plasma cells of polyclonal type and the formation of lymphoid follicles with active germinal centers. A differential diagnosis within the testicle should be made with the lymphoma (primary or secondary), the leukemic infiltration and the seminoma with marked stromal lymphoid reaction.

Evidence for a role of endogenous opioids in the nigrostriatal system: influence of naloxone and morphine on nigrostriatal dopaminergic supersensitivity

The effects of morphine and naloxone on nigrostriatal function were evaluated by their influence on rotational behavior in rats with unilateral lesions of the substantial nigra. Two different rotational syndromes which result from different lesion placements, were examined. Rats with the contraversive syndrome, when given apomorphine, rotate away from the lesioned side, while rats with the ipsiversive syndrome rotate toward the lesioned side. In both syndromes, rats rotate toward the lesioned side when given amphetamine. Morphine or naloxone, alone, was without effect in either syndrome. Morphine antagonized rotation by either apomorphine or amphetamine in both syndromes. Naloxone stimulated apomorphine-induced rotation in contraversive rats and antagonized amphetamine-induced rotation in ipsiversive rats. These findings support a functional role of endogenous opioids in this dopaminergic system. The effects of morphine and naloxone on apomorphine-induced rotation indicate that opiates act at a postsynaptic site in this system. Finally, the different responses to naloxone and morphine in the two rotational syndromes suggest that an enkephalinergic asymmetry may underlie the differences in behavioral responses between these two syndromes.

Primary liposarcoma of the right ventricle and pulmonary artery: surgical excision and replacement of the pulmonic valve by a Björk-Shiley tilting disc valve

A case of primary liposarcoma of the right ventricle and pulmonary artery is presented. The clinical picture, diagnostic studies, operative treatment and postoperative evolution are commented upon. Attention is drawn to the fact that this is the third case of liposarcoma of the heart to be operated upon, and the first needing pulmonary valve replacement. The literature related to this exceedingly rare primary neoplasm of the heart is reviewed.