Leukemia-associated skin infiltrates.
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Acute Disease↗
Biomedical subjects
M J Keating
Publications and source records attributed to M J Keating.
Mononuclear cell polyamine content associated with myeloid maturation in patients with leukemia during administration of polyamine inhibitors.
Fourteen patients with acute leukemia in relapse were treated with difluoromethylornithine (DFMO) alone or in combination with methylglyoxal-bis(guanylhydrazone) (MGBG) as part of Phase I studies. Five patients included in the trial exhibited morphologic evidence of cellular differentiation during the course of treatment. In one patient who exhibited no blasts and a normal white blood cell differential at the end of treatment the mononuclear cell content of all three polyamines declined after an initial increase in spermidine and spermine content. In the other patients in whom the cellular maturation was less pronounced the mononuclear cell polyamine levels remained stable or increased over the treatment time. No absolute difference was apparent between the cellular polyamine levels detected in patients at the times of the greatest increase in per cent circulating neutrophils as compared to the cellular levels present in patients whose circulating mononuclear cell number were increasing. Circulating mononuclear cell putrescine, spermidine, and spermine levels varied over two orders of magnitude from patient to patient and the range of values detected in each state completely overlapped those present in the other. It does not appear from the present study that there is a consistent human leukemic cell polyamine content at which cellular differentiation occurs.
Adolescent↗
Changing patterns of binocular visual connections in the intertectal system during development of the frog, Xenopus laevis. I. Normal maturational changes in response to changing binocular geometry.
During metamorphic and post-metamorphic life in the frog. Xenopus laevis, growth-related changes in skull shape produce radical alterations in the spatial relationship between the two eyes. These changes in binocular visual geometry were measured using optical techniques. Between the onset of metamorphic climax at stage 60 and adulthood (2 or more years post-metamorphosis) each eye migrates nasally by 55 degrees and dorsally by 50 degrees with respect to the major body axes of the animal. As a result the nasotemporal extent of the binocular visual field increases from 30 degrees to 162 degrees between these ages. Electrophysiological methods were used to determine changes in the neural representation of the binocular visual field at the paired midbrain optic tecta and in the tectal projection of pairs of corresponding retinal loci at various developmental points between these ages. The proportion of each tectal surface devoted to the representation of the binocular visual field increases from 11% at stage 60 to 77% at adulthood. Retinal correspondence, and hence the tectal projection of corresponding retinal loci, undergoes radical alteration during this period. In normal adults an intertectal system of connections selectively links the tectal projection of corresponding retinal loci and thus provides a neuronal mechanism for integrating binocular visual information in the optic tecta. Electrophysiological methods were used to determine how the intertectal system accommodates the developmental challenge posed by the enlarging binocular visual field and changing retinal correspondence. Between stage 60 and adulthood the ipsilateral visuotectal projection which is the product of the intertectal system, increases in size as the binocular visual field and its tectal representation enlarges. Moreover, throughout this period, it provides a mechanism for integrating binocular visual information in the optic tecta by maintaining its spatial registration with the contralateral visuotectal projection from the other eye. Analysis of the pattern of functional intertectal connections reveals that during the course of normal maturation this system undergoes continuous processes of expansion and of orderly and major remodelling.
Action Potentials↗
Changing patterns of binocular visual connections in the intertectal system during development of the frog, Xenopus laevis. II. Abnormalities following early visual deprivation.
During normal metamorphic and post-metamorphic growth of the frog, Xenopus laevis, there is a major and orderly remodelling of the pattern of neuronal connections in the intertectal system. These changes preserve the spatial registration of binocular visual inputs to each optic tectum in the face of continuous changes in relative eye alignment (Grant and Keating 1989). We suggested that visual experience might be utilised by the intertectal system to effect the maturational remodelling of its connections, with particular involvement in maintaining binocular visual registration. To investigate this suggestion we studied the development of the intertectal system in animals that had been reared in total darkness from before the onset of function in the system. Visual deprivation did not affect the developmental ocular migration that normally occurs in Xenopus, nor did it affect the maturation of the contralateral visuotectal projection. Abnormalities were, however, observed in the ipsilateral visuotectal projection of all dark-reared animals studied, reflecting perturbation of the underlying intertectal system. The abnormalities included disorder and deficits in the projection, which became more marked with age. Quantitative analyses of the spatial registration of binocular visual inputs to the optic tectum revealed that, in all dark-reared animals studied, registration was both significantly poorer and systematically shifted compared to normal controls. Analysis of maturational changes in the pattern of intertectal connections in visually-deprived animals led to the conclusion that intrinsic developmental processes generate an initially well-organised intertectal system and programme much of its continuous expansion with age. Visual experience, however, is necessary for the large scale and orderly remodelling of the system which, during normal maturation, preserves binocular visual registration despite changes in interocular alignment.
Action Potentials↗
5-bromodeoxyuridine (BUdR) quenching of acridine orange fluorescence distinguishes cycling and non-cycling normal and malignant bone marrow cells in vitro.
Suppression of the green fluorescence of acridine orange by 5-bromodeoxyuridine incorporation into cellular DNA was measured by flow cytometry. Bone marrow cells from normal volunteers and patients with chronic myelogenous leukemia acute lymphocytic leukemia acute myelogenous leukemia and multiple myeloma were incubated with BUdR in vitro. By 24 h acridine orange stained cycling cells that had synthesized DNA in the presence of BUdR were differentiated from quiescent cells as a second peak with quenched green fluorescence (DNA). After 72 h in culture 11-65% of the G0/G1 cells from normal bone marrows and bone marrows with myeloid leukemia were identified as cycling in culture by the presence of a second peak with quenched green fluorescence. A greater percentage of cells with BUdR quenched AO fluorescence was associated of acridine orange was higher in the cycling cells that had synthesized DNA in the presence of BUdR than in the non-cycling G0/G1 cells. In one patient with AML there was quenching of the DNA fluorescence of the aneuploid population but not the diploid population indicating that the aneuploid leukemia cells were proliferating. In contrast in patients with multiple myeloma, the quenched fluorescence of the diploid cell population and not the aneuploid cells, indicated that the diploid cells were proliferating. The cells from patients with untreated ALL failed to proliferation prohibiting an in vivo assessment of growth. Although measurements of proliferation obtained by this method are clearly influenced by the cell's adaptation to culture, measurement of BUdR quenching of acridine orange fluorescence is technically feasible and can identify and allow characterization of the cycling population of cells.
Acridine Orange↗
Intertriginous infections in adults receiving antileukemia chemotherapy.
Because intertriginous infections in patients receiving antileukemia chemotherapy may be life-threatening, all sites where skin contacts skin should be thoroughly examined daily. Early detection and immediate medical intervention designed to confine and cure the infection before it progresses to blood-borne dissemination of the infecting organisms are essential in these immunosuppressed patients.
Antineoplastic Agents↗
Patient-specific dose rate for continuous infusion high-dose cytarabine in relapsed acute myelogenous leukemia.
We hypothesized that the steady-state concentration of intracellular cytarabine 5'-triphosphate (ara-CTPss) in leukemia cells is proportional to the dose rate of cytarabine (ara-C) during continuous infusion. To evaluate this possibility, patients with acute myelogenous leukemia in relapse were treated with two sequential schedules of serially increasing ara-C dose rates over a total of 36 hours. Schedule I consisted of serial infusions of 250, 500, and 750 mg/m2 each over 12 hours. Subsequently, patients entered on schedule II received 500, 1,000, and 1,500 mg/m2 serially, each over 12 hours. Steady-state levels of ara-CTP were achieved within four hours after beginning ara-C infusion and, in separate studies of a single ara-C dose rate, were shown to be maintained beyond 36 hours. Four patients treated with schedule I and two patients treated with schedule II showed a linear dose rate-dependent increase-of ara-CTPss at all three dose rates. The cells of one patient on schedule I and two patients on schedule II had a dose rate-dependent ara-CTPss increase only over the first two dose levels, while no increase or lower ara-CTPss was observed at the third dose rate. The ara-CTPss of one patient on schedule II did not change. These results suggest that there is a proportionality between the continuous infusion dose rate of ara-C and the ara-CTPss in circulating leukemia cells within the dose range of 250 to 1,000 mg/m2 over 12 hours. This opens the possibility that pharmacologic determinations may be used to redirect the ara-C dose rate to achieve a desired ara-CTPss level in leukemia blasts during therapy.
Adult↗
Response to salvage therapy and survival after relapse in acute myelogenous leukemia.
The response to and survival following first salvage therapy regimens for 243 patients with acute myelogenous leukemia (AML) treated between 1974 and 1985 were evaluated. Eighty (33%) patients obtained a complete remission (CR), 24% died prior to achieving a response, and 43% were resistant on their first salvage regimen. The median survival was 18 weeks. Five percent overall and 16% of the CR patients are predicted to survive for more than 5 years. The factor most strongly associated with response and survival was the duration of the initial remission with 49 of 82 (60%) patients whose initial CR duration was at least 1 year in duration obtaining a second CR v 31 of 161 (19%) for patients with a shorter remission (P less than .01). Age, liver function, serum lactic dehydrogenase (LDH), karyotype, and the proportion of blasts plus promyelocytes present at the time of starting salvage therapy were strongly associated with probability of response and survival. Multivariate analysis was used to develop logistic regression and proportional hazard models to predict probability of response and survival, respectively. The major regimens used were conventional-dose cytarabine (ara-C) (combined with anthracyclines or amsacrine), high-dose ara-C, rubidazone, amsacrine (AMSA), other anthracyclines, and autologous or allogeneic transplant programs. After allowing for the prognostic factors in the models, specific treatment regimens were not strongly associated with prognosis.
Adult↗
Fludarabine: a new agent with major activity against chronic lymphocytic leukemia.
Fludarabine was used to treat 68 patients with previously treated chronic lymphocytic leukemia (CLL). Nine (13%) patients achieved a complete remission and 30 (44%) a partial remission. The response rates for Rai stages 0 to 2, 3, and 4 were 64%, 58%, and 50% respectively. Seventeen (43%) of the 40 Rai stage 1 to 3 patients and four (19%) of the Rai stage 4 patients returned to Rai stage 0. Survival was strongly correlated with the final Rai stage achieved. The survival of the 11 partial responders with residual disease consisting only of residual bone-marrow nodules was similar to the complete responders (36+ months) and superior to the other partial response patients (16 months). The response to fludarabine was rapid, with 36 (92%) of the 39 responders having achieved at least a partial response following the first three courses. Complete responses occurred in the blood, liver, spleen, and lymph nodes in 48% to 69% of the patients. Eradication of all disease in the bone marrow occurred in only 13% of the cases. Neutropenia and thrombocytopenia occurred in 56% and 25% of evaluable courses. Major infections occurred in 9% of evaluable courses and fevers of unknown origin or minor infections in 12% of courses respectively. Myelosuppression and infection were more common in patients with initial Rai stages 3 and 4 and in nonresponding patients. Other toxicity was mild. No CNS toxicity was noted.
Antimetabolites, Antineoplastic↗
Piperazinedione plus total body irradiation: an alternative preparative regimen for allogeneic bone marrow transplantation in advanced phases of chronic myelogenous leukemia.
Twenty-one patients with Philadelphia chromosome-positive chronic myelogenous leukemia (CML) in advanced phases were treated with piperazinedione (PIP), total body irradiation (TBI) and allogeneic bone marrow transplantation. Eleven were in blastic transformation, five were in accelerated phase, and five were in second chronic phase. The median age was 29 years (range, 13-41 years); there were 14 males. All patients but one were rendered aplastic by this regimen. Of these, 17 had hematologic engraftment, recovering granulocytes to 1.0 x 10(9)/l in a median of 28 days (range, 11-52 days). Three patients failed to engraft. Of those who engrafted, five relapsed and died of disease, one relapsed and died of a polymicrobial wound infection, nine patients died of treatment-related complications, including graft-versus-host disease, interstitial pneumonitis and sepsis, and one patient developed large-cell lymphoma 27 months after transplant and died of this 18 months later. One patient relapsed after 31 months died of polymicrobial sepsis at 37 months, and one patient remains disease-free at 54+ months. The 3-year survival rate was 14%. Survival at 1 year was related to having a spleen that did not extend beyond 2 cm below the left costal margin at the time of transplantation, and those with a large spleen at initial presentation relapsed more often. PIP-TBI with allogeneic bone marrow transplantation can induce durable remissions in a small proportion of patients in advanced phases of CML, but it is not superior to cyclophosphamide-TBI in this patient group.
Antineoplastic Combined Chemotherapy Protocols↗
Analysis of risk factors for fatal hemorrhage during induction therapy of patients with acute promyelocytic leukemia.
Acute promyelocytic leukemia (APL), an uncommon subtype of acute myelogenous leukemia (AML), has a high incidence of early hemorrhagic death during induction therapy; however, patients with APL surviving induction and obtaining complete remission have a good prognosis, with a longer remission duration than other subtypes of AML. We sought to determine if changes in selected clinical and laboratory coagulation parameters during induction therapy were significantly associated with fatal hemorrhage in that week, or were predictive of fatal hemorrhage in the following week. The first six weeks of induction therapy were studied in 65 patients, during which time 23 patients (35%) died from hemorrhagic complications. Time intervals analyzed were week 1, week 2, weeks 3 and 4, and weeks 5 and 6. There was no significant difference in the prevalence of severe hypofibrinogenemia (less than 150 mg%), prolongation of the prothrombin time (greater than 14 s), or presence of infection between patients who sustained fatal hemorrhage versus those who did not, for any given time period. The most significant parameter was the inability to obtain a posttransfusion platelet count of over 40,000/microliters in at least one half of the platelet transfusions administered in that week (p less than 0.001). This last parameter was the only variable that was also significantly associated with an increased risk of fatal hemorrhage for the following week (p less than 0.005). Clinical trials investigating management of coagulopathy in APL should evaluate the effect of therapy on response to platelet transfusion as well as on other laboratory parameters.
Adolescent↗
Prediction of survival during induction therapy in patients with newly diagnosed acute myeloblastic leukemia.
Among 569 patients with newly diagnosed AML, 16% died in the 4 weeks following initiation of remission induction therapy. Eight pretreatment characteristics were found to be independently associated with 4-week survival: performance status, bilirubin, age, neutrophil count, fibrinogen, albumin, hemoglobin, and creatinine. A model incorporating these characteristics prospectively stratified a separate group of 198 patients into two comparably sized groups differing substantially in both 4-week survival rates (71% (95% confidence limits, 61-80%) vs. 91% (95% confidence limits, 83-96%] and in survival rates throughout remission induction. Characteristics associated with failure to survive 4 weeks were unassociated with resistance to therapy. This suggests that patients who fail to survive induction are qualitatively different than patients who survive induction but exhibit resistance to treatment. Different therapeutic strategies might be appropriate in the two groups. The model presented here can be used to identify patients at increased risk of death during remission induction.
Adult↗
Treatment of the blastic phase of chronic myelogenous leukemia with mitoxantrone and high-dose cytosine arabinoside.
Twenty-seven patients in the blastic phase of chronic myelogenous leukemia received combination chemotherapy with mitoxantrone 5 mg/m2 intravenously daily for 5 days, and cytosine arabinoside 3 g/m2 intravenously over 2 hours every 12 hours for six doses. The patients' median age was 42 years (range, 19-61 years), and 26 of them had Philadelphia chromosome-positive disease. Overall, seven patients (26%) achieved complete remission, and one (4%) had a partial remission for an overall response rate of 30%. Eight patients died during remission induction, and 11 had resistant disease. The median survival was 14 weeks for the total population, and 24 weeks for patients achieving a complete remission. The nonmyelosuppressive toxicity of the combination was acceptable; serious neurologic and pulmonary toxicities were uncommon. Significant marrow hypoplasia was observed resulting in a high incidence of febrile episodes (85% of patients). The combination of mitoxantrone and high-dose cytosine arabinoside did not significantly improve overall prognosis. Since chemotherapy continues to produce disappointing results, other innovative approaches need to be explored.
Adult↗
Mitoxantrone and high-dose cytosine arabinoside in refractory acute myelogenous leukemia.
Forty-four patients with a diagnosis of refractory or relapsed acute myelogenous leukemia received salvage chemotherapy with high-dose cytosine arabinosine 3 g/m2 intravenously over 2 hours every 12 hours for six doses and mitoxantrone 5 mg/m2 intravenously daily for 5 days. Overall 16 patients (36%) had a complete remission; 16 patients (36%) had resistant disease; and 12 (27%) died during induction therapy. The most significant predictive factor for remission was the duration of first remission: the response rate was 17% for patients whose first remission duration was shorter than 12 months (including those who did not achieve a first remission), 45% for those with a first remission lasting between 12 to 18 months, and 69% for those with longer remission durations (P = 0.008). Other predictive factors for higher response rates were a younger age group, a good performance status, and a favorable or diploid karyotype. The median survival from start of therapy was 4 months for the total population and 10 months for patients with remission. Serious side effects including pulmonary toxicity and neurotoxicity occurred in less than 10% of patients. This incidence was significantly lower than previous high-dose cytosine arabinoside schedules of 3 g/m2 for nine to 12 doses (total dose, 27 to 36 g per course). Significant granulocytopenia and thrombocytopenia were universal resulting in fever or documented infections in 98% of patients. We conclude that the combination of high-dose cytosine arabinoside and mitoxantrone is an effective antileukemic regimen with acceptable toxicity. Future studies should incorporate it as part of the frontline induction or maintenance strategies in newly diagnosed patients with acute myelogenous leukemia.
Adolescent↗
Characteristics of accelerated disease in chronic myelogenous leukemia.
Determination of the characteristics of accelerated disease in chronic myelogenous leukemia (CML) helps in individual prognostication, and in the introduction and analysis of investigative approaches based on risk-benefit ratios. The outcome of 357 patients with Philadelphia chromosome-positive CML was analysed from the time of development of suspected features of accelerated disease. Median survivals shorter than 18 months were associated with the appearance of any of the following: cytogenetic clonal evolution; extramedullary disease; peripheral blasts greater than or equal to 15%, peripheral blasts and promyelocytes greater than or equal to 30%, or peripheral basophils greater than or equal to 20%; platelet count less than 1.0 X 10(5)/microliters; marrow blasts greater than or equal to 15%, marrow blasts and promyelocytes greater than or equal to 30%, or marrow basophils greater than or equal to 20%. Relative hazard ratios, or risk of death per unit time, were calculated based on the relative survivals of patients who did or did not develop the particular feature of accelerated disease, after accounting for the time to development of the characteristic. Further analysis identified five features that have additive independent prognostic importance: cytogenetic clonal evolution; peripheral blasts greater than or equal to 15%; peripheral basophils greater than or equal to 20%; peripheral blasts and promyelocytes greater than or equal to 30%; and thrombocytopenia. By providing an objective estimate of prognosis in accelerated disease, the model identifies patients in need of different therapeutic interventions before the development of blastic crisis.
Follow-Up Studies↗
Alterations in bone marrow and blood mononuclear cell polyamine and methylglyoxal bis(guanylhydrazone) levels: phase I evaluation of alpha-difluoromethylornithine and methylglyoxal bis(guanylhydrazone) treatment of human hematological malignancies.
Nine patients with hematological malignancies were treated with difluoromethylornithine and methylglyoxal bis(guanylhydrazone). The number of circulating blast cells decreased in all of the patients treated with DFMO and MGBG for longer than 1 wk. Morphological evidence of myeloid maturation was evident in four patients with leukemia and the circulating M Protein decreased in one patient with multiple myeloma. The polyamine content of the mononuclear cells in both the peripheral blood and bone marrow was transiently increased after the initial MGBG dose. During administration of DFMO decreases were achieved in the peripheral blood mononuclear cell putrescine levels in 7 patients, spermidine levels in 5 patients, and spermine levels in 4 patients. Alterations in bone marrow mononuclear cell polyamine levels were similar to those which occurred in the peripheral cells. An average of 9 days of DFMO treatment was required to lower mononuclear cell polyamine levels. Three of the 4 evaluable patients receiving multiple MGBG doses had an increased mononuclear cell content of MGBG after DFMO pretreatment. Enhancement of cellular MGBG levels was not directly correlated to the degree of cellular polyamine depletion.
Adult↗
Acute myeloblastic leukemia with hyperleukocytosis: risk factors for early mortality in induction.
Eighty-five patients with acute myeloblastic leukemia (AML) presenting with hyperleukocytosis (HL) were analyzed to assess morbidity and mortality in early induction. Patients who failed to achieve remission were older and more often had pulmonary leukostasis (62% vs 23%, p = .01) and hepatomegaly (54% vs 31%, p = .06) at presentation. Thirty-seven patients (44%) did not achieve complete remission (CR); 17 (54%) died early in induction therapy, 11 directly as a result of pulmonary hemorrhage with respiratory failure, while 5 had both pulmonary hemorrhage with respiratory failure and CNS hemorrhage. Early death patients were older and more often had pulmonary leukostasis (88% vs 29%, p less than .0001), hepatomegaly (71% vs 34%, p = .01), hyperbilirubinemia (60% vs 16%, p = .01) and hypofibrinogenemia (47% vs 12%, p less than .01) at presentation. Primarily for technical reasons, preinduction leukapheresis was not employed as often in this very-high-risk group as in other patients (56% vs 82%, respectively). Thus, sufficient heterogeneity exists in patients presenting with HL to define a subset of patients at particularly high risk for early mortality. Preinduction leukapheresis applied in a prospective controlled fashion should be evaluated to assess if such treatment may decrease early mortality in this group.
Adolescent↗
Guidelines for clinical protocols for chronic lymphocytic leukemia: recommendations of the National Cancer Institute-sponsored working group.
The National Cancer Institute (NCI)-sponsored Chronic Lymphocytic Leukemia (CLL) Working Group was convened to develop a set of standardized eligibility, response, and toxicity criteria for clinical trials. We recognized the previous efforts in 1967 (published again in 1973 as the report of the Chronic Leukemia-Myeloma Task Force [1] and 1978 of Cancer and Leukemia Group B (CALGB) [2]). We have used these reports for guidance during the current effort. Several noteworthy developments in the past few years have made it necessary to modify the previous guidelines. First, the diagnostic criteria for CLL and its clinical staging have been developed and well defined. Second, although staging systems facilitated entry of comparable and relatively homogeneous groups of patients in clinical trials, the definitions of response (CR) and partial response (PR) were not uniformly adopted from the previous guidelines in the clinical trials (Tables IA, IB); therefore, comparisons of results obtained in different studies became difficult. Third, there has been an improvement in our understanding of the immunology and biology of CLL. Finally, we are witnessing the emergence of several chemotherapy agents that promise impressive activity in CLL (e.g., 2'-deoxycoformycin [3], fludarabine monophosphate [4, 5]), and thereby offer the potential for improving survival time in this disease. To best identify regimens worthy of continued pursuit in large comparative trials, standardized guidelines for evaluation are essential. A number of laboratory investigations are also presented for which scientific interest is high yet relevance remains to be determined; thus, they are presented as companion studies to the clinical trials. This mechanism allows for flexibility in the testing of these questions and for additional ideas in the future without requiring modification of an entire treatment protocol. The following guidelines were developed to be used as a form of standardization for clinical trials, incorporating current technologies, yet remaining relevant to the general hematology/oncology community. Based on the membership of the Working Group, it is expected that these guidelines will serve as the criteria for most clinical trials in the near future.
Antineoplastic Agents↗