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[Factors determining the prognosis of leukemia].

The prognostic factors of acute leukemia in children are described. The maintenance of the first complete remission is the principal aim of treatment. Initial high leucocyte counts over 50 x 10(9)/l and leukemic infiltration of the central nervous system and the testis are poor prognostic signs. The morphological classification of acute lymphoblastic leukemia versus acute non-lymphoblastic leukemia is more important than the differentiation in lymphoblastic types. Immunological characterisation as a B-cell leukemia seems to hold a poor prognosis. Cell replication rate, chromosomal studies and HLA typing are of growing importance but should not influence the choice of therapy at this moment. Sex, race and age of onset are factors, reported to be of importance, are worth to be studied more intensively in connection to the other factors. The quality of the results in trials and in different centres urge to a multi-variate analysis of the data in order to prevent unreliable conclusions.

Age Factors↗

[Chronic myeloid leukemia and periurethral adenoma].

Dysectatic disturbances in leukemia patients can be determined by leukemic infiltration of the prosthate or by the evolution of a co-existing peri-urethral adenoma. Indications and results of physiotherapy and surgery are evaluated in connection with an observation of peri-urethral adenoma in a patient with chronic myeloid leukemia.

Humans↗

[Hepatic biopsy in acute leukemia].

In 25 patients with acute leukemia that presented chantes in liver function tests, 29 liver biopsies were done by percutaneous needle or peritoneoscopy and directed needle, to determine the nature of the lesion. In one case leukemic infiltration was found; 16 patients showed nonspecific lesions, one, granulomatous hepatitis, one, viral hepatitis; one showed no changes in the biopsy. In these twenty cases the treatment was not modified, the survival time was from 15 to 57 months (median 25 months), and 14 an still in remission. Five patients (20%) showed drug-induced hepatitis; in these it was necessary to modify to chemotherapy, the survival time in four cases was 2 to 9.6 months (median 4.8 months) and one is still in remission after 36 months of treatment. It is concluded that hepatic biopsy may be very useful in evaluating the undesirable effects of treatment of acute leukemia and in making therapeutic decisions. The risks of this procedure and the contraindications are similar in patients with acute leukemia and those with other diseases.

Acute Disease↗

[Extraintestinal salmonellosis in patients with blood diseases caused by Salmonella enteritidis].

Four cases of extraintestinal salmonellosis caused by Salmonella enteritidis were described. Underlying diseases in the three patients were haematological neoplasms (2 splenectomized and 1 with massive leukemic infiltrations of the spleen) and in the fourth haemophilia B: only that patient had a prior symptomatic intestinal infection. Blood cultures for S.ent. were positive in all patients and additionally in that suffering from Hodgkin's disease urine, lymph node and stool cultures also showed S.ent. In the haemophiliac patient culture of suppurated hematoma was positive. All patients recovered from S. sepsis but three then died of their neoplastic diseases. The haemophiliac patient is in a good condition. Various disturbances in the immunological tests were observed.

Adolescent↗

[Simultaneous bilateral facial paralysis].

Simultaneous bilateral facial paralysis (SBFP) is very rare, but it can present itself as the first complaint in a wide spectrum of diseases and a comprehensive evaluation must be completed. Bilateral Bell's Palsy can be diagnosed only when all other possible causes have been excluded. The prognosis and treatment for SBFP is dependent upon the underlying etiology. We present four cases of SBFP seen in our department which were finally diagnosed as leukemic infiltration, sarcoidosis, Bell's Palsy and demyelinating polyneuropathy (probably Guillain-Barré syndrome). The most important etiologies of the SBFP and the management of this entity are discussed.

Adult↗

The spectrum of cutaneous lesions in pediatric patients with leukemia.

This is a clinical study that attempts to determine the incidence and patterns of cutaneous lesions in 109 pediatric patients with leukemia. Non-specific lesions, namely, adverse reactions to chemotherapy, complications of immunosuppression, and hemorrhagic diathesis were seen in 88.7% of those patients with acute lymphocytic leukemia and in 88.9% of patients with acute non-lymphocytic leukemia. Leukemia cutis was seen in three patients with acute non-lymphocytic leukemia, and in one patient with congenital leukemia. It seems that although skin complications are a frequent event in the course of childhood leukemia, leukemic infiltration of the skin a is rare event.

Adolescent↗

Terminal deoxynucleotidyl transferase staining of malignant lymphomas in paraffin sections.

Terminal deoxynucleotidyl transferase (TdT) represents a useful marker for the diagnosis of acute lymphoblastic leukemia and lymphoblastic lymphoma. It is usually assayed in fresh tissue or cell suspensions by enzyme analysis, immunofluorescence, or immunoperoxidase. We have obtained satisfactory staining for TdT in routinely processed paraffin sections using a recently described antigen retrieval pretreatment based on microwave oven heating of the sections and a polyclonal rabbit anti-TdT serum. With this technique, we assayed paraffin sections from lymph nodes of 91 patients with a variety of malignant lymphomas, including 35 cases of lymphoblastic lymphoma. The specificity of this immunoperoxidase method of TdT analysis was confirmed by comparing the results obtained with conventional TdT analysis by indirect immunofluorescence. Neoplastic cells from 33 of the 35 (94%) patients with lymphoblastic lymphoma were TdT positive with both techniques. All remaining 50 cases of other subtypes of malignant lymphoma were TdT negative. Specificity was further confirmed by demonstrating TdT-positive blasts in paraffin sections of bone marrow biopsies from 44 patients with TdT-positive (by indirect immunofluorescence) acute leukemias and in paraffin sections of extramedullary leukemic infiltrates from eight patients with relapsed acute lymphoblastic leukemia. Other control material studied included eight lymph nodes with Hodgkin's disease, four normal spleen, seven reactive lymph nodes, and 25 nonneoplastic bone marrow samples, all of which gave the expected results, i.e., rare scattered TdT-positive cells in bone marrow and lymph nodes, absence of staining in Hodgkin's disease malignant cells and spleen. Our results confirm that TdT is a specific marker for the diagnosis and classification of lymphoblastic lymphoma.(ABSTRACT TRUNCATED AT 250 WORDS)

DNA Nucleotidylexotransferase↗

Experimental model for MDS-like myelodysplasia in transgenic mice harboring the SV40 large-T antigen under an immunoglobulin enhancer.

The SV40 large T gene under the control of immunoglobulin enhancer induced hyperproliferation of multi-lineage hematopoiesis in transgenic mice. Hence the disease has been considered to be an appropriate experimental model for MDS-like myelodysplasia, sequential pathological changes in the development of the disease are introduced in the report. Huge splenomegaly was the major gross abnormality, which developed with 100% frequency; neither hepato-renal, nor other thymico-lymphatic involvement was common. During the progressive increase in splenic weight, extensive proliferation of multi-lineage hemopoiesis was prominent, although no differences were apparent in the cellular proportions of each hematopoietic element compared with normal spleens, either in flow-cytometric analysis using markers for each subset of hematopoietic elements, or in the histological findings. In the later phases of the disease, the proliferating cell type tended to shift to a variety of single to oligo-lineage hemopoiesis, but the majority of mice still showed the presence of multi-lineage hemopoiesis; histologically, such hemopoiesis was somewhat dysplastic, but had no apparent nature of leukemic infiltration. Several transplantation-assays essentially supported the low neoplastic potential of proliferating cells even in later phase. A long-term observation was made aiming to induce more frequent transition of this abnormal hemopoiesis into a single-lineage neoplasm by transplantation of pre-onset spleen cells, as well as bone-marrow cells from transgenic mice at an early phase of the disease, into lethally irradiated C57BL/6 mice. This trial resulted in a variety of neoplastic growths in the recipients; not only was myelodysplastic hypercellularity seen, but also, single-lineage hemopoietic malignancies, such as B-cell lymphomas/leukemias, histiocytic malignancies, and even myeloid leukemias. The transition from multi-lineage myelodysplasia into single lineage hemopoiesis at some frequency is reminiscent of myelodysplastic syndromes (MDS) in humans. Higher frequency of transition into lymphoid malignancies may be due partly to the immunoglobulin enhancer used as a promoter unit. The results that the SV40 large T antigen was expressed in every proliferating cells, there was no apparent increase in multi-CSFs activity; together with the results of the transplantation assays suggest that the hyperproliferation of the cells is directly induced by the expression of SV40 large T antigen in the hemopoietic cells themselves.

Animals↗

[Prolymphocytic B-cell leukemia with fatal acute liver failure. A case report].

Prolymphocytic leukemia (LPL) is a well defined entity with a relatively low incidence in our country. This disease usually is seen in patients over 50 years of age, and there is a very definite male preponderance. This lymphoproliferative disorder is characterized by very high white cells counts, massive splenomegaly, poor response to therapy and short term survival. The neoplastic cell in prolymphocytic leukemia usually is of B-cell origin (80% of cases). In our patient, affected by B-lineage prolymphocytic leukemia, a acute hepatic failure occurred, leading him to death in a short time. Autoptic findings evidenced a massive leukemic infiltration of the liver with parenchymal necrosis that caused fatal hepatic failure. Autoptic findings did not show histological patterns of acute viral infections or of any other infectious or systemic disease which could have induced a so massive liver injury. In literature there are no evidences of such a massive and lethal involvement of the liver during prolymphocytic leukemia or chronic lymphocytic leukemia and patients affected by LPL generally come to death because of other causes.

Diagnosis, Differential↗

[Macro-orchidism: new pathogenetic and histopathologic aspects].

Macro-orchidism (MO) is the increase of the testicular volume, up to 25 ml in the adult male. It is frequently associated with mental retardation (MR) with fragile X-chromosome (FXC) (Martin-Bell syndrome). Sometimes it is of unknown origin and is called "benign idiopathic macro-orchidism" (BIMO). MO has also been described in association with bilateral testicular tumors, idiopathic precocious puberty, juvenile hypothyroidism and, more rarely, with congenital testicular cysts (cystic testicular dysplasia) and testicular microlithiasis in a patient treated with GH. The most common presentation is MR associated with MO, with positive or negative FXC. Among MO with MR and FXC-marfanoid habitus patients have been described and in the Atkin-Flaitz syndrome patients. Management of MO must be conservative in all cases and testicular biopsy must only be performed to diagnose leukemic infiltration or carcinoma in situ (CIS), or as the last fertility diagnostic test in BIMO. A wide range of primary testicular lesions may histopathologically be found: preserved spermatogenesis tubes, only Sertoli cell pattern and complete tubular sclerosis. Interstitial edema, frequently implicated in the MO pathogeny, does not explain by itself the important increase in testicular volume. In our laboratory, we have demonstrated that the increment of the testicular volume in MO is associated with a significant increase in the length of the seminiferous tubules. MO may pathogenically be intimately related to some hormonal regulation mechanism or to a higher seminiferous tubule sensitivity to FSH.

Diagnosis, Differential↗

Gonadal stromal tumors, gonadoblastomas, epidermoid cysts, and secondary tumors of the testis in children.

Gonadal stromal tumors generally are benign and hormonally silent. When hormonally active, they may cause either virilization or feminization, posing an endocrine threat to the prepubertal boy. Accurate diagnosis is essential to differentiate those tumors that require medical management from those best treated by surgical ablation and to distinguish the benign ones from the malignant. Leukemic infiltration is the most common secondary testis tumor; others are neuroblastoma, Wilms' tumor, and gonadoblastoma.

Child↗

Demyelinating neuropathy and acute lymphocytic leukemia.

We report a 67-year-old man with acute lymphocytic leukemia (ALL) who developed a rapidly progressive areflexic quadriparesis following chemotherapy. Electrophysiologic studies demonstrated an acute demyelinating polyneuropathy. Although peripheral nervous system dysfunction in ALL is often attributed to leukemic infiltration or chemotherapy, a diligent search with electrophysiologic evaluation should be considered and may suggest alternative diagnoses.

Action Potentials↗

[Testicular and paratesticular tumors in children].

Testis tumors in children occur infrequently and exibit differences in their histopathology, clinical behaviour and therapy from their adult counterparts. From 1979 to 1994, 17 children and adolescent with testicular tumors were treated at the Pediatric Surgical Department of Vicenza Regional Hospital. Paratesticular rabdomiosarcoma were present in 3 cases, 4 patients had embrional carcinoma, 1 Sertoli cell tumor, 2 Leydig cell gonadal stromal tumor, and leukemic infiltrates of the testis were clinically evident in 7 patients. We report our clinical series and discuss in relation to clinical characteristic, histopathology and therapy and conclude that the improved survival during the past decade is attributable to better diagnostic imaging thecniques, the availability of serum tumor markers to monitor disease activity and more effective chemotherapy.

Adolescent↗

[Non-sarcomatous bilateral exophthalmos disclosing acute myeloblastic leukemia in children].

The authors report a bilateral exophthalmos due to a leukemic infiltration of the orbital lacrimal glands during an acute myeloblastic leukemia in a ten-year-old boy. This rare orbital localization revealed the leukemia. It was not a granulocytic sarcoma. Its importance leads to the extraction of the lacrimal glands in order to prevent the eyes from corneal perforation.

Child↗

Clinical and laboratory studies of 2-chlorodeoxyadenosine +/- cytosine arabinoside for relapsed or refractory acute myelogenous leukemia in adults.

Previous studies in pediatric patients with acute myelogenous leukemia (AML) have suggested that 2-chlorodeoxyadenosine (2CdA) is an effective therapeutic agent. Santana et al (J Clin Oncol 1992; 10: 364-370) reported a CR rate of 8/17 (95% Cl 23-72%) in children with relapsed AML and a median first CR of 21 months. The activity of 2CdA in adults with relapsed or refractory leukemia was therefore investigated in a phase I study. In the phase II study, based on biochemical modulation rationale, 2CdA was combined with Ara-C for adults with relapsed AML to test the effectiveness of this combination therapy. In the phase I study 27 patients (25 AML and two MDS) with a median first CR duration of 21 weeks, received 2CdA at doses ranging from 5 to 13 mg/m2/day by continuous infusion (CI) for 7 days. In vitro and ex vivo pharmacologic studies performed to determine the effect of pretreatment with 2CdA on Ara-CTP accumulation in leukemic blasts demonstrated a 50-65% increase in the rate of Ara-CTP accumulation. Based on this biochemical modulation, 2CdA (12 mg/m2/day x 5 days by CI) was combined with Ara-C (1 g/m2/day over 2 h) in a phase II study. Seventeen patients (15 AML, two MDS) with relapsed AML (median 1st CR of 19 weeks) were treated. In the phase I study two patients died before the day 14 marrow (ED). Marrow hypoplasia developed in 16 of the remaining 25. Leukemic regrowth occurred in nine after a median hypoplastic period of 2 weeks (range 1-3 weeks). The other seven patients died with aplastic marrows, median duration of hypoplasia was 2 weeks, range 1-4 weeks. None achieved CR and the median survival was 10.5 weeks. Toxicity generally was mild except for three late occurring cases of grade III or IV renal dysfunction and two cases of tumor lysis syndrome. The MTD was 10.8 mg/m2/day x 7 days. In the phase II study two patients, both with AML, achieved CR (95% CI 1-33%). In both cases leukemia relapsed after 10 weeks and 17 weeks. There was one ED. Most (11/16) cleared their marrow although leukemic infiltrate regrew in six cases. Toxicity was generally mild, with two episodes of grade 2 GI bleeding, one episode of severe renal dysfunction and one case of grade 2 CNS toxicity. We conclude that as a single agent 2CdA at the MTD is a cytoreductive agent but is not sufficient to achieve CR in adults with relapsed AML. While combination of Ara-C with 2CdA increases the Ara-CTP uptake in these heavily treated patients this regimen does not appear to be an improvement over existing modalities.

Adult↗

Allospecific CD8+ Tc1 and Tc2 populations in graft-versus-leukemia effect and graft-versus-host disease.

Allogeneic CD8+ T cells mediate both a graft-vs-leukemia (GVL) effect and graft-vs-host disease (GVHD). To evaluate whether CD8 cells of defined cytokine phenotype differentially mediate these processes, alloreactive donor CD8+ T cells preferentially secreting type I or type II cytokines were generated by alloantigenic priming in vitro in the presence of IL-12 or IL-4, respectively. Both cytokine-secreting subsets lysed allogeneic tumor targets in vitro ("Tc1" and "Tc2" subsets). A transplantation model was established (B6 into B6C3F1, 1050 cGy host irradiation) using the 32Dp210 myeloid line (bcr/abl transfected, H-2k; 1 x 10(4) tumor cells/recipient). Compared with leukemia controls (death at 12.9 days post-bone marrow transplantation), both Tc1 and Tc2 recipients were conferred a survival advantage. At cell doses of 2 to 2.5 x 10(7), the Tc1-mediated GVL effect (mean survival of 34.2 days) was more potent than the Tc2-mediated GVL effect (mean survival of 20.5 days; Tc1 > Tc2, p = 0.009). On day 15, histologic examination showed that Tc1 recipients had undetectable tumor burdens, whereas Tc2 recipients had extensive leukemic infiltrates. However, Tc2 recipients had essentially no histologic evidence of GVHD, whereas Tc1 recipients had mild to moderate GVHD (average GVHD scores of 1/40 and 9.3/40, respectively). In contrast, recipients of uncultured CD8+ donor T cells developed severe GVHD (average GVHD score of 26.7/40). Because in vitro-generated, alloreactive Tc1 and Tc2 populations mediated GVL with reduced GVHD, we conclude that both subsets may improve the therapeutic outcome of allogeneic T cell transfers in patients with leukemia.

Acetylcysteine↗

Molecular study of hairy cell leukemia variant with biclonal paraproteinemia.

We report an unusual case of hairy cell leukemia variant with IgA and IgG-lambda biclonal gammopathy exhibiting light chain and a surface immunoglobulin class different from that of the paraproteins. In addition, we documented by gene rearrangement study that the hairy cell leukemia variant clone appears independent from the paraprotein-producing cells. The kappa light chain was expressed on the surface of hairy cell leukemia variant cells. Southern blot analysis revealed rearrangement of the kappa-light-chain gene and germline configuration of lambda-light-chain gene. We observed significant clinical improvement and reduction in the leukemic infiltrate in the patient after treatment with 2-chlorodeoxyadenosine (2-CdA). The intensity of the rearranged kappa-light-chain gene band decreased with therapy and increased at relapse without significant change of the paraproteins. Previously reported cases of hairy cell leukemia variant with paraproteins are reviewed, and our patient's contribution to the understanding of this association is stressed.

Aged↗

Video assisted thoracoscopic biopsy for interstitial lung disease.

At the University of Maryland Medical Systems, 356 consecutive thoracoscopic procedures were performed including 147 lung resections for various indications. Forty-nine patients underwent thoracoscopy for the diagnosis of interstitial lung disease. Two patients underwent bilateral procedures after a gap of more than six months for suspected malignancy. There were 28 females and 21 males. Age ranged from 23 to 75 years. The mean length of operation was 45 minutes and the mean length of chest tube duration 1.3 days. There were no deaths, no re-explorations or need to convert to an open thoracotomy. Staphylococcal pneumonia developed in one patient postoperatively requiring admission and intravenous antibiotics. One patient with systemic pulmonary hypertension was ventilator dependent for 48 hours. All patients, except two ventilator dependent patients, were intubated with a double lumen tube. CO2 insufflation at the rate of 2 L/min and pressure of 10 mmHg was used in all patients. Biopsy of at least two lobes was performed in all patients with resection of grossly abnormal lung. A single chest tube was left at the end of the procedure. The tissue diagnosis was interstitial fibrosis in 19 patients. Bronchiolitis obliterans with organizing pneumonitis (BOOP) was seen in 7 patients. Foreign body granulomas were seen in 8 patients. Allergic alveolitis was diagnosed in 4 patients. Emphysematous changes with pneumonitis was observed in 3, nonspecific pneumonitis in 2. Anthracosis, connective tissue disorder, leukemic infiltrate with interstitial fibrosis and CMV pneumonitis were observed in one patient each. The clinical diagnosis correlated with pathological diagnosis and intraoperative findings. Thoracoscopy is a safe and effective method for diagnosis of interstitial lung disease.

Adult↗