Toxicity and efficacy of intensive chemotherapy for children with acute lymphoblastic leukemia (ALL) after first bone marrow or extramedullary relapse

BACKGROUND

Approximately 25% of children newly diagnosed with acute lymphoblastic leukemia (ALL) will eventually experience leukemic relapse, with bone marrow being the most common site of recurrence. The ability to achieve a durable second remission is complicated by toxicity and resistant disease. We report a novel combination of chemotherapy for relapsed pediatric ALL.

PROCEDURE

Thirty pediatric patients with relapsed medullary (n = 18) and extra-medullary (n = 12) ALL were enrolled at three pediatric institutions. Following receipt of induction and the first Block A and Block B of intensification, each patient was evaluated for toxicity, efficacy in achieving remission, and long-term survival. Additionally, minimal residual disease (MRD) detection by multidimensional flow cytometry (MDF) was performed.

RESULTS

During induction, the major non-hematopoeitic toxicities were mucositis (30% of patients) and bacteremia (50% of patients). Two patients (7%) died of toxicity during induction. Toxicity during intensification Block 1A and 1B was markedly reduced. Eight-nine percent of patients with marrow disease achieved a remission following induction and intensification. The event-free survival (EFS) for all patients at 2 and 4 years were 60% (95% CI: 42-78%) and 49% (95% CI: 30-68%), respectively.

CONCLUSIONS

This regimen for patients with relapsed ALL was successful in achieving a second remission for the majority of patients with acceptable toxicity.

Asparaginase Pharmacokinetics After Intensive Polyethylene Glycol-Conjugated L-Asparaginase Therapy for Children with Relapsed Acute Lymphoblastic Leukemia

PURPOSE

Asparaginase therapy is an important component in the treatment of children with acute lymphoblastic leukemia. Polyethylene glycol-conjugated asparaginase (PEG-ASNase) has significant pharmacological advantages over native Escherichia coli asparaginase. We investigated the pharmacokinetics of PEG-ASNase, presence of antibodies to PEG-ASNase, and concentrations of asparagine in serum and cerebrospinal fluid (CSF) in combination chemotherapy for relapsed pediatric acute lymphoblastic leukemia.

EXPERIMENTAL DESIGN

Twenty-eight pediatric patients with relapsed medullary (n = 16) and extramedullary (n = 11) acute lymphoblastic leukemia were enrolled at three pediatric institutions and had at least two serum and CSF samples obtained for analysis. Patients received induction therapy (including PEG-ASNase 2500 IU/m2 intramuscularly weekly on days 2, 9, 16, and 23) and intensification therapy (including PEG-ASNase 2500 IU/m2 intramuscularly once on day 7). Serum samples were obtained weekly during induction and intensification. CSF samples were obtained during therapeutic lumbar punctures during induction and intensification.

RESULTS

Weekly PEG-ASNase therapy resulted in PEG-ASNase activity of >0.1 IU/ml in 91-100% of patients throughout induction. During intensification, PEG-ASNase on day 7 resulted in PEG-ASNase activity >0.1 IU/ml in 94% and 80% of patients on days 14 and 21, respectively. Serum and CSF asparagine depletion was observed and maintained during induction and intensification in the majority of samples. PEG-ASNase antibody was observed in only 3 patients.

CONCLUSIONS

Intensive PEG-ASNase therapy in the treatment of relapsed acute lymphoblastic leukemia reliably results in high-level serum PEG-ASNase activity, and asparagine depletion in serum and CSF is usually achieved. Incorporation of intensive PEG-ASNase in future trials for recurrent acute lymphoblastic leukemia is warranted.

Influence of age upon Ifosfamide-induced nephrotoxicity

BACKGROUND

Ifosfamide-induced nephrotoxicity is well recognized in children, although it has also been reported in adults. Whether ifosfamide nephrotoxicity is more common in children than in adults is not known.

PROCEDURE

Medical records of adults and children diagnosed with sarcoma whom received ifosfamide with a cumulative dose >20 g/m(2) were evaluated. Twenty-five children (</=18-years of age) and 28 adults were identified.

RESULTS

National Cancer Institute Common Toxicity Criteria grade 3-4 ifosfamide-induced nephrotoxicity was present in 24 and 17% of children and adults, respectively (P = 0.58). Cumulative ifosfamide doses were similar between the two populations, with the median (range) of 70.2 g/m(2) (22.4-72) for children and 59 g/m(2) (20.8-146) for adults (P = 0.25). Logistic regression analysis indicated that neither age or cumulative ifosfamide dose were associated with grade 3-4 ifosfamide-induced nephrotoxicity (P = 0.36).

CONCLUSIONS

Children and adults receiving >20 g/m(2) of ifosfamide have similar susceptibility to ifosfamide-induced nephrotoxicity. Factors other than age and cumulative dose should be considered for understanding the inter-individual variation in nephrotoxicity.

Fractionated low-dose radiotherapy after myeloablative stem cell transplantation for local control in patients with high-risk neuroblastoma

BACKGROUND

The optimal administration of radiotherapy for patients with high-risk neuroblastoma (NB) currently is undefined in the context of modern therapy using myeloablative chemotherapy with autologous stem cell rescue (hematopoietic stem cell transplantation [HSCT]).

METHODS

The authors conducted a retrospective review of the records of 21 consecutive patients with high-risk NB to assess local control and toxicity of external beam radiotherapy (XRT). Therapy included multiagent induction chemotherapy and delayed surgical resection, consolidation of HSCT and local XRT, and 13-cis-retinoic acid maintenance therapy. XRT was delivered to the primary site, using postchemotherapy volumes, and to initial metastatic sites with 1-2 cm margins to 2100 centigrays (cGy) using 14 fractions administered once daily.

RESULTS

Four of 21 patients did not receive XRT due to toxic death (n = 2), disease progression before XRT (n = 1), or parental refusal (n = 1). The median time to XRT post-HSCT was 54 days. Thirteen patients received a second peripheral blood stem cell infusion after completing XRT. Twelve of the 14 patients who received XRT post-HSCT and for whom toxicity data were available had Grade 3-4 acute toxicities, including gastrointestinal toxicity (n = 8), hematologic toxicity (n = 9), and infection (n = 1). Nonrecurrent long-term toxicities included prolonged nutritional deficiency (n = 9) and leg-length discrepancy (n = 1). Tumors recurred in 7 of 21 patients (5 of 17 patients who received radiotherapy), either within a radiation field (n = 1) or at distant nonirradiated sites (n = 6). The estimated local failure rate was 7% (95% confidence interval [95% CI], 0-14%), with a 2-year event-free survival rate of 48% (95% CI, 26-70%).

CONCLUSIONS

Post-HSCT, fractionated XRT to 2100 cGy was a tolerable and effective treatment for patients with high-risk NB, and minimal recurrences were observed at designated XRT sites.

Evaluation of early marrow response in childhood aneuploid acute lymphoblastic leukemia: flow cytometric DNA analysis versus standard morphology

Despite improved survival rates for childhood acute lymphoblastic leukemia (ALL), the relapse rate remains at 20-30%. Early peripheral blood and bone marrow (BM) responses have been associated with more favorable outcomes; all current children's cancer group (CCG) protocols for ALL require BM evaluation at days 7 and 14 with subsequent therapy based on the results. Morphologic interpretation of aspirate smears during induction chemotherapy is challenging, as the samples are often hypocellular, excessively friable, and cytologically altered by drugs. We have shown discordancy of day 7 and 14 BM lymphoblast counts using morphologic and flow cytometric immunophenotypic analyses (FC). The aim of our study was to determine the utility, reliability, and cost effectiveness of lymphoblast enumeration using DNA content analysis by flow cytometry (DNA-FC) and to further demonstrate the subjectivity of morphologic review. All new cases of ALL had DNA-FC and FC analyses. The percentage of lymphoblasts as determined by both methods was compared for 82 aneuploid cases. Three pathologists independently reviewed aspirate smears from 39 bone marrow samples of aneuploid ALL that were obtained during early induction. These results were compared among themselves and with the results obtained by DNA-FC. We found excellent correlation between the percentage of lymphoblasts as determined by DNA-FC and FC (R2 = 0.97) over a range of 0 to 99%. Pathologic review agreed with the DNA-FC, on average, 68%. The sensitivity, specificity, and positive and negative predictive values of morphologic review, averaged 53, 84, 78, and 63%, respectively, when using DNA-FC as the "gold standard." All three pathologists achieved agreement of lymphoblast percentage by morphology in 72%. In our laboratory, the use of DNA-FC equates to one-sixth the time and one-half the price of FC per exam. We have shown a strong correlation between blast counts determined by DNA-FC and FC. DNA-FC is an objective, economical, and reliable method to assess early response in induction marrows from aneuploid ALL where morphology is often uninterpretable. This test is highly reproducible and available at most pediatric institutions. Prospective studies need to be employed to evaluate the effect of more definitive methods (DNA-FC and FC) of assessing the early response in bone marrows on prognosis.

Pattern of disease recurrence and prognostic factors in patients with osteosarcoma treated with contemporary chemotherapy

BACKGROUND

The goal of the current study was to define the clinical features and outcome of recurrent osteosarcoma (OS) in children and young adults initially treated with contemporary chemotherapy.

METHODS

The authors reviewed the clinical features, therapy, and outcome for 59 patients from the Mayo Clinic (Rochester, MN) and Children's Hospital and Regional Medical Center (Seattle, WA). They were diagnosed initially with OS between January 1990 and December 2000, received multiagent chemotherapy (most frequently cisplatin, doxorubicin, high-dose methotrexate, and ifosfamide), and developed disease recurrence after achieving an initial complete response (CR).

RESULTS

The most common site of initial disease recurrence was the lung only (n = 36 patients), followed by distant bone (n =8 patients), combined lung and other sites (n =7 patients), and other sites (n =8 patients). The median time to first disease recurrence was 15 months (range, 2-92 months) from the initial diagnosis. Thirty patients with isolated pulmonary recurrence achieved a second CR, either with surgery alone (n =15 patients) or surgery and salvage chemotherapy (n =15 patients). For this group, the 4-year disease-free survival (DFS) and overall survival rates were 7% (95% confidence interval [95% CI], 0-16%) and 28% (95% CI, 11-45%), respectively. For all 59 patients with recurrent OS, the 4-year DFS and overall survival rates were 6% (95% CI, 0-12%) and 23% (95% CI, 10-36%), respectively. The only factors associated with improved DFS and overall survival rates were unilateral pulmonary recurrence, solitary pulmonary nodule at recurrence, more than 24 months between the initial diagnosis and first disease recurrence, and achievement of a second CR.

CONCLUSIONS

The DFS and overall survival rates for recurrent OS after contemporary therapy remained poor even for patients with isolated pulmonary recurrence. Therefore, new treatment strategies are needed.

Intensive induction chemotherapy and delayed irradiation in the management of parameningeal rhabdomyosarcoma

PURPOSE

To evaluate local control, event-free survival, and overall survival for patients with parameningeal (PM) rhabdomyosarcoma (RMS) treated with intensive chemotherapy and delayed irradiation.

PATIENTS AND METHODS

Thirteen consecutive patients with PM RMS were treated with an institutional protocol from 1992 to 1998 at the University of Washington/Children's Hospital and Regional Medical Center and Deaconess Medical Center. Patients received intensive chemotherapy consisting of vincristine, doxorubicin, cyclophosphamide, ifosfamide, and etoposide prior to radiotherapy. Irradiation was delayed, in contrast to current Intergroup Rhabdomyosarcoma Study Group (IRSG) recommendations.

RESULTS

Median follow-up was 39 months. Eleven patients had high-risk features, including five with intracranial extension. All patients responded to the intensive chemotherapy, with 38% exhibiting a complete response and the remaining 62% a partial response. Radiation was administered a median of 21 weeks from initiation of chemotherapy. The Kaplan-Meier estimate of 5-year local control was 92%, with event-free survival and overall survival rates of 83%.

CONCLUSIONS

With intensive induction chemotherapy, delayed irradiation for PM RMS does not compromise local control. Event-free survival and overall survival rates compare favorably with recently IRSG trials employing early irradiation. Delaying irradiation allows for intensification of chemotherapy and could permit response-based radiation volume and/or dose modifications, which could decrease treatment-related morbidity.

Prolonged survival after invasive aspergillosis: a single-institution review of 11 cases

PURPOSE

To perform a retrospective review of the authors' experience with invasive aspergillosis (IA) in a pediatric population treated with conventional chemotherapy. Case series of IA in the pediatric oncology population are limited but generally report poor overall survival.

METHODS

Medical records were reviewed of all patients receiving conventional chemotherapy for malignant disease who developed IA at Children's Hospital and Regional Medical Center, Seattle, Washington, between January 1, 1995, and January 1, 2002.

RESULTS

During the study period there were 11 cases of IA in pediatric cancer patients treated with conventional chemotherapy. All patients had pulmonary IA; two also had evidence of disseminated disease. All patients underwent diagnostic tissue biopsy. Sixty-four percent required further surgery to excise bulky disease. Medical therapy varied with disease presentation and the overall clinical picture, although prolonged treatment with amphotericin B and itraconazole was the mainstay of therapy. Resolution of clinical disease was seen in 91% of patients. Seventy-three percent received further chemotherapy. The 3-year estimated survival was 82%, with a median follow-up of 32.5 months.

CONCLUSIONS

Early diagnosis and aggressive intervention improve long-term survival from IA in immunocompromised pediatric oncology patients. Aggressive surgical resection, prolonged medical therapy after gross resolution of disease, and chemoprophylaxis during subsequent chemotherapy decrease the likelihood of recurrent IA despite subsequent cytotoxic therapy. The ability to proceed with intensive chemotherapy despite a history of IA may improve long-term survival.

Peripheral blood stem cell support reduces the toxicity of intensive chemotherapy for children and adolescents with metastatic sarcomas

BACKGROUND

To increase the dose intensity (DI) of chemotherapy for pediatric patients with metastatic sarcomas, including the Ewing sarcoma family of tumors (ESFT) and rhabdomyosarcoma (RMS), the authors tested the feasibility of an intensive regimen supported by granulocyte-colony stimulating factor (G-CSF) and peripheral blood stem cells (PBSC).

METHODS

Twenty-three children and adolescents with metastatic sarcomas received vincristine, doxorubicin, cyclophosphamide, ifosfamide, sodium mercaptoethanesulfonate (mensa), and etoposide (VACIME) chemotherapy, consisting of 8 courses of vincristine 2 mg/m(2) on Day 0, doxorubicin 37.5 mg/m(2) per day on Days 0-1, cyclophosphamide 360 mg/m(2) per day on Days 0-4, ifosfamide 1800 mg/m(2) per day on Days 0-4, mesna 2400 mg/m(2) per day, and etoposide 100 mg/m(2) per day on Days 0-4. Doxorubicin was omitted in Courses 7 and 8. G-CSF was given after each course of therapy. Courses of therapy were repeated every 21 days or as soon as hematopoietic recovery permitted. PBSC were collected twice: first, after Course 2 (infused after Courses 3 and 4) and, second, after Course 4 (infused after Courses 5 and 6). Surgical resection followed Course 6, and radiotherapy followed Course 8.

RESULTS

PBSC collections were adequate in 91% of all harvests. The mean DI was 82% (standard deviation, 14%) of the intended DI, which was greater than historic data without PBSC support. Seventeen patients (74%) achieved a complete response (CR), 12 patients with chemotherapy alone and 5 more patients after undergoing surgical resection. Fifteen patients developed progressive disease, with a 2-year event free survival (EFS) rate of 39% (95% confidence interval, 19-59%). Hematopoietic toxicity was severe and cumulative, although it was less than that seen previously without PBSC support.

CONCLUSIONS

PBSC-supported multicycle chemotherapy is a feasible method to increase chemotherapy DI for pediatric patients with metastatic sarcomas. Although the CR rate compared favorably with previously reported response rates, the 2-year EFS rate was similar to that achieved with other intensive regimens.

Treatment of metastatic osteosarcoma with the somatostatin analog OncoLar: significant reduction of insulin-like growth factor-1 serum levels

BACKGROUND

Insulin-like growth factor-1 (IGF-1) has been implicated in the growth and/or metastasis of osteosarcoma (OS) and chondrosarcoma based on in vitro and experimental animal studies.

STUDY PURPOSE

To determine the degree of growth hormone (GH), IGF-1 axis blockade, toxicities, and antitumor effect of OncoLar (ONC) (Novartis, East Hanover, NJ, U.S.A.) in OS.

DESIGN/METHODS

A phase 1 study with ONC enrolled 21 OS patients (median age 19 y) in four cohorts: ONC 60 mg or 90 mg intramuscularly every 4 weeks with/without tamoxifen (TAM) 20 mg oral daily.

RESULTS

There were no dose-limiting toxicities. Nineteen percent of patients had grade III drug-related toxicities including: 62% of patients showed progressive disease after two courses (8 wk). Nineteen percent received four courses. No clinical responses were observed. At weeks two and eight of therapy, IGF-1 serum levels dropped 46% ( < 0.0001, n = 21) and 53% ( = 0.003, n = 10). The difference of the area under the curve (AUC) minus baseline AUC (DeltaAUC) for arginine-stimulated GH serum levels at week two was lower than baseline ( < 0.01). At weeks two and eight, GH peak values were lower than baseline ( < 0.0001 and = 0.002, respectively).

CONCLUSIONS

A long-acting somatostatin analog was able to lower IGF-1 levels of OS patients. IGF-BP-3 and GH were only transiently reduced. Although ONC was well tolerated, no sustained clinical responses were observed. The pathophysiology of serum versus tissue concentrations of IGF-1 as well as the interplay of IGFs, IGF-binding proteins, and other growth factors and cytokines in osteosarcoma warrants further investigation. A better understanding of these processes should lead to a more effective exploitation of these pathways for the targeted therapy of OS.

Evaluation of chemotherapy response in pediatric bone sarcomas by [F-18]-fluorodeoxy-D-glucose positron emission tomography

BACKGROUND

Response to neoadjuvant chemotherapy is a significant prognostic factor for osteosarcoma (OS) and the Ewing sarcoma family of tumors (ESFT). Conventional radiographic imaging does not discriminate between responding and nonresponding osseous tumors. [F-18]-fluorodeoxy-D-glucose (FDG) positron emission tomography (PET) is a noninvasive imaging modality that accurately predicts histopathologic response in patients with various malignancies. To describe the FDG PET imaging characteristics and to determine the correlation between FDG PET imaging and chemotherapy response in children with bone sarcomas, we reviewed our single institution experience.

METHODS

Thirty-three pediatric patients with OS or ESFT with osseous primary sites were evaluated by FDG PET. All patients received standard neoadjuvant chemotherapy. FDG PET standard uptake values before (SUV1) and after (SUV2) chemotherapy were analyzed and correlated with chemotherapy response assessed by histopathology in surgically excised tumors. Twenty-six patients had SUV1, SUV2, and surgical excision.

RESULTS

Although the mean SUV1 in children with OS or ESFT were similar (8.2. vs. 5.3, P = 0.13), mean SUV2 for OS patients was greater than the values for ESFT patients (3.3 vs. 1.5, P = 0.01). All ESFT patients and 28% of OS patients had a favorable histologic response to chemotherapy (>or= 90% necrosis). Combining ESFT and OS patients, both SUV2 and the ratio of SUV2 to SUV1 (SUV2:SUV1) were correlated with histologic response (P = 0.01 for both comparisons).

CONCLUSION

FDG PET evaluation of pediatric bone sarcomas demonstrated significant alteration in response to neoadjuvant chemotherapy. SUV2 and SUV2:SUV1 correlated with histopathologic assessment of response and potentially could be used as a noninvasive surrogate to predict response in patients.

Improved outcome for patients with middle ear rhabdomyosarcoma: a children's oncology group study

PURPOSE

The goal of this study was to define the clinical features and optimal therapy for children and adolescents with middle ear (ME) rhabdomyosarcoma (RMS).

PATIENTS AND METHODS

We reviewed demographic data, clinical features, therapy (including chemotherapy, surgery, and radiation), and outcome for the 179 eligible patients with ME RMS who were enrolled onto Intergroup Rhabdomyosarcoma Studies (IRS) I through IV or pilot studies between November 1972 and December 1997.

RESULTS

Most patients were younger than 10 years old (90%), and 63% were male. Because of the parameningeal location, most tumors were not resected before chemotherapy (group I, < 1%; group II, 4%; group III, 84%; group IV, 12%). Although most tumors were locally invasive (T2, 89%), the majority were small (< or = 5 cm, 66%), lacked nodal metastases (N0, 86%), and had embryonal histology (85%). The 5-year failure-free survival (FFS) and overall survival (OS) estimates were 67% and 72%, respectively. Both FFS and OS improved significantly over the course of IRS I through IV (3-year FFS and OS: IRS-I, 42% and 42%; IRS-II, 70% and 74%; IRS-III, 65% and 72%; IRS-IV pilot, 81% and 96%; IRS-IV, 88% and 88%, P <.001). Lower clinical group or stage and smaller tumor size were associated with better outcome. Age, sex, tumor invasiveness, and nodal metastases were not predictive of outcome.

CONCLUSION

Patients with ME RMS generally present with small, unresectable, invasive tumors at a site traditionally considered prognostically unfavorable. Nevertheless, such patients have benefited markedly from improvements in multimodal, risk-based therapy during the course of IRS I through IV, and with contemporary therapy, most are cured.

The utility of skin biopsies in pediatric cancer patients: a single-institution, retrospective review

Medical records of all patients who were diagnosed with a malignancy and who underwent a skin biopsy were reviewed to determine the clinical utility of skin biopsies in this population. Skill biopsies resulted in a change or refinement of the prebiopsy diagnosis in 44% of patients undergoing an initial evaluation for a malignancy, 57% of patients on therapy, and 17% of patients off therapy. Skin biopsies led to a change in therapy in 26%, 34%, and 17% of each respective group. Overall, the skin biopsy changed or refined the prebiopsy diagnosis in 45% of cases and altered therapy in 38%. Skin biopsy is a clinically useful tool in pediatric oncology patients for the evaluation of cutaneous findings that elude diagnosis by visual inspection.

Stages of change and weight loss among rural African American women

OBJECTIVE

Obesity is a prevalent public health problem in the United States, especially for rural African American women, and causes increased morbidity and mortality. The purpose of this analysis was to determine whether the transtheoretical stages of change model was generalizable to weight loss intention among overweight and obese rural African American women and to identify important predictors of the stages of change.

RESEARCH METHODS AND PROCEDURES

The study was conducted in two rural counties in central Virginia. A population-based sample of 200 women under the age of 40 completed questionnaires concerning weight loss behavior and beliefs about weight. Ordinal logistic regression was used to predict stage of change.

RESULTS

A total of 142 of the 200 women (71%) were overweight or obese (body mass index of > or =25) and were classified into a stage of change. Overall, 30% of respondents were in the precontemplation stage, 15% in the contemplation stage, 48% in the preparation stage, 4% in the action stage, and 3% in the maintenance stage. Education, what friends think about weight, body mass index, and a scale of the positive aspects of weight loss were significant predictors of the stage of change (p < 0.05).

CONCLUSIONS

Several predictors of stage were the same as those found in studies of other health behaviors, and this research provides support for applying a stages of change model for weight loss intention among rural African American women. Two predictors in particular, significance of what friends think about weight and a scale of the positive aspects of weight loss, have implications for health education initiatives and social support in weight loss interventions.

Computed tomography in the evaluation of febrile neutropenic pediatric oncology patients

AIM

To evaluate the diagnostic utility of computed tomography (CT) obtained during prolonged febrile neutropenia in pediatric oncology patients.

METHODS

We evaluated the medical records of all patients with a malignant disease who had a CT examination during an episode of febrile neutropenia lasting for 4 days or more at Children's Hospital and Regional Medical Center in Seattle, WA, between January 1, 1997, and June 1, 1999.

RESULTS

CT was performed on 83 patients to evaluate 109 episodes of prolonged febrile neutropenia. Sixty-eight (62%) of the initial CT scans demonstrated abnormalities, leading to changes in therapy in 42 (39%). The diagnostic and therapeutic utility of CT varied by anatomic site. Abdominal and head/neck CT detected abnormalities in only 19 and 8% of studies, respectively, resulting in therapy changes in 9 and 4%, respectively. Sinus CT demonstrated abnormalities in 41% of cases and altered therapy in 24%. Chest CT had the highest diagnostic utility, with 49% of cases demonstrating abnormalities, leading to therapy alteration in 30%. CT was rarely abnormal in the absence of localizing signs or symptoms. In 55 instances 1 or more follow-up scans were done. Thirteen follow-up CT scans showed abnormalities that led to a change in therapy.

CONCLUSIONS

CT-detected abnormalities frequently lead to alterations in therapy, particularly sinus and thoracic CT. Most patients with CT-detected abnormalities have symptoms or signs referable to the site of abnormality. Asymptomatic febrile neutropenic children rarely have CT findings that lead to a change in therapy.

Successful dose-intensive treatment of desmoplastic small round cell tumor in three children

Desmoplastic small round cell tumor (DSRCT) is a rare soft tissue tumor of primitive origin occurring primarily in children and young adults. Based on published reports in the literature, the response to conventional chemotherapy is poor. We report three pediatric patients successfully treated with dose-intensive, multimodal therapy. Between August 1994 and March 1998, we evaluated three consecutive patients with DSRCT at Children's Hospital and Regional Medical Center, Seattle, Washington. We established the diagnosis based on clinical presentation, radiologic staging, and pathologic review with immunohistochemical staining. All patients received a combined modality protocol including dose-intensive chemotherapy (two of them with peripheral blood stem cell [PBSC] support), second look surgery, and consolidative local irradiation. The patients remain in continuous remission at 66, 42, and 26 months after diagnosis, respectively. Two of our patients were younger than any previously reported patient, extending the age group for which DSRCT should be considered on diagnosis of small round cell tumors. The uniform survival achieved in our series indicates potential benefit for the combination of dose-intensive multiagent chemotherapy, local irradiation, and aggressive surgical approach in this disease.

Meningitis in pediatric cancer patients: a review of forty cases from a single institution

BACKGROUND

Although the clinical features of bacterial meningitis in adult cancer patients and in healthy children have been described, no previous large series has described the clinical features of meningitis in pediatric cancer patients. We performed a retrospective review of bacterial or fungal meningitis in pediatric cancer patients to determine its clinical presentation, microbiology and outcome.

METHOD

We reviewed the medical records of all patients younger than 18 years old with a diagnoses of any malignancy and bacterial or fungal meningitis at Children's Hospital and Regional Medical Center in Seattle, WA, from January, 1981, to June, 1998.

RESULTS

During the study period there were 40 cases of bacterial or fungal meningitis in 36 pediatric cancer patients. Most patients (65%) had recent neurosurgery, a central nervous system device or cerebrospinal fluid leak. Neutropenia was present in 30% of patients. Fever and altered mental status were the most consistent signs at presentation. In addition at least one additional symptom or sign of meningitis (headache, neck pain or rigidity, seizures or photophobia) was present in 77% of cases. Staphylococcus aureus and Streptococcus pneumoniae were the most common microbiologic isolates. The five patients with fatal outcome were neutropenic. Neutropenia and seizures within 2 days of presentation were associated with long neurologic sequelae.

CONCLUSIONS

Meningitis in pediatric cancer patients was associated with significant morbidity and mortality. Pediatric cancer patients with meningitis had clinical features and microbiology distinctly different from those of adult cancer patients and normal children with meningitis.

Spontaneous remission of congenital leukemia

Most patients with congenital leukemia do not survive past infancy despite aggressive chemotherapy. We describe three patients with congenital leukemia who have undergone prolonged periods of spontaneous remission. Our experience suggests that some patients with congenital leukemia may benefit from initial conservative management without chemotherapy. We summarize the clinical presentations of these patients and review the literature.

Inactivation of p53 enhances sensitivity to multiple chemotherapeutic agents

Many tumor types have p53 and/or RB mutations, and it is unclear what role the mutations of these tumor suppressor genes have on the efficacy of chemotherapeutic agents. The effect of p53 and RB inactivation on sensitivity to chemotherapeutic drugs was examined using a model system in which p53 or RB was inactivated in normal human foreskin fibroblasts (HFFs) by acute expression of human papillomavirus (HPV) 16E6 or 16E7. Cytotoxicity assays showed that HFFs expressing HPV 16E6 were 6- to 9-fold more sensitive to the DNA crosslinkers cisplatin and carboplatin and 7.8- to 11.5-fold more sensitive to the tubulin polymerizing agent paclitaxel than were LXSN-expressing cells. Analysis of mouse embryonal fibroblasts lacking p53 (p53-/-) compared with mouse embryonal fibroblasts homozygous (p53+/+) and heterozygous (p53+/-) for wild-type p53 confirmed the role of p53 in the enhanced sensitivity to cisplatin. Treatment with the alkylating agents melphalan and nitrogen mustard resulted in 3.8- to 7.3-fold greater sensitivity in HPV 16E6- or 16E7-expressing cells compared with LXSN-expressing cells. Enhanced sensitivity to cisplatin in cells lacking p53 function was explored by examination of its effects on cell cycle progression after exposure. When treated with cisplatin, HFFs expressing 16E6 showed delayed progression through S phase relative to HFFs expressing LXSN. The delay in S phase progression was coincident with the induction of p53 protein levels in LXSN-containing HFFs, suggesting a role for p53 in DNA repair of cisplatin-induced damage. These results indicate that the inactivation of p53 in the absence of other genetic alterations leads to enhanced sensitivity to multiple chemotherapeutic agents rather than to increased resistance.

Serum parathyroid hormone (PTH) in pregnant women determined by an immunoradiometric assay for intact PTH

Most studies of circulating PTH levels using traditional RIAs have supported the concept of physiological hyperparathyroidism of pregnancy, with pregnant women having serum immunoreactive PTH levels significantly higher than those in nonpregnant subjects. However, such RIAs are insensitive and often detect inactive PTH fragments, so that the correlation between PTH immunoreactivity and bioactivity is poor. Employing a new intact PTH immunoradiometric assay (Allegro-Nichols), we reassessed the effects of pregnancy on parathyroid function. The mean serum PTH level in 81 pregnant women was 14.4 +/- 6.3 (+/- SD) compared to 24.8 +/- 9.0 ng/L in 11 normally cycling nonpregnant women (P less than 0.001). The mean serum total and ionized calcium levels in the 2 groups were similar. In 5 of the pregnant women, serum bioactive PTH, determined by cytochemical bioassay, was slightly lower (7.7 +/- 3.4 ng/L) than in normal individuals (11.1 +/- 1.9 ng/L). Our findings suggest, in contrast with the results of most previous studies, that serum intact PTH may decline during pregnancy.