[Status of plasmapheresis and cyclosporin A in the treatment of systemic lupus erythematosus]

We report the history of 2 teenagers suffering from systemic lupus erythematosus for more than 5 years. Both of them were treated with total plasma exchange (TPE) and Ciclosporin A. They responded well to this therapy and achieved remissions. Especially the 2nd patient showed a dramatic clinical improvement after a relapse caused by sun exposure. Both treatment modalities are discussed and the following conclusions are drawn: TPE is an important therapeutic element in treating patients with SLE, whereas Ciclosporin A is not recommended for therapy of first choice. Further prospective and controlled studies have to show, if there is a benefit of this therapy, especially in childhood.

[Intraspinal, extradural hemorrhage in a 7-year-old boy with hemophilia B]

A 7-year-old boy with severe hemophilia B suffered an intraspinal extradural hemorrhage without preceding trauma. Since the age of 3 years the patient is HIV-1 positive. The actual hemorrhage caused a strong pain in the thoracolumbar area without signs of spinal cord compression. It was diagnosed by CT-scan. By early high dose factor-IX substitution the hemorrhage was stopped and no neurological complications occurred. The further substitution regime is described.

Spinal space occupying lesions in thalassemia major

A 17 year old patient suffering from thalassemia, who had been dependent on transfusions since the age of three, showed an increasing incomplete sensory and motor transverse cord lesion below T-10. The causes were found to be multiple epidural erythropoietic foci, confirmed by myelography, CT, and biopsy. The lesions were located in the thoracic, lumbar, and sacral regions. Complete remission of the neurological symptoms was achieved by an immediate hypertransfusion regimen and subsequent local radiation therapy of the neuroaxis. Thirty-six cases of thalassemia and spinal space occupying lesions have been reported in the literature. The therapeutic results of these are presented and compared with our findings.

Chemotherapy for bone marrow relapse of childhood acute lymphoblastic leukemia

Results of the BMF study group trials ALL-REZ 83 and 85 for relapsed acute lymphoblastic leukemia (ALL) are presented. For children with late marrow relapse, remission rates of about 90% were seen in both studies. In children treated for early marrow relapse, the remission rate in study ALL-REZ 85 was superior (86% vs 62%). The probability of event-free survival for all patients and for those with early marrow relapse was also statistically significant (P less than 0.05). Children with T-cell ALL had an extremely unfavourable prognosis in both studies.

Hemofiltration and plasmapheresis in newborns using a small blood pump system

Extracorporeal detoxification methods in newborns and premature infants are unavailable and contraindicated because of technical problems. The authors' experiences with a blood pump unit that was miniaturized for hemodialysis, hemofiltration, and plasmapheresis in newborns are reported. In 28 newborns and premature infants, 32 hemofiltrations, 3 hemodialyses, and 57 plasmaphereses were carried out for different diseases. Thirteen of 28 patients died despite hemofiltration and/or plasmapheresis as a result of their primary disease and/or immaturity, and 15 patients improved.

[The clinical significance of pseudouridine determination of the urine in children and adolescents]

A HPLC-method is described to determine the Pseudouridine/creatinine ratio in spontaneous urine samples in infancy and childhood. The urines of 74 healthy children between 1 and 18 years of age and of 231 children with different diseases were examined for this ratio, making 1097 measurements. 157 children suffered from a malignant disease, 66 of them having an acute leukemia. Those patients, who remain in remission of the leukemia showed normal values, whereas the others had elevated ratios, reflecting the activity of the leukemia, when they were followed up by multiple determinations. Perhaps it is also possible to detect preclinical stages of leukemia by measuring the pseudouridine/creatinine ratio routinously over a long period of time. Today no strict correlation between the prognosis of leukemia and the level of this ratio can be drawn. Similar behaviour of the pseudouridine/creatinine ratio is seen in other malignant diseases with exception of brain tumors. The difference to leukemias is, that all other malignant tumors show more often normal values in patients with a remaining tumor. A pathological value of pseudouridine may also be seen in others than malignant diseases.

[Skeletal changes in thalassemia]

Display of this hereditary blood disease (haemoglobinopathy) which is endemic in the Mediterranean area and rarely appearing in our area, characterized by early blood cell destruction and increasing transfusion siderosis of internal and endocrine organs, secondary osteoporosis, epiphyseal growth disturbances and spontaneous fractures by means of two typical cases.

[Cardiac dysfunction in children with thalassemia major]

Evaluation of the cardiac function of seven patients with beta-thalassemia major was performed by continuous electrocardiography recording during a 24 hr period and during a short term exercise program. A reduction in left ventricular function was assessed by echocardiography and radiocardiography during resting and during exercise. Serious arrhythmias of various forms in the oldest patients (17 and 20 years) were observed during these tests. The younger patients were asymptomatic and their cardiac function tests showed no abnormality. In order to prevent transfusion related cardiac iron toxicity it would seem mandatory to motivate patients for better compliance while on chelation therapy.

Intraspinal mesenchymal chondrosarcoma in a three-year-old boy

A case is presented of a 3-year-old boy with a mesenchymal chondrosarcoma extending from the 1st to the 5th lumbar vertebra. This is the youngest case of a mesenchymal chondrosarcoma located outside the skeleton or in the C.N.S. After assumed total excision with subsequent radiotherapy and chemotherapy, local tumor recurrence and (later) systemic metastases were detected. Standard therapy should include radical excision because of the high incidence of local recurrence and subsequent radiotherapy because of the expected high incidence of tumor cells in the CSF. The value of chemotherapy cannot be assessed, as it has been applied in only one other case found in the literature.

[Stereotaxic diagnosis of brain tumors in childhood as a principle for therapy planning]

Brain tumors of the various histologic types and topographical localization may occur in children. The incidence of brain tumors under the age of 15 years is 2.4-6.5/100,000. Due to the profound physiopathological differences between the various types of cerebral tumors can the choice of the adequate method of treatment not accurately be made without the exact knowledge of the histologic nature. Modern imaging techniques facilitate the visualization of cerebral lesions, do not furnish however a histologic diagnosis. Stereotactic biopsy allows by a direct approach to the lesion--without removal or retraction of healthy brain tissue, as well in the supra--as in the infratentorial space, to establish the histologic diagnosis. This is, together with the topographical localization and the volume, an essential factor for the choice between open surgery, external irradiation (teletherapy), stereotactic interstitial radiation therapy (brachytherapy), stereotactic endocavitary treatment or conservative management.

[Bronchocentric granulomatosis as a manifestation of allergic bronchopulmonary aspergillosis without bronchial asthma]

A 17-year-old girl developed fever, cough and hemoptysis, as well as bouts of septic fever, dyspnea on exertion, cyanosis and weight loss. Opacification in the left lower lung was a persistent feature. Complement-fixation reaction to Aspergillus fumigatus was 1:80, and there were four precipitation lines against this fungus on immunoelectrophoresis. Aspergilli were also demonstrated in sputum and bronchial aspirate. Because the patient's condition deteriorated an atypical lingula resection was performed and cortisone treatment begun postoperatively. Subsequently all abnormal findings disappeared and the patient was cured. Two subsequent exposures to Aspergillum on the parental farm produced high fever, cough, dyspnea and thoracic pain. Histological examination of the lingular specimen revealed bronchocentric granulomatosis. In this case it was the rarely occurring morphological manifestation of an allergic bronchopulmonary aspergillosis without bronchial asthma.

Acute leukemia with chromosome translocation (4;11): 7 new patients and analysis of 71 cases

Clinical and laboratory features of seven patients with acute leukemia associated with the (4;11) chromosome translocation are presented. Leukemic blasts of these patients showed lymphoid morphology in 6 (although 1 was treated for monoblastic leukemia 3 years earlier) and monocytoid morphology in 1, were positive for TdT and HD 37 (CD 19) in 6 patients, whereas weak expression of CALLA was seen in only 1 patient and T-lineage-associated antigens in none. Leukemic blasts from four patients showed the simultaneous expression of B-lymphoid and myeloid antigens, suggesting leukemogenesis in a very early multipotent progenitor cell. In 2 patients an isochromosome of the long arm of No. 7 chromosome was found in the leukemic karyotypes in addition to t (4; 11) (q 21; q 23); in one instance present at diagnosis, in the other one occurring at relapse. In one other patient leukemia karyotype also demonstrated trisomy 8. Leukemic cells of three patients were investigated by molecular genetics and demonstrated immunoglobulin gene rearrangements for the Ig heavy chain sequences but not for the light chain constant regions and T cell receptor sequences. All patients were treated by intensive chemotherapy. Four of the 7 patients are in continuous complete remission. The longest event-free survival time (over 2 1/2 years) was seen in one patient who had also DOWN-syndrome. Including these 7 patients a clinical analysis of 71 patients with t (4; 11) acute leukemia was made, emphasizing the following characteristics at diagnosis: female sex (62%), age under 2 years (49%), leukocyte count over 100 X 10(9)/1 (61%), splenomegaly (80%), CNS-disease (11%). Survival of over 2 years was reported in less than 15% of the patients. It remains to be seen if risk-adapted treatment can alter the course of this early B-precursor acute leukemia with hitherto very bad prognosis.

[Treatment of acute lymphoblastic leukemia in childhood and adolescence: results of the multicenter therapy study ALL-BFM 81]

In therapy study ALL-BFM 81 633 previously untreated patients with acute lymphoblastic leukemia (ALL) less than 18 years of age have been recruited from April 1, 1981 to September 30, 1983 and treated in 37 institutions throughout West-Germany and Austria. Here only therapy results of 611 patients with non-B-ALL are presented. Patients with ALL of B-type are described elsewhere. In this fourth consecutive trial of the BFM study group three major questions have been asked: 1. Is it possible to assess the individual risk for relapse more accurately by the use of a risk factor rather than by the risk score which was the discriminator in studies ALL-BFM 76 and ALL-BFM 79? Does this risk factor discriminate more precisely patients at the highest risk for relapse? Offers more intensive risk-adapted therapy to this patient group a better chance for disease-free survival? 2. In patients at a standard risk for relapse with a risk factor below 1.2--approximately 60% of patients with non-B-ALL--can radiotherapy for prevention of CNS disease effectively be replaced by chemotherapy (intermediate dose Methotrexate)? 3. It is possible to reduce duration of maintenance therapy by 6 months to a total duration of 18 months with no unfavorable effect? To assess the radiation problem in standard risk patients and to evaluate the importance of duration of maintenance therapy two randomisations have been utilized. After a median duration of study ALL-BFM 81 of 4 1/2 years and 3 1/4 years after the study had been closed (date of evaluation January 1, 87) the answers are as follows: 1. For the majority of patients risk-adapted therapy had a curative effect. The probability for event-free survival (EFS) in standard risk patients in slightly above 70%, in medium risk patients 67%. In high-risk patients risk-adapted therapy did not improve prognosis, the EFS being still in the order of 50%. A good assessment of the individual risk for relapse is possible by the newly introduced risk factor. This principle is superior to the risk score used in former studies ALL-BFM 76 and ALL-BFM 79 because a low risk group (risk factor below 0.8) could be identified including approximately 25% of all patients with non-B ALL. Selection, quality, and timing of therapy elements remain the decisive prognostic factors, however. 2. Standard risk patients with a risk factor below 0.8 can effectively be protected for CNS relapse by treatment with intermediate dose Methotrexate.(ABSTRACT TRUNCATED AT 400 WORDS)

Aggressive combination chemotherapy of bone marrow relapse in childhood acute lymphoblastic leukemia containing aclacinomycin-A: a multicentric trial

An intensive 7-day combination chemotherapy protocol was designed to reinduce children with early bone marrow relapse of acute lymphoblastic leukemia (less than 6 months after the end of or during preceding treatment). This aggressive approach seemed to be justified for a group of patients who were at the highest risk for ultimate treatment failure. In all, 38 children were enrolled for study. The ratio of male (median age, 10 years) to female (median age, 13 years) subjects was 27:11. Thirty patients were treated for their first relapse and eight for their second or subsequent relapse. Isolated bone marrow involvement was present in 24 cases. All patients had received heavy pretreatment including anthracyclines with cumulative doses of between 120 and 240 mg/m2. 22 of these patients, achieved complete remission, ten did not respond to therapy, and six died from the toxicity of the protocol. Cardiac failure was the cause of death in one child (after additional radiotherapy for a mediastinal mass). No further clinical manifestation of cardiomyopathy could be observed. The other five patients died from hemorrhages or infectious complications. The main side effects were fever, gastrointestinal problems, stomatitis, and severe bone marrow aplasia lasting for about 2 weeks with nadirs of platelets and white blood count around days 10-14. The remission rate of 60% was acceptable, though not satisfactory. Only four children survived disease-free for 13+, 14+, 20+, and 22+ months after diagnosis of relapse.

[Behavior of glucosephosphate isomerase in children with malignant diseases]

The normal range of glucose-phosphate-isomerase (GPI) in the plasma of children during the first month of life is up to 80 U/l; until the end of the second year of life between 11 and 50 U/l; thereafter the upper limit is 46 U/l. In osteogenic sarcoma or medulloblastoma there is a good correlation between activity of GPI in plasma and clinical tumor stage. In a lot of other tumors sensitivity of this enzyme is either very low as in Ewing-sarcoma or myeloic leukemia or there is no consistent relation to the extent of the tumor. High activities of GPI are equally obtained in children suffering from cystic fibrosis, diabetes mellitus or muscular dystrophy. GPI is not valid as a tumor marker even being raised in sarcoma and medulloblastoma as mentioned. So it is not necessary to check GPI activity as a part of routine enzyme chemistry.

[Thrombocyte morphology and function during high-dose immunoglobulin therapy in acute and chronic idiopathic thrombocytopenic purpura. 1]

We examined the effectiveness of a high-dose Immunglobulin therapy in 8 patients with idiopathic thrombocytopenic purpura (ITP) and measured the number, the morphology and the function of Thrombocytes as well as thrombocyte dependent clotting parameters. 0.5 g/kg/B.W. 7s-Immunglobulin (7s-IgG) per treatment led to normal thrombocyte numbers in 7 out of 8 patients. The maximal thrombocyte-rise occurred on the 4th-10th day of treatment. Simultaneously bleeding time, thrombocyte-volume distribution frequency and Ristozetin-ADP and Collagen induced thrombocyte-aggregation normalized-indication as well as cause of the 7s-IgG-therapy are discussed.