[Therapeutic applications of hypothermia in intensive care]

A brief review about the effects of hypothermia is presented, with regards to the difference between accidental hypothermia and controlled mild hypothermia (Core temperature = 33-35 degrees C). Mild hypothermia does not seem to affect the cardiac performance, while recent experimental reports show potential protective effects on the cardiac muscle during acute infarction. Mild hypothermia improve the outcome of brain function after cardiac arrest and head injury, while experimental reports show a potential protective effect of local spinal cord cooling during ischemic injury. Induced hypothermia of single organ is widely applied in liver resection and in other surgical procedures, further the cardiac ones. In the acute respiratory failure, mild hypothermia may induce a decrease in PaCO2, in sedated and muscle relaxed patients, due to the decrease of metabolic demand. In this setting a mild induced hypothermia potentially may decrease the side effects of therapeutic hypoventilation (permissive hypercapnia) both on haemodynamics and brain circulation. Preliminary data are presented about five ALI/ARDS patients, enclosed in a randomized trial, who were mechanically ventilated and cooled with an air-sheet: three patients died because of underlying disease and two patients survived with complete recovery. Mild controlled hypothermia seems to provide new interesting clinic uses.

Dose-finding study of epidoxorubicin and docetaxel as first-line chemotherapy in patients with advanced breast cancer

BACKGROUND

Anthracyclines and taxanes are the most active drugs against breast cancer and the search after their optimal combination is under intensive investigation in both the advanced and early disease settings. A dose-finding study of epidoxorubicin (E) and docetaxel (D) was conducted in advanced breast cancer (ABC) to define the maximum tolerated dose (MTD) of the combination with and without granulocyte colony-stimulating factor (G-CSF) support and to characterise its toxicity and activity profile.

PATIENTS AND METHODS

Forty-two patients who received neither palliative chemotherapy nor adjuvant anthracyclines (55% with dominant visceral disease and 66% with > or = 2 sites involved) with measurable/evaluable lesions, were treated at four dose levels starting from E 75 mg/m2 and D 75 mg/m2 to E 120 mg/m2 and D 85 mg/m2. A maximum of four cycles of the combination was given every three weeks and four additional cycles of single agent D were allowed in responding patients. Cardiac function was monitored at baseline and at every second course by echocardiography.

RESULTS

Febrile neutropenia (two patients) and prolonged, severe neutropenia (absolute neutrophil count (ANC) < 0.1 x 10(9)/l for more than three days; one patient) defined the MTD of the combination without G-CSF support at E 90 mg/m2 and D 75 mg/m2. G-CSF was then routinely administered from the subsequent dose level of E 120 mg/m2 and D 75 mg/m2. The MTD with G-CSF support was established at E 120 mg/m2 and D 85 mg/m2 (one patient with neutropenic fever together with failure of ANC recovery at day 21, three patients with ANC less than 0.1 x 10(9)/l for more than three days, one patient with both and one patient with grade 4 thrombocytopenia and toxic death from typhlitis while neutropenic). No severe neurotoxicity, mucositis, or fluid retention were observed and there were no clinical signs of cardiotoxicity. Antitumor activity was not a primary endpoint of the study: the overall response rate (ORR) in 40 evaluable patients was 60% (95% confidence interval: 43%-75%, 58% in liver disease, 84% in soft tissue) with no apparent dose-related effect. After a median follow-up of 19 months (range 2-30+), the overall time to progression (TTP) in nine patients without maintenance hormonal therapy was five months.

CONCLUSIONS

The combination of E and D proved to be an effective and safe regimen in poor- prognosis patients with ABC. G-CSF support allowed higher doses to be delivered safely but dose escalation did not translate into improved response rates (RR). The MTD without growth factors support was used, in a phase II trial, which also included patients with previous anthracycline-containing adjuvant regimens.

[Prophylaxis of toxic effects on the peripheral venous system associated with intravenous administration of vinorelbine]

Vinorelbine is effective in the treatment of a number of malignancies. However, beside the haematologic and not haematologic toxicity as thrombocytopenia, granulocytopenia, fatigue, paresthesias, nausea and vomiting, one of the most common side effects is the local irritation with thrombophlebitis. The side effect, reported in about 10-26% of patients receiving vinorelbine infusions, is due to the vescicant and irritant action of the drug. Many studies have been performed in order to reduce the incidence of venous irritation either with concomitant administration of anti-inflammatory drugs as defibrotide or ketorolac, or changing infusion schedule from bolus infusion to a 20-30 minute infusion. Aim of this review is to define peripheral venous system toxicity of vinorelbine and the best way of administration.

Clinical and molecular follow-up by amplification of the CDR-III IgH region in multiple myeloma patients after autologous transplantation of hematopoietic CD34+ stem cells

BACKGROUND AND OBJECTIVE

Autologous blood stem cell transplantation (ABSCT) using chemotherapy-induced mobilization of peripheral blood stem cells (PBSC) is being increasingly used in the treatment of multiple myeloma (MM). We report the clinical and molecular follow-up of 10 MM patients who underwent autologous stem cell transplantation with peripheral blood selected CD34+ cells, as support therapy following a myeloablative conditioning regimen.

DESIGN AND METHODS

The CDR-III coding region of the IgH gene was studied by a) consensus PCR applied to 8 MM patients, or b) by direct sequencing of PCR product generated by family-specific primers in the remaining two patients (who became immunofixation analysis (IF) negative). In this case, two patient-specific primers were generated, thus obtaining a high PCR assay sensitivity and specificity (ASO PCR).

RESULTS

Seven patients are alive: 4 of them have serum M protein assessable by IF, while 1 was not a secretor and 2 converted from serum IF positivity to negativity 6 and 12 months after ABSCT. Three patients died: 1 from disease progression and 2 from infective complications during clinical remission. The molecular analysis during the follow-up showed that the bone marrow samples from the two patients who obtained IF negativity were persistently PCR positive for the presence of rearranged CDR-III region. Moreover, despite the remarkable reduction of myeloma burden, a minimal level of residual myeloma cells was still detectable by molecular analysis.

INTERPRETATION AND CONCLUSIONS

These results confirm that although positive selection of CD34+ cells markedly reduces the contamination of myeloma cells from apheresis products by up to 3 log, and provides a cell suspension capable of restoring normal hematopoiesis after ablative conditioning regimen, it does not abrogate myeloma cell contamination in most of the apheresis products.

ChlVPP/ABV-VP16 hybrid regimen for advanced Hodgkin's disease: a study in 36 patients

Prolonged remission can now be induced in the majority of patients with advanced Hodgkin's disease (HD) by the use of non-cross-resistant regimens. The aim of this retrospective analysis was to evaluate the efficacy and tolerability of a hybrid chemotherapy regimen (ChlVPP/ABV-VP16) in this unfavorable subset of patients. From 1982 to 1997 thirty-six previously untreated patients with advanced HD, Stages IIB to IV according to the Ann Arbor classification, were treated with the ChlVPP/ABV-VP16 regimen. The median age of the group was 29 years (range, 18 to 74), and 50% of them had bulky disease. Complete remission (CR) was induced in 31 patients (86%); 3 patients achieved partial responses and 2 had progressive disease. The median follow-up duration is 5.7 years, with a 5-year overall survival rate of 80%. At 5 years, the time to progression (TTP) and event-free survival (EFS) were 71% and 64%, respectively. Acute toxicity was quite acceptable, and there were no treatment-related deaths. A total of 3 second malignancies (8%) were documented. In conclusion, the ChlVPP/ABV-VP16 hybrid is an active regimen for use in advanced HD. Its overall survival, TTP and CR rates make this regimen an attractive alternative to MOPP/ABVD. However, the possibility of the development of second tumors is worrisome, although the relatively brief interval between the end of treatment and tumor detection may imply caution about the possible relationship.

Adverse events occurring during bone marrow or peripheral blood progenitor cell infusion: analysis of 126 cases

Bone marrow (BM) and/or peripheral blood progenitor cells (PBPC) given after high-dose chemo-radiotherapy are commonly cryopreserved. Re-infusion of the thawed product can cause cardiovascular and other complications. We compared two groups of adult patients receiving autologous BM or PBPC transplant to assess the incidence of adverse events occurring during infusion. Fifty-one patients received BM, and 75 PBPC. The two groups were comparable in respect of age, total volume infused, quantity of dimethylsulfoxide (DMSO) and number of polymorphonuclear neutrophils. Patients receiving PBPC had a higher number of nucleated cells per kg of body weight; those in the BM group received a significantly greater quantity of red cells. Non-cardiovascular complications occurred in 19% and 8% of patients rescued by BM and PBPC respectively. The incidence of hypertension was 21% in the BM and 36% in the PBPC group. Asymptomatic hypotension was more frequent in PBPC patients (P<0.001). Bradyarrhythmia was noticed in two of 75 PBPC patients and in 14 of 51 BM patients (P<0.001). In the former group one patient had heart block; he died of renal failure 10 days later. Bradycardia and hemoglobinuria were more common in patients receiving BM where a higher concentration of red cells was present (P<0.001). Since bradyarrhythmias may be a life-threatening complication we advise continuous careful monitoring during infusion of thawed BM. The strong correlation between bradycardia and red blood cell contamination suggests the use of purified products with a very low red cell content.

Chemotherapy and donor peripheral blood progenitor cells for acute leukemia in early relapse after allogeneic bone marrow transplantation

Ten patients with acute leukemia (AL) in early relapse after allo-BMT were treated with a modified MEC (mitoxantrone, etoposide and Ara-C) regimen followed by donor PBPC collected after mobilization with G-CSF. Seven patients achieved CR or had normal hemopoietic reconstitution: two had an early relapse at days +53 and +48, two patients died from acute GVHD at days +31 and +96, one died of interstitial pneumonia at day +55, and two patients experienced long-term survival. One patient with refractory disease and nodal involvement who did not respond to the first BMT had overt expansion of the leukemia at day +36; one patient with Ph+ ALL and one with ANLL evolving from MDS, both with skin involvement, had blast cells in peripheral blood at day +27 and +26, respectively. Transient cytopenia occurred in all patients; a normal granulocyte and platelet count was achieved within 3 weeks in all patients but one; acute GVHD occurred in six patients, and four had chronic GVHD. This approach is feasible in patients in early relapse after allo-BMT. It assists prompt re-establishment of normal donor hematopoiesis avoiding the prolonged cytopenia observed after donor lymphocyte infusion in AL patients relapsed after allo-BMT.

Photoinscription of Bragg gratings within a germanosilicate fiber subjected to a high static electric field

The kinetics of Bragg grating growth in germanosilicate fibers subjected to a high static electric field are compared with those obtained without any electric field. The gratings were written by exposure of the fiber core to laser light at 244 or 193 nm. These experiments gave some clues about the mechanisms responsible for both the photosensitivity in germanosilicate fibers and the nonlinear second-order UV-induced susceptibility in silica glasses. The refractive-index modulation proved to be significantly higher in the fibers subjected to an electric field. Furthermore, the change in the fiber's mean effective refractive index as a function of exposure time was not monotonic. This evolution can be explained by the assumption that some electric-field-induced diffusion of electron trapped centers [Ge(1) and Ge(2)] from the fiber core is involved.

Autologous peripheral blood stem cell transplantation in acute myeloblastic leukaemia and myelodysplastic syndrome patients: evaluation of tumour cell contamination of leukaphereses by cytogenetic and molecular methods

We evaluated 18 acute myeloblastic leukaemia (AML) and myelodysplastic syndrome (MDS) patients with abnormal karyotype at diagnosis who underwent peripheral blood stem cell (PBSC) transplantation. To evaluate the presence of residual tumour cells, bone marrow (BM) samples and PBSC collections were analysed by cytogenetics and in selected cases also by fluorescence in situ hybridisation (FISH) and molecular studies. All patients were considered to be in morphologic and cytogenetic complete remission (CR) at the time of mobilisation. Seven patients showed neoplastic cells in PBSC harvest and/or BM specimen before reinfusion. Cytogenetic studies revealed contamination in apheretic collections in one patient only, while three patients had BM but not PBSC contamination. Three more patients had leukaemic cells both in the BM and PBSC. All but one (with only BM contamination) of these patients relapsed within 9 months. However, five more patients relapsed after transplantation: in four cases there was no cytogenetic sign of contamination either in PBSC or BM cells and in one case no molecular evidence was revealed either. This study suggests that, whereas the presence of leukaemic cells in autologous grafts correlates with a poor prognosis, the lack of detection of tumour cells is not always predictive of long-term disease-free survival. More importantly, PBSC collections from AML patients are not contaminated by leukaemic cells if the BM is disease-free.

Fournier's gangrene: a clinical presentation of necrotizing fasciitis after bone marrow transplantation

Three patients with ANLL developed Fournier's gangrene as an early complication after allo-BMT (two cases) and auto-BMT (one case); two patients were in first CR, the third had resistant disease. Patients developed fever, perineal pain, swelling and blistering of the genital area. Pseudomonas aeruginosa was isolated from the lesions and patients received systemic antibiotic therapy, surgical debridement and medication with potassium permanganate solution. Two patients made a complete recovery although one died of sepsis. The third had progressive involvement of the abdominal wall and later died of leukemia. Early diagnosis of this disorder and prompt initiation of appropriate therapy can prevent progression of this acute necrotizing infection.

Role of autologous bone marrow transplantation as consolidation therapy in acute promyelocytic leukemia patients in complete remission

Autologous bone marrow transplantation (ABMT), which consents a low mortality rate, has been proposed as an alternative approach to maintenance chemotherapy in patients with acute promyelocytic leukemia (APL) in first complete remission irrespective of the patients' molecular status. Sixteen patients with acute APL in complete remission were submitted to ABMT and were analyzed for the presence of the PML-RARa fusion gene by reverse transcription-polymerase chain reaction (RT-PCR). Our study demonstrated that continued positivity of PCR analysis before ABMT could predict subsequent relapse in patients who undergo un-purged ABMT procedures.

Disappearance of PML/RAR alpha acute promyelocytic leukemia-associated transcript during consolidation chemotherapy

BACKGROUND AND OBJECTIVE

Acute promyelocytic leukemia (APL) (M3 according to FAB classification) is a subtype of acute myelogenous leukemia characterized by a specific t(15;17) (q22;q12) chromosomal translocation. The majority of APL patients achieve morphologic remission after induction chemotherapy. They can be followed from this point by cytogenetic and molecular analysis of the persistence of the PML/RAR alpha transcript. In order to determine the influence of successive courses of consolidation chemotherapy on clinical and molecular outcome, APL patients treated with all-trans retinoic acid (ATRA) and chemotherapy (AIDA-GIMEMA-LAP0493 protocol) were investigated.

DESIGN AND METHODS

Twenty-four APL patients (pts) (15 males; 9 females) were studied by RT-PCR and cytogenetic analysis at diagnosis, after induction chemotherapy, at each point after any of three consolidation courses, and every 3 months during the first years of maintenance therapy. The median follow-up was 24 months (mths) (range 7-40 mths).

RESULTS

All pts achieved hematologic remission after induction chemotherapy. Our results demonstrate that the majority (87%) of APL patients were still molecularly positive for the APL associated transcript after induction chemotherapy, while the majority (80%) of APL patients became PCR-after the second consolidation chemotherapy.

INTERPRETATION AND CONCLUSIONS

The role of the third consolidation chemotherapy course in converting patients with persistent molecular evidence of disease from PCR+ to PCR- was minimal. We confirm the validity of molecular follow-up after single courses of chemotherapy in monitoring the role of molecular remission.

Long-term disease-free acute promyelocytic leukemia patients really can be cured at molecular level

The characteristic t(15;17) translocation involving chromosomes 15 and 17 is specifically associated with both the common and the variant subtypes of acute promyelocytic leukemia (APL) (M3 according to FAB classification). At the molecular level, it fuses genes encoding PML on chromosome 15 and the nuclear retinoic acid receptor-alpha (RAR alpha) on chromosome 17. The subsequent expression of PML/RAR alpha fusion mRNA provides a potential molecular marker that can be detected in leukemic cells taken from patients with APL. Using PML and RARa sequence specific primers, reverse transcription-polymerase chain reaction (RT-PCR) assays have been developed for detection of PML/RAR alpha transcript in leukemic cells obtained from patients; these RT-PCR assays are more sensitive than conventional cytogenetic analysis.

Maintenance and recovery characteristics of sevoflurane anaesthesia in adult patients. A multicenter, randomized comparison with isoflurane

BACKGROUND

The goal of the present multicenter, prospective, randomized clinical investigation was to compare the clinical efficacy and safety of sevoflurane and isoflurane during maintenance of and recovery from general anaesthesia in adult patients.

METHODS

With the approval of the Ethical Committee and the patient informed consent, 143 ASA physical status I-II patients, aged 18-65 years, were randomized in order to receive either isoflurane (n = 71) or sevoflurane (n = 72) as the main general anaesthetic. After an oral diazepam (0.1-0.2 mg kg-1) and atropine (0.007-0.01 mg kg-1) premedication and a standardized intravenous induction, general anaesthesia was maintained by adjusting the end-tidal concentrations of the inhalational agent for the maintainance of cardiovascular stability. At the end of surgery the anaesthetic vapours were discontinued, and the neuromuscular block was reversed; the following times were recorded: time of eyes opening, time of command response and suitability for discharge from the recovery area. The occurrence of any untoward event was also recorded. Preoperatively and 24 hr after surgery, blood was collected in order to assess renal an hepatic functions.

RESULTS

No differences in demography, duration of surgery, exposure to the inhalational agent and haemodynamic effects were observed between the two groups. Patients receiving sevoflurane showed shorter times for the achievement of extubation (median: 9 min versus 13 min, p = 0.002), eyes opening (median: 10 min versus 13 min, p = 0.002), command response (11 min versus 15 min, p = 0.002) and suitability for discharge from recovery room (median: 19 min versus 22 min, p < 0.05) than those receiving isofluorane. No intra- and intergroup differences were observed in pre- and post-operative laboratory testing of renal and hepatic function.

DISCUSSION

We conclude that sevoflurane, when compared to isoflurane, provides a similarly safe maintenance but allows for a more rapid emergence from general anaesthesia.

Early detection of relapse by prospective reverse transcriptase-polymerase chain reaction analysis of the PML/RARalpha fusion gene in patients with acute promyelocytic leukemia enrolled in the GIMEMA-AIEOP multicenter "AIDA" trial. GIMEMA-AIEOP Multicenter "AIDA" Trial

Although the majority of patients with acute promyelocytic leukemia (APL) are potentially cured by treatments combining all-trans retinoic acid (ATRA) and chemotherapy (CHT), a sizable proportion (around 30%) will relapse during follow-up. Retrospective molecular monitoring studies using reverse transcriptase-polymerase chain reaction (RT-PCR) for the specific PML/RARalpha fusion gene, have shown that a positive test usually precedes the occurrence of hematologic relapse. Prospective RT-PCR analyses were performed since 1993 at diagnosis and at preestablished time intervals during follow-up in bone marrow (BM) samples of 163 patients with PML/RARalpha+ APL enrolled in the multicenter Gruppo Italiano Malattie Ematologiche Maligne dell' Adulto (GIMEMA) trial AIDA (All-trans retinoic acid plus Idarubicin). Treatment consisted of ATRA and idarubicin for induction followed by three polychemotherapy courses as consolidation. The sensitivity level of the RT-PCR assay for PML/RARalpha, as assessed by serial dilution experiments, was 10(-4). All patients were in hematologic remission and tested PCR- at the end of consolidation. Of 21 who converted to PCR-positive thereafter, 20 underwent hematologic relapse at a median time of 3 months (range, 1 to 14) from the first PCR+ result. Seventeen of these 21 (81%) PCR+ conversions were recorded within the first 6 months postconsolidation. Of 142 who tested persistently PCR- in >/=2 tests after consolidation, 8 had hematologic relapse and 134 remained in complete remission (CR) after a median follow-up of 18 months (range, 6 to 38) postconsolidation. Using a time-dependent Cox model, the relative risk of hematologic relapse of patients who converted to PCR+ was 31.8 (confidence limits 95%, 12.9 to 78.3). Our results indicate that conversion to PCR positivity for PML/RARalpha during remission is highly predictive of subsequent hematologic relapse and highlight the prognostic value of stringent molecular monitoring during the early postconsolidation phase in APL. As a result of the present study, salvage treatment in patients enrolled in the GIMEMA trial AIDA is now anticipated at the time of molecular relapse, defined as the conversion to PCR positivity in two successive BM samplings during follow-up.

Hematopoietic progenitor cell collection and neoplastic cell contamination in breast cancer patients receiving chemotherapy plus granulocyte-colony stimulating factor (G-CSF) or G-CSF alone for mobilization

BACKGROUND

We compared hematopoietic progenitor cell (HPC) collection and neoplastic cell contamination in breast cancer patients given cyclophosphamide (CTX) plus granulocyte-colony stimulating factor (G-CSF) or G-CSF alone for mobilization.

PATIENTS AND METHODS

In 57 stage II-III breast cancer patients, CD34+ cells, colony-forming units-granulocyte macrophage (CFU-GM), early HPC and breast cancer cells were counted in HPC collections obtained after CTX plus G-CSF (n = 27) or G-CSF-alone mobilization (n = 30).

RESULTS

The CD34+ cell collection was about two-fold greater after CTX plus G-CSF mobilization (11.0 +/- 7.9 vs. 5.8 +/- 3.5 x 10(6)/kg, P < 0.001). Similarly, the total number of CFU-GM, CD34+CD38- cells and of week-5 cobblestone area forming cells (CAFC) collected was significantly higher in patients mobilized with CTX plus G-CSF. Breast cancer cells were found in the apheresis products of 22% of patients mobilized with CTX plus G-CSF and in 10% of patients mobilized with G-CSF alone (P = 0.36). Of seven patients who failed G-CSF-alone mobilization and eventually underwent chemotherapy plus G-CSF mobilization, none had cytokeratin-positive cells after G-CSF mobilization, whereas four out of seven had cytokeratin-positive cells after chemotherapy plus G-CSF (P = 0.07 by chi 2 test).

CONCLUSION

The CTX plus G-CSF mobilization protocol was associated with a significantly higher HPC collection. However, this benefit was not accompanied by a reduction in the incidence of tumor-contaminated HPC graft.