Salivary secretion rate, yeast cells, and oral candidiasis in patients with acute leukemia

Stimulated salivary secretion rate was repeatedly determined in 29 patients with acute leukemia during two periods of cytotoxic treatment in myelosuppressive doses. For comparison, the salivary secretion rate was studied in 83 healthy persons and in three other groups of hospitalized patients without malignant disorders. At the start of cytotoxic treatment the secretion rate in the patients with leukemia was lower than in healthy persons. The rate fell significantly after 1 to 3 days and later rose to the level seen in the healthy persons. Several interacting factors may have contributed to the decrease in salivary secretion rate, but the most important factor was probably the use of antiemetic drugs during the first 3 days of the study periods. No relationship was found between salivary secretion rate and the number of gram-negative rods found in the mouth. Patients with low salivary secretion rates had high numbers of yeast cells and more often oral candidiasis.

[Ultrasonographic characteristics of the liver in chronic and acute leukemia]

Parenchyma of the liver and blood flow in the portal system were studied in patients with acute and chronic leukemias. Ultrasonic investigations of the liver with the use of Doppler's method were conducted in 82 leukemia patients. It has been found that in most cases of leukemia not only the size but also ultrasonic characteristics of parenchyma of the liver are changed. The echo-structure of the liver depends, first of all, on the duration of the disease and chemotherapy conducted, and, to a lesser degree, on the clinico-morphological forms of leukemias. At the same time a rise is observed in the portal blood flow rate that may be compensatory in response to anemia. Pronounced dilatation of the splenic vein and of the main stem of the hepatic vein, as well as an increased minute blood volume in hepatic vein of chronic leukemia patients, are, probably, caused by increased venous outflow from the enlarged spleen.

Functional myocardial impairment in children treated with anthracyclines for cancer

A non-invasive exercise method was used to look for myocardial damage in apparently normal children who had received moderate doses of anthracyclines for treatment of cancer. 19 children (mean [SD] age 10.6 [4.3] years) who had received anthracyclines (mean total dose 230 [119] mg/m2) and 10 who had received other cytotoxic drugs (mean age 13.3 [4.9] years) were selected from 263 children attending routine follow-up examinations. They underwent measurement of heart rate, blood pressure, and left ventricular dimensions by echocardiography before and after exercise on a bicycle for a maximum of 10 min. All 29 were in remission. All the subjects showed normal fractional shortening (FS = left ventricular end-diastolic minus end-systolic diameter as a percentage of the end-diastolic diameter) at rest, but the increase in FS on exercise was significantly lower in the children who had received anthracyclines than in those who had not (3 [16]% vs 23 [17]%; p less than 0.05). This difference remained significant after adjustment for age and drug exposure. However, there were no significant differences between the groups in the adjusted mean percentage changes on exercise in heart rate or systolic or diastolic blood pressure. Disease type had no effect on the cardiological indices. Thus, many children who have received anthracyclines may have suffered subclinical myocardial damage. Post-exercise echocardiography seems a useful non-invasive method for detecting such damage. Long-term cardiological follow-up of these patients is needed.

Functional p75 interleukin-2 receptor expression on the fresh blast cells in childhood acute lymphoblastic leukemia with natural killer cell properties

Neoplastic cells of childhood acute lymphoblastic leukemia (ALL) with natural killer (NK) cell properties were studied for the expression of p75 interleukin-2 receptors (IL-2R) and the receptor functions. Freshly prepared blast cells from a patient with ALL had NK cell properties: (1) the phenotype such as CD56+, CD2+, E-rosette+, CD3-, and CD19-; and (2) the presence of spontaneous cytotoxicity against NK-sensitive K562 target cells. Although p55 Tac antigen was not detectable, there was the expression of p75 IL-2R on the freshly prepared blast cells: 70% of the cells reacted with Mik-beta 1 monoclonal antibody against p75 IL-2R as determined by flow cytometry. Two-color flow cytometry revealed that the blast cells expressed both p75 IL-2R and NKH-1. NK activity of the blast cells was augmented by their treatment with 1,000 U/ml recombinant IL-2 (rIL-2): the cytotoxicity level as percentage lysis increased to 38.7% from 22.0% when the normal lymphocyte value increased to 62.1% from 46.2%. Although the blast cells possessed no apparent level of proliferative capacity, the addition of 1,000 U/ml rIL-2 yielded a 2.7-fold increase in their thymidine uptake. These results demonstrate the expression of functional p75 IL-2R on the patient's blast cells with NK cell properties.

Subtle primary hypothyroidism in patients treated for acute lymphoblastic leukemia

We evaluated serum thyroid hormone and thyroid antibody levels, the serum TSH response to TRH, and the circadian pattern of serum TSH in 10 children and adolescents after radiation therapy for acute lymphoblastic leukemia. Four patients had received central nervous system preventive cranial irradiation and intrathecal chemotherapy, and the remaining 6 patients were treated with craniospinal irradiation for central nervous system relapse. Serum total T4 and T3 concentrations were within the normal range and thyroid antibodies were negative in all patients. Four patients who had received craniospinal irradiation had low free T4 levels. Prior to TRH administration, the overall mean serum TSH concentration was 5.4 +/- 1.3 mU/l, and the mean peak response to TRH was 33 +/- 6.5 mU/l. Both were significantly increased when compared to the levels observed in our control population (p less than 0.05 and less than 0.025, respectively). The overall mean nadir diurnal TSH was 3.6 +/- 0.8 mU/l, and the mean peak nocturnal TSH was 6.9 +/- 1.3 mU/l, both significantly elevated when compared to normal children (p less than 0.025). The mean nocturnal TSH surge, however, was not significantly different from normal. Four of 6 children treated with craniospinal irradiation, and one of four children treated with cranial irradiation had increased basal and peak serum TSH concentrations in response to TRH. One of the patients treated with cranial irradiation had an abnormal nocturnal TSH surge. We conclude that subtle primary hypothyroidism is relatively common in patients with acute lymphoblastic leukemia, particularly in those who have been treated with craniospinal irradiation.

Late cardiac effects of doxorubicin therapy for acute lymphoblastic leukemia in childhood

BACKGROUND

Cardiotoxicity is a recognized complication of doxorubicin therapy, but the long-term effects of doxorubicin are not well documented. We therefore assessed the cardiac status of 115 children who had been treated for acute lymphoblastic leukemia with doxorubicin 1 to 15 years earlier in whom the disease was in continuous remission.

METHODS

Eighteen patients received one dose of doxorubicin (45 mg per square meter of body-surface area), and 97 received multiple doses totaling 228 to 550 mg per square meter (median, 360). The median interval between the end of treatment and the cardiac evaluation was 6.4 years. Our evaluation consisted of a history, 24-hour ambulatory electrocardiographic recording, exercise testing, and echocardiography.

RESULTS

Fifty-seven percent of the patients had abnormalities of left ventricular afterload (measured as end-systolic wall stress) or contractility (measured as the stress-velocity index). The cumulative dose of doxorubicin was the most significant predictor of abnormal cardiac function (P less than 0.002). Seventeen percent of patients who received one dose of doxorubicin had slightly elevated age-adjusted afterload, and none had decreased contractility. In contrast, 65 percent of patients who received at least 228 mg of doxorubicin per square meter had increased afterload (59 percent of patients), decreased contractility (23 percent), or both. Increased afterload was due to reduced ventricular wall thickness, not to hypertension or ventricular dilatation. In multivariate analyses restricted to patients who received at least 228 mg of doxorubicin per square meter, the only significant predictive factors were a higher cumulative dose (P = 0.01), which predicted decreased contractility, and an age of less than four years at treatment (P = 0.003), which predicted increased afterload. Afterload increased progressively in 24 of 34 patients evaluated serially (71 percent). Reported symptoms correlated poorly with indexes of exercise tolerance or ventricular function. Eleven patients had congestive heart failure within one year of treatment with doxorubicin; five of them had recurrent heart failure 3.7 to 10.3 years after completing doxorubicin treatment, and two required heart transplantation. No patient had late heart failure as a new event.

CONCLUSIONS

Doxorubicin therapy in childhood impairs myocardial growth in a dose-related fashion and results in a progressive increase in left ventricular afterload sometimes accompanied by reduced contractility. We hypothesize that the loss of myocytes during doxorubicin therapy in childhood might result in inadequate left ventricular mass and clinically important heart disease in later years.

Initial electroencephalographic findings in children with acute lymphoblastic leukaemia

Electroencephalography (EEG) was performed on 66 children with acute lymphoblastic leukaemia, 45 before treatment and 21 during the first 5 days of chemotherapy. The patients, aged 7 months to 16 years, 33 boys and 33 girls, had been admitted to the Department of Paediatrics, University of Oulu, between March 1976 and January 1987. The EEG findings were compared with those in 66 age and sex-matched control children chosen at random from the local population. The patients had significantly more frequent and more severe disturbances in background activity (p less than 0.001) than the controls and increased slow waves in the occipital (p less than 0.001) and temporal regions (p less than 0.01). The patients who had received chemotherapy before the EEG recording had EEG disturbances significantly more frequently than the other patients (p less than 0.01), but the latter still had EEG abnormalities significantly more frequently than their matched controls, although they did not have severe changes (grade 3). The results suggest that chemotherapy increases EEG changes during the early days of induction therapy and possibly induces long-term disturbances in brain function. The associations between EEG changes and clinical findings were also analysed and the results show that a long duration of leukaemic symptoms or an aggressive disease may lead to EEG abnormalities.

Clinical characteristics and treatment outcome of children with acute lymphocytic leukemia and Down's syndrome. A Pediatric Oncology Group study

Of 2947 children with acute lymphocytic leukemia (ALL), treated during three consecutive studies of the Pediatric Oncology Group (1974-1986), 52 (1.8%) had Down's Syndrome (DS). Comparison of clinical and laboratory characteristics showed no significant differences in leukocyte count, racial distribution, sex ratio, platelet count, incidence of mediastinal mass, lymphadenopathy or hepatosplenomegaly, or percentage of blood or bone marrow blasts for children with ALL with or without Down's Syndrome (DS-ALL or NDS-ALL, respectively). However, children with DS-ALL were slightly older at the time of presentation and had higher hemoglobin values. The relative frequency of each major immunophenotype (early pre-B, pre-B, T, or B) was also comparable for patients with or without DS. For this report, treatment regimens were categorized as either conventional (no consolidation therapy) or intensive. Cox regression analysis revealed that the presence of DS, a higher leukocyte count, black race, or age older than 10 years was independently associated with a poorer event-free survival (EFS) for children treated with conventional chemotherapy. However, for the cohort of children who received intensive chemotherapy, DS was no longer an independent risk factor. In fact, event-free survival (EFS) was markedly improved to a level comparable with that observed in the children diagnosed as having NDS-ALL. On the other hand, serious toxicity, requiring interruption of treatment, was significantly more frequent in the intensively treated children with DS compared with similarly treated patients with NDS-ALL, although deaths resulting from toxicity occurred infrequently.

Longitudinal growth in children with non-Hodgkin's lymphoma and children with acute lymphoblastic leukemia: comparison between unirradiated and irradiated patients

Longitudinal growth was studied in children treated for non-Hodgkin's lymphoma (NHL). The aim of the study was to compare these children's growth velocity with findings in a previous study we performed on age-matched children with acute lymphoblastic leukemia (ALL) who received cranial irradiation. Nine children with NHL with an onset time of treatment between 4 and 9 years of age (mean 6.5 years) were studied with annual body measurements taken from the time of the diagnosis and thereafter annually during the following 4 years. None of the children received cranial irradiation. During the first treatment year a significantly low mean height velocity was observed (-1.4 standard deviation score [SDS]) for the NHL group. The consecutive two 1 year periods showed a normalization of the mean height velocity. For the group of children with ALL, there was a more prominent negative effect on height during the first 2 years of treatment than for the NHL group in the present study. After the cessation of therapy, the children with NHL showed a reduced catch-up growth compared with the children with ALL. The explanation offered is that cranial irradiation has a heavier impact on growth than chemotherapy during the first 2 years of treatment, but an intense chemotherapy during the maintenance period could have a considerable impact in blunting growth.

Dentofacial development in long-term survivors of acute lymphoblastic leukemia. A comparison of three treatment modalities

Ninety-seven children who were diagnosed with acute lymphoblastic leukemia before 10 years of age and treated with chemotherapy alone, chemotherapy plus 1800-cGy cranial irradiation (RT), or chemotherapy plus 2400-cGy RT were evaluated for effects of therapy on dentofacial development. All patients were seen at least 5 years postdiagnosis. Dental abnormalities were determined from panoramic radiographs, and craniofacial evaluations were made from lateral cephalometric radiographs. Ninety-one (94%) of all patients and 41 (100%) of patients younger than 5 years of age at diagnosis had abnormal dental development. The severity of these abnormalities was greater in children who received treatment before 5 years of age and in those who received RT. Observed dental abnormalities included tooth agenesis, arrested root development, microdontia, and enamel dysplasias. Craniofacial abnormalities occurred in 18 of 20 (90%) of those patients who received chemotherapy plus 2400-cGy RT before 5 years of age. Mean cephalometric values of this group showed significant deficient mandibular development. The results of this study suggest that the severity of dentofacial-developmental abnormalities secondary to antileukemia therapy are related to the age of the patient at the initiation of treatment and the use of cranial RT.

Prospective neurophysiological study in children treated for acute lymphoblastic leukaemia: serial EEG during treatment and long-term follow up with evoked potentials

In 79 children treated for acute lymphoblastic leukaemia according to protocol ALL-BFM 81, serial EEG examinations were performed before, during and after therapy. Diffuse changes of the background activity were observed in 64% of the children at the time of diagnosis. During induction and reinduction treatment with vincristine and L-asparaginase, and with some delay after CNS irradiation, a marked slowing developed in up to 65% of patients. Children who had not been irradiated showed transient disturbances during treatment with medium-dose-methotrexate. Reinduction induced more abnormal EEGs in the children who had been irradiated. At the end of maintenance therapy, only slight EEG changes were found. No differences between the irradiated and non-irradiated group were then seen. Children with CNS leukaemia or seizures differed from those with an uncomplicated treatment in that they more often showed focal and persistent disturbances. In 39 patients who stayed in first remission for at least 18 months after the termination of treatment, a follow up investigation was performed. From the EEG examination, including power spectral analysis, no differences were found between irradiated and non-irradiated patients. Slowing of the dominant frequency was seen in the patients with more severe leukaemia and in those whose EEG had been markedly abnormal at diagnosis. The visually evoked potentials were normal in all groups of patients. In the brainstem auditory evoked potential, a prolongation of the latency of wave I and a decrease of the I-V interval was found in irradiated patients. We conclude that the diffuse EEG changes frequently emerging during treatment are reversible. Persistent or lateralized changes can indicate a neurological complication.(ABSTRACT TRUNCATED AT 250 WORDS)

[Somatic development after successful therapy of acute lymphoblastic leukemia]

The authors evaluated 55 subjects after successful treatment of acute lymphoblastic leukaemia in childhood as regards height, body weight and sexual maturation. In 23 the final height could be evaluated, which was somewhat lower than the mean height of the population, lower than could be expected according to the genetic potential and height before the diseases with a more evident deficit in women. There was an obvious tendency to overweight. Early onset of menarche was recorded.

Directions for future research in childhood lymphoblastic leukemia

Progress in therapy of acute lymphoblastic leukemia continues at a steady pace, with event-free survival rates approaching 90% for low-risk and standard-risk patients. The challenge now is to use the emerging new insights into the unique biology of the leukemic lymphoblast to create novel strategies for curing ALL with minimum toxicity. It is hoped by all of us that these volumes help to stimulate development of new approaches to curing ALL at the lowest possible cost to the patient and to society.

[Autologous bone marrow transplantation in children with acute leukemia]

Eight children with acute leukemia were treated with chemoradiotherapy or high-dose chemotherapy followed by infusion of autologous marrow unpurged or purged mainly with monoclonal antibodies. Four were treated in their first remission, three in their second remission, and one in the fourth remission. Patients were isolated in laminar air flow rooms with sterile conditioning. Infused mononuclear cells ranged from 1.0 to 3.8 x 10(7)/kg. Hematologic engraftment was obtained in five patients. The other three patients, who were treated with monoclonal antibody or drug, received unpurged back up marrow because of delayed bone marrow reconstitution. Two recovered, but one died before engraftment. Hematologic recovery was delayed after autologous bone marrow transplantation. The median time to achieve 1,000 leukocytes/microliters, 500 neutrophils/microliters, and last platelet transfusion was 36 days (12-90), 36 days (12-90), and 70 days (39-214), respectively. Moreover, further increases beyond these levels remained unusually slow, especially in platelets. Two of eight patients relapsed at 5 and 15 months and the other patient died of interstitial pneumonitis. Actuarial disease free survival was 62.5%. There was a trend toward improved disease free survival for patients transplanted in the first remission (100%).

Hormonal and growth status in long term survivors of acute lymphoblastic leukemia (ALL) in children

Nineteen children and adolescents in long-term complete remission from acute lymphoblastic leukemia (ALL) were studied for hormonal and growth status after cessation of therapy. Cranial irradiation of 600-2,400 cGy was given for C.N.S. prophylaxis in 18 out of 19 patients, and additional irradiation of 2,000 cGy was given to both testes of a prepubertal boy because of testicular infiltration. The time ranges after cranial irradiation and cessation of therapy at the time of study were 61-137 months and 5-127 months respectively. Thyroid hormone, cortisol and peak cortisol response after ACTH stimulation were normal in every tested children. Basal serum gonadotropin and sex steroid values were appropriate in the majority of patients. A child who received testicular irradiation, had elevated levels of gonadotropins. Glucagon stimulation test (GST) and/or L-Dopa propranolol test (DP test) were used to study growth hormone (GH) response. None had peak GH value less than 7 ng/ml. Ten patients had peak GH values of over 15 ng/ml. Nine female patients had normal puberty and regular menstruation. Eight out of ten male children also had normal puberty. All except two male patients had normal linear growth within 2 standard deviations of the mean. The mean attained final height of 11 children was not significantly different when compared to the mean predicted heights obtained from Bayley-Pinneau and Tanner methods. Excessive weight gain during and after cessation of chemotherapy was observed in the majority of children. Continuing long-term review of these children is essential.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory care for patients with acute leukemia: an alternative to frequent hospitalization

Over the past 5 years, 23 cancer patients diagnosed with adult acute leukemia have been able to receive their required therapies primarily on an ambulatory basis. This included chemotherapy, antimicrobials, and blood product infusions. The ambulatory primary nurse has been a vital facilitator in designing and implementing a care plan that includes drug administration, symptom management, and the complex coordination of community resources. The relationship that develops between the patient, family, and primary nurse is also a key factor in the effectiveness of such an ambulatory program.

Bone pain as an initial symptom of childhood acute lymphoblastic leukemia: association with nearly normal hematologic indexes

We reviewed the records of all patients with a diagnosis of ALL made at our center during a 13-year period to determine the relationship between bone pain and the hematologic findings at diagnosis of acute lymphoblastic leukemia. Of 296 eligible patients, 179 (60%) had no bone pain (group 1), 65 (22%) had some bone pain (group 2), and 52 (18%) had prominent bone pain that overshadowed other manifestations of the leukemia (group 3). Statistically significant differences were found between the groups for hemoglobin concentration (p less than 0.001), leukocyte count (p = 0.014), absolute neutrophil count (p = 0.002), percentage of circulating blast cells (p = 0.009), and platelet count (p less than 0.001). Children in group 3 had values closer to normal for all these values than those of patients in the other groups. Group 3 patients had symptoms an average of more than 2 weeks longer before diagnosis, and had significantly lower serum uric acid and higher calcium levels than patients in the other groups had. No differences were detected among the groups in age at diagnosis, gender, or survival rate. We conclude that children with acute lymphoblastic leukemia who have prominent bone pain preceding the diagnosis frequently have nearly normal hematologic values and that this feature may contribute to a delay in diagnosis.

Bone lining (endosteal) cells and hematopoiesis: a light microscopic study of normal and pathologic human bone marrow in plastic-embedded sections

Human trabecular bone that encloses the bone marrow (BM) is covered by a single layer of thin, sometimes inconspicuous, flat, elongated (spindle-shaped) endothelium-like cells with a round or oval nucleus. These "bone lining" cells, or endosteal cells (EC), form a continuous membrane (endosteum) over the trabecular bone surfaces. In most cases, the composition and thickness of these cells do not vary unless the cells are in intimate contact with hematopoietic tissue. In that instance, they are seen as a single layer adjacent to hematopoietic tissue or as a zone of tightly packed or loosely arranged mononuclear (hematopoietic) cells, some apparently originating from the endosteum. In a reparative process, such as following BM harvest, during which bony trabeculae (BT) are mechanically fractured, these cells are seen giving rise to osteoprogenitor (osteoblasts and osteoclasts) cells. Occasionally, the EC appear similar to BM stromal cells (morphologically and by their association with collagen/reticulin fibers) and are best seen at or near the BT that are cut tangentially. Short processes extending from the EC towards the underlying osteocytes have also been observed, suggesting that a channel of communication exists between them and osteocytes. Our observations, coupled with the experimental findings of others (i.e., that hematopoietic stem cells are concentrated near the endosteum, that cells responsible for BM and stroma regeneration are derived from the endosteal layer, and that high concentrations of hematopoietic colony-stimulating factors are produced there), indicate that, in addition to functioning as a simple membranous covering layer for BT, the endosteum helps to support osteocytes and maintains mineral homeostasis.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of culture on pain in Anglo and Hispanic children with cancer

This study sought to determine if cultural heritage and acculturation influence the perception and expression of pain and anxiety. The study was based on self-report and observation of Anglo and Hispanic children with cancer undergoing invasive procedures. Seventy-eight children between the ages of 3 and 15 participated. Thirty-five were Anglo and 43 were Hispanic. A significant inverse relationship between age and observed and reported distress was noted in both ethnic groups. The Anglo and Hispanic children had remarkably similar behavioral responses. Hispanic parents, however, reported significantly higher levels of anxiety than Anglo parents.

Transient focal leukoencephalopathy following intraventricular methotrexate and cytarabine. A complication of the Ommaya reservoir: case report and review of the literature

A 14-year-old boy, suffering from acute lymphoblastic leukemia with meningeal involvement, was treated with intraventricular methotrexate and cytosine arabinoside, administered via an Ommaya reservoir (OR). Three months later, right occipital headache, vomiting, and lethargy appeared. Cerebrospinal fluid specimens showed increased proteins and a right frontal slow-wave focus was evident on the EEG recording. The computed tomography scan revealed white matter hypodensity within the right frontal and rolandic regions. After injection of medium contrast, an abscesslike hyperdensity appeared, surrounding both a well-placed cannula tip and the right frontal horn of the lateral ventricle. Brain swelling and shift signs were also evident. Nine cases of focal methotrexate leukoencephalopathy have been previously reported, and in six of these there was a misplaced OR cannula tip. The focal methotrexate leukoencephalopathy seems to be related to the neurotoxicity of the drugs administered, and may also exist with a well-placed OR cannula tip. Immediate removal of the catheter may be associated with a benign evolution.

Treatment of meningeal relapse in childhood acute lymphoblastic leukemia: II. A prospective study of intellectual loss specific to CNS relapse and therapy

Changes in intellectual function during the course of treatment for acute lymphocytic leukemia were studied. Twenty-four children had baseline psychological evaluations and annual reevaluations for 3-6 years postdiagnosis. Treatment in all patients included combination chemotherapy, 2,400 cGy prophylactic cranial irradiation, and intrathecal methotrexate. Central Nervous System (CNS) relapse occurred in eight of these children. It was then treated with 3,000 cGy cranial plus 1,800 cGy spinal irradiation. Patients who remained in continuous complete remission showed no decline in global intelligence quotient (IQ). Patients who experienced CNS relapse had a mean decline of 16 IQ points by 3 years postdiagnosis and the long-term survivors displayed a mean loss of 25 IQ points 5-6 years postdiagnosis. Three of the five long-term survivors of CNS relapse function within the retarded range of mental ability and require special education. The other two have learning problems and display poor academic performance relative to same-age peers. There was no association noted between age at diagnosis and ultimate loss of IQ points. This prospective study suggests that children who receive a second course of cranial irradiation for treatment of CNS relapse are at high risk for significant and progressive intellectual loss.