Acute lymphocytic leukemia in adults: a retrospective study and analysis of current management options

OBJECTIVE

To examine current therapeutic modalities for acute lymphocytic leukemia (ALL) in adults, analyze prognostic variables, and offer treatment recommendations.

DESIGN

We reviewed our experience with 90 adult patients with ALL examined at the Mayo Clinic between 1982 and 1992 and used it as a background for discussion of prognostic factors and management options in adult patients with ALL.

MATERIAL AND METHODS

The pretreatment characteristics of patients, types of induction chemotherapy, and postremission treatment, including bone marrow transplantation (BMT), were analyzed for prognostic significance for each of three outcomes: complete remission (CR) rate, duration of CR, and overall survival of patients.

RESULTS

Of the 90 study patients, 80 had received induction chemotherapy. Overall long-term survival for treated patients was 25%. None of the 10 patients younger than 18 years of age underwent BMT, and their long-term survival was 80%. Of the other 70 patients, who were 18 years old or older, 42 (60%) had a CR with induction chemotherapy. Of these 42 patients, 31 did not undergo BMT, and their long-term survival was less than 13%. BMT was done in six patients during a first CR (with 100% survival), in four during a later CR (with 50% survival), and in six with disease (with 17% survival). The median age of patients who received chemotherapy was 50 years (range, 19 to 87) and that of patients who underwent BMT was 34 years (range, 18 to 46). Overall, age was the only significant prognostic factor.

CONCLUSION

With our application of current chemotherapy, the outcome in adult patients (18 years old or older) with ALL was dismal. The results were considerably better in patients younger than 18 years of age or in those who underwent BMT as post-remission therapy. Comprehensive assessment of our experience and that in the literature, however, did not resolve issues about current management. Participation of patients in comparative trials is critical for determining the best therapy for ALL in adults.

An interleukin-4-induced transcription factor: IL-4 Stat

Interleukin-4 (IL-4) is an immunomodulatory cytokine secreted by activated T lymphocytes, basophils, and mast cells. It plays an important role in modulating the balance of T helper (Th) cell subsets, favoring expansion of the Th2 lineage relative to Th1. Imbalance of these T lymphocyte subsets has been implicated in immunological diseases including allergy, inflammation, and autoimmune disease. IL-4 may mediate its biological effects, at least in part, by activating a tyrosine-phosphorylated DNA binding protein. This protein has now been purified and its encoding gene cloned. Examination of the primary amino acid sequence of this protein indicates that it is a member of the signal transducers and activators of transcription (Stat) family of DNA binding proteins, hereby designated IL-4 Stat. Study of the inhibitory activities of phosphotyrosine-containing peptides derived from the intracellular domain of the IL-4 receptor provided evidence for direct coupling of receptor and transcription factor during the IL-4 Stat activation cycle. Such observations indicate that IL-4 Stat has the same functional domain for both receptor coupling and dimerization.

THC: YAG Laser Sclerostomy with Preoperative Mitomycin-C Subconjunctival Injection in Rabbits

Subconjunctival fibrosis is one of the major causes of most bleb failures. To inhibit the wound-healing process and to achieve a better intraocular pressure (IOP) lowering effect as well as bleb formation, we performed a sclerostomy using a THC:YAG laser (thulium, holmium, and chromium-doped yttrium-aluminum-garnet crystal) and a subconjunctival injection of mitomy-cin-C given 24 h or 5 days before a filtering operation or soon after the filtering process in rabbits. A 1-mm conjunctiva wound was made 12 mm away from the sclerostomy site to allow for entry of an optic probe for delivering energy. Forty-eight rabbits were divided into four groups. Group I received a subconjunctival injection of 0.2 ml of 0.2 mg/ml of mitomycin-C 24 h before the operation. The same dosage of mitomycin-C was given to Group II 5 days before the operation and to Group III immediately following the operation. Group IV served as a control, and only 0.2 ml of normal saline solution was given 24 h preoperatively. One eye of each rabbit was randomly selected for the experiment, while the other eye served as a control. The bleb lasted 30.9 $pM 15.7 days in Group I, 16.0 $pM 6.4 days in Group II, 15.5 $pM 6.5 days in Group III, and 2.3 $pM 0.7 days in Group IV. The IOP lowering effect was parallel to bleb formation. The results demonstrate that a subconjunctival mitomycin-C injection given 24 h before a filtering operation is more effective in prolonging the filtering effect produced by the THC:YAG laser than one given postoperatively.

THC:YAG laser sclerostomy with mitomycin subconjunctival injection in rabbits

We performed sclerostomy using THC:YAG laser (thulium, holmium, chromium doped YAG crystal) and subconjunctival injection of mitomycin soon after the filtering process in rabbits to observe the lowering effect of intraocular pressure(IOP) and filtering bleb formation. A 1-mm conjunctiva wound was made 12 mm away from the sclerostomy site to allow the entry of the optic probe for delivering energy. Forty-eight rabbits were divided into 3 groups. After sclerostomy, Group I received 0.2 ml normal saline subconjunctival injection and Group II and III received 0.2 ml mitomycin injection of 0.1 and 0.2 mg/ml respectively. One eye of each rabbit was randomly selected for the experiment while the fellow eye served as control. The bleb lasted 1.4 +/- 0.5 days (or 1 to 2 days) in Group I, 8.5 +/- 4.5 days (or 4 to 17 days) in Group II and 15.4 +/- 10.9 days (or 4 to 37 days) in Group III. The IOP lowering effect was significantly enhanced in Group III. The postoperative complication was minimal corneal punctate erosion in the mitomycin group, but all of them, however, resolved within one week. The results demonstrated that mitomycin is effective in prolonging the filtering effect produced by the THC:YAG laser.

The role of venous hypertension in the pathogenesis of Legg-Perthes disease. A clinical and experimental study

Thirty-two patients in whom Legg-Perthes disease apparently involved only one hip were examined with venography, measurement of intraosseous and intra-articular pressures, arthrography, and dynamic triphasic bone-imaging with 99mTc methylene diphosphonate. The arterial flow of blood in the affected femoral head was slightly decreased, but the difference from that on the normal side was not statistically significant. However, there was marked disturbance of the venous drainage in the diseased hip, elevated intraosseous pressure in the affected femoral neck, and increased intra-articular pressure in the involved hip compared with the normal side. An animal model was then created in twenty immature dogs, venous drainage was obstructed, and intraosseous pressure of the femoral head and neck was elevated by injection of four milliliters of semiliquid silicone into the femoral neck. In eleven of the dogs, areas of avascular necrosis resembling those associated with Legg-Perthes disease developed in the femoral head.

Pigmented Paget's disease of the male breast

Paget's disease of the breast presents as an eczematous lesion of the nipple. Histologically, it is characterized by malignant intraepidermal cells associated with an underlying ductal carcinoma. Paget's disease of the male breast is rare. Although melanin has been found within the malignant cells of Paget's disease, no clinically pigmented lesion has yet been reported. We present a case of pigmented Paget's disease of the male breast and review the pathogenesis of this disease.