Central nervous system involvement in haematological malignancies

We have reviewed our experience of central nervous system (CNS) involvement in 540 patients with lymphoma or acute leukaemia treated at the Royal Infirmary of Edinburgh between 1979 and 1987. CNS invasion is a significant problem in acute lymphoblastic leukaemia but may well respond to treatment, while in acute non-lymphoblastic leukaemia this complication occurs too infrequently to justify routine CNS prophylaxis. CNS involvement in Hodgkin's disease or non-Hodgkin's lymphoma (NHL) of low-grade malignancy was uncommon, exclusively of the extradural variety, and did not appear to alter the ultimate prognosis. Diffuse leptomeningeal involvement occurred with significant frequency in more aggressive NHL, often while the disease was in systemic remission or during remission induction. The prognosis for leptomeningeal disease or intracranial mass lesions was extremely poor and some form of CNS prophylaxis may be justified in aggressive NHL.

Cervical intraepithelial neoplasia in lymphoma patients: a cytological and colposcopic study

Twenty-seven patients with Hodgkin's (n = 19) and non-Hodgkin's (n = 8) lymphomas underwent cytological and colposcopic screening of the uterine cervix. Colposcopically directed cervical punch biopsies were taken from all patients in whom a colposcopic abnormality was detected. Lymphoma patients were compared with 79 controls with normal cervical cytology and no known haematological abnormality. Colposcopically directed punch biopsies were taken from the cervical transformation zone of all controls. Significantly more lymphoma patients (19%) than controls (3%) had CIN II or III (P less than 0.01) and cervical human papillomavirus infection, as judged by the presence of koilocytes (52% of lymphoma patients; 27% of controls; P less than 0.02). All six lymphoma patients with CIN had Hodgkin's disease (HD), and five had received combination chemotherapy. Half of the cases of CIN in lymphoma patients and all the cases of CIN in control patients were not detected by cervical cytology. This study suggests that female patients with HD are at increased risk of CIN, and that cervical cytology alone may be an inadequate form of screening for these patients.

Lomustine, vindesine and bleomycin (LVB) used in the treatment of relapsed advanced Hodgkin's disease. A prospective study on behalf of the East of Scotland and Newcastle Lymphoma Group (ESNLG)

Sixty-three patients with relapsed advanced Hodgkin's disease were treated with lomustine (CCNU), vindesine and bleomycin (LVB). Age range was 17-72 years, with 38 males and 25 females. Thirty patients achieved complete remission (CR) with a median duration of 24+ months (range 3-55). Nineteen continue in unmaintained CR. CR rates were highest for those patients who relapsed greater than 6 months after first line treatment and for those at second or subsequent relapse. CR rates were higher in those with nodal only relapse. Twenty-seven patients were non-responders and six were partial responders. These 33 patients were subsequently changed to alternative chemotherapeutic regimes and 26 failed to respond to any therapy and have since died. Only one patient is in unmaintained complete remission. The regimen was well tolerated by patients, and easy to administer. It produced no serious episodes of toxicity. We conclude that LVB is of value in the management of relapsed advanced Hodgkin's disease especially in chronic relapsing patients, and where relapse occurs greater than 6 months after the first line treatment. We are presently unsure whether it offers any advantage over reintroduction of first line treatment in the latter group.

Methylprednisolone, etoposide, vindesine, and chlorambucil (PEEC) alone or alternating with CHOP as initial or salvage therapy for non-Hodgkin's lymphoma

A novel cytotoxic drug combination, PEEC, has been tested in the initial or salvage treatment of lymphomas. The PEEC combination alone is active in high grade or intermediate grade NHL with two complete and two partial remissions out of four patients so treated. When combined with standard CHOP therapy using an alternating regime, seven out of 11 patients obtained a complete remission and four partial remission. Ten patients were well, off treatment, beyond one year from presentation. The combination was less impressive, however, as salvage therapy with two partial responses in a heavily pre-treated group of nine patients.

Can bone marrow transplantation be offered to more patients in south east Scotland?

The number of patients with haematological malignancies and aplastic anaemia treated by allogeneic bone marrow transplantation in South East Scotland between 1983-1986 is apparently greater than that estimated by the Black Report in 1982. The potential for increasing the use of this effective therapy by using bone marrow donors from the extended family or national volunteer panels is discussed.

Plasma levels of highly sulphated glycosaminoglycans are raised in patients with chronic myeloid leukaemia

A study of absolute basophil counts and plasma levels of highly sulphated glycosaminoglycans in 30 peripheral blood samples from 21 patients with different leukaemias was performed. This revealed significantly raised levels of both plasma highly sulphated glycosaminoglycans and basophils in those patients with chronic myeloid leukaemia, as compared to those with other types of leukaemia and 35 normal controls. A strong correlation (r = 0.83) was observed between the levels of highly sulphated glycosaminoglycans and basophil counts in the group as a whole, supporting a direct relationship between the two. The elevated plasma levels of highly sulphated glycosaminoglycans may contribute to the bleeding tendency reported in some patients with chronic myeloid leukaemia.

Adult Gaucher disease in association with acute leukaemia

A non-Jewish patient diagnosed as having Gaucher disease at the age of 67 is described. Fourteen months after presentation he was diagnosed as having acute myeloid leukaemia. A possible association between Gaucher disease and acute myeloid leukaemia is suggested.

Transfusion-induced graft versus host disease in pregnancy

We report the unusual occurrence of fatal post-transfusion graft versus host disease manifest predominantly in the skin in an apparently immunocompetent host.

Lysosomal enzyme abnormalities in preleukaemic Sweet's disease: case report

Quantitative and qualitative abnormalities in marrow lysosomal enzymes, suggestive of acute myeloid leukaemia, were detected in a patient with Sweet's disease and monocytosis 12 months before she presented with acute myelomonocytic leukaemia. Biochemical characterisation of blood and marrow cell extracts may help to identify those patients with Sweet's disease and other preleukaemic conditions who are most at risk of developing leukaemia.

The efficacy and toxicity of VAD in the treatment of myeloma and related disorders

Impressive results have recently been reported in 29 cases of advanced refractory myeloma treated with 4-d infusions of Vincristine and Adriamycin (VAD). We report our own experience with this protocol in 13 cases of myeloma and related lymphoproliferative disorders. In 2 of these cases, VAD was used as first line treatment. Objective responses were seen in two-thirds of cases and the major complication of therapy was infection, predominantly bacterial in nature.

Marrow transplantation for non-Hodgkin's lymphoma: a multi-centre study from the European Co-operative Bone Marrow Transplant Group

Twenty-five patients with intermediate- or high-grade non-Hodgkin's lymphoma (NHL) were treated by allogeneic bone marrow transplantation. For the nine patients transplanted in first complete remission the disease-free survival was 100%; of the nine patients transplanted in subsequent remissions four (44%) achieved long-term disease-free survival but two died of relapsed lymphoma. For the seven patients transplanted at a time when they had active disease, the initial complete remission rate was high but four died of progressive lymphoma and no patient achieved long-term disease-free survival. The incidence of complications associated with allogeneic bone marrow transplantation was similar to that observed in other series of patients transplanted for haematological malignancy and was related to the status of the disease at the time of transplant. Thus allogeneic bone marrow transplantation is a radical but effective treatment for patients with NHL who have 'minimal residual disease'. Efforts to define further the subset of patients who can most successfully be treated by transplantation may improve the overall results.

Bilateral testicular plasmacytoma

A case is reported of a 55-year-old man with asynchronous bilateral testicular plasmacytoma. Despite chemotherapy and radiotherapy he died seven and a half years after the original diagnosis of testicular plasmacytoma, and 13 months after developing evidence of disseminated myeloma. The testicular plasmacytomas may have arisen as a result of seeding from a systemic myelomatous process.

Retrospective investigation of transfusion-related non-A, non-B viral hepatitis associated with M2 antigen

A retrospective study of transfusion-related non-A, non-B viral hepatitis was conducted in seven patients. Findings showed that six recipients had been exposed to at least one unit of blood possessing a putative serological marker for non-A, non-B hepatitis, the M2 antigen or anti-M2IgM. The M2 markers were associated with non-A, non-B hepatitis that developed 3-7 weeks after transfusion. It sees increasingly probable that M2 markers may be useful for diagnosis and/or prevention of post-transfusion hepatitis.

Acute autonomic neuropathy in association with systemic lupus erythematosus

A patient is described with acute autonomic neuropathy, developing post partum in association with systemic lupus erythematosus, and showing a rapid clinical response to steroids. The pattern of tissue damage is suggestive of an immunologically mediated mechanism.

Abnormal pattern of erythrocyte ageing in hereditary spherocytosis as shown by Percoll density gradient centrifugation

Erythrocytes from individuals with Hereditary Spherocytosis (HS) were fractionated on Percoll density gradients. The osmotic fragility, mean cell volume, mean cell haemoglobin concentration, reticulocyte count and cell morphology of the fractions showed that the gradients separate the erythrocytes according to age, the older small spherocytes appearing in the dense fractions. Comparison of the well established parameters of erythrocyte ageing, pyruvate kinase activity, acetylcholinesterase activity and cell potassium content in normal and HS erythrocyte fractions of similar age revealed abnormalities in the senescence of HS erythrocytes both before and after splenectomy.

A representation for shape based on peaks and ridges in the difference of low-pass transform

This paper defines a multiple resolution representation for the two-dimensional gray-scale shapes in an image. This representation is constructed by detecting peaks and ridges in the difference of lowpass (DOLP) transform. Descriptions of shapes which are encoded in this representation may be matched efficiently despite changes in size, orientation, or position. Motivations for a multiple resolution representation are presented first, followed by the definition of the DOLP transform. Techniques are then presented for encoding a symbolic structural description of forms from the DOLP transform. This process involves detecting local peaks and ridges in each bandpass image and in the entire three-dimensional space defined by the DOLP transform. Linking adjacent peaks in different bandpass images gives a multiple resolution tree which describes shape. Peaks which are local maxima in this tree provide landmarks for aligning, manipulating, and matching shapes. Detecting and linking the ridges in each DOLP bandpass image provides a graph which links peaks within a shape in a bandpass image and describes the positions of the boundaries of the shape at multiple resolutions. Detecting and linking the ridges in the DOLP three-space describes elongated forms and links the largest peaks in the tree. The principles for determining the correspondence between symbols in pairs of such descriptions are then described. Such correspondence matching is shown to be simplified by using the correspondence at lower resolutions to constrain the possible correspondence at higher resolutions.

Emotional impact of diagnosis and early treatment of lymphomas

Psychiatric morbidity, relevant symptoms and satisfaction with communication were assessed in patients suffering from malignant lymphoma. Before treatment started 15 of 40 patients had clinically significant psychiatric morbidity. Treatment, in its early stages, was not associated with a significant change in mean psychiatric morbidity scores but there was a decrease in ratings of concern about illness and an increase in ratings of nausea. Eleven of 31 patients seen for a second interview reported dissatisfaction with some aspect of communication with the medical staff. The findings suggest that emotional distress can be contained with a policy of frank communication; nevertheless dissatisfaction is common, being associated with initial less concern, good general health and neurotic personality traits. Personality assessment should be incorporated in future studies of doctor-patient communication.

Mediastinal Hodgkin's disease and thymic cysts

2 cases of nodular sclerosing Hodgkin's disease with apparent mediastinal recurrence following mantle irradiation are described. In both cases the abnormal mass was found at thoracotomy to be a benign thymic cyst. The possible aetiology of thymic cysts in this context and the importance of obtaining repeat biopsies in cases of suspected relapse are discussed.

Syngeneic bone marrow transplantation in T-cell acute lymphatic leukaemia

A case of bone marrow transplantation in a child aged seven years from his identical twin is described. The features of interest are that this was a patient with a T-cell lymphoblastic leukaemia transplanted in remission with very rapid recurrence of leukaemia following transplantation.

Non-spherocytic haemolytic anaemia in mother and son associated with hexokinase deficiency

The case history, laboratory findings and properties of the enzyme in a patient with hexokinase deficiency are reported. The mother had a haemolytic disorder of similar severity. In these cases the expression of the disease in both mother and son suggests a dominant mode of inheritance. This family further illustrates the necessity of taking the reticulocyte level into account when interpreting red cell enzyme levels.

Sea blue histiocytosis in a patient with chronic non-neuropathic Niemann-Pick disease

A patient with Niemann-Pick disease is reported together with family studies. Her liver and bone marrow were shown to be infiltrated with sea blue histiocytes. Other organs, spleen and lung, were presumably also involved but histological proof was not obtained. Enzyme assay of leucocytes, lymphocytes, and cultured skin fibroblasts showed the patient to be deficient in sphingomyelinase activity. In fibroblasts, activity was 5% of normal while for the parents activity was about 50% of normal. The expected partial deficiency was not found using leucocytes or lymphocytes from the parents. Heat stability studies on fresh fibroblast extracts from the propositus indicated that residual sphingomyelinase activity was slightly more labile than that of the controls. It seems clear that chronic Niemann-Pick disease without neurological involvement is associated with sea blue histiocytosis.

Human erythrocyte fraction in "Percoll" density gradients

A new rapid method for the age fractionation of human erythrocytes by centrifugation through a "Percoll" density gradient is described. The fractionation is demonstrated by density-related changes in the volume, haemoglobin concentration, pyruvate kinase and acetylcholine esterase activities and potassium contents of the erythrocytes, and the distribution of reticulocytes on the gradients.

Pseudo-Chediak-Higashi anomaly in promyelocytic leukaemia associated with intravascular coagulation

Giant granules were present in the cytoplasm of marrow granulocytes and in abnormal immature leucocytes circulating in the blood of a patient with promyelocytic leukaemia associated with intravascular coagulation. These granules resembled those seen in Chediak-Higashi syndrome.

Surface membrane characteristics of cells from human acute monocytic leukaemia

The clinical and laboratory features of 4 patients with acute monocytic leukaemia are described. Surface membrane receptor studies of these patients have shown increasing strength of receptor expression occurs with increasing morphological maturity of the monocyte. In addition, the study shows that expression of membrane receptors can vary from patient to patient and also with time and treatment in an individual patient. A further finding has been the loss of positivity with specific anti-monocyte serum when the disease becomes refractory to therapy.

Ultrastructural studies of leucocytes which form rosettes with homologous erythrocytes in human auto immune haemolytic anaemia

Leucocytes which form rosettes with himologous erythrocytes in auto-immune haemolytic anaemia, infectious mononucleosis and following the stimulation of lymphocyte cultures with PHA have been studied by electron microscopy. The studies showed that the predominant homologous rosette forming cell was lymphocytic and the evidence favoured the conclusion that they were non-immune in nature. This identification does not classify the lymphocyte as thymus or bone marrow derived. Just under half (44%) of the total lymphocytic RFC had perinuclear microfilaments and limited clearing of the plasma of ribosomes close to the cell membrane. These features are consistent with activated T lymphocytes. The remainder of the lymphocytic RFC had no features which allowed their identification as T or B cells. The form of contact between lymphocytic RFC and erythrocyte was mainly of a pointlike nature, with little deformation or invasion of the attached erythrocytes. Monocytes were the only other type of cell encountered with any frequency. Their prime distinguishing feature was the deformation of attached red cells which they caused.

Autoimmune haemolytic anaemia with anti-A autoantibody

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Recovery of hypothalamic-pituitary-adrenal function after intermittent high-dose prednisolone and cytotoxic chemotherapy

Hypothalamic/pituitary and adrenal (HPA) function was assessed in ten patients who received intermittent high-dose prednisolone and cytotoxic chemotherapy for 5-40 months. Standard insulin hypoglycaemia (IHT), thyrotrophin-releasing hormone and tetracosactrin tests were performed 36 hr after the last dose of prednisolone and subsequently 10 days--52 weeks after completion of all chemotherapy. In the first tests there was evidence of impaired hypothalamic-pituitary function judged by peak adrenocorticotrophic hormone (ACTH), growth hormone (GH) and thyrotrophin (TSH) responses, and corresponding plasma corticosteroid responses were sub-normal in five patients. In the final IHTs, seven patients had persistently subnormal ACTH responses but all the corresponding plasma corticosteroid responses returned to normal. Mean peak corticosteroid responses to insulin and tetracosactrin and peak GH responses were significantly greater than in the first tests. Such chemotherapy regimens may have prolonged effects on hypothalamic/pituitary function but the demonstration of normal corticosteroid responses to hypoglycaemia and tetracosactrin indicates that these patients' stress responses will be normal as early as 10 days after treatment is stopped.

Leukapheresis for papilloedema in chronic granulocytic leukaemia

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Activated T-cell in autoimmune haemolytic anaemia

In 12 of 14 patients with clinically active autoimmune haemolytic anaemia high levels (9-78%) of homologous and autologous rosetting cells were found in the peripheral blood. In 10 of these patients, who were observed over a period of 2 years, the levels bore a direct relationship to the activity of the disease. The cells so identified were T-lymphocytes. The role of cells, identified by this method in AIHA, is discussed.

Mononeuritis multiplex in a patient with macroglobulinaemia

A case is described of a 73 year old male with Waldenström's macroglobulinaemia and hyperviscosity in association with neurological abnormalities, the Bing-Neel syndrome. The relationship of the clinical features to changes in serum viscosity and the response to therapy with plasmapheresis and chlorambucil are discussed.

Sea-blue histiocytosis associated with hyperlipidaemia

A patient with sea-blue histiocytosis in spleen and bone marrow with an accompanying hyperlipidaemia is described. The hyperlipidaemia was due to an increase in "free" cholesterol, lecithin, and triglycerides. Despite these findings lecithin-cholesterol acyl transferase activity was normal. Although the precise biochemical defect was not identified, there was a failure of transport of cholesterol from chylomicrons in vitro. We propose that the sea-blue histiocyte is a marker, in some cases, of abnormal lipid metabolism.

Hypothalamic/pituitary/adrenal function in patients treated with intermittent high-dose prednisolone and cytotoxic chemotherapy

Hypothalamic/pituitary/adrenal (H.P.A.) function was assessed in ten patients receiving intermittent high-dose prednisolone and cytotoxic chemotherapy for myeloma of lymphoma in order to predict their possible requirement for additional steroid therapy between and at the end of treatment courses. Standard insulin hypoglycaemia tests performed 36 hours after the last dose of prednisolone often demonstrated impairment of corticotrophin (adrenocorticotrophic hormone, A.C.T.H.) and growth-hormone responses, indicating hypothalamic/pituitary suppression; plasma-corticosteroid responses to endogenous A.C.T.H. and tetracosactrin were abnormal in two patients, indicating secondary adrenal suppression. Such hypothalamic/pituitary and adrenal suppression may make these patients susceptible to acute adrenal insufficiency in times of stress. H.P.A. function should be fully assessed on completion of chemotherapy.

The association of alpha2-macroglobulin with lymphocyte membranes in chronic lymphocytic leukaemia and other disorders

The association of alpha2-macroglobulin (alpha2M) with the surface membranes of human peripheral blood lymphocyte preparations has been investigated by the direct immunofluorescent technique. The percentage (and total number) of lymphocytes with detectable alpha2M on their surface is significantly increased in chronic lymphocytic leukaemia. The incidence of alpha2M-positive cells in normal and pathological conditions closely parallels that observed with conjugated antiserum to the kamma and gamma light chains of human immunoglobulin. It bears no relationship however to the plasma alpha2M levels or to the age of the donor. Additional blocking studies with aggregated human IgG, soluble antigen-antibody complexes and the F(ab')2 moiety of the anti-alpha2M, and indirect immunofluorescent studies with the latter, indicate that the fluorescence observed is not due to interaction of the conjugated reagent with Fc or C3 receptors.