[Initial central nervous system involvement in a case of non-secretory multiple myeloma]

A 56-year old woman with non-secretory multiple myeloma presented with involvement of the base of brain and meningeal infiltration. Initial involvement of central nervous system is very rare in multiple myeloma, no such pathology being reported in non-secretory myeloma thus far.

Invasive pulmonary aspergillosis prior to BMT in acute leukemia patients does not predict a poor outcome

Eight patients with acute leukemia (AL) and invasive pulmonary aspergillosis (IPA) developing during previous antileukemic therapy underwent BMT (autologous in 6 cases and allogeneic 2). IPA was treated prior to BMT with full doses of amphotericin B, associated with surgical resection in three cases. One patient was treated with amphotericin B and itraconazole. Prior to BMT, seven patients had minimal residual pulmonary lesions. All patients received amphotericin B (0.5 mg/kg/day) during the aplastic period prior to engraftment. One patient died of Gram-negative septic shock before engraftment. Seven patients achieved complete hematological engraftment without any evidence of IPA reactivation. Amphotericin B was well tolerated with only minimal transient renal dysfunction in three patients. Later pulmonary complications related to IPA were observed in only one patient who developed a self-limited episode of hemoptysis. One patient died of CMV pneumonitis and two of leukemia relapse. Four patients survive disease-free and without complications related to IPA. We conclude that the reactivation of correctly treated IPA can be successfully prevented in BMT patients by use of prophylactic amphotericin B. With this approach, prior IPA is not a contraindication to BMT.

Alternating combination VCMP/VBAP chemotherapy versus melphalan/prednisone in the treatment of multiple myeloma: a randomized multicentric study of 487 patients

PURPOSE

To determine whether combination chemotherapy with alternating cycles of vincristine, cyclophosphamide, melphalan, and prednisone (VCMP) and vincristine, carmustine (BCNU), Adriamycin (doxorubicin; Farmitalia, Carlo-Erba Laboratories, Spain), and prednisone (VBAP) is better than the standard melphalan-prednisone (MP) regimen in multiple myeloma (MM).

PATIENTS AND METHODS

From January 1985 to December 1989, 28 institutions of the Spanish Cooperative Group for Hematological Malignancies Treatment, Spanish Society of Hematology (PETHEMA) entered 487 eligible patients with symptomatic MM into the study. Patients were randomized to receive either MP or alternating courses of VCMP and VBAP. Logistic regression and the Cox proportional hazards models were used to assess the association between patients' characteristics and response rate and survival, respectively.

RESULTS

Among 449 patients who were assessable for response, the overall response rate to MP was 51.8% (31.5% objective response plus 20.3% partial response) as compared with 62.7% (45.2% objective response plus 17.5% partial response) to VCMP/VBAP (P = .025). Also, a significantly higher proportion of objective responses was observed with combination chemotherapy (45.2% v 31.5%; P = .004). The factors associated with an unfavorable response rate in the overall series were low platelet count, treatment with MP, high creatinine level and immunoglobulin, (IgG) monoclonal (M)-component. No significant differences were found when survival rates of both groups of patients were compared. However, patients with IgA myeloma treated with VCMP/VBAP survived significantly longer than those who received MP (median, 20.2 v 38.4 months; P < .005).

CONCLUSION

These results indicate that combination chemotherapy improves response rate in MM. However, this does not result in a significantly different survival rate, except for patients with IgA myeloma, who survive significantly longer with combination chemotherapy.

HLA phenotype and haplotype frequencies in the Cantabria (middle north Spain) population

The gene and haplotype frequencies of the HLA-A and -B locus antigens were determined in 502 unrelated individuals from Cantabria (middle North Spain). Our results were compared with those reported for other European and Spanish populations. The haplotypes with significant linkage disequilibrium were also analyzed in various Spanish population samples in order to establish possible relationships with geographic situation and historical events.

[Bone marrow autotransplantation in patients with acute myeloblastic leukemia in primary remission]

Fifteen bone marrow autotransplants (BMAT) in patients with acute myeloblastic leukemia (AML) were performed after the first remission. The mean age was 37 years (range 12 to 60 years). According to the morphological classification FAB, 8 patients had monocytic leukemia (M4, M5) and 7 myeloid leukemia (M1, M2, M3). The mean interval elapsed between the date of complete remission and the BMAT was 3.9 months (range 1 to 5-9 months). In 8 patients this interval was longer than 6 months and in 7 cases it was shorter than 6 months. After achievement of the complete remission all patients underwent certain cycles of intensification before the BMAT. Eight patients received only a cycle whereas 7 patients received more than one cycle (between 2 and 4). The conditioning protocol consisted of cyclophosphamide (CP) (60 mg/kg x 2) and total body radiotherapy (TBR) (10 Gy) in 9 patients; CP and busulfan in five; and CP, cytarabine at high doses and melphalan in one case. Marrow extraction was performed after completion of chemotherapy of intensification. In 5 cases the bone marrow was depleted of leukemic cells by previous in vitro treatment with ASTA-Z. There are at present 8 alive patients. The survival free of illness was 51.8%. Seven patients died: 3 cases because relapse of the leukemia, 3 due to attachment failure of the transplantation, and one patient suffered a viral myocarditis. The survival free of illness was significantly longer in those patients transplanted after 6 months of the complete remission.

A randomized multicentric study comparing alternating combination chemotherapy (VCMP/VBAP) and melphalan-prednisone in multiple myeloma

Between January 1985 and December 1988, 386 patients with multiple myeloma were randomized to receive either MP or combination chemotherapy based on alternating cycles of VCMP and VBAP. The major prognostic parameters did not differ significantly between both treatment groups. A significantly higher proportion of objective responses was observed with combination chemotherapy as compared to MP (47.8 vs 32.2, P = 0.01). The median survival for all patients was 33.5 months. So far no significant differences were found when comparing the survival curves from both groups of patients. However, the median survival of MP-treated patients is 26.8 months, whereas the median survival of patients receiving VCMP/VBAP has not yet been reached. The definitive analysis must await the evaluation of all patients entered into the study and a longer follow-up time.

[Anti-HCV antibodies among blood donors in Cantabria. Incidence and relation to transaminase levels]

The incidence of anti-HCV antibodies found in 1,918 blood donors from Cantabria was 0.31%. Taking a level of 80 U/L ALT as a standpoint, 0.21% of samples with lower values correspond to anti-HCV positive cases, versus 6.25% of samples above that figure. Within those donors with ALT greater than 80 U/L, viral and non-viral profiles were established from biochemical criteria, their anti-VHC positivity frequencies being 22.22% and 0%, respectively. Non-viral profile donors represent 1% of the total number who might not be rejected.

Therapy of advanced myelodysplastic syndrome with aggressive chemotherapy

Nine patients with advanced stages of myelodysplastic syndrome (MDS) received aggressive chemotherapy with high-dose cytarabine or with a standard acute myeloid leukemic regimen. Six of them were in frank acute myeloid leukemic phase. The mean age was 57 years (range 32-71). Seven patients obtained remission, 6 complete remission (CR) and 1 partial remission. The induction remission rate was 77.7%. There were 2 deaths in the aplasia period because of infectious complications. The mean duration aplasia was 36 days (range 21-69). In spite of this all responders received further consolidation chemotherapy. The mean duration of CR was 10 months. We concluded that patients with MDS with excess of blasts and blastic transformation may be treated with aggressive chemotherapy with low toxicity and high remission rate, similarly to de novo acute myeloid leukemia.

[Prospective study on the prevalence of iron deficiency in Cantabria among children 6 to 14 years old]

Iron deficiency is the most common worldwide micronutrient deficiency in developed countries. To analyze its prevalence in children and adolescent population from our region, we studied Hb, Hto, red cell volumes, serum iron, total iron binding capacity, transferrin saturation and serum ferritin in a population of 380 individuals. These also fulfilled an epidemiological questionnaire. Mean values and normal reference ranges are shown according to age sex, which is very important to optimize the identification of individuals with iron deficiency. Overall prevalence of iron deficiency was 15.7% and it was higher in adolescent males from 12-14 years (21.8%) and children from 6-8 year (18.8%). Significant differences related to residence or to socioeconomic status were not found. The health consequences of iron deficiency are to be considered in any public health planning project.

Treatment of myelodysplastic syndrome with 1.25-dihydroxy-vitamin D3

1.25-dihydroxy-vitamin D3 (1.25 (OH)2D3) was tested in seven patients with myelodysplastic syndrome. The study was undertaken because 1.25 (OH)2D3 promotes differentiating myeloid cells in vitro and because of a prior report of potential benefit in a clinical study. The drug was given orally at a dose of 2.5 micrograms/day for a minimum of 8 weeks (range 8-28). After therapy, there were no significant changes in any of the parameters observed in peripheral blood or bone marrow. We did not observe any feature of granulocytic-monocytic differentiation. Treatment was well tolerated. One patient died because of bone marrow failure. Survivors have persisting myelodysplastic syndrome and continue to be transfusion dependent. 1.25 (OH)2D3 has no beneficial effect in patients with myelodysplastic syndrome with this dose regimen.

Hairy-cell leukaemia associated with auto-immune disorders in the form of a 'lupus-type' anticoagulant and a positive direct Coombs' test

An account is given of a case of hairy-cell leukaemia associated with a 'lupus-type' anticoagulant and a positive direct Coombs' test, both of which were clinically symptom free. This is yet another example of the coexistence of hairy-cell leukaemia and an auto-immune disorder, but the disorder in question has not been described previously.

Acquired von Willebrand's syndrome associated with hydatid disease of the spleen--disappearance after splenectomy

A new case of acquired von Willebrand's syndrome (vWS) is described in a 31-year-old woman with a hydatid splenomegaly and with a history of repeated abortions at an advanced stage of pregnancy, a positive serology for syphilis and a mildly elevated titre of antinuclear antibodies, with no family history of bleeding. There is an inhibitory effect on factor VIII: C (antihaemophilic factor) as well as on factor VIIIR: Ag (related antigen) and on factor VIIIR: RCo (ristocetin cofactor), and it is precipitated by rabbit anti-IgG antiserum. This inhibitory effect was demonstrated using the patient's plasma heated to 56 degrees C for one hour so as to dissociate circulating immunocomplexes. All the abnormalities of haemostasis, as well as the positive serology for syphilis, disappeared after splenectomy, and the ANA titre reverted to normal. The clinical and biological peculiarities of the case are discussed, and are interpreted in the light of the findings recorded in patients showing "lupus" anticoagulant.