Cytogenetic studies, ras mutation, and clinical characteristics in primary myelodysplastic syndrome. A study on 68 Chinese patients in Taiwan

Cytogenetics and clinical features were studied for 68 Chinese patients with primary myelodysplastic syndrome (MDS). Ras mutation was analyzed in 25 of them. Thirty-four patients (50%) had clonal chromosomal abnormalities at initial analysis. The most common cytogenetic aberrations were -7, +8, 5q-, and 20q-, which occurred in 11 (16.2%), seven (10.3%), five (7.4%) and three patients, respectively. The incidence of -7 was higher and that of 5q- lower in our patients than in patients from most other geographic areas. The 17 patients with multiple chromosomal abnormalities had a significantly shorter median survival (9 months) than the 34 patients with normal karyotype (33 months) and the 17 patients with patients with single anomalies (26 months). Evolution to acute leukemia occurred in 20 patients (29%) after a median interval of 8 months following the diagnosis. Patients with multiple cytogenetic changes at initial analysis or in subsequent studies had a significantly higher frequency of acute transformation than others (55% vs. 18.6%, p = 0.007); the same was not true if only the data of initial study were considered. Serial cytogenetic studies are important in patient follow-up. N-ras mutation was detected in 5 (20%) of 25 patients within the study. There was no correlation between the gene mutation and acute transformation. But combing the data of N-ras mutation and cytogenetics, patients with either the N-ras mutation or clonal chromosomal abnormalities were at significantly higher risk for developing acute leukemia than those with neither of the changes (77% vs. 25%).

Cytomegalovirus-induced persistent mononucleosis in an infant

Chronic mononucleosis has recently gained much attention in the literature. Almost all cases of this new syndrome have been ascribed to persistent Epstein-Barr virus infection. However, a case presented with infantile chronic mononucleosis syndrome caused by persistent cytomegalovirus infection. Transient clonal chromosomal change was noted during follow-up.

L-asparaginase-related pancreatic pseudocyst: report of a case

Pancreatitis following the administration of L-asparaginase (L-asp) has been well documented. However, the progression of such pancreatitis to pseudocyst formation in some patients has been rarely reported. The few reported cases have been teenagers, with the exception of one adult. All pseudocysts required surgical management. This report documents a pancreatic pseudocyst in a seven-year-old girl with acute lymphoblastic leukemia whose treatment regimen included L-asp. The pseudocyst was managed medically with nasogastric decompression, intravenous hyperalimentation, and antibiotics. The pseudocyst resolved spontaneously in one month without complication.

Infantile endodermal sinus tumor presenting with vaginal bleeding: report of a case

Endodermal sinus tumor (EST) of the vagina is extremely rare and primarily affects infants. We report on a six-month-old female infant with EST of the vagina who presented with vaginal spotting of one month's duration. Pelvic ultrasound and computerized tomography showed a 3.8 x 3.5 cm heterogeneous mass between the bladder and the rectum. The serum alpha-fetoprotein (AFP) level was high (1270 ng/mL) and the beta-human chorionic gonadotropin was undetectable. She received surgical intervention followed by chemotherapy. The patient was disease-free and serum AFP remained undetectable during the eight-month follow-up period.

Peripheral T-cell lymphoma in childhood: a report of five cases in Taiwan

We encountered five children with peripheral T-cell lymphoma (PTL) at National Taiwan University Hospital (NTUH) from 1985-1989. The patients were four boys and one girl, aged between 5 and 13 years. The duration of prediagnostic symptoms varied from 1 month to 5 years. All had pyrexia and lymphadenopathy; one had a prolonged history of granulomatosis with repeated infection. Four had hepatosplenomegaly. One patient presented with diffuse pulmonary infiltration and impending respiratory failure. All patients were negative for human T-cell leukemia virus (HTLV)-I antibody, and positive for HBsAg. Four patients who had EBV-viral capsid antigen (VCA) IgG and who were IgM tested were positive for EBV-VCA IgG, but only two had evidence of active EBV infection. Tumor cell markers were examined and showed the following phenotypes: all patients were CD2, CD3, and CD7 positive but CD19 and CD20 negative; three patients were CD4 positive and CD8 negative; the other two patients were CD4 negative and CD8 positive. Four patients died 2-7 months after diagnosis. The remaining patient received allogeneic bone marrow transplantation and has survived free of disease for more than 22 months after transplant. Our five cases reconfirm the high frequency of diagnostic delay, the heterogenous immunophenotypes, high mortality, and poor responsiveness to conventional therapy for PTL. Bone marrow transplantation in the early stage might be a possible cure of this disease.

Bone marrow transplantation for severe aplastic anemia

Fifteen patients (nine male, six female) with severe aplastic anemia (SAA) undergoing HLA-identical allogeneic bone marrow transplantation (BMT) received preparative regimens consisting of cyclophosphamide and total lymphoid irradiation. Patients were aged from eight to 26 years (median 15 years). Prophylaxis of graft versus host disease (GVHD) including cyclosporine and short course methotrexate was administered. One early death occurred at day 8 post BMT. Among the other 14 patients, one died of sepsis at day 53 with no evidence of engraftment, 13 were engrafted despite the number of donors exposed in transfusions of previous blood components. Eleven patients have survived from six to 100 months (median, 54 months), post BMT. The remaining two patients died of acute GVHD-related infections on days 44 and 63. Acute GVHD occurred among eight of 13 engrafted patients, five of whom were grades II-IV clinically. Chronic GVHD developed among five patients, three of whom were clinically progressive and extensive. Two of three patients with extensive chronic GVHD had received transfusion of donor's buffy coat after BMT. Our data indicate an engraftment rate of 87% (13/15). The projected probability of disease-free survival was 73% (11/15) at 9.3 years after BMT according to the Kaplan-Meier model. Further efforts must be made to eliminate GVHD and to control fatal infections.

Sonography of ocular choroidal melanomas

Ocular choroidal melanomas lend themselves particularly well to evaluation by sonography. This essay illustrates the different appearances of ocular melanoma as depicted with sonographic imaging, including conventional gray-scale sonography and duplex Doppler, color flow Doppler, and three-dimensional display.

Studies on the concentration of arsenic, selenium, copper, zinc and iron in the blood of blackfoot disease patients in different clinical stages

Flame atomic absorption spectrophotometric methods were developed for the determination of zinc, copper, arsenic, iron and selenium in blood samples. Data from blackfoot disease patients in five clinical stages were compared with those from healthy controls. Copper concentrations were the same for all clinical stages. Arsenic increased in the initial three stages but decreased thereafter, although arsenic was previously considered to be the major causative agent of the disease. The decrease of arsenic in the later stages was attributed to the antagonistic effect of selenium, and the decrease of iron during the progress of the disease is thought to be due to the antagonistic effect of arsenic in the initial stages and the loose of haemoglobin in the later stages.

Comparison of clinical and biologic features between myeloid and lymphoid transformation of Philadelphia chromosome positive chronic myeloid leukemia

Analysis of clinical and biologic features of chronic myeloid leukemia (CML) in blast crisis (BC) was performed on 36 patients: 25 had myeloid and 11 had lymphoid transformation. The median duration from diagnosis to onset of BC was significantly shorter in patients with lymphoid BC (6 months) than in those with myeloid BC (41 months). Patients in lymphoid transformation showed better response to therapy and had a significantly longer median survival time after BC than patients with myeloid transformation (56% vs 0% and 10 months vs 4 months, respectively). The leukemic cells from all the patients with lymphoid BC showed B-cell immunophenotype, confirmed by the presence of immunoglobulin (Ig) heavy chain gene rearrangements in the five patients studied. Two of the eight patients with complete marker study expressed myeloid-associated antigens on the blasts. A high incidence of CD7 expression (7/17 or 41%) was found in patients with myeloid BC, but none of the patients who had DNA analysis showed rearrangement of T-cell receptor beta chain gene. Chromosomal abnormalities +8, +19, +21, and i(17q) were detected only in the patients with myeloid BC but not in those with lymphoid BC. Combined analysis of the patients in this series and those reported previously has revealed a statistically significant difference in the distribution of bcr breakpoints between myeloid and lymphoid BC: the bcr breakpoints in more than half of the patients with myeloid crisis were mapped to Zone 2 while those in patients with lymphoid crisis occurred most frequently in Zone 3.

Predicted toxicities of aryl alkanols and related compounds

The relative toxicity of selected aryl and/or alkyl alcohols was evaluated in the batch culture Tetrahymena pyriformis population-growth impairment assay. Chemicals evaluated included normal and branched primary alcohols with mono-, bi- or diaromatic substituents as well as aryl-substituted ethers. Log 1-octanol/water partition coefficients (log Kow) along with previously developed quantitative structure-activity relationships (QSARs) for both the non-polar narcosis and polar narcosis mechanism of action were used to predict relative toxicity. Observed and predicted toxicities measured as log IGC50(-1) were compared. All phenols and naphthyl-substituted compounds, as well as the biphenyl methanols, benzhydrols and 1,1-diphenylethanol, model more accurately as polar narcotics. Both monoaromatic- and diaromatic-substituted branched arylalkyl alcohols, as well as monoaromatic ethers, model best as non-polar narcotics. The C1-C6 straight-chain aryl alkanols, as well as 3-phenyl-1-butanol, model intermediately between non-polar and polar narcosis. The triaromatic-substituted alcohol was not toxic at saturation. These findings are consistent with the idea that narcosis, the reversible state of arrested bioactivity, is a series of mechanisms.

The role of colour flow Doppler ultrasonography in the investigation of disease in the eye and orbit

Colour flow Doppler ultrasonography is a relatively new technique in which colour-encoded representations of flowing blood are imposed over a conventional grey-scale ultrasound image. This allows interrogation of a relatively large volume of tissue to determine the presence and direction of blood flow. The waveform tracings are then evaluated by means of conventional Doppler imaging. We demonstrate examples of normal vascular structures in the orbit and describe the application of this technique in the investigation of vascular disease, such as carotid-cavernous fistula and ischemic disease. The technique can also be used to evaluate ocular membranes and masses. Colour flow Doppler imaging promises to be an important advance in ophthalmic ultrasonography.

Characterization of acute myeloid leukemia (AML) coexpressing lymphoid markers: different biologic features between T-cell antigen positive and B-cell antigen positive AML

The clinical and biologic characteristics of acute myeloid leukemia (AML) with coexpression of lymphoid-associated antigens (Lym+ AML) were studied from 39 cases who represented 24% of 161 newly diagnosed de novo AML. Twenty-seven cases (16.8%) were positive for the expression of T-cell markers (T+ AML) and 12 (7.5%) for B-cell markers (B+ AML). Chromosomal abnormalities t(9;22)(q34;q11) and t/del(11)(q23), which were considered to be associated with acute leukemia coexpressing markers of more than one cell lineage, were detected in five and in four patients, respectively. There was no prognostic significance of B-cell or T-cell antigen expression in AML. Of 12 T+ AML cases in which cells were available for gene analysis, all showed germline configuration of immunoglobulin heavy chain and T-cell receptor beta chain genes, while seven of nine B+ AML showed rearrangements of either or both of the genes. Double labeling of the cells with myeloperoxidase and lymphoid markers demonstrated that individual blasts in all the five T+ AML tested were simultaneously expressing myeloperoxidase activity and CD7; however, most blasts in the three B+ AML studied expressed either myeloperoxidase activity or CD10, but not both. In eight of the nine T+ AML tested, the T-cell antigen-positive leukemic blasts were significantly decreased to less than 10%, after in vitro culture with the differentiation-inducing agent phorbol ester. B-cell markers remained positive (> or = 20%) on the cells in the two B+ AML who had the same study. These findings suggested that T+ AML and B+ AML might have different biologic features. Further studies on more patients are needed to clarify this point.

Profile measurements of cylindrical surfaces

We introduce an interferometric method for measuring the profiles of cylindrical surfaces. A Fizeau interferometer with a flat reference is used to test part of a cylindrical surface, and various parts of the surface can be tested by the rotation of the surface. The algorithm for linking separate measurements is described, and testing examples for measuring sagitta over 3 mm of a cylindrical surface with an elliptical cross section are included. Measurement results show that repeatability for the above test to the order of 1 microm, is feasible.

Hepatitis C virus infection in volunteer blood donors in Taiwan. Evaluation by hepatitis C antibody assays and the polymerase chain reaction

A total of 2671 plasma samples that were selected from 22,500 volunteer blood donors in Taiwan were studied for hepatitis C virus (HCV) infection. The donors were stratified into three groups by serum alanine aminotransferase (ALT) levels. Of the donors, 20,768 (92.3%) had an ALT level less than 30 IU/L (group 1), 1080 (4.8%) had an ALT level between 31 and 45 IU/L (group 2), and 652 (2.9%) had an ALT level greater than 45 IU/L (group 3). To study anti-C100-3 hepatitis C antibody, 2023 plasma samples (10%) from group 1, 321 (30%) from group 2, and 327 (50%) from group 3 were randomly selected and tested. Twenty-one (1.04%) of group 1 donors, 13 (4.05%) of group 2 donors, and 26 (7.95%) of group 3 donors were positive for anti-C100-3, respectively. These seropositive samples were further tested by a recombinant immunoblot assay, by a polymerase chain reaction for HCV RNA, by a second-generation recombinant antigen-based immunoassay (r-HCV), and by a synthetic peptide-based immunoassay (EIA3) for HCV antibodies. By the polymerase chain reaction, 26 of the 60 donors were positive for HCV RNA. The HCV RNA was more frequently found in donors with an ALT level greater than 45 IU/L than in those with an ALT level less than 45 IU/L (15 of 26 vs nine of 34, respectively); in donors who were recombinant immunoblot assay reactive or indeterminate than in those who were recombinant immunoblot assay negative (17 of 21 or seven of 14 vs two of 25, respectively); and in donors who were EIA3 positive (25 of 33 vs one of 27) or r-HCV positive (25 of 35 vs one of 25). Based on these data, we anticipate that screening by anti-C100-3 in Taiwan will exclude approximately 3280 potentially infectious donations under the current screening policy but will result in the loss of 6860 donations that will be negative for HCV RNA per year. Because of its high sensitivity and specificity, EIA3 or r-HCV seems to be a potentially better screening method for HCV carriers.

Corneal topography following excimer photorefractive keratectomy for myopia

Corneal topographic analysis was performed on 97 consecutive eyes with at least one month follow-up after excimer laser photorefractive keratectomy for myopia. Centration of the ablated zone was documented in all eyes at the one month postoperative examination with the Topographic Modeling System (Computed Anatomy Inc., NY). Thirty-seven percent of eyes were within 0.25 mm of the pupillary center (PC); 48% of eyes were between 0.25 and 0.50 mm, 13% were between 0.50 and 1.00 mm, and 2% were more than 1.00 mm from the PC. The greatest amount of decentration was 1.50 mm. The mean decentration was 0.36 mm. The surface regularity index (SRI), which is a measure of the optical performance of the cornea, was significantly less at the sixth postoperative month than at the first postoperative month (P = .013). No correlation between the SRI and the amount of decentration was found. Four main patterns of ablation were noted by differential topographic analysis at the one month interval. A central uniform ablation was present in 45% of eyes; "semicircular ablations" were present in 33% of eyes, a "keyhole" ablation pattern in 12%, and a curious "central bump" ablation pattern in 10%. Corneal topographic analysis was a useful tool for documenting and quantitating results following excimer photorefractive surgery.

Ultrasonographic findings in the anterior segment of the eye obtained with a nondedicated unit

Many abnormalities of the anterior segment of the eye can be detected by ultrasonography (US), and associated anomalies of the posterior segment that are difficult to detect clinically may also be demonstrated by this modality. A total of 48 patients with ultrasonographically detectable abnormalities in the anterior segment were examined with real-time high-resolution US; 51 abnormalities were demonstrated. The most common problems were cataract (19 cases), intraocular lens implant (10), dislocated lens (9) and tumour (8). In addition, 23 abnormalities of the posterior segment of the eye were found. Six of the lesions in the posterior segment were obscured by those in the anterior segment and could be detected only by US.

Characterization of Philadelphia-chromosome-positive acute leukemia by clinical, immunocytochemical, and gene analysis

Philadelphia chromosome (Ph') was detected at presentation in 10 out of 110 patients with acute lymphoblastic leukemia (ALL) and five of 168 patients with acute myelogenous leukemia (AML). Two other ALL patients who had studies at relapse were also included in the analyses. One of the 12 Ph'-positive (Ph+) ALL patients had simultaneous expression of myeloid-associated antigen on the leukemic blasts, while all the five AML patients coexpressed markers of lymphoid cells. Double labeling of the cells with myeloperoxidase and CD10 on three Ph+ AML cases showed that most leukemic blasts expressed either myeloperoxidase activity or CD10 but not both. Cross-lineage gene rearrangements of T-cell receptor (TCR) beta-chain gene were detected in three of the eight Ph+ ALL patients tested. All the four Ph+ AML cases studied showed immunoglobulin heavy chain gene rearrangements, and three of them also had simultaneous rearrangements of TCR beta-chain gene. The results revealed that Ph+ acute leukemia in this study belonged either to ALL or mixed lineage leukemia, and none was pure AML. This finding is contrary to that of acute blast crisis of chronic myelogenous leukemia in which the majority of patients had myeloid transformation. Rearrangements of bcr were detected in four of the 10 Ph+ ALL and three of the four Ph+ AML patients tested. No significant difference was noted in the clinical or hematologic manifestations among Ph+ leukemia with or without bcr rearrangements.

Long-term observation of pediatric aplastic anemia

Fifty-nine verified cases of acquired aplastic anemia (AA), diagnosed at the Pediatric Department of the National Taiwan University Hospital from 1977 to 1987, were reviewed and analyzed. The demographic features showed a high relative incidence (acute myelogenous leukemia/AA ratio, 2.2/1), a high percentage of non-severe AA (39%) and a high association with hepatitis (20.8%). No evidence of hepatitis A, B or C virus infection was found in five cases of hepatitis-associated AA. No sex preponderance was noted in this pediatric series. The 10-year projected survival rate of the total series approached 55%. The crude two-year-survival and two-year-transfusion-free-survival rates were 59% and 44%, respectively, in the conservative therapy group treated with androgens and steroids; 36% and 32%, respectively, in patients with severe AA in the conservative therapy group; and 73% and 64%, respectively, in the aggressive therapy group treated with cyclosporin, anti-lymphocyte globulin or bone marrow transplant. The major causes of death were hemorrhage (44%) and infection (56%) in the conservative therapy group; but in the aggressive therapy group, two out of three deaths were related to therapeutic complications. Multivariate analysis of prognostic factors revealed that severity and treatment modality were independent risk factors. Only two out of 31 patients who survived more than two years (long-term survivors) experienced late mortalities. At two, five, seven and 10 years after diagnosis, 61%, 55%, 41% and 40% of the long-term survivors had inadequate hematopoietic recovery.

Cytogenetic study of acute lymphoblastic leukemia and its correlation with immunophenotype and genotype

Among 72 Chinese patients with acute lymphoblastic leukemia (ALL), 50 had clonal chromosomal abnormalities. Structural abnormalities were detected in 42 patients: these included t(9;22) in 9, t(1;19) in 6, t(4;11) in 5, del(11)(q23) in 4, and del(6q) in 4. Adults had a higher incidence of t(9;22) and t(1;19) but a lower incidence of t(4;11) and hyperdiploid greater than 50 karyotype than children. A significant difference was also noted in white blood cell (WBC) count among various karyotypic groups. Patients with chromosomal abnormalities t(9;22), t(1;19), t(4;11) and del(11) (q23) had a shorter complete remission duration as compared with patients free of these abnormalities. Immunophenotyping was performed on 69 patients. All patients with t(9;22), t(1;19), and t(4;11) had B-lineage ALL restricted to certain stages of maturation: groups III and IV, groups IV and V, and group II, respectively (according to the classification of Foon and Tood). Among patients with t(9;22), t(4;11), and del(11)(q23), which have been considered to be associated with acute mixed-lineage leukemia, one each, respectively, showed myeloid antigen expression on the leukemic blasts (My+ ALL). No cross-lineage rearrangements of immunoglobulin (Ig) or T-cell receptor (TCR) genes were detected in these karyotypic subgroups of patients who underwent gene analysis.

Acute myelofibrosis terminating in acute lymphoblastic leukemia: report of one case

A four-year-old boy suffered from acute myelofibrosis which became acute lymphoblastic leukemia during the course of the disease. Histologic and immunophenotypic studies revealed that the leukemic cells were lymphoblasts. Immunophenotypic examination also excluded the possibility of acute megakaryoblastic, monocytic and myeloid leukemia. Thus terminal leukemic transformation, in some cases of acute myelofibrosis, may be of a lymphoid nature.

Analysis of hemoglobin gamma chain in patients with Cooley's anemia in Taiwan

The beta-like globin gene cluster, consisting of five genes and a pseudogene, is located on chromosome 11 and is arranged in the order 5'-epsilon-G gamma-A gamma-phi beta-delta-beta-3'. With the fast and sensitive method of high-performance liquid chromatography (HPLC) in the gradient mobile system, we studied the G gamma values of fetal hemoglobin in 34 patients with Cooley's anemia, 100 normal adults and 100 newborns. There were 84 newborns with a mean G gamma value of 67.41 +/- 2.37%, 15 newborns with a G gamma value of 83.45 +/- 1.92% and one newborn with a G gamma value of 100%. Because the medium value of 67.41% and 100% is near the value of 83.45%, we speculate that there are different g gene genotypes; that is, the group with a G gamma value of 100% has a genotype of G gamma-G gamma/G gamma-G gamma, the group with a G gamma value of 83.45% has a genotype of G gamma-G gamma/G gamma-A gamma, and the group with a G gamma value of 67.41% has a genotype of G gamma-A gamma/G gamma-A gamma. The G gamma value for normal adults was 41.84 +/- 20.91%. While the G gamma values for patients with Cooley's anemia were divided into two groups, 56.23 +/- 6.55% and 80.60 +/- 3.05%. There was no case having a G gamma value of 100%. Our results suggest that the expression of the gamma gene in Cooley's anemia is similar to that of the newborns.

QSARs for monosubstituted phenols and the polar narcosis mechanism of toxicity

Eighty 2-, 3-, and 4-position monosubstituted phenols representing various substituents were evaluated for relative toxicity, log IGC50(-1), with a short-term static protocol in the Tetrahymena population growth inhibition bioassay. Quantitative structure-activity relationships (QSAR) were examined using the 1-octanol/water partition coefficient (log K(ow)) and ionization constant (pKa) as independent variables. Four derivatives did not elicit the measured response at saturation. Five derivatives revealed altered high-performance liquid chromatography spectra with time. None of these derivatives were included in QSAR development. In addition, the carboxyl and nitroso derivatives were detected as statistical outliers. The model log IGC50(-1) = 0.6655 (log K(ow)) - 0.1464 (pKa) + 0.2206, n = 67, r2 = 0.909, s = 0.212, was found to be an excellent predictor of activity of phenols which elicit their toxic response by the polar narcosis mode of action. For the most part the tested derivatives showed little abiotic loss over the duration of the bioassay.

Real-time sonography in ocular trauma

Real-time sonography was evaluated retrospectively in 71 consecutive patients with ocular trauma. A total of 51 vitreous hemorrhages, 20 hemorrhages in the anterior chamber, 22 retinal detachments, seven choroidal detachments, five foreign bodies, and 12 dislocated lenses were identified sonographically. In 10 instances (three choroidal detachments, six retinal detachments, and one lens dislocation), these sonographic findings were not apparent on clinical examination. One hemorrhage of the anterior chamber was missed on sonography. Both sonography and clinical examination failed to visualize one retinal detachment. The results of this study show that real-time sonography is valuable in the assessment of ocular trauma and supplements clinical examination with valuable information.

Infantile osteopetrosis: report of two cases

Two cases of infantile osteopetrosis are reported. Both were males aged four and eight months at presentation. They presented with osteosclerotic change of the bone, leukoerythroblastic anemia, optic atrophy, hepatosplenomegaly and frequent infection. The histology of the bone showed thickened bone trabeculae with little osteoclastic activity, although in one patient the number of osteoclasts increased, while in the other they did not. One received a bone marrow transplant (BMT) but died from disseminated cytomegaloviral infection, pulmonary hemorrhage and sepsis. The post-transplant marrow histology showed evidence of engraftment and osteoclastic activity. The other only received a course of prednisolone, which was of little help. His condition has followed a natural course with progressive visual impairment and marrow failure. Our cases suggest that infantile osteopetrosis should be taken into consideration in dealing with infants who present with early marrow failure and that patients of infantile osteopetrosis should receive BMT. BMTs appear to be the only cure. They should be given as early as possible to avoid major consequences and severe infection.

A pathologic study of childhood lymphoma in Taiwan with special reference to peripheral T-cell lymphoma and the association with Epstein-Barr viral infection

The authors retrospectively reviewed the clinicopathologic and immunologic features of 65 consecutive cases of childhood lymphoma reported between 1980 and 1989. Southern blot hybridization was also performed in 23 cases to study their association with Epstein-Barr virus (EBV) and human T-cell leukemia virus type 1 (HTLV-1). The 65 cases included 56 non-Hodgkin's lymphoma (NHL) (86%) and 9 Hodgkin's disease (HD) (14%). The NHL could be classified into the following groups: Group I, small noncleaved cell lymphoma (20 cases); Group II, lymphoblastic lymphoma (17 cases); Group III, large cell lymphoma (17 cases); and miscellaneous (2 cases). There was no follicular lymphoma case. Immunohistochemical study on paraffin sections and/or frozen specimens in 47 cases of NHL showed that all the Group I cases belonged to B-cell neoplasm (17 of 17 cases); most of the Group II cases belonged to T-cell neoplasm (9 of 14 cases); and most of the Group III cases were peripheral T-cell lymphoma (PTL) (8 of 16 cases), including 2 cases of Ki-1 lymphoma. The majority of childhood NHL belonged to high-grade malignancy with an aggressive clinical course (median survival time, 8 months). The EBV DNA could be detected from the tumor tissues in 4 of 6 PTL, but in none of the remaining 19 cases of NHL including 6 Burkitt's type lymphomas. HTLV-1 proviral genome was not detected in all specimens examined. The authors concluded that the distribution pattern and clinicopathologic feature of childhood lymphoma in Taiwan are comparable to that in Japan and western countries. The frequent association of EBV with aggressive PTL was unique and deserves additional investigation.

Malignant urinary tract tumor in childhood

Fifty-one patients under the age of 18 with histologic-proven malignant urinary tract tumors were encountered at the Department of Pediatrics of National Taiwan University Hospital from 1979 to 1989. There were 47 tumors arising from the kidney, 2 from the bladder, and 2 from the urethra. For upper urinary tract tumors, abdominal mass (92%) and abdominal distension (86%) were the most common symptoms and signs. For lower urinary tract tumors, painless hematuria, bladder distension and urinary difficulty were most frequently encountered. Associated anomalies were found in one-fifth of our patients, including kyphosis, undescended testes, hypospadias, inguinal hernia, intersex and congenital heart disease. Diagnosis was aided by plain X ray, abdominal ultrasonography, intravenous pyelography, computed tomography, or angiography in upper urinary tract tumors, and cystoscopy, cystography and computed tomography in lower urinary tract tumors. Multimodal treatment including total excision, multiagent chemotherapy, and radiotherapy were performed. Postoperative complications included infection (22%), ascites (19%), ileus, pleural effusion, scoliosis, neuropathies, and growth retardation. The local recurrence rate was 32%, and the metastatic rate was 34%. The overall mortality rate was 53% for an average follow-up period of 38 months. The causes of death included sepsis, respiratory failure and hepatic failure. The two-year survival rate was 47.6%. The important prognostic factors included histology, staging and vascular invasion, in addition to combined chemotherapy and radiotherapy.

Sonography of the eye

Real-time sonography of the eye is a technique that is rapidly performed and readily available in most sonography departments. It is less expensive than CT and MR imaging and, if necessary, may be performed at the patient's bedside. This essay demonstrates a few of the large number of clinical entities that may be successfully examined with this technique.

Hemorrhagic pericardial effusion in beta-thalassemia major: report of a case

Although sterile pericardial effusion occurs in about half of the patients with massive iron overload, hemorrhagic pericardial effusion is rarely seen in beta-thalassemia major patients. A 10-year-old girl with beta-thalassemia major who was diagnosed in her early infancy developed a massive hemorrhagic pericardial effusion. She was receiving blood transfusions every 4-6 weeks without chelating therapy with an average hemoglobin (Hb) level of 6-9 g/dL. Progressive hepatospenomegaly was noted during the course. She had complained of orthopnea with palpitation and bilateral leg edema before admission. After evaluation, a massive pericardial effusion was found and pericardiocentesis was performed twice, which revealed a bloody and uncoagulable effusion. Finally a pericardial window was performed to eliminate the bloody effusion. Negative etiological evaluations of blood and pericardial effusion were reported. Pathological examination of the pericardial biopsy revealed hemosiderosis with a few lymphocytic infiltrates. We report this case for its rarity and its necessity for urgent treatment.

Profile measurement of an aspheric cylindrical surface from retroreflection

A new algorithm for measuring the profile of an aspheric cylindrical surface is developed in which directions of the surface normal and slopes at various locations are found with the aid of a retroreflected beam. The locations of retroreflection can be found with the simple algorithm developed in this paper, and the surface profile is integrated from the slope. The accuracy of the new algorithm is determined mostly by the algorithm's ability to find the true range of the surface being integrated. In the measurement of the surface sagitta over the range of 5000 microm, the accumulated error from the integration is less than 30microm.

Fulminant childhood hemophagocytic syndrome mimicking histiocytic medullary reticulosis. An atypical form of Epstein-Barr virus infection

Ten cases of pediatric fulminant hemophagocytic syndrome, encountered between 1986 and 1989, are described. They occurred in the summer, and the patients presented with fever, jaundice, hepatosplenomegaly, pancytopenia, coagulopathy, and abnormal liver function. Bone marrow studies revealed infiltration by atypical T-lymphoid cells, rare B immunoblasts, and mature histiocytes with hemophagocytosis. Initially, histiocytic medullary reticulosis was suspected in six cases. The clinical course was characterized by rapid deterioration, with a mean period of 16 days from onset of fever to death. The main causes of death were coagulopathy with multiple organ failure and opportunistic infection. In seven of eight cases studied by serologic assay and Southern blot hybridization, acute or active Epstein-Barr virus (EBV) infection was documented. It is suggested that an atypical or fulminant form of primary EBV infection distinct from classic infectious mononucleosis was prevalent in previously healthy children in Taiwan. Younger age involvement and seasonal clustering were characteristic of the disorder described.

Burkitt's and non-Burkitt's type lymphoma: clinicopathological and radiological manifestations

Nine cases of Burkitt's type and 5 case of non-Burkitt's type small, non-cleaved cell lymphoma were retrospectively studied to evaluate their clinical and radiological manifestations. In the Burkitt's group, the median age of onset was 9 years old; the male to female ratio was 2:1; and the most frequent presentation was abdominal mass. These features conformed to those of non-endemic (or American) type Burkitt's lymphoma. In comparison with the Burkitt's group, less male-predominance (M:F = 2:3) and cervical mass as the most frequent initial symptom were found in the non-Burkitt's group. Plain films and computed tomographies were collected to evaluate the encroachment of the disease into various organs or compartments. There was a statistically significant correlation in site of the main mass between these two types; the Burkitt's type prefers extranodal, whereas the non-Burkitt's type prefers nodal, involvement. Computed tomographic appearance of Burkitt's lymphoma was also analyzed and summarized by the following five aspects: (1) tumor location-predominantly in the abdomen or head/neck region; (2) tumor density-rather homogeneous and slightly less than that of muscle; (3) tumor margin-often well-localized with distinct contrast to adjacent normal tissue; (4) extranodal predilection- the most frequent pattern of involvement; and (5) bony chang-often mild, despite the size of the mass.

Hepatoblastoma in infancy and childhood: a clinical and pathological study of 32 cases

During the twenty-nine-year period from June 1959 to October 1988, 32 infants and children with histology-proved hepatoblastoma were seen at the Department of Pediatrics, National Taiwan University Hospital (NTUH). The age at diagnosis ranged from four days to six years, with a mean of one year and eight months. Most of the patients (87.5%) were under the age of three. There was no sex predilection (16 males, 16 females). The most common presenting signs were an upper abdominal mass (71.9%) and/or abdominal distention (62.5%). Physically, all the patients revealed hepatomegaly, with or without mass. Laboratory abnormalities included primarily thrombocytosis (64.3%), elevated serum aspartate aminotransferase (75.0%), serum alanine aminotransferase (62.5%), cholesterol (78.3%) and alphafetoprotein (92.3%). According to the classification of Ishak and Glunz, 56.3% of these belonged to the epithelial type; the others belonged to the mixed type. During the follow-up period, 6 patients with complete resection of the tumor remained alive from 2 years to 17 years and 4 months. Twenty-two patients died from 8 days to 16 months after diagnosis. Four patients were lost to follow-up. The two-year survival rate was 21.4% (6/28). Complete resection of the tumor was the key treatment for achieving survival.

A subset of acute lymphoblastic leukemia with co-expression of myeloid antigens: prevalence and clinical significance

In order to evaluate the biological features and clinical significance of myeloid antigen expression in acute lymphoblastic leukemia (ALL), immunophenotype analysis was performed on leukemic cells from 160 patients diagnosed as ALL by the French, American and British (FAB) criteria using a comprehensive panel of monoclonal antibodies to lymphoid and myeloid associated antigens. Expression of myeloid antigens was found in 32 cases (20%), including 11 out of 49 adults (22.4%) and 21 out of 111 children (18.9%). CD33 was positive in 18 patients (11.3% of the total cases), CD13 in 15 patients (9.4%), CD 11b in 12 patients (7.5%) and CD14 in 1 patient (0.6%). Nine patients expressed two or more myeloid antigens. There were no significant differences in clinical manifestations and hematological pictures between the ALL patients with myeloid antigen expression (My+ ALL) and those without (My- ALL). No consistent chromosomal abnormality was found in My+ ALL. Eighty percent of the childhood and 44.4% of the adult My+ ALL patients achieved complete remission, compared with 87% and 80%, respectively, for childhood and adult My- ALL, but the differences were not statistically significant. After a median follow-up of 2.1 years, there were also no statistically significant associations between myeloid antigen expression and shorter duration of remission or poorer survival rate for patients with both adult and childhood ALL.

Corneal topography of keratoconus

Sixty-three eyes of 49 patients with keratoconus were studied by means of computer-assisted corneal topographic analysis. Two patients with keratoconus in one eye had no topographic evidence of keratoconus in the opposite eye. Keratoconic topographic alterations were classified into two groups. The majority of the patients (72%) had peripheral cones, with steepening extending to the limbus. In this group, the steepening was commonly restricted to one or two quadrants. In some cases, however, the changes involved nearly the entire corneal surface. The remaining group (about one quarter of the keratoconus patients) had steepening that was restricted to the central cornea. In either group, the topographic alterations in the two eyes of any single patient were characterized by a high degree of nonsuperimposable mirror-image symmetry (enantiomorphism). In the majority of patients, however, there was a large and statistically significant disparity between the two eyes in the power at the apex of the cone and the total cylinder [mean differences 8.2 +/- 6.0 D (p less than 0.0001) and 4.3 +/- 2.7 D (p less than 0.0001), respectively].

Immunoglobulin and T-cell receptor gene rearrangements in acute lymphoblastic leukemia--a higher incidence of double rearrangements in patients with myeloid antigen expression

Among 160 patients who were diagnosed as having acute lymphoblastic leukemia (ALL) by French American British (FAB) criteria, 32 patients (20%) expressed myeloid-associated antigens on leukemic blasts (My+ALL). Correlation of immunophenotype with rearrangement of immunoglobulin (Ig) heavy chain and T-cell receptor (TCR) beta chain genes was performed on 73 of these patients (21 were My+ALL). Rearrangements of both Ig and TCR genes (double rearrangements) were detected in 24 patients, including three (19%) of 16 T-lineage ALL. 17 (33%) of 52 B-lineage ALL, and four of five ALL expressing both B and T-cell surface markers. Also a higher incidence of double rearrangements in My+ALL was found as compared with My-ALL (43% vs 29%). This difference was more evident when only B-lineage ALL was considered (50% in My+ patients vs 24% in My- patients). However the difference is not statistically significant yet possibly due to the small number of patients in the study. Further studies on more patients are needed to confirm this. In My-B-lineage ALL, rearrangements of TCR beta chain gene were restricted to certain subgroups (Groups III & IV) of patients who expressed CD10 surface antigens but lacked cytoplasmic Ig. In My+ B-lineage ALL, rearrangements of TCR beta chain gene could be found in various subgroups studied (Groups II through V). Cross-lineage gene rearrangement in My+ALL may involve mechanisms different from those in My-ALL.

Epstein-Barr virus-associated peripheral T-cell lymphoma of activated CD8 phenotype

Two childhood cases are reported of peripheral T-cell lymphoma; the neoplastic cells expressed activated CD8 (T8) phenotype and contained Epstein-Barr viral (EBV) DNA. Both patients had an aggressive and rapid clinical course despite chemotherapy. Elevated titers of antibodies to EBV-viral capsid antigen (greater than 640) and early antigen (greater than 10) were found in both patients. Histology revealed pleomorphic immunoblastic lymphoma with extensive necrosis in one case and an angioimmunoblastic lymphadenopathy-like pattern containing Reed-Sternberg-like giant cells in the other. Southern blot hybridization studies showed clonal rearrangement of the T-cell-receptor beta gene in both cases, and a cytogenetic study on one case revealed clonal structure abnormality involving chromosomes 1, 6, 7, 10, and 19. Analysis of the tumor DNA showed a high copy number of EBV genome per cell compared with that of Raji and Marmoset B 95.8 lines; the study for human T-cell leukemia virus type I was negative. The EBV genome was found by in situ hybridization in the tumor nuclei in both cases. In addition to Burkitt's lymphoma, T-cell lymphoma of the helper phenotype, and Hodgkin's disease, EBV can contribute to the development of CD8-positive aggressive T-cell lymphoma.

Epiphora: treatment by means of dacryocystoplasty with balloon dilation of the nasolacrimal drainage apparatus

A new interventional radiologic procedure was developed for treatment of epiphora. A small-bore, soft-tipped guide wire was introduced through the superior canaliculus and guided under fluoroscopic control through the nasolacrimal drainage system for retrieval through the nasal aperture. A small-bore angioplasty catheter was then introduced in a retrograde direction into the nasolacrimal drainage apparatus and dilated under fluoroscopic control. The procedure was attempted in 18 eyes of 17 patients with moderate to severe epiphora and was technically completed in 16; 13 of these cases demonstrated improvement, with 11 patients showing complete resolution of symptoms. In the three patients whose epiphora did not improve, no worsening of symptoms occurred. These results are preliminary; follow-up ranged from 7 weeks to 6 months. The authors believe that this technique may hold promise in the treatment of epiphora and may obviate the use of more invasive procedures.

Delayed erythropoiesis after major ABO-incompatible bone marrow transplantation: report of a case

Major ABO-incompatible bone marrow transplantation (BMT) may be associated with delayed erythropoiesis. A 38-year-old man (blood group O) with chronic myelogenous leukemia received a BMT from his histocompatibility antigen (HLA) identical brother (blood group A). The pre-BMT anti-A titer of the patient was 1:4. The harvested marrow was depleted of RBC by 6% hydroxyethyl starch sedimentation and Ficoll-Hypaque gradient centrifugation. No acute hemolysis occurred after marrow infusion. Myeloid and megakaryocytic series engrafted promptly. However, delayed erythropoiesis up to day 266 was found. Prolonged presence of anti-A antibody was noted for more than 250 days after BMT, although the peak titer was only 1:8. After the reconstitution of bone marrow, the erythroid series was confirmed as donor origin (RBC cell typing A). It is proposed that the prolonged presence of anti-A antibody probably produced from the residual host B lymphocytes, would destroy the regenerating erythroid precursors. Also, use of cyclosporin A may be associated with higher rates of prolonged production of anti-A/B antibodies and the subsequent delayed erythropoiesis.

Clinical observation of Wilms' tumor

Forty-two cases with Wilms' tumor encountered in the National Taiwan University Hospital from 1978 through 1989 were retrospectively reviewed. Included were 19 boys and 23 girls, with an age range at diagnosis from 7 days to 10 years; a majority were in the first 6 years of life. The presenting symptoms and signs included: abdominal mass (89.2%), hypertension (57.9%), hematuria (28.2%), gastrointestinal symptoms (26.3%), fever (24.3%), and body weight loss (21.6%). The initial laterality of tumor was 28 right and 14 left, with one contralateral and one ipsilateral relapse. One extrarenal Wilms' tumor (right inguinal lymph nodes) was encountered. Every case was confirmed by pathology. Histologic findings included typical Wilms' tumor (35/42), rhabdoid (3/42), anaplastic (3/42), and clear cell (1/42) types. The common sites of metastasis were lung, liver and bone. Major complications during or following therapy were severe pancytopenia, ileus, sepsis or pneumonia, delayed wound healing and tumor rupture with hemorrhage. Rare complications included irradiation hepatitis (venooclusive disease) and colitis. There were 20 deaths. The causes of death were respiratory or hepatic failure due to tumor metastasis, sepsis and internal hemorrhage. Mortality (19/20) usually occurred within two years after diagnosis and therapy. The two-year's relapse-free survival and two-year's survival rates were 51.2% and 53.7%, respectively.

Ronchi test and a new phase reduction algorithm

To fully interpret the Ronchigram, a good automatic phase reduction algorithm is necessary. A new phase reduction algorithm, originally designed for interferometry test of large optics, is presented for the Ronchi test. Due to the common path property, only two Ronchigrams shifted by pi/2 are necessary for the reproducing phase. Accuracy can be better than one-thirtieth of the grating space. Methods are suggested for finding spherical aberration and astigmatism without integrating the phase using the Ronchi test. Tests of results using the new algorithm show good agreement with typical interferometry tests.

Primary myelofibrosis in children: report of 4 cases

From 1982 to 1985, four cases of primary myelofibrosis were diagnosed in our department. Three were boys and one was a girl. Their ages ranged from 7 months to 15 years. The diagnosis was made based on anemia, leukoerythroblastic change and presence of giant platelets in the peripheral blood, and a bone marrow biopsy showing myelofibrosis. Most of them had anemia, fever, and hepatosplenomegaly on admission. The anemia was severe and refractory to repeated transfusions and steroid therapy in 3 out of the 4 cases. Splenectomy was performed in 1 case, but without satisfactory results. The clinical course and blood pictures in one case resembled leukemia of megakaryocyte lineage (M7), but results of marker studies of the blast cells ruled out the possibility of M7. Three of them underwent leukemic transformation within 2 years and died soon after. The other one died of sepsis 2 weeks after diagnosis. Myelofibrosis in childhood occurs rarely, however, when it does, it always runs a rapid and fatal course.

Infant leukemia: an analysis of nine Chinese patients

A study was made of the cellular and molecular characteristics of nine Chinese infants, consecutively presenting with acute leukemia. Five cases were acute lymphoblastic leukemia (ALL); four were acute nonlymphoblastic leukemia (ANLL). Hyperleukocytosis, hepatosplenomegaly, and poor response to conventional therapy were common features, and CNS involvement was detected at diagnosis in three cases. The blast cells from all five cases with ALL expressed early B-cell markers, i.e., HLA-DR+, CD19+, but CD10-. Terminal deoxynucleotidyl transferase (TdT) was present in blasts from four of the five cases and periodic acid-Schiff staining in blasts from two patients only. The leukemic cells of one patient also showed positive nonspecific esterase activity and expressed myeloid-associated antigens CD33 (My9), CD11 (OkM1), and CD14 (My4 and Mo2). Molecular analysis of leukemic cell DNA from this and two other patients showed rearrangement of the immunoglobulin (Ig) heavy-chain genes, but without any evidence of kappa light-chain gene rearrangement. T-cell receptor (TCR) genes remained in the germline configuration in these cases. Cytogenetic analysis showed translocation t(4;11) (q21;q23) in all four cases studied. In the group of ANLL, three cases belonged to the M4 and one to the M2 subtype. Chromosomal abnormality involving 11q23 was also detected in two patients: t(11;17)(q23;q11) and del(11)(q14q23) in each case respectively. Neither Ig nor TCR gene rearrangement was present in blast cells from patients with ANLL. The data indicate that chromosomal rearrangement of band 11q23 was quite common in Chinese infants with either form of leukemia, a finding that may have pathogenetic implications.

An adjustable single running suture technique to reduce postkeratoplasty astigmatism. A preliminary report

The authors compared postkeratoplasty astigmatism over a 4-month period after surgery in a randomized, prospective study of two groups of patients (total N = 18) who received two different suture techniques. The test group N = 8) had a single running suture with postoperative suture adjustment; on the basis of computer-assisted topographic analysis, the suture was tightened in the flatter meridian and loosened in the steeper meridian in the first month after surgery. The control group (N = 10) had a standard double running suture procedure with no postoperative adjustment; the single running 10-0 nylon suture was removed 3 months after surgery. Four months after penetrating keratoplasty, mean (+/- standard deviation) astigmatism in the test group was 1.7 +/- 0.7 diopters (D), and all patients had less than 2.6 D of astigmatism. In the control group, mean astigmatism was significantly higher (5.4 +/- 2.4 D; range, 0.7-9.0 D; P less than 0.01). The results suggest that postkeratoplasty astigmatism can be reduced with the single running suture technique accompanied by postoperative suture adjustment.

bcr rearrangements in Philadelphia chromosome-positive acute lymphoblastic leukemia. A study of five Chinese patients in Taiwan

Cytogenetic studies were successfully conducted on 73 Chinese patients with acute lymphoblastic leukemia (ALL). A Philadelphia chromosome (Ph) was identified in four (9%) of the 46 children and in four (15%) of the 27 adults. None of these patients had any clinical features suggestive of chronic myelogenous leukemia (CML). Leukemic cells from five of the eight Ph-positive (Ph+) ALL patients were analyzed for bcr rearrangement by Southern blot analysis with three restriction enzymes and two bcr probes. One of the three children and both adult patients studied showed bcr rearrangement. Based on the data from the literature and the present study, 58% of adult and 14% of childhood Ph+ ALL patients demonstrated bcr rearrangement. There were no significant differences in clinical or laboratory findings between the two groups of patients with or without bcr rearrangement. Patients who had Ph+ ALL but no bcr rearrangement appear to have been victims of de novo acute leukemia, but it was still difficult to determine whether patients with bcr rearrangement had acute lymphoid transformation of subclinical CML. More studies and longer follow-ups are needed for clarification.

Topographic changes in contact lens-induced corneal warpage

Twenty-one eyes of 12 patients with contact lens-induced corneal warpage were followed prospectively using computer-assisted topographic analysis. Sixteen eyes had worn rigid contact lenses (13 eyes, polymethylmethacrylate; three eyes, gas-permeable), and five eyes had worn soft contact lenses. Initial corneal topographic patterns were characterized by the presence of central irregular astigmatism, loss of radial symmetry, and frequent reversal of the normal topographic pattern of progressive flattening of corneal contour from the center to the periphery. A correlation was noted between the initial corneal topography and the resting position of the contact lens on the cornea for nine of the 16 eyes with rigid contact lenses. Initial topography for each of these corneas showed relative flattening of the corneal contour underlying the resting position of a decentered contact lens. Superior-riding lenses produced a topography that simulated early keratoconus. After cessation of contact lens wear, 16 of 21 eyes had a change in corneal shape to a topography that was consistent with a normal pattern. Five corneas stabilized with an abnormal topographic pattern. A much longer time without contact lenses than had been previously reported, up to 5 months, was required for a return of a stable corneal topography in eyes with contact lens-induced corneal warpage caused by rigid lenses.