Treatment of hypogammaglobulinaemia in chronic lymphocytic leukaemia by low-dose intravenous gammaglobulin

Intravenous immunoglobulin replacement therapy reduces the number of bacterial infections in B-cell chronic lymphocytic leukaemia (B-CLL) patients. However, due to the complexity of immunodeficiency in B-CLL and the cost-effectiveness of replacement therapy, it is important to identify patients who are likely to benefit from the treatment and to investigate which dose should be used. 15 patients with hypogammaglobulinaemia and a history of recurrent infections received a fixed dose of 10 grams of gammaglobulin intravenously every 3 weeks. Serum IgG levels were significantly higher after three doses (p = 0.0002), and stabilized just above lower reference value after 11 doses. The total number of infection-related events during 168 months before therapy was compared to the total number of infection-related events in 169 months during therapy. The number of antibiotic prescriptions was reduced from 78 to 54 (N.S.), the number of admissions to hospital due to infections was reduced from 16 to 5 (p = 0.047) and the number of febrile episodes was reduced from 63 to 31 (p = 0.004). We conclude that a fixed low dose of gammaglobulin intravenously can restore normal serum IgG levels in hypogammaglobulinaemic B-CLL patients, and leads to a decreased number of febrile episodes and admissions to hospital due infections.

Effects of stair-stepping exercise direction and cadence on EMG activity of selected lower extremity muscle groups

Step ergometry has become a popular treatment mode in cardiovascular fitness and knee rehabilitation programs. The following study describes the effects of forward stair stepping at 35 and 95 steps/minute and forward and retrograde stair stepping at 60 steps/minute on the mean electromyographic (EMG) activity of the gluteus maximus, rectus femoris, vastus medialis, semimembranosus/semitendinosus, and gastrocnemius muscles. Thirty-three subjects without prior lower extremity pathology participated in the study. Analysis of variance was used to compare mean EMG activity during the knee extension phase of the different stepping conditions. Significant differences (p < 0.05) in mean EMGs of gluteus maximus, rectus femoris, vastus medialis, and gastrocnemius were noted across all cadences. The semimembranosus/semitendinosus EMG activity displayed a single significant difference between the cadences of 35 and 95. The comparison between forward and retrograde stepping identified only one significant difference in mean EMG (semimembranosus/semitendinosus). The effects of cadence on EMG activity should be considered when developing conditioning or rehabilitation programs for the lower extremity. Faster cadences result in increased peak activity of shorter duration for the gluteus maximus, quadriceps, and gastrocnemius. There is no apparent difference in EMG activity of the hamstrings due to cadence. Also, noting the minimal activation that occurs, stair-stepping exercise would not be recommended for strengthening of the hamstrings musculature.

Xanthomonas maltophilia bacteremia in immunocompromised hematological patients

Epidemiological, microbiological and clinical characteristics of 14 episodes of Xanthomonas maltophilia bacteremia in 12 seriously immunocompromised hematological patients, admitted to Rigshospitalet in Copenhagen over the 3-year period 1989-91, were evaluated. The results were compared with a randomly selected control group of 25 patients with Escherichia coli bacteremia. Hospital acquired bacteremia was more common among the patients with X. maltophilia bacteremia (p < 0.01). Treatment with broad-spectrum antibiotics before the bacteremic episode was markedly more common among the patients with X. maltophilia bacteremia (p < 0.001). The presence of a central venous catheter and previous treatment with corticosteroids were more frequent in patients with X. maltophilia bacteremia (p < 0.05). The X. maltophilia blood culture isolates were generally resistant to aminoglycosides and most beta-lactams. The mortality rates related to bacteremia caused by X. maltophilia and E. coli were 14% and 20%, respectively.

Changing etiology of bacteremia in patients with hematological malignancies in Denmark

To ascertain whether the microbiological etiology of bacteremia among patients with hematological malignancies has changed in Denmark, the species distribution of clinically relevant blood culture isolates from the Hematological Department at Rigshospitalet, Copenhagen in 1990 was compared with 2 previous studies (1970-72; 1981-85). In addition, time trends of the etiology of bacteremia among hematological patients in Copenhagen (eastern Denmark) and in Arhus (western Denmark) were compared. In contrast to many other studies, a significant increase in the proportion of Gram-negative aerobes was observed in Copenhagen (from 43% in 1981-85 to 55% in 1990; p < 0.05), whereas in Arhus the proportion of Gram-positive aerobes increased steadily during the 1980s (from 34% to 51%; p < 0.05). In Copenhagen, non-hemolytic streptococci and Xanthomonas maltophilia increased significantly and accounted for 10% (p < 0.01) and 5% (p < 0.05) respectively, of all isolates in 1990, whereas Staphylococcus aureus during the 2 decades studied decreased from 25% to 8% (p < 0.001). In both regions, a decrease was observed in the proportion of Pseudomonas aeruginosa which accounted for only about 5% of all isolates in 1990. No changes were observed in the rates of anaerobes and yeasts. Several factors may contribute to the reported differences in the etiology of bacteremia among hematological patients, e.g. criteria used to assign the clinical significance of the isolate, blood culture system used, practice of using indwelling intravenous catheters, different policies with respect to antimicrobial treatment, and the degree of immunosuppression. A local surveillance of blood culture isolates is mandatory if changes in etiology and resistance development are to be detected.

Multiple myeloma treated with mitoxantrone in combination with vincristine and prednisolone (NOP regimen) versus melphalan and prednisolone: a phase III study. Nordic Myeloma Study Group (NMSG)

One-hundred-and-fifty-one patients with previously untreated multiple myeloma were allocated to treatment with either NOP regimen (mitoxantrone 16 mg/m2 and vincristine 2 mg day 1 and prednisolone 250 mg day 1-4 and 17-20) or M+P regimen (melphalan 0.25 mg/kg and prednisolone 100-200 mg/day day 1-4). Both regimens were repeated every 4 weeks and were scheduled for 1 year. Seventy-seven patients were treated with NOP and 74 patients with M+P. No major clinical differences were recorded between the groups before treatment. Sixty percent of the patients responded (CR+PR) to NOP versus 64% to M+P (NS). The time to progression was 16 months (95% C.L. 14-51) in the NOP group versus 21 months (95% C.L. 15-27) in the M+P group (NS). The median survival was 14 months (7-21) in the NOP group and 31 months (21-43) in the M+P group (p = 0.02). NOP was significantly more toxic than M+P. Seven patients treated with NOP died due to infection and neutropenia and 1 patient died of cardiac toxicity, in contrast to 1 death due to infection and neutropenia in the M+P group. Gastrointestinal toxicity was acceptable in both groups. In conclusion, NOP was inferior to M+P as primary treatment of multiple myeloma.

Mouse erythrocyte rosette formation with malignant human B-lymphocytes re-evaluated: still a useful marker for differentiating mature B-cell malignancies

We have re-evaluated mouse rosette formation (MRF) as a marker for B-CLL by estimating the fraction of mouse rosette forming B-lymphocytes (identified by CD20 monoclonal antibodies) in normal donors and malignant CD20+ cell proliferations (ALL, AML, B-NHL, B-HCL and B-CLL). Whereas this ratio was increased in B-CLL, all other CD20 positive malignancies showed mean ratios of less than 0.1. As part of a Danish multi-centre study, we furthermore prospectively analysed 86 patients and found that the mouse/CD20 ratio divided the 78 patients with monoclonal B-cell populations suspected of B-CLL in two distinct groups. In the low ratio group, three patients were categorized as leukaemized B-NHL and one as PLL. The remaining three patients with low ratio were clinically and immunologically (by SmIg density and CD5 expression) B-CLL patients suggesting a frequency of MR-negative B-CLLs of approximately 5%. In the high ratio group two of 70 patients were diagnosed as B-NHLs. Thirdly, MRF was a valuable parameter in patients, where transformation of disease is suspected, since it preceded clinical changes by several months. Thus, MRF is still a useful marker in the age of monoclonal antibodies.

Mitoxantrone in the treatment of chronic lymphocytic leukemia

During the last few years it has been shown that intensive or continuing chemotherapy of patients with advanced chronic lymphocytic leukemia prolongs survival. In the search for new effective drugs with tolerable toxicity, mitoxantrone was evaluated in this phase 2 study. Seven of 11 previously untreated patients achieved complete or partial remission after single agent treatment with mitoxantrone, and 5 of .16 previously treated patients had the same degree of response. Only minor toxicity was observed. Therefore, it appears likely that mitoxantrone is as effective as chlorambucil, and it would seem justified to evaluate mitoxantrone in future combination chemotherapy regimens in patients with advanced chronic lymphocytic leukemia.

Prognostic importance of flow cytometric immunophenotyping of 540 consecutive patients with B-cell chronic lymphocytic leukemia

Blood mononuclear cells from 540 newly diagnosed, unselected patients with B-cell chronic lymphocytic leukemia (CLL) were examined by immunofluorescence flow cytometry for a panel of surface membrane markers, including IgM and IgD, the monoclonal antibodies anti-CD3, -5, -20, -21, -22, -FMC7, and, for the final 125 patients, anti-CD23. There were 503 CD5+ and 37 CD5- cases. In the CD5+ cases, the cells typically expressed IgM, IgD, CD20, CD21, CD22, and CD23. In univariate analysis, age, clinical stage, IgM-fluorescence intensity, CD23, and FMC7 had significant prognostic importance, with high IgM-fluorescence intensity, high FMC7, and low CD23 expression being associated with a short survival. There was no significant difference in survival between 351 cases expressing IgMD and 55 cases expressing IgM without IgD, or between kappa and lambda light chain monoclonal cases. CD20, CD21, and CD22 had no prognostic importance. In Cox multiple regression analyses, age, CD23, IgM-fluorescence intensity, and clinical stage (International Workshop System) had independent prognostic importance. Thus, besides clinical variables, CD23 and IgM intensity might be useful prognostic markers in the management of CD5+, B-cell CLL. The survival of CD5- patients was on the borderline of being significantly shorter than that of CD5+ patients. The majority of the CD5- cases were FMC7+, CD23-, had strong IgM fluorescence, and had splenomegaly.

Aberrations of chromosome 6 in 193 newly diagnosed untreated cases of chronic lymphocytic leukemia

Aberrations of chromosome 6 were observed in 11 of 193 cases of chronic lymphocytic leukemia diagnosed January 1, 1984-November 1, 1988 and investigated cytogenetically within 30 days after diagnosis. The 6p was rearranged in 5 cases: 4 balanced and 1 unbalanced translocation. The 6q was involved in 6 cases: 4 deletions and 2 balanced translocations. Three of the del(6q) may be identical: del(6)(q13q27). In two cases there were no additional aberrations. Aberrations of chromosome 6 correlated significantly with an advanced clinical stage, diffuse pattern of bone marrow infiltration, and increased SmIgM-fluorescence intensity. All these factors are associated with poor prognosis. Although the number of cases with 6q aberrations is still too small and the observation period too short to show significant influence on survival, the presence of 6q aberrations at diagnosis may prove useful in delineating a subtype of chronic lymphocytic leukemia with poor prognosis.

Refractory myelomatosis treated with mitoxantrone in combination with vincristine and prednisone (NOP-regimen): a phase II study. The Nordic Myeloma Study Group (NMSG)

In a phase II study, patients with refractory myelomatosis were treated with a combination chemotherapy (NOP regimen): mitoxantrone (bolus injection of 4 mg/m2 on days 1-4), vincristine (continuous infusion of 0.4 mg/24 h on days 1-4) and prednisone (250 mg/d on days 1-4 and 17-20). The treatment was repeated every 4 weeks. Ninety-two patients were treated after they were found refractory to treatment with melphalan and prednisone (and occasionally vincristine) (n = 50) or more intensive treatment regimens (n = 42) including anthracyclines (n = 18). Response (greater than or equal to 50% reduction of M protein) was obtained in 23 patients and minor response (clinical improvement but less than 50% reduction in M protein) in 22 patients. The median duration of the response was 7.5 months. Equal response rates were observed irrespective of the type of previous treatment. The major toxicity was myelosuppression with severe granulocytopenia and infections. However, the frequency decreased throughout the cycles. The NOP treatment is recommended in refractory myelomatosis, especially in patients refractory to other intensive regimens. Patients in a poor clinical condition or with thrombocytopenia before treatment should have a reduced mitoxantrone dose in the first treatment cycles.

Organic mercury in Greenland birds and mammals

Muscle, liver and kidney samples of 20 species of birds, seals, whales and polar bear were analyzed for total and organic mercury. Organic mercury concentrations varied considerably between individuals. A general tendency towards age accumulation was found, together with log-linear correlations between organic mercury concentrations in the three tissues. The major part of the muscle mercury was organic (maximum concentration found was 1235 micrograms kg-1 wet wt). This also applied to liver of birds, while in mammal liver organic mercury concentrations approached a level of 2000 micrograms kg-1 wet wt, which was not exceeded even when the total mercury concentration was greater than 100,000 micrograms kg-1 wet wt. The percentage of organic mercury in relation to total mercury in kidney of seals and whales was 10-20% (maximum 982 micrograms organic mercury kg-1 wet wt), while in polar bear it was less than 6% (maximum 217 micrograms kg-1 wet wt). For the monitoring of local food in the Arctic, the simpler and less expensive analysis of total mercury suffices when testing muscle, whereas liver and kidney should be tested for organic mercury as well.

B-cell chronic lymphocytic leukaemia: clonal chromosome abnormalities and prognosis in 89 cases

The results of cytogenetic studies are reported in 89 patients with B-cell CLL. LPS (E. coli lipopolysaccharide), PWM (pokeweed mitogen), PHA (phytohaemagglutinin), EBV (Epstein-Barr virus), TPA (phorbol 12-myristate 13-acetate), and LA (leucoagglutinin) were used as mitogens. Mitoses were obtained from 78 cases. Clonal aberrations could be demonstrated in 26 cases. Trisomy 12 was the most frequent finding (8 cases) and was sole abnormality in 4 cases. Chromosomes #14, #17, and #11 were involved in structural aberrations in 5, 7, and 7 cases respectively, but a t(11;14)(q13;q32) was the only structural aberration seen more than once. The median observation time was 47 months (range 1-87). The presence of clonal abnormalities did not influence survival significantly, either when calculated from diagnosis or from cytogenetic analysis. Patients with more than one aberration, however, had a significantly shorter survival than patients with normal mitoses only (p less than 0.05). The survival of 8 patients with trisomy 12 (in 4 as sole abnormality) was not different from that of patients with normal mitoses only.

High activity of mitoxantrone in previously untreated low-grade lymphomas

A consecutive series of 21 previously untreated patients with low-grade non-Hodgkin lymphomas were treated with mitoxantrone 5 mg/m2 daily for 3 days every 3 weeks. The cumulative dose did not exceed 165 mg/m2 in any patient. In this group, 7 patients had small lymphocytic lymphomas, 10 patients had follicular small cleaved cell lymphomas, and 4 patients had follicular mixed small- and large-cell lymphomas. Of the 21 patients, 20 obtained remission (complete in 6, partial in 14), and 15 of these are still in remission. Relapse-free survival is 68% at 2 years. None of the patients has died. Nonhematologic toxicity was modest. No severe alopecia was seen, and only 6 patients had nausea and vomiting (WHO grade 1-3). No cardiac toxicity was seen. In conclusion, mitoxantrone is a highly active and well-tolerated drug in this subset of patients. Hematologic toxicity, especially leukopenia, was dose limiting, and a reduction of the dose was necessary in 15 out of the 21 patients.

Carcinoma of the urinary bladder after treatment with cyclophosphamide for non-Hodgkin's lymphoma

We observed nine cases of transitional-cell carcinoma of the urinary bladder among patients who had had long-term treatment of other cancers with cyclophosphamide. Seven of the bladder carcinomas occurred within a cohort of 471 patients treated for non-Hodgkin's lymphomas. In this cohort the relative risk of bladder cancer was 6.8 (95 percent confidence interval, 3.2 to 14.2). The cumulative risk (mean +/- SE) was 3.5 +/- 1.8 percent 8 years after the start of treatment with cyclophosphamide and 10.7 +/- 4.9 percent after 12 years. Three of the nine patients were 50 years of age or younger; seven died with progressive bladder cancer. Subsequently, an additional patient had acute nonlymphocytic leukemia. Hemorrhagic cystitis was observed in 33 patients (cumulative risk, 11.8 +/- 2.1 percent after five years). Development of carcinoma of the urinary bladder was not related to previous hemorrhagic cystitis. The results caution against long-term treatment with cyclophosphamide for diseases with a favorable prognosis.

Refractoriness to alpha-interferon (Intron A) in previously chemotherapy-treated patients with chronic myelocytic leukaemia

8 patients with chronic myeloid leukaemia in the chronic phase who had previously received chemotherapy were given alpha-interferon (Intron A). The Intron A was administered subcutaneously at a dose of 2 x 10(6) I.U./m2 three times a week and this was increased to 4-5 million I.U./m2 daily if no response was obtained after 6-8 months. 1 patient was Philadelphia chromosome-negative and was the only one who showed a major response to treatment. The other 7 patients never achieved haematologic remissions, or even a significant reduction in the immature blood leucocyte count or spleen size.

Risk of therapy-related leukaemia and preleukaemia after Hodgkin's disease. Relation to age, cumulative dose of alkylating agents, and time from chemotherapy

391 patients treated intensively for Hodgkin's disease were followed for up to 15 years to evaluate the risk of therapy-related acute non-lymphocytic leukaemia (t-ANLL) and preleukaemia. Only two independent factors, patient age and cumulative dose of alkylating agents, were related to the risk of t-ANLL. The hazard rate of t-ANLL was roughly proportional to the square of patient age and to the total cumulative dose of alkylating agents. In 320 patients treated with alkylating agents the cumulative risk of t-ANLL increased steadily from 1 year after the start of treatment and reached 13.0% (SE 3.0) at 10 years after which time there were no further cases. Calculated from cessation of therapy with alkylating agents, however, the cumulative risk curve increased steeply during the first 1-2 years then gradually levelled out and no new cases were observed beyond 7 years. With a 15-year follow-up the general risk of solid tumours was not increased.

Lack of prognostic significance of T-lymphocyte subset counts in B-cell chronic lymphocytic leukaemia

In the 50 newly diagnosed, unselected, untreated B-CLL patients, the absolute numbers of blood T cells, T-helper cells, and T-suppressor/cytotoxic cells were by flow cytometric counting of mononuclear cells labelled with the monoclonal antibodies Leu5 (T cells), Leu3a (T-helper cells), and Leu2a (T-suppressor/cytotoxic cells). These estimations and the serum concentrations of IgG, IgA, and IgM were correlated to clinical stage (International Workshop System) and pretreatment observation time. For all patients together, the mean counts of Leu5+, Leu3+, and Leu2+ cells were significantly increased compared with the mean counts in 12 healthy controls (Mann-Whitney). In patients with advanced disease (stage B + C), both T-subset mean cell counts were significantly increased, whereas in patients with early-stage disease (stage A), although some high T-helper cell counts were noted, only the T-suppressor/cytotoxic mean cell count increase reached significance. Thus a trend was observed of a more frequent T-suppressor/cytotoxic cell predominance in early-stage disease, which is the opposite of the findings in most other prognostic studies. However, there was no significant difference in pre-treatment observation time according to T-helper: T-suppressor cell ratio below vs. above 1.0, irrespective of stage, whereas according to clinical stage, the pretreatment observation time in stage A was highly significantly longer than in stage B + C (logrank test). Thus, no independent prognostic significance of T-subset counts was found as judged by pretreatment observation time. No correlation was found between the occurrence of hypogammaglobulinaemia, T-subset ratios or T-subset counts.(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous presence of translocations t(14;18) and t(2;8) in a case of chronic lymphocytic leukemia

We report a patient with classical chronic lymphocytic leukemia of IgM kappa phenotype and a stable clinical course, in which repeated chromosome analyses of blood lymphocytes revealed the coexistence of t(14;18), a marker often associated with follicular low grade lymphocytic lymphomas, and t(2;8), a variant of the t(8;14) typically seen in Burkitt's lymphoma. Both these translocations involve immunoglobulin gene regions, the t(2;8) being almost always found in patients with kappa light chain restriction. However, in an EBV-immortalized cell line of this patient, most karyotypes contained t(14;18) alone, without the t(2;8). This suggests that t(14;18) was the primary cytogenetic event, and that t(2;8) evolved subsequently. As a secondary cytogenetic event, the t(2;8) may not share the grave clinical consequences of a primary t(2;8) as seen in Burkitt's lymphoma and related disorders.

The bone marrow histological pattern has independent prognostic value in early stage chronic lymphocytic leukaemia

The initial diagnostic bone marrow specimens from 90 consecutive, untreated patients with chronic lymphocytic leukaemia were examined for the pattern of lymphocytic infiltration in relation to clinical stage (International Workshop System) and survival. Three non-diffuse (interstitial, nodular, mixed nodular-interstitial) and one diffuse pattern were recognized. Generally, the bone marrow patterns correlated well with clinical stage: a non-diffuse pattern prevailed in early, and a diffuse pattern in later stages. However, with a Cox analysis of the covariate effect of clinical stage and bone marrow pattern on survival, the bone marrow pattern was shown to have independent prognostic significance in the early stage A in which a diffuse pattern carried a fourfold increase in death rate as compared to a non-diffuse pattern. These high risk patients could not be identified by the Rai substages of the International Workshop System.

Testicular function in young men in long-term remission after treatment for the early stages of Hodgkin's disease

16 young men in long-term remission after standard treatment for the early stages of Hodgkin's disease were examined for testicular function 48 to 125 months after termination of therapy. The patients had received mantle field irradiation, plus either irradiation of infradiaphragmatic lymph nodes (7 patients) or 6 cycles of MOPP (9 patients). 5 patients had almost normal semen quality judged by seminal fluid analysis. 11 patients had reduced semen quality (8 severely reduced) and often elevated FSH values. Semen samples of poor quality were significantly more common in patients treated with MOPP (7/9) than in those treated with infradiaphragmatic irradiation (1/7). One patient showed signs of regeneration of spermatogenesis. None had experienced reduction in libido and sexual performance after therapy; correspondingly, none had below normal testosterone values or elevated LH values. Patients should be informed about the risk of infertility before treatment. If in a given case several treatment options with equal prospective antineoplastic effect are weighed against one another, the patient's possible desire to retain fertility should favour the use of radiotherapy as opposed to chemotherapy, especially including alkylating agents.

Ovarian function in young women in long-term remission after treatment for Hodgkin's disease stage I or II

16 young women in long-term remission after first-line treatment for the early stages of Hodgkin's disease were examined for ovarian function 48 to 125 months after termination of therapy. The patients had received mantle field irradiation, plus either irradiation of infradiaphragmatic lymph nodes or 6 cycles of MOPP. 4 patients showed signs of ovarian failure judged by menopausal symptoms, menstrual pattern and/or hormone values. 12 patients had functioning ovaries; 8 of these had become pregnant after treatment, 2 had had an induced abortion, and 7 had given birth to a total of 9 healthy babies after treatment. The patients with signs of ovarian failure were older than the others, but the difference was not statistically significant. No difference between the patients who had received different treatments was established, nor does the study confirm the proposed protective effect of oral contraceptives. For women under 35 years of age, the long-term chances of preserving ovarian function after standard treatment for the lower stages of Hodgkin's disease seem to be much better than hitherto assumed.

Chronic lymphocytic leukaemia of T cell origin. Clinical variation possibly due to involvement of different T lymphocyte subpopulations

Based on the literature and 2 patients studied, we suggest that at least 2 different clinical entities are included in the concept of T CLL: (i) a clinical variant characterized by a relatively benign course, splenomegaly without lymphadenopathy, low lymphocyte count and granulocytopenia; the proliferating lymphocyte is morphologically mature, of medium size and a cytoplasm with azurophilic granules staining positively for acid phosphatase and corresponding to parallel tubular arrays as demonstrated by electron microscopy. The cells form E-rosettes, have no surface-membrane-bound Ig, but Fc-receptors for IgG. With monoclonal antibodies, the phenotype is OKT3+, OKT4- and OKT8+, theoretically corresponding to the suppressor/cytotoxic T lymphocyte subset, but functionally the cells demonstrate killer cell (responsible for ADCC), but not natural or suppressor cell activity. (ii) another clinical variant with an aggressive course, massive hepato-splenomegaly, lymph node enlargement and very high lymphocyte counts; the lymphocytes are small without cytoplasmic granules; their immunological and functional characteristics have not been determined, but morphologically the cells correspond to the T helper/inducer lymphocyte subset. Thus, involvement of different T lymphocyte subsets may be the reason for the clinical variation in T CLL.

A randomized study of radiotherapy versus radiotherapy plus chemotherapy in stage I-II non-Hodgkin's lymphomas

In a randomized, prospective trial from 1974-1978, 73 patients with non-Hodgkin's lymphomas in clinical Stage I or II were treated with extended field radiotherapy alone (RT) or RT plus adjuvant chemotherapy with vincristine, streptonigrin, cyclophosphamide and prednisone (RT + CT). With a median follow-up time of five years, 54% have relapsed in the RT group versus only 10% in the RT + CT group (P less than 0.01). There is no statistical difference in the overall survival yet, but 13/14 deaths in the RT group versus only 3/12 in the RT + CT group were due to progressive disease. Among patients with unfavorable histology, 13/22 in the RT group have died from disease progression against 3/34 in the RT + CT group (P less than 0.01). The results are in agreement with those from two other series published in detail. Based on these results we therefore recommend to use adjuvant CT with RT in all Stage I-II patients with unfavorable histology. Further observation is necessary before a conclusion can be drawn for the lymphoma patients with more favorable histology.

Nuclear clefts in chronic lymphocytic leukaemia. A light microscopic and ultrastructural study of a new prognostic parameter

Peripheral blood lymphocytes from 48 consecutive, newly diagnosed CLL patients were examined by light- and electron-microscopy for the presence of nuclear cleaving or folding. On this basis, the patients could be subdivided into 2 easily separable morphological groups. In 42 patients the lymphocytes had regular round nuclei. In 6 patients (13%) the lymphocytes of peripheral blood had a highly irregular nuclear outline characterized by pronounced cleaving or folding of the nuclear membrane. In 4 of these 6 patients immunological investigations demonstrated membrane markers consistent with B-cell monoclonality. Age, sex, distribution between stages as well as mode of clinical presentation were all alike in the 2 groups of patients. In spite of this a statistically significant, highly increased mortality was observed in patients with lymphocyte nuclear irregularities. Thus, 50% of all deaths occurred in this small group of patients. These findings indicate that lymphocyte nuclear cleaving or folding represents a stage-independent prognostic parameter, which permits selection of a small but easily identified high-risk group of patients.

Cytoplasmic inclusions in lymphocytes of chronic lymphocytic leukaemia. A report of 10 cases

Peripheral blood from 90 CLL patients was examined by light-and electron-microscopy for the occurrence of crystalline inclusions in lymphocytes. Inclusions were demonstrated in 10 patients (11%). In these patients the inclusions were present in 5-45% of peripheral blood lymphocytes. In the light microscope the inclusions appeared as rectangular, unstained structures in May-Grünewald Giemsa and PAS stains. In the electron microscope the inclusions appeared as intracytoplasmic, completely partially membrane-bound bodies, which were often associated with dilated profiles of rough endoplasmic reticulum. The ultrastructure of the inclusions was granular. In immunofluorescence staining the inclusions were found to contain immunoglobulin of the same type and class as the surface membrane-bound immunoglobulin of the neoplastic lymphocytes, most frequently IgM-lambda. The lymphocytes of one case with kappa light chains at the cell surface membrane contained inclusions of the same ultrastructural morphology as those of the other cases with lambda light chains. The presence of inclusions was not associated with any specific clinical or prognostic features. the inclusions persisted during antileukaemic therapy. Their formation may be related to a dysfunction in the synthesis of surface membrane-bound immunoglobulins.

Chronic lymphocytic leukaemia: a test of a proposed new clinical staging system

102 patients with chronic lymphocytic leukaemia underwent clinical staging according to 2 systems: the Rai staging system with 5 stages (0: lymphocytosis, I: palpable lymph nodes, II: hepato- or splenomegaly, III: Hb below 110 g/1, IV: platelet count below 100 X 10(9)/1) was compared to a staging system recently proposed by Binet, with only 3 stages (A: not more than 2 areas of palpable nodes or organs, B: at least 3 areas, C: Hb below 10 g/1 or platelet count below 100 X 19(9)/1). With the 3-stage system statistically significant differences between the stages were obtained, whereas some of the Rai stages (I-II-III) were only poorly separated. Non-haemolytic anaemia with Hb below 100 and 110 g/1) or auto-immune haemolytic anaemia. Chest X-ray findings did not influence the clinical stage.

The applicability of simple blood and bone marrow variables in prediction of acute leukaemia in patients with acquired bi- or pancytopenia

A retrospective study of 44 patients presenting with acquired bi- or pancytopenia (B/PC) and no evidence of any causal disorder was carried out. 12 patients developed acute non-lymphoblastic leukaemia after 2-51 months. Compared to the nonleukaemic subjects the preleukaemic patients at the onset of B/PC had significantly higher counts of myeloblasts and other myelopoietic cells in the bone marrow, more cellular marrows due to more dense cellularities of all compartments, higher blood granulocyte and monocyte counts, more pronounced anisocytosis, and in some cases a small number of circulating myeloblasts. A stepwise multiple logistic regression analysis identified 3 combinations of variables displaying significant simultaneous association with subsequent leukaemic transformation. Among these the combination of marrow myeloblast percentage and blood granulocyte count might be applicable to early prospective identification of patients with preleukaemic B/PC.

Effect of sodium nitroprusside on hypoxic pulmonary vasoconstriction in the dog

The objective of the study was to determine the direct actions of sodium nitroprusside (SNP) on the pulmonary vasculature actively constricted by hypoxic ventilation in the closed-chest dog. In 21 supine anesthetized (pentobarbital sodium, 25 mg/kg) dogs the left lower lobe was catheterized with a 20 F wedged-flow catheter. With constant flow to this lung lobe, lobar pulmonary artery pressure (PAP), left ventricular end-diastolic pressure (LVEDP), and lobar pulmonary vascular resistance (PVR) were studied during room air and 10% O2 mechanical ventilation. With lobar flow and LVEDP constant, observed changes of lobar PAP and PVR represent direct effects on vascular tone unaffected by passive factors. Ventilation with 10% O2 resulted in a significant increase in lobar PAP [12.2 +/- 1.6 to 17.2 +/- 1.2 (SE) Torr] and PVR [42.2 +/- 13.3 to 61.2 +/- 15.0 (SE) Torr X 1(-1) X min]. Then during continued hypoxia in 12 animals, femoral vein infusion of SNP at doses of 1, 2, and 5 microgram X kg-1 X min-1 resulted in significant decreases in lobar PAP to 14.8 +/- 1.5, 14.8 +/- 1.5, and 13.4 +/- 1.6 Torr, respectively, and in PVR to 56.7 +/- 14.1, 54.0 +/- 13.9, and 47.8 %/- 13.2 Torr X 1(-1) X min, respectively. In six animals the sequence of drug infusion was then reversed with similar results. It is concluded that the actively constricted pulmonary vascular bed is directly dilated by SNP infusion.

VP-16-213 in combination with cyclophosphamide, doxorubicin, vincristine, and prednisone in the treatment of non-Hodgkin's lymphomas

VP-16-213 has been used in 5-day courses together with cyclophosphamide, doxorubicin (Adriamycin), vincristine, and prednisone for treatment of 74 consecutive patients with non-Hodgkin's lymphomas. Ninety-one percent of patients with favourable histology and 69% with unfavorable histology achieved complete or partial remissions (overall response rate of 76%). The frequency of complete remission was disappointingly low (22%), possibly due to reduction of doses of the other myelosuppressive agents in the present combination. Further trials with VP-16-213 in other combination chemotherapy are required.

A prospective study of gentamicin ototoxicity

Twenty patients were included in a prospective otoneurological study performed to assess the ototoxicity in gentamicin therapy. Gentamicin was administered intravenously, and the serum level was currently determined. Audiographic and electronystagmographic studies were carried out at the institution and discontinuation of the treatment and again a few weeks later. Ten patients exhibited ototoxic actions, predominantly cochlear, 4 of the cases being fully reversible. Two patients developed severe hearing loss, associated in one with bilateral extinction of vestibular function. Low serum levels of gentamicin did not rule out the possiblity of ototoxicity. These results urge the continuing of prospective studies and indicate that gentamicin should be used only as a link in the primary treatment of severe infection or in cases in which other, less toxic agents have failed.

Splenectomy in chronic lymphocytic leukaemia

In a retrospective study it was endeavoured to evaluate the effects of splenectomy in chronic lymphocytic leukaemia (CLL) characterised by splenomegaly. The material comprises 42 patients subjected to the operation in the course of the past 20 years. In the majority the spleen weighed more than 1000 g. The main indication for splenectomy was anaemia, while in 9 cases it was thrombocytopenia and in 14 cases hypercatabolism. Splenectomy is followed by a pronounced increase in the venous haemoglobin level and platelet count to higher values which have been recorded for up to 3 years after the procedure. In cases where data were available, there has been weight gain and a falling basal metabolic rate. Splenectomy is effective especially in cases predominated exclusively by splenomegaly, but even in cases with marked extrasplenic manifestations, splenectomy often greatly reduces the need for prednisone and cytostatics. Increasing hepatomegaly and lymphomas were not more common after splenectomy than in a control series, and the incidence of infections was not increased after the operation. For comparison, 37 non-splenectomised patients with splenomegaly were assessed. X-radiation of the spleen seems to be insufficient, since usually it has to be repeated. Splenomegaly does not decrease spontaneously and rarely after treatment with prednisone/cytostatics. The findings indicate that splenectomy of patients with CLL and increasing splenomegaly should be performed more often and presumably also earlier than recommended in the literature.

Diffuse lymphosarcomatous infiltration in the central nervous system

Massive lymphosarcomatous infiltration, confirmed at autopsy, occurred in a 46-year-old man with neurological signs rapidly progressing to total paralysis of peripheral as well as cranial nerves. These signs set in at a time when the malignant systemic disease seemed to be otherwise in remission, and indeed they gave rise to great differential diagnostic difficulties.