Secondary malignancies after bone marrow transplantation in adults

PURPOSE

The records of 557 consecutive adult recipients of allogeneic-related and -unrelated and syngeneic bone marrow transplants (BMTs) were reviewed to determine the incidence of secondary cancers.

PATIENTS AND METHODS

Four hundred fifty-six patients were transplanted for acute lymphocytic leukemia (ALL; n = 79), acute myelogenous leukemia (AML; n = 182), and chronic myelogenous leukemia (CML; n = 195); 42 patients were transplanted for aplastic anemia (AA) and 59 for a variety of other hematologic and nonhematologic disorders, malignant and nonmalignant. Conditioning regimens included high-dose chemotherapy with or without total-body irradiation (TBI). Statistical analyses determined the cumulative incidence of developing a secondary cancer and elucidated the associated risk factors. Complete records (1 to 24 years of follow-up) on all patients were available.

RESULTS

Nine patients developed 10 secondary cancers for a cumulative actuarial risk of 12% (95% confidence interval [CI], 4.3 to 23.0) 11 years after transplant. The age-adjusted incidence of secondary cancer was 4.2 times higher than that of primary cancer in the general population. Eight of the 10 were epithelial in origin and three were cutaneous. TBI and acute graft-versus-host disease (GVHD) with a severity > or = grade II were associated with the development of any secondary cancer. On the other hand, chronic GVHD was a risk factor only for the development of secondary skin neoplasms.

CONCLUSION

Adult recipients of BMT face a significant risk of developing a secondary malignancy. Their risk is similar to that of other patients with hematologic malignancies who are treated with chemoradiotherapy only. Epithelial tumors, rather than the more commonly reported Epstein-Barr virus (EBV)-associated lymphomas, were most common. The fact that we did not routinely use T-cell-depleted marrow grafts nor anti-T-cell immunoglobulin for the treatment of acute GVHD may explain this variance.

Efficacy of enhanced external counterpulsation in the treatment of angina pectoris

Eighteen patients with chronic angina despite surgical and medical therapy were treated with an improved system of enhanced external counterpulsation (EECP) (1 hour daily for a total of 36 hours). Patients underwent a baseline treadmill thallium-201 stress test. After EECP treatment, a thallium stress test was repeated for the same exercise duration. One week after treatment, patients also underwent a maximal stress test. All patients improved in anginal symptoms and generally decreased antianginal medications, with 16 obtaining complete relief from angina. Pre- and post-thallium stress testing performed for the same duration showed complete resolution of ischemic defects in 12 patients (67%), reduction in the area of ischemia in 2 (11%), and no change in 4 (22%). Thus, a decrease in myocardial ischemia was observed in 14 patients (78%; p less than 0.01). The exercise duration of maximal stress testing after EECP significantly improved from 8.14 +/- 0.71 to 9.72 +/- 0.77 minutes (p less than 0.005), although the double product did not change significantly. Analysis of these 2 tests in the subgroup of 14 patients with improvement in thallium studies showed significant increases in both exercise duration (8.58 +/- 0.66 to 10.44 +/- 0.59 minutes; p less than 0.001) and double product (21,827 +/- 2,044 to 24,842 +/- 1,707 mm Hg.beats/min; p less than 0.01). The improvement in reperfusion defects and increase in exercise duration are reflections of improved perfusion to ischemic regions of the myocardium. EECP uses additional thigh balloons and sequenced balloon inflation, effecting a significant increase in diastolic augmentation over previously available methods.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute promyelocytic leukemia associated with a paraprotein that reacts with leukemic cells

A 29-year-old woman developed acute promyelocytic leukemia during pregnancy. At diagnosis, immediately postpartum, she was found to have IgG kappa immunoglobulin on the surface of the leukemic cells as well as a monoclonal protein of IgG kappa specificity in her serum. These resolved with chemotherapy which induced a complete remission. Immunoglobulin gene rearrangement was not found in the leukemic cells, thus indicating that the blasts were not secreting the monoclonal protein. The authors believe that the patient had an autoantibody directed at myeloid cells which was amplified by the development of the leukemic process.

Glucose metabolic rate kinetic model parameter determination in humans: the lumped constants and rate constants for [18F]fluorodeoxyglucose and [11C]deoxyglucose

The rate constants and lumped constants (LCs) for [18F]fluorodeoxyglucose ([18F]FDG) and [11C]deoxyglucose ([11C]DG) were determined in humans for the glucose metabolic rate kinetic model used to measure local cerebral glucose consumption. The mean values (+/- SE) of the LCs for [18F]FDG and [11C]DG are 0.52 +/- 0.028 (n = 9) and 0.56 +/- 0.043 (n = 6), respectively. The mean values (+/- SE) of the rate constants k*1, k*2, k*3, and k*4 for [18F]FDG for gray matter are 0.095 +/- 0.005, 0.125 +/- 0.002, 0.069 +/- 0.002, and 0.0055 +/- 0.0003, respectively. The corresponding values for white matter are 0.065 +/- 0.005, 0.126 +/- 0.003, 0.066 +/- 0.002, and 0.0054 +/- 0.0006, respectively. Using these values and previously published values for the rate constants for [11C]DG, the average whole-brain metabolic rates for glucose in normal subjects measured with [18F]FDG and [11C]DG are 5.66 +/- 0.37 (n = 6) and 4.99 +/- 0.23 (n = 6) mg/100 g/min, respectively. These values are not significantly different (t = 1.56, p greater than 0.10) and agree well with reported values in the literature determined by means of the Kety-Schmidt technique.

Renal bleeding: scintigraphic detection in a canine model

The authors evaluated a method of detecting urinary tract bleeding using Tc-99m sulfur colloid in a canine model.

Scintigraphic evaluation of the viability of cold-preserved kidneys before transplantation

Renal microcirculation studies utilizing microspheres can provide a highly reliable index of the viability of preserved kidneys. We describe a noninvasive method that permits subsequent transplantation of each tested kidney. Fresh canine kidneys were removed and perfused with either Collins' solution or Collins' solution with 5 mg/l of trifluoperazine (TFP), and preserved at 4 degrees to 6 degrees C in their respective perfusates for 5, 24, 48, or 72 hr. At the end of each period, the preserved kidney was perfused with 50,000 Tc-99m-labeled microspheres. Uniform cortical activity occurred in all kidneys preserved for 5 hr, with moderate decreases in cortical activity at 24 hr. Kidneys perfused with Collins' solution showed progressively decreasing cortical flow with sparse cortical activity after 72 hr. In kidneys perfused with Collins' solution containing TFP, however, cortical flow remained relatively well preserved at 48 and 72 hr. Direct correlation between viability of the cortical microcirculation and the capacity of the corresponding kidney to sustain life upon retransplantation into the original host was observed.

Enhanced resistance to the effects of hypothermic ischemia in the preserved canine kidney

Addition of trifluoperazine (TFP), a powerful calmodulin inhibitor to Collins' flush solution has exerted a significant protective effect on the cold-preserved kidney, with successful autotransplantation of 80% of preserved kidneys (4 of 5) after 72 hr of storage. In contrast, use of Collins' solution alone resulted in successful autotransplantation of only 33% (2 of 6) of kidneys after a similar period of preservation. In an attempt to analyze the significance of this result, the microcirculation of preserved kidneys was studied with injections of technetium-labeled microspheres into the kidneys, followed by study with a noninvasive radionuclide scintiphotography (RNS) technique that does not interfere with subsequent transplantation of the kidney. Such studies demonstrate that prolonged cold preservation after flush-cooling with Collins' solution is associated with a progressive deterioration of the integrity of the microcirculation, resulting in poor flow to the renal cortex. In contrast, when TFP is added to the Collins' solution, there are uniform increases in renal cortical flow in kidneys stored for 48 and 72 hr, with preservation of the integrity of the renal microcirculation. Biological testing shows a clear-cut correlation between these observations and the capacity of the tested kidneys to sustain life after retransplantation. Further experiments suggest that the decreases observed in cortical flow in kidneys preserved in the cold for 72 hr are a consequence of cellular swelling, and not of a vasospastic response. The data support the conclusion that TFP exerts its protective effect on the basis of its membrane stabilizing capacity as a calmodulin inhibitor, and not through direct vasodilatation.

Actin and tubulin of normal and leukaemic lymphocytes

Double labelling and the isolation of actin- and tubulin-derived peptides were used to determine the amounts of these proteins in peripheral lymphocytes from normal donors and from patients with chronic lymphocytic leukaemia. As a precaution against proteolysis, samples were boiled before assay. The actin content of chronic-lymphocytic-leukaemia (CLL) lymphocytes was 8.1 +/- 2.1% of total protein, which was lower (P less than 0.05) than the amount (12.8 +/- 3.0%) of actin found in normal lymphocytes. The tubulin content of CLL lymphocytes was 4.4 +/- 1.5% of total protein, which was also significantly less (P less than 0.05) than that of normal lymphocytes, which was found to be 6.1 +/- 1.1%.

In Memoriam. Sir Cecil Wakeley Bt KBE CB PPRCS. Founder and first Editor of the Annals of the Royal College of Surgeons of England

Images

Spleen scanning in humans with Tc-99m-labeled erythrocytes: concise communication

Technetium-99m-labeled heat-damaged erythrocytes were evaluated as a spleen imaging agent in 14 patients. Spleen-to-liver deposition ratios were increased to such an extent that the liver was rarely visualized, and interference from the hepatic left lobe of the liver was eliminated. Information obtained was accurate and diagnostically adequate in various splenic involvements. This tracer appears to be one of the better spleen imaging agents presently available.

Radiopharmaceuticals XXVII. 18F-labeled 2-deoxy-2-fluoro-d-glucose as a radiopharmaceutical for measuring regional myocardial glucose metabolism in vivo: tissue distribution and imaging studies in animals

18F-2-Deoxy-2-fluoro-D-glucose (18FDG) is rapidly extracted by the mouse heart, and the radioactivity in heart (3-4% per organ) remains relatively constant for 2 hr post injection. The brain uptake (2-3% per organ) remained relatively constant throughout the time course of the study. Liver, lungs, kidneys, small intestine, and blood all showed a rapid clearance of radioactivity after injection of 18FDG. At 120 min the heart-to-lung ratio was 12 and heart-to-liver ratio was 32. Urinary excretion of activity was approximately 16% of the injected dose at 60 min. The uptake of radioactivity by dog heart following the intravenous administration of 18FDG was 2.8-4.1% at 60 min and 2.4% at 135 min; it was regionally distributed, the areas of highest activity being the left ventricle and the interventricular septum. The brain activity was 2.1-3.5% at 120 min, with a ratio of gray matter-to-white matter of 2-3:1. Urinary excretion in dogs was 16% and 50% of the injected dose at 60 and 135 min. The chemical form of the activity in the urine, although unidentified, was not 18F-. Cross-sectional images of the myocardium of the dog after intravenous injection of 18FDG were obtained using emission tomography.

Radiographic morphometry and osteopenia in spinal osteoporosis

Measurements of bone mineral content and total-body calcium, normalized and expressed as ratios, were compared with radiographic morphometry in 45 women who had spinal osteoporosis. The radiographic indices examined included the femoral score, the femoral trabecular pattern, the biconcavity and metacarpal indices, and the total peripheral score. Both ratios and all the radiographic indices except the femoral trabecular pattern were found to be related to the number of dorsal spine fractures. The relationships observed support the following conclusions: (A) the femoral score and the metacarpal index are related to the degree of osteopenia; (B) the biconcavity index reflects the extraskeletal factors that are pathogenic in spinal osteoporosis; (C) a reduced femoral trabecular pattern index is associated with spinal osteoporosis, although this measurement is not related to the degree of osteopenia; and (D) it may be imprudent to diagnose osteoporosis from the presence of lumbar compression fractures.