Pre-B cell leukemia responds poorly to treatment: a pediatric oncology group study

Seventy-eight of 362 children with acute lymphocytic leukemia (ALL) had leukemic cells similar in phenotype to normal pre-B cells. When the clinical and laboratory features of patients with pre-B and "null" cell phenotypes of ALL were compared, no significant differences were noted, except that the pre-B cell ALL phenotype had a higher percentage of black children. In contrast, patients with T cell ALL had a higher median age at diagnosis, frequent thymic involvement, and higher WBC counts. Patients with pre-B and "null" cell ALL were treated identically and patients with T cell ALL differently. Although no difference in remission induction rates was noted between patient groups with pre-B and "null" cell ALL, the remissions were of shorter duration for patients with pre-B cell ALL (p = 0.004). Similarly, overt leukemic involvement of both the central nervous system (CNS) and bone marrow was noted sooner in the patient group with pre-B cell ALL. Univariate and multivariate Cox life table regression analyses demonstrate the independent prognostic significance of the pre-B phenotype and illustrate that the prognostic influence of potential relapse risk factors, such as WBC, sex, and age, are specific for leukemia phenotype. These findings may have importance for the design and tailoring of therapy for children with acute leukemia.

Nutrition in the treatment of cancer in children

Most malnutrition in children is iatrogenic, which, like all iatrogenic complications, ought to be averted. Data showing the consequences of malnutrition on the outcome of the child with cancer is examined, with a recommendation made for taking the nutritional state of such a patient into account. Efficacy of nutritional intervention is discussed, as are the role of micronutrients. On these bases, the suggestion to treat malnutrition in the child with cancer is strongly urged.

FDA regulations as applied to research in cancer centers. Review of problems and possible solutions

The Food and Drug Administration is charged to insure that the general public is not exposed to drugs that are either harmful or ineffective; yet, the regulations issued by the Food and Drug Administration are perceived to be in conflict with therapeutic human research. This article briefly reviews some considerations relevant to the problem. The regulations create both tensions and conflicts, but in themselves are reasonable exercises of the authority under which the FDA acts. However, regulations cannot be made either so general or so detailed that they will apply to all eventualities. A major problem is the degeneration of accountability and evaluation, from a compliance with the spirit of the recommendation to a compliance with documentation. When the review of compliance of documentation is done by inexperienced individuals, adversary relationships develop and the scientific and ethical problems are not addressed. A regulation that is meeting determined and widespread opposition is not enforceable unless it is subjected to continuous official scrutiny and to continuous coercion. The regulating agency must acquaint the regulated with the regulations, but must also convince the regulated of the necessity of the regulations. The research center serves to accentuate the differences and the problems that exist between the FDA and the research community, but is not unique in and of itself.

Confidentiality of medical records in pediatric cancer care. Myths, perceptions, and reality

Confidentiality is a complex requirement and impossible to enforce within the scientific-medical setting. Legal constraints include a patchwork of federal, state, and local laws and regulations. The setting of the teaching hospital brings its own multifaceted breaches in confidentiality. Insurance and third party payment claims necessitate opening of the patient's records. But research medicine in particular broadly disseminates large amounts of detailed information about patients, creating a situation in which it is not possible to avoid revealing the patient's identity. A distinction must be made between the breach of confidentiality in connection with dissemination of the label of the diagnosis, and breach of confidentiality in relation to details of care and clinical investigation. The problem in relation to confidentiality of diagnosis is intimately entwined with the patient's self-concept. The problem in connection with details of care and clinical investigation is the consequence of the antipathy between the physician-scientist-investigator and the physician-healer-priest. These two roles are not truly compatible and, therefore, the problem of confidentiality could be greatly alleviated if the records for those two separate roles (clinical investigator and personal physician) were kept separately.

Interaction between prognostic factors and treatment

In randomized trials, the better therapy may depend on values of a prognostic factor. This article presents methodology for subdividing a target population into three subsets: one region of superiority of each treatment, and one region of uncertainty. The basis of such a subdivision is treatment by prognostic factor interaction. The importance of this analysis in group trial sequences is discussed briefly.

Nutritional parameters in children with cancer

An analysis of commonly used nutritional parameters was made for 277 pediatric cancer patients. It is apparent that standard nutritional assessment parameters in the pediatric cancer patient may be difficult to interpret because of the disease state as well as of the treatment. On the basis of the findings of this study, dietary histories to determine caloric and protein adequacy and a measurement of weight/height percent may, in fact, be the most reliable indicators of nutritional status.

Energy and nutrient intake of children with cancer

Two hundred seventy-seven pediatric cancer patients received a nutritional assessment. Initial dietary intakes of patients with no prior treatment indicated a diet similar to that of the general population. The caloric intake was 75% of the RDA in a group of patients with non-malignant diseases and 80% of the RDA in the groups of patients with solid tumors and hematopoietic malignancies. Protein intake was greater than 100% of the RDA for all groups. Dietary iron was the nutrient lowest in intake, with a range of 70% to 78% of the RDA. At six-month evaluations, no significant changes occurred except for an increase in iron, niacin, riboflavin, and protein intakes in the group with solid tumors.

Nutritional status and anthracycline cardiotoxicity in children

The nutritional status of children in whom cardiomyopathy resulted from anthracycline chemotherapy was compared to that of a matched control group of patients who were treated similarly but who had no evidence of cardiac toxicity. Those with cardiotoxic reactions were found to be more often malnourished than were their matched controls. Once clinical manifestations of cardiotoxocity developed, the course was relentless and resistant to treatment and ended in death in 75% of the patients.

Use of thyroxine-binding prealbumin in the nutritional assessment of children with cancer

The level of thyroxine-binding prealbumin was evaluated in 87 pediatric cancer patients ages 1 through 16 years whose cancer was newly diagnosed but untreated, and 39 children with benign disease or no disease. There was no difference in levels of thyroxine-binding prealbumin between the patients with either malignant or benign disease, nor was there a difference between diagnostic categories. Prealbumin values did correlate with age. When the data were compared, there was a correlation between nutritional status and prealbumin level when the total population (N = 126) was age corrected, but not within the malignant disease group by itself. This confirms data that suggest malnutrition in children with cancer is not a result of protein depletion.

Comparison of physician and patient perceptions of communications issues

Sixty-three adolescent cancer patients and 53 physicians participated in a study designed to compare physician and patient perceptions of (1) the delivery of information at diagnosis, (2) patient reactions to treatment-related concerns, and (3) physician utilization patterns. Both patients and cancer center physicians appeared comfortable with the designation of the cancer center physicians as specific care providers for cancer-related issues and the community physicians as care providers for other health problems. however, differences in physician-patient perceptions were found in regard to the diagnostic period. Considerable disparity was also noted between physician and patient perceptions of tests and treatments, with physicians reporting significantly more patient fear, lack of understanding, discomfort, dissatisfaction with choice, and preoccupation with illness than was reported by the patients. Analysis of physician responses according to level of training showed concordance across all levels. Implications for continuing education are discussed and recommendations are offered.

Xylitol mediated amelioration of acetylphenylhydrazine-induced hemolysis in rabbits

Xylitol was investigated for its ability to ameliorate hemolytic anemia induced by acetylphenylhydrazine in rabbits. Animal experiments were performed using two different concentrations of xylitol, a 5% and a 10% solution with a total dose of 2 g/kg body weight and infusion rates of 10 mg and 20 mg xylitol per kg body weight per minute respectively. Two doses of acetylphenylhydrazine (APH), 5 and 10 mg per kg, were injected intraperitoneally as hemolytic inducers in different groups of rabbits. All the rabbits infused with xylitol showed significantly less acute APH-induced hemolysis. The isotonic 5% xylitol solution was found to maintain and restore the hematological parameters (packed cell volume, hemoglobin concentration, reduced glutathione (GSH) content, and reticulocyte counts) better than the 10% xylitol solution. Increased 51CR-red cell survival confirmed the beneficial effect of xylitol. The survival of erythrocytes as represented by chromium-labeling in rabbits infused with 5% xylitol after treatment with 10 mg/kg APH increased from about 33% (the survival of red cells in rabbits injected with APH alone) to 67% of normal rabbits' red cell survival. Erythrocytes in APH-treated animals took up xylitol more readily than erythrocytes from control animals. Our results in rabbits suggest that (1) non-toxic dosage of xylitol is effective in ameliorating the hemolytic episode induced by APH, (2) there is a dose relationship between the hemolytic effect induced by APH and the preventive effect offered by xylitol, (3) drug-challenged cells effectively acquired two to three fold more xylitol to compensate for the cellular needs than that of the normal cells, and (4) sufficient xylitol (55 mg/dl) to act as substrate for xylitol dehydrogenase was recovered intracellularly in drug-challenged rabbit erythrocyte in vivo, in spite of a low plasma (less than 30 mg/dl) concentration of the substrate. This antihemolytic affect of xylitol is likely accomplished through NADPH generation, which maintains the level of GSH and protects the hemoglobin and other structural and functional proteins against peroxidative damage.

Metabolism of xylitol and glucose in rats bearing hepatocellular

The variation in metabolism of glucose and xylitol by diverse rat hepatocellular carcinomas and partially hepatectomized rat livers was studied. The AS-30D and FB56 tumors demonstrated a significantly different degree of utilization of glucose and xylitol in vitro. This correlated partially with the low activity of polyol dehydrogenase when xylitol was used as a substrate. The activity ofa nicotinamide adenine dinucleotide-dependent polyol dehydrogenase in various hepatomas ranged from nondetectable to 30 nmol/min/mg protein, with the lower activities in FB56 and AS-30D tumors at 0 and 0.22 nmol/min/mg, respectively; while nicotinamide adenine dinucleotide phosphate-dependent xylitol dehydrogenase activities ranged from 0 to FB56 to 3.31 nmol/min/mg protein in liver regenerated for 1 week. The activities of nicotinamide adenine dinucleotide phosphate-dependent enzyme for normal liver and AS-30D tumors measured 2.2 and 0.14 nmol/min/mg protein, respectively. Although only the 311C tumor had an activity equivalent to that of normal liver, the range of the nicotinamide adenine dinucleotide phosphate-dependent polyol dehydrogenase activities among the cell lines studies is narrow. The ratios of metabolites of [14C]glucose or [14C]xylitol were determined in rats bearing AS-30D tumors. Animals were given i.v. injections of a 10% solution of [14C]glucose or [14C]xylitol, 2 g/kg body weight. Assays of neutral sugar metabolites from each substrate in the acid-soluble fraction of liver or AS-30D tumor showed that xylitol in the liver was converted primarily into glucose while in the tumor 80 to 90% of the xylitol remained unchanged. This hepatocellular carcinoma is also markedly deficient in the ability to synthesize acid-insoluble glycogen and glycoprotein from xylitol as compared to the liver.

Nutritional significance of fructose and sugar alcohols

Human metabolism of D-fructose, D-sorbitol, D-mannitol, and xylitol has been documented. In humans, sorbitol and xylitol at a single oral dose of 20 g or less and fructose at 70 g or less most likely can be fully absorbed. These there sugars can maintain, either independently or nearly independently, the integrity or the carbohydrate requirement for the growth of cells and animals. The absorption of D-mannitol is no more than 80% and is more laxative. In general, there is no adverse effect other than osmotic diarrhea after oral administration of these sugars. Transient hyperuricemia was seen in some humans. The chronic toxicity of life-long usage of these sugars in humans or other primates is not known. However, a 2-year Turku sugar studies suggested the safety of fructose and xylitol. Two-year feeding experiments in mice and rats indicated possible carcinogenicity of a high-percentage xylitol diet. Abnormalities of cellular growth were also documented in animals fed high percentages of sorbitol and sucrose. Long-term mannitol feeding experiments also revealed an increased incidence of benign thymic tumors in rats. Intravenous feeding of fructose, xylitol, and sorbitol causes major concern. The toxicity is total-dose and infusion-rate dependent. The physical toxicity induced by hyperosmolar effect of the concentrated infusion solutions can be lethal. The primary metabolic toxicities, mainly lactic acidosis and hypruricemia, are reversible. The suggested safe infusion rate of these sugars is 0.25 g/kg/h; sporadic toxic observations have been reported at this or lower doses (0.125 g/kg/h). The combination of glucose, fructose, xylitol, and sorbitol mixture intravenously is in use in Europe due to the critical threshold of each element. There are positive findings from the use of the combination in human illness (114). The beneficial effect of xylitol, mannitol, sorbitol, and fructose in decreasing order has been well documented in the prevention of dental caries in animals and in humans. Oral organisms do not appear to metabolically adapt to xylitol even after 4 years of in vivo exposure. This was based on the quantitation of xylitol dehydrogenase activity in saliva and oral organisms. In addition, a therapeutic and preventive effect for xylitol in human and animal dental caries has been demonstrated. There appears to be at least a theoretical edge in the dietary use of fructose, xylitol, and sorbitol in diabetics.(ABSTRACT TRUNCATED AT 400 WORDS)

An analysis of clinical and laboratory features of acute lymphocytic leukemias with emphasis on 35 children with pre-B leukemia

In 35 of 191 patients with acute lymphocytic leukemia (ALL) malignant cells were similar in phenotype to B-lymphocyte precursors. Both these patients' lymphoblasts and normal pre-B-cells contain cytoplasmic immunoglobulin (Ig) mu heavy chains, but have no surface Ig. In patients with pre-B leukemias, lymphoblasts containing cytoplasmic mu chains alone were often accompanied by cells of identical morphology that expressed no Ig and less frequently by lymphoblasts bearing scant amounts of surface mu. This spectrum of cellular Ig expression suggests that "null," pre-B, and intermediate pre-B/B ALLs represent closely related malignancies with complete or partial arrests at different stages of maturation. When pre-B, B, T, and "null" cell categories of ALL were compared for 22 different clinical and laboratory features, including remission rate and short-term remission duration, no statistical differences were observed between the pre-B and "null" groups. These early results suggest that pre-B-cell leukemias represents a relatively good prognostic subclass of ALL, do not require more intensive treatment than that proven to be effective for "null" cell ALL, and should be distinguished from the less common, but more clinically aggressive, B-cell subclass of ALL. Longer follow-up will be required to confirm these preliminary conclusions.

Adjuvant chemotherapy for medulloblastoma and ependymoma using iv vincristine, intrathecal methotrexate, and intrathecal hydrocortisone: a Southwest Oncology Group Study

In a prospective, randomized, cooperative group trial, the value of iv vincristine and intrathecal methotrexate and hydrocortisone as adjuvant therapy to radiotherapy in children with medulloblastoma and ependymoma was evaluated. The data showed no improvement in the survival of such children when adjuvant therapy was given.