High-dose methotrexate therapy (6-8 g/m2) in childhood malignancies: clinical tolerability and pharmacokinetics

Five children, ages 2.5 to 12 years (mean 6.2 years), with acute lymphoblastic leukemia or non-Hodgkin's lymphoma were given 22 courses of high-dose methotrexate (HD-MTX) therapy (6-8 g/m2/24 h). No serious clinical complications were encountered, but stomatitis occurred after three (14%) of the courses. First-phase elimination half-lives (t1/2(alpha)) of MTX and 7-hydroxy-methotrexate (7-OH-MTX) after 21 infusions were 2.7 +/- 0.4 h and 6.5 +/- 1.8 h (mean +/- SD). In one course (4.5%) there was delayed systemic MTX elimination, with first-phase elimination half-lives (t1/2(alpha] for MTX and 7-OH-MTX of 4.2 and 9.9 h, respectively, and second-phase elimination half-lives (t1/2(beta)) of 43 and 58 h. Significant decreases in white blood cell count, increases in serum creatinine, and increases in alanine aminotransferase and/or aspartate aminotransferase during the first 2-6 days were present in five (23%), three (14%), and six (27%) of the courses, respectively. The regimen was tolerated well by the children.

Methotrexate infusions in poor prognosis acute lymphoblastic leukemia in children: I. The Norwegian methotrexate study in acute lymphoblastic leukemia in childhood, August 1975-December 1980

One hundred fifty-three children with ALL were diagnosed in Norway in the period August 1975-December 1980. One hundred thirty-two of them received 3 infusions of methotrexate as consolidation therapy combined with methotrexate intrathecally as CNS prophylaxis. Eleven (44%) of the total 25 methotrexate cases with WBC above 50 X 10(9)/L were in CCR after 4 1/2-10 years. Two more cases had discontinued therapy, while in second remission. The event-free survival of all diagnosed 32 children in Norway with WBC above 50 X 10(9)/L was 37%. Seven infants below the age of 1 year are included in the 32 cases.

Methotrexate infusions in poor prognosis acute lymphoblastic leukemia: II. High-dose methotrexate (HDM) in acute lymphoblastic leukemia in childhood: a pilot study from April 1981

The pilot study using HDM in all cases of ALL in childhood had been run for 4 1/2 years as of September 1985. Fourteen (23%) of all 62 diagnosed cases of ALL had WBC above 50 X 10(9)/L, all 14 achieved CR. Three of them were below one year of age, two also had WBC above 400 X 10(9)/L, the third infant had B-cell-leukemia. The remaining 11 children received our new HDM protocol (Fig. 1), one of them had relapsed (BM) as of September 1985.

Pharmacokinetics of methotrexate and 7-hydroxy-methotrexate after high-dose (33.6 g/m2) methotrexate therapy

We have measured MTX and 7-OH-MTX in plasma and urine samples from a 9-year-old boy treated with six consecutive 24-h IV high-dose MTX courses (33.6 g/m2) after a relapse of ALL. The between-course pharmacokinetics of MTX and 7-OH-MTX were found to be highly reproducible. Both MTX and 7-OH-MTX elimination followed a biphasic curve, initial half-lives (t1/2(alpha] being 2.86 +/- 0.44 h and 5.14 +/- 0.46 h (mean +/- SD) and second-phase biological half-lives (t1/2(beta] being approximately 18 and 16 h, respectively. The apparent volume of distribution for MTX was 0.8 L/kg, whereas the corresponding value for 7-OH-MTX was threefold less. Since clearance of MTX was within the range reported for lower doses, the data suggest that MTX pharmacokinetics are not dose-dependent up to 33.6 g/m2.

Wilms' tumour in a horseshoe kidney. Diagnostic difficulties

A case of Wilms' tumour in a horseshoe kidney is presented. Until 1980, twenty-one cases were reported. Diagnosis may be difficult, especially as x-ray investigations, including IVP and renal angiograms, give the impression of a tumour arising outside the kidney. The distortion and dispersion of the renal pelvis and calyces usually seen with a Wilms' tumour are lacking. This is probably due to the special anatomic pattern of the horseshoe kidney, specifically the rotation of the renal pelvis around the long axis of the kidney.

Heparin for infants and children with meningococcal septicemia. Results of a randomized therapeutic trial

Heparin has been given intravenously, as part of a prospective study, to 11 of 26 infants and children with severe meningococcal septicemia. This therapy was started as early as possible following admission to hospital, and continued for two days. The age and sex distributions were roughly similar for the two treatment groups, but the prognostic signs on admission were somewhat less favourable for the group that did not receive heparin. Two boys who received heparin and two girls who did not, died. The clinical courses of the surviving patients in the two groups were also roughly similar, except that the tendency to cutaneous necroses was slightly more prominent in those who had not received heparin. We have thus no evidence that heparin has any great influence on the final outcome of meningococcal septicemia, even when given so early that shock had not developed.

Relapse rate after cessation of therapy in childhood leukemia. A material from the five Nordic countries

The experience of four hundred and ninety children from the Nordic countries who had their antileukemic therapy stopped prior to January 1981 is presented. The observation times after stopping therapy were between 1 month and 19 years. One hundred and five children (21.4%) relapsed before January 1981. No children relapsed later than four years after cessation of therapy. The calculated long term relapse rate is 28%.

Meningococcal disease--treatment of patients and household contacts below the age of 15 years

Based on extensive experience and studies, some guidelines for the treatment of meningococcal disease are presented. The physician should be watchful for signs of meningococcal disease in its early phases and be ready to institute antibiotic and fluid therapy immediately. During transport of the patient to hospital, emergency medical treatment should be continued, and the hospital personnel should be alerted to receive the patient. At the hospital, a team of physicians should be ready to deal with the ventilatory, circulatory, fluid and electrolyte problems, and other complications of meningococcaemia, as well as to ensure administration of appropriate therapy. Antibiotic therapy for household contacts should be instituted as rapidly as possible. In this way it is hoped that the toll from this devastating infection in Norway may be lessened.

Relapse rate after cessation of therapy in childhood leukemia. A follow-up report on 277 cases from the five Nordic countries

Two hundred and seventy-seven children from the Nordic countries who had their antileukemic therapy stopped before January 1979 were surveyed. The children were in remission when therapy was discontinued. So far 64 (23.1%) have relapsed. Central nervous system (CNS) and testicular leukemia have been a problem, but CNS-prophylaxis has been in common use in the Nordic countries only since 1972-1973. Most of the patients relapsed during the first year after stopping therapy, whereas no patient relapsed later than 4 years after cessation of therapy.

Hemoglobin and serum ferritin levels in mothers and infants at birth

Hemoglobin levels and serum ferritin concentrations were measured in cord blood and maternal blood taken a few hours before birth. Maternal serum ferritin levels were 29.1 +/- 18.6 micrograms/l which is lower than values given for normal adult women. Serum ferritin levels in cord blood were 144.4 +/- 73.2 micrograms/l which is higher than levels in normal adult men. No correlation was found between maternal and newborn serum ferritin levels, between newborn hemoglobin and serum ferritin levels, or between newborn birth weight and serum ferritin levels.

Effect of methotrexate on phagocytosis and killing of Staphylococcus aureus by human granulocytes

The effect of methotrexate on the phagocytosis and killing of Staphylococcus aureus by granulocytes from healthy blood donors was investigated in vitro. A concentration of methotrexate of 2.2 x 10(-4) mol/1 (100 micrograms/ml), which is readily obtained on high dose intravenous administration did not decrease the phagocytosis and intracellular killing of Staph. aureus. In addition, granulocytes isolated from patients after termination of 6 h and 24 h high-dose methotrexate infusions showed normal phagocytic activity.