Suggestion of concomitant changes of electric power consumption and childhood leukemia in Greece

Over a 14-year period (1976-89) 679 deaths from childhood leukemia were registered in Greece and the corresponding mortality over this period declined by almost 70%, with no evidence of differential reduction by gender or population type. For each of the nine geographical regions of the country, slopes of decreasing mortality from childhood leukemia over the study period were calculated and correlated with the corresponding slopes of increasing electric power consumption over the 16-year period 1970-85 (allowing for a postulated latency of about 5 years). A positive association was noted, which however was not statistically significant (p approximately 0.26). Studies of similar nature conducted in larger countries over more extended periods could contribute to the resolution of the controversy surrounding the role of electric power-generated extremely low frequency electric and magnetic fields in the etiology of childhood leukemia.

[State of the art of chemotherapy for adult acute leukemia in Japan]

For a disease like leukemia with an annual incidence of 3 to 4 per a 100,000 population, a multicenter cooperative study is essential to develop better therapeutic regimens. Our Japan Adult Leukemia Study Group (JALSG) started its first multicenter cooperative study in 1987. In the AML 87 study, response-oriented individualized induction therapy produced 78% complete remissions in 252 consecutive adult AML, a higher remission rate than that of any multicenter studies in the U.S.A. and Europe. For further development of clinical study for cancer in Japan, financial support to highly qualified clinical study groups by the government is urgently needed.

Graft-versus-host disease in children: the AIEOP-BMT Group experience with cyclosporin A

We retrospectively analyzed the data base of the Italian Association of Pediatric Hematology/Oncology BMT Group on the incidence and severity of GVHD in children given allogeneic BMT from HLA-identical sibling and receiving cyclosporin A (CsA) alone as GVHD prophylaxis. The study population included 145 patients for acute GVHD and 114 children at risk for chronic GVHD. Twelve patients had non-malignant diseases and 133 patients were affected by malignant disorders. Among the 145 patients (50 females, 95 males), 107 (74%) presented acute GVHD and 38 (26%) had no sign of disease. In the group of patients with acute GVHD, 38 children (26% of the whole study population) were found to have grade II disease, 9 (6% of the whole) grade III, 4 (3%) grade IV. Donor-recipient sex pairs had no significant influence on incidence of acute GVHD neither did donor-recipient age class stratification. Of the 114 patients evaluated for chronic GVHD, 86 (76%) developed no disease while 23 patients (20%) presented secondary chronic GVHD and 5 (4%) had de novo chronic GVHD. The incidence of chronic GVHD was higher in F-M than in M-M donor-recipient sex pairs (33% vs 11%, p < 0.05), with no difference between F-F and M-F. In patients of > 10 years, a higher incidence of chronic GVHD was observed in both female donors and recipients compared with male donors and recipients (48% vs 20% and 47% vs 19%, respectively, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

State of the science on the carcinogenicity of gasoline with particular reference to cohort mortality study results

As a result of the content of benzene in various streams of refinery products, including gasoline, it is not surprising that over the years studies and case reports have linked gasoline exposure to lymphopoietic cancers (LPC), particularly leukemia and multiple myeloma (MM). Of three recently conducted studies of gasoline-exposed workers, one shows strong associations with leukemia and MM, a second suggests some association with leukemia and did not analyze data for MM, and the third study is not possible to evaluate because of a major problem with study design. Other diseases of particular interest in relation to gasoline exposure are kidney cancer, malignant melanoma, and heart disease. One study suggests an association with kidney cancer, but the second study did not. There appears to be no association between employment in refineries or gasoline exposure and heart disease. However, evaluation of risk of kidney cancer and heart disease is somewhat difficult because investigators did not control for cigarette smoking, even though it is related to these diseases. This is of particular concern when studying gasoline-exposed workers, who because of the explosive nature of gasoline probably smoke less than the general population used for comparison of mortality. Some studies of refinery workers and gasoline-exposed workers in particular show an excess risk of death from malignant melanoma. Whether this latter association is the result of benzene/gasoline exposure, sunlight exposure, or a combination of the two cannot be determined with the data currently available.(ABSTRACT TRUNCATED AT 250 WORDS)

Rearrangements involving chromosome band 11Q23 in acute leukaemia

Rearrangements involving chromosome band 11q23 are very common in acute leukaemia, both lymphoblastic and myeloid (monoblastic), and are less common in lymphoma. Although several different genes have been cloned from translocation breakpoints, the great majority of translocations involve the MLL (myeloid-lymphoid leukaemia) gene. The MLL gene has several different names, ALL1, Htrx, HRX; the central part of the gene codes for multiple zinc fingers which show strong homology to the Drosophila trithorax gene. MLL is involved in four common translocations as well as in 25 uncommon or rare translocations, insertions and deletions. The translocation breakpoints occur within an 8.3 kb region which can be detected with a 0.74 kb cDNA probe. Twenty-five percent of patients have a deletion 3' of the breakpoint which includes the zinc finger region. Patients who previously received drugs that inhibit topoisomerase II often develop acute leukaemia with translocations involving 11q23. These translocations break MLL in the same 8.3 kb region. In the three breakpoints cloned to date, the translocation has led to a fusion gene on the derivative 11 chromosome with a chimaeric transcript, consisting of 5' MLL and the 3' segment of the other gene. Although transcripts were also cloned from the other derivative chromosome, all the evidence indicates that the critical fusion gene is on the derivative 11 chromosome. The molecular dissection of these rearrangements will provide insights into the biology of MLL and into the interaction of MLL with topoisomerase II inhibitors. In addition, this research has provided DNA probes that will be important for diagnosis and for monitoring patients during the course of their disease.

A specification test for univariate and multivariate proportional hazards models

This paper applies White's (1982, Econometrica 50, 1-25) information matrix (IM) test for correct model specification to proportional hazards models of univariate and multivariate censored survival data. Several alternative estimators of the test statistic are presented and their size performance examined. White also suggested an estimator of the parameter covariance matrix that was robust to certain forms of model misspecification. This has been subsequently proposed by others (e.g., Royall, 1986, International Statistical Review 54, 221-226) and applied by Huster, Brookmeyer, and Self (1989, Biometrics 45, 145-156) as part of an independence working model (IWM) approach to multivariate censored survival data. We illustrate how the IM test can be used for both univariate data and as part of the IWM approach to multivariate data.

A 39-year follow-up of the U.K. oil refinery and distribution center studies: results for kidney cancer and leukemia

This paper presents briefly some of the principal results of a mortality analysis of a cohort of workers employed for at least 1 year between 1950 and 1975 at eight oil refineries and approximately 750 distribution centers in the U.K., together with detailed results for kidney cancer and leukemia. Over 99% of the workers were successfully traced. Their mortality was compared with that of all males in the national population. The mortality from all causes of death is lower than that of the comparison population in both studies, and reduced mortality is also found for many of the major nonmalignant causes of death. In the refinery study, some increased mortality patterns are found for diseases of the arteries, and no healthy worker effect is found in the distribution center study for ischemic heart disease. Mortality from all neoplasms is lower than expected overall in both studies, largely due to a deficit of deaths from malignant neoplasm of the lung. Mortality from malignant neoplasm of the kidney is increased overall in the distribution center study, and in drivers in particular. The mortality from this disease increases with increased time since first exposure. The observed deaths from leukemia are slightly less than expected in the refinery study and slightly more than expected in the distribution center study. One refinery shows increased mortality due to in myeloid leukemia, and mortality is increased among refinery operators. Mortality is also raised in distribution center drivers, particularly for myeloid leukemias, including acute myeloid leukemia.

Clinical relevance of acute mixed-lineage leukemias

Conflicting results have been reported in recent years concerning the incidence and prognostic relevance of acute mixed-lineage leukemias (AMLL). Among the high number of possible hybrid antigen combinations, it is important to discriminate those occurring with sufficient frequency to be of general clinical significance. In this review an approach to a classification based upon the hierarchical import of developmental antigens seen during hemopoietic differentiation is suggested. As far as the clinical relevance of AMLL is concerned, some hybrid patterns have been found to be associated with distinct characteristics in terms of clinical features at the time of presentation and poor response to treatment. For these particular types of leukemia, the time has probably arrived to design more specific therapeutic regimens.

Exposure-response analysis of cancer mortality in a cohort of workers exposed to ethylene oxide

The authors previously reported results from the largest cohort mortality study of ethylene oxide-exposed workers that has been conducted to date. Here they extend their previous work by quantitatively examining the relation between cancer mortality and ethylene oxide exposure. This study included workers from 13 of the 14 geographically distinct facilities that were included in the previous investigation. These facilities began regularly using ethylene oxide to sterilize medical supplies or spices sometime between 1938 and 1969. Workers were followed from first exposure through December 31, 1987. Historical exposures to ethylene oxide were estimated using a regression model. Standard life-table analysis was used to examine cancer mortality in three categories of cumulative exposure to ethylene oxide. The Cox proportional hazards model was also used to examine cumulative and other measures of ethylene oxide exposure as predictors of cancer mortality. In both the life-table analysis and the Cox model, a positive trend was observed in all lymphatic and hematopoietic cancer mortality for cumulative ethylene oxide exposure. This trend was strengthened when ethylene oxide exposures 10 years prior to death were discounted (lagged) and when the analysis was restricted to neoplasms of lymphoid cell origin. Despite limitations discussed in this paper, the authors believe that these findings provide some support for the hypothesis that exposure to ethylene oxide increases the risk of mortality from lymphatic and hematopoietic neoplasms. The authors intend to continue follow-up of this relatively young cohort, which may allow more definitive conclusions to be drawn in the future.

Autologous bone marrow transplantation for acute leukemia: results and prognostic factors in 90 consecutive patients

The results of autologous bone marrow transplantation (ABMT) in acute leukemia (AL) and the prognostic factors for outcome were analyzed in a series of 90 consecutive patients treated at a single institution (mean +/- SD age: 25 +/- 11 years). Diagnosis was: AML (n = 43), ALL (n = 44), acute undifferentiated leukemia (n = 2) and acute bilineage (n = 1). Disease stage at ABMT was: first complete remission (CR1) 46 cases, CR2 33, other stages 11. Conditioning consisted of cyclophosphamide and total body irradiation in 88 patients. The 3 year probability of disease-free survival (DFS) was influenced by disease stage at ABMT: CR1 48%, CR2 28%, CR3 plus CR4 15%. The characteristics associated with a high probability of relapse were: in AML a FAB subtype other than M1 or M3 (p = 0.01) and in ALL an interval between CR1 and ABMT of < 3 months (p = 0.002). A WBC > 15 x 10(9)/l at diagnosis (p = 0.01), splenomegaly at diagnosis (p = 0.002) and time to CR1 > 4 weeks (p = 0.06) increased the risk of relapse in the entire group in CR1. In multivariate analysis, WBC at diagnosis (p = 0.006) and disease stage at ABMT (p = 0.03) independently influenced DFS. This study confirms the encouraging results of ABMT in CR1 but further antileukemia measures are necessary in patients with adverse prognostic features.

Efficacy of itraconazole in the prevention of fungal infections among neutropenic patients with hematologic malignancies and intensive chemotherapy. A double blind, placebo controlled study

We studied the efficacy and safety of itraconazole for the prevention of fungal infection in neutropenic patients given cytotoxic chemotherapy for hematologic malignancies. Patients were randomly allocated to receive either itraconazole (200 mg bd) or placebo in addition to oral amphotericin B until the patient either developed fungal infection or had completed antileukemic treatment. Forty six patients (83 neutropenic episodes) treated with itraconazole and 46 placebo treated patients (84 neutropenic episodes) were evaluable. No specific toxicity was noted. Nine fungal infections developed in the itraconazole group, of which four were histologically or microbiologically proven and 15 in the patients given placebo (eight proven) (p < 0.12). All these patients received IV amphotericin B. The incidence of Candida albicans infections tended to be lower in the itraconazole group, but overall, there was no measurable improvement in the prevention of fungal infections and mortality by itraconazole.

Heterogeneity of CD7+ 4- 8- 1- leukemia: usefulness of cytoplasmic antigen detection for subclassification

We identified CD3 and myeloperoxidase (MPO) antigens in the cytoplasm of leukemic cells from 15 patients with CD7+ 4- 8- 1- leukemia. Seven patients, five of whom had a mediastinal mass, had only cytoplasmic CD3 (cCD3) antigen; these seven were regarded as possibly being of T-lineage type. Six patients, one of whom had a mediastinal mass, showed both cCD3 and MPO; they were considered to have mixed lineage type. Two patients had neither cCD3 nor cytoplasmic myeloid antigens; they were therefore considered to have stem cell type. These two latter types were considered as the subgroups: mixed lineage or stem cell type. Patients with T-lineage type were good responders to L-17M therapy; four out of five who received L-17M therapy achieved complete remission. There were significant differences between the two subgroups in relapse-free survival, patients with T-lineage type exhibiting better prognosis than other types (p < 0.05).

Fungemia in patients with leukemia

A nine-year retrospective study on fungemia in patients with leukemia was conducted. A total of 79 episodes of fungemia in 77 patients with leukemia were documented. Candida parapsilosis fungemia was associated more frequently with the presence of a central venous line and to the use of parenteral nutrition than the other fungal species (p = 0.00026 and p = 0.01, respectively). The same fungus was isolated from both blood and surveillance cultures in 95% of Candida albicans and in 89% of Candida tropicalis fungemia (p < 0.01 and p = 0.02, respectively). The neutropenia and fungus colonization that resulted was associated significantly with the presence of invasive disease (p = 0.0024 and p = 0.0028, respectively). Conversely, central venous catheterization and parenteral nutrition appeared to be associated with episodes without deep tissue invasion (p = 0.000037 and p = 0.001, respectively). Invasive mycosis due to the fungus isolated from blood was documented in 51 patients with a mortality rate of 69%, whereas in 20 patients without invasive mycosis, mortality rate was 21% (p = 0.000059). In patients with fungemia, related or unrelated to the presence of a central venous catheter, mortality was 24% and 64%, respectively (p = 0.00042). Mortality was highest with C. tropicalis (p = 0.0017) and lowest with C. parapsilosis (p = 0.057). Severe neutropenia (polymorphonuclears < 100/mmc) appeared associated with a higher mortality rate (p = 0.012), whereas the recovery of neutropenia was related adversely to a fatal outcome (p < 0.01). With antifungal therapy, there was no statistically significant difference whether antifungal therapy was given or not.(ABSTRACT TRUNCATED AT 250 WORDS)

Disease mapping using empirical Bayes and Bayes methods on mortality statistics in The Netherlands

Data from the 64 public health service districts in the Netherlands, describing the health status of the Dutch population, were used to construct maps for several causes of deaths. The choice and estimation of the relative risk measure is described. The prior expected number of deaths was modelled using a Poisson regression approach based on a model with main effects of district and age. Desirable properties of risk parameters for disease mapping are that they both reflect the level of risk and cope with the instability in the observed measure caused by the numbers at risk in each district. Different techniques for estimation of parameters were applied: empirical Bayes estimation (EB) using a nonparametric prior and a gamma prior, and a Bayesian approach (B) with a uniform prior. For the parametric EB also a constrained estimator was used. The EB techniques studied in this paper shift or smooth the values of the risk parameter towards a global mean. In the Bayesian method applied here, spatial dependence among districts can be modelled, that is the estimates are smoothed towards a local mean. The three EB estimates gave by and large similar results, although the constrained EB estimate smoothed less, as was expected. The Bayesian estimates smoothed the estimates more or less similarly to the constrained EB.

Lymphoma, multiple myeloma and leukaemia among French farmers in relation to pesticide exposure

Lymphoma, multiple myeloma and leukaemia mortality among French male farmers and farm laborers (1984-1986) has been studied geographically. In each geographical area (89 "départements") exposure to pesticides in arable land has been characterized by an index taking into account different practices in the treatment of various crops as well as an estimate of the time per farmer spent cultivating each crop in 1970. The farmers population as a whole presented an increased mortality for multiple myeloma (SMR = 1.59, 95% CI = 1.32-1.89) and leukaemia (SMR = 1.33, 95% CI = 1.19-1.49) but not for lymphoma (SMR = 1.09, 95%, CI = 0.94-1.26). Using Poisson regression, leukaemia mortality appeared significantly linked to the pesticide exposure index (P = 0.04), after adjustment of farmers' economic status and a linear geographical gradient, whereas no significant relationship was found for lymphoma or multiple myeloma. This result reinforces a similar link reported from a previous French geographical study conducted at a smaller scale within a region.

Mortality due to pancreatic and lymphopoietic cancers in chlorohydrin production workers

Men assigned to the chlorohydrin unit of Union Carbide's South Charleston plant in the Kanawha Valley of West Virginia were followed up for mortality from 1940 to the end of 1988. This 10 year update was conducted to verify previous findings of excesses of cancer among the 278 men assigned to the chlorohydrin unit, which primarily produced ethylene chlorohydrin from 1925 to 1957. This process produced ethylene dichloride and bischloroethyl ether as byproducts. Mean duration of assignment was 5.9 years and mean duration of follow up was 36.5 years. Standardised mortality ratios (SMRs) were calculated based on comparisons with the United States white male population. Duration-response trends were assessed by internal comparisons with two different groups of unexposed chemical workers in the Kanawha Valley. The evidence that the earlier finding of an excess of pancreatic cancer was work related is strengthened by the occurrence of two additional cases (0.9 expected). The SMR for pancreatic cancer was 492 (95% CI 158-1140), based on eight observed v 1.6 expected deaths. There were no additional deaths due to leukaemia, but the three to four-fold excess risk for lymphopoietic cancers persisted due to new cases of non-Hodgkin's lymphoma and a death from multiple myeloma. The SMR for lymphatic and haematopoietic cancers was 294 (eight observed v 2.7 expected; 95% CI 127-580). Pronounced increases in risk were seen for total cancer, pancreatic cancer, all lymphatic and haematopoietic cancers, and leukaemia with increasing durations of assignment to the chlorohydrin unit. Most of the cases were first assigned to the unit in the 1930s when chemical manufacturing was in its infancy and exposures were less controlled. These data are insufficient to identify conclusively the causative agent or agents. The weight of evidence, however, based on probable exposure, known toxicity of the chemicals, and animal responses suggest that high exposures to ethylene dichloride, perhaps in combination with other chlorinated hydrocarbons, is the most likely explanation.

1993 progress report from the International Bone Marrow Transplant Registry. Advisory Committee of the International Bone Marrow Transplant Registry

The International Bone Marrow Transplant Registry is an organization devoted to scientific research in BMT. More than 230 transplant teams worldwide contribute detailed information about recipients of allogeneic and syngeneic BMT for study. Results of analyses are published in medical journals and presented at national and international scientific meetings (more than 60 publications and more than 500 presentations in the past 4 years). This collaborative research program has grown rapidly with more than 2000 cases reported annually. This report summarizes results of several recent investigations and reviews the state of BMT in leukemia and aplastic anemia.

Outcome after allogeneic bone marrow transplant for leukemia in older adults

OBJECTIVE

To determine whether age over 40 years is associated with adverse outcome after allogeneic bone marrow transplantation for leukemia.

DESIGN

A retrospective analysis of outcome after bone marrow transplants for leukemia reported to the International Bone Marrow Transplant Registry (IBMTR) among recipients 30 through 39 years, 40 through 44 years, 45 through 49 years, and 50 years of age and older.

SETTING

Transplantations performed in 138 institutions worldwide and reported to the IBMTR.

PATIENTS

A total of 2180 recipients of HLA-identical sibling bone marrow transplants for leukemia, divided into four cohorts based on age: 30 through 39 years (n = 1282), 40 through 44 years (n = 527), 45 through 49 years (n = 291), and 50 years and older (n = 80).

MAIN OUTCOME MEASURES AND RESULTS

Incidence of leukemia-free survival, graft-vs-host disease, and relapse was comparable among the four age cohorts. Patients with advanced leukemia aged 45 years or older had a slightly higher risk of treatment-related mortality, and the 45- through 49-year-old cohort had a higher risk of interstitial pneumonia.

CONCLUSIONS

These data indicate that among leukemia patients over 30 years of age at the time of allogeneic bone marrow transplantation, increasing age into the fifth decade does not adversely affect outcome after transplants from HLA-identical siblings.

Splenectomy in lymphoproliferative disorders: a report on 70 cases and review of the literature

Between February, 1970 and September, 1991, we performed splenectomies on 70 patients with chronic lymphoproliferative disorders including primary leukemias: 19 B-cell chronic lymphocytic leukemia, 1 B-cell prolymphocytic leukemia, 22 hairy cell leukemias, 4 large granular lymphocytic leukemias, 1 T-cell prolymphocytic leukemia, and non-Hodgkin's lymphomas (NHL): 10 splenic lymphomas with villous lymphocytes, 4 follicular lymphomas, 5 mantle cell lymphomas, 3 lymphoplasmacytic and 1 large cell NHL. The primary indications for surgery in this series were therapy-resistant disease (40%) and therapeutic splenectomy (38%). Postsplenectomy, 70% of patients had a complete hematological response, 23% had a partial response, and 7% were nonresponsive. Median treatment-free survival correlated with the hematologic response postsplenectomy and the underlying diagnosis. Better treatment-free survivals were seen in patients with lesser degrees of anemia and thrombocytopenia. Overall, improvements were more pronounced in the B-cell than in the T-cell disorders. Indications for further therapy, postoperative morbidity and mortality, and survival times are discussed along with a review of the literature. These findings advocate a continuing role for splenectomy in symptomatic lymphoid malignancies running with splenomegaly and hypersplenism.

Bone marrow transplantation

Bone marrow transplantations have a definite role in treatment of leukemias and lymphomas. In acute myeloid leukemia and CML an allogeneic transplant using an HLA identical donor certainly provides a far superior survival than chemotherapy. Patients with Ph' chromosome need to be transplanted in first remission if a suitable donor is available. In recurrent lymphomas the best results are achieved if the patient is transplanted in complete remission. Transplantation done using minor mismatched family donors or unrelated donors are still considered experimental and more data is needed before final recommendations can be made. Availability of supportive services is an absolute must prior to establishing transplant program. Selection of patients for transplantation should be done after carefully reviewing the indications and discussing with the family the emotional, financial and physical burden of the procedure. For selected indications in leukemias and lymphomas, BMT may be the only viable treatment option and therefore must be considered.

Prognostic factors of invasive pulmonary aspergillosis in leukemic patients

The study objective was to identify prognostic factors associated with survival in patients treated for acute leukemias who developed invasive aspergillosis (IA) during induction therapy. This retrospective analysis involved 21 patients treated in two hematologic centers over a six-year period. All were treated in protective isolated rooms with high-dose amphotericin B as soon as fungal infection was suspected. Ten (45%) of the twenty-one patients died. There was no statistical difference between the patients who survived and those who died in relation to the mean time of onset of IA or the total and mean daily dose of amphotericin B. On the other hand a favourable outcome correlated strongly with complete leukemic remission (p < 0.0001): all but one of the patients with objective residual leukemia died of IA, whereas all those who achieved complete hematological remission survived. In conclusion, it seems that the main vital prognostic factor in these leukemic patients with IA was the achievement of complete remission. We were unable to control IA in 10 of 11 patients with refractory leukemia, regardless of neutropenic status, despite early administration of high-dose amphotericin B. All the patients who achieved complete remission were successfully treated with amphotericin B.

[Hodgkin's lymphoma and secondary leukemias]

The increase of survival in patients with Hodgkin's disease (HD) has made appear the problem of secondary neoplasms, included acute leukemias. The authors evaluate the incidence of acute leukemias in 205 HD with a follow-up more than 12 months (mean 92 months). With regard to these latter, 18 (8.7%) were treated with radiotherapy alone, 69 (33.6%) with chemotherapy alone and 118 (57.5%) with a combination of radiotherapy and chemotherapy. Chemotherapy consisted of 2-12 courses of MOPP alone or in combination with ABVD. The relative risk of acute leukemias is 96.7 (CI 95%: 44.2-183.6): nine cases against an expectancy of 0.093. The risk changes during five-years periods, but not significantly, and it not declines after ten years from the diagnosis. Only the alkylating chemotherapy seems to be important to favour the onset of acute leukemias. Among the patients who received a number of courses of MOPP less or equal than 6 (177), seven developed an acute leukemia (relative risk 85.3; CI 95%: 34.3-175.9); among those who received more than 6 (9), two developed an acute leukemia (relative risk 333.3; CI 95%: 40.3-1204.1). Neither the addition of radiotherapy nor the stage nor the splenectomy nor the histotype favour the onset of acute leukemia.