Prognostic importance of ophthalmic manifestations in childhood leukaemia

In order to assess the systemic prognosis of children with leukaemic ocular involvement, 63 of 131 patients admitted to hospital with acute leukaemia were evaluated ophthalmically. A total of 28 of 63 showed ophthalmic involvement and were followed up for up to 84 months. Twenty seven of 28 patients (96.4%) died within 28 months after the onset of ocular involvement and within 83 months after the onset of leukaemia. The 5 year survival rate of patients with ophthalmic manifestations was 21.4% (6/28). This survival rate was significantly lower than that of those who lacked ophthalmic manifestations (16/35: 45.7%, p < 0.05). All of the patients with ophthalmic manifestations had either bone marrow relapse or central nervous system leukaemia. The prognosis was related to risk factors such as central nervous system leukaemia or bone marrow relapse in most cases.

Cytogenetic features of neonatal leukemias

We reviewed a series of 41 neonatal leukemias (NL), including published cases karyotyped by banding techniques, but excluding Down syndrome-associated cases and analyzed distribution of cytogenetic anomalies with respect to other clinical variables and outcome. The most frequent chromosomal changes in this age group involve rearrangements of 11q23, which is correlated with high white blood cell (WBC) count at onset and type of leukemia. A discrete heterogeneity of cytogenetic abnormalities is also evident, however, possibly reflecting other specific pathways in NL development. With respect to prognosis, cytogenetic abnormalities are a strong indicator of poor prognosis.

Changing trends in allogeneic bone marrow transplantation for leukemia in the 1980s

OBJECTIVE

To identify changes in practice and outcome of bone marrow transplants for leukemia in the 1980s.

DESIGN

Comparison of key explanatory and outcome variables in five 2-year cohorts, from 1980 through 1981 to 1988 through 1989, using a large database of detailed clinical information.

PATIENTS

Recipients (7788) of bone marrow transplants for acute lymphoblastic, acute myelogenous, or chronic myelogenous leukemia reported to the International Bone Marrow Transplant Registry, Milwaukee, Wis, by 185 transplant teams worldwide.

RESULTS

Linear increases occurred during the periods 1980 through 1981 to 1988 through 1989 as follows with 95% confidence intervals: (1) transplants for chronic myelogenous leukemia from 14% +/- 2% to 35% +/- 2%; (2) transplants from unrelated donors from 1% +/- 1% to 7% +/- 1%; (3) preparative regimens without radiation from 3% +/- 1% to 30% +/- 2%; and (4) use of methotrexate plus cyclosporine to prevent graft-vs-host disease from 2% +/- 1% to 55% +/- 2%. Among recipients of human lymphocyte antigen-identical sibling bone marrow, the 2-year probability of treatment-related mortality decreased by 6% to 22%. The probability of relapse decreased from 46% +/- 6% to 38% +/- 6% in intermediate leukemia but did not change appreciably in early or advanced leukemia. Probabilities of leukemia-free survival improved from 51% +/- 4% to 57% +/- 3% in early leukemia, from 28% +/- 4% to 36% +/- 5% in intermediate leukemia, and from 12% +/- 4% to 18% +/- 5% in advanced leukemia. A separate analysis of a homogenous population of patients indicated that improvements in outcome in the 1980s were due to improvements in transplant practice rather than improved patient selection.

CONCLUSIONS

Modest increases in leukemia-free survival rates occurred after human lymphocyte antigen-identical sibling bone marrow transplants in the 1980s. Improvements were due primarily to reductions in treatment-related mortality with little or no change in relapse risk. More effective antileukemia strategies and continued reductions in treatment-related toxic effects are needed.

Multiphenotypic acute leukemias: clinicopathologic correlations and response to therapy

Multiphenotypic acute leukemias (MAL), defined by the coexpression on most blast cells of antigens classically attributed to different lineages, remain a rare event. We isolated a series of 26 such cases from a cohort of 1565 leukemic patients whose cells were immunophenotyped at diagnosis. Markers of B and myeloid lineage (BM) were associated in 16 cases (62%), 3 coexpressed B and T markers (BT), and T-cell and myeloid antigens (TM) were found in 7 (27%). A tumoral syndrome was observed in 69% of the patients, without significant differences between the immunophenotypic subgroups. Median event free survivals in the three immunophenotypic subgroups as defined were respectively 24 months for BM-MAL, 4 months for TM-MAL and 7 months for BT-MAL respectively. The poorer prognosis of TM-MAL was significantly different from that of BM-MAL (p < 0.001). This concurred with the poorer prognosis associated with CD7 expression or absence or CD10, both characteristic features of TM-MAL.

Assessment of the spatial occurrence of childhood leukaemia mortality using standardized rate ratios with a simple linear Poisson model

Reports of a suspected cluster of childhood leukaemia cases in West Central Phoenix have led to a number of epidemiological studies in the geographical area. We report here on a death certificate-based mortality study, which indicated an elevated rate ratio of 1.95 during 1966-1986, using the remainder of the Phoenix standard metropolitan statistical area (SMSA) as a comparison region. In the process of analysing the data from this study, a methodology for dealing with denominator variability in a standardized mortality ratio was developed using a simple linear Poisson model. This new approach is seen as being of general use in the analysis of standardized rate ratios (SRR), as well as being particularly appropriate for cluster investigations.

Chronic leukaemias

In recent years many subtypes of CLL and some CML variants have been recognized throughout the world by means of careful clinical, epidemiological, immunological, molecular biological and viral studies. Most striking has been the establishment of a close association between certain immunophenotypical subtypes of CLL and infection with HTLV-I and possibly HTLV-II. CLL has consistently been shown to have a strong genetic component and a low incidence among Asians, but a growing body of evidence also links this major leukaemia type with environmental factors including solvents, unidentified farming and other occupational exposures. In contrast, CML is characterized by few genetic associations, relatively homogenous world-wide distribution, greater frequency in Blacks than in Whites, little evidence of viral aetiology, and evidence that exposures to ionizing radiation, benzene and possibly other chemical agents are important aetiological factors. Most studies suggest that acquired rather than genetic factors are of greater importance in the aetiology of CML, but this conclusion is somewhat difficult to reconcile with the relatively small variation in incidence rates internationally. Common to both disorders in most populations are an increasing incidence with age, male predominance, and stability of incidence, survival and mortality over the years, exclusive of improved survival of CML following allogeneic bone marrow transplantation.

Higher cure rates in acute leukemia: now more probable with increasingly effective induction therapy

Traditional therapy of acute myelogenous leukemia has not cured more than 10% of patients and, of acute lymphoblastic leukemia not more than 30% of adults. In part, this is due to the lack of agents effective enough to induce remissions of such quality that cure is possible. The introduction of mitoxantrone and its use in high dose with high-dose cytarabine for induction therapy, raises the possibility of an increased cure rate of acute myelogenous leukemia and acute lymphoblastic leukemia.

Mortality among workers engaged in the development or manufacture of styrene-based products--an update

Mortality was updated another 11 years through 1986 for a previously studied cohort of 2904 male chemical workers who were potentially exposed to styrene and related materials for a year or more between 1937 and 1971. Substantial deficits in mortality from all causes and total cancer were observed in the cohort when it was compared with white males in the United States, and also other chemical workers who were unexposed to styrene-based products. Mortality from leukemia was slightly less than expected during the updated period, in contrast to an excess of lymphatic leukemia observed in the original period. Yet small elevations in risk of other types of lymphatic cancer, particularly multiple myeloma, persisted. The risk of these cancers did not increase with estimated intensity or duration of styrene exposure. The findings are discussed in context with those of studies of similarly exposed workers in related industries.

Bone marrow transplantation for childhood leukemia: five years' experience in a pediatric hematology center

BACKGROUND

Fifty-three children (39 male, 14 female, median age 9 years 3 months) with different forms of leukemia underwent bone marrow transplantation (BMT) at our center. Various conditioning regimens were used according to the disease and time of BMT. In this paper we evaluate the impact of the experience of a pediatric hematology center on BMT-related problems in children.

METHODS

We analyzed disease-free survival (DFS), early BMT-related effects, hepatic, cardiac and respiratory function and late endocrine effects as shown by standard instrumental and laboratory tests.

RESULTS AND CONCLUSIONS

Outcome (overall median follow-up 34 months) was satisfactory. Three years DFS was 50.1% in all patients, 58.8% in lymphoblastic leukemia in 2nd complete remission (CR), and 50.0% in acute myeloid leukemia (some in 2nd or subsequent CR). Three of four patients with chronic myeloid leukemia were alive at 38 months. Management of the problems causing early post-BMT toxicity contributed to a progressive fall in early morbidity and mortality (14.3% in the last 3 years). Pre-BMT hepatitis in most patients was not associated with increased post-BMT hepatotoxicity. Cardiac function, even in patients given aggressive anthracycline treatment before BMT, remained normal 3 years after transplantation, as did respiratory function, although 8 cases presented subclinical restrictive and/or obstructive alterations. Compensated hypothyroidism was observed in 9 patients. Six boys received replacement treatment for hypogonadism. Severe height impairment was seen in 2 patients. Post-BMT endocrine and growth effects require a longer follow-up for definitive conclusions to be drawn.(ABSTRACT TRUNCATED AT 250 WORDS)

Cancer mortality after iodine-131 therapy for hyperthyroidism

Cancer mortality was studied in 10,552 Swedish hyperthyroid patients treated with 131I between 1950 and 1975. The patients were matched with the Swedish Cause-of-Death Register and the cases of 977 patients who died from cancer or leukemia were studied. The patients had been followed up for an average of 15 years (range 0 to 35 years), and the overall standardized mortality ratio (SMR) was 1.09 [95% confidence interval (CI) = 1.03 to 1.16], with a higher risk for women. The highest mortality was seen during the first year after exposure (SMR = 1.15) and decreased for the following 9 years (SMR = 1.04). The risk of dying from a cancer in the digestive tract and respiratory organs was significantly elevated more than 10 years after exposure, as was the overall cancer mortality (SMR = 1.14). No increased risk was seen for leukemia, bladder cancer or breast cancer. Younger patients and those receiving 131I at higher activity had higher SMRs than older patients and those receiving lower activity. Patients with toxic nodular goiter had higher risk than those with Graves' disease. The lack of increasing mortality over time and with increasing activity of 131I administered argues against a carcinogenic effect of 131I. However, in the case of cancers of the stomach, the 131I exposure could have contributed to the excess mortality from these cancers.

[Mortality from childhood and adolescent leukemia in Spain (1951-1985)]

PURPOSE

To study the mortality due to leukaemia during childhood and youth in Spain in the period 1951-1985.

MATERIAL AND METHODS

The mortality for all types of leukaemia in that period was studied in three aspects: (a) By reviewing the rates of specific mortality for ages under 20 years, at quinquennial intervals and per millions of inhabitants of those ages. (b) Studying the mortality per cohorts of births at five-year intervals from 1951-1955 to 1981-1985. (c) Attaining the statistical value, "observed deceased" of leukaemia in people under 15 years of age for the period studied and on each year of that period, and comparing such value with the number of "expected deceased", with regard to the reference year, 1965.

RESULTS

A decreasing trend was observed along the whole period. As for ages, there seems to be some tendency to stabilisation of the mortality in the last five-year period, 1981-1985 (there is a decrease only in the 15-18 age-group). These data were confirmed when assessing the mortality per "birth cohorts" or generations, and after plotting the figures of "observed" and "expected" mortality in accordance with the previous evolution.

CONCLUSION

It was inferred that regard to the mortality of childhood and youth leukaemia, in Spain the situation has improved markedly, doubtless as a result of better therapeutical approach. This evolution closely resembles the patterns of the most developed countries from a sanitary standpoint.

[Bone marrow transplantation with T-cell depletion and hyperfractionated whole-body irradiation. The radiobiological and clinical correlations]

Total body irradiation (TBI) and cyclophosphamide (Cy) is the conventional conditioning regimen for the patients who are to receive bone marrow transplantation (BMT). It is one of the most effective treatments for acute and chronic leukemias. In this paper we discuss the clinical and radiobiological features relative to TBI methods and to the kind of BMT. Graft-versus-host disease (GvHD) incidence is decreased by the depletion of T-lymphocytes from donor's bone marrow which causes high rates of rejection and relapses. Thus, more aggressive conditioning regimens are necessary than unmanipulated BMT. The results are also examined of different experimental and clinical trials on the immunohematological features of T-depleted BMT and the radiobiological behavior of normal and pathological target tissues due to different methods of TBI. We report the experience of the Perugia Bone Marrow Transplantation Unit and Radiation Oncology Service. We treated 54 patients suffering from acute leukemia (AL) and 34 cases with chronic myeloid leukemia (CML) with T-depleted allogeneic HLA-identical BMT. Three different conditioning regimens were employed in an effort to enhance cytoreduction and immunosuppression without significantly increasing extramedullary toxicity. TBI was administered according to a hyperfractionated scheme of 3 fractions a day for 4 days. The third conditioning regimen, including also thiothepa (TT), gave the best results in terms of stable uptake and leukemic cells eradication. Disease-free survival (DFS) is 55.5% in the patients with AL at a median follow-up of 40 months; in the patients with CML who were not treated with TT, DFS is 10% at a median follow-up of 60 months, while it is 66.6% at a median follow-up of 12 for the group of patients who received also TT. The conditioning regimen with hyperfractionated TBI, Cy and TT was effective and well tolerated; 12.5% of patients developed interstitial pneumonia.

Expression of surface adhesion molecules CD54 (ICAM-1) and CD58 (LFA-3) in adult acute leukemia: relationship with initial characteristics and prognosis

Adhesion molecules CD58 and CD54 are involved in cell-cell interactions that are potentially important in the biology of acute leukemia (AL). Expression of these molecules was studied in 79 cases of adult AL including 50 cases of acute non-lymphoid leukemia (ANLL) and 29 cases of acute lymphoid leukemia (ALL) using an indirect immunofluorescence technique. CD58 was expressed in 45 +/- 26% of ANLL cells and 43 +/- 32% of ALL cells, and its expression did not correlate with any other marker. In ALL, the expression of CD58 was inversely correlated with the presence of a clinical tumoral syndrome (p = 0.0009), leucocytosis (p = 0.005), and the percent of peripheral blast cells (p = 0.001). The major finding in this study was the association between CD58 expression and prognosis. In ANLL, higher expression of CD58 was independently associated with higher CR rate (p = 0.04), longer overall survival (p = 0.02), and longer disease-free survival (p = 0.007). In ALL, higher expression of CD58 was associated with longer survival (p = 0.05). CD54 was expressed only on 17 +/- 16% of ANLL cells and 11 +/- 11% of ALL cells; its expression on ANLL was positively correlated with that of CD11 (p = 0.03), CD15 (p = 0.001) and CD34 (p = 0.01). CD54 expression did not correlate with clinical and hematologic characteristics. We conclude that the expression of adhesion molecule CD58, but not CD54, in AL is related to initial characteristics and evolution of the disease.

Second HLA-identical sibling transplants for leukemia recurrence

We analysed data from 114 recipients of HLA-identical sibling transplants who relapsed and received a second transplant between 1978 and 1989. Twenty-nine patients had acute lymphoblastic leukemia, 46 acute myeloid leukemia and 39 chronic myelogenous leukemia. Median (range) interval between first and second transplants was 15 (1-80) months. Following the second transplant, graft failure occurred in 2%, acute graft-versus-host disease (GVHD) in 27% and chronic GVHD in 21% of patients at risk. Risks of interstitial pneumonia and hepatic veno-occlusive disease were higher after the second than the first transplant. Two-year probabilities (95% confidence interval) of treatment-related mortality, relapse and leukemia-free survival were 41% (30-53%), 65% (53-75%) and 21% (14-30%), respectively. Leukemia-free survival was 7% (2-19%) among patients relapsing less than 6 months after their first transplant, with high rates of both relapse, 77% (49-92%), and treatment-related mortality 69% (46-85%). In contrast, leukemia-free survival was 28% (19-41%) in those relapsing more than 6 months after the first transplant; in this group the probability of relapse was 59% (45-72%) and treatment-related mortality 30% (20-43%). Factors correlated with better outcome included a diagnosis of chronic myelogenous leukemia, relapse more than 6 months after the first transplant, acute leukemia in remission prior to the second transplant and good performance status.

Diagnostic and clinical importance of interleukin-2 receptor alpha chain expression on non-T-cell acute leukaemia cells

The expression of interleukin-2 receptors (IL-2R) was examined in 328 adult patients with non-T-cell (non-T) acute leukaemia and blast crisis of chronic myelocytic leukaemia (CML.BC) using two monoclonal antibodies, anti-Tac for IL-2R alpha chain (IL-2R alpha) and Mik beta 1 for IL-2R beta chain (IL-2R beta). Leukaemic cells in the following cases were positive for anti-Tac; 28/192 of acute myelocytic leukaemia (AML), 24/44 CML-BC, 4/28 CD19(+)CD10(-) acute lymphoblastic leukaemia (ALL), and 20/64 common ALL (c-ALL). IL-2R beta was not detected on leukaemic cells of any case examined. Eleven of IL-2R alpha(+) AML were derived from myelodysplastic syndrome. None of the IL-2R alpha positive leukaemic cells responded to exogenous recombinant human IL-2 (rhIL-2) in culture. In addition, IL-2R alpha expression on non-T leukaemic cells was closely correlated with coexpressing different lineage markers and the presence of the Philadelphia abnormality. Marked increase of serum soluble IL-2R alpha was demonstrated in the IL-2R alpha(+) patients examined. Clinically, the IL-2R alpha(+) patients showed significantly lower response to chemotherapy and poorer prognosis than IL-2R alpha(-) patients. Our results clearly indicate the diagnostic importance of IL-2R alpha expression in non-T acute leukaemia with a close relation to the particular cellular characteristics and the prognosis.

An updated cause specific mortality study of petroleum refinery workers

An update of a cohort study of 14,074 employees at the Richmond and El Segundo refineries of Chevron USA in California was conducted to further examine mortality patterns. The update added six years of follow up (1981-6) and 941 deaths. As in the previous study, mortality from all causes (standard mortality ratio (SMR) = 73) was significantly lower among men compared with the general United States population. Significant deficits were also found for all cancers combined (SMR = 81), several site specific cancers, and most non-malignant causes of death. Mortality from suicide was increased relative to the United States as a whole. Based on a comparison with California rates, however, men had fewer deaths from suicide than expected. Standard mortality ratios were raised for several other causes of death, but only leukaemia and lymphoreticulosarcoma exhibited a pattern suggestive of an occupational relation. The increase appeared to be confined to those hired before 1949, and in the case of lymphoreticulosarcoma, to Richmond workers.

Mortality of a young population after accidental exposure to 2,3,7,8-tetrachlorodibenzodioxin

The mortality experience of 19,637 people aged 1-19 years living in an area around Seveso, Italy, contaminated by 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) after an accidental explosion in a chemical plant was examined for the period 1976-1986. For comparison, the mortality of the population of nearly 100,000 people living in the surrounding districts was examined. People who left the study area were followed up. Vital status ascertainment was successful in over 99% of the cases. A group of 186 children who contracted chloracne, a reversible marker of TCDD intoxication, shortly after the accident were in the study: none of them died during the observation period. Among the exposed, mortality owing to all causes, to all accidents and to all cancers failed to show major departure from expectations. Five leukaemia deaths were observed, four among males and one among females; the corresponding relative risks were 2.1 (95% confidence interval (CI): 0.7-6.9), and 2.5 (95% CI: 0.2-27.0), respectively. Two lymphatic leukaemias among males yielded a RR = 9.6 (95% CI: 0.9-106.0). Mortality owing to congenital anomalies showed a nearly twofold increase in the contaminated area; however, five out of seven observed cases were born before the accident. Interpretation is limited by the small number of deaths, short latency period and low validity of death certificate information for certain causes, and by the definition of exposure which was based merely on residence. The follow-up is continuing. A cancer morbidity study is in progress.

[Hyperleukocytic acute leukemia. Clinico-biological characterization, response to treatment and prognostic factors]

The white-cell count acquires an important prognostic value in acute leukaemia. Thus, very high leucocytosis conveys high risk of early death due to leucostasis. The clinico-biological features at diagnosis, response to therapy and prognostic factors of 69 cases of acute leukaemia with hyperleucocytosis (ALHL) are reported in this paper. All the patients had white-cell count over 100 x 10(9)/L and had been followed up at the Haematology Service of the Hospital La Fe between 1977 and 1989. There were 49 cases of acute nonlymphoblastic leukaemia (ANLL), 18 cases of acute lymphoblastic leukaemia (ALL) and 2 of unclassified acute leukaemia. The incidence of ALHL was 14%, and the mortality on the first week after diagnosis reached 20%, this being higher in ANLL. The actuarial median of complete remission duration was 9 months. The achievement of remission was associated with the morphological subtype, the patient's age and the presence of constitutional symptoms at onset, while the duration of remission was associated with the presence of fever and the need more than one chemotherapy course to attain remission. ALHL need new therapeutic strategies in order to diminish the rate of early death and to achieve longer survival.

Allogeneic bone-marrow transplantation without protective isolation in adults with malignant disease

Bone-marrow transplant (BMT) patients are severely immunocompromised immediately after the procedure and they are commonly nursed in strict protective isolation to reduce the risk of both infection and graft-versus-host disease (GvHD). We have studied a consecutive series of patients to see whether protective isolation is of benefit as prophylaxis against infectious complications of BMT. 50 consecutive patients who had malignant disease and received their first BMT from siblings or unrelated donors were nursed in standard single rooms with visitors instructed to wash their hands. A subset of 20 patients living locally spent a median of 25 days in hospital after BMT; they also spent some time at home on a median of 8 days before engraftment and 3 patients went home on more than 90% of their hospital days. 16 patients (32%) had positive bacterial cultures and/or focal infection. Gram-positive bacteraemia was found in 12 subjects (24%) but there were no gram-negative or deep fungal infections. Grade II or III acute GvHD developed in 17 patients (34%). There were no deaths from infection or acute GvHD. Transplant-related mortality was 6% in the first 100 days and 18% overall with a median follow-up of 22 months. Our mortality data compare favourably with those from institutions with strict isolation procedures. We conclude that BMT may be safely completed in some institutions without either protective isolation or the need to confine patients continuously in hospital.