Prolonged second remissions in childhood acute lymphocytic leukemia: a report from the Childrens Cancer Study Group

To date, median duration of second and subsequent remissions in childhood acute lymphocytic leukemia (ALL) has been short, with most studies reporting median remission duration less than 6 months. In May 1979, the Childrens Cancer Study Group (CCSG) undertook a pilot study to assess the efficacy of a vincristine, methotrexate, and L-asparaginase regimen (modified Capizzi) for maintenance in children with ALL in second or subsequent remission. Thirty patients were treated with this maintenance regimen. By life table analysis, predicted median duration of hematologic remission was 57 weeks. Ten patients (33%) were in continuous hematologic remission at 1 year and three (10%) continue in remission greater than 2 years from maintenance onset. Major toxicity included leukoencephalopathy in four patients, three of whom had experienced at least one central nervous system relapse prior to study entry. Allergic reactions to Escherichia coli L-asparaginase were common. Nine of 30 patients experienced at least one CNS relapse during therapy. We conclude that a modified Capizzi regimen is the most effective regimen reported to date for maintaining second and subsequent remission in childhood ALL. CCSG is currently utilizing this regimen in an ongoing open study.

Renal cell carcinoma in children

Data from four pediatric hospitals concerning 20 children treated for renal cell carcinoma (RCC) from 1964-1978 were reviewed. Median age of the patients (pts) was 11.8 years (range, 14 months-19 years). Twelve were male and eight female; 17 were white and three black. Most patients presented with pain and hematuria with or without a palpable mass. An intrarenal tumor was detected at IV urography (17 pts), arteriography (2 pts), or at surgery (1 pt). Treatment consisted of nephrectomy in 15 pts, renal biopsy (4 pts), or no surgery (1 pt), followed by chemotherapy (5 pts), radiation therapy (1 pt), or both (7 pts). Ten pts died of distant metastases at a median of one year (range, 0.2 to two years) after diagnosis. The other 10 pts (50%) survive free of relapse at a median of 4 years (range, two to ten years) from diagnosis. Proportions surviving free of recurrent disease two or more years by National Wilms' Tumor Study (NWTS) Group were 5/5 in Group I, 3/7 in Group II, 1/3 in Group III, and 1/5 in Group IV; by age at diagnosis, 6/6 in those under 11 years old and 4/14 in those 11 or older; and by type of surgery, 10/15 who had nephrectomy and 0/5 with limited or no surgery. The data indicate that radiation and chemotherapy had only minor if any influences on relapse-free survival. We conclude that (1) RCC in children is similar to its counterpart in adults; (2) RCC has a worse prognosis than Wilms' tumor except for the earliest stage; (3) nephrectomy alone is adequate treatment for Group I RCC, and (4) young age (less than 11 years old) may be prognostically favorable.

Do infants with stage IV-S neuroblastoma need treatment?

The study reports the results of treatment in 31 infants under age 12 months with stage IV-S neuroblastoma diagnosed between 1976 and 1979. All had small or undetected primary tumours associated with disease in one or more of the following sites: liver, skin, or marrow. The primary site was left adrenal (in 16), and other areas included paravertebral, mediastinum, and pelvis (in 5); in 3 the primary site could not be found. Distant disease was found in the liver (in 29), marrow (in 16), and skin (in 8). Other sites affected were pancreas, pleura, peritoneum, and regional nodes. Treatment varied according to the clinical course of the disease; most patients had very little. In 19 primary tumour was resected, in 21 the liver was irradiated with a median dose of 450 rad, and 15 received chemotherapy in courses varying between 1 month and 1 year. Nine patients had resection of the primary tumour as their only treatment and all survive; a total of 16 patients had sites of disease which regressed spontaneously. Four of 31 patients died in the first 2 months despite vigorous measures, all from some complication of the disease or its treatment. The projected 2-year survival rate is 87%. Children with this 'special' pattern of widespread neuroblastoma fare well with little or no treatment unless early complications develop. In this study none died of late progression of their disease.

Relapse rates following cessation of chemotherapy during complete remission of acute lymphocytic leukemia

The therapeutic benefit of maintenance chemotherapy beyond three years for children with acute lymphocytic leukemia (ALL) in continuous complete remission was evaluated by the investigators of Childrens Cancer Study Group (CCSG). Two hundred and twenty leukemic children in first remission for three years or longer and who had received at least three years of continuous chemotherapy were eligible. One hundred and one patients were randomized to either continue chemotherapy for an additional three years or to discontinue therapy, and 119 patients nonrandomly continued or discontinued therapy. The patients had received a variety of chemotherapy regimens. The study period extended from April 1970 until December 1977, with a median follow-up time of 25 months. Relapses occurred in 15 randomized patients (15%). Randomized patients remaining on chemotherapy experienced a statistically significant lower relapse rate than patients randomized to discontinue therapy. Also among randomized patients, bone marrow relapse was significantly more frequent in males than in females. Considering the total patient group, age and white blood count at diagnosis had no significance in predicting relapse. Of relapse events in males, 21% were isolated testicular relapses, identifying the testicles as a major risk site in males completing three years of continuous complete remission. This study demonstrates that continuing chemotherapy beyond three years results in a significant prolongation of remission in males, although the eventual survival outcome for later discontinuance of therapy will require longer follow-up.

Cold-adaptive modifications in man induced by repeated short-term cold-exposures and during a 10-day and-night cold-exposure

Two types of cold exposures were carried out in humans. A. Fourteen subjects were exposed 4-7 times within 2 weeks to the following conditions: ambient temperature was decreased from 28 degrees C to between plus and minus 5 degrees C; the subjects wore a bathing suit and remained in a resting position during the exposure which lasted for 1h. B. Nine conscripts were studied before and after a 10-day exercise, during which they were exposed to moderately cold conditions during day and night. The exercise did not require increased physical activity. In two thirds of the subjects A, metabolic reactions and shivering threshold were shifted to a lower weighted mean body temperature as well as a lower esophageal temperature ("hypothermic" type of adaptation). This modification in the thermoregulatory system was linked with a reduction in thermal discomfort and cold sensation. No change was found in the resting metabolic rate nor was there any indication of the development of non-shivering thermogenesis. Similar modifications were found in 4 of the 9 soldiers (study B). These 4, however, had particularly high shivering thresholds before the 10-day exercise and the values found thereafter were no lower than those found in the remaining five and in the subjects of group A before the cold-exposure regimen.

Adaptive modifications in the thermoregulatory system of long-distance runners

In seven long-distance runners (42 km or more) the thermoregulatory responses to acute external cooling and heating, under resting conditions, were recorded and compared with those in physically untrained controls. Sweating as well as shivering thresholds were significantly decreased in the runners when compared either in terms of mean body temperature (Tb) or esophageal temperature (Tes); Tb and Tes were reduced in the runners at rest under thermoneutral conditions. Moreover, cold sensation in the runners occurred at lower Tb. The runners thus behaved as if the "set point" of their thermoregulatory system had been reset to a lower level. As for the sweating threshold, the shift is quantitatively comparable to that found in heat adaptation. The described modifications in long-distance runners would prolong the time period until a dangerous body temperature-one of the important limiting factors in physical endurance-is reached during heavy exercise.