Myeloid mixed chimerism is associated with relapse in bcr-abl positive patients after unmanipulated allogeneic bone marrow transplantation for chronic myelogenous leukemia

BACKGROUND AND OBJECTIVE

Although bcr-abl polymerase chain reaction (PCR) positivity after bone marrow transplantation (BMT) for chronic myelogenous leukemia (CML) is significantly related to relapse, the predictive value of the assay is not very high and therefore most investigators consider that qualitative RT-PCR data alone are too imprecise to enable clinical decisions to be taken in individual cases. To define the clinical outcome of bcr-abl positive patients after unmanipulated BMT better, we sought the origin of hematopoiesis and traced its evolution over time.

DESIGN AND METHODS

Forty-nine patients received allogeneic BMT for CML (39 in chronic phase and 10 in accelerated phase/blast crisis). Median follow-up was 61 months (range 4-92). mRNA and DNA were used to assess bcr-abl and chimerism status respectively. Quantitative VNTR-PCR on total cells and lymphoid or myeloid population allowed us to assign and measure the origin of hematopoiesis.

RESULTS

Both bcr-abl positivity and the presence of mixed chimerism (MC) were significantly associated with relapse (p = 0.0009 and p < 0.0001 respectively). Relapse was observed in one of 39 patients with complete donor chimerism and in 6 of 9 patients with MC. These six cases showed increasing levels of host hemopoiesis and bcr-abl positivity in the CD15-positive population prior to relapse. The other three cases had decreasing or stable low-level MC which was restricted to the T-cells as well as bcr-abl negativity.

INTERPRETATION AND CONCLUSIONS

Whereas the simple detection of bcr-abl fails to identify patients who will relapse with certainty, the assessment of MC by VNTR-PCR does identify patients headed to relapse. Confirmation of myeloid involvement and increasing levels over time further elucidates the clinical outcome of bcr-abl positive patients after BMT.

Functional derivatives of 5-benzo[1, 3]dioxol-5-yl-1-methyl-1H-imidazole-2-carbaldehyde and evaluation of leishmanicidal activity

New imidazole derivatives were obtained after subjecting 5-benzo[1, 3]dioxol-5-yl-1-methyl-1H-imidazole-2-carbaldehyde to a Knoevenagel reaction. Some of these compounds exhibit significant in vitro leishmanicidal activity.

[The monitoring of BCR-ABL mRNA by reverse transcription PCR in patients undergoing allogeneic bone marrow transplantation for acute lymphoblastic leukemia with a positive Philadelphia chromosome]

BACKGROUND

Allogeneic bone marrow transplantation (BMT) has been performed as one mode of cure-oriented therapy for Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL-Ph' positive). However, the clinical significance of the residual BCR-ABL-positive clones after BMT is still controversial.

PATIENTS AND METHODS

The BCR-ABL gene (p210 and p190) was prospectively studied by nested RT-PCR in 8 ALL-Ph' positive patients undergoing BMT.

RESULTS

All patients received BMT at the time of clinical remission (CR). However, minimal residual disease (MRD) was detected in 7 of them. MRD detected just before BMT seems to be eradicated by BMT protocol. Four patients remained in CR and did not show BCR-ABL transcripts. Other 4 patients, relapsed, demonstrating MRD, which preceded recurrence by a median time of 6 weeks. Three relapsed patients showed p190 transcript and only one, p210 type.

CONCLUSIONS

The RT-PCR assay appears to be a useful test for predicting at high risk of relapse after BMT and may identify patients who might benefit from therapeutic interventions. The finding that the expression of p190 BCR-ABL may carry an especially high risk of relapse suggests a different clinical and biologic behaviour between p190 and p210 BCR-ABL.

Stage, percentage of basophils at diagnosis, hematologic response within six months, cytogenetic response in the first year: the main prognostic variables affecting outcome in patients with chronic myeloid leukemia in chronic phase treated with interferon-alpha. Results of the CML89 trial of the Spanish Collaborative Group on interferon-alpha2a and CML

BACKGROUND AND OBJECTIVE

Interferon-a (IFN) is increasingly being used as the drug of choice in chronic myeloid leukemia patients. The main objectives of the study were to study the influence of the classic prognostic variables and response to IFN, and to assess the influence of this response on the course of the disease and survival.

DESIGN AND METHODS

Single arm, prospective, multicenter study, without a control group. Only Ph1-positive CML patients were included. The treatment scheme was biphasic: the patients first received standard chemotherapy and thereafter IFN-a2a was used as monotherapy, with a target dose of 9 MU/d/s.c.

RESULTS

Twenty-one centers in Spain enrolled 132 patients (72 men, 60 women). The median dose of IFN given was 5.8 MU/d, and the median treatment duration was 431 days (range: 18-2,597). Seventy-two percent of patients obtained a hematologic response in the first six months of IFN treatment. Genetic response was obtained in 47% of the patients, and the response was major or complete in 27% and 19%, respectively. The median time to obtain this response was 7, 9, and 18 months for minimal, partial and complete genetic response, respectively. Multivariant analysis showed that only a higher percentage of basophils at diagnosis was associated with a worse hematologic response at six months (p=0.001) (OR: 1.23) and with a worse cytogenetic response in the first year of IFN therapy (p=0.018) (OR: 1.4). Over an observation period of 8 years, 35.6% of the patients died, and 85 (64.4%) remained alive. With a median follow-up of 42 months (3.7-98), the 6-year projected probabilities of survival and transformation-free survival were 0.61+/-0.07 vs. 0.54+/-0.07, respectively. Patients with Kantarjian's stage 3 disease or in a high-risk Sokal group had lower probabilities of survival, but these systems did not adequately discriminate in our series. Obtaining a complete hematologic response in the first six months of IFN therapy was favorable in terms of overall survival (p=0.05; HR=0.33). Cox's analysis demonstrated that obtaining a cytogenetic response in the first year was independently associated with better overall survival (p=0.04; HR=0.19) and better transformation-free survival (p=0.0035; HR=0.11).

INTERPRETATION AND CONCLUSIONS

Nearly half of the patients obtained some degree of Philadelphia suppression, which was major in 27%, and complete in 19%. A higher percentage of basophils at diagnosis was the only variable associated with a lower probability of cytogenetic response. Obtaining a cytogenetic response during the first year of IFN treatment was a favorable and independent variable in terms of survival and transformation-free survival. Obtaining a major cytogenetic response during this period decreased the risk of transformation twenty times. Our results suggest that the effect of IFN on survival is independent of the classic prognostic variables.

Genetic, phenotypic and clinical features of acute lymphoblastic leukemias expressing myeloperoxidase mRNA detected by RT-PCR

Myeloperoxidase (MPO) is found in the azurophilic granules of normal myelocytic cells. Cytochemical staining for MPO activity is used clinically to distinguish myeloid from acute lymphoid leukemias (ALL). However, using a highly sensitive RT-PCR technique, it is possible to detect MPO mRNA in otherwise clear ALL. The significance of this finding remains poorly understood. We have extended our observations to a series of 57 patients with the primary diagnosis of ALL (46 patients tested at diagnosis and 11 cases at relapse). We identified 25 cases (43.8%) of MPO mRNA(+)/enzyme(-) ALL (17 B cell and eight T cell lineage). Expression of myeloid antigens (CD13 or CD33) were detected in nine of them, and remarkably, 18 cases (72%) displayed CD34. Of these 25 MPO mRNA(+) leukemias, 10 (40%) are Bcr-Abl positive (with P210 fusion transcript in five patients while the five remaining cases carried P190 transcript). Moreover, 11 of 16 myeloid negative cases were also negative for any type of Bcr-Abl and MLL rearrangement, indicating that MPO mRNA positivity is not either invariably related to that chromosomal abnormality or necessarily associated with the presence of other myeloid differentiation features. Interestingly, six of these 11 cases are T-ALL, suggesting the presence of some overlapping phase for T and myeloid lineage commitment. Taken together, these findings could suggest a separate biological disease with immature origin and bipotential differentiation capability, which involves B and T-ALL subtypes and should lead to new investigations regarding their prognostic impact.

Influence of dietary nucleotides on plasma immunoglobulin levels and lymphocyte subsets of preterm infants

We examined the effects of nucleotide supplementation to a preterm adapted milk formula on the lymphocyte subsets and plasma IgG, IgM and IgA levels in preterm infants for the first three months of life. Two groups of preterm infants received a milk formula or the same formula supplemented with CMP, AMP, UMP, GMP and IMP to mimic the concentration of acid-soluble nucleotides found in human milk. Blood samples were obtained at birth, 10 days, 20-30 days and 3 months of age. Preterm infants fed the nucleotide formula exhibited higher plasma levels of IgM in all postnatal study periods than neonates fed the standard formula; moreover, IgA was also higher at 3 months of age in nucleotide formula fed infants. No major differences were seen between groups for IgG levels and lymphocyte subsets. Thus, dietary nucleotides appear to exert actions on immature human neonate lymphocytes enhancing the in vivo production of Ig which may have a role in the defense capacity of neonates.

Bone mineralization status measured by dual energy radiographic densitometry in preterm infants fed commercial formulas

We have studied the effect of two preterm commercial infant formulas with different calcium and phosphorus contents on the mineral balance and bone mineralization of 30 preterm infants at 1 month of age. Bone mineralization was measured by dual energy X-ray densitometry. The formula supplying a higher content of calcium and phosphorus promoted higher mineral retention (P<0.01) as well as higher bone mineral content (1.556 vs. 1.073 g, P<0.01) and bone mineral density (0.458 vs. 0.424 g/cm2, P<0.05), approaching values of the control group, which comprised a cohort of 15 preterm newborns whose gestational age was 4 weeks older than the subjects selected to be fed with the formulas. The intake of calcium correlated with retention (r=0.69); the phosphorus intake also correlated with phosphorus retention (r=0.95). Intakes of calcium and phosphorus correlated with the bone mineral content (r=0.65) and with bone mineral density (r=0.49). We conclude that formulas for preterm infants should not have a calcium content lower than 120 mg/100 kcal and should have a calcium/phosphorus ratio of about 2 to promote adequate bone mineralization.

Special formulas in infant nutrition: a review

Special formulas should only be used by medical prescription and for those lactating infants with diagnosed nutritional problems. Lactose-free formulas or those based on soy are the logical choice when the exclusion of lactose from the diet is considered necessary. At present, there is no concensus on the appropriateness of soy formulas for the treatment and prevention of nutritional allergies and current opinion seems to favour hydrolyzed protein formulas. High-degree protein hydrolysate formulas are used to treat lactating infants with an allergy to cow milk proteins or with serious nutritional problems. These formulas are not without risk, as they may contain residual epitopes capable of provoking a severe allergic reaction. Before using these formulas, allergenicity tests should be performed, particularly for highly sensitive infants. The unpleasant taste and high cost of these formulas, in addition to possible nutritional problems, limit their use in the prevention of atopic disease, although their efficacy is well established. Partially protein hydrolysate formulas are only used for preventive purposes and are not suitable for lactating infants with a proven allergy to cow milk. Although these formulas can reduce the incidence or delay the appearance of certain atopic symptoms, they have not been shown to prevent IgE-mediated allergic reactions to cow's milk and so their effectiveness is open to question.

Neonatal dietary gangliosides

Gangliosides are glycosphingolipids that are widely distributed in vertebrate tissues and body fluids and which are specially abundant in neural tissues. Milk from different species has a particular ganglioside content and profile. Human milk has a higher content of gangliosides than bovine milk. GD3 and GM3 are the predominant individual gangliosides in bovine milk. In human colostrum GD3 is also the main ganglioside whereas in human mature milk GM3 predominates over the other gangliosides. Human milk also contains GM1 and a number of highly polar gangliosides, which may play an important role in infant physiology. GM1 has been shown to inhibit Escherichia coli and Vibrio cholerae enterotoxins. We have found that a ganglioside-supplemented infant formula modifies the intestinal ecology of preterm newborns, increasing the Bifidobacteria content and lowering that of Escherichia coli. Although the exact mechanism by which dietary gangliosides reduce the fecal content of Escherichia coli is unknown, in vitro experiments suggest that they may act as false intestinal receptors for some strains of this bacteria. Since GD3 and other gangliosides have been involved in mechanisms of lymphocyte activation and differentiation, dietary gangliosides might have a function in intestinal immunity development.

Plasma and red blood cell fatty acid composition in small for gestational age term infants fed human milk or formula

The purpose of the present study was to evaluate the effects of feeding human milk or milk formula on the fatty acid composition of plasma and red blood cell (RBC) lipids in at term small for gestational age infants (SGA) for the first 3 months of life. One group of infants received a formula with a linoleic:alpha-linolenic acid ratio of 10:1 (MF group). Another group served as control and received their own mother's milk (HM group). Blood samples were taken at birth and at 1 week, 4 weeks, and 3 months of life. Plasma and RBC fatty acid composition were analyzed by gas liquid chromatography and results of total plasma lipids were expressed as concentrations by adding an internal standard. Concentrations of saturated and monounsaturated fatty acids increased in total plasma lipids with age in all infants. In contrast, those fatty acids decreased when results were expressed as percentages of total fatty acids. Long-chain polyunsaturated fatty acids (LCP) decreased regardless of how results were expressed, but the absolute concentrations of these fatty acids in plasma available for tissue accretion were greater than suggested by the percentage results. Plasma and RBC docosahexaenoic acid (22:6n-3) decreased in the MF group in comparison to the HM group. Arachidonic acid (20:4n-6) was lower in plasma of MF-fed infant but not in RBC phospholipids. We conclude that term SGA infants fed an adapted milk formula with a linoleic:alpha-linolenic acid ratio of 10:1 but devoid of LCP may lead to a low n-3 LCP status.

Addition of gangliosides to an adapted milk formula modifies levels of fecal Escherichia coli in preterm newborn infants

Because some gangliosides bind bacteria, we tested the influence of supplementating an adapted milk formula with gangliosides, at a total concentration of 1.43 mg/100 kcal, on the fecal microflora of preterm infants. At all sampling times, feces from infants fed with ganglioside-supplemented formula had significantly lower relative content of Escherichia coli than feces from infants fed with control milk formula: the difference was especially significant at age 7 days postnatal < .001). At age 30 days postnatal, fecal bifidobacterial counts were higher in infants fed with ganglioside-supplemented formula (P < .05). We conclude that gangliosides at concentrations present in human milk significantly modify the fecal flora.

[Comparison of chemotherapy CHOP vs. CHOP/VIA in the treatment of aggressive non-Hodgkin's lymphoma: a randomized multicenter study of 132 patients. The PETHEMA group. Program for Study and Therapeutics of malignant hemopathies. Spanish Association of Hematology and Hemotherapy]

BACKGROUND

To compare standard chemotherapy CHOP (cyclophosphamide, adriamycin, vincristine and prednisone) with the regimen CHOP/VIA (VP-16, iphosphamide and cytarabine) in terms of response to therapy, response duration, survival and toxicity in patients with aggressive lymphoma.

PATIENTS AND METHODS

132 patients (84 males and 48 females; median age, 55 years) were included from 12 Spanish Institutions, diagnosed of non-Hodgkin's lymphoma of intermediate or high grade, in stages II-IV and previously untreated. Patients were randomized to receive CHOP or CHOP/VIA.

RESULTS

After excluding 14 not assessable cases, 62 patients (52.5%) received CHOP, and 56 (47.5%) CHOP/VIA. No significant differences were found on main prognostic factors between such groups. Response was assessable in 114 cases (CHOP: 61; CHOP/VIA: 53) 39 patients (64%) receiving CHOP achieved complete response (CR), and 2 (3%) partial response (PR), whereas in the CHOP/VIA group CR and PR rates were 63% (34/53), and 7% (4/53), respectively. 14 patients (36%) treated with CHOP and 12 (35%) treated with CHOP/VIA eventually relapsed, with an actuarial risk of relapse at 36 months of 43% and 40%, respectively. Median survival was 37 months. No differences were found between both therapeutic groups, with an overall survival at 36 months from diagnosis of 53.5% (CI 95%: 40-67) for CHOP and 48% (CI 95%: 34-62) for CHOP/VIA. Finally, toxicity was not different for both arms.

CONCLUSION

In the present study in patients with aggressive NHL chemotherapy regimens CHOP and CHOP/VIA showed similar results in terms of response, response duration, survival and toxicity.

Late intensification chemotherapy has not improved the results of intensive chemotherapy in adult acute lymphoblastic leukemia. Results of a prospective multicenter randomized trial (PETHEMA ALL-89). Spanish Society of Hematology

BACKGROUND AND OBJECTIVE

Intensive induction and post-remission therapies have improved the prognosis in adult acute lymphoblastic leukemia (ALL). However, different from children, the impact of late intensification therapy in the overall results of treatment has not been consistently evaluated. The objective of this study was to analyze the results of a multicenter prospective protocol, PETHEMA ALL-89, in which, after intensive induction and consolidation therapy, randomization to receive delayed intensification treatment was performed.

DESIGN AND METHODS

One hundred and eight adults (age > or = 15 years) diagnosed with ALL (ALL L3 excluded) in 22 Spanish hospitals from 1989 to 1994 were treated with a five-drug induction therapy, followed by four cycles of early post-remission treatment during four months, and maintenance therapy for two years. Patients in remission at the end of the first year were randomized to receive one six-week cycle of late intensification therapy. Uni- and multivariate analyses of early response to treatment, complete remission (CR), leukemia-free survival (LFS) and overall survival (OS) were performed.

RESULTS

The median (range) age of the series was 28 (15-74) years and leukocyte count 26 x 10(9)/L (1-600). ALL L1/L2 was present in 38/70 patients, early pre-B in 13, common in 53, pre-B in 12 and T in 30 cases. The CR rate was 86%, and refractory disease 9%. Median LFS was 34 months, with a 5-yr probability of 41% (95% CI, 29-53), whereas median OS was 51 months and 5-year probability 47% (34-59%). There were no differences in either LFS and OS between patients who did or did not receive delayed intensification therapy. Prognostic factors for CR attainment were advanced age and slow response to therapy. These two features were, in addition to high leukocyte counts, the parameters with negative influence in both LFS and OS.

INTERPRETATION AND CONCLUSIONS

The results of PETHEMA ALL-89 are similar to those referred in other chemotherapy-based protocols in adult ALL. Delayed intensification has not improved the length of remission and survival. Efforts to improve the prognosis of adult ALL patients must be mainly focused in early intensification treatment.

Autologous stem cell transplantation for poor prognosis Hodgkin's disease in first complete remission: a retrospective study from the Spanish GEL-TAMO cooperative group

Although more than 50% of Hodgkin's disease patients are cured with conventional chemotherapy, many will relapse and eventually die from their disease. Many efforts have been made to identify poor prognostic factors that could be useful in selecting high-risk patients in 1st CR who may benefit from high-dose chemo/radiotherapy. However, the role of early transplantation in 1st CR remains unclear. We have retrospectively analyzed the results obtained with this procedure in 22 hospitals belonging to the Spanish GEL/TAMO cooperative group. Twenty-seven patients, of whom 19 were males, underwent autologous transplantation for Hodgkin's disease in 1st CR between January 1987 and January 1996. Remission had been achieved after one (n = 22) or two (n = 5) lines of treatment. Twenty-four patients had advanced stage disease, 12 patients bulky mediastinal disease, nine bone marrow involvement and 18 had extranodal disease. Peripheral blood was used as the source of hematopoietic stem cells in 15 patients, BM in nine, and both in three. All but three patients received chemotherapy-based conditioning regimens (16 CBV, four BEAM and four BEAC), while three were conditioned with CY and TBI. There were no transplant-related deaths. Median (range) times to recover >0.5 x 10(9)/l neutrophils and >50 x 10(9)/l platelets were 14 (8-56) days and 16 (8-240) days, respectively. With a median follow-up of 30 (8-66) months, 21 patients are alive and in continuous CR. Four patients who relapsed after transplant at 8, 17.5, 22 and 26 months achieved a second CR with conventional chemotherapy; one patient relapsed 92 months post-transplant and died 5 months afterwards. Another patient died 30.5 months post-transplant from a secondary malignancy. In conclusion, high-dose therapy in poor prognosis Hodgkin's disease in 1st CR was well tolerated with no transplant-related mortalities. Although the follow-up of this series is relatively short, our results seem promising. Nevertheless, late relapses can occur, and the role of this procedure vs conventional treatment in very high-risk patients should be assessed in prospective randomized studies.

[Role of nitrates in pharmacologic modulation of reflected waves and their significance in the treatment of arterial hypertension in the elderly]

OBJECTIVE

To analyse the efficacy of a sustained release form of isosorbide mononitrate in the treatment of isolated systolic hypertension in the elderly.

PATIENTS

24 patients suffering from essential hypertension and with an average age of 68.5 +/- 1.1 years were studied: 20 male and four female patients, all with isolated systolic hypertension (systolic blood pressure (SBP) > 160 mmHg and diastolic blood pressure (DBP) < 90 mmHg). None of the patients had received pharmacological treatment for their hypertension. None were receiving other medication or displayed concomitant pathologies.

METHODS

Assessment of all the patients was made with the measurement of their occasional blood pressure, ambulatory measurement of blood pressure and the measurement of pulse wave velocity in two arterial zones (carotid-femural) by mecanography before and after thirty days of monotherapy with a single 50 mg dose of a sustained release form of isosorbide mononitrate. Four patients were withdrawn from tests due to signs of intolerance to the drug.

RESULTS

A fall in occasional blood pressure was recorded, with statistical significance in relation to SBP only: SBP-192 +/- 15.5-->164 +/- 10.2 mm Hg (p < 0.001); DBP-85 +/- 4.2-->83 +/- 5.4 mm Hg. Ambulatory blood pressure readings also showed a significant drop in average SBP readings over the 24 hours: SAP 152.6 +/- 13.6-->140.5 +/- 15.4 mm Hg (p < 0.03); DBP 77.2 +/- 8.7-->72.3 +/- 5.47 mm Hg. No significant changes in pulse wave velocity were recorded for the zones studied: carotid-femural -20.8 +/- 6.0-->21.7 +/- 5.1 m/sec; femural-foot -4.5 +/ -1.4-->4.4 +/- 2.6 m/sec; a marked alteration in the morphology of arterial pulse in the aortic zone was observed, however, with a clear levelling off and reduction of the systolic peak.

CONCLUSION

Treatment with nitrates may be a new and effective alternative for the treatment of the age group in question. It acts specifically on the pathophysiological mechanisms of isolated systolic arterial hypertension in the elderly. Changes in reflected wave velocity (retrogrades) seem to cause the significant reduction in SBP, observed in this group of patients.

[24-hour arterial pressure study and diabetic neuropathy and angiopathy of the lower limbs]

AIMS

To study the circadian variation of BP in diabetics with chronic late complications (autonomic neuropathy, peripheral neuropathy and macroangiopathy of the lower limbs).

PATIENTS AND METHODS

We studied 35 NIDDM patients, 22 male and 13 female, with a mean age of 62.17 +/- 8.66 years, all with hypertension (HBP) or with BP levels close to normal, many of them under anti-hypertensive therapy (mean BP in clinical measurements: 164 +/- 23.16 mmHg systolic and 92.14 +/- 11.06 mmHg diastolic). Twenty-four suffer from autonomic neuropathy, 23 from peripheral neuropathy and 11 from macroangiopathy of the lower limbs. The control group is composed of 10 patients with essential HBP without other observable pathology, with a mean age of 68.5 +/- 3.63 years and BP in clinical measurements: systolic 192 +/- 15.49 mmHg and diastolic 88 +/- 4.21 mmHg (without any previous therapy). The record of the BP circadian profile was made, with the use of a Spacelab monitor, model 90207, 5 days after anti-hypertensive therapy was suspended.

RESULTS

The mean BPs in 24 hours were: control group-systolic BP 152.6 +/- 13 mmHg and diastolic 79.8 +/- 13 mmHg; diabetics-systolic BP 136.82 +/- 15 mmHg and diastolic 77.4 +/- 8 mmHg. The daily and nocturnal mean BPs were 158.5 +/- 8.5 and 146 +/- 8.4 mmHg (systolic) and 82.8 +/- 5.7 and 70.9 +/- 5.1 mmHg (diastolic) in the control group, while they were, in diabetics, 141.3 +/- 15.7 and 135.6 +/- 16.6 mmHg (systolic) and 79.6 +/- 7.1 and 72 +/- 8.2 mmHg (diastolic). In diabetic patients, considering the groups with and without autonomic neuropathy, the difference between daily and nocturnal mean BP was 1.6 vs 9.4 mmHg systolic and 4.9 vs 9.4 mmHg, diastolic.

CONCLUSIONS

In both groups, the mean BP levels in 24 hours were notoriously lower than those obtained from the clinical measurements: the differences were 40 mmHg (control group) and 27.2 mmHg (diabetics) for systolic BP and 8.2 mmHg (control group) and 14.7 mmHg (diabetics) for diastolic. The BP circadian profiles show a lower variability, with absence of the nocturnal reduction, specially evident in diabetic patients with autonomic neuropathy versus other groups.

CHOP vs. ProMACE-CytaBOM in the treatment of aggressive non-Hodgkin's lymphomas: long-term results of a multicenter randomized trial.(PETHEMA: Spanish Cooperative Group for the Study of Hematological Malignancies Treatment, Spanish Society of Hematology)

From May 1985 to May 1989, 175 patients with previously untreated aggressive non-Hodgkin's lymphoma were randomized to receive CHOP or ProMACE-CytaBOM. Eligibility criteria included follicular large-cell diffuse small cleaved-cell, diffuse mixed, diffuse large-cell and immunoblastic lymphoma with an Ann Arbor stage II, III or IV. One hundred and forty-eight patients were evaluable. There were no significant differences between the 2 treatments in response rate (83.5% [57.5% CR] for CHOP vs. 88% [62% CR] for ProMACE-CytaBOM), time to treatment failure (29% vs. 31% at 5 yr), or overall survival (42% in both groups at 5 yr). Furthermore, there were no significant differences between the 2 regimens when response rates and outcome were analyzed for different prognostic subgroups. Toxicity was not significantly different between the 2 regimens, although only 1 patient died as result of treatment-related toxicity in the CHOP arm compared to 6 patient in the ProMACE-CytaBOM group (p = 0.126). In conclusion, in this study ProMACE-CytaBOM has not proved to be superior to CHOP in aggressive lymphomas. This trial gives support to the notion that CHOP still is the standard chemotherapy for aggressive lymphomas, and that new treatment approaches for these lymphomas should be compared to CHOP.