Acute lymphoblastic leukaemia in a child with cystic fibrosis

The association of cystic fibrosis (CF) and acute lymphoblastic leukaemia (ALL) is extremely rare. Only three cases have been reported in the literature and all of them had a fatal outcome. In this paper we describe the case of a little girl who was diagnosed with CF (mild course) when she was five months old, and who presented at the age of five years with ALL (intermediate risk). Complete Remission (CR) was rapidly obtained with standard chemotherapy for ALL.; treatment was continued for two years without major complications and with no apparent influence on the course of CF. The patient remains alive and well and in continuous CR four years after discontinuing treatment, and six years after the diagnosis of ALL.

Minimal residual disease in childhood acute lymphoblastic leukemia: analysis of patients in continuous complete remission or with consecutive relapse

Differences in tumor cell burden among acute lymphoblastic leukemia (ALL) patients are largely unexplored, because methods of detecting residual malignant cells have not been sufficiently sensitive. Using the polymerase chain reaction (PCR) amplification of rearranged T-cell receptor delta(TCR delta)-chain junctional sequences for the preparation of clonospecific probes, we performed a retrospective PCR study of remission bone marrow (BM) samples in seven pediatric patients with ALL who subsequently relapsed (the largest series studied so far) and in 10 patients who were in longterm (greater than 39 to greater than 72 months) remission. Following two rounds of PCR primed by nested amplimers, 1 x 10(-4) to 1 x 10(-6) cells could be identified in 16 out of 17 cases. PCR analysis of 39 BM and peripheral blood samples obtained from ALL patients considered to be in complete remission according to morphological criteria revealed the following results. In BM remission specimens of all 10 patients in continuous complete remission for a long time (median 55 months), no residual leukemic cells could be identified in the latest remission sample available for PCR analysis. In three patients the persistence of residual leukemic cells, or the continuous increase of residual blasts to the point of clinical manifestation, were indicative of impending relapse. In three patients PCR analysis failed to identify residual leukemic cells in BM samples obtained 2, 6 and 16 months respectively before clinical relapse. Differences in the duration of minimal residual disease were not associated with distinct clinical-hematological features. In one patient a different pattern of V delta 2 recombination occurred in leukemic cells from diagnosis to relapse, thus preventing the further monitoring of the patient by the initial clonospecific probe.

Central venous catheter-related complications after bone marrow transplantation in children with hematological malignancies

We studied infectious and mechanical complications occurring with 55 central venous catheters (CVCs) managed in hospital and at home, in 53 children with hematological malignancies who underwent bone marrow transplantation (BMT). The total catheter life span was 6906 days (median 111), 2359 days (median 40) in hospital and 4547 days (median 78.5) at home. Duration of neutropenia was 1241 days (median 20), mostly in hospital. We observed 21 CVC-related infections from 17/55 CVCs (31%): 0.30 episodes/100 days of CVC use with 0.55/100 days in hospital vs 0.17/100 days at home. Antibiotic treatment resolved 72% of infections without CVC removal, which was required in six instances. There were 14 mechanical complications (0.20 episodes/100 days of CVC use) in 6/55 CVCs (11%), with three removals. Interventions to resolve mechanical problems included catheter declotting by urokinase, repair and replacement. We conclude that CVC is an essential component of care of children with cancer undergoing BMT and that it has a relatively low complication rate. Most complications can be resolved by an appropriate CVC handling and by a multidisciplinary intervention in the critical post-BMT phase.

An unclassified case of congenital dyserythropoietic anaemia with a severe neonatal onset

The case of a 13-year-old child with a congenital dyserythropoietic anaemia (CDA) is reported. A severe anaemia associated with a slight increase in reticulocytes, erythroblastosis, hyperbilirubinaemia, hepatosplenomegaly, generalized oedema and hypoproteinaemia was present at birth. Three exsanguino-transfusions were needed in the first 4 days of life. In the following years a continuous transfusional regimen was maintained in association with a chelating treatment. Bone marrow aspirates showed a striking hyperplasia of the erythroid lineage with ineffective erythropoiesis and changes of erythroblastic nuclei which were double but incompletely separated. Numerous histio-erythroblastic islands were also present. Electron microscopy studies did not show specific alterations of the erythropoietic cells. By a long-term evaluation of the clinical signs and of the haematological data, we came to the conclusion that the case does not fit into any of the three classical categories of CDA.

High-dose methotrexate administration and acute liver damage in children treated for acute lymphoblastic leukemia. A prospective study

BACKGROUND

Methotrexate-induced hepatotoxicity following chronic low-dose administration has been extensively reported. Current protocols now include high-dose methotrexate (HDMTX), but there are few studies providing data on its acute hepatotoxicity in childhood leukemia.

METHODS

To evaluate the prevalence of HDMTX-induced acute hepatotoxicity, sixty-eight consecutive children with ALL were prospectively studied from diagnosis to the end of HDMTX courses with biochemical and clinical evaluation performed at regular intervals.

RESULTS

Prevalence of HDMTX-induced acute hepatotoxicity was 1.47% (1/68 patients). ALT values did not change in 22% (15/68) and decreased in 76.4% (52/68) after HDMTX infusion. Mean ALT levels calculated in all the patients decreased significantly during HDMTX administration when compared to the values reached during induction (p less than 0.0001). Direct hyperbilirubinemia was present only in the child with HDMTX-related hepatotoxicity.

CONCLUSIONS

The use of HDMTX in the treatment of childhood ALL is not associated with major evidence of direct acute hepatotoxic effects, while it may modify the pattern of preexisting liver diseases.

Successful use of high-dose cyclophosphamide in a child with severe autoimmune hemolytic anemia

We report the case of a five-month-old boy with a life-threatening autoimmune hemolytic anemia that was unresponsive to conventional therapy with steroids, high-dose immunoglobulin, azathioprine and splenectomy. Despite these therapies, the patient's condition worsened, requiring 2-3 blood transfusions/day, since the hemoglobin level was constantly below 4 g/dl. We eventually increased immunosuppression by giving high-dose cyclophosphamide and the child showed a striking, sudden improvement, followed by complete recovery. No major long-term complications were observed.

Isolated breast relapse after allogeneic bone marrow transplantation for childhood acute lymphoblastic leukemia

Unusual sites of relapses following bone marrow transplantation (BMT) for childhood acute lymphoblastic leukemia (ALL) are rarely reported. We report the case of a 16-year-old girl who presented with an isolated right breast relapse 8 months after allogeneic BMT for ALL in second remission. Biopsy showed an ALL infiltrate. Bone marrow and CSF were normal. The girl never showed before extramedullary involvement. She was treated with local radiotherapy and mild systemic chemotherapy. Nine months after breast relapse, she presented an isolated central nervous system relapse. The treatment of isolated extramedullary relapses following BMT is still controversial.

Hepatitis C virus infection and chronic liver disease in children with leukemia in long-term remission

Antibody to the recently identified hepatitis C virus (HCV) was investigated in sera of 50 leukemic children who had chronic liver disease (CLD), observed for 1 to 12.6 years after therapy withdrawal. All patients were tested for anti-HCV at regular intervals: Ortho-enzyme-linked immunosorbent assay (ELISA) test was performed in all cases. Reactive sera were also tested by recombinant immunoblotting assay to define the specificity of the results obtained by ELISA. Twelve cases (24%) were persistently positive (group A), 11 (22%) were transiently anti-HCV+ positive (group B), and 27 (54%) were negative. Mean SGPT peak during follow-up was significantly higher in group A (P = .014, A v B and P less than .00001, A v C). SGPT normalized off-therapy in 1 of 12 cases (group A), 10 of 11 (group B), and 19 of 27 (group C) (P = .0004, A v B and P = .012, A v C). Accordingly, liver histology, available in 37 patients, showed signs of chronic hepatitis in all patients in group A while most patients in group B and C had less severe liver lesions. These results indicate that HCV plays a significant role in the etiology of chronic hepatitis in leukemic patients and that persistent anti-HCV activity correlates with a more severe CLD, which could jeopardize the final prognosis of children cured of leukemia.

[Intestinal hemorrhage in a milk-fed infant: a case of laryngo-tracheo-gastric duplication]

An important gut hemorrhage in a breast fed child is not a usual event. If, in addition, the etiology represents a real rarity, even the most sophisticated diagnostic trials can't give any aid and this constitutes a hard diagnostic and therapeutic problem. In this report, the authors describe how, after a long sequence of analysis and exams, no certain diagnosis was possible, till serious anaemia gave indication to an explorative laparatomy. Laparatomy became both diagnostic and therapeutic and allowed to discover a rare malformation: a tracheal-gastric duplication.

Parenchymal brain leukemia. Case report: problems related to the diagnosis and treatment

A case of intracerebral nodular leukemic mass that developed in a girl eight years after a diagnosis of acute lymphoblastic leukemia (ALL) and 18 months after second discontinuation of therapy for a central nervous system (CNS) relapse is reported. The morphologic picture and the long time that elapsed from the diagnosis raised the suspicion of a cerebral neoplasm; the immediate and dramatic effect of steroid treatment, on the contrary, indicated the presence of a leukemic infiltration and in the meantime, a bone marrow relapse occurred. The patient soon after received high-dose Cytosine Arabinoside (HD ARA C) + Vincristine (VCR) + Levo-Asparaginase (L-ASE) + Prednisone (PDN) without any intrathecal antiblastic drug. We observed a neurological recovery and a complete disappearance of the mass. After consolidation of the remission the patient began an ablative regimen for bone marrow transplantation. The efficacy of HD ARA C in the treatment of the intracerebral nodular leukemic mass is emphasized.

Total parenteral nutrition and nutritional assessment and leukaemic children undergoing bone marrow transplantation

The aggressive radiotherapy and chemotherapy used in conditioning regimens for children with leukaemia undergoing bone marrow transplantation (BMT) cause a severe catabolic state. Total parenteral nutrition (TPN) is indispensable in the management of these patients. 25 children with leukaemia undergoing BMT were studied to evaluate the efficacy of TPN and the value of anthropometric parameters and biochemical variables (albumin, retinol-binding protein and prealbumin) in monitoring nutritional status in the critical post-BMT phase. The complications of TPN were mainly metabolic, generally mild and easily controlled. The hyperalimentation solution and infusion line were not responsible for infection in any patient. The marked variations in anthropometric parameters and albumin expected in such patients were not observed in our children due to the nutritional support given. Prealbumin and retinol-binding protein showed statistically significant, positive variations (P less than 0.01), thus proving sensitive indices of the response to nutritional repletion.

Overdose of vinblastine in a child with Langerhans' cell histiocytosis: toxicity and salvage therapy

The therapeutic index of antineoplastic agents is generally low, therefore, errors in administration can cause severe, life-threatening toxicity. The publication of cases of overdoses may provide useful information on the causes of the mistakes, on drug-induced toxic effects, and on salvage therapy. We report a case of vinblastine overdose in a child affected by Langerhans' cell histiocytosis, Hand-Schüller-Christian syndrome according with the previous classification of histiocytosis X. To our knowledge this is the highest dose of vinblastine ever administered. The child was given salvage therapy with steroids and citrovorum factor. Major side effects were neurologic toxicity (seizures, coma) and marrow aplasia, which improved and gradually resolved beginning day 12.

Acute respiratory failure and pulmonary thrombosis in leukemic children

Acute respiratory failure (ARF) in an 11-year-old child with pre-T acute lymphoblastic leukemia (ALL) at the beginning of induction therapy was observed, connected with a pulmonary thrombosis and not with an infective origin. A systematic search for this pathology identified six other children with the same pulmonary complication, five of whom where in the early phase of acute nonlymphoblastic leukemia (ANLL) and one in induction therapy for ALL in marrow relapse. At the beginning of the symptomatology, all children presented severe hypoxia and hypercapnia, with no or minimal chest radiograph abnormalities and no clear hemodynamic involvement. In all patients the arteriography and nuclear imaging studies confirmed the diagnosis. The causes of the thrombi could be connected with neoplastic emboli after cell lysis and/or with the vascular damage resulting from antiblastic therapy. Intravenous urokinase treatment and respiratory assistance had been successfully carried out in six of seven children.

Doxorubicin and m-AMSA induced DNA damage in blast cells from AML patients

We investigated m-AMSA or doxorubicin (Dx) induced DNA single-strand breaks (DNA-SSB) in myeloid leukemia cells obtained from 8 adult patients suffering from AML. Highly purified AML cells were stimulated to proliferate with the addition of the appropriate growth factor (GCT) and exposed to different concentrations of m-AMSA or Dx for 1 or 4 h, respectively. DNA-SSB were determined by alkaline elution techniques. Either the kinetics or the amounts of DNA-SSB caused by both topoisomerase II inhibitors were variable among different cases. By increasing m-AMSA concentrations there was a concomitant increase in DNA-SSB up to a plateau at the highest concentrations. Dx induced DNA-SSB followed a bell shape curve with a decrease in the number of breaks at the highest concentrations that was evident in most cases. The interindividual variability of Dx-induced DNA-SSB was not correlated with intracellular Dx concentrations as assessed by flow cytometry. No correlation was evident between the amount of DNA breaks induced by m-AMSA and that induced by Dx. These data suggest that AML cells derived from different patients are not necessarily cross-sensitive or cross-resistant to topoisomerase II inhibitors with different chemical structures such as amsacrine or anthracyclines.

Social integration of the older thalassaemic patient

Because social policy favours the fullest possible social integration of chronically ill patients, we have evaluated the facilities that are needed to achieve this for patients with beta thalassaemia major in the light of the therapeutic advances that now permit them to survive into adulthood. We have investigated the social integration of adolescent and young adult thalassaemic patients, 171 from Greece and 112 from Ferrara in Italy. Patients in both areas show a good level of social integration and favourable self image, indicating what may be achieved by providing psychosocial support as part of a comprehensive approach to treatment.

Cytotoxicity and DNA damage caused by 4-demethoxydaunorubicin and its metabolite 4-demethoxy-13-hydroxydaunorubicin in human acute myeloid leukemia cells

4-Demethoxydaunorubicin (4-DMDR) and its major metabolite 4-demethoxy-13-hydroxydaunorubicin (4-DMDRol) were investigated for their cytotoxicity and mode of action against human leukemic cells. The drug and its metabolite appeared to be equally potent as both inhibitors of cell proliferation and inducers of DNA double-strand breaks in the OCI AML-3 cell line and cells derived directly from patients with acute myeloid leukemia (AML). This suggests that 4-DMDRol plays an important role in the antileukemic activity of 4-DMDR.

Congenital refractory anaemia with vacuolisation of bone marrow precursors, sideroblastosis and growth failure in a girl with normal endocrine pancreatic function

The case is described of an 8-years-old girl with consanguineous parents. She was apparently well, apart, from growth retardation, until 18 months of age when she developed severe normocytic hypochromic anaemia. Bone marrow examination revealed vacuolisation of the erythroid and myeloid precursor, and electron microscopic studies showed striking sideroblastosis with ringed arrangement of the iron granules. Porphyrin metabolism was apparently normal, whereas blood levels of iron and ferritin were high. A careful study of the exocrine pancreas showed completely normal function. Vitamin B6 administration was unsuccessful. The patient is transfusion-dependent, and iron chelation treatment has produced good results. The case could be a new entity or a variant of congenital sideroblastic anaemia, since it has some features in common with the syndrome described by Pearson et al.

Isolated testicular relapse in a boy with acute lymphoblastic leukemia following allogeneic bone marrow transplantation

About 5-10% of boys with acute lymphoblastic leukemia (ALL) present with isolated testicular relapse. Very frequently these relapses occur during treatment or in the following six months, and in these cases the prognosis is very severe. The patients are usually treated with radiotherapy and chemotherapy or bone marrow transplantation (BMT). Testicular relapses after BMT are relatively rare. We report the case of a child with ALL who presented testicular relapse during therapy and was treated with local radiotherapy (2000 cGy), chemotherapy and allogeneic matched BMT. The preparative regimen consisted of Cyclophosphamide (60 mg/kg/day x 2 days) and total body irradiation (200 cGy x 2/day x 3 days). Engraftment was documented at day + 14. The patient presented again with testicular relapse at day + 146, and was therefore treated with orchiectomy, local radiotherapy and systemic chemotherapy. A marrow relapse followed, however, at day + 284 and the patient died of progressive disease.