Acute nonlymphocytic leukemia with marrow eosinophilia and chromosome 16 abnormality: a report of 18 cases

This article reports 18 cases of acute nonlymphocytic leukemia (ANLL) and abnormal chromosome 16. Thirteen had the same hematological pattern at diagnosis, i.e., peripheral blood hyperleukocytosis with high percentage of monocytes and blast cells, and bone marrow showing three different cell populations: (a) myeloblasts, (b) monocytes and promonocytes, and (c) abnormal eosinophils. In these cases the diagnosis was acute myelomonocytic leukemia with bone marrow eosinophilia, as described. However three other cases were of the M5 type and two others of the M2 type, all showing an abnormal eosinophilia in their bone marrow. All cases showed an abnormal chromosome 16 in the bone marrow cells: inv (16) in 13 cases, t (16;16) in two, del (16) in one of poor quality, and in two other translocations involving band 16q22. In one case the inv (16) was found in a subclone, indicating that it could be a secondary cytogenetic defect. Five patients died soon after diagnosis; the other 13 had a median complete remission duration of 8 months. The central nervous system was frequently involved upon relapse. We do not support the hypothesis that patients with M4-Eo ANLL and chromosome 16 abnormality have a favorable prognosis.

Long-term culture of peripheral blood stem cells: the effect of the addition of an irradiated stromal layer

We have studied peripheral blood stem cells (PBSC) collected by cytapheresis following intensive chemotherapy, from 13 patients with acute leukemia, in long term culture (LTC). Peripheral blood was cultured with (n = 10) and without (n = 21) the addition of a preformed, irradiated stromal layer. In this latter LTC our results confirm that peripheral blood is capable of producing CFU-GM and nucleated cells in the absence of the formation of an adherent stromal layer. However, peripheral blood cultured in the presence of an irradiated stromal layer is capable of a significantly higher proliferative response (total production of CFU GM per flask - mean = 57529) than in the absence of an irradiated stromal layer (total production of CFU GM per flask - mean = 26739, p less than 0.03). Our results suggest that PBSC contain a primitive nonplastic adherent cell that requires the presence of a stromal layer for its expression. These findings provide further support for the use of peripheral blood stem cells for autologous transplantation.

Comparison of allogeneic or autologous bone marrow transplantation and chemotherapy in patients with acute myeloid leukaemia in first remission: a prospective controlled trial

Eighty-five adult patients under the age of 50 years with acute myeloid leukaemia (AML) were entered into a prospective controlled study conducted to compare the effectiveness of allogeneic or autologous bone marrow transplantation and intensive chemotherapy for patients in first complete remission. Sixty-one patients (72%) achieved complete remission then received a consolidation treatment. After consolidation, 58 patients who were still in remission were assigned to three different therapeutic modalities. Fifty-two patients were evaluable: 20 patients who had an HLA-identical sibling donor underwent allogeneic bone marrow transplantation within 3 months after achievement of complete remission; the other 32 patients were randomized to receive autologous bone marrow transplantation or intensive sequential chemotherapy. The actuarial risk of relapse at 3 years was 18% for the allogeneic patients, 50% for the autologous patients and 83% in the chemotherapy group. The difference was highly significant (P less than 0.0002). The disease-free survival was respectively 66% (95% confidence interval 41-85%), 41% (95% confidence interval 16-66%) and 16% (95% confidence interval 0-31%) (P less than 0.004). We conclude that allogeneic bone marrow transplantation is presently the best therapeutic approach for patients with AML in first complete remission.

Anti LFA1 monoclonal antibody for the prevention of graft rejection after T cell-depleted HLA-matched bone marrow transplantation for leukemia in adults

A mouse IgG monoclonal antibody (MoAb) directed against the human LFA1 molecule (25.3 MoAb) was used in nine adult leukemic patients to prevent graft rejection after T cell-depleted HLA matched bone marrow transplantation. Based on the results of a previous study in children 0.1 mg/kg of 25.3 was given on days -3, -1, +1, +3, +5 in addition to a standard conditioning regimen with cyclophosphamide (120 mg/kg) and fractionated total body irradiation. The marrow transplant was T cell-depleted using T101 Fab immunotoxin ricin A chain. Seven patients received post-graft immunosuppression with methotrexate and cyclosporine A; two patients received no immunosuppression post-graft. A mean T cell depletion of 98.3% (80-100%) was achieved. Tolerance to the infusions of 25.3 MoAb was excellent. No patient developed any form of graft-versus-host disease. However two patients failed to engraft and three patients had delayed graft failures. These results show that this regimen of anti LFA1 MoAb, which was extremely good at permitting engraftment of HLA mismatched T cell-depleted transplant in children with constitutional diseases, is not able to prevent graft failure and rejection of T cell-depleted HLA matched transplants in adults with leukemia. Further efforts are needed to overcome graft failures in this clinical situation.

[Randomized prospective study of ceftazidime versus a cefotaxime-tobramycin combination in acute leukemia in therapeutic aplasia]

In a prospective study, 157 patients with prolonged aplasia (PMN less than 500/mm3 during more than 21 days), hospitalized in a protected environment unit, were randomly assigned to receive ceftazidime alone or cefotaxime + tobramycin for initial febrile episodes. Age, sex, underlying diseases, duration of neutropenia, digestive decontamination regimen, clinical and microbiological characteristics of infections were similar in the two groups. Patients were evaluated for their initial response to antibiotics (defervescence in 48 hours, maintained 7 days) and long term response (prevention of another infection during aplasia). The overall initial response to ceftazidime was 48/71 (68 per cent) and to cefotaxime + tobramycin 55/86 (64 per cent). The long term response to ceftazidime was 33/71 (46.5 per cent) and to cefotaxime + tobramycin 31/86 (36 per cent). In conclusion, ceftazidime alone was as effective as cefotaxime + tobramycin in the first line treatment of febrile episodes in neutropenic patients.

[Early septicemia episodes in 143 bone marrow grafts]

Twenty-one early bacteremias have occurred before engraftment in 143 allogeneic bone marrow transplantation recipients. In the majority of cases (13/21) Gram positive cocci were isolated with a predominance of coagulase-negative staphylococci (62%). The analysis of the infection prevention program showed that: 1) the adjunction of vancomycin to a total gut decontamination did not decrease significantly the incidence of bacteremia caused by Gram positive cocci. 2) The isolation in laminar air flow room seems to decrease the severity of infections but does not influence their frequency.

[Circulating hematopoietic cells. Results of 6 autologous grafts]

Six patients with acute non-lymphocytic leukemia underwent autologous transplantation of circulating stem cells collected during remission. They were given cyclophosphamide (120 mg/kg) and total body irradiation (1,000-1,200 rads) (five patients) or busulfan (16 mg/kg) and melphalan (140 mg/m2) before the transfusion of 6.7 X 10(8) nucleated cells/kg corresponding to 19.7 X 10(4) CFU-GM/kg. Granulopoietic engraftment was observed in every case and was influenced by the number of CFU-GM injected. Megakaryocytic recovery was obtained in four cases.

Allogeneic bone marrow transplantation in adults with acute lymphoblastic leukemia in first complete remission

Twenty-seven patients ranging in age from 15 to 36 years participated in a pilot study, and underwent allogeneic bone marrow transplantation (BMT) for acute lymphoblastic leukemia (ALL) in first complete remission (CR) in four French centers. All patients were grafted from human leukocyte antigen/mixed leukocyte culture (HLA/MLC) identical sibling after conditioning regimen consisting of cyclophosphamide and total body irradiation (TBI). Sixteen patients are alive in persistent first remission, with a median follow-up of 56 months (range, 41 to 82 months). The 6-year Kaplan-Meier probability of disease-free survival (DFS) is 59%. Only three patients relapsed (5, 7, and 7 months after transplantation). These interesting results have led us to propose, in accord with a French multicentric protocol, allogeneic BMT for adults under 40 years of age during the first CR of ALL.

[Intestinal decontamination in the neutropenic patient. Apropos of a prospective randomized study]

Sixty-five patients undergoing remission-induction chemotherapy for acute leukemia in a protected environment unit were randomly assigned to selective antimicrobial modulation of the intestinal flora (SAM) with trimethoprim-sulfamethoxazole, or total antibiotic decontamination (TAD) with gentamicin, vancomycin and colimycin. Digestive tract colonization with Streptococcus D was more prevalent in the SAM group (p less than 0.01); colonization with yeasts was more prevalent in the TAD group (p less than 0.001). However, there was no difference between the two groups as regards to clinically and microbiologically documented infections, septicemias and survival. Selective antimicrobial modulation with trimethoprim-sulfamethoxazole is as effective and cheaper than total antibiotic decontamination with gentamicin, vancomycin and colimycin.

[Collection and freezing of blood stem cells in acute nonlymphoblastic leukemia]

Blood-derived hemopoietic stem cells were collected using a continuous (10 patients) or a semi-continuous flow separator (2 patients) in some patients with acute non-lymphocytic leukemia. For ten out of those patients, five to seven leukaphereses were performed during a short period (median = 11 days) of marrow recovery following severe aplasia induced by an intensive chemotherapy. The mean number of CFU-GM cells collected per leukapheresis and per patient respectively was 6.7 X 10(4)/kg and 38.5 X 10(4)/kg. This latter number was similar to that obtained during a marrow harvest performed for a bone marrow transplantation, suggesting that high numbers of hemopoietic stem cells can be collected from the peripheral blood in leukemic patients and used for autologous transplantation.

Successful autologous transplantation with peripheral blood hemopoietic cells in a patient with acute leukemia

One patient with acute nonlymphocytic leukemia (ANLL) in remission was given intensive chemotherapy (DAT regimen) as late intensification treatment. Seven leukaphereses were performed during the period of marrow recovery following aplasia induced by the DAT regimen. High numbers of nucleated cells (7.8 X 10(8)/kg) and granulocyte-macrophage precursors (9.5 X 10(4)/kg) were collected and then cryopreserved and stored in liquid nitrogen. When he relapsed, the patient was treated with etoposide (600 mg/m2), cyclophosphamide (120 mg/kg), and total body irradiation (1000 rad), followed by the transfusion of thawed autologous leukocytes. The time to reach 0.5 X 10(9) granulocytes/liter and 50 X 10(9) platelets/liter was 16 and 35 days, respectively. This observation demonstrates that circulating hemopoietic stem cells are capable of complete hemopoietic reconstitution after marrow-ablative therapy with supralethal doses of chemoradiotherapy.

Acute eosinophilic leukemia with a translocation (10p+;11q-)

Eosinophilic leukemias are difficult to individualize amid the hypereosinophilic syndromes. Chromosomal abnormalities when present within the eosinophils are of critical value in the diagnosis of a malignancy. We report here the case of a 27-year-old woman who had been healthy, until recently when she suddenly developed hepatosplenomegaly and lymph node enlargement, and considerable eosinophilia in blood and bone marrow. The morphologically abnormal cells (large pseudo Pelger eosinocytes) predominated in the cytology. The establishment in these cells of a clonal chromosomal anomaly, t(10;11)(p14;q21), favored the malignancy and diagnosis of acute eosinophilic leukemia.

Acute myeloid leukemia with marrow hypereosinophilia and chromosome 16 abnormality

This article reports six cases of acute nonlymphocytic leukemia (ANLL) and an abnormal chromosome #16. All had the same hematologic pattern at diagnosis, i.e., peripheral blood hyperleukocytosis with a high percentage of monocytes and blast cells. The bone marrow showed three different cell populations: (a) myeloblasts, (b) monocytes and promonocytes, and (c) abnormal eosinophils. In three cases, an ultrastructural study confirmed the cytologic data. In all six cases, the diagnosis was acute myelomonocytic leukemia with bone marrow eosinophilia (M4-Eo). All cases showed an abnormal chromosome #16 in the bone marrow cells; in four cases, well-banded chromosomes were obtained, showing a pericentric inversion inv(16)(p13;q22). One patient had a 4-year remission, and another is still in remission 14 months after diagnosis. Three patients relapsed 7, 9, and 20 months after diagnosis. The last patient died soon after diagnosis. Thus, we do not support the hypothesis that patients with M4-Eo ANLL and chromosome #16 abnormality have a favorable prognosis.

Relationship between patients' age, bone marrow karyotype, and outcome of induction therapy in acute myelogenous leukemia

Bone marrow karyotypes were performed in 88 cases of adult acute myelogenous leukemia (AML) at diagnosis and classified NN (normal), AA (abnormal), and AN (mixture of normal and abnormal metaphases). A clear relationship was found between karyotype and complete remission (CR) rate: 58% CR in (NN + AN) cases; 14% CR in AA cases (P less than .009). This relationship was even stronger when only patients under 60 years of age were studied. Considering failures of induction treatment, no relationship was found between the NN/AN/AA classification and a drug resistance. In patients over 60, the worse prognosis could be explained by an inferior ability to tolerate intensive treatment.

Megakaryoblastic transformation of primary thrombocythemia

The progression of primary thrombocythemia (PT) into acute leukemia was diagnosed in a 64-year-old man who was previously treated by hydroxyurea without alkylating agents or radioactive phosphorus. Such an event has only been reported in very rare cases. The blast cells had a lymphocytic morphology but were identified as promegakaryoblasts by the ultrastructural demonstration of platelet peroxidase. These data suggest that a megakaryoblastic transformation could occur in PT as had previously been reported in chronic granulocytic leukemia.

[Acute transformation of chronic myeloid leukemia: disappearance of the Philadelphia chromosome after autograft]

Two patients with chronic granulocytic leukemia (C.G.L.) undergoing transformation were treated by high dose chemotherapy and total body irradiation followed by autografting of hematopoietic stem cells collected and cryo-preserved at the time of diagnosis. Recovery of hematopoiesis was characterized by disappearance of the Philadelphia chromosome in most metaphases. A new approach of the management of C.G.L. is discussed.