Acute myeloid leukaemia with an unusual phenotype: myeloperoxidase (+), CD13 (-), CD14 (-) and CD33 (-)

We herein describe an unusual case of acute myeloid leukaemia (AML) showing strong cytochemical reactivity for myeloperoxidase (MPO) but surprisingly no reactivity using flow cytometry for any of the lineage-specific cell surface markers, i.e. myelomonocytic antigens CD13, CD14 and CD33; or B-lymphoid antigens CD19, CD20 and immunoglobulins; or T-lymphoid antigens CD2, CD3 and CD5. The strong reactivity for MPO and the complete absence of reactivity for CD13 and CD14 was verified by an independent assay involving alkaline phosphatase-anti-alkaline phosphatase (APAAP). Our case is of interest for at least two reasons: First, a poorly differentiated variant of AML (negative for MPO but positive for one or more of the myeloid-lineage CD antigens) has been designated FAB M0. In terms of the expression of phenotypic markers, our case may be considered as an 'MPO (+), CD antigen (-) AML'. The CD antigens are known to be expressed very early during myeloid differentiation whereas MPO (in its functional form) is viewed as being expressed relatively late in the process. It is therefore intriguing from a biological standpoint why the supposedly early antigens (CD33 and CD13) remain unexpressed; this may represent an example of 'asynchronous differentiation' in leukaemia. Second, from a practical standpoint, the use of immunophenotyping as a first-line diagnosis would fail to detect such cases. This case strengthens the notion that immunophenotyping by flow cytometry does not eliminate the necessity of performing peroxidase cytochemical staining.

Evaluation of the dysmyelopoiesis in 336 patients with de novo acute myeloid leukemia: major importance of dysgranulopoiesis for remission and survival

Myelodysplastic features and myeloperoxidase (MPO) deficiency have been investigated in a series of 336 cases of de novo acute myeloid leukemia (AML) to clarify their impact on the outcome of such patients and to compare with the previous results from the literature. Dysplastic features were defined according to the FAB criteria. Trilineage disease (TLD) was observed in 11.6% of patients (39 cases), and the complete remission rate (CR) was 56.4% for TLD patients compared to 74.4% for patients without any dysplastic features (p = 0.03). The effects of dysgranulopoiesis (DysM) alone or in combination were assessed using a logistic regression analysis. This analysis revealed that only DysG had any effect on CR rate (p = 0.013). The CR rate for patients with DysG was 56.6% and 71.5% for patients without DysG. We were unable to find any correlation between MPO deficiency, dysplastic features and CR rate. Cytogenetic analysis could be assessed for 119 patients. For patients with DysG, 10 karyotypes were normal and 20 were abnormal compared to 48 normal and 41 abnormal for patients without DysG (p = 0.05). We conclude that the presence of DysG in de novo AML exerts a negative effect on the ability to achieve a CR and is related to a higher frequency of cytogenetic abnormalities.

Morphology and classification of myelodysplastic syndromes

The FAB classification has provided a common language for clinicians and pathologists in the investigation of myelodysplasia. It has also provided prognostic information, given the excellent correlation between FAB subgroup and survival (see Table 2). Refinements in immunologic and cytogenetic typing should provide further prognostic power and correlation with the underlying biologic processes.

Varying intensity of postremission therapy in acute myeloid leukemia

The Eastern Cooperative Oncology Group (ECOG) conducted a randomized trial in patients less than or equal to 65 years old (median, 44 years) to determine whether increasing the intensity of postremission therapy in acute myeloid leukemia (AML) would improve the outcome. After uniform induction therapy, patients in complete remission (CR) who were less than 41 years old and who had a histocompatible sibling underwent allogeneic bone marrow transplantation (alloBMT) (54 patients). The remainder of patients in CR were randomized to receive either 2 years of continuous outpatient maintenance therapy with cytarabine and 6-thioguanine (83 patients) or a single course of inpatient consolidation therapy consisting of 6 days of high-dose cytarabine plus 3 days of amsacrine (87 patients). The median duration of follow-up is now 4 years, and patients are included in the analyses of outcome regardless of whether they relapsed before starting the intended treatment. Four-year event-free survival (EFS) was 27% +/- 10% for consolidation therapy versus 16% +/- 8% for maintenance therapy (P = .068) and 28% +/- 11% versus 15% +/- 9% (P = .047) in patients less than 60 years old. The outcome for patients receiving alloBMT was compared with the subset of patients less than 41 years old who received consolidation therapy (N = 29) or maintenance therapy (N = 21). Four-year EFS was 42% +/- 13% for alloBMT, 30% +/- 17% for consolidation therapy, and 14% +/- 15% for maintenance therapy. AlloBMT had a significantly better EFS (P = .013) than maintenance therapy, but was not different from consolidation therapy. In patients less than 41 years old, 4-year survival after alloBMT (42% +/- 14%) did not differ from consolidation therapy (43% +/- 18%), but both were significantly better than maintenance therapy (19% +/- 17%), P = .047 and .043, respectively. The mortality rate for maintenance therapy was 0%, consolidation therapy, 21%; and alloBMT, 36%. Consolidation therapy caused an especially high mortality rate in the patients greater than or equal to 60 years old (8 of 14 or 57%). The toxicity of combined high-dose cytarabine and amsacrine is unacceptable, especially in older patients, and alternative approaches to consolidation therapy such as high-dose cytarabine alone need to be tested. In AML, a single course of consolidation therapy or alloBMT after initial CR produces better results than lengthy maintenance therapy. Although EFS and survival of alloBMT and consolidation therapy do not differ significantly, a larger number of patients need to be studied before concluding that they are equivalent.

Polishing study using Teflon and pitch laps to produce flat and supersmooth surfaces

Teflon polishing is compared with pitch polishing as a method for achieving supersmooth and flat optical surfaces. Because a Teflon lap wears slowly, it will retain its surface shape to produce extremely flat optical surfaces, lambda/100, consistently and reliably for extended periods of time, of the order of days. To compare the two methods, we polished 50-mm-diameter samples of various optical materials, using colloidal suspensions in water on both pitch and Teflon laps under the same polishing conditions. Flatness was maintained to better than lambda/10, and roughness less than 10 A rms was measured on all samples by two Talystep surface-profiling instruments, one in the United States and one in Australia, with excellent agreement between measurements made by the two instruments. It was possible to obtain flat andsmooth surfaces (<4-A rms roughness) on all materials (except for F4, flint glass), but only certain combinations of material, abrasive, and lap could be used to give the correct polishing conditions and s rface chemistry.

Sequential administration of recombinant interferon alpha and deoxycoformycin in the treatment of hairy cell leukaemia

Both recombinant interferon alpha and deoxycoformycin (dCF) are effective in the treatment of hairy cell leukaemia. In an attempt to reduce the complications from dCF therapy, a pilot study of the Eastern Cooperative Oncology Group (ECOG) first treated patients with interferon to improve peripheral blood cell counts before dCF treatment began. Thirty-four patients were treated for 3 months with recombinant interferon alpha-2a (rIFN alpha-2a), 3 x 10(6) IU subcutaneously three times a week for 3 months, and then by dCF, 4 mg/m2 intravenously every 2 weeks for a maximum of 12 months. The overall response rate was 94% (32/34); 76% of patients (26/34) had complete response (CR) (90% confidence interval, 62-88%) and 18% (6/34) partial response. One patient was found to have a Mycobacterium avium infection while receiving rIFN alpha-2a. Without specific antimycobacterial therapy and with continued administration of rIFN alpha-2a and dCF, the infection resolved and he achieved CR. Three patients had culture-negative febrile episodes during the dCF phase of treatment. Non-disseminated herpes zoster developed in four patients, but three of the episodes occurred only after treatment was discontinued. Sequential administration of rIFN alpha-2a and dCF resulted in fewer infections (P = 0.027) than in ECOG's previous study of dCF used alone. Two patients died, one of combined hairy cell leukaemia and non-Hodgkin's lymphoma of intermediate histologic type 17 months after entry into the study and the other of cardiac arrest 20 months after entry. Thirty-two patients were alive with a median follow-up of 21 months (range 13-31 months). This combination produces durable CRs with a low incidence of infection.

Microstructure characterization by angle-resolved scatter and comparison to measurements made by other techniques

The theory and measurement of angle-resolved scatter are described. Values of rms roughness that were obtained by using this technique to characterize four different materials are compared with values that were obtained by using a total integrated scatter measuring instrument, an optical profiler, and a mechanical profiler. The spatial frequency bandwidths and modulation transfer functions of the four instruments are different, and results are described in light of these differences.

Perceived intergenerational solidarity and psychological distress among older Mexican Americans

A model separating and relating dimensions of intergenerational solidarity with measures of psychological distress was investigated for older Mexican Americans. Solidarity consisted of measures of similarity, affection, and association. Measures of psychological distress were somatic/retarded symptoms, depressed affect, and positive affect. To evaluate whether emotional closeness with a particular child modified the linkages, the model was analyzed separately based on whether or not the elderly participant reported that the child included in the intergenerational study was her or his closest child. The findings indicated that the impact of affection and association was a function of the particular dimension of distress and the emotional closeness of the child. Although the proposed model needs expanding, it provides some support for the expectation that family solidarity has important consequences for elderly Mexican Americans.

Malignant melanoma: primary presentation in bone marrow and lymph node

We describe an unusual presentation of malignant melanoma with simultaneous lymph node and bone marrow metastasis. In addition the disease was associated with immune-mediated thrombocytopenia. A brief remission was obtained with combination chemotherapy.

The prevalence of homocysteinemia and hypercholesterolemia in angiographically defined coronary heart disease

Total serum homocysteine and cholesterol levels were determined in 163 male patients with typical angina who were subjected to coronary angiography. The prevalence of homocysteinemia in coronary heart disease (CHD) was 41.9%. Serum homocysteine levels were significantly elevated (p less than 0.05) in patients with major occlusion in two or three coronary arteries. Furthermore, the prevalence of homocysteinemia correlated positively (p less than 0.05) with the number of coronary vessels that were occluded. The prevalence of hypercholesterolemia was 34.9%, but, in contrast to homocysteinemia, no graded strength of association with the number of stenotic coronary arteries could be demonstrated. The results suggest that homocysteinemia may contribute significantly to the development of coronary heart disease.

Low-dose chemotherapy with central nervous system prophylaxis and zidovudine maintenance in AIDS-related lymphoma. A prospective multi-institutional trial

OBJECTIVE

--To ascertain if low-dose multiagent chemotherapy, with central nervous system prophylaxis and antiretroviral therapy, might be associated with increased efficacy and decreased risk of intercurrent infection in patients with malignant lymphoma related to the acquired immunodeficiency syndrome (AIDS).

DESIGN

--A phase II prospective clinical trial, with median follow-up of 33 months.

SETTING

--Eight university hospitals, within the context of the AIDS Clinical Trials Units, sponsored by the National Institute of Allergy and Infectious Diseases.

PATIENTS

--Forty-two patients with AIDS-related malignant lymphoma. All were evaluable for toxicity assessment, and 35 for response.

INTERVENTION

--A low-dose modification of the M-BACOD regimen (day 1): cyclophosphamide, 300 mg/m2 intravenously (IV); doxorubicin, 25 mg/m2 IV; vincristine sulfate, 1.4 mg/m2 IV; bleomycin, 4 mg/m2 IV; dexamethasone, 3 mg/m2 orally on days 1 through 5; methotrexate, 500 mg/m2 IV on day 15, with leucovorin rescue. Intrathecal cytosine arabinoside (50 mg) to all on days 1, 8, 21, and 28, with radiation therapy to a helmet field to those with central nervous system involvement. Zidovudine for 12 months after completion of four to six cycles of chemotherapy.

MAIN OUTCOME MEASURES

--Response rate and number of opportunistic infections.

RESULTS

--Response rate was 51% with a complete response of 46%. Of 16 complete responses, relapse occurred in four, none isolated to the central nervous system. Opportunistic infections occurred in 21% of those receiving treatment. Median duration of survival among all 42 patients is 5.6 months, 6.5 months in 35 patients evaluable for response, and 15 months in patients with complete response. Lower concentration of CD4 cells, history of prior AIDS, bone marrow involvement, and stage IV disease were independently associated with decreased survival.

CONCLUSIONS

--Low-dose chemotherapy with central nervous system prophylaxis and zidovudine maintenance may be associated with durable remissions in AIDS-related lymphoma with fewer opportunistic infections than noted in prior reports.

Medical surveillance for leukemia at a petrochemical manufacturing complex: four-year summary

Four-year results are presented on 2086 participants of a medical surveillance program of current and retired employees at a manufacturing complex in Illinois. Annual complete blood cell count testing and intensive follow-up of all out-of-normal-range results began in 1985 on a voluntary basis. The program to date has not identified any evidence for an unusual distribution of out-of-range complete blood cell count results. Active employees with out-of-range complete blood cell count values had no increase in adverse health outcomes compared with those with in-range values. Retired employees with out-of-range values were more likely to have a serious underlying medical condition, but this appeared to be more a function of age than of occupational exposure. Four cases of myelodysplastic syndrome were brought to our attention as a result of the program, but there is no similarly followed population available for comparison to determine whether this represents an increase over expected cases. The lack of correlation of out-of-range complete blood cell count results in active employees with serious hematologic disease raises significant questions about the utility of such surveillance for chemically exposed groups (eg, benzene-exposed workers) when exposure levels are low and well controlled.

Proposal for the recognition of minimally differentiated acute myeloid leukaemia (AML-MO)

We describe a form of acute myeloid leukaemia (AML), designated AML-MO, with minimal myeloid differentiation, not included previously in the FAB classification. AML-MO cannot be diagnosed on morphological grounds alone as the blast cells are large and agranular, sometimes resembling L2 or, rarely, L1 lymphoblasts, and should be identified by the following features: negative myeloperoxidase (MPO) and Sudan Black B reaction (or positive in less than 3% of blasts), negative B and T lineage markers and expression of myeloid antigens recognized by at least one monoclonal antibody, CD13 or CD33. Other myeloid markers are also often positive and these include CD11b and the enzyme MPO demonstrated by immunocytochemistry and/or electron microscopy analysis. The findings in a group of 10 cases satisfying the criteria for AML-MO are described. AML-MO represents 2-3% of all cases of AML and 1-1.5% of all acute leukaemias. Its clinical and biological significance is not yet apparent but its identification in a larger number of cases may achieve this aim.

13-cis-retinoic acid in the treatment of elderly patients with acute myeloid leukemia. A phase II pilot study of the Eastern Cooperative Oncology Group

The management of acute myeloid leukemia in the elderly (65 years and older) is unsatisfactory because of poor patient tolerance of standard myeloablative chemotherapy. The authors conducted a Phase II study to evaluate the effectiveness and toxicity of 13-cis-retinoic acid (CRA) in the therapy of elderly patients with acute myeloid leukemia (AML). Patients presenting with leukocyte counts less than 20,000/microliters were treated with CRA alone. Those with leukocyte counts of 20,000/microliters or greater were pretreated with hydroxyurea, followed by CRA. Twelve of 18 patients received at least 4 weeks of CRA and were thus considered evaluable for toxicity and response. No objective responses were observed. Cis-retinoic acid administration was well tolerated; only modest dermatologic, musculoskeletal, and gastrointestinal toxicity was observed. Alternative therapeutic strategies should be investigated in this subpopulation of AML patients.

High-dose dexamethasone for refractory or relapsing multiple myeloma

In order to assess the efficacy and toxicity of dexamethasone as a single agent without the concomitant infusion of Adriamycin and vincristine (VAD), an ECOG pilot study was initiated using 40 mg by mouth daily for 4 days every week for 8 weeks. Patients who responded were then maintained on the same treatment, but at 2 week intervals. Of the 32 patients evaluable for response, three were completely refractory to all prior therapy. All patients had advanced disease and 26 had received multiple prior treatments. There were 13/32 (40%) objective responses by ECOG criteria. Of the 28 patients evaluable for subjective response, i.e., significant decrease in performance status and/or bone pain, eight (28.5%) responded. Of the 34 patients evaluable for toxicity, 19 patients (55%) had moderate to severe side effects, including nine who had central nervous system effects, three who had gastrointestinal bleeding, two who had pulmonary emboli, one with psychosis, and four who had serious infections with one death. Median survival for the entire group was 19 weeks, with 31 weeks in the responders and 9 weeks in the non-responders. Although high-dose dexamethasone is capable of producing a significant number of partial responses (40%), it is associated with excessive toxicity. Less frequent administration of the dexamethasone at 2 week intervals was well tolerated in the maintenance of partial response, but has not been studied for efficacy in induction of remission.

Pentostatin induces durable remissions in hairy cell leukemia

Fifty patients with hairy cell leukemia were treated with pentostatin (2'-deoxycoformycin; dCF) for a median of 3 months; 32 (64%) patients achieved complete remission (CR), and 10 (20%) patients achieved partial remission (PR), for an overall response rate of 84%. After reaching maximal response, no maintenance therapy was administered. The median duration of follow-up is now 39 months, and only four of 32 patients in CR and two of 10 patients in PR have relapsed. dCF therapy produces durable long-term, disease-free survival in patients with hairy cell leukemia.

Unexpected immunoglobulin light chain gene rearrangements in myeloid antigen positive acute lymphoid leukemia

Blast cells from 10 immunologically diagnosed adult acute lymphoid leukemias expressing myeloid antigens (M+ALL) were studied for immunoglobulin heavy (IgH) and light chain as well as T-cell receptor (TCR)-beta chain gene rearrangements. All but one leukemic isolate met the FAB-criteria for ALL. DNA from 2 patients with pre-pre-B-ALL (CD10-) and 1 patient with common ALL contained rearranged Ig light chain (kappa in two, lambda in one case) in addition to rearranged IgH genes. The TCR-beta chain gene was germline in all pre-pre-B leukemias and rearranged in common ALLs (bigenotypic features). One patient with mature B-ALL showed IgH and light chain gene rearrangements. DNA from 2 pre-T-ALLs contained rearranged TCR-beta chain genes plus rearranged IgH genes in one case. Ig light chain gene rearrangements in immature M+ALL were not associated with gross chromosomal abnormalities except for one Philadelphia chromosome positive case. The occurrence of Ig light chain gene rearrangements in M+ALL with immature lymphoid immunophenotype might represent an hitherto unrecognized aberrant differentiation potential of transformed multipotential stem cells with commitment towards the lymphoid lineage.

Long term survival in acute myeloid leukemia: the Eastern Cooperative Oncology Group (ECOG) experience

A retrospective analysis of two ECOG adult AML trials conducted from 1976 to 1983 was carried out focusing on long term disease-free survival. This report summarizes the data on 545 patients with a minimum follow up of 7 1/2 years. The complete remission rate was 57% with an estimated cure rate of 12%. Of several prognostic variables examined only FAB type M3 (promyelocytic leukemia) was statistically significant (estimated cure rate of 33% vs 9% for other FAB subtypes).

Treatment patterns in low-grade non-Hodgkin's lymphomas: a single institution study

Ninety-two cases of low-grade non-Hodgkin's lymphoma were examined retrospectively to assess to what extent treatment deferral is practiced at a single university hospital with a local referral base. Clinical characteristics of this patient group were also analyzed; 70% of these cases were of nodular lymphocytic, poorly differentiated (NLPD) histology, and 74% were stage III or IV. Twenty-two cases were not treated initially. Nine eventually required treatment at a median of 16 months. Survival did not differ based on whether treatment was initially deferred. Nodal progression was the most common reason for beginning treatment after initial deferral, and most cases of advanced stage disease required treatment because of nodal involvement or B-type symptoms at diagnosis. Presence of intra-abdominal adenopathy often prompted initial treatment even in asymptomatic cases. In this series, as compared to previously reported series of treatment-deferred cases, more patients were judged to require treatment at disease outset, and the median time to treatment in those in whom treatment was initially deferred but then instituted was shorter. Despite this, for the entire population, 69% of total follow-up time was spent off therapy.

Prognostic implication and characterization of the blast cell population in the myelodysplastic syndrome

The bone marrow smears of 18 confirmed cases of MDS were analyzed carefully for the presence of "hypergranular type III blasts", defined as more than 20 fine azurophil primary granules per cells. The concordance was close to 80% among 5 observers. Thirty-nine percent (7 cases) were reclassified as RAEB-t rather than RAEB. The presence of these hypergranular blasts was not suggestive of increased differentiation but rather leukemic cells. The reassignment of cases altered the median survival for the various subcategories, providing a clearer separation with the introduction of type III blasts than without utilizing these cells which were separated from the promyelocyte family. The introduction of this new blast cell definition in a larger series of patients is recommended to confirm these preliminary observations.

Classifications of acute myeloid leukemia

A detailed description of the various subtypes of the acute myeloid leukemias is provided. The importance of cytochemistry and monoclonal antibodies is discussed.

Chronic myelomonocytic leukemia

Thirty adult patients with CMML were evaluated to determine prognostic factors that might have an impact on conversion to acute leukemia and survival. Neither leukocyte count nor monocyte count correlated with survival. The median survival for all 30 cases was 41 months. Patients with less than 5% marrow blasts had a median survival of 60 months but those with 5-20% blasts had only a 9-month median survival.

Blastic phase of chronic myeloid leukemia (blCML): a proposal for standardization of diagnostic and response criteria

The selection of optimal treatment among the alternatives that are available is especially difficult in blastic phase of chronic myeloid leukemia (blCML) because of the absence of universally agreed upon criteria for the diagnosis of this phase and the absence of definitions of response. Variable response rates, from less than 10 to greater than 90% have been reported, but the highest response rates, in general, have not been reproducible. The application of strict morphologic, cytogenetic, and molecular biologic studies should provide the means for selection of optimal treatment among the new therapies that will be introduced in the future.