[Exercise cardiorespiratory parameters in children motivated to physical activity after treatment for acute lymphoblastic leukemia]

BACKGROUND

Children treated for acute lymphoblastic leukemia (ALL) with anthracycline antibiotic agents must be followed up for the danger of late cardiotoxic effects of the treatment. Another threat represents the consequence of the protective upbringing and inactive lifestyle. The aim of present study was to assess the exercise cardiorespiratory indexes and anthropometric variables in previously treated children without clinical, ECG and echocardiographic signs of cardiotoxicity, who had been motivated to physical activity.

METHODS AND RESULTS

29 children (12.3 +/- 2.7 years old) previously treated for ALL with anthracyclines were examined. The cumulative dosis of anthracyclines was 224 +/- 39.4 mg/m2. The treatment was finished before 4.8 +/- 2.1 years and after this period no signs of the late cardiotoxicity were detectable. Both children and their parents were encouraged to the regular physical activity of submaximal intensity. 29 age- and sex-matched control subjects were healthy children, never limited in their activities, but without special physical training. As soon as the basic anthropometric data had been verified, both groups completed a progressive exercise test with the assessment of submaximal and maximal spiroergometric indexes. In all parameters followed we failed to prove any significant differences between the two groups. The treated children exhibited only slightly lower body height, higher body weight and higher percentage of body fat. They reached lower respiratory exchange ratio (R), with higher oxygen uptake on both submaximal and maximal load levels.

CONCLUSIONS

When sufficiently motivated, children surviving five years after the treatment with anthracycline for ALL, who have no signs of cardiotoxic effects, have their functional cardiorespiratory capacity approximately comparable to that of healthy children.

Short-term effects on linear growth and bone turnover in children randomized to receive prednisolone or dexamethasone

AIM

To compare the relative potency of prednisolone (Pred) and dexamethasone (Dex) on short-term growth and bone turnover.

METHOD

Prospective study over 16 weeks of children randomized to receive Pred (40 mg/m2) or Dex (6.5 mg/m2) for the first 5 weeks as part of the MRC-ALL97/99 induction chemotherapy for acute lymphoblastic leukaemia (ALL).

MEASUREMENTS

Lower leg length velocity (LLLV) and weight, serum IGF-I, serum bone alkaline phosphatase (bALP) levels and creatinine-adjusted, urinary excretion of deoxypyridinoline cross-links (DPD).

SUBJECTS

Nineteen children (eight boys, 11 girls) with a median age of 5.9 years (range 2.6-13) and with a diagnosis of ALL.

RESULTS

At week 2 of therapy, median LLLV in the Dex group was -1.5 mm/week (range 0.7 to -2.1) and significantly lower than the LLLV in the Pred group which was -0.1 mm/week (range 0.20 to -0.28; P < 0.05). In the Dex group, LLLV remained lower at week 8 (med LLLV, -0.3 mm/week, range 0 to -1.3) compared to LLLV in the Pred group at 0.3 mm/week (range 0.2-1.0; P < 0.05). Body weight showed an increase after week 2 and reached a peak in both groups of children at week 6. The change in weight from baseline was greater in the Dex group than the Pred group reaching a maximum change by week 5 of 17.5% (range 5-25) and 8.7% (range -3 to 18), respectively (P < 0.05). At presentation, median IGF-I level for the whole group was 83.5 micro g/l (range 31.8-293). IGF-I levels fell markedly during Dex therapy and continued to remain lower than baseline. At weeks 4, 6 and 8, median change in IGF-I from baseline was lower in the Dex group than the Pred group. From week 1 to week 3, median change in bALP was 72% (range -8 to 304) in the Pred group, whereas in the Dex group change in bALP was -1% (range 23 to -28; P < 0.005). By week 3, median bALP was higher in the Pred group at 65 U/l (range 36-187) than in the Dex group at 39 U/l (range 26-60; P < 0.05) but by week 6 median bALP in the Pred group had fallen to a similar level to the Dex group. At presentation, median DPD was 22 nmol/l (range 17-38) and 20 nmol/l (range 12-26) in the Pred and Dex groups, respectively (ns), reaching a nadir between weeks 3 and 6. The median percentage change in DPD in the Pred and Dex group from week 1 to week 3 was -34% (range -7 to 14) and -53% (range -6 to -69), respectively (ns). By week 8, DPD excretion had started to rise more dramatically in the Pred group such that the median DPD was 35 nmol/l (range 10-53) in the Pred group and 22 (range 9-30) in the Dex group (P < 0.05). On average, between weeks 2 and 8, LLLV was three times lower, percentage gain in weight was three times higher, bALP was 1.3 times lower and DPD was 1.5 times lower in the Dex group than the Pred group.

CONCLUSION

Pred and Dex both affect short-term growth and bone turnover. The mechanism of the effect on bone formation may be different between the two drugs. Dex may be about 18 times more potent than Pred at suppressing short-term linear growth and stimulating weight gain, and about nine times more potent at suppressing bone turnover. Glucocorticoids have a variable effect on different parameters of growth and bone turnover and the intensity may depend on the steroid used.

Altered bone mineral density and body composition, and increased fracture risk in childhood acute lymphoblastic leukemia

OBJECTIVE

To evaluate fracture rate and bone mineral density (BMD) and body composition in children with acute lymphoblastic leukemia (ALL) treated with dexamethasone-based chemotherapy.

STUDY DESIGN

Children with ALL (n = 61) participated. At diagnosis, during therapy, and one year after cessation of therapy, BMD and body composition were measured using dual energy X-ray absorptiometry of lumbar spine (LS) and total body (TB). Serum markers of bone turnover were assessed.

RESULTS

BMD(LS) was significantly reduced at diagnosis, and remained low during therapy. BMD(TB) was normal at diagnosis, with a fast decrease in the first 32 weeks, in which chemotherapy was relatively intensive. Apparent ("volumetric") BMD(LS) was also reduced, but this did not reach significance at diagnosis and follow-up. Bone formation markers were reduced at diagnosis; formation as well as resorption markers increased during treatment. Fracture rate was 6 times higher in ALL patients compared with healthy controls. Lean body mass was decreased at baseline. Percentage of body fat increased significantly during therapy. After ALL treatment was completed, BMD and body composition tended to improve.

CONCLUSIONS

Children with ALL are at risk for osteopenia because of the disease itself and the intensive chemotherapy. Fracture rate increases substantially, not only during but also shortly after treatment.

Relationship between chromosomal changes complexity and disease aggressiveness in myeloid and lymphoid disorders

In this paper are presented four cases, with unusual chromosomal abnormalities, identified at the first presentation, among over 100 patients with myeloid and lymphoid acute and chronic leukemias cytogenetically investigated. The complexity and nature of cytogenetic abnormalities was in direct relationship with the disease evolution. The first case, a 22 years old man with acute lymphoblastic leukemia type L3, exhibited many structural changes in bone marrow cells with diploid number of chromosomes: del(3)(q26); del (5)(p13); t(8;14) (q24;q32); del(9)(p11q11);inv(15)(p12qter). The second case, a 62 years old woman, diagnosed as poorly differentiated acute leukemia, refractory to treatment, showed hiperdiploidy (48-54 chromosomes) and 3-4 markers derived from chromosomes 5 and 12. The third case, a young man of 27 years old, diagnosed as acute myeloid leukemia, apart of Philadelphia chromosome, presented trisomy 16, both in diploid and aneuploid cells. None of these three patients did respond to any medical therapy. Their rapid death was a powerful proof of the correlation between the complexity of genome changes and disease aggressiveness. In the fourth case, a constitutional translocation t(3;5)(q26.3;q21) identified in a 72 years old woman with essential thrombocythemia, appeared not to be involved in the etiology of the disease. In this case, the treatment with hydroxyurea was successful and the disease evolution was favourable. In conclusion, we appreciate that in the three cases of myeloid and lymphoid leukemias it was a direct relationship between the complexity of genomic changes and the aggressiveness of the disease.

Clinical significance of dual color-dual fusion translocation fluorescence in situ hybridization in the detection of bcr/abl fusion gene

OBJECTIVE

To study the expression of bcr/abl hybridized gene in chronic myeloid leukemia (CML), acute lymphatic leukemia (ALL) and polycythemia vera (PV), and its clinical significance.

METHODS

The bcr/abl hybridized gene of interphase metaphase cells of bone marrow in 67 such patients were investigated with a probe of dual color-dual fusion translocation fluorescence in situ hybridization (D-FISH).

RESULTS

In 38 CML patients, 34 (89.5%) were positive, with one having a typical t (9; 22) at first, which changed into negative after having been treated with interferon for 38 months. In another patient, 60 days after post-allogeneic peripheral blood stem cell transplantation (PBSCT), the cytomorphology and cytogenetics were in completely remission. But 3% cells were bcr/abl positive as detected by D-FISH. Six (25%) of 24 ALL patients were positive for Bcr/abl fusion gene, which was negative in 2 PV patients. Three patients suspected of having CML were also negative and one of these three was finally diagnosed as suffering from primary thrombocythemia and one, acute myeloid leukemia (M(2a)) as detected by ETO/AML(1) gene, though the other one was still not confirmed. Two (67%) of the 3 bcr/abl negative CML patients and 5 (87%) of the 6 bcr/abl positive ALL patients had refractory leukemia.

CONCLUSION

bcr/abl hybridized gene is accurately detected by a probe of dual color-dual fusion translocation fluorescence in situ hybridization, which can serve as an effective index for clinical diagnosis, estimation of prognosis and monitor of minimal residual disease in some hematopathies.

Acute biphenotypic leukemia in the adults

OBJECTIVE

To study the clinical, biological features and prognosis of acute biphenotypic leukemia (BAL) in the adults.

METHODS

Bone marrow specimens of 63 BAL patients were evaluated to prove the diagnosis and the classification by morphologic, cytochemical, immunologic and cytogenetic (MIC) examinations. These patients were treated with protocols suitable for acute myeloid leukemia (AML), or acute lymphoblastic leukemia (ALL), or both.

RESULTS

No significant difference in clinical features was observed between BAL, AML or ALL. Morphologically, the subtypes of M(5), M(1) and M(2) were predominant in AML, as L(2) and L(1) were in ALL. Immunologically, coexpression of myeloid and B lineage associated antigens was predominant and CD(34) was hyperexpressed in BAL, which suggested that BAL might originate from malignant transformation of earlier hematopoietic cells. Cytogenetically, Ph chromosome was observed in 25.5% (13/51) of BAL patients. Prognostically, both the treatment response and the overall survival of BAL patients were poor.

CONCLUSION

Patients with BAL have unique clinical, biological and prognostic features.

[Exercise tolerance in patients after acute lymphoblastic leukemia treatment in childhood]

The purpose of the presented study was to define the exercise tolerance in patients after acute lymphoblastic leukemia (ALL) treatment in childhood. Three groups of persons were examined: group A: 20 children, aged 7-19 years (mean 12.4 y), examined immediately after ALL therapy completion, with cumulative anthracycline (ATC) doses administered 155.8-300 mg/m2 and dexrazoxane, as cardioprotectant, group B: 36 patients, aged 12-24 years (mean 15.9), being 3-5 years after ALL treatment, who received ATC in cumulative doses 148.6-416.7 mg/m2, without cardioprotection, group C: 28 healthy volunteers, aged 9-25 years (mean 17.3), as controls. All the examined patients belonged to NYHA functional class I. In all subjects the exercise treadmill test was performed according to modified Bruce protocol. The parameters analysed were: MET--number of metabolic effort units achieved at the test, HRmax--maximal heart rate during exercise, %HRmax--percent of maximal HR for given patient's age achieved during the STdep--depression of ST segment in electrocardiography (ECG) immediately after the maximal exercise. During the exercise members of all 3 groups achieved the required HRmax without serious complaints and ECG abnormalities. Examined persons in group A,B and C presented with effort levels (MET), %HRmax, STdep that did not differ significantly. Only HRmax in groups A and C were higher than that achieved by members of group B.

Male sex and low physical activity are associated with reduced spine bone mineral density in survivors of childhood acute lymphoblastic leukemia

Survivors of acute lymphoblastic leukemia (ALL) are at risk of osteoporosis and obesity. We studied bone mineral density (BMD), percent of fat mass (%FM), and activity levels in survivors of ALL treated without radiotherapy. Lumbar and total areal BMD (g/cm2) and %FM were measured in 28 survivors (aged 5.7-14.7 years) of childhood ALL by dual-energy X-ray absorptiometry (DXA) scan (GE Lunar, Prodigy) an average of 5 years after completion of chemotherapy (UK Medical Research Council randomized trial protocol XI [UKALL XI]). One boy fractured his arm during treatment. Apparent volumetric lumbar BMD (BMD(vol); g/cm3) was calculated and %FM was adjusted for sex and age (%FM(adj)). Physical activity was measured by accelerometer and questionnaire. The results were compared with 28 sex- and age-matched healthy controls. Total body and lumbar areal BMD (g/cm2) were not different between the ALL group and the control group. However, mean lumbar BMD(vol) in survivors of ALL was significantly lower than in controls (0.303 +/- 0.036 g/cm3 vs. 0.323 +/- 0.03 g/cm3; p < 0.01), which mostly was caused by the difference in boys (0.287 +/- 0.032 g/cm3 vs. 0.312 +/- 0.027 g/cm3; p < 0.05). Weekly activity score by questionnaire was significantly lower in the ALL group than in the control group (geometric mean 50 vs. geometric mean 74; p < 0.05). Male gender, low activity levels and an intravenous (iv) high dose of methotrexate were associated with low lumbar BMD(vol). Patients who received an iv high dose of methotrexate (n = 18) had significantly higher %FM(adj) than those with intrathecal methotrexate only (n = 10; 141 +/- 70% vs. 98 +/- 37%;p < 0.05). In conclusion, male survivors of childhood ALL have reduced lumbar BMD(vol), whereas no such difference was seen in girls. Overall, survivors of ALL were physically less active than their healthy controls and lower activity correlated with lower lumbar BMD(vol) and higher %FM(adj).

The nonobese diabetic/severe combined immunodeficient (NOD/SCID) mouse model of childhood acute lymphoblastic leukemia reveals intrinsic differences in biologic characteristics at diagnosis and relapse

Acute lymphoblastic leukemia cells from 19 children, including 7 who remain in first complete remission (CR1), were engrafted into nonobese diabetic/severe combined immunodeficient (NOD/SCID) mice. High-level infiltration of bone marrow, spleen, and liver was observed, with variable infiltration of other organs. The immunophenotypes of xenografts were essentially unaltered compared with the original patient sample. In addition, sequencing of the entire p53 coding region revealed no mutations in 14 of 14 xenografts (10 from patients at diagnosis and 4 at relapse). Cells harvested from the spleens of engrafted mice readily transferred the leukemia to secondary and tertiary recipients. To correlate biologic characteristics of xenografts with clinical and prognostic features of the patients, the rates at which individual leukemia samples engrafted in NOD/SCID mice were analyzed. Differences in biologic correlates were encountered depending on stage of disease: a direct correlation was observed between the rate of engraftment and length of CR1 for samples harvested at relapse (r = 0.96; P =.002), but not diagnosis (r = 0.38; P =.40). In contrast, the in vivo responses of 6 xenografts to vincristine showed a direct correlation (r = 0.96; P =.002) between the length of CR1 and the rate at which the leukemia cell population recovered following vincristine treatment, regardless of whether the xenografts were derived from patients at diagnosis or relapse. This study supports previous findings that the NOD/SCID model of childhood ALL provides an accurate representation of the human disease and indicates that it may be of value to predict relapse and design alternative treatment strategies in a patient-specific manner.

Central nervous system prophylaxis with high-dose methotrexate does not give rise to significant electroencephalographic changes in children with acute lymphoblastic leukemia

Acute, subacute, and chronic neurologic complications have been reported in children treated with high-dose methotrexate for various malignant diseases. It was the aim of this study to monitor central nervous system treatment with high-dose methotrexate in children with acute lymphoblastic leukemia by serial electroencephalographic (EEG) examinations. Electroencephalographic examinations with quantitative computed analysis were performed in 21 children before and on the third day after each of four high-dose methotrexate infusions with leucovorin rescue according to protocol M of trial ALL-BFM 90 of the German Society for Pediatric Haematology and Oncology. Six patients with a medium risk of relapse also received L-asparaginase. In the cohort treated with methotrexate solely, no statistically significant changes of the quantitative EEG parameters could be demonstrated. Only two children with delayed serum methotrexate clearance showed reversible diffuse EEG slowing of a slight to moderate degree. In the group with additional L-asparaginase treatment, slight transient EEG slowing also occurred. Our findings indicate that in patients with a normal methotrexate clearance during central nervous system treatment with high-dose methotrexate according to trial BFM-ALL 90, usually no subacute or cumulative EEG changes have to be expected. If neurologic or psychiatric symptoms or EEG slowing occur, delayed methotrexate clearance must be suspected.

Child clinical/pediatric neuropsychology: some recent advances

The neuropsychological assets and deficits of several types of pediatric neurological disease, disorder, and dysfunction are described. These are examined from the perspective of the syndrome of nonverbal learning disabilities (NLD) and the "white matter model" designed to explain its complex manifestations. It is concluded that children with some of these diseases exhibit the NLD phenotype, whereas others do not. For the most part, the diseases in which the NLD phenotype is particularly evident are those wherein it has been demonstrated that perturbations of white matter (long myelinated fibers) are particularly prominent.

[The relationship between expression of lung resistance-related protein gene or multidrug resistance-associated protein gene and prognosis in newly diagnosed acute leukemia]

OBJECTIVE

To evaluate the relationship between the expression of lung resistance-related protein (lrp) gene or multidrug resistance-associated protein (mrp) gene and prognosis in untreated acute leukemia (AL) patients.

METHODS

Reverse transcriptase-polymerase chain reaction (RT-PCR) was used to examine the expression of lrp and mrp gene in 58 newly diagnosed AL patients.

RESULTS

The positive rate of lrp and mrp gene expression in newly diagnosed acute lymphocytic leukemia (ALL) group was 15.0% and 40.0% and it was 15.8% and 42.1% in newly diagnosed acute nonlymphocytic leukemia (ANLL) group. In both the ALL and ANLL groups, the difference of the first complete remission rate in lrp negative and in lrp positive patients was not significant (P > 0.05), the same results were found with mrp gene. The difference of the first complete remission rate between lrp(+)/mrp(+) and lrp(-)/mrp(-) patients was significant (P < 0.05). There was no relationship between lrp and mrp gene.

CONCLUSION

Neither lrp nor mrp gene as a single indicator to forecast original multidrug resistance is sensitive, but lrp combined with mrp as one indicator will be sensitive.

Forskolin-mediated G1 arrest in acute lymphoblastic leukaemia cells: phosphorylated pRB sequesters E2Fs

Increased intracellular levels of cAMP, induced by forskolin, lead to permanent G1 arrest of Reh cells. As expected, we observed a rapid dephosphorylation of the retinoblastoma protein (pRB) within 2 hours of forskolin treatment concomitant with reduced activity of the pRB-specific kinases. Interestingly, however, the dephosphorylation of pRB, as well as the inhibition of the kinase activities, was only transient, despite the permanent arrest of cells in G1. Importantly, although the pRB-specific kinases were fully active after 48 hours, pRB became only partially rephosphorylated.

The transient dephosphorylation of pRB could be explained by the transient decrease in the activities of the pRB-specific kinases, but to understand why pRB became only partially rephosphorylated, despite fully activated kinases,we postulated that cAMP could activate a pRB-directed phosphatase. It was therefore interesting to find that the phosphatase inhibitor, tautomycin, was able to abolish the forskolin-mediated dephosphorylation of pRB, without increasing the activities of the pRB-specific kinases.

To understand how Reh cells expressing hyperphosphorylated forms of pRB can remain arrested in G1, we used three different methods to test for the ability of pRB to form functional complexes with the family of E2F transcription factors. As expected, we observed an increased complex formation between E2F-1, E2F-4 and pRB after 2 hours when pRB was in its most dephosphorylated state. Suprisingly, however, prolonged treatment with forskolin, which induced partial rephosphorylation of pRB, in fact further increased the complex formation between the E2Fs and pRB, and this also resulted in reduced E2F-promoter activity in vivo. These data imply that in Reh cells, partially phosphorylated forms of pRB retain the ability to inhibit E2F-promoter activity, and thereby prevent cells from entering into S-phase.

Primary cutaneous lymphoblastic lymphoma presenting in an 8-week old infant

BACKGROUND

We report a case of primary cutaneous lymphoblastic lymphoma (LBL) presenting in an 8-week-old infant.

METHODS

Histopathology and flow cytometric analysis confirmed the diagnosis of a lymphoblastic lymphoma. The cells expressed CD19, CD20, CD34 and surface immunoglobulin (sIg).

RESULTS

The cells were negative for TdT and CD99. This unusual immunophenotype has been described as "transitional pre-B-cell", in that the cells express both immature markers (CD34) and mature markers (sIg).

CONCLUSIONS

To our knowledge, only five other cases of sIg positive precursor B-cell LBL have been reported in the literature. This may represent the youngest reported case of primary cutaneous LBL, occurring at 8weeks of age.

Comparison of intramuscular therapy with Erwinia asparaginase and asparaginase Medac: pharmacokinetics, pharmacodynamics, formation of antibodies and influence on the coagulation system

Asparaginase comes from different biological sources and the various preparations have different pharmacokinetic properties, and their tendency to induce side-effects is different. Erwinia asparaginase (ASNase) has a shorter half-life than the Escherichia coli preparations, and it has been reported to be less immunogenic than the E. coli preparations and to induce fewer coagulation disorders. Children with newly diagnosed acute lymphoblastic leukaemia (ALL) were included in this study. Twenty-seven patients were treated with Erwinia ASNase (induction therapy 30.000 IU/m2/d i.m. for 10 d, and re-induction therapy 30.000 IU/m2 twice a week for 2 weeks) and 15 were treated with ASNase Medac (induction therapy 1.000 IU/m2/d i.m. for 10 d, and re-induction therapy 5.000 IU/m2 i.m. twice a week for 2 weeks). Blood samples were drawn to determine enzyme activity, l-asparagine, anti-asparaginase antibodies, and coagulation parameters. After i.m. administration, Erwinia ASNase displayed a protracted absorption phase compared to ASNase Medac. The mean bioavailability after i.m. administration was 27% for Erwinia ASNase and 45% for ASNase Medac respectively. Mean trough enzyme activities during induction therapy were Erwinia ASNase 1748 IU/l and ASNase Medac 272 IU/l, and during re-induction therapy Erwinia ASNase 83 IU/l and ASNase Medac 147 IU/l. We conclude that in this setting, therapy with ASNase Medac resulted in sufficient treatment during both phases of therapy, whereas treatment with Erwinia ASNase resulted in unnecessarily intense therapy during the induction phase and insufficient treatment during the re-induction phase. There was no significant difference in the incidence of antibody formation, and therapy with Erwinia ASNase resulted in a more pronounced influence on the coagulation parameters than therapy with ASNase Medac.

Philadelphia chromosome-positive acute lymphoblastic leukemia in Taiwan

From January 1986 to December 1998, 26 (23%) of 114 acute lymphoblastic leukemia (ALL) patients older than 15 years were found to have Philadelphia (Ph) chromosome. They accounted for 28% (26 of 94) of the patients with B-lineage ALL. Compared with the other 88 ALL patients, the leukemic cells from all but one Ph-positive ALL patients were early pre-B cells with a higher rate of CD34 expression (92% vs 50%, P<0.05). At presentation, the Ph-positive adult ALL patients had higher circulating blasts (mean 21.4 vs 3.66x10(4)/microl, P<0.05) and lower initial platelet counts (mean 4.47 vs 7.34x10(4)/microl, P<0.01) and showed a trend toward higher frequency of initial central nerve system (CNS) involvement (25% vs 11%, P=0.098) than the others. Among patients with adequate chemotherapy, 16 (64%) of the 25 Ph-positive ALL patients achieved complete remission (CR), an incidence marginally lower than that of Ph-negative ALL (62 of 76, 82%, P=0.06) and significantly lower than that of Ph-negative B-lineage ALL (50 of 58, 86%, P=0.0037). However, all patients relapsed except for those who received allogeneic hemopoietic stem cell transplantation (allo-HSCT). The probabilities of 5-year continuous CR and 5-year survival for Ph-positive adult ALL patients were significantly inferior to those for Ph-negative adult ALL patients (0% vs 12%, P=0.0001, and 7% vs 19%, P=0.047, respectively), and those for Ph-negative B-lineage ALL (0% vs 14%, P<0.0001, and 7% vs 23%, P=0.002, respectively). Prognostic factors were analyzed among the Ph-positive ALL patients including the 26 adults mentioned above and an additional 11 children. No clinical or biological characteristics such as age, sex, initial circulating blast count, extramedullary involvement, or CD34 expression had an impact on the disease outcome. Allo-HSCT in first CR may improve the probability of 5-year continuous CR (100% vs. 0% for those without allo-HSCT, P=0.0091) although only three patients received it in this study. In conclusion, Ph-positive ALL patients tended to have a poor prognosis, regardless of whether other possible risk factors were present or not. Aggressive treatment, such as high-dose chemotherapy with allo-HSCT, should be considered for these patients to improve survival.

Oral and dental care in acute lymphoblastic leukaemia: a survey of united kingdom children's cancer study group centres

OBJECTIVES

To examine the provision of oral and dental care for children receiving treatment for acute lymphoblastic leukaemia (ALL) in United Kingdom Children's Cancer Study Group (UKCCSG) centres.

SAMPLE AND METHODS

A postal questionnaire was sent to a named consultant at each centre. All 22 centres responded.

RESULTS

The majority of centres carry out an oral assessment at the time of diagnosis, although various health care professionals are responsible for this. A dentist routinely attends out-patient clinics in only a minority of centres, although the majority have facilities for the provision of dental treatment 'on site'. In the main, children requiring dental treatment are referred to the Hospital Dental Service. Almost a quarter of centres do not have an oral care protocol.

CONCLUSIONS

The development of appropriate dental services at tertiary referral centres should be vigorously pursued.

Hemorrhage in the oculomotor nerve as a complication of leukemia

Oculomotor paralysis of a patient with leukemia was revealed at autopsy to be caused by a hemorrhage in the oculomotor nerve. In a 63-year-old woman with pre-B-cell acute lymphatic leukemia, leukemic invasions occurred in her spinal cord and right oculomotor nerve during a hematological remission state. The oculomotor palsy was aggravated to complete paralysis during a leukemic relapse, which lasted until her death. An autopsy revealed a hemorrhage along with leukemic cells in the right oculomotor nerve at the segment in the upper orbital fissure. Although hemorrhagic oculomotor paralysis is a very rare complication, reports of its occurrence will likely increase with improved survival times of leukemia patients due to advances in chemotherapy.

Expression and localization of the CDC34 ubiquitin-conjugating enzyme in pediatric acute lymphoblastic leukemia

Ubiquitin-dependent protein degradation impacts many cellular processes.However, the regulation of ubiquitin-conjugating enzymes (UBCs) in cancer is unknown. We find that the human CDC34 UBC protein is expressed at a 3-4 fold higher level (P < 0.001) in pediatric T cell than in pre-B-cell acute lymphoblastic leukemia (ALL) before treatment in two independent patient sets. The level of CDC34 mRNA was similar in both types of leukemia. CDC34 expression levels in normal resting T cells, B cells and activated T lymphocytes was comparable with pre-B-cell ALL. CDC34 protein (but not mRNA) was also increased in T-cell ALL compared with pre-B-cell ALL cell lines. The difference in expression was not attributable to mutation or associated with altered CDC34 stability. Immunohistochemistry and cellular fractionation reveals a heterogeneous CDC34 expression pattern including cells containing primarily cytoplasmic or nuclear protein. Thus, a feature of pediatric T-cell ALL is posttranscriptional up-regulation and heterogeneous localization of the human CDC34 UBC.

Effect of glucocorticoid therapy on energy intake in children treated for acute lymphoblastic leukemia

Despite a widespread belief that glucocorticoid therapy is associated with positive energy balance and excess weight gain there is a dearth of quantitative evidence about its effects and the underlying mechanisms of any effects. The primary aim of the present study was to quantify the effect of dexamethasone and prednisone treatment on energy intake in children treated for childhood acute lymphoblastic leukemia. A secondary aim was to test for differences in excess weight gain between patients treated using the 2 glucocorticoids. We measured energy intake in 26 patients (mean +/- SD age, 6.3 +/- 2.3 yr) during a 5-d period "on" steroids and again in the week before steroid treatment. Changes in body mass index from diagnosis to 1 and 2 yr postdiagnosis were expressed as SD scores. Steroid treatment was associated with a significant increase in energy intake of approximately 20% (mean paired difference, 1.7 MJ/d; SD, 2.8; 95% confidence interval, 0.7-2.8 MJ/d), with no significant difference between the 2 steroids. The mean change in body mass index SD score was +0.38 (SD, 1.10; P < 0.05) to 1 yr and +0.68 (SD, 1.38; P < 0.05) to 2 yr, with no significant difference between the 2 groups of patients. Glucocorticoid treatment in childhood acute lymphoblastic leukemia increases energy intake markedly, and this effect contributes to the excess weight gain and obesity characteristic of patients being treated for acute lymphoblastic leukemia.

[Renal function in children after treatment of acute lymphoblastic leukaemia (ALL)]

The aim of the study was to evaluate the renal function (on the basis of serum: cystatin C, creatinine, beta2-microglobulin(B2M) levels, creatinine and cystatin C clearance, and urine osmolality) in 37 children with ALL (acute lymphoblastic leukaemia) after completing intensive treatment (9 in course of maintenance therapy), depending on nephrotoxic antibiotics use (</=3 times vs > 3 times) and methotrexate dose (1.0 g/m2 vs 5g/m2). The control group was formed by 15 healthy children.

RESULTS

1) Serum cystatin C, creatinine, beta2-microglobulin levels creatinine and cystatin C clearance, and urine osmolality were similar in the analysed and control groups. 2) We did not find any differences between the analyzed parameters in the groups of children: a) in maintenance therapy and after the end of the therapy, b) received methotrexate in the dose of 5.0 g/m2 vs 1.0 g/m2, c) not treated children and treated </= 3 times and gt; 3 times with nephrotoxic antibiotics.

CONCLUSION

The renal function is normal after completion of antileukaemic therapy in spite of previous use of nephrotoxic drugs.

Evaluation of the hypothalamic-pituitary-adrenal axis in children with leukemia before and after 6 weeks of high-dose glucocorticoid therapy

Among the adverse effects arising from chronic high-dose glucocorticoid treatment, adrenal insufficiency secondary to suppression of the hypothalamic-pituitary-adrenal (HPA) axis is a cause for concern. Glucocorticoid-induced adrenal suppression is related to the duration of therapy, type of steroid used and dosage, and schedule of glucocorticoid administration. To evaluate the suppression and recovery time of the HPA axis in children with acute leukemia, we performed the ovine CRH (oCRH) stimulation test in 15 patients, who were given high doses of dexamethasone as part of their induction chemotherapy for 42 days. The oCRH tests were performed before, and 7 and 14 days after, discontinuation of the glucocorticoid. The ACTH levels were not significantly different among the 3 tests. The cortisol levels, however, were significantly (albeit mildly) lower, both basally and after oCRH, 1 and 2 weeks post treatment than before therapy. Six patients had cortisol values that remained suppressed 2 weeks after discontinuation of therapy. One of these patients had manifestations of mild adrenal insufficiency, 6-8 days after discontinuation of therapy, but required no glucocorticoid coverage. We conclude that up to 2 weeks after discontinuation of 6 weeks of high-dose dexamethasone administration, the HPA axis of patients with acute leukemia is mildly suppressed but infrequently associated with clinical manifestations of adrenal insufficiency. This may indicate that major stress, when concurrent with glucocorticoid treatment, may prevent clinically significant adrenal suppression.