[Premature rupture of membranes at term. Retrospective study of 88 cases]

A retrospective study enabled us to evaluate the "wait-and-see" attitude adopted in our department in case of premature rupture of the membranes at term. The series included 88 patients (9.74%) who delivered spontaneously or after induction. The following maternal parameters were studied:time between rupture and delivery, pyrexia and chorioamnionitis number of vaginal digital examinations, histology and placental bacteriology. Neonatal criteria were based upon an infection assessment. Our results showed that approximately 80% of patients were in labor within 24 hours following rupture. Cesarean section rate remained stable (13%) in comparison with the overall rate for the department. Neonatal infectious morbidity (5.7%) showed no increase. The incidence of chorioamniotitis did not vary (7 cases) but appeared to be related to the number of vaginal examinations before labor. In conclusion, our attitude of temporization did not result in any increase in the number of cesarean sections nor of neonatal infections in comparison with the general population in the department. Prostaglandins might be useful in unfavorable obstetric situations.

Clinical, morphologic, cytogenetic and prognostic implications of CD34 expression in childhood and adult de novo AML

Expression of CD34 by leukemic blasts was analyzed in 230 pediatric and 251 adult patients with de novo AML enrolled in two large multicenter trials (AML-BFM-87 and AMLCG respectively). The association between CD34 positivity and morphological classification according to FAB criteria, cytogenetic aberrations, immunophenotypic features and clinical characteristics was investigated. CD34 was expressed (> or = 20%) by leukemic cells from 45% of childhood and 43% of adult AML patients. CD34+ AML was often associated with M1/M2 morphology as well as the coexpression of CD7 and TdT. Translocation t(8;21), inv(16) and chromosome 5 and 7 aberrations were more frequently observed in CD34+ AML. There was a low frequency of CD34 expression in infant AML but no age dependency was evident in adult patients. CD34 expression exerted no influence on the rate of complete remissions (CR) after intensive multidrug induction therapy. In adults, 56% of the CD34-positive and 64% of CD34-negative cases achieved CR (P = 0.29), and the childhood trial even revealed a slight advantage for CD34+ AML with a CR rate of 80% vs. 71% for CD34-negative cases (P = 0.068). Long-term follow-up disclosed no significant differences in remission duration or event-free survival between the CD34-positive and CD34-negative groups. In conclusion, CD34+ AML patients comprise a heterogeneous group with good as well as poor risk factors. Though characterized by some distinct features, CD34 lacks prognostic significance in de novo AML patients submitted to intensive polychemotherapy.

Seric and local antibodies against a synthetic peptide of HPV16

An ELISA method was used to detect IgG and IgA directed against a synthetic peptide derived from the E2 ORF of the human papillomavirus (HPV) 16 in sera and in cervico-vaginal secretions from 20 women without evidence of HPV infection and from 41 women with histological diagnosis of HPV infection. The proportion of IgA positive sera (63.4% in the case-group vs. 20.0% in the control-group) and secretions (48.8% in the case-group vs. 15.0% in the control-group) was significantly higher in women with HPV infection and seemed to increase with the severity of the cervical lesion. Such a difference was not found for specific IgG. Comparing, for each patient, the antibody level in the serum and in the secretions, we found that the amount of IgA was at mean 2.4 times higher in the sera than in the secretions.

Cervical cancer screening with cervicography and cytology

The results of colposcopy and directed biopsies were compared with the cytological findings and cervicography in 1539 asymptomatic outpatients undergoing routine cervical cancer screening in order to compare the accuracy of cervicography and cytology and to assess the potential benefits of the combination of both screening tests. With the new reporting criteria, cervicography looked less sensitive (53% vs. 56%; P = 0.718) and significantly less specific (97% vs. 98%; P = 0.040) than cytology. In comparison with cytology and at the expense of a recall rate of 9%, the combination of both screening tests and to an increase of the sensitivity (77% vs. 56%; P = 0.013) but also to a decrease of the specificity (95% vs. 98%; P < 0.0001) and of the positive predictive value (44% vs. 60%; P = 0.051). When the original reporting criteria were applied to cervicography, the combination of both screening tests led to optimal sensitivity and negative predictive value (100%, respectively) at the expense of an unrealistic recall rate of 20%. Consequently, cervicography should not be considered as an alternative to cytology for cervical cancer screening since its accuracy is not significantly better and its rate of technically defective tests is significantly higher. The combination of both methods increases the sensitivity of cervical cancer screening at the expense of a high recall rate, of which cost effectiveness has to be assessed.

Osteosarcoma of the trunk treated by multimodal therapy: experience of the Cooperative Osteosarcoma study group (COSS)

The case histories of all patients with osteosarcoma of the trunk entered into the consecutive studies COSS 80 through COSS 86 of the Cooperative German/Austrian Osteosarcoma Study Group (COSS) were analyzed in order to evaluate their clinical characteristics and the impact of modern neoadjuvant therapy on prognosis. They were compared to those of all patients with extremity osteosarcoma treated according to the same protocols. While tumors of the trunk comprised only 32 (4.8%) of 665 primary classical osteosarcomas, secondary osteosarcomas were much more likely to be located in bones of the axial skeleton (6 of 18, 33%). Patients with primary osteosarcoma of the axial skeleton were older (mean: 20.8 vs. 15.2 years, P < 0.01) and were more likely to present with metastases at diagnosis (34% vs 12%, P < 0.001) than those with primary extremity osteosarcoma. In contrast to extremity tumors, local surgical treatment failure was very common in osteosarcomas of the trunk. Complete tumor removal was achieved in less than half of all evaluable cases. The prognosis of eight patients with localized primary axial osteosarcoma and effective surgical local control was not inferior to that of 483 equally evaluable patients with extremity tumors. In conclusion, while secondary systemic spread of axial osteosarcoma may be avoided in patients treated with multiagent chemotherapy, successful treatment is often barred by primary metastatic disease and inability to control the local tumor site.

[HBV-DNA assay by hybridization in solution. Value of low levels measured with the Abbott-Genostics device]

Quantitation of HBV-DNA is the most precise test for measuring viral replication. A commercial liquid phase hybridation test (Abbott) is now commonly used for diagnosis and monitoring of chronic hepatitis B. Interpretation of weak positive results obtained with this test are often difficult. Fifty-four sera with a concentration lower than 12 pg/ml with the Abbott HBV-DNA assay were tested with another commercial hybridation assay (Digene-Murex) and with an in-house PCR test. PCR is positive in 24 sera among the 35 HBs antigen positive sera, but is always negative in HBs Antigene negative sera. All the HBe Antigen positive sera were positive with the PCR test. A positive result was obtained with the Digene test in only 14 sera, 13 of them were confirmed by PCR. Ten sera among the remaining 11 PCR positive sera had a low HBV-DNA concentration but under the Digene cut-off level (10 pg/ml). The sensitivity could be greatly enforced with a lower cut-off level without any lack of specificity. The PCR test remains very helpful for sera with low concentration of HBV-DNA.

[Reducing radiation dosage to 20-30 Gy in combined chemo-/radiotherapy of Hodgkin's disease in childhood. A report of the cooperative DAL-HD-87 therapy study]

The main objective of the multicenter study DAL-HD-87 was to evaluate for the involved-field irradiation a dose reduction by 5 Gy compared with the precursor studies HD-82 and HD-85. Moreover, the decisional strategy for selective laparotomy developed on the basis of retrospective analyses in study HD-82 was to be tested in a prospective design. Chemotherapy in group 1 (stages I, IIA) consisted in 2 OPA cycles (vincristine, prednisone, adriamycin). Group 2 (stages IIEA, IIB, IIIA) received 2 x OPA + 2 x COP(P), and group 3 (stages IIEB, IIIB, IV) 2 x OPPA (with procarbacine) + 4 x COP(P). For the subsequent radiotherapy, doses of 30, 25, and 20 Gy respectively were applied in the 3 groups. Fields with incomplete lymphoma regression were to receive an additional boost of 5-10 Gy. -Exploratory laparotomy was considered indicated in the event of abnormal findings in abdominal CT/ultrasonography and/or enlargement of lymph nodes at the pulmonary hilus.

RESULTS

From Dec. 1986 to Sept. 1990, 204 pts from 51 centres were enrolled in the study. 196 were evaluable. 109 pts (55.6%) were laparotomized, 58 (29.6%) splenectomized. The accuracy for the prediction of an abdominal involvement was 72.3% in case of abnormal findings in abdominal CT/ultrasound but only 36.4% in case of enlarged lymph nodes at the pulmonary hilus without abdominal abnormalities. 91.2% of the removed spleens were proven involved. -2 out of 196 pts suffered progression under treatment, and 22 relapsed (as of 1 Jan, 1994). 6 pts died, 4 of whom succumbed to Hodgkin's disease, and 2 to intercurrent infections. 2 pts in first remission developed a secondary malignancy, namely 1 malignant histiocytoma in radiation field and 1 ANLL. Another patient developed a thyroid carcinoma following salvage therapy for a relapse. The probabilities of event-free survival (EFS) and survival after 7 years are for the total group: 85% and 97%, in group 1: 84% and 99%, in group 2: 82% and 93%, and group 3: 89% and 95%. Comparison with the precursor studies HD-82 and HD-85 reveals that the dose reduction in radiotherapy has not affected the results. Differences in EFS are exclusively correlated with changes in chemotherapy.

Prenatal diagnosis of cystic neuroblastoma

Cystic adrenal masses are unusual in the fetus. The most common diagnosis for adrenal cyst is hemorrhage. We report 2 cases of cystic neuroblastoma diagnosed prenatally by ultrasound. In each case, diagnosis was confirmed in the neonatal period first by scintigraphy, then by histology. Differential diagnosis and management after delivery are discussed.

Hepatitis C: description of a highly sensitive method for clinical detection of viral RNA

To improve the sensitivity of hepatitis C virus RNA (HCV RNA) detection in serum by 'nested' polymerase chain reaction (PCR), primers belonging to 5' non-coding (5'NC) regions were used to compare the classical phenol/chloroform technique by using the proteinase K and silica gel technique with guanidinium thiocyanate. The silica gel techniques was found to be more efficient and sensitive for the extraction and purification of viral RNA from serum samples. The silica gel technique also avoids contact with hazardous volatile chemicals like phenol and chloroform and provides a better protection for viral RNA. Furthermore, the RNA detection sensitivity was greatly improved by modifying the buffer for reverse transcription and PCR. Using silica gel extraction, and the modified buffer, viral RNA was detected in 699 sera from anti-HCV second generation ELISA positive patients. These sera were distributed in second generation RIBA confirmed, indeterminate and non confirmed groups with PCR positive rates of 71.4%, 45.7% and 15.8%, respectively. Two out of 227 ELISA negative patients showed the presence of HCV RNA in serum. An association between the presence of antibodies against a determined viral peptide and viremia was not detected.

Intraperitoneal mitoxantrone as consolidation treatment for patients with ovarian carcinoma in pathologic complete remission

BACKGROUND

Stages II-IV ovarian cancer in pathologic complete remission (pCR) at second-look surgery have a high relapse rate (50%) during the first 2 years. Considering relapse sites (abdomen and/or pelvis), intraperitoneal (IP) therapy is a logical approach. Mitoxantrone is an effective drug against ovarian cancer cells in vitro and is an attractive agent for IP therapy because of its very low peritoneal clearance. The value of IP mitoxantrone was studied as consolidation treatment of ovarian cancer in pCR at second-look surgery.

METHODS

Fifty patients with Stages II-IV ovarian cancer (8, Stage II; 37, Stage III; 5, Stage IV) were included in this Phase II study, which began in June 1988. All patients had undergone initial cytoreductive surgery followed by 6 cyclophosphamide, doxorubicin, and cisplatin cycles. All patients were in pCR, as confirmed by second-look surgery. Consolidation treatment consists of 20 mg (total dose per cycle) IP mitoxantrone every 3 weeks for six cycles.

RESULTS

Toxicity was limited to mild abdominal pain not requiring dose reduction (90% pain grade < or = 2). With a median follow-up of 2 years, the 5-year predicted survival is 59.8% (95% confidence interval [CI], 48.3 - 71.3), and the disease-free survival (DFS) rate is 47.3% (95% CI, 36.7 - 57.9). Patients with no or microscopic residual disease after initial surgery had a better 5-year DFS rate (75.8%) than those with macroscopic residual disease (31.2%) (P = 0.01).

CONCLUSION

IP mitoxantrone (20 mg/cycle) is feasible with an acceptable abdominal toxicity. The results in terms of DFS are encouraging, but a randomized study versus no treatment is necessary to prove the value of this consolidation treatment.

ACTH revisited: effective treatment for acute crystal induced synovitis in patients with multiple medical problems

OBJECTIVE

To determine the effectiveness of adrenocorticotropic hormone (ACTH) for acute gouty arthritis and pseudogout in a population of patients with multiple coexisting medical problems.

METHODS

We retrospectively reviewed our experience with parenteral ACTH 40 or 80 units intravenous, intramuscular, or subcutaneous tid with tapering in the treatment of 38 patients. Thirty-three patients had documented acute gout and 5 patients had documented acute pseudogout. A total of 43 episodes of acute crystal induced synovitis were treated. The indications for using ACTH included congestive heart failure, chronic renal insufficiency, gastrointestinal bleeding, or no response to NSAID:

RESULTS

All episodes of pseudogout resolved in an average of 4.2 days. Of the episodes of acute gout, 97% resolved in an average of 5.5 days. Although mild hypokalemia, hyperglycemia, fluid retention and rebound arthritis occurred as adverse effects, none was severe and all were easily controlled.

CONCLUSION

ACTH is a safe and effective treatment for acute gout and pseudogout, especially in patients with multiple medical problems.

[Cost of acute hepatitis A in adults in France]

OBJECTIVES

Seroprophylaxy against hepatitis A has been limited to subjects visiting endemic areas or in contact with acutely infected patients due to the short half-life and high cost of the non-specific immunoglobulins. Inactivated vaccines might offer a better solution, but the real cost factors remain unknown. We undertook this study to determine the cost of acute hepatitis A.

METHODS

Serum samples from all the non-hospital medical laboratories in the Lyon (France) area were prospectively screened to identify 100 consecutive patients with acute hepatitis (positive for hepatitis A IgM antibodies). A questionnaire was addressed to these 100 subjects 1 year later requesting information on health care expenditures and work loss related to their episode of acute hepatitis A. Imprecise answers were completed by telephone interview.

RESULTS

Answers were obtained from 92 subjects. Confirmation was obtained that the 8 other subjects had not died from their episode of acute hepatitis. Only two patients were hospitalized (for 2 and 4 days). Total mean cost (including medical expenditures and work loss was 11,789 French francs (range 1,524-62,117). Medical consultations and prescriptions comprised 20.0% of the total cost. The real mean cost of work loss (8,423 F) was greater than the cost calculated by the national health service (6,500 F).

CONCLUSIONS

This evaluation of the real cost of hepatitis A in non-hospitalized patients should contribute to the definition of an adapted policy for the prevention of hepatitis A.

Unilateral nephrectomy and cisplatin as risk factors of ifosfamide-induced nephrotoxicity: analysis of 120 patients

PURPOSE

This study was performed to identify risk factors of ifosfamide-induced renal damage.

PATIENTS AND METHODS

Renal function was assessed in 120 patients at a minimum of 3 months after completion of chemotherapy including ifosfamide. The cumulative ifosfamide dose ranged from 2 to 95 g/m2 (median, 30 g/m2). Ten patients had undergone unilateral nephrectomy; combination cytostatic treatment included cisplatin in 51 and methotrexate in 57. Sixty-eight patients had received gentamicin treatment. The glomerular filtration rate was estimated using the Schwartz formula. Proximal tubular function was assessed by the percent reabsorptions of glucose and 16 amino acids, the fractional excretion of sodium, and the fractional reabsorption of phosphate. In addition, the serum bicarbonate level was measured.

RESULTS

Proximal tubular dysfunction--with a predominance of renal amino acid (66.3%) and phosphate loss (38.3%)--was much more frequent than both glomerular impairment and acidosis. Seven patients were identified as having renal Fanconi's syndrome, and generalized tubulopathy was noted in another 15 patients. Ifosfamide-induced nephrotoxicity was dose-dependent, with a weak linear inverse correlation between cumulative ifosfamide dose and fractional phosphate reabsorption. Unilateral nephrectomy proved to be the single most important risk factor (odds ratio for the development of renal Fanconi's syndrome, 11.4), but cisplatin also significantly enhanced ifosfamide-mediated nephrotoxicity. Methotrexate, gentamicin, and patient age at primary diagnosis had no influence on renal function.

CONCLUSION

Ifosfamide chemotherapy should probably be restricted in patients after unilateral nephrectomy.

[Classification of AML by morphologic, immunologic and cytogenetic criteria. Review with reference to subtypes in the AML-BFM-87 study]

The current FAB classification of acute myelogenous leukemia (AML) by morphologic, immunologic and cytogenetic features is described and the incidence of subtypes and variant forms of AML in study AML-BFM-87 is given. In general, lymphoblastic or myeloid blast populations can be identified by morphologic, cytochemical and immunologic parameters, while immunophenotyping facilitates diagnosis in biphenotypic leukemia. Furthermore, the AML subtypes M0 and M7 (defined in 1985 and 1991) can only be ascertained by the presence of lineage-associated markers. Whereas chromosome aberrations provide an insight into the neoplastic process and assure diagnosis. Thus, next to morphologic findings, immunologic and cytogenetic studies are essential for a definite diagnosis of AML.

Synovial sarcoma of childhood and adolescence. Report of the German CWS-81 study

BACKGROUND

Synovial sarcoma is the third most common pediatric soft tissue tumor. It requires an aggressive approach to achieve a cure. However, optimal treatment modalities adapted to disease extension and histologic variants have not been determined because there is little information about prospectively treated patients.

METHODS

A multicenter trial for soft tissue sarcomas (Protocol CWS 81) was conducted in West Germany between 1981-1985, and 31 patients with synovial sarcoma were registered. Treatment included multiagent chemotherapy and irradiation after initial tumor excision or biopsy. The male-female ratio in this group was 1:1.6 with a median age of 14 years (range, 1-19 years). The median follow-up time after diagnosis was 101 months (range, 77-131 months).

RESULTS

The overall event-free survival (EFS) for patients with synovial sarcoma was 74.2% at 5 years. Group I-II tumors had a significantly better prognosis than those in Group III-IV (EFS at 5 years 84.4% and 58.3%, respectively; P = 0.024). Small tumors (< 5 cm) responded better than larger tumors (> or = 5 cm; EFS, 93% versus 58%; P = 0.029). Synovial sarcoma involved the extremities in 28 patients who had a better outcome compared with those with extremity rhabdomyosarcoma in this study (EFS for Group I-IV was 82% versus 24%, P = 0.001).

CONCLUSIONS

The results appeared superior to previous experience using radical surgery alone and suggested that after initial, nonmutilating surgery, adjuvant chemotherapy, and irradiation contributed to the improved long-term survival.

Prognostic implication of immunodetection of P glycoprotein in Ewing's sarcoma

Increased expression of P glycoprotein is associated with multidrug resistance in many cell lines. P glycoprotein has been detected in different human tumors. To assess the implication of multidrug resistance in the prognosis of Ewing's sarcoma the expression of P glycoprotein was studied immunohistochemically in pre- and post-therapeutic tumor tissues of 21 cases treated according to the CESS 81 or 86 protocol. The response to chemotherapy was evaluated histologically. Formalin-fixed, paraffin-embedded and fresh frozen sections were immunostained with a monoclonal antibody to P glycoprotein, clone JSB 1, using the double APAAP method. P glycoprotein was detected in 12 cases of 21 (57%) in either pre- or postchemotherapy tumor tissues. From the 21 cases 8 revealed a good morphological response to chemotherapy (33%); 10 of the 13 non-responders were positive for P glycoprotein (77%), but only 2 of the 8 responders (25%). The difference was statistically significant (P < 0.05). Comparing P glycoprotein expression with the clinical outcome, we found that 7 of 12 positive cases had died (58%). From the negative cases only 3 of 9 had died (33%). However, judged by the Kaplan Meyer life tables, these data were not significant. In conclusion our results suggest that the immunodetection of P glycoprotein indicates a poor response to chemotherapy and probably a bad clinical outcome for Ewing's sarcoma patients.

Does cranial irradiation reduce the risk for bone marrow relapse in acute myelogenous leukemia? Unexpected results of the Childhood Acute Myelogenous Leukemia Study BFM-87

PURPOSE

One of the goals of study AMA-BFM-87 was to test prospectively in acute myelogenous leukemia (AML) patients if cranial irradiation could be replaced by late intensification therapy with high-dose cytarabine (Ara-C) and etoposide (VP-16).

PATIENTS AND METHODS

Patients with a low risk of CNS relapses (ie, no initial CNS disease, WBC count at diagnosis < or = 70.000/microL) were randomized for irradiation (group A, 31 patients). In 25 patients (group B), randomization was refused. As interim results showed no increase of CNS relapses in nonirradiated patients, prophylactic irradiation was discontinued after 2 1/2 years to prevent unnecessary CNS toxicity. Forty-four patients (group C) entered the study after randomization had been stopped.

RESULTS

In all patients with a low risk of CNS recurrences (n = 100), a significantly higher probability of relapse-free interval (pRFI) of 5 years was found in irradiated patients (pRFI = .78) compared with nonirradiated patients (pRFI = .41) (P = .007). Moreover, a slightly higher incidence of CNS relapses was observed in nonirradiated patients. Due to the small number of patients, this was not observed when randomized patients only were analyzed. In accordance with these findings, the favorable outcome of low-risk patients in the preceding study, AML-BFM-83 (pRFI > .80), could only be reproduced in study AML-BFM-87 in patients who had received cranial irradiation.

CONCLUSION

These results indicate that cranial irradiation should be an integral part of the treatment of all AML patients not undergoing bone marrow transplantation. Residual blasts in the CNS may escape systemic chemotherapy and lead to recurrence of the initial disease not only in the CNS, but also in the bone marrow.

Superior prognosis in combined compared to isolated bone marrow relapses in salvage therapy of childhood acute lymphoblastic leukemia

Three hundred twenty-six children with bone marrow (BM) relapse of non-B acute lymphoblastic leukemia (ALL) were stratified according to the time of relapse in three consecutive multicenter trials--ALL-REZ BFM 83, 85, and 87. Employing an intensive polychemotherapy regimen, extramedullary involvement appeared to be predictive of superior outcome in both strata as well as in the whole group (probability of 7-year event-free survival (EFS) 42% in combined vs. 15% in isolated BM relapse, P = 0.015). Children with combined BM relapse occurring later than 6 months after completion of front-line therapy reached EFS estimates of 60%. We conclude that results of conventional polychemotherapy with BFM relapse protocols are equivalent to those achieved by bone marrow transplantation in children with late combined BM relapse.

Development of hypertension in neuroblastoma during therapy: a case report

A case of stage 4 neuroblastoma that developed excessive hypertension on day 120 of chemotherapy is presented. The tumor initially had responded well to chemotherapy; however, while the tumor mass decreased, plasma and urine catecholamines and the blood pressure increased. The plasma concentrations of noradrenaline, adrenaline, and dopamine increased to 26.4, 1.8, and 36.2 micrograms/l, respectively. The profile of catecholamine metabolites changed: on day 150 of therapy, noradrenaline, adrenaline, and dopamine levels were increased, whereas HVA and VMA levels were decreased when compared to day 1 of therapy. The only residual neuroblastoma tissue visible on MIBG scintigraphy on day 150 of treatment was a metastasis in the left tibia which was irradiated with 24 Gy. The adrenaline concentration in the left femoral vein was twice as high compared to the right femoral vein. A treatment, possibly radiation-associated tumor cell alteration resulting in a different catecholamine production, is discussed.