Extremity reconstruction using the "fillet of sole" flap

Foot skin can be used in traumatic nonreplantable leg amputations as an immediate neurovascular free flap for proximal stump reconstruction. The thick, glabrous skin on the sole of the foot provides durable, sensate coverage. The flap is large, avoids a secondary donor site, and can survive on either the dorsalis pedis or posterior tibial artery if one preserves the connecting deep plantar branch of the dorsalis pedis artery. Two cases of immediate stump reconstruction using the "fillet of sole" flap are presented.

Cyclosporin A in marrow transplantation for leukemia and aplastic anemia

A total of 29 consecutive patients with leukemia or aplastic anemia who received an HLA-identical marrow graft were given cyclosporin A (CyA) to prevent graft-versus-host disease (GvHD). These patients were compared with an historic group of 25 similar patients with leukemia or AA given methotrexate (MTX) for GvHD prophylaxis at this institution. Engraftment was faster in patients given CyA when compared with MTX patients, with less days of granulocytopenia (P = 0.04), a shorter interval before reaching a platelet count of 70 X 10(9)/l (P = 0.04), fewer major infections (P = 0.01), and fewer days on intravenous antibiotics (P = 0.02). There were no graft failures in CyA patients compared with four of 25 in MTX patients (P = 0.01). Early mortality was lower in CyA patients but not significantly (P = 0.06). The incidence of pulmonary complications was comparable, five of 29 and seven of 25 in CyA and MTX patients, respectively, but the clinical features of such complications differed. Interstitial pneumonia developing after day 30 was seen in MTX patients, whereas an acute respiratory distress syndrome developing between day +8 and day +18 was seen in CyA patients. Acute GvHD was less severe in CyA patients (P = 0.04), but chronic GvHD was comparable (P = 0.3). The actual one-year survival is currently 72% and 52% in CyA and MTX patients, respectively (P = 0.1). Although our initial experience with CyA is encouraging with regard to engraftment and acute GvHD, optimization of CyA protocols will probably be needed for it to be proven as having a definite advantage over MTX.

Bone marrow transplantation (BMT) for acute nonlymphoid leukemia (ANLL) in first remission

20 patients with acute nonlymphoid leukemia (ANLL) in first remission were given cyclophosphamide, 120 mg/kg, followed by total body irradiation (TBI) and an HLA-identical allogeneic marrow transplant (BMT). TBI was delivered in a single dose (10 Gy on day -1) in 2 patients, or in fractionated doses (3.3 rad/day on days -3, -2, -1) in 18 patients. The median age of patients was 22 years (range 2-44). Median time from remission to BMT was 5 months (range 1-12). 5 patients died of transplant-related toxicity (graft-versus-host disease with or without interstitial pneumonia) and 15 are alive 7-77 months post-BMT (median 20). The actuarial 72 months survival is 73%. There has been one relapse in a 2-year-old child, 4 months post-BMT, in the marrow and in the testis. The 72-month actuarial disease-free survival is 68%. The actuarial probability of relapse is 7%. This study indicates that a high proportion of ANLL patients treated in first remission with fractionated TBI and allogeneic marrow transplantation can become long-term disease-free survivors.

Fractionated total body irradiation in marrow transplantation for leukaemia

Thirty consecutive patients with leukaemia were prepared for bone marrow transplantation (BMT) with cyclophosphamide (CY) 120 mg/kg followed by total body irradiation (TBI). TBI was delivered in a single dose (sTBI) of 10 Gy, at a dose rate of 0.06-0.08 Gy/min, or in fractionated doses (fTBI) of 3.3 Gy/d, on each of 3 consecutive days, at the same dose rate. Lung shielding was adopted for all patients, in order to obtain a homogeneous dose delivered to the lung and at midline. The first 12 patients were prepared with sTBI and the following 18 with fTBI. Several variables (remission status, mode of irradiation, prevention of graft versus host disease (GvHD) with methotrexate (MTX) or cyclosporin A(CyA) were then analysed for their influence on (a) incidence and mortality of GvHD, (b) incidence and mortality of interstitial pneumonia (IP), (c) 100-d survival, and (d) relapses. Our data suggest that fTBI is the single most important factor associated with a lower incidence of IP (P = 0.002), a lower mortality from GvHD and IP (P = 0.03 and 0.001) and a better 100-d survival (P = 0.03). Remission status had no significant influence on GvHD, IP and acute mortality. When compared to MTX, the use of CyA was associated with less GvHD and IP, but when only patients in remission given fTBI were analysed, this was no longer true. Relapses were mostly influenced by the remission status of the patient at transplant (P = 0.001). Although this is not a randomized study, our data suggest that fTBI can reduce the acute risks of marrow transplantation in leukaemia.

[Acute non-lymphoblastic leukemia in patients treated for Hodgkin's disease. Analysis of 309 cases]

The analysis of 309 Hodgkin patients treated by radiotherapy alone or in association with chemotherapy, between 1969 and 1979, has shown seven cases of ANLL (acute non lymphoblastic leukemia). The incidence was 2.26% in the overall group and 3.38% in the patients treated with combined therapies. From the frequency and distribution of ANLL in the various treatment groups we can argue that: ANLL may be considered as a second, therapy-induced tumor, correlated with the association of chemotherapy and radiotherapy.

High dose bolus methylprednisolone for the treatment of acute graft versus host disease

Nineteen patients with acute graft versus host disease (GvHD) following bone marrow transplantation (BMT) were treated with high dose bolus 6-methylprednisolone (BMPr), at the dose of 20 mg/kg/day i.v. for the first 3 days, 10 mg/kg/day i.v. for the following 4 days, and then at doses gradually tapered down to 1 mg/kg/day. All patients except one, who was given preventive BMPr 5 mg/kg/day i.v. on alternate days, were placed on preventive methotrexate therapy after BMT. Sixteen patients were grafted with an HLA matched, and three patients with an HLA mismatched marrow. Overall complete response rate in the HLA matched group was 43%, with an additional 50% showing a partial response. In the HLA mismatched group there were no responses and all three patients proved refractory to BMPr. With respect to organ involvement the complete and partial response rates were respectively 50% and 33% in the skin, 36% and 28% in the liver, 18% and 55% in the gut. Six of sixteen patients in the HLA matched group and none of the three in the HLA mismatched group are surviving. Thirteen patients died: nine patients for causes directly or indirectly related to GvHD, four of other causes (relapse, rejection, hemorrhage and idiopathic interstitial pneumonia). Side effects of BMPr consisted in hyperglicemia, and steroid associated gastritis in 2/3 of the patients, both of which responded well to conventional treatment. This study indicates that high dose BMPr is an effective form of treatment for established acute GvHD, and has no major side effects. The efficacy of BMPr is less clear in recipients of HLA mismatched grafts.

[Total body irradiation in the preparation of leukemic patients for bone marrow transplantation]

Total body irradiation is today the main conditioning method for patients who have bone marrow transplantation. The most diffuse procedure, as proposed at the Fred Hutchinson Cancer Research Center of Seattle, has been employed in this study. Our clinical material comprises 16 patients; 5 with acute lymphoid leukemia; 5 with acute myeloid leukemia; 4 with chronic myeloid leukemia in accelerated fase; and 2 in blastic crisis. Clinical results and toxicity are discussed, with emphasis to interstitial pneumonia.

[Ewing's sarcoma. Results of treatment in 16 consecutive cases]

In the period January 1974-August 1981, 16 previously untreated cases of Ewing's Sarcoma have been diagnosed at the Giannina Gaslini Children's Hospital Genova. Eight were male, eight female. Median age at diagnosis was 11 years. Two patients presented with a unique metastatic lesion, in the right lung and in an illiac lymph node, respectively. Fourteen patients have been initially treated with local radiotherapy (dosages ranging form 4,800 to 6,600 rads) in association with antiblastic polichemotherapy utilizing 4 drugs (Adriamycin, Actinomycin D, Vincristine, Cyclophosphamide). The Rosen et al.'s T-2 protocol was adopted, modifying the initial phase in order to give more weight to Adriamycin and reduce the toxic effects related to radio-chemotherapy combination. Two patients bearing a costal primary were immediately treated with a more complex and aggressive chemotherapy (T-6 Protocol), followed by local irradiation (in one case preceded by surgical ablation) and then chemotherapy again (T-2 protocol, second phase) for 10 months. Treatment determined a fast subjective relief in the 13 symptomatic patients. All 16 cases achieved a status of complete remission. Four of them subsequently relapsed: locally in two, in distant sites in the remaining 2. All 4 died 12-27 months form diagnosis. Twelve patients are presently alive without evidence of disease at 3-92 months (median 37 months) following diagnosis. Treatment has caused early and delayed toxicity in all cases. However, the entity of these complications varied considerably from one patient to an other. Age at diagnosis and site of primary tumor were the factors most relevant in this respect.

Bone marrow transplantation for severe aplastic anemia. A report of 9 cases

9 patients with severe aplastic anemia (SAA) were treated with bone marrow transplantation (BMT). 5 were conditioned with cyclophosphamide and received and HLA-identical graft (4 patients) or a mismatched graft (1 patient): 1 rejected the graft on day 30 and died on day 34 during conditioning for a second transplant; 1 died on day 15 with acute and severe graft versus host disease (GvHD) in the absence of haemopoietic engraftment; 3 are alive and complete chimeras at 1,069, 490 and 332 days after transplantation. GvHD developed in 4 patients and was treated successfully in 3 with high dose methylprednisolone and/or antilymphocytic globulin (ALG). 4 patients were conditioned with ALG and received bone marrow from a haploidentical sibling or parent: 1 patient was refractory; 3 patients showed evidence of hematologic reconstitution, but 2 of these required a second course of ALG. 3 patients in this group are alive between 60 and 490 days; 1 patient died on day 121 of HBSAg-negative acute hepatitis.

[Radiotherapy of Hodgkin's disease: indications, methodology and clinical observations]

Staging and general management in Hodgkin's disease are reviewed and the radiotherapy technique described. Short-term results with a personal series of 33 cases are reported and early side-effects discussed.