Leukemias, myeloma, and other lymphoreticular neoplasms

Safety and Efficacy of Bendamustine and Rituximab (BR) Regimen in Indian Chronic Lymphocytic Leukaemia Patients

We investigated the safety and efficacy of bendamustine-rituximab (BR) in previously untreated symptomatic and advanced CLL patients, as there is no data available on BR from the Indian subcontinent.This retrospective study included 120 consecutive treatment naïve patients with CLL without del (17p), who were registered at the Department of Medical Oncology, AIIMS between January 2010 and July 2018. Bendamustine was given at a dose of 90 mg/m2 on days 1 and 2, combined with rituximab 375 mg/m2 rituximab on day 1, every 28 days for up to 6 courses. Event-free survival (EFS) was defined as the date of treatment to date of relapse, disease progression, or death due to any cause.The median age was 57 years (range: 30-75 years). As per the clinical Rai stage, 30 (25%) patients were in stage II, 42 (35%) were in stage III and 48 (40%) were in stage IV. ZAP70 was positive (> 20%) in 50%, CD 38 was positive (> 30%) in 33%, and CD49d was positive (> 30%) in 49% of cases. Beta-2 microglobulin (B2M) was elevated (≥ 3.5 mg/L) in 80% of cases. Fifty-five cases (50%, n = 110) were IGHV mutated. The mean number of cycles was 5 (1-6). The overall response rate (ORR) seen with BR was 90% and complete response was 45%. Median progression-free survival was 24 months with a median follow-up period of 29 months. Haemoglobin (< 10 g/dL), elevated B2 M, unmutated IGHV had a statistically significant adverse impact on EFS on univariate analysis but on multivariate analysis, only IGHV mutation status was found to had significance on EFS. The median EFS was 27 months in IGHV mutated versus 18 months in IGHV unmutated-CLL patients (p = 0.001). Grade 3/4 neutropenia, thrombocytopenia, anemia, and infections were observed in 30.6%, 8%, and 12% respectively. The most common non-hematological toxicity was skin rash which was grade 1/2 in 24 (20%) cases and grade 3/4 in 12 (10%) cases. This is the largest study from India to demonstrate the safety and efficacy of BR in symptomatic CLL patients. BR is an effective and safe regimen in the first-line treatment of CLL. Unmutated-CLL patients have inferior EFS than mutated-CLL patients. Skin toxicity was the most common adverse effect seen in our population which was observed in around one-third of cases.

Trends in Disease Burden of Chronic Lymphocytic Leukemia at the Global, Regional, and National Levels From 1990 to 2019, and Projections Until 2030: A Population-Based Epidemiologic Study

Background

The prognosis of chronic lymphocytic leukemia (CLL) has been improved dramatically, but there are limited studies focusing on CLL disease burden on a global scale. We aimed to evaluate the accurate assessment of the disease burden of CLL that may provide more detailed epidemiological information for rational policies.

Methods

The main source of the data was the Global Burden of Disease (GBD) study 2019. Incident cases, death cases, disability-adjusted life years (DALYs), and their corresponding age-standardized rates (ASRs) from 1990 to 2019 were used to describe the burden of CLL. Data about attributable risk factors were also extracted and analyzed. Bayesian age-period-cohort (BAPC) models were used to assess and project the incidence and mortality rates till 2030.

Results

Globally, the incidence of CLL had been increasing. Deaths and DALYs decreased slightly. The burden of death and DALY is affected by socio-demographic index (SDI). The incidence rate, death rate, and DALY rate of CLL increased significantly with age. Male-to-female ratios of incidence rates varied in different SDI quintiles. Smoking, high body mass index, and occupational exposure to benzene or formaldehyde were the potential risk factors related to CLL. Global ASIRs might tend to increase until 2030, while ASDR would decrease until 2030.

Conclusion

The disease burden of CLL decreased in higher SDI countries but increased in lower ones. Strategies for early detection of asymptomatic CLL, development of novel drugs, and measures against attributable factors should be implemented to combat CLL burden.

Atypical Mycobacterium Abscessus Infection in Stable Chronic Lymphocytic Leukemia: A Case Report and Review of the Literature

Chronic lymphocytic leukemia is the most common blood cancer in adults. A major cause of morbidity and mortality associated with this cancer stems from opportunistic infections. Similar to many cancers, the inherent effects of battling a raging disease along with the many treatment options causing immunosuppression to lend to the likelihood of obtaining secondary infections.

As it is important for physicians to note the ever-increasing secondary complications, which can manifest in the long-term management of immunosuppressed patients, we present a case of an 86-year-old Caucasian female with stable chronic lymphocytic leukemia who developed intermittent presentation of lung abscesses due to growth of atypical Mycobacterium species. With the advent of new treatment options, there has been an increased rate of drug-resistant organisms, lending for the need for more awareness to the severity of these secondary complications and for better options in preventing their occurrence.

A Needle in the Haystack: A Rare Case of Spontaneous Tumor Lysis in Newly Diagnosed Chronic Lymphocytic Leukemia Unmasked by Acute Renal Failure

Tumor lysis syndrome (TLS) is the phenomenon of metabolic derangements that typically follows the initiation of cytotoxic chemotherapy. Metabolic disturbances include hyperphosphatemia, hyperkalemia, hyperuricemia and hypocalcemia. Hematological malignancies are associated with spontaneous TLS (STLS), which is cell lysis in the absence of chemotherapy. STLS is extremely rare in chronic lymphocytic leukemia (CLL). This has been documented only once in the medical literature, making this an extraordinarily uncommon case. We present here a 68-year-old male with a history of benign prostatic hyperplasia (BPH) who is admitted for a two-week history of abdominal pain and three days of anuria, despite adequate fluid intake. Laboratory values yielded a greatly elevated leukocyte count with a lymphocytic predominance and smudge cells. Potassium, phosphorus, and uric acid were also significantly increased. EKG revealed peaked T-waves. Flow cytometry confirmed the presence of an abnormal B-cell population consistent with B-cell chronic lymphocytic leukemia, with the following markers: CD19+, CD20+, CD23+, CD5+, CD10-. He was diagnosed with CLL and treated with aggressive fluid resuscitation, allopurinol and rasburicase. The patient had another similar episode within one month. His CLL fluorescence in-situ hybridization (FISH) showed complex cytogenetics with unmutated IgVH and he was subsequently started on ibrutinib.

A Patient with Chronic Lymphocytic Leukemia with Pancreatic Involvement

A 78-year-old female with a past medical history of hypertension, type 2 diabetes mellitus, and chronic lymphocytic leukemia was hospitalized for poor appetite, weight loss, and night sweats. On physical exam, there was no palpable lymphadenopathy, and her abdomen was soft and nondistended. Laboratory results showed a hemoglobin count of 13.3 g/dl, hematocrit 41.3%, white blood cell 68.4 × 103 μL with lymphocytes 92.0%, total bilirubin 0.4 mg/dL, aspartate transaminase 14 U/L, and alanine transaminase 15 U/L. CT of the chest, abdomen, and pelvis showed hypodense lesions within the pancreatic body (1.4 × 1.4 cm) and medial aspect of the pancreatic head (1.2 cm) as well as mild splenomegaly (13 cm craniocaudally). She subsequently underwent endoscopic ultrasound (EUS) with fine needle aspiration (FNA) of the pancreatic mass. Flow cytometry revealed expression of CD5 and CD23, consistent with chronic lymphocytic leukemia.

Dielectrophoresis-based microfluidic platforms for cancer diagnostics

The recent advancement of dielectrophoresis (DEP)-enabled microfluidic platforms is opening new opportunities for potential use in cancer disease diagnostics. DEP is advantageous because of its specificity, low cost, small sample volume requirement, and tuneable property for microfluidic platforms. These intrinsic advantages have made it especially suitable for developing microfluidic cancer diagnostic platforms. This review focuses on a comprehensive analysis of the recent developments of DEP enabled microfluidic platforms sorted according to the target cancer cell. Each study is critically analyzed, and the features of each platform, the performance, added functionality for clinical use, and the types of samples, used are discussed. We address the novelty of the techniques, strategies, and design configuration used in improving on existing technologies or previous studies. A summary of comparing the developmental extent of each study is made, and we conclude with a treatment of future trends and a brief summary.

Obinutuzumab for the treatment of chronic lymphocytic leukemia and other B-cell lymphoproliferative disorders

INTRODUCTION

Chemoimmunotherapeutic regimens using the anti-CD20 antibody rituximab improved significantly the survival rates in various B-cell lymphoproliferative disorders (LPDs), including chronic lymphocytic leukemia (CLL). The next-generation CD20 antibody obinutuzumab represents an addition to the drug armamentarium used for the therapeutic management of patients with LPDs. Areas covered: Herein, the authors discuss the biochemical and conformational engineering of obinutuzumab to increase antibody-dependent cell-mediated cytotoxicity and direct cell death. They also describe the available preclinical data on obinutuzumab's role in B-cell LPDs. Furthermore, the authors summarize the Phase I and II clinical trials of obinutuzumab, focusing on the main pharmacokinetic/pharmacodynamic characteristics, the most common clinically significant adverse events, dose optimization, and clinical outcomes of patients with CLL and other B-cell LPDs treated with obinutuzumab as monotherapy or in combination with other agents. To put these data in perspective, the use of obinutuzumab is compared with that of rituximab in CLL and other B-cell LPDs. Expert opinion: Clinical trials have demonstrated that obinutuzumab is well tolerated. The novel mechanism of action of obinutuzumab is associated with significant efficacy in CLL and other B-cell LPDs. Ongoing clinical trials are expected to determine the optimal use of obinutuzumab in these diseases.

Duvelisib: a phosphoinositide-3 kinase δ/γ inhibitor for chronic lymphocytic leukemia

INTRODUCTION

Frontline chemotherapy is successful against chronic lymphocytic leukemia (CLL), but results in untoward toxicity. Further, prognostic factors, cytogenetic anomalies, and compensatory cellular signaling lead to therapy resistance or disease relapse. Therefore, for the past few years, development of targeted therapies is on the rise. PI3K is a major player in the B-cell receptor (BCR) signaling axis, which is critical for the survival and maintenance of B cells. Duvelisib, a PI3K δ/γ dual isoform specific inhibitor that induces apoptosis and reduces cytokine and chemokine levels in vitro, holds promise for CLL. Areas covered: Herein, we review PI3K isoforms and their inhibitors in general, and duvelisib in particular; examine literature on preclinical investigations, pharmacokinetics and clinical studies of duvelisib either as single agent or in combination, for patients with CLL and other lymphoid malignancies. Expert opinion: Duvelisib targets the PI3K δ isoform, which is necessary for cell proliferation and survival, and γ isoform, which is critical for cytokine signaling and pro-inflammatory responses from the microenvironment. In phase I clinical trials, duvelisib as a single agent showed promise for CLL and other lymphoid malignancies. Phase II and III trials of duvelisib alone or in combination with other agents are ongoing.

Watch and Wait in Lebanese Chronic Lymphocytic Leukemia Patients: How Relevant is it?

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most frequent form of leukemia in Europe and North America, and it mainly affects older individuals. Many approaches are implemented in the management of CLL from a watch and wait (WandW) strategy to chemotherapeutic regimens. We here reviewed our clinical practice for the relevance of the W and W strategy in Lebanese CLL patients.

MATERIALS AND METHODS

A total of 95 patients with CLL diagnosed in four institutions in Lebanon, between 1992 and 2013, were selected and their files were reviewed. Characteristics of these patients were noted including age, sex, RAI and Binet scores, CBC values, presence of hepatomegaly or splenomegaly, performance of bone marrow biopsy or peripheral blood flux cytometry for diagnosis, adoption of W and W strategy, different chemotherapeutic regimens and the indications for treatment.

RESULTS

Some 38 patients (40%) diagnosed with CLL were women and 57 (60%) were men with a mean age of 65.1 years [36-89]. Of the total, 50.5%, 17.2%, 14%, 7.5% and 10.8% had an RAI score at diagnosis of 0, 1, 2, 3 and 4, respectively, while 65.6%, 17.2% and 17.2% had Binet scores of I, II and III. The mean lymphocyte count at diagnosis was 39885/mm3 [1596-290000], the mean hemoglobin level was 12.7 g/dl [6.2-17] and the mean platelet count was 191255/mm3 [14000-458000]. While 26.3% of patients with CLL had splenomegaly, only 7.4% had hepatomegaly. Some 33.7% had undergone a bone marrow biopsy, 66.3% flow cytometry of circulating blood and 5.3% a lymph node biopsy. Overall, the W and W was adopted in 62.4% (58) of patients with a mean duration of 37.7 months [3-216]. The W and W was used in 82.6%, 73.3%, 46.2%, 14.3% and 0% of patients having RAI scores of 0, 1, 2, 3 and 4, respectively, and, it was used in 80%, 46.7% and 6.25% with Binet scores of I, II and III. The most frequent indication for treatment was anemia and thrombocytopenia, accounting for 32.7% of cases. The most frequently used chemotherapeutical regimens were chlorambucil until the end of the last century and flufarabine-cyclophosphamide-rituximab during the last decade.

CONCLUSIONS

This retrospective review of CLL clinical practice showed an important implementation of the W and W strategy with a long duration, especially in early stage cases with low RAI or Binet scores.

Combined chronic lymphocytic leukemia and prolactinoma: a rare occurrence in a patient presenting with pituitary apoplexy

The authors describe a rare case of combined pituitary chronic lymphocytic leukemia (CLL) and prolactinoma in a 77-year-old man presenting with apoplexy. This case highlights the importance of evaluating the pituitary gland in patients with CLL who present with clinical manifestations of apoplexy as well as the need to carefully evaluate pathological specimens from the gland for the presence of lymphocytic cells in those patients. This is the first reported case of a combined CLL-prolactinoma pituitary lesion presenting with apoplexy.

Novel agents for chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is a heterogeneous group of B-cell neoplasm. CLL is typically sensitive to a variety of cytotoxic agents, but relapse frequently occurs with conventional approaches. The treatment of CLL is evolving rapidly with the introduction of novel drugs, such as bendamustine, ofatumumab, lenalidomide, ibrutinib, idelalisib, veltuzumab, XmAb5574, navitoclax, dasatinib, alvespimycin, and TRU-016. This review summarizes the most current clinical experiences with these agents in the treatment of CLL.

Evaluation of seasonality in the diagnosis of acute myeloid leukaemia among adults in the United States, 1992-2008

Recent studies have suggested seasonal variation in the diagnosis of acute myeloid leukaemia (AML), and the aetiological role seasonal factors may play in this group of haematological neoplasms remains unclear. We evaluated potential seasonality of AML diagnosis among adults. Cases included were ascertained from the Surveillance, Epidemiology, and End Results (SEER) 13 registries from 1992-2008. Chi-square analysis for heterogeneity and multiple Poisson regression using parametric harmonic modelling and bootstrap testing were used to detect possible monthly variation. Months of peak diagnoses were December and January, although some variation was present by sex and age. Heterogeneity across months was statistically significant (P < 0·001). In stratified analyses, monthly variation was detected only among males (P = 0·009) and in cases aged 65 years and older (P = 0·031). Poisson regression found no seasonal effect among all cases when fit to the sinusoidal model (P = 0·110). However, similar variation among males (P = 0·009) and cases aged 65 years and older (P = 0·018) was present. There is growing evidence of seasonality in AML diagnosis, particularly among older persons and men. Investigation of specific seasonal risk factors would be informative in explaining the aetiology behind the observed variation.

A case of chronic lymphocytic leukemia with massive ascites

An 81-year old woman with a history of chronic lymphocytic leukemia (CLL) was admitted with night sweats and abdominal distension. A complete blood count showed hemoglobin 5 g/dL, white blood cell (WBC) count 28.5×10(9)/L and platelets 38.4×10(9)/L. Peripheral blood smear examination showed a large number of smudge cells and lymphocytosis composed of mature-looking lymphocytes with clumped nuclear chromatin. Computed tomography scan demonstrated enlarged cervical, axillary, paraaortic, retroperitoneal and mesenteric lymph nodes with concomitant omental thickening and ascites. Also, the liver and the spleen were enlarged in the presence of multiple ill-defined hypoechoic areas in the latter. Histopathological analysis of the cervical lymph node biopsy was consistent with CLL. Bone marrow examination showed diffuse infiltration of the marrow with small lymphocytes. Analysis of the ascitic fluid revealed an exudate with WBC 1220 cells/mL. Cytocentrifuge preparation of the ascitic fluid showed small mature lymphoid cells containing hyperchromatic nuclei with coarsely granular chromatin. On flow cytometric analysis of the ascitic fluid, expression of CD5, CD19, CD20, CD22, CD23, CD45 and HLA-DR was compatible with a diagnosis of CLL, in accordance with the results of the peripheral blood analysis. The patient was treated with chemotherapy consisting of cyclophosphamide, vincristine and prednisolone but died within one month after development of non-chylous ascites.

Cancer incidence among adolescents and young adults in urban Shanghai, 1973-2005

BACKGROUND

Lack of cancer incidence information for adolescents and young adults led us to describe incidence trends within the young population of 15 to 49 year-olds in urban Shanghai between 1973 and 2005.

METHODS

During 1973 to 2005, data on 43,009 (45.8%) male and 50,828 (54.2%) female cancer cases aged 15-49 years from the Shanghai Cancer Registry were analyzed. Five-year age-specific rates, world age-standardized rates, percent change (PC), and annual percent change (APC) were calculated using annual data on population size and its estimated age structure.

RESULTS

During the 33-year study period, overall cancer incidence of adolescents and young adults among males marginally decreased by 0.5% per year (P<0.05). However, overall cancer incidence for females slightly increased by 0.8% per year (P<0.05). The leading cancer for males in rank were liver, stomach, lung, colorectal, and nasopharyngeal cancers and for females were breast, stomach, colorectal, thyroid, and ovarian cancers. Among specific sites, incidence rates significantly decreased for cancers of the esophagus, stomach, and liver in both sexes. In contrast, incidence rates significantly increased for kidney cancers, non-Hodgkin lymphoma, and brain and nervous system tumors in both sexes and increased for breast and ovarian cancers among females.

CONCLUSIONS

Overall cancer incidence rates of adolescents and young adults decreased in males whereas they increased in females. Our findings suggest the importance of further epidemiology and etiologic studies to further elucidate factors contributing to the cancer incidence trends of adolescents and young adults in China.

Cost-effectiveness of adding rituximab to fludarabine and cyclophosphamide for the treatment of previously untreated chronic lymphocytic leukemia

A recent phase III trial demonstrated improved progression-free survival (PFS) and overall survival (OS) associated with adding rituximab to fludarabine and cyclophosphamide (R-FC) compared to FC in treatment of previously untreated chronic lymphocytic leukemia (CLL). A cost-effectiveness analysis of R-FC over FC was performed from a US third-party payer perspective over a lifetime horizon in the base case. One-way, two-way and probabilistic sensitivity analyses were conducted to assess the robustness of the results. A secondary analysis was performed by also considering a societal perspective. R-FC was associated with an incremental 1.15 quality-adjusted life-years (QALYs) compared to FC and resulted in an incremental cost-effectiveness ratio of $23 530 per QALY in the base case and $31 513 per QALY considering a societal perspective. Results were most sensitive to time horizon, discount rate and unit drug cost for rituximab. Within the limitations of modeling long-term outcomes, R-FC is cost-effective for previously untreated CLL.

Recombinant antibodies encoded by IGHV1-69 react with pUL32, a phosphoprotein of cytomegalovirus and B-cell superantigen

Leukemia cells from patients with chronic lymphocytic leukemia (CLL) express a highly restricted immunoglobulin heavy variable chain (IGHV) repertoire, suggesting that a limited set of antigens reacts with leukemic cells. Here, we evaluated the reactivity of a panel of different CLL recombinant antibodies (rAbs) encoded by the most commonly expressed IGHV genes with a panel of selected viral and bacterial pathogens. Six different CLL rAbs encoded by IGHV1-69 or IGHV3-21, but not a CLL rAb encoded by IGHV4-39 genes, reacted with a single protein of human cytomegalovirus (CMV). The CMV protein was identified as the large structural phosphoprotein pUL32. In contrast, none of the CLL rAbs bound to any other structure of CMV, adenovirus serotype 2, Salmonella enterica serovar Typhimurium, or of cells used for propagation of these microorganisms. Monoclonal antibodies or humanized rAbs of irrelevant specificity to pUL32 did not react with any of the proteins present in the different lysates. Still, rAbs encoded by a germ line IGHV1-69 51p1 allele from CMV-seropositive and -negative adults also reacted with pUL32. The observed reactivity of multiple different CLL rAbs and natural antibodies from CMV-seronegative adults with pUL32 is consistent with the properties of a superantigen.

NF-kappaB as a prognostic marker and therapeutic target in chronic lymphocytic leukemia

Chronic lymphocytic leukemia is the most common adult leukemia and is currently incurable with conventional chemotherapeutic agents. Over the last few years, significant discoveries have been made regarding the biology that underpins this disease. These new insights have allowed us to develop more rational prognostic tools and identify promising novel therapeutic targets. In this review, we highlight the importance of both constitutive and inducible DNA binding of the transcription factor NF-kappaB in chronic lymphocytic leukemia. We describe the current knowledge regarding the activity and function of specific NF-kappaB subunits in this disease, and discuss the complex mechanisms that regulate NF-kappaB activation in vivo. In addition, we provide compelling evidence for the utility of the NF-kappaB subunit, Rel A, as a prognostic marker and as a therapeutic target in this disease, and we also describe how this protein may contribute to the drug resistance commonly encountered with this condition.

Comparison of two regimens for the treatment of elderly patients with acute lymphoblastic leukaemia (ALL)

Acute lymphoblastic leukemia (ALL) represents a rare malignancy in the elderly and few authors have specifically focused on the treatment of ALL in this setting. We recently published the results of a prospective phase II study comprising an induction therapy with vincristine, Daunoxome and dexamethasone (VDXD) given to 15 patients aged 60 years. Here, we update the results after enrolling 17 patients, and we compare these with the results obtained in 17 elderly patients treated according to the GIMEMA ALL 0288 protocol. With the VDXD combination, elderly ALL had a higher CR rate (76.5%) than with the 0288 protocol (41%), and it was likely due to both lower induction mortality (17.5% vs. 35%) and a less resistant disease (6% vs. 24%). Infectious complications were more frequent with the VDXD combination whereas non-hematological side effects were comparable. Despite the similar DFS obtained with the two induction treatments, median EFS (3.9 months with 0288 vs. 12.8 with VDXD; p = 0.0486) and OS (4.5 vs. 21 months; p = 0.0239) were significantly higher with the VDXD regimen. In elderly ALL patients the administration of high-dose daunorubicin as a liposomal compound is feasible and seems able to improve CR rate, EFS and OS without increase in toxicity.

Relative seroprevalence of human herpes viruses in patients with chronic lymphocytic leukaemia

BACKGROUND

Herpes virus infections may have a significant role in chronic lymphocytic leukaemia (CLL) due to their ability to modulate the host's immune system.

MATERIALS AND METHODS

We examined the seroprevalence of four herpes viruses [Cytomegalovirus (CMV), Epstein-Barr Virus (EBV), human herpes virus (HHV)-6 and -7] in a cohort of European CLL patients (cohort 1, n = 100) in relation to the immunoglobulin variable heavy (IGHV) chain gene use and compared serological results with those obtained from age- and gender-matched healthy adults (n = 100).

RESULTS

CMV-seroprevalence was significantly higher in CLL cohort 1 (79%) than in the control cohort (57%, P = 0.001); the seroprevalence of EBV (89% vs. 94%), HHV-6 (73% vs. 60%), or HHV-7 (35% vs. 35%) was not. In CLL cohort 1, use of IGHV3-30 was more prevalent among CMV-seropositive and of IGHV3-21 among HHV-7-seronegative cases. To investigate the generalizability of these findings, we investigated the herpes virus seroprevalence in a second cohort of age-matched CLL patients from a different geographical area (USA, n = 100, cohort 2). In cohort 2, CMV-seroprevalence was comparable with that of the control cohort (53%). Seroprevalence of EBV, HHV-6 and HHV-7 were 85%, 88% and 73% respectively. In CLL cohort 2, use of IGHV3-30 or IGHV3-21 was not associated with any of the herpes viruses investigated.

CONCLUSIONS

CMV-seropositivity is associated with CLL in selected patient cohorts. However, the considerable variation in herpes virus-specific seropositivity between geographically distinct CLL cohorts indicates that seropositivity for any of the four human herpes viruses investigated is not generally associated with CLL.

Immunohistochemistry for human concentrative nucleoside transporter 3 protein predicts fludarabine sensitivity in chronic lymphocytic leukemia

Fludarabine (F-ara-A) is widely used as palliative treatment in chronic lymphocytic leukemia (CLL). Clinical resistance is frequently observed, and adverse effects are common. To date, no practical assay exists to identify patients likely to derive benefit from F-ara-A. We previously reported that high mRNA levels encoding human concentrative nucleoside transporter 3 (hCNT3) protein in CLL correlated with clinical resistance to F-ara-A. This study explores the value of immunohistochemistry (IHC) for hCNT3 as a marker of F-ara-A resistance in CLL. We studied 36 CLL patients who received F-ara-A monotherapy and had suitable pre-F-ara-A tissue available. IHC was performed with validated hCNT3-specific monoclonal antibodies and quantitatively scored by a hematopathologist blinded to clinical outcomes. Relationships between hCNT3 staining in CLL cells and time to progression (TTP), overall response (OR), and overall survival (OS) were assessed. Dichotomization of quantitative hCNT3 staining showed that subjects with high hCNT3 IHC scores had a significantly shorter TTP with F-ara-A treatment compared to those with a low score (hazard ratio, HR, 3.16; P=0.006). Median TTP was 4.7 vs 11.2 months, respectively. On multivariate analysis, hCNT3 score was the only clinical parameter independently associated with TTP (HR, 3.12; P=0.01). OR and OS did not differ significantly between the dichotomized groups. We found a strong relationship between IHC staining of hCNT3 and clinical resistance to F-ara-A therapy in CLL. If confirmed, IHC for hCNT3 may be routinely used to predict those patients unlikely to benefit from F-ara-A, thereby avoiding F-ara-A-related toxicities.

Immunophenotypic features distinguishing familial chronic lymphocytic leukemia from sporadic chronic lymphocytic leukemia

BACKGROUND

Familial chronic lymphocytic leukemia (CLL) has the most frequent familial aggregation among hematological malignancies. Familial CLL families have been studied to identify susceptibility genes and other factors that contribute in the etiology of CLL. To date no study has been conducted to evaluate and compare patterns of cell surface antigen expression in familial CLL and sporadic CLL.

METHODS

The pattern of cell surface antigen expression was studied in familial and sporadic CLL to determine if unique identifiers of familial CLL could be detected. Survival in familial CLL verses sporadic CLL was compared and the association between prognosis and CD38 expression studied.

RESULTS

Familial and sporadic CLL demonstrated the same characteristic immunophenotype (positive for surface immunoglobulin, CD5, CD19, and CD23 with dim CD20, and CD22). CD2 and CD13 expression, however, were more frequent (30% of cases) in familial CLL (P = 0.0003 for CD2, P = 0.006 for CD13) than in sporadic CLL (2-6%). There was no significant difference in survival in the two groups studied. Although the incidence of CD38 expression was similar in familial and sporadic CLL (47% and 44% respectively) the association with prognosis differed. There was a trend to decreased survival in CD38 positive sporadic (P = 0.06) but not familial CLL patients.

CONCLUSIONS

We conclude that detection of CD2 or CD13 expression in CLL suggests familial CLL and examination of family history for additional affected members is warranted. Furthermore, CD38 expression does not carry the negative prognosis observed in sporadic CLL.

Epidemiology of the plasma-cell disorders

This review of the plasma-cell disorders begins with the definition of monoclonal gammopathy of undetermined significance (MGUS). The prevalence of MGUS in white and black populations is described. MGUS is a common finding in the medical practice of all physicians, and thus it is important to both the patient and the physician to determine whether the monoclonal protein remains stable or progresses to multiple myeloma (MM), Waldenström's macroglobulinemia (WM), primary systemic amyloidosis (AL), or a related disorder. The long-term (almost 40 years) follow-up data of 241 patients in the Mayo Clinic population is provided. In a large study of 1384 patients with MGUS from southeastern Minnesota, the risk of progression to MM, WM, AL, or other disorders was approximately 1% per year. Risk factors for progression are provided. The incidence of MM in Olmsted County, Minnesota, remained stable for the 56-year span 1945-2001. The apparent increase in incidence and mortality rates among patients with MM in many studies is due to improved case ascertainment, especially among the elderly. The incidence and mortality rates of MM in the United States and other countries are presented. The major emphasis is on the cause of MM, which is unclear. Exposure to radiation from atomic bombs, therapeutic and diagnostic radiation, and in workers in the nuclear industry field are addressed. Many studies involving agricultural occupations, exposure to benzene, petroleum products, and engine exhaust and other industrial exposures are discussed. Tobacco use, obesity, diet, and alcohol ingestion are all possible causes of MM. Clusters of MM have been noted. Multiple cases of MM have been found in first-degree relatives.

Acute Myeloid Leukemia: Epidemiology and Etiology

Although acute leukemias are infrequent diseases, they are highly malignant neoplasms responsible for a large number of cancer-related deaths. Acute myeloid leukemia (AML) is the most common type of leukemia in adults, yet continues to have the lowest survival rate of all leukemias. While results of treatment have improved steadily in younger adults over the past 20 years, there have been limited changes in survival among individuals of age >60 years [1, 2].

Chronic lymphocytic leukaemia and small lymphocytic lymphoma: overview of the descriptive epidemiology

The 2001 World Health Organization classification scheme considers B-cell chronic lymphocytic leukaemia (CLL) and small lymphocytic lymphoma (SLL) in an aggregate category (CLL/SLL) because of shared clinicopathological features. We have estimated age-adjusted incidence rates (IRs) of CLL and SLL in the population-based Surveillance, Epidemiology and End Results Program in the United States to analyse patterns of CLL and SLL separately and jointly. Age-standardized to the 2000 US population, overall IRs were 3.83 per 100 000 person-years for CLL (n = 15 676) and 1.31 for SLL (n = 5382) during 1993-2004. Incidence of the combined entity, CLL/SLL, was 90% higher among males compared to females, and the male:female IR ratio was significantly higher for CLL (1.98) than for SLL (1.67). CLL/SLL IRs were 25% and 77% lower among Blacks and Asian/Pacific Islanders, respectively, compared to Whites. A significant reporting delay was evident for CLL but not for SLL, so that CLL/SLL temporal trends must be interpreted cautiously. CLL and SLL IRs increased exponentially with age among all gender/race groups, with CLL IRs increasing more steeply with advancing age than SLL. Avenues of future research include assessment of delayed- and under-reporting to cancer registries and exploration of race, gender, and age effects in epidemiological studies.

Risk patterns of multiple myeloma in Los Angeles County, 1972-1999 (United States)

OBJECTIVE

To describe the risk patterns of multiple myeloma in Los Angeles County (LAC).

METHODS

Incident multiple myeloma cases diagnosed from 1972 to 1999 were ascertained by the population-based cancer registry for LAC. Average annual age-specific and age-adjusted incidence rates (AAIR), standardized to the 2000 US census age distribution, were calculated using age-, race-, sex- and socioeconomic status (SES)-specific denominators estimated for all years from US census data for 1970, 1980 and 1990. Odds ratios (ORs) for risk by birthplace and religion were estimated using multivariate logistic regression, comparing multiple myeloma patients with other cancer patients.

RESULTS

All groups experienced increasing incidence with age; African-Americans experienced the steepest increase which began a decade earlier compared to other groups. Overall incidence rates were 50% higher among males (n = 4,692) than females (n = 4,343) (p < 0.05). AAIRs were highest for African-Americans, followed by Spanish-surnamed whites (SSW), non-Spanish-surnamed whites (NSSW), Filipinos and other Asian groups. Among African-Americans, incidence rates increased with increasing SES. US-born SSW had 14% lower risk compared to non-US born SSW (OR = 0.86, 95% confidence interval [CI] = 0.74-0.99]. Jews had an 11% higher risk compared to Protestants (OR = 1.11; 95% CI = 0.99-1.24).

CONCLUSION

Risk patterns suggest a role for both environmental and genetic factors.

Acute myeloid leukemia: epidemiology and etiology

Acute myeloid leukemias (AMLs) are infrequent, yet highly malignant neoplasms responsible for a large number of cancer-related deaths. The incidence has been near stable over the last years. It continuously shows 2 peaks in occurrence in early childhood and later adulthood. With an incidence of 3.7 per 100,000 persons and an age-dependent mortality of 2.7 to nearly 18 per 100,000 persons, there is a rising awareness in the Western world of AML's special attributes resulting from an ever-aging population. To objectively describe epidemiologic data on this patient population, recent publications were evaluated to make transparent the current trends and facts. A review of the literature is presented, reflecting highlights of current research with respect to AML etiology. To estimate outcome and discuss informed treatment decisions with AML patients of different age groups and different biologic risk categories, it is mandatory to consider that the outcome results reported in clinical trials were until now heavily biased toward younger patients, whereas the overall dismal prognosis documented in population-based studies most likely reflects the exclusion of older patients from aggressive treatment. The etiology for most cases of AML is unclear, but a growing knowledge concerning leukemogenenic agents within chemotherapy regimens for other malignancies is already available. This includes specific associations of the most frequent balanced translocations in AML, including the "good-risk" abnormalities comprised by the core binding factor leukemias (i.e., AML with the translocation (8;21) and inversion of chromosome 16, and acute promyelocytic leukemia with the translocation (15;17)). In contrast to these genetic alterations, epigenetic lesions, e.g., promoter silencing by hypermethylation of the p15/INK4b and other genes, are increasingly recognized as important in the pathogenesis of AML.

Advances in the pathologic diagnosis and biology of acute myeloid leukemia

In a general surgical pathology practice, cases of acute myeloid leukemia (AML), including myeloid sarcoma, are relatively rare; the diagnosis is very often difficult, however, and consequences of a missed or improper diagnosis compromise patient care. Currently, accurate diagnosis of every case of AML requires integration of the morphological features and results of cytochemical and immunohistochemical stains, flow cytometric immunophenotyping, cytogenetics, and molecular studies. This review focuses on a practical approach to diagnosis of AML according to current standard of practice and discusses some of recent changes in the field of AML.

The influence of increasing age on the deliverability and toxicity of fludarabine-based combination chemotherapy regimens in patients with indolent lymphoproliferative disorders

BACKGROUND

Fludarabine-based combination chemotherapy regimens are highly effective in the treatment of patients with indolent lymphoproliferative disorders. Despite the prevalence of such disorders in older patients, the effect of increasing age on the deliverability of these regimes has not been assessed.

METHODS

The authors analyzed the effect of increasing age on the deliverability and toxicity of 3 fludarabine-based regimens, all using fludarabine 25 mg/m2 per day for 3 days intravenously every 28 days, in 180 patients who were stratified into 2 age groups (age <60 years and age > or =60 years), with multivariate analysis to control for other differences between groups. The authors also explored the impact of age > or =70 years within the older cohort.

RESULTS

Older patients were more likely to experience an episode of nonsevere hematologic or infectious toxicity, but there was no difference in the rate of severe toxicity. Toxicity rates per cycle did not differ between age groups. The rates of neutropenia (absolute neutrophil count [ANC], < 1.0 x 10(9)/L) and severe neutropenia (ANC, 0.5 x 10(9)/L) were 22% and 13%, respectively, in older patients versus 20% and 11%, respectively, in younger patients (P > .1 for both). The rates of thrombocytopenia (platelet count, <100 x 10(9)/L) and severe thrombocytopenia (platelet count, <50 x 10(9)/L) were 21% and 5%, respectively, in older patients and 16% and 5%, respectively, in younger patients (each P value > .1). The rate of infection was 18% per cycle in older patients and 15% per cycle in younger patients (P = .2), with no difference noted in severity. Other organ toxicities were uncommon and showed no difference between age groups. The treatment-related mortality rate was <1% in both cohorts (P > .5). In multivariate analysis, increasing age and performance status influenced the incidence of hematologic toxicity, whereas only performance status influenced the rate of infection and severe infection.

CONCLUSIONS

Fludarabine-based combination chemotherapy regimens were well tolerated and can be delivered safely to older patients who have a good performance status with modestly increased myelosuppression but no increase in severe infectious complications or treatment-related mortality.

An overview of targeted treatments in cancer

BACKGROUND

The concept behind cancer treatment has evolved over the past decade from systemic, nonspecific, high-dose chemotherapy to targeted therapy and the introduction of cancer vaccines. Advanced technology and a better understanding of the cellular mechanisms that control cancer biology have helped in the development of such targeted treatment.

OBJECTIVE

The aim of this article was to review some of the new and commonly used targeted treatments in cancer, emphasizing their mechanisms of action, safety profiles, and clinical applications.

METHODS

The terms cancer, chemotherapy, monoclonal antibodies, targeted treatment, tyrosine kinase, epidermal growth factors, epidermal growth factor receptor, and cancer vaccines were used to search MEDLINE for English-language studies in humans, published between 1966 and March 2003. Identified publications addressing the objectives of this article were selected for review.

RESULTS

All-trans-retinoic acid, imatinib, gemtuzumab ozogamicin, rituximab, alemtuzumab, trastuzumab, cetuximab, and gefitinib are recently developed cancer therapies that target specific types of cells and receptors. They have been used in a variety of hematologic and solid tumors, and their tolerability makes them attractive for use even in elderly and extensively pretreated patients. Vaccines using dendritic cells, tumor cells, and fusions of tumor cells and antigen-presenting cells have also shown some promise in research, but further study is needed to obtain better, sustained results.

CONCLUSIONS

Targeted treatment and cancer vaccines are novel approaches in the treatment of cancer. Both fields are expanding rapidly, with new technology and ongoing medical research. The clinical implications of such agents, administered either solely or in combination with established chemotherapeutic agents, may ultimately lead to better regimens and improved clinical responses.

Cancer incidence in adolescents and young adults in the United States, 1992-1997

PURPOSE

To examine cancer incidence patterns among adolescents and young adults in the United States.

METHODS

Cancer incidence data from 26 population-based central cancer registries for 1992-1997 were used. Individual cancers were grouped into specific diagnostic groups and subgroups using an integrated classification scheme. The integrated scheme was developed for this study and was based on the most commonly used schemes in population-based epidemiologic studies: Surveillance, Epidemiology, and End Results Program's site groups, International Classification of Childhood Cancer, and International Agency for Research on Cancer's Histological Groups for Comparative Studies. Percent distributions and age-specific incidence rates per million population were computed for adolescents (aged 15-19 years) and young adults (aged 20-24 years) by gender.

RESULTS

The data for 26,010 cancer cases were examined. Among 15-19-year-olds, the five most common cancers were Hodgkin's disease, leukemia, cancer in the brain and other nervous system, bone cancer, and non-Hodgkin's disease. Among 20-24-year-olds, the five most common cancers were Hodgkin's disease, testicular cancer, thyroid cancer, melanoma of the skin, and leukemia. The proportions and rates of the histologic subtypes for most of the common cancers changed with advancing age. For example, among 15-19-year-olds, acute lymphocytic leukemia accounted for approximately 60% of leukemias in males and 50% in females. Among 20-24-year-olds, however, the corresponding percentages of acute lymphocytic leukemia were 37% in males and 31% in females. For ovarian cancer, the germ cell tumor was the most common subtype (54.6% of all ovarian cancers) among 15-19-year-olds. In contrast, ovarian carcinoma was the predominant subtype (70.4%) among 20-24-year-olds. For both age groups, the incidence rates of nodular Hodgkin's disease, melanoma of the skin, and thyroid cancer were significantly greater in females than in males.

CONCLUSIONS

Cancer incidence patterns among adolescents and young adults are distinctive. In these age groups, a transition from predominantly pediatric histologic subtypes to adult subtypes was observed for Hodgkin's disease, leukemia, ovarian cancer, and soft tissue sarcoma. Gender differences were found for Hodgkin's disease, melanoma of the skin, and thyroid cancer.

[Incidence and survival of leukemias according to the different histologic subsets, in Tarragona, Spain, between 1980-1994]

BACKGROUND

To study the incidence and survival of leukemias according to the different histologic types in Tarragona, Spain.

MATERIAL AND METHOD

Analysis of the information obtained from the Cancer Registry of Tarragona (Spain) between 1980-1994. The leukemias were classified in: acute lymphoblastic leukemia (ALL), acute myelogenous leukemia (AML), chronic lymphoid leukemia (CLL) and chronic myeloid leukemia (CML). The estimated incidence rates have been adjusted to the worldwide population, the percentage of the incidence annual change through Poisson regression models and the relative survival using the registry of death rate of Catalonia.

RESULTS

The adjusted rate for leukemias between the period 1990-1994 was 8.0 per 100,000 inhabitants in men and of 5.2 in women, being the CLL the most frequent subtype. Regarding the trend of incidence an increase of the CLL of 2.2% annual (CI 95%, 0.1-6.6) in men and of 7.7% (CI 95%, 1.4-14.4) in women was observed. In the remaining subtypes, there was no trend, but the non-classified leukemias decreased a -10.8% annual (CI 95%, -15.0 to -6.4) in men and a -9.9% annual (CI 95%, 15.4 to -4.0) in women. 5-year relative survival (RS5y) for the total leukemias was 37.7% in men and 45.3% in women. It stands out the CLL with a RS5y of 64.8% in men and of 75.7% in women and childhood ALL with a RS5y of 83.0% in boys and of 84.9% in girls.

CONCLUSIONS

In Tarragona, Spain, an increase of the CLL incidence has been observed suggesting an improvement in the diagnosis, parallel to a decrease of the non-classified leukemias. The survival in this cohort of patients was similar to the that reported in other european registries.

Genetic susceptibility to childhood acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer. The origin of this disease can be explained by a combination of genetic susceptibility factors and environmental exposures. For the purpose of our study it can be considered as a complex disease, caused by the "carcinogenic" effect of the environment modified by a series of genes. In population, these genes tend to occur in allelic forms representing functional polymorphisms thus explaining inter-individual variability in cancer susceptibility. The latter can be evaluated more realistically in childhood ALL than in sporadic cancers of the adult because of its relatively short latency period. We asked therefore, the question about the role of genes controlling the efficiency of xenobiotics metabolism in childhood leukemogenesis. Xenobiotics (drugs and carcinogens) are excreted from the body after metabolic conversion by enzymes mediating oxidation activation (Phase I) and conjugation detoxificaton (Phase II). Functional variants of these enzymes, resulting from known DNA polymorphisms in the corresponding genes, were shown to influence the risk to a variety of solid tumours in adults. A case-control study on ALL patients and healthy controls in a French-Canadian population was carried out by examining the loci of Phase I, CYP1A1 and CYP2D6, as well as Phase II enzymes, GSTM1, GSTT1, NAT1 and NAT2. The NAT2 slow-acetylator, CYP1A1*2A and GSTM1 null genotypes were shown to be significant risk determinants of ALL (OR=1.6, 1.8 and 1.8, respectively), whereas, polymorphisms in CYP2D6 and GSTT1 genes did not seem to play an important role in the aetiology of ALL. Interestingly, the risk associated with NAT2 slow-acetylators was most apparent among males homozygous for NAT1*4 (OR=3.3) whereas girls carrying the CYP1A1*4 allele were significantly underrepresented in the patient group (OR=0.2). These findings point to a gender-specific effect of DNA variants which, at least in part, may explain why ALL is more prevalent among boys. To assess gene-gene interactions, NAT2 slow-acetylators were considered together with GSTM1 null genotypes and CYP1A1*2A alleles. The combined presence of two risk-elevating genotypes appeared to confer an increased risk of ALL among the carriers (OR=2.6). This risk was increased further (OR=3.3) when all three genotypes occurred in the same individuals indicating that the combination of susceptibility variants is more predictive of risk then either of them independently. The association of leukemogenesis in children with metabolising gene variants suggests causal relation to environmental exposures.

In vitro and in vivo antitumor activity of YoshixolTR against murine L1210 leukemic cells

In this report, antiproliferative effects of YoshixolTR in vitro and in vivo were investigated in murine L1210 cells. A proliferation of L1210 cells in vitro was inhibited by YoshixolTR in a dose- and time-dependent manner. This inhibition showed an arrest at the G0/G1 stage of the cell cycle, followed by a flow cytometric measurement. YoshixolTR induced apoptosis-like cell death identified by histological observations (scanning electron and transmission electron microscopy), DNA fragmentation, and a smaller increase in lactate dehydrogenase (LDH). In the in vivo experiments, YoshixolTR (5 microl/kg of body weight, on days 1, 3, and 5) was injected intraperitoneally in mice inoculated with L1210 cells. No marked prolongation of survival occurred between the control group and treated group. However, a survival curve in the treated group showed a shift toward a possible longer survival time. Additionally, on the basis of apoptosis-like cell death due to YoshixolTR as indicated above, a possibility of immunotherapy as a tumor vaccine has been examined. A vaccination of rabbit anti-serum, which consisted of components from the L1210 cells killed by YoshixolTR, produced a dramatic improvement of viability in the leukemic mice. In conclusion, YoshixolTR has an anti-leukemic potency with a new biological mechanism and an inductive potency of super-antigens as immunotherapeutic agents against malignant tumors.

Susceptibility to Childhood Acute Lymphoblastic Leukemia: Influence of CYP1A1, CYP2D6, GSTM1, and GSTT1 Genetic Polymorphisms

Although acute lymphoblastic leukemia (ALL) is the most common childhood cancer, factors governing susceptibility to this disease have not yet been identified. As such, ALL offers a useful opportunity to examine the glutathione S-transferase and cytochrome P450 genes in determining susceptibility to pediatric cancers. Both enzymes are involved in carcinogen metabolism and have been shown to influence the risk a variety of solid tumors in adults. To determine whether these genes played a similar role in childhood leukemogenesis, we compared the allele frequencies of 177 childhood ALL patients and 304 controls for the CYP1A1, CYP2D6, GSTM1, and GSTT1 genes. We chose the French population of Quebec as our study population because of its relative genetic homogeneity. The GSTM1 null and CYP1A1*2A genotypes were both found to be significant predictors of ALL risk (odds ratio [OR] = 1.8). Those possessing both genotypes were at an even greater risk of developing the disease (OR = 3.3). None of the other alleles tested for proved to be significant indicators of ALL risk. Unexpectedly, girls carrying the CYP1A1∗4 were significantly underrepresented in the ALL group (OR = 0.2), suggesting that a gender-specific protective role exists for this allele. These results suggest that the risk of ALL may indeed be associated with xenobiotics-metabolism, and thus with environmental exposures. Our findings may also explain, in part, why ALL is more prevalent among males than females.

Susceptibility to Childhood Acute Lymphoblastic Leukemia: Influence of CYP1A1, CYP2D6, GSTM1, and GSTT1 Genetic Polymorphisms

Although acute lymphoblastic leukemia (ALL) is the most common childhood cancer, factors governing susceptibility to this disease have not yet been identified. As such, ALL offers a useful opportunity to examine the glutathione S-transferase and cytochrome P450 genes in determining susceptibility to pediatric cancers. Both enzymes are involved in carcinogen metabolism and have been shown to influence the risk a variety of solid tumors in adults. To determine whether these genes played a similar role in childhood leukemogenesis, we compared the allele frequencies of 177 childhood ALL patients and 304 controls for the CYP1A1, CYP2D6, GSTM1, and GSTT1 genes. We chose the French population of Quebec as our study population because of its relative genetic homogeneity. The GSTM1 null and CYP1A1*2A genotypes were both found to be significant predictors of ALL risk (odds ratio [OR] = 1.8). Those possessing both genotypes were at an even greater risk of developing the disease (OR = 3.3). None of the other alleles tested for proved to be significant indicators of ALL risk. Unexpectedly, girls carrying the CYP1A1∗4 were significantly underrepresented in the ALL group (OR = 0.2), suggesting that a gender-specific protective role exists for this allele. These results suggest that the risk of ALL may indeed be associated with xenobiotics-metabolism, and thus with environmental exposures. Our findings may also explain, in part, why ALL is more prevalent among males than females.

Solitary bone plasmacytoma: outcome and prognostic factors following radiotherapy

PURPOSE

To clarify the natural history of solitary plasmacytoma of bone (SBP) after radiation treatment.

METHODS AND MATERIALS

Between 1965-1996, we identified 57 previously untreated patients with a SBP. A serum myeloma protein was present in 33 patients (58%) and Bence Jones proteinuria was present in an additional eight patients (14%). The median radiotherapy dose was 50 Gy (range, 30-70 Gy). Overall survival, cause-specific survival, and freedom from progression to multiple myeloma were calculated actuarially.

RESULTS

Local control was achieved in 55 of 57 patients (96%). For those 29 patients (51%) who subsequently developed multiple myeloma, the median time to progression was 1.8 years. There was a direct correlation between persistence of abnormal protein following radiotherapy and the likelihood of developing multiple myeloma. Among 11 patients with disappearance of myeloma protein, only two developed multiple myeloma after 4 and 12 years, in contrast to progression in 57% of patients with a persistent protein peak and 63 % of those with nonsecretory disease (p = 0.02). Among 23 patients with thoracolumbar spine disease, 7 of 8 patients staged with plain radiographs alone developed multiple myeloma in comparison with 1 of 7 patients who also had magnetic resonance imaging (MRI) (p = 0.08). For all patients, the median survival from radiotherapy was 11.0 years. The median cause-specific survival of patients with disappearance of myeloma protein was significantly longer than that of the remaining patients (p = 0.004).

CONCLUSION

Results supported the importance of precise staging that includes MRI of the spine for optimum patient selection and the application of definitive radiotherapy. Those patients with myeloma protein that disappears following radiotherapy represent a category with a high likelihood of cure.

Racial differences in the prevalence of monoclonal gammopathy in a community-based sample of the elderly

PURPOSE

To determine if there is an increased prevalence of monoclonal gammopathy in elderly blacks compared with whites, analogous to the difference in incidence of multiple myeloma reported for the two racial groups and to confirm age and gender relationships.

PATIENTS AND METHODS

Subjects were from the Duke Established Populations for the Epidemiologic Study of the Elderly, selected on the basis of stratified random household sampling. Blacks were oversampled to allow for increased statistical precision in racial comparisons. In all, 1,732 subjects (aged > 70 years) consented to blood drawing and constitute the sample for this study. Monoclonal immunoglobulins were determined by agarose gel electrophoresis and immunofixation.

RESULTS

One hundred six subjects (6.1%) had a monoclonal gammopathy. There was a greater than twofold difference in prevalence between blacks (8.4%) and whites (3.8%) (P < 0.001); monoclonal gammopathy prevalence increased with age, and was greater in men than women. Those with monoclonal gammopathy did not differ from those without in socioeconomic status, urban/rural residence, or education. The presence of monoclonal gammopathy was not associated with any specific diseases nor with impaired functional status. There was a slight increase in serum creatinine levels and decrease in hemoglobin and albumin levels in patients with monoclonal gammopathy, but no difference in interleukin-6 (IL-6) levels. Moreover, IL-6 levels were not correlated significantly with the level of monoclonal protein.

CONCLUSION

Prevalence of monoclonal gammopathy is significantly greater among blacks than whites in a community-based sample, in approximately the same ratio that multiple myeloma has been reported in the two groups. Given the absence of correlation with environmental factors, there may be a biological racial difference in susceptibility to an early event in the carcinogenic process leading to multiple myeloma.

Multiple myeloma: a patient with unusual features including intracranial and meningeal involvement, testicular involvement, organomegaly, and plasma cell leukemia

A 27-year-old Chinese male presented with multiple myeloma. Over his 18-month course he manifested a number of unusual features of his disease including his young age, marked organomegaly, a testicular plasmacytoma, multiple intracranial extraskeletal plasmacytomas and meningeal involvement, and peripheral blood plasmacytosis. The case is described and recent literature on these rare manifestations is reviewed.

Hematopoietic and lymphatic malignancies in vehicle mechanics

Although it is generally acknowledged that benzene causes leukemia, especially acute myeloid leukemia, considerable divergences persist in the assessment of the leukemia risk due to occupational low-level benzene exposure. Specifically, the risk for vehicle mechanics is considered by some authors as being nondetectable with epidemiologic methods, whereas others calculated that the incidence rate of leukemia (all types) in vehicle mechanics is increased more than 60 times. The purpose of this review is to examine the publications on this topic in light of criteria for causal inference and to discuss the possible role of bias, confounding factors, and chance. The results of this analysis reveal that there are surprisingly few epidemiologic observations supporting an increased incidence of leukemia in vehicle mechanics. Apparently, publications suggesting a leukemogenic effect of low-level benzene exposure in garage mechanics are more often quoted than their negative counterparts, although they are not better designed.

Solitary plasmacytoma of bone and soft tissue

PURPOSE

This retrospective review evaluates the results of radiotherapy used for curative intent in the management of solitary plasmacytoma.

METHODS AND MATERIALS

Between August 1963 and January 1993, 37 patients with a solitary plasmacytoma were treated with curative intent at the University of Florida. Criteria for inclusion in the study were (a) a biopsy-proven plasmacytoma, (b) no tumor in the bone marrow on biopsy, and (c) no evidence of disseminated disease on skeletal survey. The primary site was osseous in 27 patients and extramedullary in 10 patients; 9 of the 10 extramedullary lesions were located in the upper respiratory passages. Treatment consisted of primary radiotherapy in all but one patient, who received surgical resection alone. Two patients also received adjuvant chemotherapy. The median radiation dose was 43.2 Gy in 1.8-Gy fractions. Absolute survival, progression to myeloma, and local control rates were calculated using the Kaplan-Meier method. A multivariate analysis was performed for prognostic factors predictive of absolute survival.

RESULTS

Multivariate analysis revealed tumor type (osseous vs. extramedullary) to be predictive of absolute survival (p = 0.12). Factors not predictive of survival were age, sex, use of chemotherapy, immunoglobulin level, and type of immunoglobulin elevated. Patients with osseous tumors had a lower survival rate than those with extramedullary tumors (55% vs. 80% at 10 years, p = 0.06). Multiple myeloma was more likely to develop in patients with osseous tumors (54% vs. 11% at 10 years, 100% vs. 33% at 15 years, p = 0.03). Of patients in whom multiple myeloma developed, those with osseous tumors had a poorer survival rate after development of myeloma (32% vs. 100% at 5 years, p = 0.11). Local relapse developed in 1 patient with an osseous tumor 10 months after treatment with 28.3 Gy in 14 fractions; this was controlled with an additional 28.3 Gy in 10 fractions. Local failure did not develop in any patient with an extramedullary tumor.

CONCLUSIONS

Radiotherapy is an effective local treatment for solitary plasmacytoma. Osseous tumors were found to have a poor prognosis compared with extramedullary tumors.