Treatment of acute leukemia

Indications for and benefits of intensive therapies in treatment of childhood cancers

There has been a striking improvement in the overall numbers of children and adolescents who become disease-free and remain disease-free as a result of intensive therapy as defined today, for the following cancers: acute nonlymphocytic leukemia (ANLL), non-Hodgkin's lymphoma (NHL), poor risk acute lymphocytic leukemia (ALL), osteosarcoma, and Ewing's sarcoma. The therapy for each of these tumors, with the exception of osteosarcoma, consisted of combination chemotherapy with or without radiotherapy and was started as soon after diagnosis as possible. Aggressive therapy of osteosarcoma has consisted of surgical removal of lung metastases and chemotherapy. Intensive chemotherapy recently has included the use of high doses of certain drugs such as cytosine arabinoside (Ara-C), methotrexate, VP-16-213 and melphalan in the treatment of patients with tumors that are currently difficult to treat.

Cytosine arabinoside stability in intravenous admixtures with sodium bicarbonate and in plastic syringes

The increased use of high-dose cytarabine in the treatment of neoplasms prompted this study on the reconstituted stability of cytarabine in intravenous admixtures with sodium bicarbonate and in plastic syringes. The study of the effect of sodium bicarbonate was prompted by the frequent use of this agent in patients being treated with cytarabine as a means of achieving systemic alkalinization in order to manage hyperuricemia. The stability of reconstituted cytarabine in plastic syringes was measured to determine whether cytosine arabinoside could be reconstituted and stored prior to use. The results of this study indicate that sodium bicarbonate 50 mEq/L in the intravenous solution containing cytarabine has no effect on the chemical stability of cytarabine for at least one week at room temperature or in the refrigerator. Consequently sodium bicarbonate and cytarabine can be coadministered in one intravenous solution. The reconstituted stability of cytarabine at 20 mg/ml and 50 mg/ml is not affected by storage in plastic syringes.

Acute lymphoblastic leukemia: the significance of nuclear convolutions

Because of the significance attributed by some investigators to the presence of cells with convoluted nuclei in lymphoblastic lymphoma, and the absence of any information on the presence and significance of such cells in acute lymphoblastic leukemia (ALL), we reviewed the blood, bone marrow films, and clinical records of 101 children with ALL. We attempted to determine whether leukemic cells with convoluted nuclei can be recognized in such films, and if so, whether this observation has clinical significance. In fifty-seven of the patients the leukemic cells had convoluted nuclei. For the purposes of this study, our patients were divided into three groups: Group I, 44 patients without cells having convoluted nuclei: Group II, 30 patients with 10% or fewer convoluted nucleus cells (CNC); and Group III, 27 patients with more than 10% CNC. Clinical comparison of the three groups with respect to age and sex distribution, physical and hematologic findings at presentation, response to therapy and survival showed no significant differences. Patients with a mediastinal mass had a significantly shorter survival compared to those without a mediastinal mass, regardless of the presence or absence of CNC (p = 0.0001). Our results indicate that the nuclear convolutions can easily be recognized in blood or bone marrow films of patients with ALL, and that their presence has no provable clinical significance.

Surface markers and prognostic factors in acute lymphoblastic leukemia

We investigated the surface markers on lymphoblasts from 37 patients with acute lymphoblastic leukemia. Spontaneous rosette formation with sheep erythrocytes (E rosettes) identified T cells and the presence of surface immunoglobulin identified B cells. Eight patients had T-marker lymphoblasts; 28 had no markers (null lymphoblasts), and one patient had B-marker lymphoblasts. The eight patients with T-marker acute lymphoblastic leukemia had massive leukemic infiltration, frequently a mediastinal mass, and a poor prognosis. The T-marker lymphoblasts had a weak or negative periodic acid-Schiff reaction and a very low antigenic stimulation to allogeneic lymphocytes. The association of T-marker lymphoblasts and some of the conventional poor-risk factors appears to be reliable in predicting a poor prognosis.

The slowly dying child

Potential cure and prolonged survival has modified the outlook for childhood cancer. Longevity has made most important the real ization that the child and family encounter many psychological stresses. Understanding this phenomena adds to the ultimate success of care.