Acute nonlymphocytic leukemia

Attachment Style and Mental Health: A 1-Year Follow-Up Study of Mothers of Infants with Congenital Heart Disease

The longitudinal contribution of attachment style to mental health was examined among mothers of infants with Congenital Heart Disease (CHD). Eighty-five mothers of newborns with CHD completed self-report scales tapping attachment style, appraisal of motherhood, ways of coping with motherhood tasks, and mental health 2 weeks after the infant’s CHD diagnosis and 1 year later. Mothers’ attachment anxiety and avoidance at Time 1 were related to poor mental health at the same point of time. In addition, attachment avoidance at Time 1 predicted further deterioration of mental health from Time 1 to Time 2. Attachment style at Time 1 also predicted the ways mothers appraised and coped with motherhood tasks, which, in turn, were related to mental health changes. The theoretical implications of the data were discussed.

Upper airway obstruction as the presenting manifestation of leukemia

The general clinical features of the acute pediatric leukemias are similar. There is a fairly consistent picture of brief symptoms, which include weakness or fatique, bleeding or bruising, and bone or joint tenderness. Acute or subacute fever also is a common symptom. The fever can result from the underlying malignancy, but is more often the result of an infectious complication. We present a toddler, ultimately diagnosed with acute leukemia, who experienced few of the classic features. He presented as a case of febrile upper airway obstruction.

Coming to terms: parents' response to a first cancer recurrence in their child

The purpose of this study was to explore, using grounded theory, the process experienced by parents who are dealing with the first recurrence of cancer in their child. The sample of 33 guardians (27 mothers, 1 grandmother, and 5 fathers) was drawn from three pediatric oncology settings. Data were collected through interviews, observations, and medical record review. Thirteen parents were interviewed to validate first the evolving and, later, the complete study findings. Four interactive components emerged: regulating shock, situation monitoring, alternating realizations, and eyeing care-limiting decisions. The overall organizing construct induced from these components was labeled "coming to terms." This construct represents the parents' efforts to overcome shock and despair to make wise decisions about treatment while accepting that the outcome if beyond their control, and to help their child have the optimal chance for cure while preparing for the child's possible death.

Neurologic features as initial presentations of childhood malignancies

Thirty patients were examined initially because of neurologic problems and later were diagnosed as having systemic malignant disorders. Acute leukemia was the most common malignancy (36.6%), followed by neuroblastoma (33.3%), non-Hodgkin lymphoma (13.3%), rhabdomyosarcoma (10%), Ewing tumor (3.3%), and Hodgkin lymphoma (3.3%). Four of the 11 acute leukemia patients had nervous system involvement due to meningeal, orbital, or cerebellar infiltration. The complaints of the remaining patients included back pain, weakness, and difficulty in walking, all of which were caused by anemia or bone pain. Neurologic involvement in systemic malignancies, other than acute leukemia, mainly appeared as spinal cord compression (7 with neuroblastoma, 3 non-Hodgkin lymphoma, 1 rhabdomyosarcoma, 1 Ewing tumor), orbital or cavernous sinus infiltration (3 with acute leukemia, 1 rhabdomyosarcoma), and VIIth cranial nerve involvement (2 with rhabdomyosarcoma). One patient had skull infiltration without any neurologic deficit. Cerebellar signs were caused by the remote effects of cancer. It is concluded that acute leukemia is the first and neuroblastoma is the second most common malignancy among childhood systemic malignancies presenting with neurologic involvement; however, neuroblastoma is the most common cause of spinal cord compression.

Treatment of childhood acute nonlymphoblastic leukemia: a review

Recommendations for the treatment of ANLL in general, and in pediatrics more specifically, are still conflicting. Overall, a child diagnosed with ANLL has a 35-50% of remaining alive long term, without disease. Induction chemotherapy with cytarabine and daunorubicin will achieve remission in about 80% of children with ANLL. So far, intensifying induction chemotherapy by adding more agents has not changed this result significantly. Major changes in induction chemotherapy may come from either new chemotherapeutic agents or biological agents that hasten bone marrow recovery after treatment. Such an approach might allow more dose-intensive drug administration without increased toxicity. Another question that is slowly being answered with the ongoing trials is the one concerning maintenance. So far, all the pediatric trials that have tried to shorten the maintenance therapy of this disease were able to do so without jeopardizing the final outcome. The final optimal minimal duration of therapy has yet to be established. The best therapy for a patient who has achieved a remission is still the most difficult question regarding the treatment of this disease. So far, allogeneic BMT has yielded the best results, with a disease-free interval varying between 55 and 65%. However, one-third of these patients have chronic GvHD and, therefore, a somewhat diminished quality of life. As preparative regimens and marrow purging protocols evolve, the results of autologous bone marrow transplantation seem to be improving, with disease-free intervals of 35-50% reported.

Initial blood fetal hemoglobin concentration is elevated and is associated wtih prognosis in children with acute lymphoid or myeloid leukemia

We examined the relationship between initial blood fetal hemoglobin (HbF) concentration and prognosis in 100 children with leukemia. HbF concentration was usually elevated and ranged between 0 and 19.5 g/l. Multivariate analysis showed that, in patients with acute lymphoblastic leukemia (ALL), each increment of 1 g/l in initial HbF concentration resulted in a 1.13-fold rise in the risk of death or relapse (95% confidence limits 1.01-1.25, P less than 0.05). In patients with myeloid leukemias, each increment of 1 g/l in HbF was associated with a 1.20-fold (1.05-1.37, P less than 0.02) rise in the risk of death or relapse. In the patients with myeloid leukemias the mean initial HbF concentration was also higher (3.4 g/l; 0.5-19.5 g/l) than in the patients with ALL (1.1 g/l; 0-18.7 g/l; P = 0.08). Our results indicate that the degree of increase in HbF synthesis is associated with the degree of malignancy: the more aggressive the disease, the more augmented is the synthesis of HbF.

Central Nervous System (CNS) Involvement in Acute Nonlymphocytic Leukemia (ANLL)

The incidence of central nervous system (CNS) involvement and effects of therapy were reviewed in 42 consecutive pediatric patients with acute nonlymphocytic leukemia (ANLL). The morphology of ileukemic cells was considered M1 in 13, M2 in 7, M3 in 5, M4 in 8, and M5 in 9. Two patients with M5 morphology presented with CNS disease at diagnosis. Systemic Ara-C treatment was included as a mainstay of remission induction and maintenance program for all patients. With the exception of the M5 group, none of the patients received direct CNS prophylactic therapy. There was a 0% incidence of CNS relapse: in this group of patients. Median duration of remission for all patients (excluding the M5 group) was 33 months. This experience may indicate that systemic treatment with Ara-C may provide some degree of CNS prophylaxis in ANLIL.

Biologic and cytogenetic characteristics of leukemia in infants

Clinical features, leukemic cell characterization, chromosomal findings, and treatment outcome were analyzed in a retrospective study of 30 cases with acute leukemia of infancy, 24 infants with acute lymphoblastic leukemia (ALL), and six cases with acute nonlymphoblastic leukemia (ANLL). Extensive bulky disease with organomegaly, central nervous system (CNS), and skin involvement were prominent features at diagnosis with a higher frequency in ANLL as compared to ALL. Four of six ANLL patients were classified as monocytic or myelomonocytic. In the ALL group nine of 24 (36%) were non-L1 morphology and six of 17 (33%) were common ALL antigen (CALLA) negative, the majority of them (five of six) were included in the non-L1 group. Immunophenotyping revealed four cases with early B-cell (three patients: Ia+B4+, and one patient: Ia+) and two cases with T-cell. Mixed lineage leukemia was found in five infants. Heavy chain immunoglobulin gene rearrangement was present in six cases tested, two CALLA+, two with Ia+B4+, and two were undifferentiated mixed lineage leukemia. Chromosomal aberrations were detected in ten of 18 patients, mostly in ANLL and CALLA negative ALL. Translocations were detected in six patients, involving 4q21-23 and 11q23 in three and two cases, respectively. The probability of five-year DFS were 27% for the whole group. The worst prognosis was observed in infants younger than 6 months of age, in whom the leukemia cell characteristics was compatible with stem cell: ANLL, very early pre-B, or undifferentiated mixed type. The chromosomal aberrations found in all cases included translocation with the seemingly nonrandom breakpoints at 4q21 and 11q23, and breakpoints that corresponded to known fragile sites. This finding may be suggestive of an underlying genetic predisposition associated with the poor prognosis of leukemia of infancy.

Biologic characteristics and treatment of acute nonlymphocytic leukemia in children. Report of the ANLL Strategy Group of the Childrens Cancer Study Group

Today approximately 75 per cent of children with ANLL can be induced into a complete remission and approximately 40 per cent will have an event-free survival for more than 3 years, irrespective of whether they received a bone marrow transplantation or chemotherapy after induction. In order to achieve these results very intensive therapy is required. The morbidity and mortality of treatment are high. The length of therapy needed after induction of remission is not known. Whether or not maintenance therapy is required is perhaps related most directly to the intensity of the therapy employed. Similarly, the role of bone marrow transplantation in patients in first remission, treatment of CNS leukemia, and treatment of chloromas are controversial. There is general agreement that WBCs over 100,000, acute monoblastic leukemia in infants less than 2 years of age, and certain chromosomal abnormalities are associated with a poor prognosis. Although there has been a dramatic improvement in the treatment of ANLL over the past 15 years, stratification of therapy based on biologic parameters, and alteration of treatment based on the early responses to treatment may be required before further advances will be made.

Heterogeneity among the acute nonlymphocytic leukemias: value of immunophenotype for diagnosis, prognosis, and therapy

Immunophenotyping of acute nonlymphocytic leukemia has confirmed previous observations on the heterogeneity of this disease. The lack of leukemia-specific monoclonal antibodies as well as antibodies reactive with early myeloid cells is reflected in poor correlation of morphologically and cytochemically defined FAB classes with the immunophenotype of the leukemic cells. Possible exceptions are the microgranular variant of FAB-M3, megakaryocytic leukemia (FAB-M7), and early erythroid leukemias (FAB-M6). The use of antibody panels can alleviate the differential diagnosis of acute lymphoid and myeloid leukemias, especially those occurring in infants, and the discrimination of FAB-L2 and FAB-M1. Also, the immunophenotyping of presumptive hybrid leukemias can help to resolve the many questions about these leukemias with a particularly poor prognosis. The challenge for multiinstitutional groups is to define those clinically relevant subgroups of acute nonlymphocytic leukemia in children that have general acceptance and could provide the basis for new treatment strategies.

CHOP treatment of childhood acute myelogenous leukemia with monocytic differentiation: a report on five cases

Five children with M4 or M5 acute myelogenous leukemia (AML) not responding to previous treatment or in relapse were treated with a four-drug protocol consisting of cyclophosphamide, adriamycin, vincristine, prednisone, and CNS prophylaxis. There were two treatment failures; the remaining three patients have achieved complete remission, lasting 18+, 13+, and 12+ months respectively. Further follow-up is to be performed.

The medical and surgical management of typhlitis in children with acute nonlymphocytic (myelogenous) leukemia

The treatment of acute leukemia in childhood has been increasingly successful. Infectious complications are the major cause of morbidity and mortality among these patients receiving aggressive chemotherapy. In particular, neutropenic enterocolitis or typhlitis has had a reported mortality of 50% to 100%. The authors reviewed a series of 77 previously untreated patients with acute myelogenous leukemia begun on treatment from March 1976 to June 1984 to better define the characteristics of typhlitis and its optimum management. Twenty-five patients had episodes of typhlitis, characterized by fever, abdominal pain, and tenderness, occurring during periods of neutropenia. Ten of these patients had watery diarrhea as a major additional symptom, and nine patients had a significant episode of gastrointestinal bleeding. In seven instances, blood culture results were positive, all for intestinal flora. The episodes of typhlitis occurred most frequently during the induction therapy (19 patients). Five patients experienced typhlitis during maintenance therapy, and one patient had acute appendicitis. Two patients had typhlitis during their reinduction therapy, and of note, one had had abdominal symptoms during her initial induction. All patients were treated initially with broad-spectrum antibiotics and bowel rest. Four criteria have been used for surgical intervention: (1) persistent gastrointestinal bleeding after resolution of neutropenia and thrombocytopenia and correction of clotting abnormalities; (2) evidence of free intraperitoneal perforation; (3) clinical deterioration requiring support with vasopressors, or large volumes of fluid, suggesting uncontrolled sepsis; and (4) development of symptoms of an intra-abdominal process, in the absence of neutropenia, which would normally require surgery. Using these criteria, five patients required surgical intervention for typhlitis or its sequelae and one for acute appendicitis. There was one perioperative death resulting from miliary tuberculosis. Among the 21 patients managed medically, there was 1 death resulting from typhlitis in a patient in whom surgery was deferred because of her multiple failures to enter remission.