Anaplastic large cell lymphoma presenting as a mass in the uterine cervix: a case report

T-cell lymphoma is an extremely rare form of malignancy in the female genital tract. Most of the reported cases of lymphoma are B-cell lymphomas. A few cases of primary T-cell lymphomas involving the vagina or the vulva have been reported. We are reporting the first case of anaplastic large cell lymphoma (ALCL) presenting as a uterine cervical mass. The patient is a 24-year-old female who presented to the emergency room with a history of menorrhagia, night sweats and 40-pound weight loss. The diagnosis of ALCL was confirmed through immunohistochemical studies with strong CD30 and ALK expression. Fluorescent hybridization showed a rearrangement of the anaplastic lymphoma kinase (ALK) gene. Since ALCL may have a variable expression of T-cell antigens, the diagnosis may easily be missed when CD45 and/or CD3 is negative, and screening epithelial stains for carcinoma (e.g., p63 and EMA) are positive. CD30 must be performed to raise the consideration of ALCL when reniform nuclei are observed.

Genetic subgroups inform on pathobiology in adult and pediatric Burkitt lymphoma

Burkitt lymphoma (BL) accounts for most pediatric non-Hodgkin lymphomas, being less common but significantly more lethal when diagnosed in adults. Much of the knowledge of the genetics of BL thus far has originated from the study of pediatric BL (pBL), leaving its relationship to adult BL (aBL) and other adult lymphomas not fully explored. We sought to more thoroughly identify the somatic changes that underlie lymphomagenesis in aBL and any molecular features that associate with clinical disparities within and between pBL and aBL. Through comprehensive whole-genome sequencing of 230 BL and 295 diffuse large B-cell lymphoma (DLBCL) tumors, we identified additional significantly mutated genes, including more genetic features that associate with tumor Epstein-Barr virus status, and unraveled new distinct subgroupings within BL and DLBCL with 3 predominantly comprising BLs: DGG-BL (DDX3X, GNA13, and GNAI2), IC-BL (ID3 and CCND3), and Q53-BL (quiet TP53). Each BL subgroup is characterized by combinations of common driver and noncoding mutations caused by aberrant somatic hypermutation. The largest subgroups of BL cases, IC-BL and DGG-BL, are further characterized by distinct biological and gene expression differences. IC-BL and DGG-BL and their prototypical genetic features (ID3 and TP53) had significant associations with patient outcomes that were different among aBL and pBL cohorts. These findings highlight shared pathogenesis between aBL and pBL, and establish genetic subtypes within BL that serve to delineate tumors with distinct molecular features, providing a new framework for epidemiologic, diagnostic, and therapeutic strategies.

Subtype-specific and co-occurring genetic alterations in B-cell non-Hodgkin lymphoma

B-cell non-Hodgkin's lymphoma (B-NHL) encompasses multiple clinically and phenotypically distinct subtypes of malignancy with unique molecular etiologies. Common subtypes of B-NHL such as diffuse large B-cell lymphoma (DLBCL) have been comprehensively interrogated at the genomic level. But rarer subtypes such as mantle cell lymphoma (MCL) remain sparsely characterized. Furthermore, multiple B-NHL subtypes have thus far not been comprehensively compared using the same methodology to identify conserved or subtype-specific patterns of genomic alterations. Here, we employed a large targeted hybrid-capture sequencing approach encompassing 380 genes to interrogate the genomic landscapes of 685 B-NHL tumors at high depth; including DLBCL, MCL, follicular lymphoma (FL), and Burkitt lymphoma (BL). We identified conserved hallmarks of B-NHL that were deregulated in the majority of tumor from each subtype, including the frequent genetic deregulation of the ubiquitin proteasome system (UPS). In addition, we identified subtype-specific patterns of genetic alterations, including clusters of co-occurring mutations and DNA copy number alterations. The cumulative burden of mutations within a single cluster were more discriminatory of B-NHL subtypes than individual mutations, implicating likely patterns of genetic cooperation that contribute to disease etiology. We therefore provide the first cross-sectional analysis of mutations and DNA copy number alterations across major B-NHL subtypes and a framework of co-occurring genetic alterations that deregulate genetic hallmarks and likely cooperate in lymphomagenesis.

Targetable genetic alterations of TCF4 (E2-2) drive immunoglobulin expression in diffuse large B cell lymphoma

The activated B cell (ABC-like) subtype of diffuse large B cell lymphoma (DLBCL) is characterized by chronic activation of signaling initiated by immunoglobulin μ (IgM). By analyzing the DNA copy number profiles of 1000 DLBCL tumors, we identified gains of 18q21.2 as the most frequent genetic alteration in ABC-like DLBCL. Using integrative analysis of matched gene expression profiling data, we found that the TCF4 (E2-2) transcription factor gene was the target of these alterations. Overexpression of TCF4 in ABC-like DLBCL cell lines led to its occupancy on immunoglobulin (IGHM) and MYC gene enhancers and increased expression of these genes at the transcript and protein levels. Inhibition of TCF4 activity with dominant-negative constructs was synthetically lethal to ABC-like DLBCL cell lines harboring TCF4 DNA copy gains, highlighting these gains as an attractive potential therapeutic target. Furthermore, the TCF4 gene was one of the top BRD4-regulated genes in DLBCL cell lines. BET proteolysis-targeting chimera (PROTAC) ARV771 extinguished TCF4, MYC, and IgM expression and killed ABC-like DLBCL cells in vitro. In DLBCL xenograft models, ARV771 treatment reduced tumor growth and prolonged survival. This work highlights a genetic mechanism for promoting immunoglobulin signaling in ABC-like DLBCL and provides a functional rationale for the use of BET inhibitors in this disease.

Mantle cell lymphoma: initial report from the North American Mantle Cell Lymphoma Consortium

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Background: The goal of the North American Mantle Cell Lymphoma (MCL) Project is to evaluate the clinical, biological, and genomic markers that affect the outcome of patients with MCL. Methods: We have retrospectively studied the clinical and pathological features of 307/421 patients diagnosed with MCL between January 2000 to December 2012 from 23 institutions across North American. Results: The male to female ratio of MCL patients was 3.5:1, with a median age of 66 years (range: 24-106 years). Approximately 29% of patients (78/269) presented with B symptoms and 257 (257/307, 83.7%) patients had extranodal involvement at diagnosis. Median follow-up was 7.1 years (range, 0.03 to 16.6 years) with the five-year PFS and OS at 27.8%, and 54.4%, respectively. Univariate analysis revealed that the following factors were significantly associated with both inferior OS and PFS ( p< 0.05): older age (≥60 years), presence of B symptoms, advanced Ann Arbor stage, elevated LDH, low platelets (≤100K/ml), blastoid/pleomorphic cytology, Ki67 proliferation ≥30%, circulating tumor cells, no transplantation (vs. transplantation), and allogeneic (vs. autologous) stem cell transplantation. In addition, large tumor size (maximal diameter > 3cm), high WBC ( > 10×103/ml), CD5 or CD23 positivity, and a complex karyotype were associated with inferior OS ( p< 0.05). Multivariate Cox regression analysis showed age (≥ 60y; p= 0.0028, HR = 2.44, 95% CI: 1.36-4.38) and high LDH ( p= 0.0062, HR = 2.19, 95% CI: 1.25-3.84) were the two factors predicting the clinical outcome. MIPI-c, a commonly used prognostic scoring system which includes Ki67, stratified the 100 MCL cases into four group with distinct clinical outcomes ( p< 0.001). Using readily-available clinical and pathological variables, we developed a simple and robust scoring system, MIPI-P (pathology), which consisted of age (≥60 years), LDH (high), Ki67 index (≥30%), Ann Arbor stage (III/IV), and cytological type (blastoid/pleomorphic), each contributing one point. The MIPI-P system stratified 104 MCL cases into three distinct groups ( p< 0.001). Median survival for the different groups were: low grade (0-1 points): 11.8 years; intermediate grade (2-3 points): 4.9 years; and high grade (4-5 points): 1.6 years. We further validated this system in an independent cohort of 33 MCL cases and confirmed that the modified MIPI-P provided robust prognostic predication ( p= 0.014). Conclusions: The clinical and biologic characteristics of MCL can provide information assisting with the prognosis of patients with MCL.

Flow cytometric characteristics of extrathymic thymocytes in adenoid tissue: A case report and comparison to normal thymus and thymoma

BACKGROUND

Normal thymocyte precursors in secondary lymphoid organs have previously been described. It is important to recognize normal thymocyte precursors by flow cytometry to differentiate them from T-cell lymphoblastic leukemia.

METHODS

A 3-year-old boy status 2 years post-allogenic cardiac transplant underwent adenoidectomy to exclude post-transplant lymphoproliferative disorder. Microscopic, immunohistochemical, and flow cytometry analyses of the adenoid were performed.

RESULTS

By flow cytometry, a population of CD45+(dim)/CD7+(bright)/CD3- cells were observed at 1.0% of lymphocytes. These cells expressed CD10, partial CD34, and exhibited acquisition of CD4 followed by CD8. Within the brighter CD45+ lymphocytes, a population of CD3-/CD4+/CD8+ thymocytes and a similarly sized population of CD4+/CD8+ cells exhibiting acquisition of low-density CD3 were identified. By immunostaining, clusters of TdT+/CD1a+/CD4+/CD8+ T-cells were identified in the interfollicular areas. Compared to normal thymus, thymocytes in the adenoid tissue lacked the classic CD4xCD8 winged differentiation profile but showed a normal early precursor pattern.

CONCLUSIONS

Thymocytes in adenoid show a similar differentiation pattern to thymus and thymoma. However, the classic winged pattern of common thymocyte differentiation may not be readily apparent in thymocytes differentiating outside of the thymus. Recognition of the early thymocyte precursor antigen acquisition profile can be crucial to correct interpretation. © 2017 International Clinical Cytometry Society.

The stromal cell marker SPARC predicts for survival in patients with diffuse large B-cell lymphoma treated with rituximab

The cellular composition of the tumor microenvironment may affect survival in diffuse large B-cell lymphoma (DLBCL). We performed immunostains for 2 stromal cell markers, CD68 and SPARC (secreted protein, acidic and rich in cysteine), in 262 patients with DLBCL treated with rituximab and cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP-like therapies. Patients with any SPARC+ cells in the microenvironment had a significantly longer overall survival, and patients with high SPARC positivity in the microenvironment also had a significantly longer event-free survival. Survival differences were mainly due to the prognostic effect of SPARC+ cells in activated B-cell (ABC)-type DLBCL, with no effect found in the germinal center B-cell-type DLBCL. Of clinical features examined, only the number of extranodal sites was significantly associated with SPARC expression. Multivariate analysis revealed that SPARC expression predicted patient survival independent of the International Prognostic Index or tumor cell of origin. SPARC expression in the microenvironment of DLBCL can be used for prognostic purposes, determining a subgroup of patients with ABC DLBCL who have significantly longer survival. More aggressive chemotherapy protocols should be considered for patients with ABC DLBCL without SPARC+ stromal cells. CD68 expression by cells in the microenvironment did not predict survival.

Bacterial contamination and over-dilution of commercial infant formula prepared by HIV-infected mothers in a Prevention of Mother-to-Child Transmission (PMTCT) Programme, South Africa

To examine the safety of formula feeds used by mothers participating in a Prevention of Mother-to-Child Transmission (PMTCT) programme, contents of 94 feeding bottles collected at a PMTCT-clinic were analysed. An additional 17 samples were taken from already prepared feeds during home visits, as well as 21 samples from bottles prepared under observation. Living conditions and educational levels were overall good and mothers had been counselled on safe formula preparation. Samples were analysed for faecal bacteria, using Escherichia coli and Enterococcus sp. as indicators. Protein concentration was used as an indicator of concentration of the formula. Out of 94, 63 (67%) of samples obtained at the clinic and 13/16 (81%) of available home samples were contaminated with faecal bacteria, compared to 8/21 (38%) of those prepared under observation. Out of 94, 58 (62%) of the clinic samples containing E. coli and 23/94 (24%) of those containing Enterococcus sp. were contaminated with more than the US government recommended limit of 10 CFU/ml. Out of 94, 26 (28%) of samples obtained at the clinic, 8/17 (47%) of home samples and 3/21 (14%) of those prepared under observation were over-diluted, compared to standards. Many mothers did not follow recommended practices in preparing and feeding the bottles.

The effects of a 3-year obesity intervention in schoolchildren in Beijing

BACKGROUND

Childhood obesity has become a health problem in urban areas in China. Intervention to reduce childhood obesity should be of high priority. School-based intervention programmes are needed to deal with the growing prevalence of childhood obesity in China.

METHODS

Five primary schools were selected randomly for this study in the Beijing urban area in China; two were allocated to the intervention group and three to the control group. A total of 2425 children (1029 children in intervention schools and 1396 children in control schools) took part in the study for 3 years. In the intervention group, children and their parents were involved in a programme of nutrition education and physical activity. Control school students followed their usual health and physical education curriculum with no extra intervention.

RESULTS

After the 3-year intervention, the prevalence of overweight and obesity were significantly lower in the intervention schools than in the control schools (overweight: 9.8% vs. 14.4%, P < 0.01; obesity: 7.9% vs. 13.3%, P < 0.01). The prevalence of overweight and obesity decreased by 26.3% and 32.5% in intervention schools respectively after intervention. The prevalence of overweight and obesity increased in control schools. There was also significant difference in body mass index between intervention and control schools (18.2 +/- 2.6 vs. 20.3 +/- 3.4, P < 0.01) after intervention. More non-obese children became obese in the control schools (7.0%) than in the intervention schools (2.4%) at end line (P < 0.01). Among the children who were obese at baseline, 49.2% remained obese at end line in intervention schools while 61.9% remained obese in control schools (P < 0.01).

CONCLUSIONS

Our study showed that an intervention programme could be feasible in schools in Beijing, China. The prevalence of overweight and obesity was reduced in schoolchildren in Beijing through an intervention focused on nutrition education and physical activity. Overweight and obesity children as well as normal weight children and their parents should be involved in such an intervention programme.

Sustainable universal salt iodization in low-income countries - time to re-think strategies?

OBJECTIVE

Sustained iodine deficiency control requires sustainable mechanisms for iodine supplementation. We aim to describe the status of salt iodation machines, salt producers' experiences and quality of salt produced in Tanzania.

METHODS

Qualitative and quantitative data was collected from the factory sites, observations were made on the status of UNICEF-supplied assisted-iodation machines and convenience samples of salt from 85 salt production facilities were analysed for iodine content.

RESULTS

A total of 140 salt works visited had received 72 salt iodation machines in 1990s, but had largely abandoned them due to high running and maintenance costs. Locally devised simple technology was instead being used to iodate salt. High variability of salt iodine content was found and only 7% of samples fell within the required iodation range.

CONCLUSION

Although iodine content at factory level is highly variable, overall iodine supply to the population has been deemed largely sufficient. The need for perpetual iodine fortification requires reassessment of salt iodation techniques and production-monitoring systems to ensure sustainability. The emerging local technologies need evaluation as alternative approaches for sustaining universal salt iodation in low-income countries with many small-scale salt producers.

Iodine deficiency persists in the Zanzibar Islands of Tanzania

BACKGROUND

Iodine is an essential micronutrient for normal human growth and development. It is estimated that more than 1.6 billion people live in iodine-deficient environments, yet there are still some countries and areas where the prevalence of iodine-deficiency disorders is unknown.

OBJECTIVE

To establish the prevalence of iodine-deficiency disorders in the Zanzibar Islands, a community assumed to have ready access to iodine-rich seafoods.

METHODS

In a cross-sectional study, 11,967 schoolchildren were palpated for goiter prevalence, a subsample was evaluated for urinary iodine concentration, and the availability of iodated salt was assessed at the household and retail levels.

RESULTS

The mean total goiter prevalence was 21.3% for Unguja and 32.0% for Pemba. The overall median urinary iodine concentration was 127.5 microg/L. For Unguja the median was 185.7 microg/L, a higher value than the median of 53.4 microg/L for Pemba (p < .01). The household availability of iodated salt was 63.5% in Unguja and 1.0% in Pemba. The community was not aware of the iodine-deficiency problem and had never heard of iodated salt.

CONCLUSIONS

The inadequate intake of iodine documented in the Zanzibar Islands belies the common assumption that an island population with access to seafood is not at risk for iodine-deficiency disorders. We urge health planners to implement mandatory salt iodation and education efforts to alleviate the situation.

Portal hyperperfusion causes disturbance of microcirculation and increased rate of hepatocellular apoptosis: investigations in heterotopic rat liver transplantation with portal vein arterialization

Clinical results of portal vein arterialization (PVA) in liver transplantation are controversial. One reason for this is the lack of a standardized flow regulation. Our experiments in rats compared PVA with blood-flow regulation to PVA with hyperperfusion in heterotopic auxiliary liver transplantation (HALT). In group I (n = 19), the graft's portal vein was completely arterialized via the right renal artery in-stent technique, using a 0.3-mm stent, leading to a physiological average portal blood flow. In group II (n = 19), a 0.5-mm stent was used. In group II, the average portal blood flow after reperfusion was significantly elevated (group II: 6.4 +/- 1.5; group I: 1.7 +/- 0.4 mL/min/g of liver weight; P < .001). The sinusoidal diameter after reperfusion was significantly greater in group II (9.8 +/- 0.5 microm) than in group I (5.5 +/- 0.2 microm; P < .001). Red blood cell velocity in the dilated sinusoids was significantly lower in group II (171 +/- 18 microm/s) than in group I (252 +/- 13 microm/s). Stasis of erythrocytes occurred; consequently, the functional sinusoidal density was significantly reduced in group II (38 +/- 7%) compared with group I (50 +/- 3%; P < .01). Two hours after reperfusion of the portal vein, the number of apoptotic hepatocytes was significantly higher in group II than in group I (I: 0 +/- 0 vs II: 7 +/- 9 M30-positive hepatocytes/10 high-power fields). The 6-week survival rate was 9 of 11 in both groups. In group II, 6 of 9 grafts showed massive hepatocellular necroses after 6 weeks, whereas in group I, only 1 of 9 presented a slight hepatocellular necrosis. Finally, our results demonstrate negative effects of portal hyperperfusion in transplanted livers, which are correctable by adequate flow regulation.

A two year family based behaviour treatment for obese children

BACKGROUND

Childhood obesity has become a nutritional problem in China since the 1990s.

AIMS

A family based behavioural treatment was developed and tested, to see if its use was feasible in China and to evaluate its impact on obese schoolchildren.

METHODS

In a single school in Beijing, 33 obese children were randomly assigned to a treatment group and 35 to a control group. The treatment group participated in a family based behavioural treatment programme for two years. Height and weight were measured every six months for all participants. Blood pressure, cholesterol, and triglyceride levels were measured at baseline and after two years of programme implementation.

RESULTS

Body mass index (BMI, kg/m2) was significantly reduced in the treatment group (from 26.6 (1.7) to 24.0 (0.9), 95% CI 2.06 to 3.18) but not in the control group (from 26.1 (1.5) to 26.0 (1.6)). Total cholesterol decreased 5.5% and triglycerides 9.7% in the treatment group. There was a significant correlation between change in BMI and change in triglycerides. There were no significant changes in plasma lipids in the controls. Blood pressure values also decreased significantly in the treatment, but not the control group.

CONCLUSIONS

A family based behavioural intervention was feasible to use in treating obesity in schoolchildren in Beijing, China. After two years of implementation, it successfully decreased the degree of obesity, reduced levels of blood pressure, and decreased serum lipids in treatment; there were no significant changes among control children.

Loss of major histocompatibility class II expression in non-immune-privileged site diffuse large B-cell lymphoma is highly coordinated and not due to chromosomal deletions

Decreased major histocompatibility class II (MHCII) expression is associated with poor survival in diffuse large B-cell lymphoma (DLBCL). Immune-privileged site DLBCL (IP-DLBCL) patients reportedly have frequent large deletions at the MHCII locus whereas the mechanism of decreased expression in non-IP-DLBCL is unknown. Gene expression profiling data were used for correlation analyses between expression levels of MHCII genes with each other and their transcriptional regulator, CIITA. Comparative genomic hybridization (CGH) assessed chromosomal alterations at MHCII-related loci. Finally, a map was created of expression of genes that are telomeric, within, or centromeric to the MHCII locus. Correlation coefficients among MHCII genes ranged from 0.73 to 0.92, whereas those between adjacent and intervening genes were lower (-0.12 to 0.49). Correlations between MHCII and CIITA expression were higher (0.53 to 0.60) than between CIITA and neighboring genes (-0.05 to 0.22). In 23 MHCII(-) cases, CGH detected 2 losses and 2 gains at MHCII loci. Expression of genes telomeric, within, and centromeric to MHCII loci were near normal in most MHCII(-) cases. Large deletions of the MHCII locus are uncommon in non-IP-DLBCL, implicating altered transcription as the operative mechanism for decreased expression.

Iodine nutrition among indigenous Tarahumara schoolchildren in Mexico

This paper adds iodine data to the nutritional survey recently published in the Eur J Clin Nutr (2004;58:532-540) to identify growth retardation and micronutrient deficiencies among Tarahumara children from five selected indigenous boarding schools in Mexico. Total goiter rate (TGR) (n=384), urinary iodine concentrations (UI) (n = 100), and iodine content of salt were measured. Overall, TGR was 7.0% (grade 1 = 6.8%, grade 2 = 0.2%). The median UI of the group was 125 microg/l, while the median UI across the schools ranged from 92.0-156.5 microg/l, with 32 and 6% of the children having UI between 50-99 microg/l and 20-49 microg/l, respectively. The iodine content in all the salt packages checked at the schools was above 25 parts per million. Based on TGR and UI, there is a marginal iodine deficiency in this sample of children, probably due to an insufficient iodine intake. These results add to existing evidence that iodine deficiency still constitutes a public health problem in certain populations living in the mountainous regions in Mexico.

Anticancer activity of a lectin-rich mistletoe extract injected intratumorally into human pancreatic cancer xenografts

BACKGROUND

In single case observations, tumour remissions after intratumoral injections of mistletoe extracts have been described.

MATERIALS AND METHODS

We investigated the antitumour activity of intratumorally (i.t.)-injected lectin-rich mistletoe extract at different dosages and i.t.-injected mistletoe lectin I in comparison to intravenous (i.v.) Gemcitabine and i.t. treatment with placebo in a human pancreatic cancer xenograft.

RESULTS

In a preliminary dose-response experiment, the most marked tumour inhibition was induced when mistletoe extract was given at 8 mg/kg body weight (BW) and mistletoe lectin I at 5.3 microg/kg BW. In a second experiment, bi-weekly i.t. injections of mistletoe extract over 8 weeks resulted in a very high antitumour activity with an optimal T/C value (=median relative tumour volume of the test group vs. the control) of 0.4% combined with 3/8 partial and 3/8 complete remissions. Gemcitabine was less active with 2/8 partial and 1/8 complete remissions and an optimal TIC of 4.6%.

CONCLUSION

I.t.-injected lectin-rich mistletoe extract should be further evaluated in patients with inoperable locally advanced pancreatic cancer.

Nutritional status of indigenous children at boarding schools in northern Mexico

OBJECTIVE

To assess the nutritional status of Tarahumara children at indigenous boarding schools.

DESIGN

Cross-sectional comprehensive nutritional survey.

SETTING

The schools sampled were located in indigenous municipalities of the northern Mexican state of Chihuahua.

SUBJECTS

The study was carried out in 2001 among 331 children aged 6-14 y from a sample of five schools. Anthropometric measurements, a thyroid exam and capillary haemoglobin levels were obtained from the children. Serum concentrations of ferritin, iron, total iron-binding capacity, vitamin B(12), folic acid and zinc were collected from a subsample of 100 children.

RESULTS

The prevalence of wasting and overweight (children 6-9 y) was 1.1 and 4.6%, respectively, and of underweight, risk of overweight and overweight (10-14 y) was 3.2, 5.1 and 0.6%, respectively. Stunting (6-12 y) was present in 22.3% of the children. The total goitre rate was 5.4%. The prevalence of anaemia was 13% (boys 11.4, girls 14.5%). Overall, 24.2% of the children were iron deficient (depletion 11.1%, deficient erythropoiesis 3%, iron deficiency anaemia 10.1%). No child had folic acid values <3 ng/ml, but 20.2% had low (<200 microg/dl) and 27.3% marginal (200-300 microg/dl) vitamin B(12) levels, and 80.2% had low zinc concentrations (<60 microg/dl).

CONCLUSIONS

Nutritional underweight and stunting were similar to those reported in rural localities at the national level, but overweight was less prevalent in children aged 10-14 y. Various micronutrient deficiencies was identified including zinc and vitamin B(12), but the prevalence of iron and folic acid deficiency was lower than expected. These results suggest that Tarahumara children attending boarding schools may be the better-off children from these extremely poor and marginalized areas.

SPONSORSHIP

Swedish Agency for Research Cooperation with Developing Countries and the Mexican Social Security Institute.

CNOP for diffuse aggressive non-Hodgkin's lymphoma: the Nebraska lymphoma study group experience

The purpose of this study was to evaluate the CNOP regimen (cyclophosphamide, mitoxantrone, vincristine, and prednisone) throughout a community based oncology network with a large number of elderly non-Hodgkin's lymphoma (NHL) patients. Three hundred and seventy-three previously untreated patients with diffuse aggressive NHL received the CNOP regimen administered through a community oncology network, the Nebraska Lymphoma Study Group (NLSG). The complete response rate was 60% with an overall response rate of 73%. The estimated 4-year event-free survival for patients <60years was 44%, compared to 38% for those >age 60 (p = 0.18). However, the 4-year estimated overall survival for patients <60 years was 62% compared to 44% for those >60 years (p < 0.001). Prognostic factors predictive for a poor event-free survival were male gender, stage III/IV disease, Karnofsky score <80, and elevated lactic dehydrogenase (LDH). The lymphoma specific cumulative death rate was 29% for patients <60 years compared with 33% for patients >60 years (p = 0.07). After failing CNOP the 4-year overall survival (OS) was 19%. The estimated 4-year OS for patients who failed CNOP and went on to receive high-dose chemotherapy (HDC) and autologous hematopoietic stem cell transplant (ASCT) was 64% for patients < age 60 and 48% for those >60 years (p = 0.23). In conclusion, CNOP chemotherapy administered to patients with diffuse aggressive NHL in a community oncology network produces similar result to that reported for other anthracycline based regimens reported in the literature. Patients >age 60 had a higher rate of failure due to causes other than lymphoma which accounted for a worse survival long-term. However, patients of all ages who failed CNOP and who were able to receive HDC and ASCT demonstrated long-term disease survival after the transplant.

Hodgkin's disease in the elderly: improved treatment outcome with a doxorubicin-containing regimen

PURPOSE

Hodgkin's disease (HD) is a malignancy that displays a bimodal age distribution. Previous reports of treatment in patients greater-than-or-equal 60 years have found a poor outcome, particularly in patients with advanced disease. Because of an improved side-effect profile, the regimen of chlorambucil, vinblastine, procarbazine, and prednisone (ChlVPP) has been proposed for use in elderly patients.

PATIENTS AND METHODS

From September 1982 to May 1998, 262 patients with previously untreated HD received either ChlVPP (n = 176) or ChlVPP plus doxorubicin/bleomycin/vincristine (ChlVPP/ABV hybrid; n = 86). Fifty-six patients were greater-than-or-equal 60 years old, and 206 were younger than 60 years.

RESULTS

The 5-year overall survival (OS; 87% v 39%) and the 5-year event-free survival (EFS; 75% v 31%) favored patients younger than 60 years of age. Prognostic factors analyzed in patients greater-than-or-equal 60 years of age, other than type of therapy, included sex, stage, Karnofsky performance score, lactic dehydrogenase, number of extranodal sites, B symptoms, size of largest mass, and histologic subtype. In patients older than 60 years, none of the clinical features was a statistically significant predictor of EFS; however, ChlVPP/ABV hybrid was associated with a decreased risk of an event (relative risk, 0.40; 95% confidence interval, 0.19 to 0.83; P =.014) compared with ChlVPP. The 5-year OS for patients greater-than-or-equal 60 years who received ChlVPP was 30%, compared with 67% for those patients receiving the ChlVPP/ABV regimen (P =.0086)

CONCLUSION

Patients greater-than-or-equal 60 years with HD who require chemotherapy are better treated with ChlVPP/ABV hybrid than with ChlVPP alone.

Atypical Lymphoproliferative Diseases

This review addresses the clinical presentation, pathology, and therapy of several uncommon lymphoid proliferations. Because these lymphoproliferations span the characteristics of reactive polymorphous proliferations to clonal malignant neoplasms, they are often difficult to diagnose and treat effectively. In Section I, Dr. Greiner describes the pathology of the spectrum of atypical lymphoid disorders including Castleman's disease, angioimmunoblastic lymphadenopathy, lymphadenopathy in autoimmune diseases, posttransplant lymphoproliferative disorders, and X-linked lymphoproliferative disorder. The relationship to Epstein-Barr virus (EBV) and human herpsesvirus-8 (HHV-8) is discussed, and molecular diagnostic assays and principles for obtaining proper diagnostic evaluation are emphasized. In Section II, Dr. Armitage presents a practical approach to the management of Castleman's disease. The discussion includes the importance of confirmation of the histological diagnosis and careful staging evaluation, therapeutic options, and the increased risks for infection and lymphoma. The appropriate roles of surgical excision, corticosteroids, and combination chemotherapy are addressed along with alternative strategies such as anti-interleukin-6 and bone marrow transplantation. In Section III, Dr. Gross reviews the treatment of EBV-associated lymphoproliferative disorders in primary immunodeficiencies and in post-transplant patients. He gives an update on the recent molecular discoveries in X-linked lymphoproliferative disorder. Preliminary results of a phase II trial of low-dose cyclophosphamide in posttransplant lymphoproliferative disorders and the use of GM-CSF as preemptive therapy are presented.

Iron deficiency anemia in Tarahumara women of reproductive-age in northern Mexico

OBJECTIVE

To determine the prevalence of iron deficiency anemia (IDA) among Tarahumara women of reproductive age.

MATERIAL AND METHODS

A cross-sectional survey was conducted in a representative sample of 481 women aged 12-49 years, residents of Guachochi Municipality, Chihuahua, from June to September 1998. The hemoglobin (Hb) level was measured in capillary blood using the Hemocue technique, and the serum ferritin level in capillary serum spotted on filter paper, in a sub-sample of women. Central tendency and dispersion measures were estimated; the Chi-squared test was used to test differences in proportions and ANOVA and Bonferroni's test for differences in means.

RESULTS

Prevalence of anemia (mean Hb +/- S.D.) was 16.1% (140 +/- 16 g/l) and 25.7% (129 +/- 12 g/l) for non-pregnant and pregnant women, respectively. Pregnant women in the 3rd trimester and those who were breast-feeding their children during the first 6 months after delivery had the highest prevalence of anemia (38.5% and 42.9%, respectively). Iron deficiency was responsible for most of the anemia found in this sample.

CONCLUSIONS

This study provides relevant information for the development of intervention programs to treat and prevent IDA in this ethnic group.

Information and socioeconomic factors associated with early breastfeeding practices in rural and urban Morogoro, Tanzania

A cross-sectional study was undertaken in a rural and an urban area in Tanzania with the aim of identifying factors related to early infant feeding practices. The study included 320 mothers from each area with infants below 7 mo of age. A significant proportion of both rural and urban mothers had erroneous beliefs about infant feeding practices. None of the socioeconomic, demographic or biological variables studied were associated with feeding practices. Urban residence was positively associated with the duration of exclusive but not predominant breastfeeding. Better knowledge about specific breastfeeding issues was positively associated with the duration of both exclusive and predominant breastfeeding. Ownership of a radio was positively associated with both exclusive and predominant breastfeeding in the rural area. Although both rural and urban mothers had a high antenatal clinic attendance rate, 65% of the rural and 14% of the urban mothers delivered at home. Urban mothers informed about breastfeeding at the antenatal clinic had better feeding practices.

CONCLUSION

We hypothesize that exclusive breastfeeding is not a traditionally recognized practice and thus its duration is mainly associated with information and knowledge about breastfeeding. This suggests that information programmes to provide knowledge, beginning at antenatal visits, may reduce premature complementation, though additional support may also be required.

Clinical and pathological features of posttransplant lymphoproliferative disorders: influence on survival and response to treatment

PURPOSE

To review the clinical and pathological characteristics of patients with posttransplant lymphoproliferative disorders (PTLD) occurring after solid organ transplantation and determine the influence of these characteristics on response to treatment and survival.

PATIENTS AND METHODS

Retrospective review of 32 patients.

RESULTS

Overall five-year survival was 59%. Forty-five percent of patients diagnosed within the first year after transplant had advanced disease. Characteristics that were associated with poorer survival were diagnosis within the first year posttransplant, monoclonal tumors and presentation with an infectious mononucleosis-like syndrome. Six of eight patients treated with surgery are alive and disease-free.

CONCLUSION

Patients with PTLD can achieve long-term survival. Surgery can play an important role in selected patients. Characteristics that may be associated with poorer survival are diagnosis within the first year after transplant, presence of a monoclonal tumor or an infectious mononucleosis-like presentation.

Evidence of grave vitamin A deficiency among lactating women in the semi-arid rural area of Makhaza in Zimbabwe. A population-based study

OBJECTIVE

To assess the vitamin A and iron status of lactating women.

DESIGN

A population-based cross-sectional descriptive study.

SETTING

A semi-arid rural area of Makhaza in Zimbabwe.

SUBJECTS

Two hundred and seven lactating women with babies aged 2-12 months.

METHODS

Serum retinol (SR) was measured by HPLC, serum ferritin (SF) by ELIZA, haemoglobin (Hb) by HemoCue and C-reactive protein (CRP) by a turbo metric method. A seven-day recall of consumption of vitamin A containing foods was recorded.

MAIN OUTCOME MEASURES

Relative dose response (RDR), SR, SF, Hb and CRP.

RESULTS

Dark green leafy vegetables were the main sources of vitamin A; retinol-containing foods and yellow to red fruits and vegetables were rarely consumed. Five women had elevated CRP and these women had lower SR (P < 0.001) than the rest. Forty percent of the women had vitamin A deficiency (SR < 20 microg/dl), 76% had low liver stores of vitamin A (RDR > 20%) while 15 women had both abnormal SR and abnormal RDR. Forty percent had anaemia (Hb < 12 g/l) while 12% had iron deficiency (SF < 12 microg/dl) and 4% (n = 7) had iron deficiency anaemia.

CONCLUSION

Vitamin A and iron deficiencies are problems of public health significance among the lactating women in the Makhaza area.

Supplementing lactating women with puréed papaya and grated carrots improved vitamin A status in a placebo-controlled trial

Doubts have been raised about the effectiveness of carotene-containing foods in improving the vitamin A status of populations at risk. We investigated the effect of papaya and carrots on the vitamin A status of lactating women with 2- to 12-mo-old infants in ZIMBABWE: The women were randomly assigned to three supplementation groups and a placebo group, and received 6 mg of beta-carotene capsules, 650 g puréed papaya, 100 g grated carrots or a placebo, daily for 60 d. All groups were given a meal containing 10 g of vegetable oil daily. Serum retinol, relative dose response, serum ferritin, hemoglobin and C-reactive protein were measured before and after the supplementation period. Mean serum retinol increased significantly after supplementation in the beta-carotene group (P < 0.001), the papaya group (P < 0.001) and the carrot group (P < 0.001), but not in the placebo group (P > 0.05). The relative dose response decreased significantly (P < 0.05) in the beta-carotene and papaya groups, but not in the carrot or placebo groups (P > 0.05). There was an increase in mean serum ferritin in all groups but the increase did not differ among groups. The hemoglobin increases in the beta-carotene and papaya groups were greater than that in the placebo group. We conclude that puréed papaya and grated carrots can improve the vitamin A and iron nutriture of lactating women. These findings reinforce the importance of plant food-based approaches in the control of vitamin A deficiency in low income countries.

Exclusive breast-feeding is rarely practised in rural and urban Morogoro, Tanzania

OBJECTIVE

To investigate and compare feeding practices among infants of less than 7 months of age in a rural and an urban area in Tanzania.

DESIGN

Cross-sectional, questionnaire-based interview of mothers and focus group discussions with extension workers and community leaders.

SETTING

Eleven villages in a rural district and 10 wards in an urban district in the Morogoro region, Tanzania, west of Dar es Salaam.

SUBJECTS

Probability samples of mothers with infants of less than 7 months of age from each area).

RESULTS

Exclusive breast-feeding was rarely practised in either the rural or urban areas investigated. However, the urban mothers initiated breast-feeding earlier, discarded colostrum less frequently, breast-fed exclusively for a longer period, gave breast milk as the first feed more often and delayed the introduction of solid foods for longer than their rural counterparts. The rural mothers, on the other hand, breast-fed their previous infants slightly longer than the urban mothers.

CONCLUSIONS

The better performance of urban mothers could be partly due to sustained breast-feeding support in hospital settings and other campaigns which may not have reached the rural areas. In both the rural and urban areas more efforts are needed to encourage exclusive breast-feeding, to avoid premature complementation and, in the case of the urban areas, to protect extended breast-feeding.

Variability in nutrient intakes among pregnant women in Indonesia: implications for the design of epidemiological studies using the 24-h recall method

Few studies have assessed the reliability of dietary intake methods during pregnancy. Between 1996 and 1998, a longitudinal study of dietary intake during pregnancy was carried out among 451 women in Central Java, Indonesia. Six 24-h recalls were performed each trimester. We report here on intraindividual and interindividual variability in energy and nutrient intakes, as well as the reliability of the 24-h diet recall method. Implications of the use of different numbers of replicate days for estimating dietary intake and the relationships between dietary intake and health outcomes are also discussed. Intravariance-to-intervariance ratios were <1 for energy and carbohydrates and >1 for all other nutrients throughout pregnancy. Reliability analyses found good agreement (reliability coefficient >0.7) with three replicates for the macronutrients, but at least six replicates were needed for an agreement of > or =0.6 for the micronutrients. To estimate true individual average intake with a precision of +/-20%, six replicate recalls were sufficient for energy, carbohydrates, vitamin A, iron and vitamin C. In conclusion, mean intake of several nutrients can be reliably measured with the 24-h recall method, using a limited number of days. The nutrient of interest, the primary objectives and method of analyses should all be taken into account when planning sample size and number of replicates.

Increase in serum beta-carotene following dark green leafy vegetable supplementation in Mebendazole-treated school children in Bangladesh

OBJECTIVE

To study the effect of consumption of dark green leafy vegetables (DGLV) and sweet pumpkin on serum beta-carotene and retinol concentrations in children treated for Ascaris lumbricoides.

DESIGN

Experimental study with a randomised design.

SUBJECTS

A total of 110 primary school children aged 8-12 y in northwestern Bangladesh.

INTERVENTIONS

All children were de-wormed and 2 weeks later randomly assigned to one of three groups to receive for 6 days per week, for 6 weeks, one complete meal containing either: (1) 4.4 mg beta-carotene from DGLV (n=37, after 18 dropouts); (2) 1.5 mg beta-carotene from sweet pumpkin (n=36, 18 dropouts); or (3) vegetables containing virtually no beta-carotene (control) (n = 37, 18 dropouts).

RESULTS

Significant increases (P < 0.001) in mean serum beta-carotene concentrations were seen in all three study groups, with a statistically higher increase (micromol/l) in the DGLV group (0.44; 95% confidence interval (CI) 0.32, 0.55) compared to the control group (0.20; 95% CI 0.14, 0.26; P = 0.002). The increase in serum retinol (micromol/l) was statistically significant (P=0.04) only in the DGLV group (mean 0.066; 95% CI 0.002, 0.13), but this increase was not different from the increase in the control group.

CONCLUSION

In children successfully treated for Ascaris lumbricoides, a substantial increase in serum beta-carotene was seen after feeding with a moderately high cumulative dose of DGLV for 6 weeks.

Infant feeding practices during the first six months of life in a rural area in Tanzania

OBJECTIVE

To assess breastfeeding practices in infants aged 0-6 months, focussing particularly on beliefs, knowledge and practices affecting exclusive breastfeeding.

DESIGN

A house-to-house survey with individual interviews using a structured questionnaire, key informants interviews and focus group discussions.

PARTICIPANTS

One hundred and seven mothers were interviewed, nearly all of those living in Nkinga community with infants less than seven months old. The focus group discussions and key informant interviews were also held.

SETTING

Nkinga community, Igunga District, Tabora region, Tanzania.

RESULTS

Sixty four per cent of the sample was put to the breast within two to eleven hours. Prelacteal feeds were given to about 25% of the infants. The type of prelacteal fluid given was mainly glucose water in hospital and plain water with home deliveries. Forty six per cent of the mothers discarded colostrum. The median duration of exclusive breastfeeding was about two months and of full breastfeeding was about four months.

CONCLUSION

The average duration of exclusive breastfeeding, though far below recommended levels, is higher than is found in most studies in Africa and Tanzania. This may be due to the efforts of hospital staff who had received special training on breastfeeding in recent years.

Five-year follow-up of a food-based vitamin A intervention in Tanzania

OBJECTIVE

: To evaluate the long-term effects of a horticultural and nutrition education intervention in rural Tanzania.

DESIGN

: A quasi-experimental post-test design was used.

SETTING

: The research was carried out in 10 villages in Singida region, Tanzania.

SUBJECTS

: Mothers and their children aged 6-71 months (n = 236) from an experimental (Ilongero) and control (Ihanja) area were interviewed regarding knowledge and practices related to vitamin A nutrition. Intake of vitamin A-rich foods by the children during the 7 days prior to the interview was recorded. Stools were examined for helminths and serum samples were analysed for retinol and C-reactive protein (CRP) (n = 146) for the children aged 12-71 months.

RESULTS

: Knowledge and practices were more favourable to vitamin A intake in the experimental area than in the control area, and an increased frequency of intake of green leaves was associated with higher serum retinol values. The experimental area had lower mean serum retinol levels (13.7 microg dl(-1), n = 75) than the control area (19.3 microg dl(-1), n = 71). One likely confounder was the higher helminth infestation in the experimental area (n = 75, 79%) than in the control area (n = 71, 49%) (P < 0.001). Children with helminths (n = 94) had a lower mean serum retinol level than those without (n = 52) (12.3 +/- 5 vs. 24 +/- 10 microg dl(-1); P = 0.001).

CONCLUSIONS

: Food-based vitamin A programmes can make sustainable improvements in knowledge and dietary practices but these may not necessarily be reflected in increases in serum retinol. Programme implementation and evaluation should take confounders into consideration as, in this case, helminth infestation.

How exclusive is exclusive breastfeeding? A comparison of data since birth with current status data

BACKGROUND

There is no accepted and widely used indicator for exclusive breastfeeding since birth. Indeed, the difference between 'current status' data on exclusive breastfeeding and data on 'exclusive breastfeeding since birth' is rarely recognized. We used data from a longitudinal study to examine this issue.

METHODS

A descriptive longitudinal, prospective study design was used in which 506 mother-infant pairs were included. The mothers completed daily recordings on infant feeding during the first nine months after birth. A research assistant conducted fortnightly home visits with structured interviews. The resulting data on breastfeeding patterns are presented in two different ways: analysis of 'current status' data based on a single 24-hour recording of infant feeding at 2, 4 and 6 months of age, and analysis of data 'since birth', i.e. data on infant feeding for every day, starting from birth until the ages of 2, 4 and 6 months.

RESULTS

A wide discrepancy between the results obtained from the two analyses was found. The difference in the exclusive breastfeeding rate was over 40 percentage points at both 2 and 4 months of age (92% versus 51% at 2 months and 73% versus 30% at 4 months) and 9 percentage points at 6 months (11% versus 1.8%).

CONCLUSIONS

Current status indicators based on a 24-hour period may be inadequate and even misleading for many purposes. We propose that in many studies an indicator called 'exclusive breastfeeding since birth' could be added.

Relationships between vitamin A, iron status and helminthiasis in Bangladeshi school children

OBJECTIVE

To explore the relationships between biochemical indicators of vitamin A and iron status and the intestinal helminths Ascaris lumbricoides and hookworm in primary school children.

SETTING

Two rural governmental schools in northwestern Bangladesh.

DESIGN

Cross-sectional study.

SUBJECTS

The sample consisted of 164 children in grades 3-5.

METHODS

Serum retinol and beta-carotene (by high-performance liquid chromatography, HPLC), haemoglobin (HemoCue), ferritin (enzyme-linked immunoadsorbent assay, ELIZA) and height and weight were measured. Dietary intake of vitamin A was assessed using a food frequency questionnaire and faecal analyses were done using Stoll's egg-count technique.

RESULTS

The mean serum retinol was 26.8 microg dl(-1) and 20% had a level of < 20 microg dl(-1), the cut-off value for low vitamin A status. There was a strong positive association between serum beta-carotene and serum retinol (r = 0.44, P < 0.001), suggesting those with higher retinol levels had a higher carotene intake. Thirty-one per cent were anaemic (Hb < 11.5 g dl(-1)), 30% had iron deficiency (serum ferritin < 12.0 microg l(-1)) and 14% were suffering from iron deficiency anaemia. Children with a serum retinol level of 20 microg dl(-1) had significantly lower ferritin (14.0 compared to 26.0 microg l(-1), P = 0.005) and Hb levels (11.7 compared to 12.4 g dl(-1), P = 0.005) than those with higher levels. The proportion of iron deficiency anaemia was significantly greater among children with hookworm. Our data suggest that hookworm exerts its impact on iron status independently of the vitamin A status of the host.

CONCLUSIONS

Programmes to improve iron status should consider including both vitamin A prevention programmes and deworming.

Coverage and cost of iodized oil capsule distribution in Tanzania

Distribution of oral iodized oil capsules (IOC) is an important intervention in areas with iodine deficiency disorders (IDD) and low coverage of iodized salt. The mean reported coverage of 57 IOC distribution campaigns from 1986-1994 of people aged 1-45 years in 27 districts of Tanzania was 64% (range 20-96%). This declined over subsequent distribution rounds. However, due to delayed repeat distribution, only 43% of person-time was covered, based on the programme objective of giving two IOC (total 400 mg iodine) at 2-year intervals. Three different capsule distribution strategies used in 20 distribution rounds in 1992-1993 were analyzed in depth. Withdrawal of financial support for district distribution expenses under the 'district team' strategy, and the subsequent change to integrated 'primary health care' distribution, increased delays and capsule wastage. The third, more vertical strategy, 'national and district teams', accomplished rapid distribution of IOC about to expire and subsequently a return to the initial 'district team' allowance strategy was made. Annual cost of 'district team' distribution was 26 cents per person (400 mg iodine/2 years). Cost analysis revealed that the IOC itself accounts for more than 90% of total costs at the levels of coverage achieved. IOC will be important in the elimination of IDD in target areas of severe iodine deficiency and insufficient use of iodized salt, provided that high coverage can be achieved. Campaign distribution of medication with high item cost and long distribution intervals may be more cost-effectively performed if separated from regular PHC services at their present resource level. However, motivating health workers and community leaders to do adequate social mobilization remains crucial even if logistics are vertically organized. Insufficient support of distribution expenses and health education may lead to overall wastage of resources.