A nomogram of clinical and biologic factors to predict survival in children newly diagnosed with high-risk neuroblastoma: An International Neuroblastoma Risk Group project

BACKGROUND

Long-term outcome remains poor for children with high-risk neuroblastoma (five-year overall survival [OS] ∼50%). Our objectives were to (a) identify prognostic biomarkers and apply them in a nomogram to identify the subgroup of ultra-high-risk patients at highest risk of disease progression/death, for whom novel frontline therapy is urgently needed; and (b) validate the nomogram in an independent cohort.

METHODS

A total of 1820 high-risk patients (≥18 months old with metastatic neuroblastoma), diagnosed 1998-2015, from the International Neuroblastoma Risk Groups (INRG) Data Commons were analyzed in a retrospective cohort study. Using multivariable Cox regression of OS from diagnosis, a nomogram was created from prognostic biomarkers to predict three-year OS. External validation was performed using the SIOPEN HR-NBL1 trial cohort (n = 521), evidenced by receiver operating characteristic curves.

RESULTS

The nomogram, including MYCN status (P < 0.0001), lactate dehydrogenase (LDH) (P = 0.0007), and presence of bone marrow metastases (P = 0.004), had robust performance and was validated. Applying the nomogram at diagnosis (a) gives prognosis of an individual patient and (b) identifies patients predicted to have poor outcome (three-year OS was 30% ± 5% for patients with a nomogram score of > 82 points; 58% ± 1% for those ≤82 points). Median follow-up time was 5.5 years (range, 0-14.1).

CONCLUSIONS

In high-risk neuroblastoma, a novel, publicly available nomogram using prognostic biomarkers (MYCN status, LDH, presence of bone marrow metastases; https://neuroblastoma.shinyapps.io/High-Risk-Neuroblastoma-Nomogram/) has the flexibility to apply a clinically suitable and context-specific cutoff to identify patients at highest risk of death. This will facilitate testing urgently needed new frontline treatment options to improve outcome for these children.

Association of Disease Subtype and Duration with Echocardiographic Evidence of Pulmonary Hypertension in Myeloproliferative Neoplasm

BACKGROUND

Pulmonary hypertension (PH) can complicate the course of myeloproliferative neoplasms (MPNs). Echocardiography is a useful noninvasive screening test for PH in populations at risk. We aimed to investigate the echocardiographic evidence of PH and clinical characteristics of patients with MPNs.

METHODS

This study included 197 patients with MPNs (mean age, 59 ± 14 years; females, 53%; mean disease duration, 3.4 ± 2.8 years). Clinical and laboratory characteristics, including JAK2V617F mutation status, were obtained. All participants underwent a comprehensive transthoracic echocardiographic examination. The echocardiographic evidence of PH was defined as systolic pulmonary artery pressure (SPAP) ≥40 mm Hg.

RESULTS

Overall, 11 patients (5.5%) with SPAP ≥40 mm Hg had echocardiographic evidence of PH. Patients with myelofibrosis had echocardiographic evidence of PH more often than patients with other MPNs (p < 0.001). Disease duration since the diagnosis of MPNs was 6.7 ± 4.6 years in the PH group and 3.1 ± 2.5 years in the non-PH group (p < 0.001). There was a weak positive correlation between SPAP values and time since diagnosis (r = 0.236, p =0.001). JAK2V617F mutation was not associated with PH. In multivariate logistic regression analysis, the presence of myelofibrosis (odds ratio [OR]: 22.177, 95% CI: 4.480-109.790, p < 0.001), long disease duration (OR: 1.217, 95% CI: 1.024-1.447, p = 0.026), and high uric acid levels (OR: 1.868, 95% CI: 1.049-3.328, p = 0.034) were found to be related with the echocardiographic evidence of PH. Survival was worse in the PH group (p = 0.0001).

CONCLUSION

Our results suggest that patients with myelofibrosis are more likely to develop PH than other MPNs patients. Disease duration may predict the development of PH in MPN patients.

Recent aspects for disseminated carcinomatosis of the bone marrow associated with gastric cancer: What has been done for the past, and what will be needed in future?

Disseminated carcinomatosis of the bone marrow is characterized by widespread bone metastasis (bone marrow infiltration) from solid tumors with hematological disorders coexisted. This disease is frequently complicated with gastric cancer among solid tumors although its incidence is very rare. In recent years, technological innovations in diagnosis and treatment for cancer have remarkably improved, which made survival rates of various cancers prolonged. Prognosis of disseminated carcinomatosis of the bone marrow associated with gastric cancer, however, is still poor (less than a year), possibly because this disease has not been given attention due to low incidence. In this review, I summarize the results obtained for the past, and propose ways to improve the prognosis of this disease.

Development and Validation of a Prognostic Score to Predict Survival in Adult Patients With Solid Tumors and Bone Marrow Metastases

Bone marrow metastasis (BMM) in patients with solid cancers is indicative of advanced-stage disease with a poor prognosis. The clinical features and outcomes remain unclear. We aimed to develop a scoring system to predict survival in these patients to help with clinical decision making. A total of 165 adult patients diagnosed with solid cancers and BMM between 2000 and 2014 were selected as the derivation cohort. A risk model was developed using multivariate logistic regression from the derivation cohort and a marrow metastases prognostic score (MMPS) was generated. An independent cohort of 156 patients from 3 other hospitals was selected using the same recruiting criteria to validate the MMPS as a predictor of survival. The MMPS was calculated based on 4 independent prognostic variables: the Eastern Cooperative Oncology Group performance scale, site of cancer, platelet count, and neutrophil-to-lymphocyte ratio. Patients in both the derivation and validation cohorts were stratified into good, intermediate, and poor prognostic groups based on their MMPS. The median survival in each risk group of the derivation cohort was 241, 58, and 11 days for the good, intermediate, and poor prognostic groups, respectively, and 305, 65, and 9 days, respectively, in the validation cohort. The c-statistic values for prediction of mortality at 3, 6, and 12 months were significantly higher for the MMPS than for the Eastern Cooperative Oncology Group performance scale in both cohorts. We developed a risk model that accurately predicted survival in adult patients with solid cancers and BMM. This scoring system may help patients and clinicians with treatment decisions.

Decreased expression of CXCR4 chemokine receptor in bone marrow after chemotherapy in patients with non-Hodgkin lymphomas is a good prognostic factor

Background

CXCR4 chemokine receptor is constitutively expressed on normal and malignant B lymphocytes derived from patients with B-cell lymphoproliferative disorders and has a significant role in cell migration to lymph nodes and bone marrow. Non-Hodgkin's lymphomas (NHL) constitute a heterogeneous group of lymphoproliferative diseases, which can localize not only to lymph nodes, but also can migrate to peripheral blood and metastase to other organs, including bone marrow.

Aim

The purpose of this study was to determine CXCR4 gene expression in peripheral blood and bone marrow of NHL patients before and after treatment.

Methods

Samples of lymphoma lymph nodes, peripheral blood and bone marrow aspirates of patients with B-cell NHL were taken at diagnosis and after chemotherapy. Gene expression was determined by the reverse transcription (RT)-polymerase chain reaction method. Expression was estimated from 0 AU (no amplificate signal) to 3 AU (maximal amplificate signal).

Results

No significant difference in the level of CXCR4 expression was found in reactive lymph nodes compared to lymphoma samples We observed high level of CXCR4 expression in most patients before treatment: in bone marrow: 3 AU-10 pts, 2 AU–8 pts, 1 AU–2 pts. In peripheral blood: 3 AU–14 pts, 2 AU–4 pts, 1 AU–1 pts, 0 AU–1 pts. After chemotherapy, significant decrease in CXCR4 expression was observed. Bone marrow: 3 AU–5 pts, 2 AU–7 pts, 1 AU–5 pts, 0 AU–3 pts (p = 0.03). Peripheral blood: 3 AU–2 pts, 2 AU–6 pts, 1 AU–10 pts, 0 AU–2 pts (p = 0.0002). There was a good response to treatment in patients with significant decrease of CXCR4 expression in the bone marrow after treatment with 10-fold lower risk of death (p = 0.03).

Conclusions

Decrease in CXCR4 expression in the bone marrow of NHL patients after chemotherapy may be a good prognostic factor.

[Prognostic value of bone marrow lesions in children with neuroblastoma detected by flow cytometry]

The purpose of the study was to evaluate the prognostic value of the detection of tumor cells in the bone marrow (BM) in children with neuroblastoma (NB) by flow cytometry. The detection of tumor cells was performed in BM of 51 patients with NB (24 boys and 27 girls) aged from 6 days to 15 years (median--1 year 3 months). Flow cytometry allowed determining NB cells in BM in a much larger number of cases than cytomorphology (49.0% and 29.4% of patients, respectively). Patients, in whom NB cells were not detected in BM by flow cytometry, had significantly better event-free and overall survival rates as well as progression free survival (83.5%, 87.7% and 86,8%, respectively) compared with those in whom immunophenotyping revealed the tumor cells (28.0%, 35.87% and 34,3%, respectively). The prognostic value of the detection of BM lesion by flow cytometry was also confirmed in selected groups of patients with other criteria of stratification. Therefore the detection of tumor cells in BM by flow cytometry could potentially be considered in conjunction with other factors in choosing treatment strategy in patients with NB.

Symptomatic bone marrow involvement in breast cancer--clinical presentation, treatment, and prognosis: a single institution review of 22 cases

AIM

In contrast to marrow micrometastasis, development of symptomatic bone marrow involvement (bone marrow carcinomatosis, BMC) is a rare event in the course of metastatic breast cancer; published evidence on the outcome with systemic treatment is even more scarce. The objective of this study was to provide our institution's experience with the clinical presentation, prognosis, treatment, and associated complications of marrow involvement in breast cancer.

PATIENTS AND METHODS

Twenty-two breast cancer patients with BMC diagnosed between 1995 and 2009 were analyzed.

RESULTS

All patients presented with osseous metastases at the time of diagnosis of BMC. Anemia was the most prominent hematologic sign present in 17/22, followed by thrombocytopenia. Cytotoxic treatment was offered to 21/22 of patients. The majority showed an improvement of cytopenia following treatment (10 out of 14 anemic patients, 6 out of 9 thrombocytopenic patients, all 4 leukopenic patients). The complication rate was acceptable, with only 5 grade 3 or 4 events related to cytopenia (febrile neutropenia, bleeding). The estimated median overall survival from the date of BMC diagnosis was 19 months. After 4 years, 4 of the patients were still alive. Interestingly, prognosis from the time of first diagnosis of BMC was independent of the duration of metastatic disease before BMC had been diagnosed.

CONCLUSION

Bone marrow involvement has to be considered in breast cancer patients, in particular in those with bone metastases and otherwise unexplained cytopenia. The peripheral blood smear can serve as a simple diagnostic tool, but the extent of erythroblastosis is not correlated with survival. Even with severe BMC-associated cytopenia, aggressive combination treatment regimens are indicated, since most patients show improved marrow function after chemotherapy and long-lasting survival is possible.

Transformation potential of bone marrow stromal cells into undifferentiated high-grade pleomorphic sarcoma

PURPOSE

Bone marrow adherent cells contain conventional bone marrow stromal cells and mesenchymal stem cells and these cells constitute the hematopoietic microenvironment. Mesenchymal stem cells have the capacity to give rise to multiple mesenchymal lineage cells and even ectodermal lineage cells. In the present study, we investigated what types of tumor cells are inducible from BM adherent cells by chemical carcinogens.

METHODS

Bone marrow cells from neonatal C3H/HeN mice were collected within 24 h after birth and then cultured. Four days later, bone marrow adherent cells were obtained and the cells were treated with 3-methylcholanthrene.

RESULTS

By this treatment, some transformed clones consisting of large spindle cells were obtained. The transformed cells were highly positive for CD44 and were positive for Sca-1, CD49d and CD106, whereas the cells were negative for hematolymphoid markers. The cell clones had the ability to support hematopoiesis in vitro. These results indicate that the transformed cell lines have the characteristics of BM stromal cells/mesenchymal stem cells. Moreover, during culture of the transformed cells, spontaneous bone nodule formation was observed. When the transformed cells were inoculated into immunodeficient mice subcutaneously, the neoplasms grew in the subcutaneous tissue of the mice. Microscopically and ultrastructurally, the neoplasms showed the typical morphology of undifferentiated high-grade pleomorphic sarcoma (UHGPS). Bone-related genes have been found to be expressed in both transformed cells and UHGPSs.

CONCLUSION

The present study suggests that UHGPSs are derived from BM stromal cells, probably mesenchymal stem cells.

Pancreatic cancer: a generalized disease--prognostic impact of cancer cell dissemination

BACKGROUND

Pancreatic ductal adenocarcinoma is the fifth leading cause of death among all malignancies, leading to approximately 40,000 deaths each year in Europe. The annual incidence rate for all types of pancreatic cancer is approximately nine new cases per 100,000 people, ranking it as the 11th among all cancers. Stage, grade and resection margin status are currently accepted as the most accurate pathologic variables predicting survival. All classification systems fail prognostically to distinguish between different stages. Even in patients with seemingly early tumours (T1, N0), the likelihood of relapse is high. This reflects the shortcomings of the pathologic staging to sufficiently discriminate patients with a high risk to develop tumour recurrence from those that carry a lower risk.

RESULTS

On the other hand, none of the currently used systems includes or takes into consideration the role of disseminated tumour cells neither in the lymph nodes nor in the bone marrow. Occult residual tumour disease is suggested when either bone marrow or lymph nodes, from which tumour relapse may originate, are affected by micrometastatic lesions undetectable by conventional histopathology. For detection, antibodies against tumour-associated targets can be used to detect individual epithelial tumour cells both in lymph nodes and in bone marrow. The clinical significance of these immunohistochemical analyses is still controversial. Various monoclonal antibodies are still in use for micrometastatic detection, thus contributing to the incongruity of data and validity of results. These assays have been rarely used in patients with pancreatic carcinoma.

CONCLUSION

The presence or absence of lymph-node metastases can predict the likelihood of survival for most, if not all, patients with pancreatic ductal adenocancer and the likelihood that metastases will develop at distant sites.

Results of a randomized international study of high-risk central nervous system B non-Hodgkin lymphoma and B acute lymphoblastic leukemia in children and adolescents

The prognosis for higher risk childhood B-cell non-Hodgkin lymphoma has improved over the past 20 years but the optimal intensity of treatment has yet to be determined. Children 21 years old or younger with newly diagnosed B-cell non-Hodgkin lymphoma/B-cell acute lymphoblastic leukemia (B-NHL/B-ALL) with higher risk factors (bone marrow [BM] with or without CNS involvement) were randomized to standard intensity French-American-British/Lymphoma Malignancy B (FAB/LMB) therapy or reduced intensity (reduced cytarabine plus etoposide and deletion of 3 maintenance courses M2, M3, M4). All patients with CNS disease had additional high-dose methotrexate (8 g/m2) plus extra intrathecal therapy. Fifty-one percent had BM involvement, 20% had CNS involvement, and 29% had BM and CNS involvement. One hundred ninety patients were randomized. The probabilities of 4-year event-free survival (EFS) and survival (S) were 79% +/- 2.7% and 82% +/- 2.6%, respectively. In patients in remission after 3 cycles who were randomized to standard versus reduced-intensity therapy, the 4-year EFS after randomization was 90% +/- 3.1% versus 80% +/- 4.2% (one-sided P = .064) and S was 93% +/- 2.7% versus 83% +/- 4.0% (one-sided P = .032). Patients with either combined BM/CNS disease at diagnosis or poor response to cyclophosphamide, Oncovin [vincristine], prednisone (COP) reduction therapy had a significantly inferior EFS and S (P < .001). Standard-intensity FAB/LMB therapy is recommended for children with high-risk B-NHL (B-ALL with or without CNS involvement).

Clinical outcome of low-grade NHL patients with bone marrow involvement

BACKGROUND

Bone marrow (BM) involvement in low-grade non-Hodgkin's lymphoma (NHL) has a clear impact on patients' survival. The standard practice is morphological examination of BM biopsy at diagnosis. The clinical significance of flow cytometry (FC) analysis of BM aspirates is largely unknown.

MATERIALS AND METHODS

The medical charts of 70 low-grade NHL patients, who underwent BM biopsy and FC analysis between 1994 and 2004, were reviewed.

RESULTS

Forty-three patients (61.4%) were BM+ by morphology, while in those without morphological involvement by lymphoma FC was positive in 9 (BM-FC+, 12.9%) and negative in 18 (BM-FC-, 25.7%). The median treatment-free period was shorter in the BM+ and BM-FC+ groups compared with the BM-FC- group (1 and 4 months vs. 31 months, respectively) (log-rank test, P = 0.0195). The median survival time was not reached for the BM-FC- patients, whereas for BM+ and BM-FC+ patients it was 129 and 89 months, respectively, with no significant difference between them [the difference between the BM-FC- and the two other groups was statistically significant (log-rank test, P = 0.029)].

CONCLUSIONS

The outcome of low grade NHL in patients who had BM involvement by FC alone or by morphology was similar. If confirmed, these findings suggest a modification in the workup and management of localized low grade NHL.

Prognostic importance of soluble CD23 in B-cell chronic lymphocytic leukemia

Soluble CD23 (sCD23) was proposed as a marker of disease activity and as an important prognostic parameter in B-cell chronic lymphocytic leukemia (B-CLL). In this study, prognostic significance of sCD23 in B-CLL was examined according to its temporal relationship with the known clinical parameters of the disease, CD38 and ZAP-70. Serum sCD23 levels of 36 B-CLL patients, followed up in our clinic between 1999 and 2005, and 15 healthy subjects were measured with enzyme-linked immunosorbent assay. The mean serum sCD23 level of the B-CLL patients (210.72 +/- 193.67 and 6-600 U/ml) was significantly higher than the control group (18.20 +/- 14.30 and 6-50 U/ml). Seventy-eight percent of the B-CLL patients with lymphocyte doubling time (LDT) <12 months and 24% of patients with LDT >12 months had high sCD23 levels (P = 0.008). Meanwhile, 81% of the patients with diffuse bone marrow infiltration and 33% of patients with nondiffuse infiltration had high levels of serum sCD23 (P = 0.029). A significant difference was found between B-CLL patients with Binet stages A and C (P = 0.009). Peripheral blood flow cytometry of the patients revealed a significant CD38 expression in patients with high serum sCD23 levels (P = 0.002). Similarly, an increased bone marrow zeta-chain associated protein kinase-70 (ZAP-70) expression was seen in patients with high serum sCD23 levels (P = 0.009, correlation co-efficient was 0.714). Cumulative and the progression free survivals of the patients with low serum sCD23 levels were 60.1 +/- 5.7 months [95% confidence interval (CI); 49.0-71.2] and 51.1 +/- 6.6 months (95% CI; 38.0-64.1), respectively. However, they were 43.8 +/- 6.5 months (95% CI; 31.0-56.6) and 26.5 +/- 6.4 months (95% CI; 14.0-39.1) in patients with high levels. Serum sCD23 is increased in B-CLL patients and can be used in the clinical follow-up of the disease in prediction of the tumor mass and prognosis.

Extraneural metastasis in intracranial tumors in children: the experience of a single center

Our aim is to evaluate the clinical features and outcomes of children with primary central nervous system (CNS) tumors who develop extraneural metastasis (ENM). We retrospectively evaluated children diagnosed with primary CNS tumors treated at our institution between 1972 and 2004. Of 1,011 patients these tumors, 10 (0.98%) developed ENM. The histopathologic diagnosis was medulloblastoma in six patients, germ cell tumors in two patients, and ependymoma and atypical teratoid rhabdoid tumor (ATRT) in one patient each. In six patients, the primary tumor was located in the posterior fossa; it had a supratentorial location in the patient with ATRT, was located in the sellar and suprasellar region in the two patients with germ cell tumors, and was found in the distal spinal cord in the patient with an ependymoma. In two patients ENM was detected at the time of diagnosis. In other patients ENM developed between 9 and 25 months after diagnosis. Metastatic sites included bone, bone marrow, lung, cervical lymph nodes, liver, and paranasal sinuses. Of the 10 patients who developed ENM, 8 died of their disease 0.27-16.2 months (median, 2.60 months) after it was detected. One patient with dysgerminoma is alive, without disease, 117.80 months after diagnosis of the ENM. One patient with germ cell tumor is alive with disease 11.3 months after diagnosis of the ENM. Systemic metastasis to other extraneural sites is extremely rare in children with intracranial tumors. In our series the rate of ENM is 0.98%. The liver and lung are the most common site for metastasis, followed by the bone and bone marrow. The outcome is poor in patients with CNS tumors with ENM.

Matrix metalloproteinase-13 expression is associated with bone marrow microinvolvement and prognosis in non-small cell lung cancer

Our previous study demonstrated that bone marrow microinvolvement (BMM) is an epiphenomenon of tumor progression rather than a prognostic factor in non-small cell lung cancer. We hypothesize that an increase in mesenchymal transition power in epithelial tumor cells by up-regulation of the matrix metalloproteinases (MMPs) may contribute to the existence of BMM and poorer prognosis. Hereby we conducted a prospective study of BMM and MMPs expression in a cohort of 57 non-small cell lung cancer patients. Bone aspirates were examined by immunohistochemical stains. Expressions of MMPs were checked by Human MMP primer set kit (Maxim Biotech, USA). Correlations between the MMPs expression and BMM, nodal metastasis, and prognosis were examined. Cox model analysis was used to identify independent prognostic factors. Though positive BMM was identified in 38 (66.7%) of the patients, none of the clinicopathological factors, including sex, age, cell types, tumor differentiation, nodal metastasis and TNM status of the tumor, was related to BMM by the tumor cells. Up-regulation was observed in a broad spectrum of MMPs with the exception of MMP-3. However, only MMP-13 expression correlated with the existence of BMM (p=0.006). Univariate analysis revealed MMP-3, MMP-7 and MMP-13 as negative prognostic factors. Cox model analysis revealed T-status, cell differentiation, and MMP-13 expression of the tumor as independent prognostic factors. The overall 5-year survival rate of the patients was 36.8%. The existence of BMM itself did not influence the prognosis (p=0.109), however, patients with positive MMP-13 expression (N=34) had a poorer 5-year survival rate of 26.5% (p=0.025). In summary, non-small cell lung cancer cells with MMP-13 expression, despite of BMM status, tend to shed and aggregate in the bone marrow, which is subsequently reflected in a poorer survival rate.

Liver involvement in neuroblastoma: the Memorial Sloan-Kettering Experience supports treatment reduction in young patients

BACKGROUND

We reviewed clinical and biologic findings in a series of infants with neuroblastoma (NB) in liver. The aim was to gain insights into improving therapy.

PATIENTS AND METHODS

Among 19 newly or recently diagnosed infants with NB in liver, 1987-2002, those with stage 4 involving bone received chemotherapy, while those without bone or extensive bone marrow (BM) involvement were observed or received limited treatment if NB caused life-threatening symptoms. We assessed results in the context of NB treatment risk stratification, which is based on age, stage, and selected biologic features (MYCN, ploidy, histology).

RESULTS

Six of eight infants with bone involvement became long-term event-free survivors including 1/2 with MYCN amplification and four who received only 4-6 cycles of chemotherapy; at the end of treatment, four infants had abnormalities in liver +/- the primary site, but these resolved. All 11 infants without bone lesions became long-term survivors with either no cytotoxic therapy or only one cycle of chemotherapy (+/- radiotherapy to liver), including four who had stage 4 and one stage 4S patient who still had NB in BM at age 15 months.

CONCLUSIONS

Treatment reduction should be considered for subsets of infants with non-MYCN-amplified widespread NB: stage 4 without bone or extensive BM involvement may not require cytotoxic therapy, stage 4S with symptomatic hepatomegaly may not require multiple cycles of chemotherapy, and classic stage 4 may do well with limited chemotherapy. Persistent liver abnormalities post-treatment may not require continued therapy to achieve a radiologic complete remission.

[Disseminated ovarian, bone, and bone marrow metastases from gastric cancer]

The main cause of death in patients with gastric cancer is disease dissemination. It is not clear why gastric cancer metastasizes to different organs. Early detection and destruction of circulating malignant cells before developing metastases may markedly improve survival of these patients. Krukenberg tumors (metastases of non-gynecological origin in the ovaries) usually are circular cell carcinomas of gastric cancer. Bone metastases of gastric cancer are rare, but if they are diagnosed, patients survive only 2-5 months on the average. Disseminated bone marrow metastases from gastric cancer do not always show the sudden course of the disease, but hematological complications are signs of poor prognosis. Hematological paraneoplastic disorders can be miscellaneous: they usually manifest as anemia of various origin, as leucocytosis in half of the patients, as leukemoid reactions in one-third of the patients, and as hemolysis and thrombocytopenia in half of the patients (often with disseminated intravascular coagulation). Currently, chemotherapy is the most effective treatment for outspread gastric cancer. Unfortunately, there is no exclusively effective scheme for treatment. Lymph node metastases are more sensitive to chemotherapy than primary gastric cancer, while in contrary, hepatic metastases are less sensitive than primary gastric cancer. This article includes a literature review and a rare case of gastric cancer.

Detection and clinical significance of disseminated tumour cells at diagnosis in bone marrow of children with localised rhabdomyosarcoma

Identification of patients with a poor prognosis for non-metastatic rhabdomyosarcoma (RMS) remains a clinical challenge. Prospective analysis for the presence of disseminated RMS cells in bone marrow at diagnosis, using immunocytochemistry, with MyoD1 and myogenin as markers, was carried out. Thirty-seven patients treated on RMS88 and RMS96 Italian protocols underwent staging investigations, and in addition marrow examination for occult tumour cells. All patients had negative marrow involvement using cytomorphology, but 10/37 were positive with immunostaining. With a median follow-up of 46 months (range, 12-115), 7 patients had died and 30 were disease-free. Overall survival probability was 92% in patients with no occult marrow infiltration, 47% with occult marrow infiltration (P=0.001); event-free survival probability was 89% in the former and 50% in the latter (P=0.01). Disseminated tumour cells are indicative of disease spread and are significantly linked to recurrence at distant sites and poorer outcome. Marrow examination at diagnosis using immunocytochemistry may be an additional tool to modulate treatment.

Thrombotic thrombocytopenic purpura associated with bone marrow metastasis and secondary myelofibrosis in cancer

To examine the relationship between cancer and development of thrombotic microangiopathy (TM), the medical records of patients with known TM were examined in one institution from January 1981 to December 2002. Nine out of 93 patients with the established diagnosis of TM had active cancer. All nine of those patients had thrombotic thrombocytopenic purpura (TTP). Among those patients, two patients received chemotherapy prior to the development of TTP. Six of the seven patients who received no chemotherapy had extensive bone marrow metastasis and secondary myelofibrosis. There were two patients each with breast cancer, lung cancer, and stomach cancer. Severe anemia and thrombocytopenia with leukoerythroblastosis were prominent clinical features in all six patients. Four patients had neurological (mental) changes and three developed fever, but none had significant renal dysfunction. Upon establishing the diagnosis of TTP, four patients were treated with exchange plasmapheresis (EP) and two patients were treated with chemotherapy because there were no neurological changes. Three patients achieved complete remission of TTP, one with EP alone and two with chemotherapy. The one patient who achieved remission with EP alone was later treated with chemotherapy and survived for 2 1/2 years. The other three patients treated with EP alone died within 2 months after the diagnosis of TTP. Since TTP occurred in association with bone marrow metastasis and myelofibrosis in six patients among seven chemotherapy-untreated cancer patients, this marrow change was considered to be the possible cause of the development of TTP. It is recommended that all cancer patients with unexplained anemia and thrombocytopenia be evaluated for the coexistence of bone marrow metastasis and TTP.

Detection and prognostic value of cytokeratin positive tumor cells in bone marrow of patients with renal cell carcinoma

PURPOSE

Several investigations indicate the prognostic value of disseminated cytokeratin positive tumor cells in bone marrow of patients with carcinoma of different origin. In this study we evaluated the prognostic significance of epithelial cells in bone marrow of patients with renal cell carcinoma (RCC).

MATERIALS AND METHODS

Aspiration of bone marrow was performed preoperatively in 335 patients with RCC between 1990 and 1998. A total of 287 patients fulfilled all study inclusion (eg M0 R0 tumor stage) and exclusion (eg second malignancy during followup) criteria for the final analysis. Cytospin preparations were made after density gradient centrifugation of bone marrow samples and incubated with monoclonal antibodies directed against cytokeratin 18 (CK2) and pan-cytokeratin. Staining was performed using the alkaline phosphatase-anti-alkaline phosphatase method and 256 samples were evaluated. RESULTS In 25% (63 of 256) of the patients cytokeratin positive (CK+) cells were detected in bone marrow. Tumor progression (defined as tumor associated death, local recurrence or new metastases) was present in 12% (31 of 256) during the followup period (median 40 months), and 14% (9 of 63) with CK+ cells and 11% (22 of 193) with negative bone marrow status exhibited tumor progression. Survival analysis (log-rank test) showed no significant difference between the CK+ and cytokeratin negative group. The detection of CK+ cells was not an independent prognostic parameter in multivariate analysis (Cox regression model).

CONCLUSIONS

These results indicate that the immunocytochemical detection of disseminated cytokeratin positive tumor cells in the bone marrow of patients with RCC has no prognostic significance.

Treatment of metastatic retinoblastoma

PURPOSE

The risk for death in patients with retinoblastoma is increased in those who present with metastatic disease, and the role of intensive chemotherapy and autologous hematopoietic stem cell rescue in these patients remains unclear.

DESIGN

Nonrandomized interventional case series.

PARTICIPANTS

Four consecutive patients with metastatic retinoblastoma.

METHODS

We treated four patients with retinoblastoma metastatic to the bone and bone marrow with intensive chemotherapy, consolidation with megatherapy, and autologous hematopoietic stem cell rescue. Chemotherapy included courses of carboplatin and etoposide alternating with cyclophosphamide, etoposide, and either carboplatin or cisplatin. Radiation therapy was delivered to areas of bone metastases.

MAIN OUTCOME MEASURES

Patient survival.

RESULTS

All patients completed and responded to the scheduled therapy; complete response of the bone marrow disease was documented after two courses of chemotherapy in all cases. Two patients are long-term survivors.

CONCLUSIONS

The treatment described has been successful in obtaining disease-free survival in patients with metastatic retinoblastoma.

Extraneural metastases of paediatric brain tumours

A survey of published cases of extraneural metastases of primary brain tumours in children under the age of 18 years revealed 245 cases; 60.7% occurred in boys and 27.3% were directly related to the placing of a shunt. The most common entities leading to extraneural metastases were medulloblastomas (56.3%), germinomas (9.8%), glioblastomas (6.9%), ependymomas (3.7%) and pilocytic astrocytomas (2.9%). While medulloblastomas were frequent among non-shunt-related metastases (69.4%), germ cell tumours were most common among shunt-related metastases (33.3%). Metastases were encountered equally often in bone (56.3%) and visceral organs (55.5%) but were markedly rarer in lymph nodes (25.3%). Medulloblastomas showed a preference for bones (88.3% of cases), germinomas for bones (77.8%) and visceral organs (66.7%), whereas ependymomas and ependymoblastomas were more frequently found in lymph nodes and visceral organs (71.5-100%). The most frequent sites of bone metastases were the pelvis (59.3% of cases with osseous lesions), femur (54%) and vertebrae (46%). Medulloblastomas preferentially spread into pelvis, femur and vertebrae, whereas germ cell tumours mainly involved pelvis, femur and ribs and glioblastomas vertebrae and pelvis. Most frequent sites of lymph node metastases were cervical (45.8% of cases with nodular lesions) and thoracic (31.3%) with 54% of children suffering from medulloblastomas and 7.9% from germ cell tumours. The most frequent organ involved in non-shunt-related metastases were the lungs (56.5% of children with visceral lesions) followed by muscle/soft tissue (26.9%), pleura (16.4%), skin (14.9%) and liver (13.4%). Among shunt-related cases, the peritoneum was the most frequent site (86.6% of children). The mean interval between primary brain tumour and occurrence of metastasis was 22.1 months with particularly grave outcomes among medulloblastomas, non-germinomatous germ cell tumours and glioblastomas (85.5-100% deceased children), whereas 60% of children suffering from germinomas were still alive at the time of reporting.

Disseminated tumor cells in bone marrow of patients with transitional cell carcinoma: immunocytochemical detection and correlation with established prognostic indicators

PURPOSE

Previous investigations have demonstrated the prognostic value of disseminated cytokeratin positive cells in bone marrow of patients with breast, gastric, colon and prostate cancer. We evaluated the potential of an immunocytochemical assay, using a monoclonal antibody against cytokeratin 18 (CK 18), for the detection of disseminated tumor cells in bone marrow aspirates of patients with transitional cell carcinoma.

MATERIALS AND METHODS

Bone marrow aspiration was performed preoperatively on 128 patients with transitional cell carcinoma of various stages and on 27 controls with nonmalignant disease. Cytospin preparations of mononuclear bone marrow cells were incubated with a monoclonal anti-CK 18 antibody and stained using the alkaline phosphatase anti-alkaline phosphatase technique.

RESULTS

Of the patients with transitional cell carcinoma 29.7% and none of the controls had a CK 18 positive bone marrow result. A significant correlation between the incidence of CK 18 positive cells in bone marrow and invasive transitional cell carcinoma (p <0.01), lymph node involvement (p <0.01), medium/high grade transitional cell carcinoma (p <0.01) and tumor progression in recurrent transitional cell carcinoma (p <0.05) was demonstrated. Furthermore, the mean number of CK 18 positive cells in bone marrow aspirates of patients with stage M+ and/or N+ disease was nearly 3 times as high as that of patients without clinically evident metastatic disease (10.4 versus 3.8 CK 18 positive cells per patient).

CONCLUSIONS

A significant correlation between the incidence of CK 18 positive bone marrow results in patients with transitional cell carcinoma and established risk factors could be demonstrated in our study. Further prospective followup studies should be performed to determine the prognostic value of these findings.

Docetaxel, 5-fluorouracil, and leucovorin as treatment for advanced gastric cancer: results of a phase II study

BACKGROUND

Previous studies have shown that the taxane, docetaxel, is effective in treating gastric cancer. The aim of this study was to assess the efficacy and safety of docetaxel in combination with 5-fluorouracil (5-FU) and leucovorin (LV).

METHODS

Thirty patients with histologically proven locally advanced and/or metastatic gastric cancer with WHO performance status 0-2 were enrolled and received either 75 or 100 mg/m(2) docetaxel as a 1-h intravenous infusion on day 1 every 28 days. All patients also received 5-FU (1800 mg/m(2)) plus LV (500 mg/m(2)), by continuous intravenous infusion over 24 h on days 1, 8, and 15 every 28 days. Chemotherapy was given for at least two cycles.

RESULTS

Of the 25 evaluable patients, 3 showed a complete response, 4 showed a partial response, and 11 patients had stable disease. The overall response rate was 28.0% (95% confidence interval [CI], 10.4, 45.6). The median time to progression was 5.9 months (95% CI, 5.4, 6.5), and the median overall survival was 7.7 months (95% CI, 7.2, 8.3) for the intent-to-treat population. The most frequent grade III and IV hematological toxicities were neutropenia and anemia. Febrile neutropenia was observed in 10% of patients and 2.4% of cycles. The prophylactic use of granulocyte colony-stimulating factor (G-CSF) in 3 patients reduced the incidence and severity of neutropenia. Other hematological toxicities were rare.

CONCLUSION

Docetaxel in combination with weekly 5-FU and LV is effective in treating patients with advanced/metastatic gastric cancer. This new docetaxel-containing combination shows promise as a third-generation treatment option for gastric cancer.

Micrometastasis in the bone marrow of patients with lung cancer associated with a reduced expression of E-cadherin and beta-catenin: risk assessment by immunohistochemistry

BACKGROUND

The presence of disseminated tumor cells in bone marrow is considered to be a premetastatic state, which is called micrometastasis. To evaluate the relationship between micrometastasis and cellular adhesion molecules in the primary lesion, E-cadherin and beta-catenin were immunohistochemically investigated. Methods. Fifty-eight patients with non-small cell lung cancer who underwent a complete resection were entered into this study. Tumor cells in bone marrow aspirates were detected by immunohistochemistry using cytokeratin (CK) 18. Immunohistochemical studies of E-cadherin and beta-catenin were performed in the corresponding primary tumor.

RESULTS

CK-positive cells were detected in the bone marrow aspirates from 27 of 58 patients. A reduced expression of the E-cadherin and beta-catenin was found in 16 (27.6%) and in 22 (37.9%) of 58 patients, respectively. In 26 cases with a reduced expression of E-cadherin and/or beta-catenin, 16 cases had CK-positive cells, whereas 11 of 32 cases with normal expression of both factors had CK-positive cells (P=.0392). The patients with micrometastasis demonstrated an earlier recurrence (P =.0642) and a significantly poorer survival (P =.0437) than those without such cells.

CONCLUSIONS

Micrometastasis in the bone marrow might be a significant predictor of poor prognosis, and a reduced expression of E-cadherin and beta-catenin are important determinants for the metastatic capability of individual cancer cells.

[Bone marrow involvement in ovarian cancer determined by immunohistochemical methods]

Atypical epithelial cells in the bone marrow of patients with ovarian cancer were evaluated using immunohistochemical techniques. We investigated cytospin preparations of bone marrow taken from 9 women with benign ovarian tumors and 59 women with malignant ovarian tumors. Two monoclonal antibodies (NCL-C11 and NCL-CA 125) were used. With both antibodies we were able to detect keratin and CA 125 antigen expression in the bone marrow of 9 (18.4%) of the patients with ovarian cancer. With regard to the wide histological differentiation of ovarian carcinomas, the presence of atypical epithelial cells in the bone marrow was required as a prognostic factor for survival and relapses. This should be investigated in a larger study group.

Clinical significance of occult metastatic cells in bone marrow of breast cancer patients

The early and clinically occult spread of viable tumor cells to the organism is increasingly considered a hallmark in cancer progression, as emerging data suggest that these cells are precursors of subsequent distant relapse. Using monoclonal antibodies to epithelial cytokeratins or tumor-associated cell membrane glycoproteins, individual carcinoma cells can be detected on cytologic bone marrow preparations at frequencies of 10(-5) to 10(-6). Prospective clinical studies have shown that the presence of these immunostained cells in bone marrow, as a frequent site of overt metastases, is prognostically relevant with regard to relapse-free and overall survival. This screening approach may be, therefore, used to improve tumor staging and guide the stratification of patients for adjuvant therapy in clinical trials. Another promising application is monitoring the response of micrometastatic cells to adjuvant therapies, which, at present, can only be assessed retrospectively after an extended period of clinical follow-up. The present review summarizes the current data on the clinical significance of occult metastatic breast cancer cells in bone marrow.

Evaluation of the kinetics of the bone marrow tumor load in the course of sequential high-dose therapy assessed by quantitative PCR as a predictive parameter in patients with multiple myeloma

The aim of this investigation was to examine the possible clinical significance of the kinetics of bone marrow (BM) tumor load during the course of sequential high-dose therapy (HDT) as assessed by quantitative PCR in patients with multiple myeloma. In 20 patients with multiple myeloma (MM) treated with two consecutive cycles of HDT followed by autologous peripheral blood stem cell transplantation (PBSCT), clonotypic cells in the peripheral blood (PB) and BM were quantitated by PCR using allele-specific oligonucleotides (ASO) prior to the first, immediately prior to the second, and after the second HDT. The median proportion of clonotypic cells in the BM was 1.27% before the first HDT (range, 0.03-70%), 0.17% after the first (range, 0.001-22%), and 0.05% after the second HDT (range, 0.00009-1.44%). The median number of circulating clonotypic cells was 65/ml (range, 0.9-10842) prior to HDT, 2.7/ml (range, 0-315) after the first, and 3.5/ml PB (range, 0.7-97) after the second HDT. While the median BM tumor load decreased during the first (P = 0.03) and second (P = 0.044) HDT cycles, only the first cycle resulted in a reduction of clonotypic cells in the PB (P = 0.00078 and P= 1.0, respectively). In seven patients, the BM tumor load did not decrease below the initial level after one or two cycles of HDT. All of these patients developed progressive disease (median, 19 months post first cycle; range, 10-21). Of the remaining 13 patients, only four relapsed (18, 19, 21 and 22 months after the first cycle of HDT), while nine remain in response (median followup, 29 months; range, 18-41) (log-rank test P = 0.0009). Our results indicate that the kinetics of the BM tumor load is a predictive parameter in patients with MM and identifies those patients who could benefit from further therapy including new treatment modalities.

[Micrometastatic cells in the bone marrow of patients with breast carcinoma]

BACKGROUND

The immunocytological detection of disseminated epithelial cells in bone marrow in patients with breast cancer has been performed at many hospitals and institutes since the early 1980s. Despite numerous publications in this field, it has not been possible to standardize the method and establish the ideal antibody, either nationally or internationally. Molecular biological methods using PCR technology could extend the diagnostic spectrum. However, one of the major problems in breast cancer is the lack of a disease-specific marker gene. As a result, immunocytology is still the standard procedure for tumour cell detection.

METHODS

The detection of disseminated single cells in bone marrow in primary breast cancer (also known as minimal residual disease) is a new prognostic factor for disease-free and overall survival. This has been demonstrated in three large (N > 300) groups and several small to medium groups (N = 50-300). As a marker of dissemination in a target organ for metastasis this prognostic factor corresponds much more closely to the tendency of breast cancer to early haematogenic spread. Tumour cell detection may predict the course of the disease better than the axillary lymph node status. Bone marrow aspiration and detection of disseminated cells might replace lymph node dissection, at least in those patients with small tumours and no clinical signs of lymph node involvement. This strategy will soon be investigated in appropriate studies. Another possible clinical use might be deciding on whether or not to give adjuvant systemic therapy to node-negative patients. Patients with positive tumour cell detection are at a higher risk of subsequent metastasis, even if the axillary nodes are histologically normal.

APPLICATION OF METHODS

The immunohistological or molecular biological detection of tumour cells in axillary lymph nodes might also be very useful, now that is has been shown that a considerable subset of patients determined to be node-negative by means of conventional methods, are positive according to these new techniques. These methods could be a useful supplement to sentinel node biopsy. A further potential use of this method is in monitoring therapy with new treatment modalities such as gene therapy and immunotherapy. Repeated bone marrow aspiration can provide information on the success of therapy in minimal residual disease (cytoreduction). Immunocytochemical investigation of individual cells may be useful in studying the pathogenesis of metastasis, in particular in the skeleton. Phenotyping of cells might allow statements to be made in the metastatic potential of cells and the question of cell dormancy. It remains to be hoped that this aspect of minimal residual disease will be granted more attention in future.

A strategy for modelling the effect of a continuous covariate in medicine and epidemiology

Low-dimensional parametric models are well understood, straightforward to communicate to other workers, have very smooth curves and may easily be checked for consistency with background scientific knowledge or understanding. They should therefore be ideal tools with which to represent smooth relationships between a continuous predictor and an outcome variable in medicine and epidemiology. Unfortunately, a seriously restricted set of such models is used routinely in practical data analysis - typically, linear, quadratic or occasionally cubic polynomials, or sometimes a power or logarithmic transformation of a covariate. Since their flexibility is limited, it is not surprising that the fit of such models is often poor. Royston and Altman's recent work on fractional polynomials has extended the range of available functions. It is clearly crucial that the chosen final model fits the data well. Achieving a good fit with minimal restriction on the functional form has been the motivation behind the major recent research effort on non-parametric curve-fitting techniques. Here I propose that one such model, a (possibly over-fitted) cubic smoothing spline, may be used to define a suitable reference curve against which the fit of a parametric model may be checked. I suggest a significance test for the purpose and examine its type I error and power in a small simulation study. Several families of parametric models, including some with sigmoid curves, are considered. Their suitability in fitting regression relationships found in several real data sets is investigated. With all the example data sets, a simple parametric model can be found which fits the data approximately as well as a cubic smoothing spline, but without the latter's tendency towards artefacts in the fitted curve.

Long-term results of CD34(+) cell transplantation in children with neuroblastoma

BACKGROUND

This is the first report of the long-term results of CD34(+) cell transplantation in children with neuroblastoma. We investigated the hematologic and immune recovery, posttransplant morbidity, and clinical outcome of these children.

PROCEDURE

Twenty-three children with advanced neuroblastoma had PBPCs (20 patients) or BM (3 patients) collected, followed by CD34(+) cell selection on Ceprate column. The purge of residual neuroblastoma cells was evaluated using an RT-PCR for tyrosine hydroxylase (TH) mRNA assay. Reinfusion of CD34(+) cells followed busulfan + melphalan myeloablative chemotherapy.

RESULTS

A median of 2.9 x 10(6) CD34(+) cells/kg was reinjected. Median days to achieve ANC > 0.5 x 10(9)/liter and platelets > 50 x 10(9)/liter were 13 (range 9-33) and 59 (range 22-259), respectively. Circulating T cells were primarily CD4(-)/CD8(+) with fewer than 0.2 10(9)CD4(+) cells/liter throughout the first 6 months. CD19(+) cells and CD56(+) cells were not detectable up to day +35 posttransplant. At 1 year posttransplant, 16 evaluable patients had stable hematopoiesis with 2.3 x 10(9) ANC/liter (range 0.8-4.1), 1.4 x 10(9) lymphocytes/liter (range 0.5- 2.0) and 251 x 10(9) PLT/liter (range 35-490). After the completion of hematopoietic reconstitution, six events of severe septicemia/septic shock were noted. Six children had severe VZV infections, and 2 had EBV-associated lymphoproliferation. Thirteen patients are alive with a median follow-up of 40 months (range 2-54). Ten patients have died; 8 relapsed or developed progressive disease, 1 died from nondocumented pneumopathy at day 56, and 1 developed AML-M4 at 3 years posttransplant.

CONCLUSIONS

In children, CD34(+) cell transplantation can be accomplished with a reduction of neuroblastoma cell inoculum in the selected graft as assessed by RT-PCR analysis. CD34(+) cell grafts provide successful neutrophil reconstitution. However, delayed platelet recovery, persistent decrease in CD4(+) lymphocyte levels and a high incidence of serious and life-threatening late infections were observed in these children. There remains a critical need to evaluate any real clinical benefit of CD34(+) cell autografts in neuroblastoma patients.

Testicular and paratesticular involvement by metastatic neuroblastoma

BACKGROUND

Testicular and paratesticular involvement is a less familiar feature in neuroblastoma and its prognostic impact is unclear.

METHODS

The records of 1076 male patients in the German cooperative neuroblastoma treatment trials were searched for patients with testicular or paratesticular involvement.

RESULTS

The authors found 11 children with paratesticular or testicular involvement at the time of manifestation of the disease, 3 children with testicular involvement at the time of relapse, and 1 infant with testicular involvement at the time of progression of neuroblastoma from International Neuroblastoma Staging System (INSS) Stage 4S to Stage 4. In de novo disease, the age of manifestation did not exceed 12 months. Two children had paratesticular involvement per continuitatem by growth of a primary tumor through the inguinal channel. All others had distant primary tumor. Prognosis appeared more favorable for infants (3 of 9 died) than for older children (5 of 6 died), for children with involvement of testes and < 10% involvement of bone marrow (2 of 8 died) than for children with other distant metastasis (6 of 7 died), and for children with intrascrotal involvement at first diagnosis (4 of 11 died) than for children with intrascrotal involvement during relapse of the disease (all 4 children died).

CONCLUSIONS

Paratesticular or testicular metastasis does not per se indicate unfavorable outcome and is compatible with INSS Stage 4S in infants. The age at diagnosis and the time of manifestation during disease contributed to the prognosis in those patients.

Radiotherapy and high-dose chemotherapy in advanced Ewing's tumors

BACKGROUND

Ewing's tumors are sensitive to radio- and chemotherapy. Patients with multifocal disease suffer a poor prognosis. Patients presenting primary bone marrow involvement or bone metastases at diagnosis herald a 3-year disease-free survival below 15%. The European Intergroup Cooperative Ewing's Sarcoma Study (EICESS) has established the following indications for high-dose therapy in advanced Ewing's tumors: Patients with primary multifocal bone disease, patients with early (< 2 years after diagnosis) or multifocal relapse.

PATIENTS AND METHOD

As of 1987, 83 patients have been treated in the EICESS group, 39 of them at the transplant center in Düsseldorf, who have been analyzed here. All individuals received 4 courses of induction chemotherapy with EVAJA and stem cell collection after course 3 and 4. Consolidation radiotherapy of the involved bone compartments was administered in a hyperfractionated regimen 2 times 1.6 Gy per day, up to 22.4 Gy simultaneously to course 5 and 22.4 Gy to course 6 of chemotherapy. The myeloablative chemotherapy consisted of melphalan and etoposide (ME) in combination with 12 Gy TBI (Hyper-ME) or Double-ME with whole lung irradiation up to 18 Gy (without TBI).

RESULTS

The survival probability at 40 months was 31% (44% DOD; 15% DOC). Pelvic infiltration did not reach prognostic relevance in this cohort. Radiotherapy encompassed 75% of the bone marrow at maximum (average 20%). Engraftment was not affected by radiotherapy.

CONCLUSION

High-dose chemotherapy can improve outcome in poor prognostic advanced Ewing's tumors. The disease itself remains the main problem. The expected engraftment problems after intensive radiotherapy in large volumes of bone marrow can be overcome by stem cell reinfusion.

[The use of monoclonal antibodies in the detection of small cell lung cancer metastases in bone marrow]

Expression of a number of antigens associated with small cell lung cancer (SCLC) have been proposed as a marker of malignancy and the diagnostic tool for the staging procedures and important prognostic factor. Since the bone marrow (BM) was described as a frequent site for SCLC metastases, we have decided to assess clinical importance of cancer cells detection in BM, using immunofluorescence with MAC-1, MAC-31, NSE and anti-Fucosyl-GM1 (PF3) antibodies. The group of 32 patients with SCLC was assessed using our panel of antibodies. Control group consisted of 5 patients with other malignancies (3 patients with malignant lymphoma, 1 with chronic lymphocytic leukaemia and 1 with non-SCLC). The study revealed no correlation between the expression of SCLC markers in patients BM and the cancer treatment outcome measured as a response for treatment, time to progression, and survival time, and no significant difference was found between the patients and control group.

Effects of different immunolabeling techniques on the detection of small-cell lung cancer cells in bone marrow

Recent reports have suggested that the immunodetection of tumor cells in bone marrow of small-cell lung cancer (SCLC) patients is by far more effective than traditional cytohistological methods and that this may be clinically relevant. This study aimed to evaluate whether the level of detection of tumor cells in bone marrow is affected by different immunostaining methods. Using two anti-NCAM monoclonal antibodies (MAbs), we compared four different "sandwich" methods on cytospin preparations of the N592 human SCLC cell line and of bone marrow aspirates from 37 SCLC patients. Our data indicate that the combination of the alkaline phosphatase-anti-alkaline phosphatase and streptavidin-biotin-alkaline phosphatase complex methods provides the best results in terms of sensitivity and specificity, and of intensity of immunoreaction and absence of staining background. Moreover, bone marrow micrometastases detected by this method were prognostically relevant and identified, among patients with apparently limited disease according to conventional staging procedures, a subgroup with shorter survival. We suggest that the choice of a sensitive immunostaining technique may significantly increase the detection rate of SCLC cells in bone marrow, mirroring the biological aggressiveness of the disease.

Phase II window of idarubicin in children with extraocular retinoblastoma

PURPOSE

The aim of this study was to evaluate in an upfront phase II study the response to idarubicin in children with extraocular retinoblastoma.

PATIENTS AND METHODS

The starting dose of idarubicin was 15 mg/m(2)/d (days 1 and 2) weeks 0 and 3. After an interim evaluation, the dose was reduced to 10 mg/m(2)/d (days 1 and 2) weeks 0 and 3 because of hematopoietic toxicity. Response was evaluated at week 6.

RESULTS

At the Hospital JP Garrahan (Buenos Aires, Argentina), 10 patients (five bilateral) were entered onto the study from 1995 to 1998. A total of 19 cycles were administered. Extraocular sites included orbit (n = 10), bone marrow (n = 3), bone (n = 1), lymph node (n = 1), and CNS (n = 1). The response rate was 60% (95% confidence interval, 30% to 90%). One complete response was achieved, in addition to five partial responses, two cases of stable disease, and two cases of progressive disease. All patients with bone marrow involvement achieved complete clearance of tumor cells. The patient with CNS disease had progressive disease. All patients had severe hematopoietic toxicity (grade 4 neutropenia and grade 3/4 thrombocytopenia after most cycles). Other toxicities included grade 2 diarrhea in 30%. No echocardiographic changes were detected.

CONCLUSION

Idarubicin is active in extraocular retinoblastoma. The activity of this drug should be explored in future phase III studies.

Bone marrow involvement and the prognosis of low grade non-Hodgkin's lymphoma

AIM

To analyze the bone marrow (BM) infiltration in low-grade non-Hodgkin's lymphomas (LGNHL) and assess its association with the histopathology type, clinical behavior, and disease prognosis.

METHOD

BM smears obtained by needle biopsy and stained by standard methods were analyzed in 60 patients with LGNHL using the Working Formulation.

RESULTS

BM infiltration was observed in 57% of the lymphocytic lymphomas (A), in 48% of lymphoplasmocytic/ plasmocytoid lymphomas (AI), and in 31% of follicular lymphomas (follicular small cleaved cell and follicular mixed B and C). The difference was not significant. The 5-year survival rates for patients with and without bone marrow infiltration were 53% and 56% respectively, and 10-year survival rates were 31% and 45% (p>0.05).

CONCLUSION

The presence of bone marrow infiltration at diagnosis did not significantly affect the prognosis of LGNHL.

Meta-analyses of studies on bone marrow micrometastases: an independent prognostic impact remains to be substantiated

PURPOSE

In 1997, the immunocytologic detection of isolated tumor cells in bone marrow, termed micrometastasis, will be optionally included in the tumor-node-metastasis (TNM) classification indicated M1(i). In the present meta-analyses, 20 studies, which included 2,494 patients, regarding the prognostic influence of a positive bone marrow micrometastases (BMM) status on relapse-free and/or overall survival were analyzed.

MATERIALS AND METHODS

The literature search included the Medline and Current Contents bibliographic data bases from August 1980 to June 1997. The statistical evaluation considered the prognostic influence of the prevalence of micrometastatic cells in bone marrow on relapse-free and/or overall survival. The comparable effect estimate and its corresponding 95% confidence interval (CI) were calculated with the Mantel-Haenszel method using the originally published data of the retrieved studies.

RESULTS

The presence of epithelial cells in bone marrow was detectable in all carcinoma types, with a median prevalence of approximately 35%. Fourteen of 20 studies found a positive correlation between positive BMM status and reduced relapse-free survival by univariate analysis, but only five of 11 studies confirmed positive BMM status as an independent predictor of short disease-free survival. Regarding overall survival, positive BMM status was identified univariately in five of 12 studies, but multivariately in only two studies, as an independent factor of poor survival. Despite the heterogeneity of the studies, calculation of the relative risk (RR) for reduced relapse-free survival was possible for breast cancer, which resulted in a Mantel-Haenszel RR (RR(MH)) of 1.34 (95% CI, 1.27 to 1.42).

CONCLUSION

In conclusion, the results suggest that the prognostic impact of epithelial cells in bone marrow remains to be substantiated by further studies using standardized methodic protocols before its entrance in the TNM classification.

[Expression of Lewis blood group antigens in stomach carcinoma induces metastatic potential]

In a series of gastric cancer patients twenty-eight percent of the primary tumors expressed high levels of the Lewis carbohydrate. This correlated significantly with clinicopathological parameters of advanced disease (tumor size of > 50 mm, M1 stage, UICC stage IIIB/IV). In multivariate analysis, high Lewis expression was found to be a new independent factor of poor prognosis. In addition, Lewis was expressed on solid metastases and micrometastatic cells originating from Lewis positive primary tumors. The data suggest that Lewis positive tumor cells may have an advantage in penetrating secondary organs because, like leukocytes, they can specifically adhere to activated vascular endothelia.

[Tumor cell dissemination in bone marrow and peritoneal cavity. An immunocytochemical study of patients with stomach or colorectal carcinoma]

The tumor spread and the radicality of surgical resection are the most important facts in a patient's prognosis. In spite of curative tumor resection many patients die from metastases or local tumor recurrence. One possible reason is early dissemination of tumor cells which cannot be detected with clinical methods of examination. For this reason the aim of our study was to examine both bone marrow and peritoneal lavage for disseminated tumor cells with an immunocytochemical technique in patients with a gastrointestinal carcinoma. We also wanted to find out whether there was any correlation between the incidence of tumor cell detection and the TNM classification, staging and tumor grading and whether disseminated tumor cells have any prognostic significance. Our study included 54 patients who underwent surgery in our clinic for a carcinoma of the stomach (20 patients) or the colorectum (34 patients) from November 1993 to December 1994. At the beginning of the operation bone marrow had been taken from the iliac spine, and the abdomen was irrigated with 1000 ml saline solution immediately after laparotomy or laparoscopy. After cell separation with Ficoll density centrifugation 5 x 10(5) cells were applied per slide by a cytospin technique. For detection of the tumor cells we used the APAAP technique and the following monoclonal antibodies: KL1, CK2, anti-CEA, 17-1A (bone marrow) and Ber-EP4, B72.3, anti-CEA and 17-1A (peritoneal lavage). Altogether 77% of all patients had tumor cells in the bone marrow and 69% in peritoneal lavage fluid. It was possible to detect tumor cells in bone marrow (67%) and peritoneal lavage fluid (25%) even of patients with T1 tumors. The percentage increased with depth of wall infiltration. There was a marked difference in bone marrow aspirates between patients with lymph-node-negative tumors (N0) and those with lymph-node-positive tumors (N+): 65% had tumor cells in N0 and 85% in N+ stages. This trend was also seen in patients with (M1) and without (M0) metastases, in both bone marrow aspirates and peritoneal lavage fluid. In bone marrow there was a good correlation of tumor cells with staging, but in peritoneal lavage fluid this was not so. Finally, we detected tumor cells more often in bone marrow and peritoneal lavage fluid of patients with poorly differentiated tumors (G3) or diffuse Lauren type than in patients with moderately differentiated tumors (G2) or intestinal Lauren type. After a median follow-up period of 12.5 months patients with disseminated tumor cells had a lower survival rate than patients without tumor cells.

Bone marrow involvement in Hodgkin's disease -- clinicopathological study of seven cases

Bone marrow involvement was observed in 7 cases amongst a total of 75 cases of Hodgkin's disease encountered between January 1981 and June 1990; thus representing an incidence of 9.3 percent. Analysis of these 7 cases showed male preponderance. The age ranged from 26 to 74 years. All patients presented within seven months of onset of symptoms; and all had symptoms at presentation. Lymphadenopathy was found in all the cases, splenomegaly was present in six; and hepatomegaly in 4 cases. Mixed cellularity and lymphocytic depletion subtypes showed the highest frequency of marrow involvement (6 cases; 85.7 percent). Alkaline phosphatase was raised in 6 cases (85.7%). All cases received standard combination chemotherapy with or without local radiation therapy. Two years follow-up revealed an overall survival of 42.9%. Replace free survival at the end of two years was zero, as all the cases relapsed within seven months of initiation of treatment.