The state of the art in the treatment of severe aplastic anemia: immunotherapy and hematopoietic cell transplantation in children and adults

Acquired aplastic anemia (AA) is an immune-mediated bone marrow (BM) failure where marrow disruption is driven by a cytotoxic T-cell-mediated autoimmune attack against hematopoietic stem cells. The key diagnostic challenge in children, but also in adults, is to exclude the possible underlying congenital condition and myelodysplasia. The choice of treatment options, either allogeneic hematopoietic cell transplantation (alloHCT) or immunosuppressive therapy (IST), depends on the patient's age, comorbidities, and access to a suitable donor and effective therapeutic agents. Since 2022, horse antithymocyte globulin (hATG) has been available again in Europe and is recommended for IST as a more effective option than rabbit ATG. Therefore, an update on immunosuppressive strategies is warranted. Despite an improved response to the new immunosuppression protocols with hATG and eltrombopag, some patients are not cured or remain at risk of aplasia relapse or clonal evolution and require postponed alloHCT. The transplantation field has evolved, becoming safer and more accessible. Upfront alloHCT from unrelated donors is becoming a tempting option. With the use of posttransplant cyclophosphamide, haploidentical HCT offers promising outcomes also in AA. In this paper, we present the state of the art in the management of severe AA for pediatric and adult patients based on the available guidelines and recently published studies.

A systematic review of point-of-care abdominal ultrasound scans performed by general surgeons

BACKGROUND

Ultrasound is an established imaging modality in general surgery. With the increasing use of bedside point-of-care ultrasounds, general surgeons have been incorporating this skill into their clinical practice. This systematic review provides an up-to-date summary of the evidence for abdominal ultrasound scans performed by general surgeons to diagnose intra-abdominal pathology.

METHODS

Two independent reviewers searched the PubMed database between 1 January 1980 and 1 June 2020. Articles about surgeon-performed abdominal ultrasound in adult patients were included. Studies on trauma and vascular surgery were excluded.

RESULTS

26 articles met the inclusion criteria, presented as a narrative analysis. There was good evidence for the use of surgeon-performed ultrasound, particularly in gallstone-related diseases and moderate evidence for the use of ultrasound in appendicitis. Further evidence is required for point-of-care ultrasounds for other pathologies such as diverticulitis and groin hernias. Ultrasound training for general surgeons is variable with notable heterogeneity across studies.

CONCLUSION

A standardised training programme for general surgeons will greatly improve confidence and skill. There is good evidence for the use of bedside ultrasound by general surgeons in the acute and elective setting with reduced time to definitive treatment and fewer unnecessary hospital admissions.

Efficacy and Safety of Imatinib in Paediatric CML - A Single Centre Study

BACKGROUND/AIM

Chronic myeloid leukaemia (CML) rarely affects the paediatric population and has an incidence of 0.06-0.12/100,000 children per year. The dire clinical course of paediatric CML is further exacerbated by the adverse effects of long-term imatinib therapy.

PATIENTS AND METHODS

Our cohort comprised 14 CML patients who were treated with imatinib between July 2010 and September 2018. The European Leukaemia Net (ELN) standard milestones of response criteria were used to evaluate its therapeutic effectiveness.

RESULTS

Complete haematological remission and partial cytogenetic response were achieved in all patients. Complete cytogenetic response was achieved in seven patients. Major molecular response was achieved in six patients. Two patients underwent haematopoietic stem cell transplantation due to unsatisfactory response to imatinib.

CONCLUSION

Imatinib is effective in treating paediatric CML and limits the progression to advanced stages, however, the quality of life still needs to be optimised.

Imatinib in the treatment of chronic myeloid leukemia in children and adolescents is effective and well tolerated: Report of the Polish Pediatric Study Group for the Treatment of Leukemias and Lymphomas

BACKGROUND

Chronic myeloid leukemia (CML) constitutes only 2-3% of all leukemias in pediatric patients. Philapelphia chromosome and BCR-ABL fusion are genetic hallmarks of CML, and their presence is crucial for targeted molecular therapy with tyrosine kinase inhibitors (TKIs), which replaced hematopoietic stem cell transplantation (HSCT) as a standard first-line therapy. The disease in pediatric population is rare, and despite molecular and clinical similarities to CML in adults, different approach is needed, due to the long lifetime expectancy and distinct developmental characteristics of affected children.

OBJECTIVES

The objective of this study is to evaluate treatment with imatinib in Polish pediatric patients with CML.

MATERIAL AND METHODS

We analyzed the results of treatment with imatinib in 57 pediatric patients (June 2006 - January 2016) from 14 Polish pediatric hematology and oncology centers.

RESULTS

In the study group, 40 patients continued imatinib (median follow-up: 23.4 months), while in 17 the treatment was terminated (median follow-up: 15.1 months) due to therapy failure. In the latter group, 13 patients underwent HSCT, while 4 switched to second-generation TKIs. The 5-year overall survival rate (OS) in the study group was 96%, and the 5-year event-free survival (EFS) was 81%.

CONCLUSIONS

Our results confirm that the introduction of TKI therapy has revolutionized the treatment of CML in the pediatric population by replacing the previous method of treatment with HSCT and allowing a high percentage of OS and EFS.

Knee Cartilage Regeneration with Umbilical Cord Mesenchymal Stem Cells Embedded in Collagen Scaffold Using Dry Arthroscopy Technique

Articular cartilage injuries lead to progressive degeneration of the joint with subsequent progression to osteoarthritis, which currently becomes a serious health and economic issue. Due to limited capability for self-regeneration, cartilage repair remains a challenge for the present-day orthopedics. Currently, available therapeutic methods fail to provide satisfactory results. A search for other strategies that could regenerate a hyaline-like tissue with a durable effect and adequate mechanical properties is underway. Tissue engineering strategies comprise the use of an appropriately chosen scaffold in combination with seeding cells. Mesenchymal stem cells (MSC) provide an interesting new option in regenerative medicine with solid preclinical data and first promising clinical results. They act not only through direct cartilage formation, but also due to paracrine effects, such as releasing trophic factors, anti-inflammatory cytokines, and promoting angiogenesis. The MSC can be applied in an allogeneic setting without eliciting a host immune response. Out of the various available sources, MSC derived from Wharton's jelly of an umbilical cord seem to have many advantages over their counterparts. This article details a novel, single-staged, and minimally invasive technique for cartilage repair that involves dry arthroscopic implantation of scaffold-embedded allogenic mesenchymal stem cells isolated from umbilical cord Wharton's jelly.

Association of germline genetic variants in RFC, IL15 and VDR genes with minimal residual disease in pediatric B-cell precursor ALL

Minimal residual disease (MRD) enables reliable assessment of risk in acute lymphoblastic leukemia (ALL). However, little is known on association between MRD status and germline genetic variation. We examined 159 Caucasian (Slavic) patients with pediatric ALL, treated according to ALL-IC-BFM 2002/2009 protocols, in search for association between 23 germline polymorphisms and MRD status at day 15, day 33 and week 12, with adjustment for MRD-associated clinical covariates. Three variants were significantly associated with MRD: rs1544410 in VDR (MRD-day15); rs1051266 in RFC (MRD-day33, MRD-week12), independently and in an additive effect with rs10519613 in IL15 (MRD-day33). The risk alleles for MRD-positivity were: A allele of VDR (OR = 2.37, 95%CI = 1.07–5.21, P = 0.03, MRD-day15); A of RFC (OR = 1.93, 95%CI = 1.05–3.52, P = 0.03, MRD-day33 and MRD-week12, P < 0.01); A of IL15 (OR = 2.30, 95%CI = 1.02–5.18, P = 0.04, MRD-day33). The risk for MRD-day33-positive status was higher in patients with risk alleles in both RFC and IL15 loci than in patients with risk alleles in one locus or no risk alleles: 2 vs. 1 (OR = 3.94, 95% CI = 1.28–12.11, P = 0.024), 2 vs. 0 (OR = 6.75, 95% CI = 1.61–28.39, P = 0.012). Germline variation in genes related to pharmacokinetics/pharmacodynamics of anti-leukemic drugs and to anti-tumor immunity of the host is associated with MRD status and might help improve risk assessment in ALL.

First-line immunosuppressive treatment in children with aplastic anemia: rabbit antithymocyte globulin

Immunosuppressive therapy is the treatment of choice in children with acquired severe aplastic anemia (AA) and no HLA-matched family donor. The paper presents results of a multicenter study of 63 children with AA treated with rabbit antithymocyte globulin (r-ATG) and cyclosporine A as the first line treatment in the years 1996-2012. Therapeutic effects were evaluated at Days 112, 180, and 360. At Day 112, remission was achieved in 28 out of the 63 patients (44.4 %), complete remission in 10 patients (15.9 %), and partial remission in 18 (28.5 %). At Day 180, 31 patients (49.2 %) were in remission including 15 cases in complete (23.8 %), and 16 cases in partial remission (25.4 %). One year after therapy onset, 34 patients (64.9 %) were in remission including 24 patients (38.0 %) in complete and 10 (15.9 %) in partial remission. Relapse occurred in 4 patients, from 8 months up to 2 years and 2 months after remission. One child, 5 years after remission, was diagnosed with paroxysmal nocturnal hemoglobinuria. The estimated 10-year overall survival rate and 10-year event-free survival rate were 67 % and 57 %, respectively.

Stem cell experiments moves into clinic: new hope for children with bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a chronic lung disease with long-term complications that affects mainly preterm born children with low birth weights, especially those treated with mechanical ventilation and oxygen therapy. Successful treatment of BPD could reduce the incidence of other diseases of prematurity such as periventricular leukomalacia and retinopathy. The effects of current therapies are unsatisfactory; thus, searching for novel therapeutic is underway. One promising approach seems administration of mesenchymal stem cells (MSC). Preclinical data strongly support the role of progenitor cells in the preservation of lung structure. MSC can be found more often in pre-term than term umbilical cord and its isolation from Wharton's jelly carries a potential in treating diseases of prematurity. Several questions concerning the use of MSC in BPD remain to be answered, including the amount of transferred cells, intervals between infusions, the best route for administration and the timing. MSC can be administered as a treatment or prophylaxis. However, having in mind that not all prematurely born children are at risk of developing bronchopulmonary dysplasia, a search for laboratory markers identifying potential patients should be conducted. This review summarizes the latest achievements in MSC therapy in the context of BPD.

[Avascular necrosis of the femoral head in a patient with severe aplastic anaemia]

Avascular necrosis (AVN) is a pathological condition associated with numerous processes. Most frequent causes of ischaemia of the femoral head include trauma, corticosteroid therapy, radiation therapy, alcoholism, Gaucher's disease, systemic lupus erythematosus, rheumatoid arthritis. Corticosteroid therapy is considered the most frequent risk factor for developing avascular necrosis. In this paper we report a case of a 19-year old female patient who developed avascular necrosis of the right femoral head following treatment of severe aplastic anaemia. Clinical symptoms included groin pain and fever, painful abduction and internal rotation, tenderness over the right hip joint. The plain X-ray was not specific. However magnetic resonance imaging of the hip revealed changes characteristic for avascular necrosis. Conservative treatment was administrated. Two years after the onset of first clinical symptoms the patient is able to walk without pain, although the range of motion of the right hip joint is partially diminished. We evaluated the possible risk factors of AVN, diagnostic methods and prognosis. The onset of avascular necrosis should be considered as one of the relevant complications in patients with severe aplastic anaemia following immunosuppressive treatment.

Use of perfluorodecalin for pancreatic islet culture prior to transplantation: a liquid-liquid interface culture system--preliminary report

Although the issue remains controversial, short-term culture is probably beneficial for islet graft quality. However, significant islet loss is invariably observed. This is related to reduced survival of large islets, which is compromised by hypoxia under standard culture conditions. We aimed to develop a method of culture, which would avoid exposure to relative hypoxia and hence maintain the quality of islets. Isolated rat islets cultured for 48 h in a liquid-liquid interface culture system (LICS) with a perfluorocarbon were compared to islets cultured under standard (C1) and suboptimal conditions (C2). Islets were tested for viability and response to a glucose challenge, and a marginal mass was transplanted into syngeneic diabetic recipients. The viability of islets after 24-h culture in LICS was higher than in C1 and C2 groups (89.0% vs. 77.5% and 64.6%, respectively) and decreased with time to reach 79.0%, 62.9%, and 53.4% after 72-h culture. The stimulation index in LICS-cultured islets was also significantly higher than in C1 and C2 groups (12.3 ± 0.4 vs. 5.8 ± 0.5 and 4.1 ± 0.2, respectively). Following transplantation of LICS-cultured islets 50% of recipients were rendered normoglycemic compared with 14.3% and 31.3% for C2 and fresh islets, respectively. Our liquid-liquid interface culture system using perfluorodecalin provides optimized culture conditions, which preserve both islet viability and their ability to engraft successfully after intraportal transplantation and could be used for islet transportation.

[Long-term observations of children with acute lymphoblastic leukemia and high leukocytosis treated according to modified "New York" protocols (1987-2003)]

Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy. Due to new therapeutic schedules and cooperation between oncological centers it is curable in more than 80% of affected children. For the optimalization of the therapy there is necessary to assess the risk criteria that have influence on the treatment results in the certain groups of patients. Hyperleukocytosis and the age (less than 1 year and more than 10 years) are known as unfavorable risk factors. The study was designed to assess the long-term treatment results in children with ALL and the initial leukocytosis over 50 000/mm3 with the use of the modified "New York" protocols. We present the treatment results of 340 children with ALL treated in nine centers of Polish Pediatric Leukemia/Lymphoma Study Group (PPLLSG) according to three consecutive versions of modified "New York" protocol (group I, II, and III) between 1987 and 2003. Within the analyzed groups the first complete remission (I CR) was achieved in 91%, 95% and 96% of the patients, respectively. Relapses occurred in 37%, 21.5% and 26% of the patients and 3.7%, 1.8% and 5.7% of children died in the I CR due to complications, in the I, II and III therapeutic group, respectively. Obtained 5-and 10-year event-free survival (EFS) were 56% and 53.5% for the group I and 73% and 73% for the group II. Five-year EFS for the group III was 67%. The implementation of the New York protocol in 1987 and New York I in 1997 has improved the treatment results in children with ALL and initial leukocytosis over 50 000/mm3. Protocol New York II did not further improve the treatment results. Among analyzed parameters (age, gender, the initial leukocytosis, the blast cells immunophenotype) only age had the statistical significance. The implementation of modified "New York" protocols has improved the treatment results in children with ALL and initial leukocytosis over 50 000/mm3 compared to previous results.

[The course of epstein-barr virus and cytomegalovirus infection in children with acute leukaemia during chemotherapy]

AIM

To assess the course of EBV and CMV infection among children with acute leukaemia during chemotherapy with the aim to establish an efficient monitoring strategy.

MATERIAL AND METHODS

We have analyzed 28 children with acute leukaemia (age: 4 months-16 years) treated in the Department of Paediatric Haematology and Oncology, Medical University of Warsaw between 2004 and 2007 according to accepted chemotherapy protocols. In serum samples the presence of antibodies for viral capsid antigen, for nuclear and early antigen of EBV were tested by ELISA. Antibodies against CMV were tested by MEIA. Serum, blood, bone marrow samples, were tested for EBV by nested-PCR and serum samples for CMV by QT-PCR.

RESULTS

We observed primary EBV infection in 4 patients, reactivation in 11, persistent infection in one, previously undergone infection in 12 and primary CMV infection in 1 child, reactivation in 2. Nine patients were seronegative for CMV. One fatal outcome was caused by CMV pneumonitis, confirmed by ELISA test (IgM+; IgG+). Increased total bilirubin, aminotransferases and alkaline phosphatase levels correlated with CMV DNA level in one blood sample. During the chemotherapy no EBV antibodies were detected in 6 patients despite positive results in earlier tests. Viral DNA was detected in one blood sample and in 2 patients it was detected in bone marrow.

CONCLUSIONS

In children with leukaemia during chemotherapy primary and reactivation EBV infection occurred more often than CMV infection. Part of patients with EBV or CMV infections were seronegative during chemotherapy. Molecular biology should be the method of choice for confirmation and monitoring viral infection during intensive chemotherapy for these patients.

[Lymphoproliferative disorder as a complication after haematopoietic stem cell transplantation]

Lymphoproliferative disorders (LPD) occur often in EBV-infected patients, especially in solid-organ and haematopoietic stem cell transplant recipients. The risk of developing LPD ranges from 1 to 25% and depends on the type of transplantation. We are presenting the case of a 9-year-old boy with acute myelogenous leukaemia in second remission, who developed LPD after matched unrelated donor bone marrow transplantation (MUD BMT) not identical in two loci. On day 50 after BMT the patient presented with fever and symptoms of paronychia. Two weeks later, bilateral cervical tenderness and adenopathy and hepatosplenomegaly developed. Bone marrow biopsy confirmed continuing remission. An extensive infection workup, including bacterial, mycotic and CMV infection yielded negative results. Basing on clinical picture and suspecting LPD, EBV-PCR was performed. The patient was found to have extremely high EBV DNA levels (4.905.152 genomes/mcg) in the peripheral blood. On days 64 and 73 after BMT, the patient received two doses of rituximab (MabThera) (375 mg/m(2)) After the first dose of rituximab EBV DNA copy numbers decreased to 707.723/mcg. However the patient's general condition was worsening; 71 days after BMT increasing aplasia and symptoms of venoocclusive disease (VOD) developed. The patient received two doses of defibrotide (Novarid). Despite of intensive therapy, progressive hepatic failure and increasing pulmonary oedema led to the patient's death, on day 96 after BMT.

[Results of immunosupressive therapy in children with severe aplastic anaemia. Report of the Polish Paediatric Haematology Group]

INTRODUCTION

Bone marrow transplantation from HLA identical family donors is the treatment of choice for children with severe aplastic anaemia (SAA). When there is no donor available, combined immunosuppressive therapy is given.

AIM

evaluation of results of immunosupressive therapy in children with severe aplastic anaemia.

MATERIAL AND METHODS

SAA was diagnosed in 105 children (42 girls, 73 boys), aged 2-18 years, in the eleven haematological centres in Poland, between 1993-2007. All patients received the Severe Aplastic Anaemia Working Party of the EBMT protocol which included: antilymphocyte globulin or antithymocyte globulin, cyclosporin A, prednisolone. Granulocyto- or granulocytomacrophagic-cell stimulation factor was additionally administered during deep neutropenia. Haematological response was evaluated on day 84 or 112 and 180 of the therapy.

RESULTS

complete remission occurred in 53 patients (51.5%), partial remission in 27 (24.7%), no response was obtained in 25 children (23.8%) on day 180, of the therapy. Period of observation was from 12 months to 12.5 years. During this time relapse occurred in 10 patients (9.5%). We observed 22 deaths: 8 early, during the first 3 months of IS and 14 after the first 3 months of immunosuppresive therapy (IS). At present 70 children (66.6%) are in first remission with lasts from 12 months to 12.5 years. The survival at 12.5-years is 78.6%. During the 12.5 years of follow-up we had two cases with a late clonal complication (PNH and MDS). Transformation to acute nonlymphoblastic leukaemia was observed in two of our patients.

CONCLUSIONS

1. Immunosuppresive therapy (IS) in children with SAA, without bone marrow family donors, is more effective after introduction of combined IS (12.5 years survival in this study was 80% for children with very severe aplastic anaemia (v SAA). 2. In our studies among the children followed up after IS therapy, there were: 1 case of periodic nocturnal haemoglobinuria (PNH), 1 case of myelodysplastic syndrome (MDS) and 2 cases of myeloid leukaemia (probability of incidence was 3.8%).

[Juvenile fibroadenomas in a girl with serious aplastic anaemia after immunoablative treatment - case report]

We report a 17-year old girl, with severe aplastic anaemia (SAA)and juvenile fibroadenoma. She was treated with immunoablative therapy (IST), due to lack of a family bone marrow donor. She did not respond to the first course of IST. We administered second course of IST (ATG+CSA), because there was also no unrelated bone marrow donor. In January 2007 (1 year after starting CSA treatment), a palpable mass was found in the left breast.USG examination, performed after 2 months of observation, confirmed the presence of numerous lesions in the left and right breast (suggested fibroadenoma). Diagnostic biopsy was not performed due to high risk of bleeding. During a two step operation the biggest lesions were excised. Histopathological examination confirmed the diagnosis juvenile fibroadenoma of on physical examination, 8 months after the operation, there are again palpable nodular lesions in the left breast. (USG suggests fibroadenoma) The girl remains under systematic control. Now she has partially responded after second course of IST. Juvenile fibroadenoma of the breast in our patient may be a side effect of CSA therapy (she was treated with CSA for 2 years).

[Epstein-Barr infections in children with acute leukaemia. Preliminary report]

INTRODUCTION

Epstein-Barr virus (EBV) infection is common all over the world. Primary EBV infection can lead to latent or chronic infection resulting in lymphoproliferative diseases.

THE AIM

of this study was to evaluate the effectiveness of laboratory methods used to detect EBV and to monitor EBV infections in children with acute leukaemia.

MATERIALS AND METHODS

we conducted the study on 30 children with acute leukaemia. For the present analysis we included 8 patients from whom samples were also taken three times. Studies were made on serum, blood and bone marrow. Specific IgM and IgG antibodies for viral capsid antigen (VCA), nuclear (EBN) and early antigen (EA) were tested by ELSA. The presence of DNA virus was estimated by nested PCR. The control group were 11 subjects, without chronic or neoplastic disease, undergoing routine laboratory tests in the Virology Department.

RESULTS

on admission serologied tests indicated past EBV infection in 6 out of the 8 children. Primary infection was detected in 2 patients, in one of them on day 1 of the observation and on day 22 in the other. DNA EBV was found by nested PCR in only one of the 8 infected children.

CONCLUSION

1. Results of serological investigations indicated the type of EBV infection in our patients. 2. Confirmation of EBV virus active replication by nased PCR was obtained in only 1 out of 8 patients. 3. In order to assess the effectiveness of serological and molecular methods in evaluation of EBV infection type in children with acute leukaemia, it is necessary to investigate a larger group of patients and taken at least three times.

The Gln223Arg polymorphism of the leptin receptor gene and peripheral blood/bone marrow leptin level in leukemic children

Leptin is an adipocyte-derived hormone regulating energy homeostasis and body weight. Leptin also plays a role in hematopoiesis, cell cycle regulation, and in oncogenesis. The leptin receptor is a single transmembrane protein belonging to the superfamily of cytokine receptors, structurally related to the hemopoietin receptor family. The aim of the study was to evaluate bone marrow and peripheral blood leptin level and frequency of distribution of leptin receptor gene polymorphism Gln223Arg in children with acute leukemia. The examined group included 92 children with acute leukemia (83 ALL and 9 AML) and 39 non-leukemic control children. Leptin level was measured by ELISA method at the day of leukemia diagnosis. Genomic DNA was isolated with the use of a column method and the genotyping of DNA sequence variation was carried out by the restriction enzyme analysis of PCR - amplified DNA. The samples were then electrophoresed on 2.5% agarose gel. Leptin level in leukemic children was lower than in healthy children. Bone marrow leptin level was significantly lower than that in the blood in leukemic children with ALL-T and AML. An analysis of frequency distribution of the Gln233Arg polymorphism in the leptin receptor gene in leukemic children showed lack of differences between the patients and controls. There was no difference in the genotype frequencies between the leukemic AML and ALL groups either. The results indicate a possible relation between the leptin level and leukemia development in children. The effectory effect of the hormone seems not related to Gln223Arg polymorphism of its receptor.

[Congenital leukaemia and transient myeloproliferative disorder: diagnostic difficulties--case reports]

Congenital leukaemia occurs in only 0.8% of all cases of leukaemia in children. Despite great progress in the treatment of childhood leukaemia, prognosis is still poor. This type of leukaemia must be distinguished from leukaemic reactions and transient myeloproliferative disorder. Transient myeloproliferative disorder is a rare condition in the neonatal period, connected with trisomy or other abnormalities of chromosome 21. It is characterized by high blastosis in peripheral blood and bone marrow and it usually resolves without specific therapy in 1 to 3 months. We present two cases: congenital leukaemia and transient myeloproliferative disorder. The first patient was a boy in whom congenital myelomonoblastic leukaemia (M4 in FAB classification) was diagnosed at age of 6 weeks. He was treated according to BFM-96 for acute myeloblasts leukaemia protocol, but there was no remission and he died of progressive congenital leukaemia after 4 months. The second patient was a female neonate with Down's syndrome and a cardiac defect (common atrioventricular canal) in whom hyperleukocytosis with blastosis in peripheral blood and bone marrow were detected at 2 days of age. Although no specific antileukaemic therapy was given her condition improved. At age of 3 months we observed normalisation of peripheral blood and at 5 months of age the bone marrow smear was normal. These cases confirm the difficulties in differentiation between congenital leukaemia and transient myeloproliferative disorder presented in literature. In spite of the same haematological symptoms the only difference may be detection of nonhematopoietic tissue infiltration (skin and central nervous system) commonly occurring in congenital leukaemia or the presence of trisomy and other abnormalities of chromosome 21 in transient myeloproliferative disorder.

[Results of immunosuppressive therapy in children with severe aplastic anaemia. Report by the Polish Paediatric Leukaemia and Lymphoma Study Group]

INTRODUCTION

Bone marrow transplantation from HLA identical family donors is the treatment of choice for children with severe aplastic anaemia (SAA). When no donor is available, combined immunosuppressive therapy is given.

AIM

Evaluation of results of immunosuppressive therapy in children with severe aplastic anaemia.

MATERIAL AND METHODS

SAA was diagnosed in 85 children (31 girls, 54 boys) aged 2-17.5 years in the eleven centres of the Polish Paediatric Leukaemia and Lymphoma Study Group (PPLLSG) in Poland between 1993-2003 years. All patients received protocol of the Severe Aplastic Anaemia Working Party of the Europe Bone Marrow Transplant (EBMT): antilymphocyte globulin or antithymocyte globulin, cyclosporin A, prednisolone and granulocyto- or granulocyto-macrophagic-cell stimulation factor was additionally administered during deep neutropenia. Haematological response was evaluated on day 84, 112 or 180 of the therapy.

RESULTS

complete remission occurred in 43 patients (50.5%), partial remission in 22 (25.4%), no response was obtained in 20 children (23.7%) in 180 day of the therapy. Period of observation was from 12 months to 10.5 years. During this time relapse occurred in 6 patients (7%). We observed 16 deaths: 7 early during the first 3 months of immunosuppressive therapy (IS) and 9 after the first 3 months of IS.

CONCLUSION

the actual survival at 10-years, after immunosuppressive therapy is 81.2% in our group. Transformation to leukaemia or myelodysplastic syndrome (MDS) was not observed in any of our patients. We observed one case with paroxysmal nocturnal haemoglobinuria (PNH).

Questionnaire regarding the knowledge of the rules of organ procurement from cadaveric donors for transplantation directed to the directors of medical institutions in Poland

We assessed the level of knowledge of organ procurement regulations among the directors of medical institutions in Poland. We also sought to promote the objection form, and the activity of the Central Register of Objections. A questionnaire consisting of 10 questions was sent to 381 random medical health care institution directors countrywide. In 89% of surveyed institutions, the written text of the organ procurement regulations was available and 94% of directors knew the forms of objection, but in 26% of institutions the form was not available and in 14% it was never obtainable. In the medical institutions directors' opinions, the estimated number of objections is 13% of the population in Poland. Organ transplantation is a form of treatment most medical institutions are familiar with, but the matter of donation is not as well known as transplantation, as observed in 48% of questioned institutions.

Geography of the referred potential liver recipients and donors in Poland in 2004

Our aim was to assess the accessibility of potential liver recipients to cadaveric organs and the ability of transplant teams to realize recipients needs in Poland in 2004. Our calculations revealed that in Poland the number of cadaveric liver transplants was two to three times lower than in other countries and is insufficient to meet the needs, also the number of referred potential liver recipients is two to three times lower than expected.

[Acute lymphoblastic leukemia in children with initial leucocytosis above 50,000/mm3: summary of treatment results of Polish Pediatric Leukemia/Lymphoma Study Group]

Initial leucocytosis, presence of t(9;22) and t(4;11) translocations and poor response to therapy with steroids or induction chemotherapy are still included to poor risk factors group. From 1981 to 1986, children with acute lymphoblastic leukemia (ALL) and initial WBC above 50,000/mm3, achieved significantly worse treatment results than children with lower WBC: over 6-year disease-free survival were respectively 33% and 60%. In attempt to improve treatment results in children with hyperleucocytosis, modified American protocols called: New York (1987), New York I (1997), and New York II (1999) were introduced consecutively in the centers of Polish Pediatric Leukemia/ Lymphoma Study Group. Actually treatment results obtained with those protocols in three groups of patients: group I: 214 children (1987-1996), group II: 58 children (1997-1999), and group III: 77 children (1999-2001) are presented. The observation was completed in March 31, 2004. In evaluated groups the first complete remissions (CR) were achieved in 91%, 95%, and 96% of patients, respectively. Relapses occurred in 72 patients of group I (37%), in 12 patients of group II (21%), and in 13 patients of group III (18%). The 5-year overall survivals were: 62%, 79%, and 78% (p=0.05) respectively; 5 year event-free survivals (EFS) were: 52%, 74%, and 69% (p=0.01) respectively. A significant improvement in treatment results in second compared with first group was achieved. Treatment results obtained with New York II are comparable with results obtained with New York I. The analysis of treatment results achieved shows the improvement of the prognosis in children with ALL and initial WBC above 50 000/mm3 in comparison with patients treated before 1987. There is strong necessity of unification of risk group qualification criteria in childhood ALL in term of comparable estimation treatment results achieved in different centers all over the world.

Incidence and clinical characteristics of second malignant neoplasms in children: a multicenter study of a polish pediatric leukemia/lymphoma group

BACKGROUND

The development of second malignant neoplasms (SMNs) in patients receiving chemotherapy and radiation therapy for primary cancers is one of the limitations to the quality and length of survival. The present study was undertaken to examine various characteristics of children who developed SMNs following successful therapy for primary leukemia or Hodgkin's disease (HD).

MATERIAL/METHODS

A total of 3252 children with various forms of leukemia and 849 children with HD treated between, 1970-1997 at 7 pediatric centers of the Polish Pediatric Hematology/Oncology Group and subsequently followed-up entered the study. A second malignancy was diagnosed in 36 of these children.

RESULTS

Of the 3252 patients diagnosed as having acute leukemia during this period, 16 developed SMNs (estimated frequency 0.49%). SMNs developed in 20 of the 849 children treated for HD (2.36%). The most frequent SMNs were soft tissue sarcoma and thyroid carcinomas, mainly following Hodgkin's disease. Other tumors occurred at about the same frequencies in both groups. The interval from the end of initial treatment to diagnosis of an SMN ranged from 2 years 7 months to 17 years 6 months, with a median of 7 yrs 4 mo. for acute lymphoblastic leukemia (ALL) patients and 10 years for children with HD. The estimated accumulated risk of SMN following acute leukemia is 0.95% at 15 years and, for HD, 5.1% at 20 yrs and 7% at 25 yrs.

CONCLUSIONS

Children who have been successfully treated for one cancer have a higher than expected incidence of additional tumors.

[High risk acute lymphoblastic leukaemia in children. Preliminary report after introducing a new version of New York (1997) protocol adjusted to the age of the patients. Report of the Polish Paediatric Leukaemia/Lymphoma Study Group]

The paper presents the experience of the Polish Paediatric Leukaemia/Lymphoma Study Group in the treatment of high-risk acute lymphoblastic leukaemia in children using a new version of the New York (1997-1999). Protocol with treatment intensity adjusted according to the age of the patients. From April 1997 to December 1999 a group of 49 children with leukocytosis ranging from 50 900/mm3 to 580 000/mm3 (median 122 000/mm3) and 6 children with leukocytosis below 50 000/mm3 and poor response to steroids were treated with this protocol. Children below 10 years (43 patients) were treated according to the previous protocol, children above 10 years (12 patients) were treated with intensified protocol (high doses of ARA-C in consolidation and intermediate doses of Mtx in maintenance). Induction was identical for all patients. Complete remission was achieved in 92.6% patients. There were 2 relapses. Six children died - 3 without remission, 2 due to a relapse, 1 due to treatment complications. The current opinions concerning classification of HRG-ALL and treatment possibilities in this group of children are discussed.

[Viral infection in children with malignant diseases]

Infection, including viral infection, still cause serious complication in the course of chemotherapy. Recognition of viral infections, monitoring, prophylaxis and treatment is aimed at reducing the number of infected patients, mitigating the cause of the disease and limiting deaths directly linked with infections in paediatric cancer patients. Viruses from the herpes group (HSV, VZV, EBV, CMV) are particularly dangerous. They can cause not only asymptomatic and local infectious but also general diseases and can reactivate, especially after BMT. Hepatoropic viruses (HBV, HCV) often lead to breaks in chemotherapy, while chronic viral hepatitis can lead to fibrosis, cirrhosis and even primary hepatocellular carcinoma. CMV, RSV, adenovirus influenza and parainfluenza virus cause diffuse interstitial pneumonitis and are also associated with a high rate of mortality. In this paper, we present the most frequency viral infection in children with malignant diseases, their methods of diagnosis and treatment.

[Advances in the treatment of children with high risk acute lymphoblastic leukemia (ALL) treated with modified "NEW YORK" protocols between 1987 and 2002]

From 1981 to 1986, in children with ALL and initial WBC > or = 50,000/mm3, over 6-year disease-free survival was significantly lower (33%) than in children with WBC < 50,000/mm3 (60%). In attempt to improve this unsatisfactory results, three modified American protocols named: "New York", "New York I", and "New York II", "New York I", and "New York II" were introduced consecutively in the centers of Polish Pediatric Leukemia Lymphoma Study Group (respectively, in 1987, 1997, and 1999). The treatment results achieved in three consecutive therapeutic groups of children with ALL and initial WBC > or = 50,000/mm3: group I--213 children (1987-1996), group II--58 children (1997-1999), and group III--52 children (1999-2001) are presented. The observation was completed in December 31, 2002. In three evaluated groups the first complete remissions (CRs) were achieved in 90.6%. 94.8%. and 94.2% of patients, respectively. Relapses occurred in 71 patients of group I (37%), in 9 patients of group II (16%), and in 6 patients of group III (12%). The complications of treatment caused death in 7 children of group I, in 1 child of group II, and in 2 children of group III. Eighty-one (38%), 11 (18.9%), and 9 (17.3%) patients, respectively, died due to progression of disease. The event-free survival (EFS) in three evaluated groups did not depend on age of children and WBC. The rates of 2-, 5-, and 10-year event-free survival (EFS) in group I were: 69.9%, 55.3%, and 53.6%, respectively and the rates of 2- and 5-year EFS in group II were: 80.7% and 72.7%, respectively. The rate of 2-year EFS in group III was 71.6%. The analysis of achieved treatment results in three evaluated groups shows the gradual improvement of the prognosis in children with ALL and initial WBC > or = 50,000/mm3 treated with the use of modified protocols "New York" and "New York I" in comparison with patients treated before 1987. Longer observation is needed for evaluation of efficacy and complications of "New York II" protocol.

[The assessment of the treatment of viral hepatitis C with interferon alpha in children with leukemias and lymphomas]

Interferon alfa in dose 3-6 MU IM was administered during six months 3 times per week in 30 children with chronic hepatitis C with leukaemias and lymphomas. Chronic hepatitis was diagnosed basing on anti-HCV, RNA HCV by PCR, high activity of ALT and histopathologic examination of the liver. The patients were followed-up for 12 months after IFN therapy. Sustained normalization of ALT levels, together with serum HCV RNA elimination was considered as a complete response and achieved in 33% children. Partial response (ALT normalization without serum HCV RNA elimination) was recorded in 57% patients. Anti HCV antibody was detected in all children during the time of observation.

[The efficacy of G-CSF and GM-CSF in the adjunctive treatment of infections complicating chemotherapy of acute leukemia in children]

Growth factors (G-CSF Neupogen Roche i GM-CSF Leucomax Sandoz) have been applied in 133 therapeutic and prophylactic cycles in 88 children with acute leukaemias. GM-CSF and G-CSF were administered subcutaneously or intravenously at a dose of 2 to 8 micrograms/kg for 2 to 28 days. 45 prophylactic cycles had been administered in children with acute lymphoblastic leukaemia in high risk group and in relapses, which caused significant reduction in the number of infections, time of neutropenia and fever. Therapeutic cytokines cycles were applied when the absolute neutrophil count have fallen below 0.5 x 109/l. We observed significant reduction in duration of neutropenia in these cycles. Tolerance of GM-CSF and G-CSF was good. Side effects were not observed.

Incidence and treatment of hepatitis C virus infection in children with haemophilia in Poland

In 80% of children with haemophilia treated in our department, screening tests showed the presence of antibodies against the hepatitis C virus (HCV). HCV RNA was detected in serum in 41% of cases. In 20% of cases there were periodic increases in the level of alanine aminotransferase (ALT) activity, and in these cases liver biopsy was performed after factor concentrate replacement. No haemorrhagic complications or pain complaints were reported either during the biopsy or immediately afterwards. In all cases histopathological examination revealed chronic hepatitis type C - chronic mild hepatitis and chronic minimal hepatitis. Eight boys were treated with interferon (INF) alpha. In two cases this therapy was successful. No HCV RNA was detected in serum and transaminase activity was normal during the year following interferon treatment.

[Interferon alfa in treatment of chronic hepatitis B in children with leukemias and lymphomas]

The course of the hepatitis B virus infection (HBV) in the majority of children with cancer who have undergone intensive chemotherapy is characterized by scanty symptoms and often leads to chronic hepatitis and prolonged carrier state. Twenty three children with chronic hepatitis B virus (HBV) were treated with interferon alfa after the completion of chemotherapy of leukemias and lymphomas. In the majority of cases a disproportion between symptomless clinical course of the hepatitis B virus and the rate of its active replication was observed. Presence of HBsAg and high activity of polymerase DNA HBV (pDNA) were found in all children. In the course of a 6-month treatment with interferon in a dose of 3 mil IU/m2 of the body surface a gradual decrease of pDNA activity was observed. A statistically significant difference of mean values of pDNA before and right after the treatment was determined (p < 0.05). Tests performed 3 months after the completion of the therapy showed a repeated increase of pDNA activity. Boundary values of pDNA were observed in 5 children. Complete elimination of HBs and HBe antigens has not been achieved in any of the children. While analyzing the obtained results it has to be taken into consideration that there were numerous unfavourable prognostic factors determined in the studied group of children such as: coexisting malignant disease, undergone intensive chemotherapy, long period which has passed from the moment of HBV infection until the administration of the treatment with interferon, high activity of pDNA, scanty symptoms of inflammation process. Coexisting HCV infection in 12 children, could also have a undesirable effect upon the treatment results.(ABSTRACT TRUNCATED AT 250 WORDS)