New Insights into Red Blood Cell Microcytosis upon mTOR Inhibitor Administration

The aim of this study was to evaluate the effect of everolimus, a mammalian target of rapamycin (mTOR) inhibitor, on red blood cell parameters in the context of iron homeostasis in patients with tuberous sclerosis complex (TSC) and evaluate its effect on cell size in vitro. Everolimus has a significant impact on red blood cell parameters in patients with TSC. The most common alteration was microcytosis. The mean MCV value decreased by 9.2%, 12%, and 11.8% after 3, 6, and 12 months of everolimus treatment. The iron level declined during the first 3 months, and human soluble transferrin receptor concentration increased during 6 months of therapy. The size of K562 cells decreased when cultured in the presence of 5 μM everolimus by approximately 8%. The addition of hemin to the cell culture with 5 μM everolimus did not prevent any decrease in cell size. The stage of erythroid maturation did not affect the response to everolimus. Our results showed that the mTOR inhibitor everolimus caused red blood cell microcytosis in vivo and in vitro. This effect is not clearly related to a deficit of iron and erythroid maturation. This observation confirms that mTOR signaling plays a complex role in the control of cell size.

The microbiotest battery as an important component in the assessment of snowmelt toxicity in urban watercourses--preliminary studies

The aim of the study was to use a battery of biotests composed of producers (Selenastrum capricornutum, Sorghum saccharatum, Lepidium sativum, and Sinapis alba), consumers (Thamnocephalus platyurus), and decomposers (Tetrahymena thermophila) to evaluate the toxicity of snowmelt and winter storm water samples. The toxicity of the samples collected in the winter period December to February (2010-2011), in one of the largest agglomerations in Poland, the city of Lodz, was compared to that of storm water samples taken under similar conditions in June. The most toxic snowmelt samples were found to be high acute hazard (class IV), while the remaining samples were rated as slight acute hazard (class II). L. sativum (in the Phytotox test) was the most sensitive test organism, giving 27 % of all toxic responses, followed by S. capricornutum with 23 % of all responses. T. thermophila was the least sensitive, with only 2 % of all toxic responses. The greatest range of toxicity was demonstrated by samples from the single family house catchment: no acute hazard (class I) to high acute hazard (class IV).

Palliative sedation at home for terminally ill children with cancer

CONTEXT

The presence of symptoms that are difficult to control always requires adjustment of treatment, and palliative sedation (PS) should be considered.

OBJECTIVES

We analyzed our experience in conducting PS at home for terminally ill children with cancer during a seven-year period.

METHODS

We performed a retrospective analysis of medical records of children with cancer treated at home between the years 2005 and 2011.

RESULTS

We analyzed the data of 42 cancer patients (18% of all patients); in 21 cases, PS was initiated (solid tumors n = 11, brain tumors [5], bone tumors [4], leukemia [1]). Sedation was introduced because of pain (n = 13), dyspnea (9), anxiety (5), or two of those symptoms (6). The main drug used for sedation was midazolam; all patients received morphine. There were no significant differences in the dose of morphine or midazolam depending on the patient's sex; age was correlated with an increase of midazolam dose (R = 0.68; P = 0.005). Duration of sedation (R = 0.61; P = 0.003) and its later initiation (R = 0.43; P = 0.05) were correlated with an increase of the morphine dose. All patients received adjuvant treatment; in patients who required a morphine dose increase, metoclopramide was used more often (P = 0.0002). Patients did not experience any adverse reactions. Later introduction of sedation was associated with a marginally higher number of intervention visits and a significantly higher number of planned visits (R = 0.53; P = 0.013).

CONCLUSION

Sedation may be safely used at home. It requires close monitoring and full cooperation between the family and hospice team. Because of the limited data on home PS in pediatric populations, further studies are needed.

Pediatric palliative care education for medical students: development and evaluation of a pilot program

In Poland, medical curricula cover palliative care for adults, not for children. This paper evaluates feedback of students who participated in a pilot pediatric palliative care education program.

METHOD

An anonymous questionnaire was designed for the students; they were asked to assess each aspect of the program on a scale of 0 to 6 (0 denoted complete dissatisfaction; 6, complete satisfaction).

RESULTS

207 students participated in the program, 197 evaluated it, and 160 formed the research data group. More than 50 percent gave the program 5 points (mean +/- SD; 4.91 +/- 0.9). A total of 79 students (44 percent) assessed the material as 51 to 75 percent new, and 56 students (31 percent) placed it between 76 and 100 percent. A majority indicated that the material would be most useful to them in their future clinical work. Most respondents (78 percent) stated that pediatric palliative care should be included in the pediatrics curriculum. The contribution of the program instructors was given a high score (on average, 5.26 +/- 0.52).

CONCLUSION

The pediatric palliative care education program was feasible, and it was well received by the students who undertook it.

[Can children with Hodgkin's disease be treated with chemotherapy only?]

Currently over 90% of children and adolescents with Hodgkin's disease (HD) can be cured thanks to use of multidrug chemotherapy (CT) combined with involved-field radiotherapy (IF-RT). However, the intensive treatment may increase the risk of late complications which may impair the patients' quality of life. In order to decrease the incidence of late complications the protocol with limited use of IF-RT was introduced in centers of Polish Pediatric Leukemia/Lymphoma Study Group (PPLLSG). This study presents the treatment results of patients treated with CT only in comparison with the therapy results of children treated with CT and IF-RT. From 1997 to 2006, 634 children (age: 2-22,5 years) with HD were treated in 14 oncological centers of PPLLSG. Majority of patients received CT (3-8 cycles of MVPP/B-DOPA) combined with IF-RT. In 45 patients with IA-IIA stages presenting favorable risk factors (small mediastinal tumor, peripheral nodular mass of a maximum diameter < 6 cm, involvement of less than three nodular regions, ESR < 50 mm after 1 h, histologic type other than lymphocyte depletion and very good treatment response assessed after 3 CT cycles) IF-RT was omitted. Among 634 children first complete remission (RC) was not achieved in 2.4% of patients. Relapses occurred in 24 children (3.9%). The rates of 5-year overall survival (OS), relapse-free survival (RFS) and event-free survival (EFS) were 97%, 96% i 92%, respectively. All patients treated with CT only remain in first CR. All serious late complications (including 7 second neoplasms) occurred in patients treated with CT combined with RT. Seven children died because of severe complications, among them two in first CR (aplastic anemia, sepsis). Our results show that the use of CT only in precisely selected group of patients with HD do not impair the treatment results and may decrease the risk of late life threatening complications. Treatment response assessment with the use of PET may in future increase the number of patients treated without RT and limit the need of the use of invasive diagnostic methods in patients with residual mass.

[Treatment results of children with neuroblastoma: report of Polish Pediatric Solid Tumor Group]

Approximately 60 children aged 0-18 years are diagnosed of NBL each year in Poland. About 60% of all patients suffering from NBL have a chance for durable cure. Unfortunately the prognosis for patients within the high-risk group accounting for more than 50% of all NBL patients remains poor despite the introduction of more intensive chemotherapy regimens with radical surgery procedures and megachemotherapy with subsequent stem cell transplantation. Only one third of patients in this group can be cured. To improve the treatment results of the high-risk patient group and to decrease the rate of therapy related side effects current European treatment protocols have been introduced systematically in Poland. In February 2009 information about 389 patients (age 0.1-16.5 years) diagnosed between 2001 and 2008 were obtained. Results of therapy of 319 patients who started treatment from 2001 to 2007 were analyzed. Between 104 infants and 215 children over 1 year of age, stage 4 of disease was found in 25% and 54.5%, respectively. In this period additionally to European treatment protocols, two another protocols were used. Satisfactory treatment results were obtained in 104 infants (5-year event free survival /EFS/=82.6%), irrespective of the type of treatment protocol. Over 5-year EFS for children over 1 year of age in 1, 2 and 3 stage of disease was: 100%, 86.3% and 64.5%, respectively. On the contrary, 107 patients with 4 stage of disease achieved the 5-year EFS of 27% only. Treatment results obtained in patients treated according to the European HR-NBL-1/ESIOP protocol were better than for patients treated according to other treatment protocols (5-year EFS: 31.1% and 16.4%, respectively), but difference between these groups was not significant. Between 2001 and 2007 data reporting increased to 81% from 19% noted earlier. Unfortunately, results of treatment for children over 1 year of age remain still unsatisfactory. That is why there is a need of improvement of modern, unified treatment realization as well as better data reporting. For realization of these aims adequate financial support is essential.

[Genotyping and minimal residual disease study in children with acute myeloid leukemia: preliminary results]

The aim of the paper is to present the initial results of molecular examination which was started in 2006 for children with acute myeloid leukemia. Better knowledge of biology of this disease, can result in establishing of new risk factors what allows more precise patient stratification to different therapeutic groups. Study was obtained patients until to 18 years of age treated according to AML-BFM 2004 INTERIM protocol in 14 centers of the Polish Pediatric Leukemia/Lymphoma Study Group. Mononuclear cells were collected from bone marrow on time points established according to the AML-BFM 2004 INTERIM protocol. Collected cells were isolated on Ficoll gradient, and RNA and DNA were isolated using TRIZOL reagent. To synthesize cDNA an amount of 1 mg of total RNA was used. To perform quantitative RT-PCR and RQ-PCR reactions 4 fusion gene transcripts (AML1-ETO, CBFb-MYH11, PML-RARA /subtype bcrl and bcr3/) were used according to the protocol established by Europe Against Cancer Program. An expression of WT1 gene was tested additionally. An analysis of ABL control gene was used to normalize of achieved results. Determination of duplication of FLT3 gene in DNA sample was performed with starters complementary to JM region. Genotyping was performed in 75 patients with acute myeloid leukemia so far. AML1-ETO fusion gene transcript was found in 14 patients (19%). PML-RARA (subtype bcr3) and CBFB-MYH11 gene transcripts were detected in 3 (4%) and 3 (4%) patients, respectively. Duplication of FLT3 gene was found in 4 (5.3%) cases. Between 67 tested children over expression of WT1 was present in 51 patients (76%). Analysis of MRD level in subsequent time points showed systematic decrease of number of fusion gene transcript copies and gene WT1 expression. To establish the rate of molecular marker presence in AML in children and the influence of the presence of MRD on the treatment results as well, the study has to be conducted on a larger group of patients with longer follow-up.

[Changes in the lipid profile in children with acute lymphoblastic leukaemia - the influence of the disease and its treatment]

The aim of the study was a prospective evaluation of the lipid profile in children with acute lymphoblastic leukaemia, before and during the treatment with L-asparaginase.

PATIENTS AND METHODS

Twenty-four children treated according to the ALLIC 2002 protocol entered the study. Blood samples were collected during the induction phase of treatment, on the 1st, 21st and 30(33)th day. The concentration of the total cholesterol, HDL and LDL cholesterol and triglycerides was determined. The results were analyzed in relation to the Body Mass Index, the WBC count and L-asparaginase activity. At the moment of diagnosis significantly low concentration of total cholesterol (124 mg/dl (103-153) vs 161 mg/dl (143-185), p=0,011) and HDL cholesterol (23 mg/dl (17-27) vs 56 mg/dl (44-64), p=0,00001) were observed, as well as high concentration of triglycerides (112 mg/dl (83-162) vs 73 mg/dl (62-99), p=0,009). The concentration of LDL cholesterol was similar to that observed in the control group. During further treatment the increase of the total cholesterol concentration was observed, but it was still significantly lower, when compared with the control. The values of triglycerides were significantly higher then those observed in healthy children (day 21: 88 mg/dl (67-170), p=0.08, day 33: 111 mg/dl (96-104) p=0.0004). The concentration of HDL cholesterol has increased during the treatment, but it was still lower than the HDL concentration in the control group (day 38: mg/dl (29-53), day 33: 30 mg/dl (16-50), p=0.009). No association between lipid concentration and BMI, WBC and L-asparaginase activity were found.

CONCLUSIONS

At the moment of diagnosis of ALL the potentially atherogenic lipid profile could be established. This tendency subsists during the induction phase, regardless of slight differences in particular lipid fractions.

[Acute respiratory failure in a 16-yr-old girl with alveolar soft part sarcoma]

BACKGROUND

Intensive treatment in oncology often leads to severe complications, including infection and coagulation disturbances. Among the most serious are fungal infections which are often life-threatening, and difficult to recognize and treat. We present a patient with severe pneumonia and pleural effusion, that developed during treatment of a soft tissue sarcoma with pulmonary metastases.

CASE REPORT

A 16-year-old girl was admitted to the ITU because of marked dyspnoea, bilateral pneumonia and pleural effusion. She was intubated and placed on a ventilator, and bilateral pleural drains were inserted. She also required vigorous inotropic support (dopamine + noradrenaline). CRP was 12.5-19.8 mg dL(-1) and procalcitonin was below 1 ng mL(-1)). Lung metastases and tuberculosis were excluded and fungal infection suspected. Aspergillus DNA was detected in bronchoalveolar lavage, and in blood serum (PCR). Amphotericin B and voriconazole were instituted, but without evident success, The girl was severely distressed, required mechanical ventilation with an F1O2 of 0.6, while her CRP increased to 28.4 mg dL(-1). The amphotericin was stopped and replaced with caspofungin, resulting in rapid improvement in her clinical status. The girl was extubated after 21 days of ventilation, however due to a very severe opioid withdrawal syndrome with extreme agitation, she was re-intubated. After a further two weeks on methadone and sedatives, she was extubated again, this time successfully, One month later she was discharged from the hospital, still on oral voriconazole.

CONCLUSION

Fungal infection should always be considered in immunocompromised patients with clinical signs of systemic infection. Recognition and treatment of pulmonary aspergillosis is difficult and may require multi drug therapy.

[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).

[Analysis of microvascular density and the expression of vascular-endothelial growth factor (VEGF) and its membrane receptor Flk-1 in neuroblastoma]

AIM

To assess selected angiogenic markers; microvascular density and the expression of VEGF and Flk-1 in relation to clinical features and morphologic types of neuroblastoma.

PATIENTS AND METHODS

Eighty-two children with neuroblastoma were studied. Morphological assessment was performed in paraffin embedded tissues of the primary tumours. Microvessels within tumour tissue were counted on immunohistochemically stained sections using anti CD34 antibody. The expression of VEGF and Flk-1 was estimated semiquantitively in immunohistochemically stained sections with adequate antibodies. The results of angiogenic studies were referred to the clinical data: age, clinical stage, localization and site of the primary tumour, serum LDH and ferritin at diagnosis. The correlation between angiogenic markers and morphological type of neuroblastoma was also evaluated.

RESULTS

Microvascular density varies in a wide range (32-325/mm(2)). There was no significant statistical difference between previously untreated and tumours assessed after chemotherapy. Analyzing the correlations between the angiogenic markers and clinical features we found a converse relation between the age and microvascular density. The highest expression of VEGF was found in adrenal tumours in comparison to other localizations. Undifferentiated and poorly differentiated tumours presented a higher expression of VEGF and higher vascular density. Non significant higher expression of VEGF and higher vascular density was noticed in smaller <5 cm tumours.

CONCLUSIONS

Correlations were found between the microvascular density and the age, diameter and the localisation of the primary tumour. Expression of VEGF depends on the localisation of the tumour. Neuroblastoma tumours arising in small children and poorly differentiated types of neuroblastoma indicate higher angiogenic activity.

Cytoprotective effect of amifostine in the treatment of childhood neoplastic diseases--a clinical study including the pharmacoeconomic analysis

Amifostine is an active aminothiol, which has unique properties as a radio- and chemoprotective agent. It has been reported to prevent myelosuppression and reduce the toxic effects of intensive cancer treatment. In the study, 57 courses of chemotherapy in 18 children treated because of neoplastic disease were analyzed to assess the early side effects induced by cytotoxic anticancer therapy. In 18 of them amifostine was used as the cytoprotective agent. The estimation of adverse effects was made in accordance to WHO scale of toxicity, and the pharmacoeconomic analysis was based on the costs of intravenous antibiotics, G-CSF, GM-CSF, blood preparations, immunoglobulins and days of hospitalization. The amifostine use in supportive therapy of neoplastic diseases in children decreases the number of infections thanks to the diminishing of myelotoxic effect. This not only improves the comfort of the patient but also shortens the time of hospitalization. The amifostine therapy limits the costs of treatment, but high price of the drug itself, makes however, the chemotherapy with cytoprotection comparable in pharmacoeconomic analysis to the standard treatment.

[Does the residual mediastinal mass have prognostic significance in children with Hodgkin's disease (HD)?]

Prognostic significance of residual mediastinal tumor mass in children treated for HD as well as the choice of the optimal management of these cases still remains unknown. In years 1994-2001 in 10 PPLLSG participating centers 480 children (age 2-19.7 years) were treated for HD (stages I-IV). In 338 cases initial mediastinal/lung hilus involvement was present. All patients with initial mediastinal/lung hilus involvement were treated with multidrug chemotherapy combined with involved field radiotherapy. In five cases remission was not achieved. Complete remission (CR) was achieved in 226 patients and uncertain complete remission (UCR) in 107 patients, in whom after completion of planned treatment residual changes in mediastinum/lung hilus were identified in radiological examinations. Twenty four children with persistent mediastinal tumor underwent thoracoscopy or thoracotomy. In only one case histopathological examination revealed the presence of neoplastic cells in mediastinal mass tissue, in 2 another cases cystic changes in mediastinum were present, in one case thymic tissue was identified, necrotic tissue was present in 20 cases. Among 107 children with residual mediastinal tumor and 226 patients with CR achieved, relapses occurred in 6 and 18 patients respectively. Over 5-year relapse-free survival was 92.4% and 91.3% respectively. Patients with the presence of mediastinal/lung hilus tumor after the completion of the treatment do not have an increased risk of relapse, but before the completion of therapy they require careful, clear-sighted and repeated examinations including computed tomography (CT), magnetic resonance imaging (MRI) and especially positron emission tomography (PET) to evaluate the nature of persistent lesions. Only in clinically and radiologically doubtful cases tumor biopsy with subsequent histopatological examination should be performed.

Carrier frequency of mutation 657del5 in the NBS1 gene in a population of polish pediatric patients with sporadic lymphoid malignancies

Nijmegen breakage syndrome (NBS) is a human autosomal recessive disease characterized by genomic instability and enhanced cancer predisposition, in particular to lymphoma and leukemia. Recently, significantly higher frequencies of heterozygous carriers of the Slavic founder NBS1 mutation, 657del5, were found in Russian children with sporadic lymphoid malignancies, and in Polish adults with non-Hodgkin lymphoma (NHL). In addition, the substitution 643C>T (R215W) has also been found in excess among children with acute lymphoblastic leukemia (ALL). In an attempt to asses the contribution of both mutations to the development of sporadic lymphoid malignancies, we analyzed DNA samples from a large group of Polish pediatric patients. The NBS1 mutation 657del5 on one allele was found in 3 of 270 patients with ALL and 2 of 212 children and adolescents with NHL; no carrier was found among 63 patients with Hodgkin lymphoma (HL). No carriers of the variant R215W were detected in any studied group. The relative frequency of the 657del5 mutation was calculated from a total of 6,984 controls matched by place of patient residence, of whom 42 were found to be carriers (frequency = 0.006). In the analyzed population with malignancies, an increased odds ratio for the occurrence of mutation 657del5 was found in comparison with the control Polish population (OR range 1.48-1.85, 95% confidence interval 1.18-2.65). This finding indicates that the frequency of the mutation carriers was indeed increased in patients with ALL and NHL (p < 0.05). Nonetheless, NBS1 gene heterozygosity is not a major risk factor for lymphoid malignancies in childhood and adolescence.

[Ocular complications in leukemias and malignant lymphomas in children]

PURPOSE

The aim of the study was to determine the prevalence and types of ocular abnormalities in children with leukemias or lymphomas.

MATERIAL AND METHODS

We have studied 39 children (age 0.5-17 years) with leukemia or lymphoma. Ocular manifestations were present in 54% of study group (21 children). The most frequent ocular findings were seen in conjunctiva (33.4%). 15.4% patients presented with posterior segment findings, without loss of ocular acuity. Other symptoms were dry eye syndrome and proptosis.

CONCLUSIONS

Children treated for leukemia or lymphoma should be systematically examined by ophthalmologist. Ophthalmic complications can be results of basic disease, treatment or manifestations of relapse.

[Influence of age on treatment results in children and adolescents with Hodgkin's disease]

Over the last few years, treatment failures (progression, relapse) in Hodgkin's disease (HD) occurred mainly in elder children treated in the Polish Pediatric Leukemia/Lymphoma Study Group (PPLLSG) participating centers. That is why analysis of the influence of age on the treatment outcome in children and adolescents treated with the protocol introduced in 1997 was performed. In years 1997-2001, in 10 centers of PPLLSG, 280 patients (age 2.3-18.8 years) were treated for HD. In all patients MVPP and B-DOPA chemotherapy with or without radiotherapy was introduced. Among 280 treated children the first remission was achieved in 275 patients (98.2%). Relapses occurred in 11 patients (4%). The 5-year probability of overall survival, relapse-free survival (RFS) and event-free survival (EFS) was 99%, 93% and 90%, respectively. All children with relapse were over 10 years old at the time of diagnosis (range: 10.6-17.1, median 14.6 years); mediastinal tumor mass was present in all of them. The logistic regression analysis did not reveal the border value for increasing the probability of relapse or event, thus age of 10 years (age of the youngest child with relapse) was identified as the border value. The probability of 5-year EFS and RFS for children over and under the 10th year of age was 98%, 92% and 100%, 92%, respectively. The differences were not statistically significant. Among children over the 10th year of age some features of the disease occurred more frequently: female sex, shorter history of the disease, presence of mediastinal tumor, greater stage of the disease, NS histopathological type of the disease, presence of general signs and ESR over 50 mm, greater tumor burden and higher number of involved lymphatic regions. Among the patients over the 10th year of age, the presence of the general signs and mediastinal tumor influenced the occurrence of relapses substantially. The aim of the further treatment modifications ought to comprise the need of better treatment outcome, especially in patients over the 10th years of age in which unfavorable prognostic factors are identified. child with relapse) was identified as the border value. The probability of 5-year EFS and RFS for children over and under the 10th year of age was 98%, 92% and 100%, 92%, respectively. The differences were not statistically significant. Among children over the 10th year of age some features of the disease occurred more frequently: female sex, shorter history of the disease, presence of mediastinal tumor, greater stage of the disease, NS histopathological type of the disease, presence of general signs and ESR over 50 mm, greater tumor burden and higher number of involved lymphatic regions. Among the patients over the 10th year of age, the presence of the general signs and mediastinal tumor influenced the occurrence of relapses substantially. The aim of the further treatment modifications ought to comprise the need of better treatment outcome, especially in patients over the 10th years of age in which unfavorable prognostic factors are identified.

[Over 30-year experience of Polish Pediatric Leukemia/Lymphoma Study Group for treatment of Hodgkin's disease in children and adolescents: improvement curability and decrease of serious complications]

Currently over 90% of children with HD can be cured thanks to use of chemotherapy (CT) combined with involved field radiotherapy (IF-RT). From 1971 to 2001, 1062 children and adolescents with HD (stage I to IV) were treated in 10 oncological centers PPLLSG. Majority of patients were treated with CT combined with IF-RT. Year by year the intensity of therapy (CT and RT) was gradually adjusted to the risk-factor groups, and invasive methods of staging were also gradually limited. Supportive care was improved at the same time. Along with the modified therapy protocol, five consecutive periods of time (I: 1971-82; II: 1983-87; IIII: 1988-93; IV: 1994-96; V: 1997-2001) were analyzed. In the first period the basic CT was MVPP (mechlorethamine, vinblastine, procarbazine, prednisone), while later B-DOPA (bleomycin, dacarbazine, vincristine, prednisone, doxorubicin) was gradually introduced alone or alternately with MVPP. In order to decrease the incidence of late complications, the dose of IF-RT from 45 Gy to 15-30 Gy was reduced in the next periods. In V period in 21 children with stage IA and IIA with favorable prognostic factors, CT alone was used. The probability of over 5-year: overall survival, relapse free survival and event free survival were in the I period: 92%, 83% and 77%, in the II period: 97%, 92% and 89%, in the III period: 97%, 93% and 91%, in the IV period: 95%, 91% and 90%, in the V period: 95%, 95% and 93%. Decreased rate of serious complications was also observed. Intensity of therapy should be tailored to the stage of disease, and to other significant prognostic factors. The current strategy of diagnosing and treatment of HD is aimed at balancing between the highest possible cure rates and risk of late complications.

[Iatrogenic hyperlipidemia after l-asparaginase and glucocorticoid treatment in two children with acute lymphoblastic leukemia]

L-asparaginase and glucocorticosteroides are the main drugs used in the first-line treatment in children with acute lymphoblastic leukaemia. One of the observed side effects in the increase of serum level of triglycerides is synergistic manner. The paper describes two children with acute lymphoblastic leukaemia. In these patients we could observe remarkable hypertriglyceridemia, and hypercholesterolaemia with the increase of LDL-cholesterol after applying high doses of L-asparaginase and glucocorticosteroids simultaneously. The above-mentioned disorders were transient. In the analysis of the possible reasons of this pathology we took into consideration family predispositions, the transient deficit of lipoprotein lipase induced by L-asparaginase, improper diet and hyperthyroidismus.

TEL/JAK2 tyrosine kinase inhibits DNA repair in the presence of amifostine

The TEL/JAK2 chromosomal translocation (t(9;12)(p24;p13)) is associated with T cell childhood acute lymphoblastic leukemia. The TEL/JAK2 fusion protein contains the JAK2 catalytic domain and the TEL-specific oligomerization domain. TEL-mediated oligomerization of the TEL/JAK2 proteins results in the constitutive activation of the tyrosine kinase activity. Leukemia cells expressing TEL/JAK2 tyrosine kinase become resistant to anti-neoplastic drugs. Amifostine is a pro-drug which can selectively protect normal tissues against the toxicity of anticancer drugs and radiation. We investigated the effects of amifostine on idarubicin-induced DNA damage and repair in murine pro-B lymphoid BaF3 cells and BaF3-TEL/JAK2-transformed cells using alkaline single cell gel electrophoresis (comet assay). Idarubicin induced DNA damage in both cell types but amifostine reduced its extent in control non-transformed BaF3 cells and enhanced it in TEL/JAK2-transformed cells. The transformed cells did not show measurable DNA repair after exposure to amifostine and idarubicin, but cells treated only with idarubicin were able to recover within a 60-min incubation. Because TEL/JAK2-transformed cells can be considered as model cells for certain human leukemias and lymphomas we anticipate an enhancement of idarubicin cytotoxicity by amifostine in these diseases. Moreover, TEL/JAK2 tyrosine kinase might be involved in cellular response to DNA damage. Amifostine could promote apoptosis or lower the threshold for apoptosis induction dependent on TEL/JAK2 activation.

Genotoxicity of idarubicin and its modulation by vitamins C and E and amifostine

Idarubicin is an anthracycline anticancer drug used in haematological malignancies. The main side effect of idarubicin is free-radicals based cardiotoxicity. Using the comet assay we showed that the drug at concentrations from the range 0.001 to 10 microM induced DNA damage in normal human lymphocytes, measured as the increase in percentage of DNA in the tail (% tail DNA). The effect was dose-dependent. Treated cells were able to recover within a 120-min incubation. Recognised cell protector, amifostine at 14 mM decreased the mean % tail DNA of the cells exposed to idarubicin at all tested concentrations of the drug. So did vitamin C at 10 microM, but vitamin E (alpha-tocopherol) at 50 microM increased the % tail DNA. Lymphocytes exposed to idarubicin and treated with endonuclease III, formamidopyrimidine-DNA glycosylase and 3-methyladenine-DNA glycosylase II, enzymes recognizing oxidized and alkylated bases, displayed greater extent of DNA damage than those not treated with these enzymes. Pretreatment of lymphocytes with nitrone spin traps, N-tert-butyl-alpha-phenylnitrone and alpha-(4-pyridil-1-oxide)-N-tert-butylnitrone decreased the extent of DNA damage evoked by idarubicin. To discuss the influence of vitamins and amifostine in cancer cells we used also murine pro-B lymphoid BaF3 transformed with BCR/ABL oncogene. These cells can be treated as model cells of human acute myelogenous leukemia. The response of these cells to vitamin E was quantitatively the same as human lymphocytes. However, vitamin C did not exert any effect on DNA damage and amifostine, in spite to normal lymphocytes, potentiated this effect. The results obtained suggest that reactive oxygen species, including free radicals, may be involved in the formation of DNA lesions induced by idarubicin. The drug can also methylate DNA bases. Our results indicate that not only cardiotoxicity but also genotoxicity and in consequence induction of secondary malignancies should be taken into account as diverse side effects of idarubicin. Amifostine may potentate DNA-damage effect of idarubicin in cancer cells and decrease this effect in normal cells. Vitamin C can be considered as protective agents against DNA damage in normal cells in persons receiving idarubicin-based chemotherapy, but the use of vitamin E cannot be recommended and at least needs further research.

TEL/JAK2 tyrosine kinase inhibits DNA repair in the presence of amifostine

The TEL/JAK2 chromosomal translocation (t(9;12)(p24;p13)) is associated with T cell childhood acute lymphoblastic leukemia. The TEL/JAK2 fusion protein contains the JAK2 catalytic domain and the TEL-specific oligomerization domain. TEL-mediated oligomerization of the TEL/JAK2 proteins results in the constitutive activation of the tyrosine kinase activity. Leukemia cells expressing TEL/JAK2 tyrosine kinase become resistant to anti-neoplastic drugs. Amifostine is a pro-drug which can selectively protect normal tissues against the toxicity of anticancer drugs and radiation. We investigated the effects of amifostine on idarubicin-induced DNA damage and repair in murine pro-B lymphoid BaF3 cells and BaF3-TEL/JAK2-transformed cells using alkaline single cell gel electrophoresis (comet assay). Idarubicin induced DNA damage in both cell types but amifostine reduced its extent in control non-transformed BaF3 cells and enhanced it in TEL/JAK2-transformed cells. The transformed cells did not show measurable DNA repair after exposure to amifostine and idarubicin, but cells treated only with idarubicin were able to recover within a 60-min incubation. Because TEL/JAK2-transformed cells can be considered as model cells for certain human leukemias and lymphomas we anticipate an enhancement of idarubicin cytotoxicity by amifostine in these diseases. Moreover, TEL/JAK2 tyrosine kinase might be involved in cellular response to DNA damage. Amifostine could promote apoptosis or lower the threshold for apoptosis induction dependent on TEL/JAK2 activation.

[The use of hematopoietic growth factors G-CSF/GM-CSF in the treatment of neutropenia in children with acute lymphoblastic leukemia and non-Hodgkin's lymphomas]

Maximal intensification of antineoplastic therapy is currently a predominant trend in the treatment regimens for acute leukemias and lymphomas. However, by such approach myelosuppression and counteracting its sequelae become paramount problems. Hematopoietic growth factors G-CSF/GM-CSF play a great role in this aspect of the therapy. Effects of 35 courses of G-CSF/GM-CSF were evaluated in 19 children with ALL and NHL and compared with 21 episodes of neutropenia in 15 historical controls. In the treatment group time of neutropenia was approx. 3 times shorter as compared with a control group. Fever accompanying neutropenia occurred less frequently and lasted shorter in the treatment group. Also, symptoms of infection subsided faster. Subjective life quality was better in children receiving growth factors.

[Cytoprotective effect of amifostine in children during induction therapy according to BFM-83: report on cases]

Amifostine is the agent of proved cytoprotective activity against alkylating drugs and rubidomycine. Its protective effect against other cytotoxic drugs is doubtful. BFM-83 induction therapy for ANLL (ARA-C + RUB + VP-16) which is applied to children with acute non-lymphoblastic leukemia (ANLL) commonly contributes to severe adverse reactions. We administered amifostine to three children: 2 boys with ANLL (7 and 11 yrs) and 1 girl with MDS (3 yrs) during etoposide and rubidomycine induction therapy in order to decrease chemotherapy-related adverse reactions. Doses of amifostine were 740 mg/m2, 910 mg/m2 and 910 mg/m2 respectively. Efficacy of the therapy was evaluated on the base of blast decline in the bone marrow, efficacy of the cytoprotection by myelo and nephrotoxicity symptoms analysis. Chemotherapy-related adverse effects in the children protected by amifostine were less severe and observed by the shorter periods as compared with the historical control group of 20 patients treated according to BFM-83 without cytoprotection. These cases show the potential beneficial effect of amifostine during BFM-83 induction therapy for ANLL. The further randomised clinical study of the proposed cytoprotection should be performed to establish its value.

[The assessment of hepatic enzymes' levels in children treated for leukemia and non-Hodgkin's lymphomas]

The purpose of this study was to determine the frequent of serum aminotransferase elevation in children with leukemias and non-Hodgkin's lymphomas and define the cause of this pathology. In the serum of 43 children the bilirubin concentration, activities of aspartic aminotransferase (AspAT), alanine aminotransferase (AlAT) and gammaglutamylotranspeptidase (GGTP) were measured before treatment, during and after intensive chemotherapy. 43 patients 8 (65%) had bilirubin concentration above 1.2 mg/dl and/or aminotransferase activities above 100 U/l. The most possible causes of the liver damage in the patients were: hepatotoxicity of chemotherapy, virus or bacterial infections and leukemic or lymphomatous involvement of the liver.

[Prophylactic replacement therapy of hemophilia]

Medical care of patients with hemophilia A and B involves regular ambulatory check-ups and contemporary replacement therapy. The Institute of Pediatrics in Lódź--as other medical centres in several countries--prophylactically treats some hemophilic patients, usually once per 7-10 days, with infusions of absent coagulation factor. Such treatment was carried out in 10 boys with severe hemophilia A and B with marked clinical symptoms. An analysis of health prior to and during prophylactic therapy was carried out. Such an analysis has shown that such a treatment is beneficial due to the shortening of hospitalization, change in the character of hemorrhage and possibility of rehabilitation free from the risk of complications.