Granulocyte colony-stimulating factor after intensive consolidation chemotherapy in acute myeloid leukemia: results of a randomized trial of the Groupe Ouest-Est Leucémies Aigues Myeloblastiques

PURPOSE

Ten years after the first clinical studies, the clinical impact of myeloid growth factors in acute myeloid leukemia is still unclear. One of the objectives of the Groupe Ouest-Est Leucémies Aigues Myeloblastiques (GOELAM) 2 trial was to evaluate the benefit of granulocyte colony-stimulating factor (GCSF) given only after the two courses of intensive consolidation chemotherapy (ICC) used to maintain complete remission (CR).

PATIENTS AND METHODS

One hundred ninety-four patients who were in CR after induction treatment were randomly assigned to receive G-CSF (100 patients) or no G-CSF (94 patients) after two courses of ICC (ICC 1, high-dose cytarabine plus mitoxantrone; ICC 2, amsacrine plus etoposide). G-CSF (filgrastim) was administered from the day after chemotherapy until granulocyte recovery at a daily dose of 5 microg/kg.

RESULTS

In the G-CSF group, the median duration of neutropenia (< 0.5 x 10(9)/L) was dramatically reduced, both after ICC 1 (12 v 19 days, P <.001) and after ICC 2 (20 v 28 days, P <.001). The median duration of hospitalization was also significantly shorter in the G-CSF group (24 v 27 days after ICC 1, P <.001; 29 v 34 days after ICC 2, P <. 001). The median duration of intravenous antibiotics was significantly reduced after ICC 1 and ICC 2, and the median duration of antifungal therapy was significantly reduced after ICC 1. However, the incidence of microbiologically documented infections, the toxic death rate, the 2-year disease-free survival, and the 2-year overall survival were not affected by G-CSF administration. Moreover, the median interval between ICC1 and ICC2 was reduced by only 2 days, and the number of patients undergoing ICC2 was not increased in the G-CSF arm.

CONCLUSION

G-CSF should be administered routinely after ICC to reduce the duration of neutropenia and hospitalization. However, G-CSF did not seem to significantly increase the feasibility of this two-course program or modify overall outcome.

Jumping translocation in acute leukemia of myelomonocytic lineage: a case report and review of the literature

Jumping translocation (JT) is a very rare cytogenetic event, occurring especially in cancer. We describe a case of secondary acute monocytic leukemia (AML5b) with a JT involving the 3q13-3qter segment and leading to a partial trisomy 3. Each clone with JT was associated with trisomy 8 or tetrasomy 8. The literature of JT in AML cases is reviewed: only 13 cases of AML associated with JT have been previously described, seven of which are AML4/5 FAB subtype. Jumping translocation involvement in leukemogenesis is discussed. Leukemia (2000) 14, 119-122.

Prophylactic use of itraconazole for the prevention of invasive pulmonary aspergillosis in high risk neutropenic patients

Invasive pulmonary aspergillosis (IPA) is an increasing cause of morbidity and mortality in patients with hematologic malignancies. A major program of construction work close to our unit prompted us to evaluate the efficacy of itraconazole prophylaxis in preventing IPA in these patients. During September 1994 to December 1995, 77 patients undergoing 96 neutropenic episodes (mean duration, 19.3 days +/- 9.1) received itraconazole as antifungal prophylaxis. All patients were treated in laminar air flow rooms. Itraconazole was administered at a loading dose of 600mg/d, (day 1 to day 3) and 400mg/d on the following days, in 87 instances. In the remaining episodes, the daily dose was 200 or 400mg. Oral doses were adjusted to reach a plasma itraconazole level (PIL) above 1000ng/l. In cases of inadequate PIL or poor oral intake, IV AmphoB was started at a 20 mg daily dose. Five cases of IPA (proven n = 2, probable n = 3) were observed. This represents an incidence of 5.2% of the total number of episodes. One out of 67 (2%) treatment episodes with adequate PIL were associated with IPA as compared to 4 of 29 (14%) episodes with inadequate PIL, (p < 0.02). AmphoB was added in 28 cases because of low PIL (n = 25), and/or antibiotic-resistant fever persistent pulmonary infiltrate (n = 8). These results need to be interpreted with caution, because of the absence of randomization or a control group. The efficacy of Itraconazole in neutropenic patients with high risk IPA has to be confirmed on larger and prospective studies.

[Primary adrenal lymphoma with latent adrenal insufficiency: a case report and literature review]

We report a new case of primary adrenal lymphoma with latent adrenal insufficiency and long-term remission after hydrocortisone replacement therapy. We have analyzed 29 other cases described in the literature. This disease with poor prognosis can be revealed by an incidentally discovered, frequently bilateral, adrenal mass. Adrenal insufficiency may be latent and the diagnostic procedure should include both cortisol and ACTH determination with an additional ACTH stimulation test if appropriate. Early adrenal substitution can improve patient survival.

Multidrug resistance analysis in lymphoproliferative disease of large granular lymphocytes

Multi-drug resistance (MDR) phenotype contributes to the ineffectiveness of chemotherapy. P-glycoprotein (PgP) and lung resistance protein (LRP) are proteins implicated in chemoresistance. We analysed the expression of PgP and LRP respectively in 17 and 15 cases of lymphoproliferative disease of granular lymphocytes (LDGL) including 10 cases of clonal large granular lymphocytic (LGL) leukaemia, six cases of oligoclonal (n = 5) and polyclonal (n = 1) CD3+ lymphoproliferation and one case of CD3- NK lymphocytosis. Functional PgP activity, as determined by Rh123 dye efflux assay, was found in all the patients. The mean percentage of effluxing cells was 47 +/- 22%, compared to 35 +/- 8% on normal lymphocytes (P<0.04). The efflux was blocked in the presence of verapamil, a PgP revertant agent. A high proportion of CD57+ cells (66 +/- 10%) from these patients expelled Rh123. Functional PgP activity was associated with expression of MDR1 mRNA. By using immunocytochemistry, LRP expression was detected in 11/15 patients (73%). 7/10 LGL leukaemia patients presented a LRP+/Efflux+ phenotype and 5/7 had LRP+/Efflux+/MDR1 mRNA+ phenotype. These findings suggest that the PgP+/LRP+ phenotype is frequently observed in LDGL. Its clinical relevance in aggressive cases remains to be determined.

Loss of HLA molecules in B lymphomas is associated with an aggressive clinical course

Major histocompatibility complex class I molecule expression is reduced in some malignant tumours permitting escape from immune surveillance and is therefore associated with a poor prognosis. Seven cases of non-Hodgkin lymphomas out of 300 cases of malignant lymphoproliferative disorders totally lacked expression of class I molecules as determined by flow cytometry. Clinical data confirmed a particular aggressiveness of these cases with frequent extra-nodal involvement, a poor international prognostic index, a histological high grade and a poor outcome leading to early death in five of the seven cases. A previous diagnosis of follicular lymphoma characterized by bcl-2 rearrangements was made in four of these cases. HLA-G (class Ib gene), which is reported to bind killer inhibitory receptors on NK cells, was absent from the cell surface. However, it was detected in three out of four cases at the mRNA level with transcripts encoding soluble forms. Additional analysis revealed other abnormalities: class II was negative in four out of the seven NHL cases and decreased expression of beta2 microglobulin was observed in all cases. Peptide transporter proteins (TAP1) were detected in various degrees by immunocytochemistry. These observations showed that total lack of class I or class II molecules is a rare event in NHL and is associated with a poor prognosis. This could support a role for specific autologous T cells in immune surveillance.

Inapparent polycythemia vera: an unrecognized diagnosis

PURPOSE

The Polycythemia Vera Study Group (PVSG) has established useful criteria for the diagnosis of polycythemia vera. In some circumstances, an increase of plasma volume (PV) masks that of red cell mass (RCM), with hemoglobin (Hb) and hematocrit (Ht) remaining normal. This defines the concept of inapparent polycythemia.

PATIENTS AND METHODS

One hundred and three patients seen in the hematology unit with the diagnosis of polycythemia vera were studied. There were 55 males and 48 females with a median age of 59 years. Ninety-five patients fulfilled the PVSG criteria. Spontaneous erythroid colonies and low serum erythropoietin level confirmed the diagnosis in the 8 other cases. Patients were classified according to Hb and Ht level.

RESULTS

Group A consisted of 85 patients with increased Hb and Ht defined, respectively, by Hb > 18 g/dl, Ht > 0.52 in males and Hb > 16 g/dL, Ht>0.47 in females. Group B included 18 patients (17%) with inapparent polycythemia vera (IPV) defined by a normal Hb and Ht value at diagnosis. In this group, the reasons to perform RCM were as follows: splenomegaly associated with increased platelets and/or leucocytes counts (n = 8), portal vein thrombosis (n = 5), increased platelets or leucocytes counts without splenomegaly (n = 3), and isolated splenomegaly (n = 2). The two groups were balanced in terms of age, sex, leucocyte, serum iron, and platelet level. Hemoglobin and Ht levels were significantly different between the two groups. The difference between the PV was indeed highly significant. The mean PV increase was + 9.5% (nL < +20%) in group A versus + 36.3% in group B (P < 0.00005). Red cell mass was not different between the two groups.

CONCLUSIONS

Increased Hb or Ht should constitute the sole criteria for RCM determination. In the context of portal vein thrombosis, isolated hyperleucocytosis, thrombocytosis, or splenomegaly, a RCM should be performed. The frequency of IPV remains to be specified but the diagnosis of polycythemia vera is probably underestimated.

Splenectomy in idiopathic thrombocytopenic purpura: its correlation with the sequestration of autologous indium-111-labeled platelets

We present a retrospective analysis of 111In-platelet sequestration studies in 111 patients with the clinical diagnosis of idiopathic thrombocytopenic purpura (ITP). Fifty-one of these patients underwent splenectomy, independent of the results of the 111In-platelet studies to determine if these isotopic results could accurately predict a beneficial response to splenectomy. Between January 1984 and June 1990, 111 patients who presented with ITP were subjected to a study of autologous 111In-labeled platelets through autotransfusion. The platelet sequestration site was splenic (81%), mixed (12%), or hepatic (7%). Fifty-one patients with persistent drug-resistant thrombocytopenia underwent splenectomy regardless of the isotopic results: 33 patients beyond 6 mo after diagnosis and 18 with high hemorrhagic risks before this delay. The follow-up median duration was 2.9 yr. Thirty-three of the 38 patients with splenic sequestration showed a normalized platelet count, as opposed to 2 of the 13 with mixed or hepatic sequestration (p < 0.001). In addition, platelet survival extended beyond 8 days in six patients, with no apparent sequestration site. The platelet isotopic study performed with this technique appears to be indicated in ITP: it guides clinicians in their decision to perform splenectomy and relates to a more central mechanism certain thrombocytopenias that are inappropriately categorized as ITP.

Lung abscess due to Pseudallescheria boydii in the course of acute leukaemia. Report of a case and review of the literature

We report a case of lung infection by Pseudallescheria boydii, which appeared during therapeutic aplasia in a patient with acute leukaemia. The association of sudden chest pain and fever with negative blood cultures and haemoptysic expectoration first suggested a diagnosis of pulmonary aspergillosis, in particular because evidence of lung abscesses appeared very rapidly and large mycelial filaments were found on direct examination of the expectoration. Pseudallescheria boydii was identified by culture. Investigations in vitro of the effects of antimycotics showed that the micro-organism was resistant to amphotericin B and sensitive to imidazoles. The clinical and radiological outcome after treatment with ketoconazole was favourable.

[Bone marrow allograft: value of erythrocyte enzyme phenotypes in the biological monitoring]

Differences in erythrocyte isoenzyme patterns may be used as biologic markers to monitor allogenic bone marrow transplants. In 19 patients, these markers proved useful for confirming engraftment, although they failed to predict any of the recurrences observed.

[Treatment of localized forms of Hodgkin's disease with 3 courses of chemotherapy (ABVD-MP) in combination with wide focal and prophylactic lumbo-splenic radiotherapy. The POF 81/12 protocol]

Between October 10, 1981 and December 31, 1987, we used the Hodgkin POF 81/12 protocol to treat 235 patients aged from 5 to 65 years (mean 30 years) with localized Hodgkin's disease clinically classified as stage IA (n = 6), stage IIA (n = 128) and stage IIB (n = 53). A contiguous lesion was present in 22 cases and a mediastinal lesion in 170 cases. The patients received 3 monthly courses of ABVD-MP (doxorubicin 25, bleomycin 10, vinblastine 6, dacarbazine 375 and methylprednisolone 120 mg per sq.m intravenously on days 1 and 15), except for stage IA non-mediastinal patients who received only one course. Thereafter, in the absence of failure (lack of changes or progression under chemotherapy), a 40 Gy wide focal irradiation and a 30 Gy prophylactic lumbo-splenic irradiation were performed. Complete remission (CR) was obtained in 229 patients, and the 6 failures (4 after ABVD-MP, 2 after radiotherapy) were treated with specific programmes. On December 1, 1988 (median survival 42 months, range 12-86 months) we had recorded 9 relapses (after 9 to 51 months) and 7 deaths (2 failures, 2 relapses and 3 patients in CR: ovarian carcinoma, road accident, exploratory pleural puncture). The current actuarial relapse and survival rates at 7 years are 5 and 94 respectively. Two unfavourable forms of the disease were identified: infra-diaphragmatic with massive lumbo-aortic lesions (5 cases: 1 failure, 1 relapse) and supra-diaphragmatic with a mediastinum/chest ratio of 0,45 or more (30 cases: 5 failures, 5 relapses). In the 200 patients devoid of these 2 risk factors the results obtained were: CR 100 percent, only 2 relapses and survival at 7 years 98 percent.

dATP-mediated inhibition of DNA ligase by 2'-deoxycoformycin in T and B cell leukemia

2'-Deoxycoformycin (dCF), a potent adenosine deaminase inhibitor, has been reported to display greater toxicity for T than for B lymphoblasts. Since this compound can block DNA replication and since this effect is mediated by the intracellular ATP/dATP balance, its possible effect on DNA ligase was investigated. dCF at relatively low concentrations (1 microM), in association with dATP (100 microM), is a strong inhibitor of DNA ligase in T blasts, whereas it has no significant effect in B blasts at this concentration. The AMP-ligase complex is the target of the observed inhibition because the combined presence of the inhibitor and dATP results in a more stable dAMP-ligase complex. Because of this observation and of the greater adenosine deaminase activity observed in T cells, the dATP mediated dCF inhibition of ligase might be the crucial replication target of T cell toxicity. These observations are discussed in terms of T immunodeficiencies including Graft Versus Host Disease and related syndromes.

DNA ligation in relation to DNA strand breaks in phytohemagglutinin-stimulated blast cells from acute lymphoblastic and nonlymphoblastic leukemia

DNA ligase activity was determined in the WBCs from 306 cases of acute lymphoblastic leukemia (ALL) and acute nonlymphocytic leukemia (ANLL). In T-ALL cells this activity was either low or absent. DNA analysis by nucleoid, alkaline elution, and alkaline sucrose centrifugation after cells were embedded in agarose inserts has shown more DNA breaks in T-ALL than in ANLL blasts. Phytohemagglutinin stimulation of T-ALL blasts resulted in the apparent joining of the DNA breaks. Apparent identical results can be obtained by the incubation of DNA with exogenous DNA ligase. The authors suggest that this enzyme is a crucially regulated step of replication and subsequent proliferation in this type of leukemia.

[Enzymes involved in the metabolism, replication and repair of DNA in acute leukemias (DNA ligases)]

DNA ligases are involved in DNA replication, repair and recombination. Consecutively to partial purification, these enzymes have been studied in acute leukemias and subclasses. There is a good correlation between this enzyme activity and the percentage of cells in S phase in acute myeloblastic leukemia. However, in acute lymphoblastic leukemia, a low and even absent activity (T-ALL) is observed. It is shown that in this type of leukemia, the absence of activity is due to either the absence or the non expression of the DNA ligase gene. The results are discussed in terms of the correlation between the absence of ligase activity and the expression of the TdT phenotype.

Treatment of adult acute lymphoblastic leukemia. Preliminary results of a trial from the French Group

We present here the results of a cooperative trial in 244 adult patients with acute lymphoblastic leukemia. Induction therapy with vincristine, cytoxan, and prednisone (VCP) gave the same complete remission rate after one course as more aggressive induction with vincristine, rubidazone, araC, and prednisone (VRAP) due to increased toxic death in the aggressive arm. Because of high efficacy of salvage therapy with VRAP regimen in patients failing to achieve CR with VCP regimen, patients initially randomized to receive VCP had a significantly higher CR rate than patients initially receiving VRAP (87% vs. 73%, p = 0.01). Patients randomized to receive postremission consolidation using adriamycin, araC, and asparaginase (AAA) prior to maintenance had a significantly longer remission than patients not receiving consolidation (p less than 0.005). At the time of analysis allogeneic bone marrow transplantation does not significantly increase disease-free survival when compared with intensive consolidation chemotherapy.

[A rare motive for genetic counseling: the risk of leukemia: apropos of a familial form]

Authors report one family with three cases of myeloblastic acute leukaemia in three generations. In this family, without chromosomal abnormalities (the only one possible laboratory examination), the risk is certainly increased, but it remains, fortunately, low.

Hodgkin's disease and hyperthyroidism

In recent years we have had the occasion to observe hyperthyroidism in 6 patients with Hodgkin's disease. All patients had received Mantlefield irradiation and were disease-free when hyperthyroidism appeared. Hyperthyroidism allows three different pictures to be distinguished: 1 case report of Graves' disease without ophthalmopathy, 1 case report of Hashimoto's thyroiditis corresponding to a particular form called hashitoxicosis, and 4 case reports of atypical silent thyroiditis. Reports concerning case studies of postirradiation Graves' disease or Hashimoto's thyroiditis during Hodgkin's disease are only to be found exceptionally. Atypical silent thyroiditis was recently individualized, but no postirradiation case studies have been reported. It is suggested that these 6 cases represent a radiation-induced immune thyroid disease: physiopathology and predisposing factors are discussed.

DNA ligases in human leukemia

Following partial purification on sucrose gradient and/or phosphocellulose chromatography, DNA ligase was tested in peripheral white blood and bone marrow cells of nearly 100 patients with various kinds of leukemias, mainly acute leukemias. Terminal deoxynucleotidyl transferase (TdT) was tested in parallel. DNA ligase of acute myeloblastic leukemia (AML) was extracted with the same sedimentation coefficient (5.5S) on sucrose gradient, and eluted with the same KCl molarity (0.3 M) than the one extracted from normal lymphocytes. Acute lymphoblastic leukemias (ALL) were characterized by no detectable DNA ligase activity--in most T or non T-non B-ALL, or a low activity in pre-B and B (Burkitt type) ALL, with levels similar to the one observed in chronic lymphocytic leukemia (CLL). An inverse relationship was observed between DNA-ligase and TdT in ALL, ligase being undetectable in cells positive for TdT and being present in some T or non T-non B, and in all pre-B and B-ALL negative for TdT. AML and chronic myelocytic leukemia (CML) were characterized by a markedly higher DNA-ligase activity. This activity was higher in the most differentiated subtypes--M2, M3 and M4 subtypes of FAB classification--and in CML. Moreover a high degree of correlation was observed in AML between the DNA ligase activity and the S phase fraction measured by 3 H-thymidine autoradiography or flow cytophotometry on the total cell sampling. Besides their clinical interest, these results are discussed in relation with the role of DNA-ligase in DNA replication and repair.

Critical study of staging in multiple myeloma

130 patients with multiple myeloma were reviewed for a retrospective study of their classification according to Durie & Salmon. No significant difference was found in survival between patients in stages I, II and III (median survival 24.8, 32.1, and 17.3 months, respectively). Of the classical criteria affecting survival, only the Hb level showed any significant influence (P less than 0.04). In accordance with this finding, the survival time was much shorter (P less than 0.001) in patients with renal failure than in patients without (median survival 7.4 and 24.8 months, respectively); in addition, thrombopenia, fever, old age, and above all, the % of bone-marrow plasmocytes present, were shown to be decisive factors.

Gd(-) Rennes, a new deficient variant of glucose-6-phosphate dehydrogenase associated with congenital nonspherocytic hemolytic anemia found in France

A new variant of G6PD with total enzyme deficiency associated with nonspherocytic hemolytic anemia in a 60 year old Frenchman is characterized. Partially purified enzyme revealed slow electrophoretic mobility, decreased G6P affinity, thermal instability, abnormal pH curve with a single peak at pH 5.0, abnormal utilization of 2-deoxy-G6P and deamino NADP. This variant differs from all previously reported variants associated with chronic nonspherocytic hemolytic anemia. Accordingly this variant is designated Gd(-) Rennes.

[Leukemic infiltration and adenocarcinoma of the prostate gland (author's transl)]

The appearance of a leukemic infiltration of the prostate gland as the first manifestation of a chronic lymphocytic leukemia, followed by an adenocarcinoma of the prostate gland, is exceptional, since only one case has been previously documented. For this reason the authors wish to signal the possibility of a prostatic infiltration in the course of chronic lymphocytic leukemia and insist on the association of this type of leukemia and cancer.

[Glomerular disease associated with myelofibrosis (author's transl)]

The authors report the case of a 46 year-old patient presenting with membranous-proliferative glomerular disease, megakaryocytes present in the glomerular capillaries, evolving concomitantly with myelofibrosis. There are two possible explanations for this unusual association: the glomerular disease and the myelofibrosis may both result from the same etiologic and pathogenic factor, or the glomerular disease may be the consequence, thrombocytosis existing, of platelet activation, either direct or after deposition of immune complexes. The formation of immune complexes after antigenic stimulation in myelofibrosis is theoretically compatible with immunitary anomalies found in the evolution of this disorder as described in the literature.

[Hodgkin's disease: study of delayed hypersensitivity of 64 non treated patients. Value of epicutaneous test using croton oil]

Cellular immunity in 64 patients with Hodgkin's disease was studied during diagnosis before any treatment. The functional deficiency of the thymodependent lymphocyte was demonstrated in vivo by skin tests and, in vitro, by the test of inhibition of leucocyte migration to phytohemagglutininin and spontaneous rosette formation, to sheep red cells. This deficiency correlates with the clinical spread and the histological severity. The relationship between skin anergy and biological tests was found. The epicutaneous test using croton oil possesses non-specific inflammatory activity. It is negative this test is negative, skin reactivity to specific antigens is reduced. The croton tests help interpretation of skin responses to specific antigens and thus assessment of the immune state.