Relapsed acute lymphoblastic leukaemia after allogeneic stem cell transplantation: a therapeutic dilemma challenging the armamentarium of immunotherapies currently available (case reports)

While survival rates in paediatric acute lymphoblastic leukaemia (ALL) nowadays exceed 90%, systemic ALL relapse, especially after haemopoietic stem cell transplantation (HSCT), is associated with a poor outcome. As there is currently no standardized treatment for this situation, individualized treatment is often pursued. Exemplified by two clinical scenarios, the aim of this article is to highlight the challenge for treating physicians to find a customized treatment strategy integrating the role of conventional chemotherapy, immunotherapeutic approaches and second allogeneic HSCT. Case 1 describes a 2-year-old girl with an early isolated bone marrow relapse of an infant KMT2A-rearranged B-cell precursor ALL after allogeneic HSCT. After bridging chemotherapy and lymphodepleting chemotherapy, chimeric antigen receptor (CAR) T-cells (tisagenlecleucel) were administered for remission induction, followed by a second HSCT from the 9/10 human leukocyte antigen (HLA)-matched mother. Case 2 describes a 16-year-old girl with a late, isolated bone marrow relapse of B-cell precursor ALL after allogeneic HSCT who experienced severe treatment toxicities including stage IV renal insufficiency. After dose-reduced bridging chemotherapy, CAR T-cells (tisagenlecleucel) were administered for remission induction despite a CD19^- clone without prior lymphodepletion due to enhanced persisting toxicity. This was followed by a second allogeneic HSCT from the haploidentical mother. While patient 2 relapsed around Day + 180 after the second HSCT, patient 1 is still in complete remission >360 days after the second HSCT. Both cases demonstrate the challenges associated with systemic ALL relapse after first allogeneic HSCT, including chemotherapy-resistant disease and persisting organ damage inflicted by previous therapy. Immunotherapeutic approaches, such as CAR T-cells, can induce remission and enable a second allogeneic HSCT. However, optimal therapy for systemic ALL relapse after first HSCT remains to be defined.

Multimodal Treatment of Nasopharyngeal Carcinoma in Children, Adolescents and Young Adults-Extended Follow-Up of the NPC-2003-GPOH Study Cohort and Patients of the Interim Cohort

Simple Summary

Multimodal treatment of nasopharyngeal carcinoma (NPC) in children and young adults with induction chemotherapy, followed by radiochemotherapy and interferon-β (IFN-β) maintenance, has been successfully applied in studies NPC-91 and NPC-2003 of the German Society of Pediatric Oncology and Hematology (GPOH). We, here, present updated survival rates of the NPC-2003 study cohort after longer follow-up and include 21 additional patients recruited after closure of the study and treated as per the NPC-2003 study protocol (interim cohort) in our survival analysis. Survival rates remain high after extended follow-up and in the larger cohort with EFS and OS of 94% and 97%, respectively, reinforcing the high antitumor efficacy of this multimodal treatment concept. Seven patients with CR after induction therapy received a reduced radiation dose of 54 Gy, and none of them relapsed. Thus, the reduction of radiation dose seems feasible and has the potential to reduce treatment-related late effects in this vulnerable population.

Abstract

Nasopharyngeal carcinoma (NPC) in children and young adults has been treated within two consecutive prospective trials in Germany, the NPC-91 and the NPC-2003 study of the German Society of Pediatric Oncology and Hematology (GPOH). In these studies, multimodal treatment with induction chemotherapy, followed by radio (chemo)therapy and interferon-beta maintenance, yielded promising survival rates even after adapting total radiation doses to tumor response. The outcome of 45 patients in the NPC-2003 study was reassessed after a median follow-up of 85 months. In addition, we analyzed 21 further patients after closure of the NPC-2003 study, recruited between 2011 and 2017, and treated as per the NPC-2003 study protocol. The EFS and OS of 66 patients with locoregionally advanced NPC were 93.6% and 96.7%, respectively, after a median follow-up of 73 months. Seven patients with CR after induction therapy received a reduced radiation dose of 54 Gy; none relapsed. In young patients with advanced locoregional NPC, excellent long-term survival rates can be achieved by multimodal treatment, including interferon-beta. Radiation doses may be reduced in patients with complete remission after induction chemotherapy and may limit radiogenic late effects.

Clear cell sarcoma of the kidney in Austrian children: Long-term survival after relapse

INTRODUCTION

Clear cell sarcoma of the kidney (CCSK) is a rare malignant childhood renal tumour. Recently, the central nervous system (CNS) was found to be the most frequent site of relapse associated with a poor outcome. Optimal treatment strategies are scarce.

PATIENTS AND METHODS

Retrospective data analysis of all Austrian children with CCSK. They were enrolled in the Austrian-Hungarian Wilms Tumour Study (AHWTS) 1989, the SIOP93-01 or the SIOP2001 study between 1990 and 2019. Demographic, diagnostic, treatment-related variables and survival data were analysed.

RESULTS

We identified 12 children with CCSK (M = 7, F = 5; median age 1.6 years). All had localised disease (stage I: 2; stage II: 2; stage III: 8) at diagnosis, and a first complete remission (CR1) was achieved in 12/12. Six patients are in an ongoing CR1 (median follow-up 10 years). Six other patients had a relapse (local 1; brain 5) a median time of 2.4 years from diagnosis. Two patients died of the disease 4 months and 2.8 years after first relapse. Four of five patients with CNS relapse are in CR2 with a median follow-up time of 9.3 years after relapse diagnosis. Relapse treatment included a combination of chemotherapy, radiation and surgery. Two children received high-dose chemotherapy followed by autologous stem cell rescue, and one child received intrathecal mafosphamide. Long-term side effects after treatment were impaired tubular renal function (n = 4), cardiomyopathy (n = 1) and growth disorders (n = 1).

CONCLUSIONS

In this series, the brain was the most common site of relapse. Long-term survival after recurrence was achievable with intensive multimodal therapy.

Rothia mucilaginosa bacteremia: A 10-year experience of a pediatric tertiary care cancer center

Rothia mucilaginosa is part of the oral and upper respiratory tract flora. Usually, this gram-positive coccus is not pathogenic; however, in the setting of immunosuppressed hosts, it can cause life-threatening infections as an opportunistic pathogen. Among a cohort of 1511 hematologic-oncologic patients at a pediatric tertiary care cancer center, we identified five cancer patients (0.35%) within a period of 10 years having a proven Rothia mucilaginosa bacteremia (1 culture positive: n = 3/5; > 1 culture positive: n = 2/5). With prompt and adequate antibiotic treatment, infection resolved rapidly before recovery of neutrophils and without any sequelae, suggesting that Rothia mucilaginosa bacteremia without organ involvement is not exceptionally problematic in pediatric cancer patients.

Flow Behavior of a Polypropylene Melt in Capillary Dies

Using capillary dies having different diameters, D, and length-to-diameter L/D ratios, a full rheological characterization has been carried out for a polypropylene melt, and the experimental data have been fitted both with a viscous model (Cross) and a viscoelastic one (the Kaye – Bernstein, Kearsley, Zapas/Papanastasiou, Scriven, Macosko or K-BKZ/PSM model). Particular emphasis has been given on the pressure-dependence of viscosity. It was found that only the viscoelastic simulations were capable of reproducing the experimental data well, while any viscous modeling always underestimates the pressures, especially at the higher apparent shear rates and L/D ratios.

Robust Process Control for Rubber Injection Moulding with Use of Systematic Simulations and Improved Material Data

The heating phase is by far the most time-consuming part of rubber injection moulding. The determination of a suitable curing time is difficult despite extensive injection moulding trials, since in many cases the quality of a part, such as its degree of vulcanisation which is often visually detectable only where there is significant undercure (Figure 1a), cannot be assessed without closer examination (Figure 1b). Systematic injection moulding simulation with Varimos presents an effective solution because the Varimos methodology allows virtual detection of the impacts of process parameters and their interactions, as well as visualisation of e.g. impending undercure (Figure 1c). It therefore enables part, mould and process to be optimised automatically to the desired quality criteria. As a result, it is possible not only to save valuable machine time, which would otherwise be taken up for process development, but also to define the processing window more precisely and thus to improve the economic efficiency of the process while at the same time ensuring the necessary process stability. This was successfully investigated and demonstrated using a thick-walled test piece during the RubSim project at the Polymer Competence Center Leoben GmbH in collaboration with the Injection Moulding of Polymers Group of the University of Leoben and the industrial partners SKF Sealing Solutions Austria GmbH, Engel Austria GmbH, Simcon kunststofftechnische Software GmbH and Dr. Gierth Ingenieurgesellschaft mbH.

Outcome of two patients with bilateral nephroblastomatosis/Wilms tumour treated with an add-on 13-cis retinoic acid therapy - Case report

Although the fate of nephrogenic rests varies, they are known to be precursors of Wilms tumour. Thus, nephrogenic rests require adequate treatment to prevent malignant transformation. We added 13-cis retinoic acid to the standard chemotherapy with vincristine and actinomycin-D in two patients with bilateral nephrogenic rests/nephroblastomatosis. Patient 1 also had a history of Wilms tumour. 46 (patient 1) and 81 (patient 2) months after end of treatment, both patients show stable conditions with no signs of relapse or progressive disease. Our observation supports further investigation of retinoic acid in patients with nephrogenic rests and nephroblastomatosis.

Flow Behavior of PP-Polymer Nanocomposites in Capillary and Injection Molding Dies

For simulation of thin-wall injection molding, accurate viscosity data measured at shear rates up to 800,000 s−1 and more are important, but not available in any commercial material database. Such data can be measured on conventional injection molding machines with the help of a rheological mold, which is constructed like a standard injection mold with interchangeable dies. It enables operators to measure viscosity in time on their own machines at practically relevant shear rates (from 102 s−1 to 2 × 106 s−1). A special feature allows measuring the pressure dependency of viscosity using closed-loop counter pressure control. Experimental data are evaluated taking into account the melt temperature rise due to dissipative heating. Using capillary dies having different diameters, D, and length-to-diameter L/D ratios, a full rheological characterization has been carried out for a polypropylene-filled nanocomposite, and the experimental data have been fitted both with a viscous model (Cross) and a viscoelastic one (the Kaye – Bernstein, Kearsley, Zapas/Papanastasiou, Scriven, Macosko or K-BKZ/PSM model). Four injection molding dies have been also used to reach apparent shear rates up to 800,000 s−1. Particular emphasis has been given on the pressure-dependence of viscosity. It was found that only the viscoelastic simulations were capable of reproducing the experimental data well, while any viscous modeling always underestimates the pressures, especially at the higher apparent shear rates and L/D ratios.

Wide-Angle X-Ray, Densitometric and Microscopical Studies on Injection Molded Polypropylene Disks

Circular disks (280 mm diameter, 2 mm thickness) were injection molded from two grades of isotactic polypropylene under systematic variation of processing parameters (melt temperature, mold temperature, flow rate, packing pressure, and packing time) according to a two-level fractional factorial design. The disks showed ring-shaped zones (“halos”) of enhanced turbidity. The wide-angle X-ray scattering of the disks was measured as a function of the distance from the gate at 13 positions along the radius, using a diffractometer and reflection geometry. These measurements yielded radial profiles of the orientation of α-PP and of the distribution of β-PP crystallites. Both kinds of profiles revealed clear correlations with the polymer grade and with the melt and/or mold temperature. Radial profiles of optical turbidity of the disks were obtained by means of a microdensitometer. Pronounced maxima of turbidity were found to coincide with the maxima observed in the radial distribution of β-PP. An analysis of variance (ANOVA) of the experiments showed that the mass temperature has the greatest influence on the radial distances of the maxima of turbidity. Increasing mass temperature led to decreasing radial distances of the turbidity maxima, whereas the mold temperature as well as the flow rate only had a small influence on the radial positions of the turbidity maxima. The investigation of cross-sections, which were taken from some disks at selected distances from gate, by means of optical microscopy using polarized light revealed significant changes in the morphology with increasing distance from gate, e.g., changes in the size and distribution of β-PP spherulites.

Temperature Measuring in Plastics Processing with Infrared Radiation Thermometers

In many areas of plastics processing the temperature is a decisive process control parameter. Infrared sensors that detect the heat radiation from molten plastic have a response time in the range of milliseconds. Thus in many processes they offer the only possibility to measure time dependent temperatures with high accuracy.

Comparative Wide-angle X-ray and Microscopical Studies on the Layered Structure in Injection Molded Polypropylene Disks

Circular disks (280 mm diameter, 2 mm thickness) were injection molded from isotactic polypropylene under systematic variation of processing parameters (melt temperature, mold temperature, screw velocity, packing pressure, and packing time). Sections were taken from the disks perpendicular to their surface, at 40 mm distance from gate, in different orientations, and were investigated by means of optical microscopy using polarized light and by spatially resolved wide-angle X-ray scattering. The results from X-ray scans of the cross-sections are presented in terms of several parameters characterizing the state of orientation of α-PP crystallites and the relative amount of β-PP crystallites. The profiles of the various X-ray parameters versus the distance from surface deliver a detailed picture of the layered structure of the cross-sections which is supported and supplemented by micrographs taken with polarized light. The comparison of the results obtained for disks molded under different conditions unveils clear correlations between processing parameters and morphological characteristics of the disks.

Injection Molding without Packing

By injection molding two kinds of frozen-in orientation will arise: During the filling phase the outer layers of the molding will be sheared and simultaneously cooled. This results in highly oriented layers at the outside of the molding (orientation by filling). During the packing phase the melt, forced into the cavity, gives rise to low rates of deformation in the molding, but since the viscosity has become high by cooling, high stresses and frozen-in orientation will also result (orientation by packing). This last kind of orientation can be avoided by high pressures in the filling phase, followed by immediate mechanical sealing of the cavity (injection molding without packing), and hereby a better quality of the moldings can be achieved. Some results with moldings of PS and PP are given.

Replication of Stochastic and Geometric Micro Structures – Aspects of Visual Appearance

The surface quality of injection molded parts depends on the processing conditions, the cavity surface structure, the runner system, the used polymer and the part geometry. Different replication of the cavity surface structure to the molded part influences its surface function and visual appearance. A descriptive model of the replication process has been developed, taking into account the thickness of the frozen layer during injection. The expected dependencies were proven by systematic injection molding tests with geometric surface micro structures, having depths of 45 or 100 μm and widths from 400 to 2000 μm, that were replicated into high-crystalline polypropylene (HCPP) and polycarbonate (PC). The volumetric structure replication ratio increased with rising mold temperature, melt temperature and cavity pressure. As expected, the mold temperature was dominant for very small micro features. The RMS roughness, determined by confocal microscopy and atomic-force microscopy, was found to be a suitable replication parameter for draw-polished to mirror-finished stochastic cavity surface structures. An abrupt change in wall thickness decelerated the flow front velocity, thus decreased the replicated polymer surface roughness and increased the surface gloss. Moreover, a several micrometer high “surface step” remained, due to the different thickness-dependent shrinkage. This step always ascended from the thicker to the thinner part area. The replication of a mirror-finished mold surface into HCPP was dominated by morphological effects. Local micro shrinkage differences led to micro sink marks, which affected the surface gloss much more than the mold surface structure.

Cysteinyl-leukotrienes in nasal lavage fluid in children with asthma

The aim of this study was to investigate repeatability of cysteinyl-leukotrienes (cys-LT) measurements in nasal lavage fluid (NLF) and to determine if cys-LT levels in NLF are related to asthma severity in children. As a second outcome, we investigated if cys-LT in NLF reflect lower airway inflammation as assessed by exhaled NO measurement. To assess the repeatability of cys-LT measurements, two NLF samples were obtained from eight healthy controls 24 h apart. Sixty-nine asthmatic children (mean age; range: 12.8; 7.3-17.7 yr), which were grouped according to asthma severity were studied cross-sectionally on one occasion. Cys-LT in NLF were analyzed using a specific enzyme immunoassay, exhaled NO, and pulmonary function parameters were measured. The coefficient of repeatability for the repeated cys-LT measurements was 1.45 pg/ml. Cys-LT levels in NLF differed significantly between asthma severity groups (p < 0.001): mild intermittent: [median (IQR)] 6.88 pg/ml (2.00-27.87); mild persistent: 21.09 pg/ml (4.50-84.67); and moderate persistent asthmatics: 36.41 pg/ml (11.03-118.40). Concentration of cys-LT in NLF and exhaled NO was positively correlated (r = 0.85; p < 0.001). In conclusion, concentration of cys-LT in NLF correlates with asthma severity in children and is related to lower airway inflammation.