A practical device designed to concentrate cells for cytomorphological studies of biological fluids

In the present work, a device designed for concentrating cells from biological fluids is described. The instrument consists of a tube in which the inner cavity has a conical shape at one of its ends and a small orifice is found at the bottom, while the tube's exterior maintains its cylindrical shape. The tube is placed inside a second tube that ends on a flat surface on which a glass cover slide is placed. The sample to be studied is placed in the inner tube of the assembled device and spun in a regular clinical centrifuge. Cells are collected on the glass slide, fixed and stained for microscopical studies. The device was tested using 23 samples of cerebrospinal fluid (CSF) from patients with lymphoproliferative diseases. An adequate number of intact cells was recovered for observation, and a precise diagnosis was possible. Cells from three aliquots of each CSF sample were concentrated by this method, and by the more expensive standard commercial cytocentrifuge, with similar results. The device described here provides an easy, efficient and inexpensive method, for the concentration of cells from organic fluids.

6-Mercaptopurine in cerebrospinal fluid during oral maintenance therapy of children with acute lymphoblastic leukemia

In three children receiving oral remission maintenance therapy for acute lymphoblastic leukemia, the concentrations of 6-mercaptopurine (6-MP) in cerebrospinal fluid (CSF), plasma and red blood cells were compared. CSF samples were obtained from an Ommaya reservoir previously inserted for treatment of CNS relapse. At the time of the study, the children were all in remission and had been on oral 6-MP (42-63 mg m-2) once daily for at least 24 weeks. Immediately before dose intake on the day of study (about 24 h after last dose), the concentrations of 6-MP in CSF, plasma and red blood cells were rather similar and below 20 ng ml-1 in all patients. After dose intake, the concentrations in plasma and in red blood cells increased to 40-200 ng nl-1 within 0.5-4 h. In contrast, the concentration of 6-MP in the CSF remained fairly constant around 4-10 ng ml-1 throughout the time period studied (up to 4 h). It is concluded that 6-MP can be detected in CSF during oral maintenance therapy and that the drug has different pharmacokinetic profile in CSF to that in plasma and red blood cells. Further studies are necessary to evaluate the significance of the 6-MP concentrations obtained in CSF for the prevention of CNS relapse.

Significance and limits of cerebrospinal fluid beta-2-microglobulin measurement in course of acute lymphoblastic leukemia

Cerebrospinal fluid beta-2-microglobulin (CSF-beta 2m) was measured longitudinally in 48 patients affected by acute lymphoblastic leukemia (ALL). Thirteen developed a central nervous system (CNS) involvement during the course of the disease; although moderately higher mean CSF-beta 2m levels were found in these subjects, no significant statistical differences were observed in comparison with patients without this complication and compared with the control group. No correlations were found between beta 2m and other biochemical parameters in CSF. Furthermore, CSF-beta 2m levels appeared to be influenced by previous combined chemoradiotherapeutic treatment for CNS prophylaxis, presence of meningeal non-neoplastic infiltrates, patients' ages, amount of CSF blasts, and their immunological phenotype. In particular, only clearly B-committed leukemic cells, when tested, showed a strong surface expression of beta 2m, as demonstrated by immunocytochemical detection of this protein on cell membrane. However, in specific cases, CSF beta 2m measurement and CSF/serum beta 2m ratio were helpful in diagnosing and monitoring isolated CNS disease. Such findings suggest that CSF-beta 2m assay may be a useful tool in the management of CNS involvement in the course of ALL in only selected patients, as several factors can modify the outcome.

Elevated cerebrospinal fluid leukocyte count and protein concentration at diagnosis: independent risk factors in children with acute lymphoblastic leukemia

The aim of this study was to investigate whether determination of the initial cerebrospinal fluid (CSF) protein concentration and leukocyte count in children with acute lymphoblastic leukemia (ALL) could yield useful information about the patient's central nervous system status and prognosis. The population-based unselected series comprised 160 children. The mean follow-up time was 72 months (range 25-143 months). Both the CSF protein concentration and the leukocyte count, if elevated, were significantly, although not independently, associated with diminished probability of event-free survival. The patients were divided into three groups for the final analyses: those without any abnormalities in the CSF (n = 133), those with elevated protein concentration and/or elevated leukocyte count, but with no malignant lymphoblasts in the CSF (n = 21), and those with malignant lymphoblasts in the CSF (n = 6). The probabilities of 5-year event-free survival for the first and second group were 65% and 15%; the probability of 2-year event-free survival for the third group was 17%. These differences were statistically significant (p less than 0.001). In multivariate analysis the relative risks of death or relapse for these groups were 1, 2.8 (95% confidence limits 1.5-4.9), and 7.6 (2.4-24.3), respectively (p less than 0.001). The inclusion of an elevated CSF protein concentration or leukocyte count in the risk group criteria of further trials should be considered.

Diagnosis of meningeal involvement in childhood acute lymphoblastic leukemia: cytomorphology and TdT

Between December, 1984, and May, 1986, 98 CSF samples were sent to a central laboratory by postal express. The samples could be kept in a medium for up to 24 hours after the lumbar puncture. The quality of the cells proved to be good. Excluded were 5 samples delayed in delivery and 13 samples contaminated with blood, defined as the macroscopical presence of blood. The microscopical presence of erythrocytes in the cytocentrifuge preparation can make interpretation of the results difficult. Especially when leukemic blasts are present in the blood, extreme caution is necessary. A total of 71 samples could be studied by cytomorphology as well as by TdT-IF. When cytomorphological leukemic blasts were present, this was confirmed by TdT-IF positivity in all cases. But in 6 of 71 samples, TdT-IF was positive without the presence of cytomorphological leukemic blasts. Follow-up of these patients will show whether the therapeutic regimen has to be changed.

Cytodiagnosis and monitoring of acute lymphocytic leukemia and eosinophilia in cerebrospinal fluid

A case of adult aleukemic leukemia with an isolated CNS relapse diagnosed by cytologic examination of the CSF is reported. CSF hypereosinophilia of uncertain significance was documented. Immunologic marker studies (CALLA, HTA, Tdt) were performed on the CSF and showed a null cell acute lymphocytic leukemia. Sequential CSF specimens were obtained to determine the continued presence of lymphoblasts. Cytologic monitoring of the CSF in acute leukemia is a useful technique to determine disease status and efficacy of therapy. We advocate the use of cell morphology for monitoring, reserving the use of cell markers for initial identification of malignant cells and for use when the cell morphology is altered.

Shedding of leukemia-associated P24 antigen by lymphoblastoid cell lines

We report the development of a unique enzyme-linked immunosorbent assay (ELISA) which makes possible the detection of leukemia-associated P24 antigen, utilizing its ability to bind the Ricinus communis agglutinin (RCA1) and a monoclonal antibody, SJ-9A4 simultaneously. Using the RCA1/SJ-9A4-ELISA, P24 antigen, as few as 50 X 10(3) cells from a common acute lymphoblastic leukemia (C-ALL) cell line could be detected. The presence of D-galactose gave complete and specific inhibition of P24 antigen binding to RCA1. Matched concentrations of D-glucose and D-sucrose had no effect on binding. The release of the P24 antigen into the culture medium by a C-ALL cell line maintained at 37 degrees C could be detected; however, no P24 antigen was present in the culture medium when the cells were maintained at 4 degrees C. Sequential analysis of the culture medium for soluble P24 antigen revealed that release of the P24 antigen associated with cell growth. Molecular sieve chromatography of concentrated culture medium indicated that shed P24 antigen was eluted in the macromolecule fraction. P24 antigen was detected in the cerebrospinal fluid (CSF) of four patients with P24 positive ALL at the time of relapse of the central nervous system (CNS) and was undetectable while in complete remission. The CSF from three patients with P24 negative ALL and three patients with aseptic meningitis had no detectable activity.

Immunocytochemistry of cerebrospinal fluid

In order to determine how best to study cells in cerebrospinal fluid (CSF) by immunocytochemical techniques, several crucial technical variables and five immunocytochemical methods were examined. Immunocytochemical studies could be performed on either cell suspensions or smears. The method using cell suspensions was more sensitive, producing less background staining, but requiring more cells than that using smears. Among the five methods examined, indirect immunoperoxidase (IP) and indirect immunoalkaline phosphatase (IAP) were comparable in sensitivity. The peroxidase-antiperoxidase (PAP), alkaline phosphatase-antialkaline phosphatase (APAAP) and avidin-biotin complex-immunoalkaline phosphatase (ABC-AP) methods were comparable in sensitivity and were more sensitive than either the IP or IAP technique. The peroxidase methods were plagued with problems related to endogenous enzyme activity and the ABC-AP method may exhibit undesirable background staining. Therefore, the IAP method should be used for cell suspensions and the APAAP for cells on smears. In CSF specimens with a small number of cells, immunocytochemical studies should be done on smears by the APAAP method. These conclusions are supported by our experience with CSF specimens from patients with reactive and neoplastic lymphocytoses.

Effect of dose and repeat intravenous 24 hr infusions of methotrexate on cerebrospinal fluid availability in children with hematological malignancies

This pharmacokinetic study examined the relationship between methotrexate (MTX) dose and drug concentrations in blood and cerebrospinal fluid (CSF) during repeated 24 hr infusions. Two regimens were used: an intermediate dose (ID) of 0.5 g/m2 (7 patients, 23 cycles) and a high dose (HD) of 2.5 g/m2 (8 patients, 39 cycles). Inter-patient variability in the drug concentration was apparent in serum and CSF for both doses. The dispersion was particularly wide in CSF for HD MTX. Considering median values, serum and CSF MTX were linked to dose escalation. Individual CSF/serum drug ratios were not modified by the dose (1.1% for ID MTX versus 1.4% for HD MTX). A potentially cytotoxic drug level in CSF (10(-6) M) was never obtained for ID MTX cycles, but was achieved in 44% of HD MTX cycles: for HD MTX, this corresponded to 88% of patients (7/8). Total body clearance did not modify the degree of CSF MTX passage. A positive, significant correlation (r = 0.62, P less than 0.05) was observed for ID MTX between individual serum and CSF MTX; no such relationship was seen with HD MTX. Individual cycle-to-cycle variations in the MTX concentration were particularly marked in CSF and for HD MTX, without strict concordance with blood levels.

CSF myelin basic protein levels in leptomeningeal metastases. Relationship to disease activity

Myelin basic protein (MBP) was serially measured in 177 CSF samples of 33 patients with leptomeningeal metastases and in 34 cancer controls. The mean level in cancer controls (free of neural involvement) was 5.7 +/- 0.33 ng/ml (normal less than 5 ng/ml) with abnormal elevation of MBP detected in 17%. The activity of the leptomeningeal disease was classified as either acute-progressive, stable or in remission on the basis of clinical and CSF cytological findings. CSF MBP levels were analysed in each stage. Abnormal elevation of MBP was detected in 74% of the 68 samples obtained in the acute-progressive stage (mean +/- SEM: 18.25 +/- 1.4 ng/ml, P less than 0.0001), in 24% of the 79 samples in the stable phase (mean: 7.99 +/- 0.8 ng/ml, NS) and in 20% of the 30 samples in remission (mean 5.7 +/- 0.3 ng/ml, NS). Similar changes in levels of CSF MBP were also observed in longitudinal studies of patients responding to treatment or relapsing to the acute stage. Eight patients developed treatment induced necrotizing leukoencephalopathy with typical CT-scan findings; elevated levels of CSF MBP were detected in 7 of them (mean: 21 +/- 3 ng/ml) when measured within 2 weeks of diagnosis but not when measured 2 months earlier. Our study suggests that in leptomeningeal metastases, CSF MBP levels are indicators of the disease activity, particularly if longitudinal determinations are used.

Pregnancy-specific beta 1 glycoprotein (SP1) in the cerebrospinal fluid

Pregnancy-specific beta 1 glycoprotein (SP1) was assayed by Particle Counting Assay in the cerebrospinal fluid (CSF) from 26 non-neurological patients, from 190 patients with various neurological disorders and from 84 patients with malignant hemopathies. With a sensitivity limit of 0.5 microgram/l, SP1 was undetectable in normal CSF. High levels were observed in CSF from one pregnant woman with herpetic encephalitis and from another woman with post-puerperal thrombophlebitis as a result of high serum concentrations and leakage of the blood-brain barrier. SP1 was detected at low levels in the CSF from 1 patient out of 5 with Creutzfeldt-Jakob disease and from a patient with Behçet's disease. Seven patients out of 84 with malignant hemopathies presented cerebral involvement; 3 of them had detectable SP1. However, SP1 was also detected in the CSF of 2 patients in apparently complete remission. The determination of SP1 in CSF appears to be of limited value in the diagnosis of neurological disorders and in the early detection of a cerebral localization of malignant hemopathies.

Elevated titers of cell-free interleukin-2 receptor in serum and cerebrospinal fluid specimens of patients with acquired immunodeficiency syndrome

A sensitive monoclonal antibody based ELISA was used to detect cell-free interleukin-2 receptor (IL-2R) in the body fluids of patients with acquired immune deficiency syndrome (AIDS), a variety of other disease conditions and a control group of apparently healthy (heterosexual and homosexual) males. Two of the 25 control donors showed low titers (1:8) of IL-2 receptor in the serum samples; the cerebrospinal fluid (CSF) specimens from these individuals proved negative. However, serum and CSF specimens from all the 9 patients with AIDS showed significantly elevated titers (range 1:128 to 1:4096) of IL-2 receptor. The presence of moderate titers (range 1:128 to 1:512) of circulating IL-2 receptor could also be detected in all of the 4 patients with acute lymphocytic leukemia. IL-2 receptor was detectable in the CSF and/or serum specimens from 3 of 3 patients with lung cancer, 3 of 4 patients with acute hepatitis B infection, and 2 of 3 patients with multiple sclerosis. IL-2 receptor could not be detected in the serum or CSF specimens originating from patients with legionellosis (3/3), asthma (3/3), or those with non-pulmonary febrile bacterial infections (4/4). It is concluded that soluble IL-2 receptor may be found in serum or CSF specimens from patients with certain (but not all) disease conditions including AIDS. The conspicuously elevated titers of cell-free IL-2R in the body fluids of patients with AIDS may contribute to the drastic impairment of the immune system regulation observed in such patients.

Systemic high-dose ara-C for the treatment of meningeal leukemia in adult acute lymphoblastic leukemia and non-Hodgkin's lymphoma

Considering the good penetration of systemic high-dose ara-C (HDara-C) into the CNS, we used this approach for treating overt meningeal leukemia, either isolated or with concurrent extraneurologic disease, in 15 adults with high-risk acute lymphoblastic leukemia (ALL), one adult with lymphoid blast crisis of chronic granulocytic leukemia (LBC-CGL), and four adults with poor-prognosis non-Hodgkin's lymphoma (NHL). Treatment consisted of ara-C, 3 g/m2 every 12 hours by three-hour infusion for eight doses followed by a second course of four doses on day 21. Remitters received consolidation with monthly courses of HDara-C for four doses. Additional systemic multi-drug reinduction therapy and direct CNS treatment with intrathecal methotrexate (IT MTX) and cranial irradiation (CRT) was administered to the three remitters last treated. Thirteen of 20 patients (65%) achieved complete remission (CR): seven of seven patients with isolated meningeal leukemia and six of 13 patients with concurrent CNS and bone marrow disease. Of the remaining seven patients, five had a complete CSF clearing with persistent marrow disease. In all cases there was prompt resolution of neurologic signs and symptoms. The median duration of CR was 5 months (range 2 to 8 months). The most significant toxicity seen was myelosuppression, which was predictable and manageable. Nonhematologic toxicity was generally acceptable and included moderate nausea and vomiting, diarrhea, drug fever, transient liver dysfunction, and dermatitis. No cases of CNS toxicity occurred. There were no treatment-related deaths. Disease-free survival was limited by marrow relapse, either isolated or with concurrent CNS disease. No instances of isolated meningeal relapse occurred. These results obtained in a poor-risk subset of patients indicate that HDara-C is an effective treatment for the induction of remission in ALL and NHL with meningeal leukemia. Therefore, HDara-C should be considered for inclusion in multiagent consolidation programs for patients at high risk for CNS disease.

Millipore filter vs cytocentrifuge for detection of childhood central nervous system leukemia

To evaluate the relative merits and deficiencies of Millipore filter and cytocentrifuge preparations in the detection of central nervous system (CNS) acute leukemia in pediatric patients, 300 cerebrospinal fluid (CSF) specimens from 17 patients were prepared by both methods. The 17 patients studied were all diagnosed and treated for CNS leukemia. Leukemic blast cells were found by at least one method in 91 CSF specimens, and the results of both techniques were positive in 77 (85%) of 91 specimens. Of the 14 specimens in which the results of only one method were positive, seven yielded positive results only by the cytocentrifuge method, and seven yielded positive results only by the Millipore filter method. In 12 of the 14 discrepant specimens, the paired specimen whose results were not interpreted as positive was technically unsatisfactory (nine specimens) or had cells suspicious for blast cells rather than unequivocal blast cells (three specimens). Blast cells were identified in specimens with low nucleated cell counts (less than or equal to 5/mm3) by both methods and usually were immediately preceded or followed by CSF specimens showing florid disease. We conclude that performance of both methods is unnecessary for routine surveillance if processing techniques yield quality preparations. Cytocentrifuge preparations stained by Wright's method allow better morphologic correlation with bone marrow blast cells and allow easier identification of blood or bone marrow contamination.

Meningeal leukemia diagnosed by cytocentrifuge study of cerebrospinal fluid. A study of 631 cerebrospinal fluid samples from 87 patients

Owing to improved therapy and lengthened life span, the incidence of neuromeningeal involvement in leukemia is increasing. Careful examination of the cerebrospinal fluid (CSF) is important for an early diagnosis. Among the available techniques, the use of cytocentrifugation enables us to demonstrate central nervous system leukemia even if the white blood cell count in the CSF is under 10/cu mm. We describe the results obtained by examining 631 CSF samples from 87 patients affected by acute leukemia; central nervous system luekemia was found in 22.7% of the patients suffering from acute lymphocytic leukemia and in 6.4% of those with acute nonlymphocytic leukemia (ANLL), but this ratio is higher in ANLL compared with the survival as measured in months (a ratio of 2.0 in ANLL compared with 0.50 in acute lymphocytic leukemia). A "leukemic" CSF was found in 51.5% of prophylactically treated patients and in 73.1% of the untreated ones.

[Terminal deoxynucleotidyltransferase (TdT)-positive cells in cerebrospinal fluid of children with leukemia or non-Hodgkin lymphoma: implications for the diagnosis of central nervous system leukemia]

Identification of terminal deoxynucleotidyl transferase (TdT) positive cells in sites other than bone marrow, thymus, lymph nodes and peripheral blood is indicative of a TdT positive lymphoproliferative disease. We therefore employed both a TdT-immunofluorescence (IF) assay and conventional cytomorphology to examine the cells in 421 cerebrospinal fluid samples from 60 children with a TdT positive acute lymphoblastic leukemia or non-Hodgkin lymphoma, at diagnosis as well as during follow-up. The results of the TdT assay were compared with those obtained by cytomorphological analysis of the same sample. The authors conclude that the TdT-IF assay is a valuable additional tool in diagnosing TdT positive central nervous system leukemia. It offers more reliable and conclusive diagnoses than cell count and cytomorphology alone, which might avoid both under- and overtreatment of the patient.

Cerebrospinal fluid biogenic amine metabolites in children during treatment for acute lymphocytic leukemia

To learn more about the impact of intrathecal methotrexate and cytosine arabinoside therapy on neuronal metabolism, we measured serial cerebrospinal fluid concentrations of homovanillic acid and 5-hydroxyindoleacetic acid, major metabolites of the neurotransmitters dopamine and serotonin, in children with acute lymphocytic leukemia. Multiple sequential cerebrospinal fluids were obtained from 30 children with acute lymphocytic leukemia evaluated prospectively from the time of diagnosis. We focused on the period of induction and intensification when children received weekly intrathecal chemotherapy. Paired cerebrospinal fluid specimens were also obtained at 3-month intervals from 60 children with acute lymphocytic leukemia in remission. Homovanillic acid and 5-hydroxyindoleacetic acid were measured using high performance liquid chromatography with electrochemical detection. We found that pretreatment metabolite values were no different from those in age-matched subjects in remission. In the first 5 wk of treatment, there were no significant changes in metabolite levels in patients treated exclusively with methotrexate. There was a transient decrease in homovanillic acid (-28 +/- 10%, p less than 0.001, Student's t test) and 5-hydroxyindoleacetic acid (-28 +/- 12%, p less than 0.05) in five of six patients after a single intrathecal dose of cytosine arabinoside. In the next 4 wk there was a gradual rise in levels of homovanillic acid (p = 0.001, by analysis of variance) and 5-hydroxyindoleacetic acid (p = 0.029, analysis of variance); this pattern did not correlate with administration of cranial irradiation. In children in remission, there were no significant changes in metabolite levels over a 3-month period.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrospinal fluid monoamine precursor and metabolite levels in children treated for leukemia: age and sex effects and individual variability

Lumbar cerebrospinal fluid (CSF) was obtained from children during and following treatment for acute lymphoblastic leukemia (ALL). One hundred ninety-two CSF samples from 50 subjects, which were selected to minimize the effects of the disease and its treatment (i.e., to approach "normality" as closely as possible), were analyzed for the monoamine precursors tyrosine (Tyr) and tryptophan (Trp) and the metabolites homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA). Levels of HVA (p less than 0.0001), 5-HIAA (p less than 0.002), and Tyr (p less than 0.05) decreased with age from 3 to 17 years. Significant correlations were observed between the acid metabolites HVA and 5-HIAA (r = 0.79) and between the amino acid precursors Tyr and Trp (r = 0.71). Within individuals, levels of all four compounds were relatively stable over time, with total mean coefficient of variation ranging from 20% to 25%. No significant sex differences for CSF levels of HVA, 5-HIAA, Tyr, or Trp were found. Assessment of CSF monoamine precursors and metabolites in children treated for ALL may provide a method for understanding the chronic effect of CNS trauma on the ontogeny of monoamine systems.

Diagnostic problems in cerebrospinal fluid of children with lymphoid malignancies

The interpretation of small numbers of lymphoblasts or of nonspecific pleocytosis in the cerebrospinal fluid (CSF) of children with lymphoid malignancies is difficult. In this prospective study of 204 patients, 15 had white cell chamber counts of less than or equal to 10 cells/microliter, with one or more blasts on a cytocentrifuged smear. Only 3/15 subsequently developed meningeal leukemia, and 4/15 remain in continuous complete remission. Among 53 patients with a chamber count greater than 10 WBC/microliter and no blasts, pleocytosis was associated with central nervous system (CNS) prophylaxis in half. Less common were viral syndromes, immune recovery, subsequent meningeal leukemia, active hematologic leukemia, the somnolence syndrome, leukoencephalopathy, or reaction to a previous traumatic lumbar puncture.

CSF cytology of a patient with conversion of an acute lymphatic leukemia to an acute eosinophilic leukemia

The course of leukemic disease in a male adolescent with meningeal leukemia is described. The bone marrow aspirates showed a conversion from an acute lymphatic leukemia to an eosinophilic leukemia. Four weeks after the peripheral shift of phenotype two different cell clones were detected in one CSF smear. While under ultrahigh dose araC therapy the patient died 3 months after conversion. Possible explanation for the shift of phenotype and the peculiar leptomeningeal infiltration are discussed.

Use of monoclonal antibodies to identify cerebrospinal fluid lymphoblasts in children with acute lymphoblastic leukemia

The identification of small numbers of leukemic cells in the cerebrospinal fluid (CSF) presents a diagnostic problem in the treatment of children with acute lymphoblastic leukemia (ALL). We adapted a latex sphere rosetting technique to allow us to identify simultaneously cell surface markers and cell morphology in 199 CSF samples from 34 patients and 14 control subjects. In patients without leukemic meningitis, the majority of CSF lymphocytes (69%) were found to be mature T cells positive for OKT11. A much smaller number of cells (8%) were found to be B cells positive for la. In these children, only 3% of CSF lymphoid cells expressed the common acute lymphoblastic leukemia antigen (CALLA). Similar results were found in the control subjects. By contrast, 28 CSF samples from nine children with varying numbers of CSF lymphoblasts had much greater proportions of CALLA- and la-positive CSF cells (24% to 96%). Leukemic meningitis was present in one of these patients and later developed in four others. However, three patients with small numbers of lymphoblasts present but with low proportions of CALLA-positive CSF cells (less than 5%) subsequently had normal CSF examinations. We found the use of this rosetting technique valuable in providing information complementary to that obtained from cell morphology alone about the possible malignant nature of small numbers of lymphoblast-like CSF cells seen on cytocentrifuge preparations in children with ALL.

Isotachophoresis as a useful tool for monitoring neurological complications of acute leukaemia in children

Cerebrospinal fluid proteins from 42 children with acute lymphoblastic leukaemia were analysed by isotachophoresis. The isotachopherograms of cerebrospinal fluid taken from patients undergoing central nervous system prophylaxis with neurological complications showed an increase of several peaks (albumin, prealbumin, and an unidentified peak), and changes in the globulin zone, compared with those from patients who had completed central nervous system prophylaxis for at least six months. The most striking finding was that these alterations were not associated with any other biochemical changes in the cerebrospinal fluid, as assayed by routine analysis. Isotachophoresis may be useful in the monitoring of therapy in children affected with acute lymphoblastic leukaemia.

Cerebrospinal fluid ferritin in patients with leukaemia and malignant lymphoma

To evaluate whether cerebrospinal fluid (CSF) ferritin could be of diagnostic value in haematological malignancies with central nervous system (CNS) involvement, the ferritin concentration was measured in 21 patients with acute leukaemia and lymphoma. Of the 17 patients without CNS involvement, 16 had CSF ferritin values in the normal range (2-7 micrograms/l); 1 patient had an elevated value, probably due to blood contamination in connection with a very high serum ferritin level. 4 patients had tumour invasion of the CNS indicated by the presence of blastic cells in the CSF; CSF ferritin levels in these patients were likewise in the normal range. There was no difference between CSF ferritin values in patients with and without CNS involvement. With the present assay, measurement of CSF ferritin appears to be irrelevant in the evaluation of CNS invasion in haematological malignancies.

Acute lymphoblastic leukaemia presenting with raised intracranial pressure

A child presented with raised intracranial pressure for which no cause was established. Five months later a further cerebrospinal fluid examination showed lymphoblasts expressing the common acute lymphoblastic leukaemia phenotype. Bone marrow infiltration was not present. This case illustrates the difficulties that may be encountered in establishing the diagnosis of central nervous system leukaemia.

Unreliability of beta-2-microglobulin in early detection of central nervous system relapse in acute lymphoblastic leukemia

The value of serial determination of the cerebrospinal fluid (CSF) beta-2-microglobulin (Beta 2m) level for early detection of acute lymphoblastic leukemia (ALL) in the central nervous system (CNS) has been prospectively studied in 30 children. Beta 2m was determined by micro-ELISA assay. Results demonstrated a sensitivity of 40% (95% confidence interval, 5.3-85.3%) and a predictive value of 8% (95% confidence interval, 1.0-26.0%). In post-irradiation syndrome, as well as in viral infection with cytopathological changes of white cells in CSF, beta 2m values proved to be significantly higher than in incipient CNS relapse, and these conditions, or an unknown cause, are more often associated with beta 2m elevation than CNS relapse. No relation was found between CSF white cell counts and beta 2m levels. It is concluded that beta 2m is not an appropriate test for early detection of CNS involvement in children with acute lymphoblastic leukemia.

Remission induction of meningeal leukemia with high-dose intravenous methotrexate

Twenty children with acute lymphoblastic leukemia who developed meningeal disease were treated with a high-dose intravenous methotrexate regimen that was designed to achieve and maintain CSF methotrexate concentrations of 10(-5) mol/L without the need for concomitant intrathecal dosing. The methotrexate was administered as a loading dose of 6,000 mg/m2 for a period of one hour followed by an infusion of 1,200 mg/m2/h for 23 hours. Leucovorin rescue was initiated 12 hours after the end of the infusion with a loading dose of 200 mg/m2 followed by 12 mg/m2 every three hours for six doses and then every six hours until the plasma methotrexate level decreased to less than 1 X 10(-7) mol/L. The mean steady-state plasma and CSF methotrexate concentrations achieved were 1.1 X 10(-3) mol/L and 3.6 X 10(-5) mol/L, respectively. All 20 patients responded to this regimen, 16/20 (80%) achieved a complete remission, and 20% obtained a partial remission. The most common toxicities encountered were transient serum transaminase and bilirubin elevations, neutropenia, and mucositis. One patient had focal seizures and transient hemiparesis but recovered completely. High-dose intravenous methotrexate is an effective treatment for the induction of remission after meningeal relapse in acute lymphoblastic leukemia.

Diagnosis of meningeal leukemia using immunoperoxidase methods to demonstrate common acute lymphoblastic leukemia cells in cerebrospinal fluid

The immunological phenotype of cells in the cerebrospinal fluid (CSF) was determined with immunoperoxidase techniques. A medium was used which allowed cells to stand at room temperature for 24 h without appreciable loss of cells. From 62 patients a total number of 208 CSF specimens were analysed. It proved possible to perform 4 determinations and a control reaction on 2.5 ml of CSF: cell count, cytology, E-rosetting and staining with a monoclonal antibody, provided that more than 1 cell per mm3 were present. This study focussed on the presence of the common acute lymphoblastic leukemia marker (cALL, determined with the monoclonal antibody J5). All 21 CSF specimens containing more than 5% cALL positive cells were from patients with an initial diagnosis of common ALL, 8 of these samples were considered to be normal and 3 uncertain by standard cytological criteria. Six of the 8 samples which were cytologically normal, were from patients who had clear meningeal involvement at diagnosis, or developed a relapse later. There were no patients who developed a meningeal relapse on cytological criteria that was not detected by immunocytology. In one patient a cytological diagnosis of meningeal relapse was not confirmed by immunocytology, this patient is disease free 2 yr later without cytostatic treatment. Immunoperoxidase methods to detect cALL positive cells in CSF are an invaluable aid to the diagnosis of meningeal leukemia.

Ascending myelopathy after chemotherapy for central nervous system acute lymphoblastic leukemia: correlation with cerebrospinal fluid myelin basic protein

Ascending myelopathy developed in a previously irradiated 10-year-old boy after intraventricular methotrexate and cytosine arabinoside were given for central nervous system relapse of acute lymphoblastic leukemia. The course was fatal in 10 weeks. Cerebrospinal fluid myelin basic protein levels, indicating a demyelinative process, rose prior to the onset of clinical symptoms and remained at very high levels until death. Myelin basic protein may be useful as a predictor of chemotherapy-associated neurotoxicity.

Altered central nervous system pharmacology of methotrexate in childhood leukemia: another sign of meningeal relapse

CSF and plasma antifolate concentrations during 257 intravenous (IV) infusions of high-dose methotrexate were measured in 60 children with acute lymphoblastic leukemia. In 49 children who have never had evidence for CNS leukemia, the mean steady-state CSF to plasma methotrexate ratio was 0.013 (SD = 0.01). In contrast, 11 children with overt meningeal leukemia had a 12-fold higher mean ratio of 0.157 (range, 0.013 to 0.844, p less than .01). In the group of patients studied, all of those with a CSF methotrexate concentration greater than 2 SD above the mean either had leukemic cells in the CSF or subsequently developed this condition. In two patients, overt CNS leukemia was preceded by a high CSF:plasma drug ratio at a time when there was no cytologic or clinical evidence for CNS leukemia. As previously observed with intrathecal methotrexate, we conclude that overt meningeal leukemia increases CSF drug concentrations during IV methotrexate therapy. An elevated CSF to plasma ratio may be useful to predict imminent CNS relapse or to verify completeness of response to therapy.

Central nervous system relapse surveillance by serial beta 2-microglobulin measurements in childhood acute lymphoblastic leukemia

Beta 2-microglobulin (beta 2m) is synthesized particularly in lymphocytes. Its value for early detection of central nervous system (CNS) involvement in acute lymphoblastic leukemia in children was tested by serial determinations. Before 9 overt CNS relapses, the mean increase of the cerebrospinal fluid (CSF) beta 2m concentration was 588 micrograms/l/month (range: -50 to +2020), which was significantly higher than the steady levels during maintenance treatment. Although the absolute value of CSF beta 2m was increased to 1 430 micrograms/l in the group with overt CNS relapse, individual variations in CSF beta 2m before a relapse were so great that no difference was seen between samples from CSF with or without lymphoblasts. The ratio between beta 2m in the CSF and in serum did not increase in serial samples prior to overt relapse, but the ratio was higher in patients with CNS relapse compared with a control group on maintenance therapy. In 9 children without CNS leukemia, the beta 2m concentration in CSF and serum decreased to a nadir 4 weeks after the start of induction treatment. The subsequent increase of CSF beta 2m was similar to the increase before a CNS relapse. Mean values of CSF beta 2m changes differed between groups of children with and without CNS leukemia early in the induction phase and during the maintenance treatment, but the wide range in individual values made serial beta 2m determinations unsuitable for detecting a CNS relapse.

Recognition of central nervous system leukemia by flow cytometry

Cerebrospinal fluid of 24 patients with acute leukemia was studied by DNA/RNA flow cytometry. In six of 15 patients with central nervous system (CNS) relapse, the spinal fluid cells had abnormal DNA stemlines, ranging from near haploid to hyperdiploid. In two additional cases, leukemic cells were identified by a abnormally high RNA content only. One patient had two different aneuploid cell populations in spinal fluid not distinguished by cytologic morphology. Another patient with initial diploid leukemia had CNS relapse characterized by the same DNA stemline long after a triploid DNA stemline emerged in the marrow. DNA/RNA flow cytometry detected leukemic cells that were not identified ("uniform" or "reactive") by cytological criteria in 5/6 patients studied and in addition differentiated lymphoblastic from nonlymphoblastic cell types according to low and high RNA content.

Cerebrospinal fluid polyamines in childhood leukemia

Cerebrospinal fluid (CSF) polyamines were measured in children with acute lymphocytic leukemia or non-Hodgkin's lymphoma in various stages of the disease ranging from complete remission to active central nervous system (CNS) involvement. Polyamines were analyzed by ion exchange chromatography with o- pthalaldehyde fluorimetric detection. Putrescine concentrations in random CSF samples obtained from leukemic patients with and without CNS involvement were not significantly different. Spermidine levels were generally higher in patients without CNS leukemia than in patients with the disease. In serial CSF specimens from an individual patient, spermidine levels correlated well with clinical status, being high in the active stages of the disease and low in remission. Thus, CSF polyamines appear to be of limited value as a screening test for early detection of CNS leukemia; however, they may offer an additional means of evaluating CNS leukemia and its response to therapy.

Elevated myelin basic protein levels in the cerebrospinal fluid of children with acute lymphoblastic leukemia

Cerebrospinal fluid was examined from 70 children with acute lymphoblastic leukemia for evidence of active myelin breakdown based on the release of myelin basic protein (MBP). Fifty-three asymptomatic children were followed from diagnosis with serial MBP determinations. Eight (15.1%) of 53 children had abnormal elevations of MBP, six of eight before receiving presymptomatic central nervous system therapy. Long-term observations are in progress. For comparison, six children with clinical and radiologic findings of leukoencephalopathy had abnormal MBP determinations, whereas no abnormalities were detected in 11 children with meningeal leukemia.

Low molecular weight plasma proteins in the cerebrospinal fluid of children with hematological malignancies

The concentration of beta-2-microglobulin (beta 2-m) and of post gamma globulin (P gamma G) was examined in serum and cerebrospinal fluid from children with acute lymphatic leukemia (ALL) and non-Hodgkin's lymphoma (NHL). Data were analysed in order to determine whether concentration of beta 2-m or P gamma G during remission would be of value in predicting relapse or eventual outcome. Mean serum concentration of beta 2-m was similar in good and poor prognosis patients with ALL in remission and was not significantly altered in CNS or marrow relapse. Mean CSF concentration in NHL was also similar in both prognostic groups, and in poor prognosis patients was not significantly altered in relapse. The same pattern was seen when P gamma G was measured in CSF (serum concentration of this protein being too low for accurate determination). High within patient variability of levels of beta 2-m and P gamma G appeared to relate to chemotherapy rather than the disease process. Concentration of P gamma G was persistently raised in three children with brain damage of differing etiologies. Levels of two other low molecular weight proteins, retinol binding protein and alpha 1-microglobulin, were also determined in order to establish that beta 2-m and P gamma G concentration was not influenced by alteration in permeability of the blood-brain barrier. The beta 2-m and P gamma G concentration, although higher than reported in healthy children [5] does not appear to be of value as a prognostic indicator in ALL and NHL in children.

High-dose methotrexate as part of remission maintenance therapy for childhood acute lymphocytic leukemia: a Pediatric Oncology Group pilot study

Seventeen children with acute lymphocytic leukemia (ALL) in remission were treated with parenteral high-dose methotrexate (HDM) pulses every eight weeks during standard 6-mercaptopurine and methotrexate (MTX) oral maintenance therapy. MTX (1,000 mg/m2) was infused over one hour followed by one hour of intravenous hydration for the purpose of achieving plasma and cerebrospinal fluid (CSF) levels greater than 10(-6) M for a period of 24 hours. Leucovorin (15 mg/m2) was administered orally six, 12, and 18 hours after completion of the HDM. Plasma and CSF concentrations of MTX were evaluated serially in the first 48 hours. During the first 24 hours, the plasma MTX level was maintained at greater than 10(-6) M. The patients receiving intrathecal MTX at a dose of 15 mg/m2 had an adequate, sustained MTX level in the CSF, but when no intrathecal MTX was administered, the CSF levels were less than 10(-6) M. For that reason, intrathecal MTX in a low dose (6 mg/m2) was injected intrathecally one hour after the HDM infusion, allowing the MTX level in CSF to approximate 10(-6) M over the 24 hours. The toxicity of this therapy was minimal. Due to the facts that the plasma and CSF MTX levels could be sustained above the desired concentrations and this regimen could be given in the outpatient clinic, this program has been incorporated into an ongoing study in an effort to prolong complete remissions.