Treatment of blastic plasmacytoid dendritic cell neoplasm

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare myeloid malignancy with no defined standard of care. BPDCN presents most commonly with skin lesions with or without extramedullary organ involvement before leukemic dissemination. As a result of its clinical ambiguity, differentiating BPDCN from benign skin lesions or those of acute myeloid leukemia with leukemia cutis is challenging. BPDCN is most easily defined by the phenotype CD4⁺CD56⁺CD123⁺lineage^-MPO^-, although many patients will present with variable expression of CD4, CD56, or alternate plasmacytoid markers, which compounds the difficulty in differentiating BPDCN from other myeloid or lymphoid malignancies. Chromosomal aberrations are frequent, and the mutational landscape of BPDCN is being rapidly characterized although no obvious molecular target for chemoimmunotherapy has been identified. Chemotherapy regimens developed for acute myeloid leukemia, acute lymphoid leukemia, and myelodysplastic syndrome have all been used to treat BPDCN. Relapse is frequent, and overall survival is quite poor. Allogeneic transplantation offers a chance at prolonged remission and possible cure for those who are eligible; unfortunately, relapse remains high ranging from 30% to 40%. Novel therapies such as SL-401, a diphtheria toxin conjugated to interleukin-3 (IL-3) is commonly overexpressed in BPDCN and other aggressive myeloid malignancies and has shown considerable promise in ongoing clinical trials. Future work with SL-401 will define its place in treating relapsed or refractory disease as well as its role as a first-line therapy or bridge to transplantation.

Leukemia cutis in a patient with acute myelogenous leukemia: a case report and review of the literature

Leukemia cutis is an infiltration of malignant neoplastic leukocytes or their precursors into the epidermis, dermis, or subcutis. These neoplastic cells are derived from abnormal leukocytes in the bone marrow where maturation aberrations occur. Acute myelogenous leukemia (AML) is the second most common cause of leukemia cutis and the most common leukemia among adults. In the elderly population, AML presents a challenge to the medical community because of the number of preexisting comorbid conditions and the safety profile of useful chemotherapeutic agents.

Colonic infiltration with chronic myelomonocytic leukemia

BACKGROUND

A 75-year-old female presented with a 1 month history of non-bloody diarrhea, associated with abdominal cramping and urgency. Her medical history was notable for chronic myelomonocytic leukemia, diagnosed 6 years previously and managed expectantly by monitoring the patient's complete blood count. Over several months, the patient's symptoms progressed, which resulted in significant weight loss. The patient's course of disease was ultimately complicated by acute disseminated encephalomyelitis and death.

INVESTIGATIONS

Physical examination, laboratory investigations, stool studies, colonoscopy with biopsies, immunohistochemistry and pathologic review of biopsy specimens.

DIAGNOSIS

Leukemic colitis.

MANAGEMENT

Management of underlying leukemia with systemic hydroxyurea and topical colonic 5-aminosalicylic acid therapy.

Spectrum of clinical presentation, treatment and prognosis in a series of eight patients with leukaemia cutis

All types of leukaemia can disseminate to the skin, producing cutaneous deposits known as leukaemia cutis (LC). We undertook a retrospective study to review the clinical presentations, treatment and outcome of eight patients with LC managed in our department over a period of 12 years. The clinical phenotype varied, with erythematous papules and nodules occurring with greatest frequency. Infiltrated haemorrhagic plaques and perifollicular acneiform papules were also seen. Although patients were treated aggressively for their underlying leukaemia, and received therapy directed towards LC, they tended to be refractory to treatment and the diagnosis was generally associated with a poor prognosis. The exception was a patient with chronic lymphocytic leukaemia, who survived 3 years after developing LC.

Leukemic and lymphomatous meningitis: incidence, prognosis and treatment

Neoplastic meningitis (NM) is a common problem in neuro-oncology occurring in approximately 5% of all patients with cancer. Notwithstanding frequent focal signs and symptoms in NM, NM is a disease affecting the entire neuraxis and therefore staging and treatment need encompass all cerebrospinal fluid (CSF) compartments. Central nervous system (CNS) staging of NM includes contrast enhanced cranial computerized tomography (CE-CT) or magnetic resonance imaging (MR-Gd), contrast enhanced spine magnetic resonance imaging (MR-S) or computerized tomographic myelography (CT-M) and radionuclide CSF flow study (FS). Treatment of NM involves involved-field radiotherapy of bulky or symptomatic disease sites and intra-CSF drug therapy. The inclusion of concomitant systemic therapy may benefit patients with NM and may obviate the need for intra-CSF chemotherapy. At present, intra-CSF drug therapy is confined to three chemotherapeutic agents (i.e. methotrexate, cytosine arabinoside and thio-TEPA) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Although treatment of NM is palliative with an expected median patient survival of 4 to 6 months, it often affords stabilization and protection from further neurologic deterioration in patients with NM. In patients with leukemia or lymphoma, prophylaxis of the CNS is used (utilizing a combination of high-dose systemic chemotherapy and intra-CSF chemotherapy) for patients at high risk as defined by specific tumor-related laboratory markers. Using such a risk-stratified approach, the late occurrence of CNS relapse has decreased dramatically attesting to the value of CNS prophylaxis.

Leukemic infiltration of the orbit: report of three cases and literature review

Orbital infiltration by acute lymphoblastic leukemia is rare. The authors present 3 patients, 2 with optic nerve involvement and 1 with anterior chamber infiltration, treated by chemotherapy and radiotherapy. Two are in continuous remission at 64 and 59 months and 1 relapsed in the central nervous system 35 months after ocular relapse. Visual deterioration was prevented in two. Early diagnosis and treatment are important for preservation of vision.

Allosterically controllable maxizyme-mediated suppression of progression of leukemia in mice

Chronic myelogenous leukemia (CML) is a hematopoietic malignant disease associated with expression of a chimeric BCR-ABL gene. We recently succeeded in designing a novel allosterically controllable ribozyme, the maxizyme (Tanabe et al. Biomacromolecules 2000, 1, 108-117; Kuwabara et al. Biomacromolecules 2001, 2, 788-799), that not only specifically cleaves BCR-ABL mRNA and induces apoptosis in cultured CML cells but also shows significant inhibition against the growth of an established BV173 cell line in a mouse model (Tanabe et al. Nature 2000, 406, 473-474). As an extension of our studies, we tested the maxizyme against primary CML cells in the same mouse model. The maxizyme under the control of a tRNA(Val) promoter showed significant inhibition against the growth of the primary bone marrow cells from a Japanese patient with CML. Specifically, to examine the applicability of the maxizyme in the treatment of CML, we assessed the antitumor effect of the maxizyme in murine models of CML. Fourteen weeks after the injection of primary CML cells into a NOD-SCID mouse, the bone marrow of the mouse was filled with primary CML cells as a result of diffuse leukemia. In marked contrast, when maxizyme-expressing primary CML cells were injected, the mouse remained disease-free. These results further strengthen our earlier suggestion that the maxizyme technology might provide a useful approach to the treatment of CML.

Induction of long-term remission of a relapsed childhood B-acute lymphoblastic leukemia with rituximab chimeric anti-CD20 monoclonal antibody and autologous stem cell transplantation

Childhood B-cell neoplasms account for approximately 2% of childhood acute lymphoblastic leukemia (ALL). The short but intensive chemotherapy yields a currently 75% to 85% event-free survival. The prognosis for children with relapsed disease is considered to be dismal. We report a 12-year old boy diagnosed with B-cell ALL with central nervous system (CNS) involvement. He relapsed in the bone marrow immediately after primary chemotherapy. Rituximab as a single agent achieved a complete morphologic remission. After 4 treatments with rituximab an isolated CNS relapse occurred. CNS remission was reinduced with chemotherapy and the patient received an autologous transplant with rituximab for in vivo purging. He is currently in complete clinical and molecular remission for more than 1 year.

Involvement of the lacrimal drainage system by leukemia or lymphoma

PURPOSE

To determine the clinical characteristics and outcomes of patients with leukemic or lymphomatous involvement of the lacrimal drainage system (LDS).

METHODS

A computerized retrieval system was used to identify patients with histologically proven leukemic or lymphomatous involvement of the LDS. Medical records were reviewed.

RESULTS

Biopsies of the lacrimal sac or nasolacrimal duct obtained during dacryocystorhinostomies (DCR) performed at the Mayo Clinic (Rochester, Minnesota) between January 19, 1989, and August 26, 1997, were positive for leukemia or lymphoma in 11 patients (15 LDS). Ten patients had previously diagnosed leukemia or lymphoma; the interval between the diagnosis of systemic disease and DCR averaged 5.8 years (range, 7 months to 13 years; median, 5 years). The median age at the time of LDS involvement was 72 years (range, 49 to 85 years). Seven patients (64%) were women, and all were white. The median postoperative follow-up after DCR was 38 months (range, 10 to 65 months). Eight patients had leukemic infiltration of the LDS, 2 patients had B-cell lymphoma, and 1 patient had cutaneous T-cell lymphoma. Four patients had bilateral LDS involvement, and the remainder had unilateral disease (right eye, 1 patient; left eye, 6 patients). The most common initial presentation, in 9 patients (82%), was epiphora. Lacrimal irrigation of 2 LDS was deferred because of acute dacryocystitis. Of the remaining 13 systems, 8 were completely obstructed. The blockage was low (in the lower sac or in the nasolacrimal duct) in 6 systems and high (in the upper sac or common internal punctum) in 2 systems. Four LDS were anatomically patent to irrigation but were functionally obstructed. Chemotherapy was the primary treatment in 7 patients, whereas 4 patients underwent radiation therapy. Nine patients responded well to treatment, with alleviation of signs and symptoms, and none of these patients had local recurrence during the follow-up interval.

CONCLUSIONS

Leukemic or lymphomatous involvement of the LDS is an unusual cause of tearing in elderly patients, but it should be suspected in patients with known systemic disease. Treatment comprising multiple interventions improves the signs and symptoms of this complication of lymphoproliferative disorders in most patients.

[Perianal leukemic infiltration. Case report]

BACKGROUND

Leukemic infiltration of perianal skin (leukemia cutis) is quite uncommon, and may consist of no diffuse infiltration, erythema, ulceration, fistula, and abscess. Diagnosis may be established by biopsy and adequate hematologic studies. Treatment must be conservative in patients with poorly controlled disease (sitz baths, antibiotics, radiotherapy), and surgical in patients with risk of fulminant sepsis and death.

OBJECTIVE

To report a case of leukemic perianal infiltration with atypical ulcerated lesion.

CASE REPORT

Female patient, 21 years of age with diagnosis of AML M7, began with perianal pain posterior to evacuation associated with bleeding; at perianal examination we found anterior atypical ulcerated lesion. We carried out a biopsy under suspicion of leukemic infiltration corroborated by histopathology. The patient received conservative treatment.

CONCLUSIONS

We must suspect leukemic infiltration in patients with anal symptoms and effect close surveillance. Prognosis depends on control of hematologic disease.

Ocular manifestations of leukemia: leukemic infiltration versus infectious process

OBJECTIVE

To determine whether specific guidelines can be developed to distinguish whether retinal infiltration in leukemia patients represents infection or neoplasia.

DESIGN

Retrospective noncomparative interventional case series.

PARTICIPANTS

Six patients recently seen at University of California San Francisco with retinal infiltrates in a setting of leukemia, for which adequate written and photographic information of disease course was available.

INTERVENTION

Observation consisted of retrospective review of clinic charts, hospital medical records, and fundus photographs.

MAIN OUTCOME MEASURES

Determination of whether retinal infiltrates represented neoplasia or infection was made by review of medical records.

RESULTS

In this series, neoplastic retinal infiltrates were found in patients who had newly diagnosed leukemia and those who were in blast crisis. In contrast, the two patients who were in complete remission, but had undergone bone marrow transplantation, had retinal infiltrates attributable to infection.

CONCLUSIONS

Every patient with retinal infiltrates in the setting of newly or previously diagnosed leukemia requires a systemic and central nervous system workup before the initiation of ophthalmologic treatment. The systemic status of the patient is highly informative in determining whether infection or neoplasia is responsible for the infiltration.

Otological manifestations of acute leukaemia: report of two cases and review of literature

Otological manifestations exceptionally reveal acute leukaemia, whereas leukaemic infiltration of any tissue is frequent at postmortem examination. We present two cases of acute myeloblastic leukaemia revealed by a loss of hearing due to a middle-ear leukaemic infiltration. The characteristics of such a clinical and radiological finding are emphasized. It is suggested that middle and inner ear can be a 'sanctuary' localization, which might sometimes require radiation therapy to achieve durable and complete remission.

Central nervous system involvement in adult acute lymphocytic leukemia

With effective CNS prophylaxis, most adults with ALL may remain free of CNS leukemia. Several combinations of IT chemotherapy, high-dose systemic chemotherapy, and cranial irradiation have been used with varying results. Excellent prophylaxis can be achieved without cranial irradiation, and in view of the potential acute and long-term toxicity of radiation, these methods may be preferable. A prophylactic approach tailored to the risk of CNS leukemia was shown to be valuable in childhood ALL and in at least one adult study. Further studies should focus on defining risk groups for CNS leukemia and designing effective prophylaxis for each group. More research is needed to define the intensity and duration of treatment and the role of cranial irradiation in the treatment of isolated CNS relapses.

Successful graft-versus-leukemia effect of second bone marrow transplantation on relapsed leukemia cutis that was refractory to intensive chemotherapy and donor lymphocyte transfusions in a patient with acute monocytic leukemia

We report a patient with acute monocytic leukemia (AMoL; M5) who received a second bone marrow transplantation (BMT) with graft-versus-leukemia (GVL) effect on relapsed leukemia cutis, which had been refractory to intensive chemotherapy and donor lymphocyte transfusions (DLTs). A 21-year-old woman was diagnosed with AMoL and achieved complete remission after intensive chemotherapy. The patient received a nonmanipulated allogeneic BMT from her HLA-identical father. Skin tumors developed in her upper extremities, chest, and thigh 11 months after BMT. Leukemia cutis was confirmed by skin biopsy. There was no evidence of relapse in bone marrow. The patient received several courses of chemotherapy and DLTs for the skin relapse, but the skin tumors persisted. The patient then received a second BMT from the same donor. On day 80, grade II acute graft-versus-host disease developed, and the remaining skin tumors were eradicated on day 98, most probably because of GVL effect.

Cytotoxic T-cell lymphoma diffusely involving the entire gastrointestinal tract associated with Epstein-Barr virus and tubercle bacilli infection

We describe a rare case of cytotoxic gastrointestinal T-cell lymphoma with protein-losing enteropathy. Initial examination revealed the coexistence of T-cell lymphoma and tuberculosis in the mesenteric lymph node and liver. Despite anti-tuberculosis and anti-cancer treatment, the patient experienced chronic diarrhea and malabsorption and died approximately 3 years after onset. Autopsy specimens revealed medium-sized lymphoma cells, with a phenotype of CD3+, CD4-, CD7+, CD8+, CD30-, CD56-, CD103 (HML-1)-, TIA-1+, and granzyme B+, proliferating primarily and consistently in the mucosa of the entire bowel tract from esophagus to rectum. Interestingly, Epstein-Barr virus (EBV)-encoded small nuclear RNAs were detected in the tumors by in situ hybridization. Southern blot analysis revealed monoclonal proliferation in the EBV-infected T cells. Although the present case can possibly be categorized as an intestinal T-cell lymphoma according to the Revised European-American Lymphoma Classification, the case showed a unique clinical course and distribution of lymphoma cells. We present here an interesting case of gastrointestinal cytotoxic T-cell lymphoma and examine the possible association with infectious agents.

[Late sequelae of CNS recurrence of acute lymphoblastic leukemia in childhood]

Study objective was to evaluate retrospectively central nervous system (CNS) morbidity of children with acute lymphoblastic leukemia treated with intensive chemotherapy and cranial radiotherapy for a first isolated or combined CNS relapse. Neurological (Touwen), neuropsychological (CFT 20, Wechsler scales, d2 attention test) and neuromorphological (CT, MRI) assessments were performed in 17 children (9 girls, 8 boys) aged between 7 and 14 years. Patients were off therapy for median 4 years; cranial radiotherapy for CNS relapse (12-24 Gy) was given to all patients 2 to 9 years ago (median 5.5 years). Ten patients had received preventive cranial radiotherapy during front-line treatment, previously. In this group, the cumulative radiation dose ranged between 30 and 39 Gy. Patients received 12 to 30 intrathecal methotrexate doses (median 22). Compared with normative levels for age (100 points) performance IQ (89.9) and full scale IQ (92.0), Culture Fair IQ (88.3) and attention and concentration (90.9) were significantly impaired. Verbal IQ (95.5) was not significantly different from normal expectations. Neurological investigations of 16 patients showed mild signs in 7 (44%) of them, mostly of fine-motor skills and coordination, but no major motor disability. In MRI and CT, white matter changes or ventricular enlargement were noted in 10 of 16 patients (63%). Parent-completed questionnaires indicated problem behaviors in 5 children. Cumulative doses of methotrexate correlated significantly with neuropsychological test results. Children irradiated twice as well as girls had poorer cognitive functions, not being statistically significant. Despite pathological test results, all children attended a normal school and did not exhibit obvious impairment in daily life. In conclusion, CNS relapse and attendant therapy, mostly consisting of a second course of cranial radiotherapy, caused measurable intellectual deficits and CNS morbidity, which did not result in severely impaired performance. Periodic psychological und clinical examinations are recommended for recognition of delayed morbiditiy and early intervention.

Leptomeningeal involvement in chronic lymphocytic leukemia

PURPOSE

This review and case report address the rare complication of leptomeningeal involvement in patients with chronic lymphocytic leukemia.

OVERVIEW

Chronic lymphocytic leukemia is the most common form of leukemia, with more than 200,000 cases reported in the past 20 years. An uncommon complication of the disorder is central nervous system invasion. To date, only 21 cases have been reported, and their presenting symptoms have been heterogeneous and often nonspecific, including headache, cranial nerve abnormalities, confusion, ataxia, nausea, vomiting, and fever. The diagnosis is confirmed by the presence of a clonal population of lymphocytes in the cerebrospinal fluid. Treatment is either intrathecal or intraventricular chemotherapy with adjuvant radiation therapy or radiation alone. Prognosis is improved by prompt and aggressive therapy. In this case report, a 61-year-old man developed severe ataxia, vertigo, and occipital headaches 4 weeks after diagnosis with otherwise asymptomatic chronic lymphocytic leukemia. After treatment with both radiation to the head and neck and intrathecal methotrexate the patient achieved complete symptom resolution. Thus far, no additional systemic cytotoxic chemotherapy has been necessary.

CLINICAL IMPLICATIONS

Because central nervous system invasion is uncommon in chronic lymphocytic leukemia, it may go undiagnosed and under-reported. Providers of patients with this disease need to be aware of possible central nervous system invasion when patients present with cranial nerve signs or symptoms and/or nonspecific neurologic manifestations. Early identification and prompt central nervous system-directed chemotherapy can affect morbidity and quality of life positively.

Treatment of neoplastic meningitis by targeted radiation using (131)I-radiolabelled monoclonal antibodies. Results of responses and long term follow-up in 40 patients

Between 1984 and 1993, monoclonal antibodies (MAbs) radiolabelled with (131)I were administered into the CSF of 52 patients with neoplastic meningitis (meningosis) with progressive disease despite active conventional therapy. Selection of MAbs was based on immunoreactivity with patients' tumour and lack of binding to normal central nervous system (CNS) tissue. Following full clinical assessment and neuro-imaging which included isotope flow study of CSF pathways, (131)I-MAb was administered via a ventricular access device, lumbar catheter or both. Radioisotope activity varied from 25 mCi to 160 mCi in adults. Dose escalation was carried out and some patients received multiple doses. Distribution of (131)I-MAb and clearance kinetics were derived from serial scintigraphy and CSF/blood sampling. Evidence of localisation to tumour was frequently observed. Toxicity was minimal and easily treated, although one death occurred, possibly due to a seizure. The best results were obtained in primitive neuroectodermal tumour (n=22), where 53% of evaluable cases had responses and 11% had stable disease, adults responding better than children. Three exceptional survivals have been recorded; one patient leads a normal life at 10 years 11 months, one case is alive and normal at 3 years, 2 months. A third case survived in good condition for 8 years. The mean survival of responders was 39 months and non-responders 4 months. In the total series, 50% of patients survived for at least one year with 2 long term survivors. CSF therapy with (131)I-MAb appears to be valuable as a single agent or when used in combination with other modalities. Results of treating leukaemia and carcinoma cases suggest that re-seeding into the CSF compartment from active systemic disease may account for early relapse in the CNS. One carcinoma case with no apparent systemic disease made a remarkable response and survival for 4 years following a single treatment. Neoplastic meningitis generally carries a dismal prognosis. The results obtained in this initial trial are sufficiently encouraging to stimulate further attempts at CSF therapy with (131)I-MAbs.

Animal models of leptomeningeal metastasis

Animal models of leptomeningeal metastasis (LM) should give insight into pathophysiological mechanisms and allow to evaluate new treatments including their neurotoxicity. Syngeneic models use tumor cells of mouse, rat, rabbit or guinea pig origin. Allogeneic models usually rely on human tumor cells injected into nude mice or rats. A review of the literature revealed 2 (4) different glioma, 3 medulloblastoma, 3 (3) carcinoma, 3 (1) melanoma, 1 rhabdomyosarcoma, 2 (8) leukemia and 2 (2) non-Hodgkin's lymphoma allogeneic (syngeneic) models of LM. These models have been used to study the evolution of LM and to evaluate systemic or intrathecal chemotherapy, intrathecal immunotherapy (interleukin-2, interferon-beta, uncoupled, toxin- or radionuclide-conjugated antibodies), and recently gene therapeutic approaches. On the whole, pathophysiological, therapeutic and neurotoxic findings have been well transferable to the clinical situation. Therefore, it seems rational to preclinically test new treatments in an appropriate animal model of LM before using them in patients.

Risk of extramedullary relapse following allogeneic bone marrow transplantation for acute myelogenous leukemia with leukemia cutis

Leukemia cutis (LC) is a rare feature of acute myeloblastic leukemia (AML). Little information is available regarding its prognostic influence on post-transplant outcome. In our institution, 202 patients with AML received an allogeneic HLA-identical marrow transplant from related donors between March 1982 and January 1994. Thirteen patients had prior leukemic involvement of the skin (leukemia cutis or LC group) while 189 patients did not (non-LC group). There was a higher incidence of patients with the M4-M5 FAB subtypes in the LC group (83%) as compared to the non-LC group (33%). In addition, the percentage of patients transplanted in relapse was also higher in the LC group (69 vs 15%). While there were no differences observed in the rates of relapse post-transplant in the LC and non-LC groups when matched for stage of disease at transplant, the sites of relapse differed markedly. Five of six relapses in the LC group involved extramedullary sites as compared to only six of 38 relapses in the non-LC group (P = 0.002), with a 6-year probability of extramedullary relapse of 38.5% in the LC group as compared to 3.9% in the non-LC group. This increased probability of extramedullary relapse was independent of the FAB morphology (50 vs 2% for patients with the M4-M5 subtypes in the LC and the non-LC group respectively) and of disease status at the time of transplant. Moreover, only three relapses post-transplant involved the skin, all of which were in the LC group, with a probability of skin relapse of 23.1% in this group. Patients with AML and leukemia cutis have a remarkable propensity to relapse in extramedullary sites following marrow transplantation. These relapses occur in the skin as well as other organs. Further investigations are needed to understand the biological basis of this clinical feature.

Lymphocyte infusion for delayed extramedullary relapse of acute leukemia following bone marrow transplantation

We report a case of extramedullary relapse of acute myelogenous leukemia twelve years after allogeneic bone marrow transplantation. Due to the localized nature of the relapse, we were able to eliminate a majority of the tumor burden, utilizing local irradiation. Destined with eventual systemic leukemia relapse, further therapy utilizing donor lymphocytes was given at a time of minimal disease burden. The patient remains in a state of complete remission.

T cell-depleted allogeneic bone marrow transplantation from a partially HLA-mismatched unrelated donor for progressive chronic lymphocytic leukemia and fludarabine-induced bone marrow failure

A 49-year-old man with a 3-year history of chronic lymphocytic leukemia (CLL, stage B at diagnosis) responded well to four course of fludarabine, but developed marrow failure and prolonged pancytopenia lasting 9 months following the fifth course. Fludarabine therapy could not be continued due to pancytopenia, eventually resulting in disease progression. Bone marrow transplantation from an unrelated donor mismatched at one DRB1 locus and both DQB1 loci was performed as salvage therapy. The marrow was depleted of T cells with Campath-1G. Pre-transplant immunosuppression was enhanced with 600 cGy total lymphoid irradiation and Campath-1G infusions in addition to 120 mg/kg cyclophosphamide and 1200 cGy fractionated total body irradiation. Cyclosporine alone was used as post-transplant immunosuppression. Neutrophils reached 0.5x10(9)/1 on day 14 and platelets 50 x 10(9)/1 on day 40. No acute graft-versus-host disease was seen. Bulk disease detected on CT scanning prior to BMT was found to have disappeared 10 weeks after BMT. The marrow showed residual disease (5% CD5+/CD19+ cells) 9 weeks after transplantation, which had decreased markedly at 13 (0.5%) and 26 (0.4%) weeks. The patient is currently alive and well 10 months after BMT with no clinically detectable disease. We conclude that BMT from an unrelated donor is a feasible treatment option in advanced CLL.

[Multiple intracerebral granulocytic sarcomas in a patient with chronic myeloid leukemia]

The authors describe a young man with known chronic myeloid leukemia who sought medical attention after a first episode of seizure. The hematologic investigation revealed hyperleukocytosis without evidence of blastic transformation in peripheral blood or bone marrow. Numerous intracerebral nodules, characterized pathologically as granulocytic sarcomas, were demonstrated by computed tomography and magnetic resonance imaging (MRI). The appearance of a granulocytic sarcoma in chronic myeloid leukemia is unusual, and location of the lesion in the central nervous system is rare. Follow-up MRI after treatment showed almost complete regression of all lesions. The radiologic features of this case are discussed with reference to others reported in the literature.

Case report: CT and MRI demonstration of hypothalamic and infundibular relapse in childhood acute lymphoblastic leukaemia

The central nervous system is affected in up to 10% of patients with acute lymphoblastic leukaemia, usually in the form of leptomeningeal infiltration. Parenchymal spread is rare. We report a case in which CT and MRI demonstrated hypothalamic and infundibular relapse.

[Testicular relapse in acute lymphoblastic leukemia. The experience of a pediatrics service]

Testicular relapse in Acute Lymphoblastic Leukemia is a problem which has been developing more and more, as the therapeutic protocols of acute lymphoblastic leukemia are improving. Its appearance, specially during chemotherapy, makes the prognosis of the disease poorer. There have been some diagnostic methods, used in the screening of this situation. The use of more aggressive therapeutic protocols can lead to more encouraging results. The authors of the research present seven children with testicular relapse, which represent 17% of the total group of fourty one boys with acute lymphoblastic leukemia, treated at St. o Antonio Pediatric Ward. They analyse the time of onset, the diagnostic approach of the testicular lesion, the therapeutic protocols chosen for each case and the results.

The oral health of long-term survivors of acute lymphoblastic leukaemia: a comparison of three treatment modalities

Sixty-eight children who were diagnosed with acute lymphoblastic leukaemia (ALL) prior to age 5 years and treated with chemotherapy alone, chemotherapy plus 1800 cGy cranial irradiation (RT), or chemotherapy plus 2400 cGy RT were assessed clinically for overall dental health. All patients were at least 60 months in continuous remission. Dental caries were assessed by NIDR diagnostic criteria, oral hygiene was assessed by the modified Oral Hygiene Index, and gingival health was assessed by the modified gingival index of Loe and Silness. There was no significant difference in caries experience between the three groups nor with the normal population. Those patients that received 2400 cGy RT had significantly higher plaque and periodontal index scores than patients in the other treatment groups. The results of this study suggest that: (1) children with ALL treated with any of the described modalities are at no greater risk of developing dental caries than the normal population; and (2) patients receiving 2400 cGy prior to age 5 years are at greater risk of developing periodontal disease than patients treated with other central nervous system prophylaxis regimens examined in this study.

Prevention and treatment of meningeal leukemia in children

The prevention of meningeal leukemia has long been a keystone in its cure. The need was recognized when it became apparent in the 1950s and 1960s that meningeal relapse heralded hematologic relapse and a fatal course and that its incidence increased as systemic chemotherapy became more effective in controlling hematologic and visceral leukemia. Evasion of a biologic safety net, the blood-CSF barrier, is required to prevent meningeal leukemia. Three methods are used: meningeal radiotherapy, intrathecal administration of antileukemia drugs, and high-dosage intravenous antileukemia drugs. Recent and current clinical studies reflect a continuing dialogue about which methods are preferable and under what circumstances. For prevention of meningeal leukemia, extended intrathecal therapy and intensive systemic chemotherapy appear to be as effective as radiotherapy for most patients. For treatment of overt meningeal leukemia, meningeal radiotherapy may be necessary. However, its administration compromises subsequent systemic chemotherapy so that delay may be advisable to allow intensive systemic chemotherapy for control of concurrent hematologic and visceral leukemia, whether clinically evident or not. For patients with meningeal leukemia at diagnosis, cranial irradiation may be delayed or possibly omitted if evidence of disease is minimal and intrathecal and systemic chemotherapy are intensive. For those who develop meningeal leukemia while on therapy or after its completion, cranial or craniospinal irradiation is probably required as well as intensive intrathecal and systemic chemotherapy. Hopefully, current and future studies will dispel the uncertainties and better quantitate risks and benefits of alternative methods. Whatever method is used, careful attention to technical details is required to assure optimal efficacy at the least possible expense in immediate toxicity and late sequelae.

Successfully treated optic nerve infiltration with adult T-cell lymphoma

A 45-year-old woman with adult T-cell leukemia had a sudden onset of decreased vision with central scotoma in the right eye. Right optic disc edema and thickening of the optic nerve were observed by magnetic resonance imaging. A diagnosis of leukemic infiltration to the optic nerve was made. A course of oral corticosteroid therapy was prescribed and 40 Gy of radiation was administered to the whole brain and right orbit. Her visual acuity recovered from finger counting to 20/20 within 3 weeks. We believe that this patient represents the first report of successfully treated optic nerve infiltration with adult T-cell leukemia caused by human T-lymphotropic virus type-I infection.

Long-term sequelae of therapy for childhood acute lymphoblastic leukaemia

Childhood ALL has provided the model for basic therapeutic principles in the past and now provides the model for late effects studies. Common threads which run throughout the literature in this area of clinical research are the importance of young age with increased vulnerability to long-term treatment induced sequelae and the relatively large contribution of radiation as compared with chemotherapy in the pathogenesis of adverse sequelae. Previous retrospective studies of long-term childhood ALL survivors focused on neuropsychologic changes and anatomic changes in the CNS after cranial irradiation. More recent retrospective studies have made the following new observations: (i) the high frequency of significant short adult stature in those less than 6 years of age at diagnosis who received 24 Gy cranial irradiation; (ii) actuarial risk of 2.5% of developing a second malignancy with approximately one-half of secondary malignancies occurring in the CNS in children 5 years of age or less who received cranial irradiation; (iii) the association of secondary ANLL with epipodophyllo-toxin use, and (iv) delayed cardiac toxicity despite anthracycline dosage reduction. Current therapy regimens, especially in high-risk patients, are both more successful and more intensive than those used in the past. While it will be another decade before many of the long-term sequelae begin to emerge, one can anticipate, based on current experience, some of the problems that will occur.

Central nervous system directed therapy in acute lymphoblastic leukaemia

CNS-directed treatment is an essential component of therapy for both children and adults with acute lymphoblastic leukaemia. The choice between combinations of i.t. drugs, radiotherapy and high-dose systemic chemotherapy is not a clear one and will depend on the age of the patient, the type of leukaemia and indeed the available treatment facilities. A plea is made for any prospective trials of CNS-directed therapy to incorporate formal assessment of neuropsychological performance, and in the young child, of growth and pubertal progression.

Immunotoxin therapy of leptomeningeal neoplasia

Malignant tumors of the central nervous system can result from metastatic dissemination of a variety of cancers. Percutaneous intracisternal injection of an anti-idiotype monoclonal antibody (M6) ricin immunotoxin was shown to be moderately effective in prolonging the survival of tumor bearing animals supporting the use of immunotoxins for the treatment of central nervous system neoplasia (Zovickian J and Youle R.J. J. Neurosurg 68: 767, 1988). This report describes a method that significantly improves the survival of immunotoxin treated Strain 2 guinea pigs in a syngeneic animal model of leptomeningeal neoplasia. Strain 2 guinea pigs, implanted with subarachnoid catheters, received three courses of treatment with an (M6)-intract ricin immunotoxin following intracisternal inoculation of L2C leukemia tumor cells. Animals were treated with three to four micrograms of immunotoxin in three divided doses. This was found to be less toxic and more effective than single bolus administration of immunotoxin. These results demonstrate that a permanent indwelling catheter in this animal model facilitates multiple dose delivery of immunotoxin therapy allowing the assessment of various treatment schedules and the achievement of enhanced therapeutic effect. Furthermore, these results support the continued evaluation of immunotoxins for the treatment of central nervous system neoplasia.

Leukemic ophthalmopathy: a report of 21 pediatric cases

A multicentric retrospective study on leukemic ophthalmopathy (LO) is reported. It includes 21 patients, 16 males and 5 females, with acute leukemia (AL) observed in 10 SIOP centers. LO developed in three patients at the time of diagnosis of AL; five patients were in first complete remission (three off therapy); four patients were in second or third remission; and nine were in combined relapse. Most frequent symptoms were blurred vision, photophobia, and ocular pain. Two patients with acute nonlymphoblastic leukemia died before treatment; another underwent bone marrow transplantation; one patient with B-cell acute lymphoblastic leukemia (B-ALL) treated with chemotherapy and radiotherapy died 4 months after LO; the remaining 17 children were treated according to different schedules with (10) or without (7) radiotherapy on the affected eye. Twelve patients achieved ocular remission and four of these had a second ocular relapse. Complete remission after LO treatment lasting for more than 3, 7, 24, 29 months was observed in four patients. The authors conclude that cure is possible in patients who had LO in first complete remission treated with chemotherapy and radiotherapy at high dose on the affected eye.

Disseminated necrotizing leukoencephalopathy following irradiation and methotrexate therapy for central nervous system infiltration of leukemia and lymphoma

The authors report four adult patients with disseminated necrotizing leukoencephalopathy (DNL) following therapy for central nervous system (CNS) involvements of leukemia and lymphoma. Five to fourteen months after starting therapy with 30.6-62.5 Gy of whole brain irradiation and 120-500 mg of intrathecal methotrexate (MTX), DNL developed. Brain CT scans demonstrated a characteristic symmetrical white matter low density area. Furthermore, the brain CT scans disclosed tumorous lesions with contrast enhancement in three cases. In two of the three cases autopsy proved the tumorous lesions to be necrotic foci but not leukemic tumors. Post-mortem neuropathological studies of three patients disclosed characteristic features of DNL: multiple coagulative necrosis in the white matter with myelin degeneration, swollen axons, prominent calcification, and enlarged reactive astrocytes. Three of the four patients obviously received greater doses of whole brain irradiation and intrathecal MTX than patients who remained free from DNL after treatment with whole brain irradiation and/or MTX. Analysis of the etiological factors in this series underscores the prevailing danger of treatment for neoplastic CNS involvement with excessive doses of whole brain irradiation combined with intrathecal MTX.

High incidence of meningeal leukemia in lymphoid blast crisis of chronic myelogenous leukemia

Fifteen patients with lymphoid blast crisis of chronic myelogenous leukemia (LyBC-CML) and five patients with acute lymphoblastic leukemia converting to Philadelphia-positive (Ph+) chronic myeloid leukemia (ALL Ph + CML) were followed. Seven of 15 (46.7%) LyBC-CML patients developed meningeal leukemia within a median period of 6 months (range 2-11 months), while there was no medullary relapse. Five of these responded well to triple intrathecal therapy. In the ALL Ph + CML patients, in spite of central nervous system (CNS) prophylaxis with IT MTX and 18 Gy cranial radiation, two of five patients (40%) experienced meningeal leukemia, one isolated and the other with medullary relapse. The data confirm that LyBC-CML patients experience a high incidence of meningeal leukemia. The role of CNS prophylaxis is not very clear, but its use may delay development and reduce morbidity due to CNS disease.