Correlation of in vitro culture pattern and Q-banded karyotype in acute nonlymphocytic leukemia

Both cytogenetic abnormalities and in vitro growth patterns of leukemic cells have prognostic significance in acute nonlymphocytic leukemia (ANLL). The present study was undertaken to analyze the interrelationship between these two factors and response to therapy. Blast cells from 43 patients with de novo ANLL, four patients with secondary ANLL, and two patients with ANLL following a preleukemic phase were studied using both in vitro culture in methylcellulose and quinacrine chromosome banding techniques. In 19 patients with de novo ANLL, minimal growth in culture (≤ 5 colonies without prominence of small clusters) was noted (Pattern I). Blast cells from the remaining 24 patients formed numerous abnormal clusters and colonies in a continuum distribution (Pattern II). Sixty-three percent of Pattern I patients had completely normal karyotypes (NN). Only 29% of Pattern II patients were NN. No Pattern I patient had only abnormal karyotypes (AA), while 25% of Pattern II patients were AA (p<0.05). All six patients with secondary leukemia or leukemia following a preleukemic phase demonstrated both Pattern II growth and cytogenetic abnormalities. Fifty-six percent of Pattern I patients with de novo ANLL responded to chemotherapy, 35% of Pattern II patients responded, and 0% of patients with secondary or post-preleukemic ANLL responded. The correlation between the presence of cytogenetic abnormalities in leukemic cells and a pattern of excessive, abnormal growth in vitro coupled with the trend toward poor prognosis in these patients suggests that cytogenetically abnormal cells may have a proliferative advantage both in vitro and in vivo.     

外周血未染色大细胞计数在观察急性白血病疗效中的临床意义

目的：通过测定急性自血病患者外周血未染色大细胞（LUC）的数值,初步判断化疗效果。方法：分析急性白血病患者242人次骨髓组织中原始细胞数值与LUC的数值。结果：外周血LUC数与骨髓涂片中原始细胞、外周血中的幼稚细胞均呈正相关,灵敏度64％,特异度85％,ROC曲线下面积等于0．77。结论：通过检测外周血LUC可以对急性白血病患者疾病状态进行初步判断。     

急性髓系白血病患者预后分组方式的探讨

目的 评价原发、初治急性髓系白血病(AML)患者诱导治疗后不同时间骨髓幼稚细胞比例对预后的影响.将细胞遗传学与诱导治疗后不同时间骨髓幼稚细胞比例相结合,提出新的AML患者预后分组方法.方法 回顾性分析1999年1月1日至2008年2月1日于我院住院的原发、初治AML患者(非M3型)105例,所有患者在诱导化疗结束时(T1)和(或)骨髓抑制期(T2)进行骨髓穿刺检查.有细胞遗传学资料的患者97例.结果 (1)T1或T2时间点105例行骨髓穿刺检查的患者,骨髓幼稚细胞<0.05者和≥0.05者相比,T1时间点完全缓解(CR)率分别为86.0%、47.4%,3年无复发生存(RFS)率分别为46.2%、21.6%,3年总生存率分别为49.7%、25.6%.T2时间点二者CR率分别为86.3%、41.4%,3年RFS率分别为52.4%、18.9%,3年总生存率分别为61.1%、35.2%,差异均有统计学意义.且T1和,12时间点骨髓幼稚细胞比例具有相关性.(2)将染色体核型预后中等组患者根据T1或T2时间点骨髓幼稚细胞比例分为二组:骨髓幼稚细胞<0.05者和≥0.05者.前者预后与良好组相近,后者预后与不良组相近.(3)多因素分析表明T1或12时间点骨髓幼稚细胞比例是AML患者的独立预后因素.T1时间点骨髓幼稚细胞比例可能较T2时间点骨髓幼稚细胞比例意义更大.结论 以0.05为界,T1或T2时间点骨髓幼稚细胞比例是原发、初治AML患者(非M3型)CR率、RFS、总生存的独立预后因素.将染色体核型与T1和(或)T2时间点骨髓幼稚细胞比例相结合分组,可进一步区分中等组患者,有助于评估预后和选择治疗方案.     

Coexistence of myelodysplastic syndrome and untreated chronic lymphocytic leukemia with development of acute myeloid leukemia immediately after treatment of chronic lymphocytic leukemia

A 72-year-old man originally seen for anemia and thrombocytopenia was determined to have chronic lymphocytic leukemia (CLL). Bone marrow examination at the time of CLL diagnosis revealed a small but significant population of atypical blasts. Cytogenetic analysis of the bone marrow aspirate disclosed chromosomal abnormalities (-7, +8) suggestive of a myelodysplastic syndrome. Shortly after treatment of the CLL, there was proliferation of the previously noted blast population, which cytochemical studies demonstrated to be of the myeloid series thus indicating acute myeloid leukemia superimposed on CLL. This report presents microscopic, cytogenetic, immunophenotypic, and cytochemical evidence to document the evolution of acute myeloid leukemia in the bone marrow of a patient with CLL after one course of chemotherapy.     

Slow disappearance of peripheral blast cells: an independent risk factor indicating poor prognosis in children with acute lymphoblastic leukemia

The aim of this study was to find out whether the time required for disappearance of peripheral blast cells, or blast clearance, could be used to identify patients with a slow response to treatment associated with a poor prognosis of acute lymphoblastic leukemia (ALL). Our series consisted of 158 children with newly diagnosed ALL. The mean follow-up time was 69 months (range 22 to 140 months). Blast clearance was significantly associated with length of event-free survival. Only two of nine children with blast clearance greater than or equal to 2 weeks and 4 of 11 children with blast clearance of 11 to 13 days were in remission at the time of analysis as compared with 86 of 138 of the children with more rapid blast clearance. The respective 5-year event- free survivals were 17%, 36%, and 60% (P = .003). Multivariate analysis showed that the relative risk of death or relapse in patients with blast clearance of greater than 10 days was 5.2-fold (95% confidence limits 2.1 to 13.1) as compared with the others (P less than .001). Our results indicate that patients with a slow response to treatment can be identified by simple differential peripheral cell counts during the early induction phase well before or even instead of performance of a more invasive bone marrow aspiration.     

Bone marrow cellularity at day 14 is the most important predictive factor for response in patients with AML who require double‐induction chemotherapy: Analysis from a large,single institution experience

In patients with acute myeloid leukemia (AML), the presence of residual disease at day 14 after primary induction therapy warrants consideration of a second induction cycle. However, data to guide retreatment decisions in such patients are presently limited. Here, we retrospectively reviewed data from 176 patients with AML treated at our institution with a second induction chemotherapy regimen because of day 14 residual disease. Clinical variables and nadir bone marrow features were assessed for correlations with complete remission (CR) and overall survival (OS). In our patient group, 59% achieved CR after a second induction course. Median OS for the entire group was 12.40 months (95% CI, 9.90‐14.90) but 19.07 months (95% CI, 13.13‐25.01) for those who attained a CR. Nadir marrow hypocellularity (P < 0.001) at day 14, absolute blast reduction of >50% (P = 0.030), and de novo disease status (P = 0.018) were significantly correlated with CR achievement after re‐induction. Marrow hypocellularity at day 14 was the most significant predictor of CR on multivariate analysis (P < 0.001). Nadir marrow features did not independently correlate with OS when accounting for CR status. Re‐induction was successful in achieving CR in most patients. Study patients who did not achieve CR were more likely to have nonhypocellular marrows.     

55例老年人急性白血病治疗观察

目的针对老年人急性白血病治疗方法及化疗剂量选择的意见不一，探讨支持治疗、小剂量单药化疗及联合化疗的疗效及影响预后的因素。方法回顾性分析５５例老年急性白血病患者的治疗情况，统计其完全缓解（ＣＲ）率、生存期及影响因素。结果ＣＲ率：支持治疗组１２例，为０；小剂量单药组１７例，为１７．６％；联合化疗组２６例，为３８．５％。生存期：支持治疗组平均１３天，小剂量单药及联合化疗组分别平均５．９及６．２个月。结论仅用支持治疗疗效差，联合化疗的ＣＲ率高于小剂量单药化疗者，药物毒性无增加，但未能延长患者生存期。初诊时外周血幼稚细胞过高、血小板过低者ＣＲ率低。早期病死率高、放弃治疗者多，亦是影响ＣＲ率的因素。     

Prognostic Value of Early Response to Treatment Combined with Conventional Risk Factors in Pediatric Acute Lymphoblastic Leukemia

To determine useful prognostic factors in treating childhood acute lymphoblastic leukemia (ALL), we correlated conventional risk factors and bone marrow response 14 days after induction chemotherapy. Our study included 116 precursor B-cell (n = 104) and T-cell (n = 12) ALL patients treated with our protocol between 1988 and 1999. The patients were classified into 3 initial risk groups on the basis of conventional risk factors (56 in the low-risk, 33 in the high-risk, and 27 in the very high-risk groups). All patients received similar systemic chemotherapy regimens before the evaluation of their bone marrow on day 14. We evaluated the marrow of 69 patients as M1 (less than 5% blasts), 25 as M2 (5%-25% blasts), and 22 as M3 (more than 25% blasts). Although all patients attained an initial complete remission (CR), relapse was noted in 33 of the 116 patients, and 15 patients died. All of the M1 marrow patients, irrespective of the initial risk group, showed the best event-free survival rate (85.1% +/- 3 4.4%), the lowest relapse rate (14.5%), and the highest attainment of a second CR (100%); they were defined as the new R1 prognostic group. The low-risk patients with M2 or M3 marrow (R2 group) had a relatively high relapse rate, but all of these relapsed patients were treated successfully with subsequent therapy. High- or very high-risk patients with M2 or M3 marrow (R3 group) had the worst prognosis. Our new prognostic definition (R1, R2, R3) incorporating day 14 marrow findings is useful to tailor early-phase treatments for better therapeutic results in childhood ALL.     

Acute Myelodysplasia with Myelofibrosis: a Report of Eight Cases

S ummary . Eight patients with acute myelodysplasia and myelofibrosis are described. Four cases were secondary to long-term therapy with cytotoxic agents and four were idiopathic. All cases presented with an abrupt onset of the illness, absence of organomegaly and severe pancytopenia. Bone marrow aspirate yielded adequate material in four cases and showed myelodysplasic features. Study of histological sections indicated that the bone marrow was cellular in every case, including numerous dystrophic megakaryocytes, erythroblasts, immature cells of the granulocytic series and blast cells which were difficult to identify. The reticulin network was always increased. In each case the disease was rapidly fatal. No improvement was noted with chemotherapy. In three cases an overt leukaemia developed with marked pleomorphism of blast cells. The nosology of this syndrome is discussed.     

Prediction of outcome by early bone marrow response in childhood acute lymphoblastic leukemia treated in the ALL-BFM 95 trial: differential effects in precursor B-cell and T-cell leukemia

Background

In the ALL-BFM 95 trial for treatment of acute lymphoblastic leukemia, response to a prednisone pre-phase (prednisone response) was used for risk stratification in combination with age and white blood cell count at diagnosis, response to induction therapy and specific genetic high-risk features.

Design and Methods

Cytomorphological marrow response was prospectively assessed on Day 15 during induction, and its prognostic value was analyzed in 1,431 patients treated on ALL-BFM 95.

Results

The 8-year probabilities of event-free survival were 86.1%, 74.5%, and 46.4% for patients with M1, M2, and M3 Day 15 marrows, respectively. Compared to prednisone response, Day 15 marrow response was superior in outcome prediction in precursor B-cell and T-cell leukemia with, however, a differential effect depending on blast lineage. Outcome was poor in T-cell leukemia patients with prednisone poor-response independent of Day 15 marrow response, whereas among patients with prednisone good-response different risk groups could be identified by Day 15 marrow response. In contrast, prednisone response lost prognostic significance in precursor B-cell leukemia when stratified by Day 15 marrow response. Age and white blood cell count retained their independent prognostic effect.

Conclusions

Selective addition of Day 15 marrow response to conventional stratification criteria applied on ALL-BFM 95 (currently in use in several countries as regular chemotherapy protocol for childhood acute lymphoblastic leukemia) may significantly improve risk-adapted treatment delivery. Even though cutting-edge trial risk stratification is meanwhile dominated by minimal residual disease evaluation, an improved conventional risk assessment, as presented here, could be of great importance to countries that lack the technical and/or financial resources associated with the application of minimal residual disease analysis.     

Daunomycin,cytosin-arabinoside and VP-16 (DAV) for myeloid blast crisis of CML

Summary Nine patients with myeloid blast crisis of Philadelphia chromosome-positive chronic myelocytic leukemia received 1–3 courses of intensive induction chemotherapy with DAT (daunomycin, cytosin-arabinoside and 6-thioguanin) or DAV (daunomycin, cytosin-arabinoside and VP-16). Eight patients responded with clearing of blasts from peripheral blood giving a response rate of 89%. However, bone marrow aplasia with less than 5% blasts was seen in only 2 patients. These 2 patients subsequently received an allogeneic bone marrow transplant and achieved complete remissions of 3 and 6 month duration. All patients died due to progression of blast crisis. Median survival of the group was 164 days. These results were compared to a historical control group of 31 patients with myeloid blast crisis treated with vincristine and prednisone. Despite a significantly better response rate with DAV or DAT (8 of 9 versus 9 of 31, p=0.01) survival was not significantly different than that of the control group.     

Myeloid leukaemic cells can lyse fibrin directly

Purified preparations of circulating leukaemic blast cells from patients with acute myeloid (M1-7) or acute lymphoblastic leukaemia, and the myeloid or lymphoid cells from patients with chronic myeloid or lymphocytic forms of leukaemia, were incorporated into clots prepared from fibrinogen and plasminogen. Patterns of lysis were followed and measured by light transmission in a microtitre plate reader. Mature polymorphonuclear and mononuclear cell fractions from normal individuals were studied concurrently for comparison. Blast cells from the myeloid forms of acute leukaemia (M2-4) and 'myeloid' cell fractions from patients with chronic myeloid leukaemia were capable of lysing plasminogen-containing clots; this activity was neutralized by addition of immunoglobulin against urokinase plasminogen activator (u-PA), but not by anti-tissue plasmogen activator (t-PA). Mature polymorphonuclear and mononuclear cells from normal individuals lacked lytic activity, as did the leukaemic cells from patients with acute lymphoblastic or chronic lymphocytic leukaemia. Lysed blast cells showed the presence of free plasminogen activator on sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) with overlay zymography, also neutralized by anti-u-PA, whereas normal polymorphonuclear and mononuclear cells did not. These observations suggest that mechanisms underlying some forms of severe bleeding in acute myeloid leukaemias have a critical fibrinolytic component generated by the blast cells themselves.     

Clinical relevance of immunological dissection in T-ALL: a report on 20 cases with stem cell (CD7+, CD4-, CD8-, CD1-) phenotype.

In a prospective study on 44 cases of T-cell origin acute lymphoblastic leukemia, 20 patients were found to display an immature immunophenotype (CD7+, CD4-, CD8-, CD1-) and were classified as T-stem cell leukemia (T-SCL). Twenty-four patients expressed CD4 and/or CD8 antigens on their blast cells, designated T acute lymphoblastic leukemia (T-ALL). The T-SCL subset showed a significantly higher median age, a more frequent incidence of extramedullary leukemia, a morphology L1 in most cases, and a poor response to treatment in terms of either complete remission rate or median survival duration. In addition, significant differences between the two groups were found in evaluating the number of days of blast disappearance from peripheral blood, of CR achievement, and of neutrophils and platelets recovery. We conclude that T-SCL represents a distinct clinical entity, characterized by a poor response to ALL conventional chemotherapy. Alternative therapeutic approaches should be developed for patients suffering from this form of leukemia, to modify its severe prognosis.     

Cryptosporidiosis in patients with hematologic malignancies

The clinical features of cryptosporidial infection in 20 patients with hematologic malignancies were assessed. Five patients had severe diarrhea, 10 had moderate diarrhea, and five were asymptomatic carriers of Cryptosporidium. Extraintestinal cryptosporidiosis with pulmonary involvement was observed in one case and relapse of cryptosporidiosis in four. All but one patient recovered from cryptosporidiosis whether or not spiramycin was administered. Cryptosporidiosis in T cell-depleted recipients of allogeneic bone marrow transplants did not appear more severe than that in patients undergoing autologous bone marrow transplantation or conventional chemotherapy.     

Dexamethasone in the treatment of meningeal leukemia

To determine if dexamethasone has a role in the treatment of meningeal leukemia, 8 consecutive patients with acute lymphoblastic and signs or symptoms of CNS were included in the study. After the confirmation of leukemic blast cells on cerebrospinal fluid, they received intrathecal and IV dexamethasone; 3 days later the patients received “triple” intrathecal chemotherapy with dexamethasone, methotrexate and cytarabine, and the spinal fluid was studied again. All patients had good clinical response and 7 out of the 8 patients showed reduction on the CSF cell count after the use of dexamethasone alone. The results suggest that dexamethasone is a lympholytic agent that could play a more active role in the prevention and therapy of meningeal leukemia and should be preferred over hydrocortisone in the so called “triple” intrathecal chemotherapy for the prevention and treatment of CNS leukemia. © 1995 Wiley-Liss, Inc.     

Platelet-derived growth factor (PDGF) in human acute myelogenous leukemia: PDGF receptor expression, endogenous PDGF release and responsiveness to exogenous PDGF isoforms by in vitro cultured acute myelogenous leukemia blasts

We investigated effects of Platelet-derived growth factor (PDGF) and Platelet factor 4 (PF-4) on the functional characteristics of native, human acute myelogenous leukemia (AML) blasts. AML blast expression of the PDGF-receptor alpha-chain was detected for a subset of patients (45%), whereas PDGF-receptor beta-chain expression was detected for most patients (90%). Constitutive AML blast release of the PDGF-AB isoform (the major form also derived from normal platelets) was detected for 43% of patients, whereas PDGF-BB release was not detected for any patient. The PDGF isoforms AA, AB and BB had dose-dependent and divergent effects on spontaneous and cytokine-dependent AML blast proliferation, whereas for constitutive cytokine secretion (IL-1beta, IL-6, TNF-alpha) inhibitory effects were rare and all three isoforms usually had no effect or enhanced the constitutive secretion. The PDGF effects were caused by a direct effect on the AML blasts and were not dependent on the presence of serum. The PDGF effects could also be detected after in vitro culture of AML cells in the presence of IL-4+granulocyte-macrophage colony stimulating factor. PF-4 had divergent effects on proliferation and cytokine secretion by native AML blasts. Our results suggest that exogenous (e.g. platelet-secreted) PDGF and PF-4 can function as regulators of leukemic hematopoiesis and possibly also modulate the function of residual AML cells in peripheral blood stem cell grafts. On the other hand, endogenous release of PDGF-AB by native blasts may modulate the function of normal cells in the bone marrow microenvironment (e.g. bone marrow stromal cells).     

High-dose cyclophosphamide, carmustine, and etoposide followed by autologous peripheral stem cell transplantation for patients with relapsed Hodgkin's disease.

Between February 1986 and March 1990, 56 patients with relapsed Hodgkin's disease treated with high-dose cyclophosphamide, carmustine, and etoposide (CBV) received an autologous peripheral stem cell transplantation (PSCT) rather than an autologous bone marrow transplantation (ABMT) because each patient had a marrow abnormality, either hypocellularity or tumor involvement. At least 6.5 x 10(8) [corrected] mononuclear cells/kg patient weight were collected from the peripheral blood of each patient, cyropreserved, and returned intravenously following CBV administration. Three patients had an early death 2, 22, and 25 days after PSCT. The actuarial event-free survival for these 56 patients at 3 years was 37% and was at least as good as that reported for relapsed Hodgkin's disease patients treated with CBV and ABMT. The 30 patients who had no marrow metastases at the time of PSC harvesting had an actuarial event-free survival of 47%, while those 26 patients with marrow metastases had a significantly different actuarial event-free survival of 27% (P = .02). CBV and PSCT for patients with relapsed Hodgkin's diseases who have marrow hypocellularity in traditional harvest sites or histopathologic evidence of BM metastases can result in long-term event-free survival.     

Human malignancy-associated nucleolar antigen as a marker for tumor cells in patients with acute leukemia

Tumor burden in adult patients with acute leukemia is assessed using the percentage of blast cells in the bone marrow or blood. It is clear, however, that not all blast cells are leukemic cells, especially during rapid marrow regeneration. Similarly, some leukemia cell lines have been shown to differentiate in vitro, and the same process also occurs in vivo. Therefore, the leukemic burden may be due to more differentiated cells as well as to blast cells. The purpose of this study was to investigate whether the human malignancy-associated nucleolar antigen (HMNA) could be used as a marker for leukemic cells and to examine its potential as a diagnostic tool. The proportion of HMNA-positive cells in the bone marrow of patients with acute leukemia was determined by indirect immunofluorescence with antibodies to HMNA and was compared with the differential counts routinely made in the clinic laboratory. The percentages of HMNA-positive cells among the nucleated cells in the marrow of 72 patients with clinical evidence of leukemia were significantly higher (range 9%-98%, median 83%) than those observed for nonleukemic individuals (range less than 0.05%-2.5%, median 1%) or for fractions of marrow cells from normal volunteers enriched for normal early progenitor cells (less than or equal to 2%). Patients with leukemia in remission had a lower percentage of HMNA- positive cells (range 0%-83%, median 3%). The percentage of HMNA- positive cells increased as patients approached relapse. Although the percentage of HMNA-positive cells was related to the percentage of blast cells in the bone marrow of the patients with leukemia, some partially differentiated cells were also HMNA-positive in some specimens, and some blastic cells were HMNA-negative in other specimens. These studies indicate the potential usefulness of HMNA as a marker for leukemic cells.     

Prognostic significance of surface marker analysis in childhood non-hodgkin's lymphoproliferative malignancies

Blast cell surface markers for T- and B-lymphocyte characteristics were studied at diagnosis in 73 children with non-Hodgkin's lymphoproliferative malignancies. Three distinctive groups of patients were identified on the basis of the analysis of blast cells for surface immunoglobulin (SIg), sheep erythrocyte (sE) rosette formation, and complement receptors. The seven group I patients had monoclonal IgM on their blast cells, morphologic features of Burkitt's lymphoma, abdominal masses, and very short survival. The 13 group II patients had receptors for sE, complement, or both on their blast cells, mediastinal or nodal masses, and short survival. The distinction between leukemia and lymphoma based on the presence of bone marrow involvement at diagnosis is not prognostically useful in this group of patients. The blast cells of group II patients could not be morphologically distinguished from those of the group III patients. The 53 group III patients had SIg, sE, and complement negative blast cells and could be further subdivided on the basis of white blood cell count. The nine group III_A patients (> 100.0 × 10⁹/liter) had in general short survival, while most of the 44 group III_B patients (< 100.0 × 10⁹/liter) have remained in complete remission. Positive surface markers, mass lesions, male sex, and age of diagnosis < 2 years or ≧ 10 years appear to be interrelated factors indicating poor prognosis. Elevated white blood cell count is a prognostic indicator independent of surface marker analysis or presence of mass lesions.