Flow cytometric DNA index, G-band karyotyping, and comparative genomic hybridization in detection of high hyperdiploidy in childhood acute lymphoblastic leukemia

High hyperdiploid acute lymphoblastic leukemia in children is related to a good outcome. Because these patients may be stratified to a low-intensity treatment, we have investigated the sensitivity of flow cytometry (FCM), G-band karyotyping (GBK), and high-resolution comparative genomic hybridization (HR-CGH) in detecting high hyperdiploid leukemic clones. Twenty-six girls and 34 boys with acute lymphoblastic leukemia diagnosed in 1998 to 1999 were analyzed by FCM, GBK, and HR-CGH. The correlations between DNA indices obtained by FCM, GBK, and HR-CGH were significant (rs=0.61 to 0.77; P<0.001 for all comparisons). However, in 4 of 18 patients, high hyperdiploidy was overlooked by GBK or HR-CGH, and even when FCM was applied, 2 of 18 patients with high hyperdiploidy by GBK and/or HR-CGH were classified as nonhigh hyperdiploid. If high hyperdiploid subclones were included, FCM could detect all high hyperdiploid patients found by either GBK or HR-CGH, but would then in addition classify 15% to 20% of the remaining patients as high hyperdiploid. Thus, both GBK and HR-CGH overlook patients with high hyperdiploidy, and FCM only detects all high hyperdiploid patients if small high hyperdiploid clones are included. In addition, FCM detects patients with high hyperdiploid subclones, not detected by either GBK or HR-CGH, and the challenge remains to determine the prognosis of patients with such high hyperdiploid subclones.     

The Munich study on the treatment of acute lymphoblastic leukemia in childhood (ALL 77-02)

149 children with acute lymphocytic leukemia (ALL) were admitted to a prospective therapeutic regime. Remission induction was achieved by vincristine, daunorubicine, L-asparaginase and prednisone. During consolidation the patients received three intermediate dose methotrexate (MTX) infusions over 24 hours combined with intrathecal MTX, followed by L-asparaginase. High-risk patients were treated in addition with high dose cyclophosphamide and ARA-C over 3 weeks. Standard risk patients received cranial irradiation with 18 Gy, high-risk patients with 24 Gy. Maintenance therapy was performed with 6-mercaptopurine and MTX orally. Immunologic phaenotyping revealed: c-ALL 73%, pre-T or T-ALL 15%, c/T-ALL 4% and undifferentiated leukemia (AUL) 8%. Only 1 patient was nonresponder, 7 patients died during induction therapy, 5 patients during continuous complete remission (CCR). 18 relapses occurred, 12 of which were systemic, 8 CNS and 2 testicular relapses. In the total group the 54 months probability of CCR is 0,68 +/- 0,05 (life-table-analysis), for the reduced group 0,75 +/- 0,05. In the reduced group the probability of CCR at 54 months for standard risk patients is 0,86 +/- 0,06; for high-risk patients 0,60 +/- 0,09; for patients with c-ALL 0,73 +/- 0,08; for patients with c/T-ALL 1,0 +/- 0,0; for patients with pre-T or T-ALL 0,58 +/- 0,2 and for patients with AUL 0,45 +/- 0,25. For the reduced group the CCR probability at 54 months in relation to the leukocytes (WBC) at diagnosis is in patients with WBC less than 25 X 10(3)/mm3: 0,80 +/- 0,06; for patients with WBC greater than 25 X 10(3)/mm3: 0,63 +/- 0,11.     

Chemotherapy with cyclophosphamide, vincristine, cytosine arabinoside, and prednisone (COAP) in childhood acute lymphoblastic leukemia (ALL).

Three groups of children with acute lymphoblastic leukemia (ALL) were treated with intermittent cyclophosphamide, vincristine, cytosine arabinoside, and prednisone (COAP). Group A (no prior relapse) and Group B (prior single-agent relapse) received COAP after 12 months on another chemotherapy regimen. Children in Group C (prior relapse on multiagent regimens) received COAP following A-COAP (asparaginase plus COAP) reinduction. Median disease-free survival after beginning COAP was not reached for Group A, but was only 7 months for Groups B and C. As of November 1976, there were 8 of 15 Group A patients, 1 of 12 Group B patients, and 1 of 28 Group C patients who had remained disease-free from 38 to 60 (median 54.5) months and were off chemotherapy. COAP has activity in childhood ALL. However, effectiveness is markedly diminished in patients with prior bone marrow relapse.     

In vitro effect of antitumor drugs on lymphocytic blastogenesis in childhood acute lymphoblastic leukemia (ALL) and non-Hodgkin's lymphoma (NHL).

"In vitro" sensitivity of lectin (PHA, Con A)-stimulated lymphocytes to antitumor drugs (ARA-C, ADR, VM26, MTX, CP, VCR, Vepesid, ACLA) and the clinical efficiency of the complex therapy was compared in 7 patients with ALL and 2 patients with NHL. H3-thymidin incorporation of lymphocytes labelled prior to the drug exposure was used as "in vitro" method. A fairly good correlation was found between the "in vitro" test and the clinical response to the drug administered. These results suggest that this "in vitro" test is useful in choosing the drugs to be administered in case of malignancies of children.     

伴有t(12;21)易位的儿童急性淋巴细胞白血病的临床和实验研究

目的　研究我国儿童急性淋巴细胞白血病 (ALL)中伴有t(12 ;2 1)易位者的发生率及其临床、免疫学和预后的特征。方法　采用套式逆转录聚合酶链反应 (RT PCR)技术检测TEL AML1融合基因转录本 ,联合染色体R带核型分析和流式细胞仪免疫表型分析等方法。结果　在 5 5例儿童ALL(B系ALL 40例 ,T系ALL 13例 ,T、B系双表达ALL 2例 )中共发现 8例 (2 0 % )B系ALL有TEL AML1融合基因转录本 ,证实有t(12 ;2 1)易位存在。治疗后 8例均获完全缓解 (CR) ,随访至 1999年 5月 ,均在CR中 ,无一例复发。结论　t(12 ;2 1)B系ALL是儿童ALL中最多见且预后较好的一种亚型。RT PCR检测TEL AML1融合基因转录本是诊断t(12 ;2 1)ALL和监测其微小残留病最敏感有效的方法。     

Incidence of childhood acute lymphoblastic leukemia (ALL) and population-based treatment results in Switzerland: Experiences with 507 study and 149 nonstudy patients

Of 656 patients with ALL (all types) diagnosed in Switzerland during 4 consecutive 4-year periods (1976–1979, 1980–1983, 1984–1987, 1988–1991), 507 were officially registered on protocols (“study” patients) while 149 were not (“nonstudy” patients). The mean incidence of 3.8/100,000 children <15 years/year is higher than reported for other Western countries. Evidence is presented suggesting that the 656 patients represent only approximately 90% of all children with ALL residing in Switzerland, indicating that the true incidence of ALL might even be higher. The fraction of “nonstudy” patients fell from 40% (1976–1979) to 15% (1984–1987). The rate of survival at 4 years of all patients with ALL (“study” and “nonstudy”) increased by 17% during the three consecutive periods 1976–1979, 1980–1983, and 1984–1987. As expected, a higher increase (20%) was observed in “study” patients and a statistically nonsignificant lower one (10%) in “nonstudy” patients. © 1995 Wiley-Liss, Inc.     

Corticosteroid-dependent reduction of leukocyte count in blood as a prognostic factor in acute lymphoblastic leukemia in childhood (therapy study ALL-BFM 83)

In therapy study ALL-BFM 83 a total of 630 patients with acute lymphoblastic leukemia (ALL) have prospectively been evaluated for initial response on therapy with corticosteroids. It was the aim to qualify the in vivo cytoreduction as a new predictor for therapy failure. All patients were exposed for 7 days to prednisone before combination chemotherapy at day 8 has been started. At day 0 one additional dose of Methotrexate was given intrathecally. Therapy for all patients with non-B-ALL has been stratified according to initial tumor burden (risk factor) providing four therapy branches: standard risk low (SR-L), standard risk high (SR-H), medium risk (MR), high risk (HR). After a median duration of study of 21 months, event-free survival (EFS) is for all 630 patients 73%, 81% for SR-L, 76% for SR-H, 69% for MR, and 35% for HR patients (date of evaluation Jan. 1, 1987). In this prospective study, a small subgroup of patients (n = 48; 7.6% of total group) is characterized by greater than 1000 leukemic blasts/mm3 peripheral blood at day 8 after exposure to prednisone. In this subgroup the EFS is only 43% in contrast to 76% in the complementary group of 582 patients with less than 1000 leukemic blasts/mm3 peripheral blood at day 8. Patients of that risk group are derived from therapy branches SR-H, M and HR, the latter contributing relatively most patients. In this negatively selected group all patients with an initial high white blood count, CNS disease at diagnosis, immune subtypes as prae-T-ALL (n = 6), T-ALL (n = 18), null-ALL (n = 5), and males clearly dominate. Of 48 patients with greater than 1000 blasts/mm3 at day 8 4 subsequently failed to enter remission and 8 were qualified as lateresponders. 18 patients relapsed, most of them earlier compared to those of the complementary group. The initial in vivo response on corticosteroid therapy is considered a supplementary prognostic predictor for early failure. It will be utilized in trial ALL/NHL-BFM 86 to qualify patients at the highest risk for relapse. This group of patients is supplemented in addition by non- and lateresponders and children with acute undifferentiated leukemia (AUL). The in vivo corticosteroid test is simple, generates early and reliable results and can be obtained almost always. Thus it may be recommended for use in a multicenter trial.     

DNA index and %S-phase cells determined in acute lymphoblastic leukemia of children: A report from studies ALL V,ALL VI,and ALL VII (1979–1991) of the dutch childhood leukemia study group and the Netherlands workgroup on cancer genetics and cytogenetics

DNA per cell content was routinely recorded by single-parameter flow cytometry in leukemic blasts from 473 children with acute lymphoblastic leukemia (ALL), enrolled in national studies ALL V, VI, and VII (1979–1991) of the Dutch Childhood Leukemia Study Group. The parameters bonemarrow %S-value and DNA Index were compared with clinical features, with chromosome number based on cytogenetic analyses and with treatment results in study ALL VI. %S-values, ranging between 1 and 36%, were unrelated to initial white blood cell count, immunophenotype, and DNA index but were lowest in blasts with L1 morphology. In study ALL VI (non-high risk), the survival of patients with ≦6% S-phase cells was superior to that of patients with %S-values of >6 (P = 0.030). Hyperdiploidy, defined by a DNA index ≧1.16, was compared to the cytogenetic hyperdiploid classification of n > 50. Initially there were 25 discrepancies in 189 samples jointly analysed by flow cytometry and cytogenetics. After review only five discrepancies remained unresolved. Hyperdiploidy, independent of the method used, was found to be unrelated to blast morphology and %S-phase cells but closely associated with c-ALL and was absent in T-ALL. In study ALL VI, event-free survival at 8 years of hyperdiploid patients was 90.6% but was not significantly different from non-hyperdiploid patients (EFS = 82.1%; P = 0.08). Routine DNA flow cytometry appeared a valuable adjunct to cytogenetic analyses and allowed the identification of a large subset of non-high-risk ALL patients in study ALL VI with a DNA index ≥1.16 or %S-value of ≦6.0 with highest survival probability. © 1995 Wiley-Liss, Inc.     

ALL therapy study 1971-1974 of the German working group for leukemia research and therapy in childhood: prognostic significance of initial features and different therapeutic modalities (author's transl)]

495 children and adolescents with acute lymphoblastic leukemia entered a non-randomized therapy study between January 1st, 1971, and December 31st, 1974. They were treated at 40 pediatric clinics in the Federal Republic of Germany according to the protocol of the Deutsche Arbeitsgemeinschaft für Leuk?mieforschung und -Behandlung im Kindesalter, which was closely adapted to the Memphis protocol VII. These patients were analyzed retrospectively, data of evaluation was July 31st, 1978. 7 patients (1.4%) did not achieve remission, 14 patients (2.8%) died during the induction period, and another 37 patients (7.5%) died in continuous complete remission (CCR). For purposes of comparison only the remaining 437 patients were evaluated (remission group). The 7 1/2 years' probability of CCR is 0.33 +/- 0.02 for the total group (495 patients) and 0.37 +/- 0.03 for the remission group. The probability of survival for these groups is 0.40 +/- 0.03 and 0.45 +/- 0.03, respectively. After relapse the 5 years' probability of survival is 0.03 +/- 0.02. Patients with testicular relapse have a markedly better prognosis compared to those with bone-marrow or central nervous system relapses. The most important prognostic factor was found to be the white blood count at diagnosis. There is a negative correlation between the initial white blood count and the probability of CCR. Girls fared significantly better than boys (0.46 +/- 0.04 vs 0.31 +/- 0.03 in CCR, p less than 0.01). There is convincing evidence that the impaired prognosis in boys is at least partly due to the incidence of testicular relapses (36 of 268 relapses were found to be testicular, isolated in 20 patients and combined with bone-marrow relapse in 16 patients). Patients with thymic involvement and/or positive reaction of the acid phosphatase in their blast cell did significantly worse (0.12 +/- 0.05 in CCR). Irradiation of the skull was performed in two different doses (1800 and 2400 rads). Concerning the incidence of relapses primarily located in the central nervous system patients with low-dose irradiation had no worse prognosis than those with high-dose irradiation but the incidence of bone-marrow relapses was found to be higher in the 2400 rad group (50.5% vs. 41.7% in the 1800 rad group), possibly due to the higher initial white blood count (median 8900/mul vs. 6500/mul). The addition of vincristine/prednisone reinduction courses during the first year of continuation therapy showed no significant advantage.     

Effectiveness of rubidomycin in induction therapy with vincristine, prednisone, and L-asparaginase for standard risk childhood acute lymphocytic leukemia: results of a Dutch phase III study (ALL V). A report on behalf of the Dutch Childhood Leukemia Study Group (DCLSG)

The Dutch Childhood Leukemia Study Group (DCLSG) performed a phase III study-Study (ALL) V-to evaluate the effectiveness of rubidomycin in induction therapy with vincristine, prednisone, and L-asparaginase for children (0-15 years) with standard risk acute lymphoblastic leukemia (ALL) (white blood cell [WBC] counts less than 50.10(9)/L, absence of mediastinal mass, and/or cerebromeningeal leukemia). Furthermore, the influence of initial patient and disease characteristics on the outcome was analyzed. Between May 1979 and December 1982, 240 patients entered the study and were randomized into two groups: group A (n = 122) received induction treatment with vincristine (VCR), prednisone (Pred), and L-asparaginase (L-Asp); for group B (n = 118), induction therapy consisted of VCR, Pred, L-Asp, and rubidomycin (Rub). All patients subsequently underwent cranial irradiation (doses adjusted to age) in combination with intrathecal methotrexate; maintenance therapy of 6-mercaptopurine and methotrexate for 5 weeks followed by vincristine and prednisone for 2 weeks was given for 24 months. The complete remission (CR) rate was similar in both groups (94.5%). Event-free survival (EFS) 5 years after diagnosis was higher in group B (62.5 +/- 4.5%) than in group A (54.7 +/- 4.5%), although the difference is not significant (p = 0.20). A high initial WBC (greater than or equal to 10.10(9)/L), age (greater than or equal to 10 years), a low platelet count (less than 100.10(9)/L), and a positive acid phosphatase reaction of the leukemic cells were unfavorable prognostic factors (p less than 0.05). Sex, French-American-British (FAB) classification group, immunophenotype, and treatment in specialized centers did not have a significant impact on event-free survival.