全身(全淋巴)照射后100例医源性急性放射病的临床分析

在造血干细胞移植治疗肿瘤过程中用全身照射（ＴＢＩ）或全淋巴照射（ＴＬＩ）预处理，研究受照不同剂量患者发生医源性急性放射病严重程度，治疗方法和造血恢复及相关合并症。方法１００例患者（白血病９１例，其他肿瘤９例）接受５００～１０００ｃＧｙＴＢＩ或ＴＬＩ和超大剂量化疗作预处理。结果均发生医源性急性放射病，白细胞降至（０～０．１５）×１０９／Ｌ，骨髓空虚，合并各种感染和出血。经造血干细胞移植，抗感染，应用ＧＭ－ＣＳＦ或Ｇ－ＣＳＦ积极支持治疗及保护隔离措施，９２例造血恢复，８例死于不同感染和出血。结论造血干细胞的移植起主要治疗作用，不同造血因子用于治疗急性放射病，可能是一种有希望的方法     

"Preventive" cranial irradiation in acute lymphoblastic leukemia in childhood]

In accordance with the recommendations of Pinkel, 147 children with acute lymphoblastic leukemia were treated by a combined cytostatic and radiation therapy during a joint study between May 1971 and Jan. 1, 1974. After a primary cytostatical treatment which brought about a remission of 94% of the patients within four to six weeks, the cranial irradiation was performed, depending on age, with a focal dose of 1500 up to 2400 rd in the course of three or four weeks. Simultaneously, the patients were given methotrexate intrathecally which was followed, later on, by a long-term therapy with cytostatics. By means of this combined treatment, a three-year survival was obtained in 50% (8 of 16) and a complete remission in 44% (7 of 16). The prognosis is the same for boys as for girls. A less favorable prognosis concerns the patients with an initial leukocytosisf more than 50 000 leukocytes/mm3 of blood, an age of more than ten years, and leukemic cells already demonstrable in the cerebrospinal fluid.     

Dosimetric problems associated with total body irradiation

Total body irradiation (TBI), which is carried out with high energy photons at large source distances and with large fixed fields, involves special dosimetric requirements. The dose measurements published thus far on anthropomorphic phantoms have shown that deviations from the dose values calculated with "normal" dose functions occur as a result of completely different scatter radiation distributions. The higher the photon energy selected, the more slight these deviations become.     

Effects of prophylactic irradiation of acute lymphoblastic leukemia in the central nervous system of children

The development of prophylactic therapy for acute lymphoblastic leukemia (ALL) in the central nervous system in children has resulted in an improvement of the prognosis and prolongation of patients' lives. On the other hand, late irradiation effects have increased with the improvement of the prognosis. Therefore, there is now an important need to lessen these late effects without deteriorating the prognosis. We have investigated the recurrence rate, the survival rate and the cause of death of ALL patients who were divided into a none prophylactic irradiation group and 15 Gy, 20 Gy and 24 Gy irradiation groups. The results show that the effect of prophylactic irradiation has been more effective in the 20 Gy group than that of the 24 Gy group. Furthermore, brain atrophy and leukoencephalopathy, which were investigated by X-ray CT in long-term survivors of post-prophylactic irradiation without recurrence, have been less in the 20 Gy group than in that of the 24 Gy group. This report presents the result that the most favorable dose for prophylactic irradiation for central nervous system leukemia of ALL in children is 20 Gy by a step-up method.     

Fractionated and hyperfractionated total body irradiation in the conditioning of allogenic bone marrow transplant in acute lymphatic leukemia. Results

Two different Total Body Irradiation (TBI) regimens were employed (1981 to July 1983) in Genoa in the conditioning program for the allogeneic Bone Marrow Transplantation (BMT) of 22 patients suffering from Acute Lymphoblastic Leukemia (ALL) in remission (7 patients in 1st remission, and 15 in 2nd remission). All patients were treated with Cyclophosphamide -60 mg/kg administered for two consecutive days (day -7 and -6)--and subsequently underwent fractionated TBI (days -3, -2, -1), that is, our conventional TBI regimen: 3.3 Gy/day per 3 days (total dose: 9.9 Gy). From August 1983 through 1988, 33 patients (14 in 1st remission and 19 in 2nd remission) were given 2 Gy twice a day, 6 hours apart, for 3 consecutive days (total dose: 12 Gy). Cyclosporine A was used for GvHD prophylaxis. At 58 months, out of the total figure of ALL patients in 2nd remission, 19% of those treated with 9.9 Gy/3 fr/3 days (fractionated TBI) is likely to be in remission, versus 65% of the cases treated with 12 Gy/6 fr/3 days (p less than 0.01) (hyperfractionated TBI); the actuarial overall survival is 23% after fractionated vs 60% after hyperfractionated TBI (p = 0.05). The incidence of idiopathic interstitial pneumonitis was very low (3.6%). Thus, we conclude that, in ALL patients in second remission, hyperfractionated TBI (12 Gy/6 fr/3 days) yields better results than fractionated TBI (9.9 Gy/3 fr/3 days), with lower relapse rate (33% vs 83%) and higher survival.     

A case of acute monocytic leukemia cutis treated with total skin electron beam irradiation

A 35-year-old man with acute monocytic leukemia (AMoL) cutis was treated with total skin electron beam irradiation (TSEBI), because the widespread skin infiltration of AMoL appeared after induction chemotherapy. A skin nodule was authenticated as leukemic cell by biopsy. The patient was irradiated 4 times a week with 200 cGy per fraction to a total dose of 1200 cGy, using 6 MeV electrons from 8 directions. The therapy was accomplished separately on the upper and lower halves of the body. Focus-skin distance was 310 cm. An acrylic plate applicator 1 cm in thickness was used. The dimensions were 90 x 90 cm inside length and 90 cm in height. After completion of radiotherapy, the nodular lesions of the skin nearly disappeared. Although the patient survived only 3.5 months after beginning of radiotherapy due to systemic relapse, recurrence of the skin nodule was not seen. In this case TSEBI was therefore a useful treatment for skin infiltration of AMoL.     

Brain mucormycosis in a child with acute lymphoblastic leukemia

This article reports a rare case of Brain Mucormycosis in a 12 year-old girl who presented with relapse Acute Lymphoblastic Leukemia (ALL). On the 12th day of chemotherapy, although there was no CNS symptoms, the second Lumbar Puncture (LP) revealedmthe CNS relapse which developed to Into brain abscess presenting with right side hemiparesis. The brain magnetic resonance imaging (MRI) and the brain biopsy revealed small, multifocal necrosis and acute inflammation with septal fungal hyphae branching, which was proven to be caued by Mucormycosis according to Polymerase Chain Reaction (PCR). The patient responded to treatment with intravenous liposomal Amohotericin B and Caspofungin after two months, suggesting that Brain Mucormycosis in ALL cases can be managed with sequential therapy by antifungals.     

Computed tomography of the brain following prophylactic treatment with irradiation therapy and intraspinal methotrexate in children with acute lymphoblastic leukemia

Summary In 28 children with acute lymphoblastic leukemia (ALL) computed tomography (CT) was performed in order to demonstrate possible cerebral changes following treatment with prophylactic irradiation and intraspinal methotrexate (MTX). The time of CT-scan examination varied from 1 year and 1 month to 10 years and 1 month after diagnosis of ALL. The age of the children ranged from 3 years and 11 months to 14 years and 5 months. Six children had normal CT scans, 12 children had slight atrophylike changes, and nine had severe cerebral atrophy. Two patients in the latter group presented an enlarged ventricular system as well. In one patient intracerebral calcification was the only pathologic finding. The severe changes were seen in children of all age groups, but predominantly in children with a short duration of their disease, severe symptoms, and frequent marrow relapse. Changes induced by steroid therapy may be reversible. No satisfactory explanation of the demonstrated cerebral pathologic findings can be given, except that they are the consequences of the combination of total therapy and severity of disease in the individual patient. Measurement of attenuation coefficients in grey and white matter shows increasing values with age during childhood. A combination of decreasing attenuation coefficients, especially in the white matter, and the finding of severe atrophy seems to be a bad prognostic sign.     

A quantitative MR imaging assessment of leukoencephalopathy in children treated for acute lymphoblastic leukemia without irradiation

PURPOSE: Intravenous methotrexate (IV-MTX), an effective treatment for acute lymphoblastic leukemia (ALL), has a significant toxic effect on the central nervous system, with leukoencephalopathy (LE) being the most common form. The purpose of this study was to use objective quantitative MR imaging to prospectively assess the temporal evolution of LE extent and intensity. METHODS: Forty-five children (low-risk, 10 mol/L/12F; mean age, 5.0 years at diagnosis; standard/high-risk, 11 mol/L/12F; mean age, 9.2 years at diagnosis) treated for ALL on a single institutional protocol were evaluated longitudinally to assess the extent of LE (proportion of white matter impacted) through tissue segmentation and the relative intensity of LE through relative elevations in T1 and T2 relaxation rates. One-sided Wilcoxon-Mann-Whitney tests were used to assess differences in quantitative measures at 4 different points in therapy both within and between risk arms. RESULTS: The proportion of white matter affected in both patient groups increased significantly with additional courses of IV-MTX, whereas the intensity of LE also increased steadily; however, both the intensity and extent of LE declined significantly approximately 1.5 years after completion of IV-MTX. Increases in the T1 and T2 relaxation rates above normal-appearing white matter were significantly correlated with each other and were dependent on the proportion of white matter affected. CONCLUSION: Higher doses and more courses of IV-MTX were associated with increased intensity and extent of LE. There was a significant reduction in both the intensity and extent of LE after completion of therapy. The impact of these changes on neurocognitive functioning and quality of life in survivors remains to be determined.     

Metaphyseal impaction fractures in acute lymphoblastic leukemia

Summary Patients with acute lymphatic leukaemia frequently are osteoporotic. A small subset of these develop disabling metaphyseal transverse fractures, usually bilateral and in the lower limb. These impaction fractures have a characteristic appearance and develop in recently laid down bone. They may develop ab initio or during therapy. Magnesium deficiency is found in these patients.     

Physical problems of total body irradiation

In the concept of combined treatment of acute leukemias the whole body has to be irradiated as precisely and homogeneously as reasonably achieveable. In fulfillment of these radiobiological requirements, total body irradiation (TBI) means a very special challenge to medical physicists. Very large, uniform high energy photon beams have to be realized and applied. The dose at any relevant reference point has to be determined, regarding all influences of the TBI treatment situation. The dose distribution has to be modified - if necessary - verified and recorded. The lungs - the vital organs at risk in TBI - have to be shielded to tolerable doses. Optimization of TBI demands to understand all physical limitations and to utilize all technical possibilities. These physical problems encountered with TBI dosimetry, treatment planning and treatment performance are discussed.