A model for preservation of thymocyte-depleted thymus.

DiGeorge syndrome is a disorder caused by a microdeletion on the long arm of chromosome 22. Approximately 1% of patients diagnosed with DiGeorge syndrome may have an absence of a functional thymus, which characterizes the complete form of the syndrome. These patients require urgent treatment to reconstitute T cell immunity. Thymus transplantation is a promising investigational procedure for reconstitution of thymic function in infants with congenital athymia. Here, we demonstrate a possible optimization of the preparation of thymus slices for transplantation through prior depletion of thymocytes and leukocyte cell lineages followed by cryopreservation with cryoprotective media (5% dextran FP 40, 5% Me2SO, and 5% FBS) while preserving tissue architecture. Thymus fragments were stored in liquid nitrogen at -196°C for 30 days or one year. The tissue architecture of the fragments was preserved, including the distinction between medullary thymic epithelial cells (TECs), cortical TECs, and Hassall bodies. Moreover, depleted thymus fragments cryopreserved for one year were recolonized by intrathymic injections of 3×106 thymocytes per mL, demonstrating the capability of these fragments to support T cell development. Thus, this technique opens up the possibility of freezing and storing large volumes of thymus tissue for immediate transplantation into patients with DiGeorge syndrome or atypical (Omenn-like) phenotype.

A model for preservation of thymocyte-depleted thymus

DiGeorge syndrome is a disorder caused by a microdeletion on the long arm of chromosome 22. Approximately 1% of patients diagnosed with DiGeorge syndrome may have an absence of a functional thymus, which characterizes the complete form of the syndrome. These patients require urgent treatment to reconstitute T cell immunity. Thymus transplantation is a promising investigational procedure for reconstitution of thymic function in infants with congenital athymia. Here, we demonstrate a possible optimization of the preparation of thymus slices for transplantation through prior depletion of thymocytes and leukocyte cell lineages followed by cryopreservation with cryoprotective media (5% dextran FP 40, 5% Me2SO, and 5% FBS) while preserving tissue architecture. Thymus fragments were stored in liquid nitrogen at -196°C for 30 days or one year. The tissue architecture of the fragments was preserved, including the distinction between medullary thymic epithelial cells (TECs), cortical TECs, and Hassall bodies. Moreover, depleted thymus fragments cryopreserved for one year were recolonized by intrathymic injections of 3×106 thymocytes per mL, demonstrating the capability of these fragments to support T cell development. Thus, this technique opens up the possibility of freezing and storing large volumes of thymus tissue for immediate transplantation into patients with DiGeorge syndrome or atypical (Omenn-like) phenotype.

BLM germline and somatic PKMYT1 and AHCY mutations: Genetic variations beyond MYCN and prognosis in neuroblastoma.

Neuroblastoma (NB) is the most common extra cranial solid tumor of childhood and often lethal in childhood. Clinical and biologic characteristics that are independently prognostic of outcome in NB are currently used for risk stratification to optimally the therapy. It includes age at diagnosis, International Neuroblastoma Staging System tumor histopathology and MYCN amplification. However, even in patients with theoretically good prognosis, such as localized tumor and non-amplified MYCN, either disease progress or recurrence may occur. Potential genetic determinants of this unfavorable behavior are not yet fully clarified. The presence of elevated expression of AHCY, PKMYT1, and BLM has accompanied poor prognosis MYCN-amplified neuroblastoma patients. Considering the potential implication of these genes on the clinical management of NB, we hypothesize that the identification of genetic variations may have significant impact during development of the recurrent or progressive disease. Using targeted DNA sequencing, we analyzed the mutation profiles of the genes PKMYT1, AHCY, and BLM in tumor samples of five patients with MYCN amplified and 15 MYCN non-amplified NB. In our study, BLM germline variants were detected in two patients with MYCN-non-amplified neuroblastoma. Our data allow us to hypothesize that, regardless of MYCN status, these mutations partially abolish BLM protein activity by impairing its ATPase and helicase activities. BLM mutations are also clinically relevant because BLM plays an important role in DNA damage repair and the maintenance of genomic integrity. We also found a novel variant in our cohort, PKMYT1 mutation localized in the C-terminal domain with effect unknown on NB. We hypothesize that this variant may affect the catalytic activity of PKMYT1 in NB, specifically when CDK1 is complexed to cyclins. The prognostic value of this mutation must be further investigated. Another mutation identified was a nonsynonymous variant in AHCY. This variant may be related to the slow progression of the disease, even in more aggressive cases. It affects the maintenance of the catalytic capacity of AHCY, leading to the consequent functional effects observed in the NB patients studied. In conclusion, our hypothesis may provide that mutations in BLM, AHCY and PKMYT1 genes found in children with MYCN-amplified or MYCN-non amplified neuroblastomas, may be associated with the prognosis of the disease.

Teniposide plus cytarabine as intensification therapy and in continuation therapy for advanced nonlymphoblastic lymphomas of childhood.

PURPOSE AND METHODS: Thirty-nine consecutive children (age, 2 to 11 years) with nonlymphoblastic (NL) lymphomas were treated uniformly with chemotherapy based on the LNH-II-85 protocol. The protocol consisted of a remission-induction phase that lasted 30 days and started with cyclophosphamide (CTX) 1.2 g/m2 on day 1, followed by vincristine (VCR) 1.5 mg/m2 on days 3, 10, 17, and 24, daunomycin (DAUNO) 60 mg/m2 on days 12 and 13, and prednisone 40 mg/m2/d for 30 days. If a complete remission was achieved, an intensification regimen was given that consisted of eight courses of teniposide (VM-26) 165 mg/m2 plus cytarabine (ARA-C) 300 mg/m2 every 4 days according to bone marrow tolerance. A continuation phase was subsequently started, with alternating courses of thioguanine (6-TG) 300 mg/m2/d for 4 days plus CTX 1.2 g/m2 on day 5; hydroxyurea 2.5 g/m2/d for 4 days plus DAUNO 45 mg/m2 on day 5; VCR 1.5 mg/m2 plus methotrexate (MTX) 120 mg/m2 (24 hours apart); mercaptopurine (6-MP) 500 mg/m2/d for 4 days plus MTX 40 mg/m2; and VM-26 plus ARA-C for 3 courses (4 days apart), by the end of 48 weeks. CNS prophylaxis consisted of intrathecal administration of MTX, ARA-C, and dexamethasone according to age, administered three times during remission induction and every 6 weeks afterwards. RESULTS: By the end of the analysis in July 1991, 38 of 39 patients had attained a complete remission and 36 were event-free survivors. Two failures that occurred after completion of therapy were second malignancies (acute lymphocytic leukemia and acute nonlymphocytic leukemia). CONCLUSION: These results are significantly better than those obtained with less intensive former regimens performed in our institution before the availability of VM-26. The favorable impact of an intense consolidation phase with VM-26 is remarkably exemplified by three additional patients not included in this study whose families withdrew them from therapy after the intensification phase, all three of whom have been in remission.

Neuroblastoma in a boy with MCA/MR syndrome, deletion 11q, and duplication 12q.

Deletion 11q23-->qter and duplication 12q23-->qter are described in a boy with neuroblastoma, multiple congenital anomalies, and mental retardation. The patient has clinical manifestations of 11q deletion and 12q duplication syndromes. The possible involvement of the segment 11q23-->24 in the cause of the neuroblastoma is discussed.

Disseminated Langerhans' cell histiocytosis and massive protein-losing enteropathy.

Symptomatic involvement of the gastrointestinal (GI) tract as a prominent symptom in Langerhans' cell histiocytosis (LCH) is uncommon, occurring in less than 1 to 5% of all cases, even when the disease is in its disseminated form. Up to now, there have been reports of 18 cases of LCH with GI manifestations, including our 2 cases, with diarrhea (77.7%), protein-losing enteropathy (33.3%) and bloody stool being the most frequent findings. The authors present two patients with severe diarrhea and refractory hypoalbuminemia, and with the protein-losing enteropathy documented by Cr51-labeled albumin studies. A review of the literature indicated that the presence of GI symptoms is often associated with systemic disease as well as with poor prognosis, mainly under 2 years of age. Radioisotopes are useful for documenting protein loss in several diseases with high specificity and sensitivity, and their utilization in the cases reviewed here permitted diagnoses in 6 children, as well as improved therapeutic management.

Aspergillosis in immunocompromised children with acute myeloid leukemia and bone marrow aplasia. Report of two cases.

Two cases of Aspergillosis in immunocompromised children are reported. Both were caused by Aspergillus flavus. Early diagnosis and treatment led to the remission of the process. One patient had acute myeloid leukemia; the fungus was isolated from the blood. The other patient with bone marrow aplasia, presented an invasive aspergillosis of the paranasal sinuses with dissemination of fungal infection; the diagnosis was obtained by histology and culture of biopsied tissue from a palatal ulceration.

A t(9;11) translocation in childhood acute mixed leukemia.

We present the case of a child with acute lymphoid leukemia (ALL) who was morphologically classified as FAB L1 (PAS and peroxidase were negative). Remission was achieved with an ALL-type protocol (GBTLI). Five months after the discontinuation of therapy, the patient presented mixed leukemia (CD10, CD19, CD13 and CD33 were positive) with t (9;11) (p21;q23) translocation. Unfortunately, as cytogenetic and immunophenotype studies were not performed at diagnosis, two possibilities could be considered for the relapse; secondary mixed leukemia with clonal chromosome changes, or mixed leukemia from the beginning.

[Quality of life evaluation in children and adolescents with chronic and/or incapacitating diseases: a Brazilian study]. / Evaluación de la calidad de vida en niños y adolescentes portadores de enfermedades crónicas y/o incapacitadoras: un estudio brasileño.

OBJECTIVE: To evaluate quality of life in children and adolescents with acute lymphocytic leukemia (ALL) and juvenile rheumatoid arthritis (JRA). MATERIAL AND METHODS: We administered the Children's Global Assessment Scale (CGAS), the Vineland Adaptative Behavior Scale (VABS) and the Autoquestionnaire qualité de vie enfant imagé (AUQEI) to a sample of 28 children with ALL, 28 children with JRA, and 28 healthy controls, aged 4 to 13 years old, who were diagnosed between 1 and 5 years previously. RESULTS: Slight differences were found in age between patients with ALL and those with JRA. No significant differences were found in time since diagnosis or in CGAS scores. A significant difference was found in VABS global scores, as well as in VABS communication domain scores. No significant differences were found in VABS daily living skills domain scores between patients with ARJ and healthy controls. No significant differences were found among the groups in VABS socialization domain scores or in AUQEI scores. CONCLUSION: In our study, chronically ill children clearly performed worse in adaptative behavior development. Nevertheless, their quality of life was similar to that of healthy controls. Appropriate methods to identify pediatric patients' perception of their illnesses and treatment should be urgently developed.

[Autologous bone marrow transplantation in pediatric oncology--preliminary results from the ICR]. / Transplantes autólogos de medula óssea em oncologia pediátrica--experiência preliminar do Instituto da Criança Prof. Pedro de Alcântara, do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICR).

The initial results of 19 autologous and 1 syngeneic bone marrow transplantations, done in children with neuroblastomas (14), non-Hodgkin's lymphomas (3), Ewing sarcoma (1), acute lymphocytic (1) and non-lymphocytic (1) leukemias, pioneerely started in Brazil in February, 1987, and specially after the beginning of the ICR Marrow Transplantation Program, in October, 1989, are here described. Methodology, toxicity and survival are discussed. The efforts for establishing a high technology program in a public and universitarian institution, deeply supported by the community, are emphasized. Future directions are also discussed.

A virtual reality simulator for bone marrow harvest for pediatric transplant.

Bone marrow transplant is a relatively new procedure to treat recently considered incurable diseases. One important part of the procedure is the process of harvesting the donor bone marrow. We are developing a virtual reality simulator for bone marrow harvest that integrates interactive stereo visualization and force feedback techniques. The main objective is to offer a low cost virtual reality system to boost current adopted training methodologies for bone marrow harvesting.

[Primary rhabdomyosarcoma of the heart in children. A case report]. / Rabdomiosarcoma primário do coração em criança. Relato de caso.

The authors report a case of a child, 10 years old with a primary rhabdomyosarcoma of the heart that obstructed both caval veins. The clinical picture that lasted just three months before the admission was characterized by persistent fever, accentuated loss of weight and a very deteriorated general aspect. We emphasize the clinical aspects and other subsidiary elements that easily allowed to make the precise diagnosis in life as well as the therapeutic measures and follow up, besides a review of the literature, where it was confirmed the rarity of this pathological entity.

Development of a telemedicine model for emerging countries: a case study on pediatric oncology in Brazil.

This article discusses a telemedicine model for emerging countries, through the description of ONCONET, a telemedicine initiative applied to pediatric oncology in Brazil. The ONCONET core technology is a Web-based system that offers health information and other services specialized in childhood cancer such as electronic medical records and cooperative protocols for complex treatments. All Web-based services are supported by the use of high performance computing infrastructure based on clusters of commodity computers. The system was fully implemented on an open-source and free-software approach. Aspects of modeling, implementation and integration are covered. A model, both technologically and economically viable, was created through the research and development of in-house solutions adapted to the emerging countries reality and with focus on scalability both in the total number of patients and in the national infrastructure.

[Acute leukemia as secondary neoplasms in children with advanced lymphomas]. / Leucemias agudas como neoplasias secundárias em crianças portadoras de linfomas avançados.

In 1985 a new treatment regimen for advanced non-Hodgkin's lymphoma was started in the "Instituto da Criança-HC-FMUSP". The final results are remarkably better than those achieved with former programs. Two cases of children who developed a second neoplasm after the therapy was completed are described and discussed.

[Low stage non-Hodgkin's lymphoma: cases studied in 15 years at the HC-FMUSP Children's Institute]. / Linfomas não Hodgkin de baixo estádio: casos estudados em 15 anos no Instituto da Criança-HC-FMUSP.

In the recent few years the treatment of the stages I and II of non-Hodgkin lymphomas with the simultaneous use of several drugs showed improvement of results. In the period between 1977 and 1992 three consecutive chemotherapy programs have been developed in the "Instituto da Criança-HC-FMUSP". Between 1977 and 1980 five patients belonging to stage II were treated according to the LSA 2 L-Protocol; complete remission was attained in all of them and three patients have been kept in remission so far. In 1980-1984 period a new regimen (Protocol-I-80) was instituted using the same remission induction strategy as before adding a consolidation with Cyclo and Adria combination and a continuation phase with 6-MP+MTX; five out of six patients have survived free of events till now. In the 1984-1992 period a new protocol was designed (VM-26+ARA-C) replacing Cyclo+Adria. Five patients were included and all of them are disease free survivors.

[Multicentric osteosarcoma: report of a case with synchronous lesions]. / Osteossarcoma multicêntrico: relato de um caso com lesões sincrônicas.

A case of multicentric synchronous osteosarcoma occurring in a 9 year old girl is reported. Some particular features of this rare disease namely its rapid progression despite intensive drug therapy is stressed. Current hypothesis for the occurrence of this unusual form of neoplasm are here discussed.

Concomitant p53 mutation and MYCN amplification in neuroblastoma.

The MYCN oncogene is amplified in 20% of childhood neuroblastoma and is associated independently with poor prognosis. Alteration of the p53 tumor supressor gene, in contrast, occurs infrequently in these tumors. In this report, we described a 3-year-old girl with stage IV neuroblastoma. Molecular analysis revealed, both MYCN gene amplification and a point mutation of the p53 tumor supressor gene. To our knowledge, this is the first reported case of neuroblastoma with genetic alterations of both these genes.

[Non-Hodgkin's lymphomas in childhood: results of treatment in patients in stage III]. / Linfomas não Hodgkin na infância: resultados de tratamento de pacientes em estádio III.

From January 1980 to December 1984, 22 children with non-Hodgkin's lymphoma were admitted to the "Instituto da Criança-HCFMUPS" and according to the LNH-I-80 Protocol including a remission induction phase (Cyclofosfamide day 1, Vincristine days 3, 10, 17, 24, Daunomycin days 12 and 13, Prednisone for 30 days), followed by a continuation phase (Cyclofosfamide x 7 days + Adriamycin day 8 ARA-C x 4 days + Vincristine day 5, Mercaptopurine x 4 days + Methotrexate day 5) alternating three pairs of drugs during 72 weeks. Mercaptopurine and Methotrexate given during additional 48 weeks completes therapy. Twenty-one out of 22 patients attained complete remission. One patient died after widespread infection. Six relapses occurred, five of them in Burkitt's lymphoma patients. Although highly effective in the non-Burkitt's patients, the LNH-I-80 Protocol failed in keeping Burkitt's patients in event free survival.

Calcification in primary lung non-Hodgkin lymphoma.

Calcification in lymphoma before treatment or after chemotherapy is extremely rare. There have been scarse reports of calcified masses due to Hodgkin and non-Hodgkin lymphomas, originating in the main lymphatic chains of the mediastinum and retroperitoneum. We report a case of primarily extra-nodal (pulmonary) non-Hodgkin lymphoma with calcification prior to current treatment.

Deletion of the factor IX gene as a result of translocation t(X;1) in a girl affected by haemophilia B.

A balanced de novo translocation t(X;1) is described in a girl with severe haemophilia B. The translocated X was shown cytologically to be preferentially active, and methylation analysis of the DXS255 locus confirmed the skewed X-inactivation with the paternal allele being the active one. Cytogenetic and molecular analysis showed that this chromosomal rearrangement led to the deletion of at least part of the factor IX gene. Therefore, the girl was heterozygous for factor IX deficiency and expression of her clinical phenotype was the result of the inactivation of the normal maternal X chromosome. The localization of one of the X chromosome translocation breakpoints in YAC clone 957F9, that was demonstrated to map distally to the factor IX gene, revealed the complexity of this chromosomal rearrangement.