Enhanced Risk Stratification for Children and Young Adults with B-Cell Acute Lymphoblastic Leukemia: A Children's Oncology Group Report.

Current strategies to treat pediatric acute lymphoblastic leukemia rely on risk stratification algorithms using categorical data. We investigated whether using continuous variables assigned different weights would improve risk stratification. We developed and validated a multivariable Cox model for relapse-free survival (RFS) using information from 21199 patients. We constructed risk groups by identifying cutoffs of the COG Prognostic Index (PICOG) that maximized discrimination of the predictive model. Patients with higher PICOG have higher predicted relapse risk. The PICOG reliably discriminates patients with low vs. high relapse risk. For those with moderate relapse risk using current COG risk classification, the PICOG identifies subgroups with varying 5-year RFS. Among current COG standard-risk average patients, PICOG identifies low and intermediate risk groups with 96% and 90% RFS, respectively. Similarly, amongst current COG high-risk patients, PICOG identifies four groups ranging from 96% to 66% RFS, providing additional discrimination for future treatment stratification. When coupled with traditional algorithms, the novel PICOG can more accurately risk stratify patients, identifying groups with better outcomes who may benefit from less intensive therapy, and those who have high relapse risk needing innovative approaches for cure.

Myeloablative irradiation in non-human primates.

PURPOSE: We used total body irradiation (TBI) as conditioning for cord blood transplantation studies in pigtailed macaques. In these studies, different doses of TBI were explored to obtain optimal myelosuppression with acceptable radiation-related side effects. METHODS: Four macaques received TBI ranging from 800 to 1320 cGy, followed by standard post-transplant care. Hematopoietic recovery was monitored by CBC and donor contribution by variable number of tandem repeats analysis. RESULTS: Animals receiving 800 or 1020 cGy TBI tolerated the irradiation well with autologous recovery of neutrophils within 24 days. At a dose of 1200 cGy, neither autologous recovery nor extramedullary toxicity was observed. A fourth animal received 1320 cGy of TBI and suffered significant toxicity necessitating termination of the study. CONCLUSIONS: We conclude that previously considered myeloablative doses of TBI allowed for autologous recovery in the pigtailed macaque, and that a dose of 1200 cGy may be most appropriate, providing both myeloablation and acceptable non-hematopoietic toxicities.

2006 Bethesda International Consensus recommendations on the flow cytometric immunophenotypic analysis of hematolymphoid neoplasia: medical indications.

The clinical indications for diagnostic flow cytometry studies are an evolving consensus, as the knowledge of antigenic definition of hematolymphoid malignancies and the prognostic significance of antigen expression evolves. Additionally the standard of care is not routinely communicated to practicing clinicians and diagnostic services, especially as may relate to new technologies. Accordingly there is often uncertainty on the part of clinicians, payers of medical services, diagnostic physicians and scientists as to the appropriate use of diagnostic flow cytometry. In an attempt to communicate contemporary diagnostic utility of immunophenotypic flow cytometry in the diagnosis and follow-up of patients with hematolymphoid malignancies, the Clinical Cytometry Society organized a two day meeting of international experts in this area to reach a consensus as to this diagnostic tool. This report summarizes the appropriate use of diagnostic flow cytometry as determined by unanimous approval of these experienced practitioners.

JAK/STAT pathway inhibition overcomes IL7-induced glucocorticoid resistance in a subset of human T-cell acute lymphoblastic leukemias.

While outcomes for children with T-cell acute lymphoblastic leukemia (T-ALL) have improved dramatically, survival rates for patients with relapsed/refractory disease remain dismal. Prior studies indicate that glucocorticoid (GC) resistance is more common than resistance to other chemotherapies at relapse. In addition, failure to clear peripheral blasts during a prednisone prophase correlates with an elevated risk of relapse in newly diagnosed patients. Here we show that intrinsic GC resistance is present at diagnosis in early thymic precursor (ETP) T-ALLs as well as in a subset of non-ETP T-ALLs. GC-resistant non-ETP T-ALLs are characterized by strong induction of JAK/STAT signaling in response to interleukin-7 (IL7) stimulation. Removing IL7 or inhibiting JAK/STAT signaling sensitizes these T-ALLs, and a subset of ETP T-ALLs, to GCs. The combination of the GC dexamethasone and the JAK1/2 inhibitor ruxolitinib altered the balance between pro- and anti-apoptotic factors in samples with IL7-dependent GC resistance, but not in samples with IL7-independent GC resistance. Together, these data suggest that the addition of ruxolitinib or other inhibitors of IL7 receptor/JAK/STAT signaling may enhance the efficacy of GCs in a biologically defined subset of T-ALL.

Pre- and post-transplant quantification of measurable ('minimal') residual disease via multiparameter flow cytometry in adult acute myeloid leukemia.

Measurable ('minimal') residual disease (MRD) before or after hematopoietic cell transplantation (HCT) identifies adults with AML at risk of poor outcomes. Here, we studied whether peri-transplant MRD dynamics can refine risk assessment. We analyzed 279 adults receiving myeloablative allogeneic HCT in first or second remission who survived at least 35 days and underwent 10-color multiparametric flow cytometry (MFC) analyses of marrow aspirates before and 28±7 days after transplantation. MFC-detectable MRD before (n=63) or after (n=16) transplantation identified patients with high relapse risk and poor survival. Forty-nine patients cleared MRD with HCT conditioning, whereas two patients developed new evidence of disease. The 214 MRD(neg)/MRD(neg) patients had excellent outcomes, whereas both MRD(neg)/MRD(pos) patients died within 100 days following transplantation. For patients with pre-HCT MRD, outcomes were poor regardless of post-HCT MRD status, although survival beyond 3 years was only observed among the 58 patients with decreasing but not the seven patients with increasing peri-HCT MRD levels. In multivariable models, pre-HCT but not post-HCT MRD was independently associated with overall survival and risk of relapse. These data indicate that MRD(pos) patients before transplantation have a high relapse risk regardless of whether or not they clear MFC-detectable disease with conditioning and should be considered for pre-emptive therapeutic strategies.

A distinctive nuclear morphology in acute myeloid leukemia is strongly associated with loss of HLA-DR expression and FLT3 internal tandem duplication.

In a 5-year survey of nonpromyelocytic/nonmonocytic acute myeloid leukemias (AMLs) diagnosed in the University of Washington Hematopathology Laboratory, we identified 19 cases containing distinctive, cup-like nuclear indentation in 10% or more of the blasts ('AML-cuplike'). Fourteen of these cases (74%) demonstrated near-complete loss of HLA-DR expression, while the other five cases showed partial loss of HLA-DR. A total of 16 of the cases (84%) demonstrated internal tandem duplication (ITD) of the Flt3 gene. When compared to a selected set of AMLs lacking this nuclear morphology, AML-cuplike was significantly more likely to lack HLA-DR and CD34 expression, to express CD123 without CD133, to have a normal karyotype, and to harbor the Flt3 ITD. To characterize AML-cuplike in an unselected series of AMLs, we analyzed 42 consecutive nonpromyelocytic/nonmonocytic AMLs diagnosed in our laboratory during a 6-month period in 2002. Strikingly, in this unselected series, there was a statistically significant coincidence of invaginated nuclear morphology, loss of HLA-DR, and presence of the Flt3 ITD beyond that expected if these three features were unrelated, suggesting that AMLs with these three features may represent a distinct AML subset.

Comparison of minimal residual disease as outcome predictor for AML patients in first complete remission undergoing myeloablative or nonmyeloablative allogeneic hematopoietic cell transplantation.

Minimal residual disease (MRD) is associated with adverse outcome in acute myeloid leukemia (AML) after myeloablative (MA) hematopoietic cell transplantation (HCT). We compared this association with that seen after nonmyeloablative (NMA) conditioning in 241 adults receiving NMA (n=86) or MA (n=155) HCT for AML in first remission with pre-HCT bone marrow aspirates assessed by flow cytometry. NMA patients were older and had more comorbidities and secondary leukemias. Three-year relapse estimates were 28% and 57% for MRD(neg) and MRD(pos) NMA patients, and 22% and 63% for MA patients. Three-year overall survival (OS) estimates were 48% and 41% for MRD(neg) and MRD(pos) NMA patients and 76% and 25% for MA patients. This similar OS after NMA conditioning was largely accounted for by higher non-relapse mortality (NRM) in MRD(neg) (30%) compared with MRD(pos) (10%) patients, whereas the reverse was found for MRD(neg) (7%) and MRD(pos) (23%) MA patients. A statistically significant difference between MA and NMA patients in the association of MRD with OS (P<0.001) and NRM (P=0.002) but not relapse (P=0.17) was confirmed. After adjustment, the risk of relapse was 4.51 times (P<0.001) higher for MRD(pos) patients. These data indicate that the negative impact of MRD on relapse risk is similar after NMA and MA conditioning.

Education, outreach and the future of remote sensing in human health.

The human health community has been slow to adopt remote sensing technology for research, surveillance, or control activities. This chapter presents a brief history of the National Aeronautics and Space Administration's experiences in the use of remotely sensed data for health applications, and explores some of the obstacles, both real and perceived, that have slowed the transfer of this technology to the health community. These obstacles include the lack of awareness, which must be overcome through outreach and proper training in remote sensing, and inadequate spatial, spectral and temporal data resolutions, which are being addressed as new sensor systems are launched and currently overlooked (and underutilized) sensors are newly discovered by the health community. A basic training outline is presented, along with general considerations for selecting training candidates. The chapter concludes with a brief discussion of some current and future sensors that show promise for health applications.

Interferon-alpha treatment of posttransplant lymphoproliferative disorder in recipients of solid organ transplants.

Posttransplant lymphoproliferative disorder (PTLD) has been treated with decreased immunosuppression, antiviral medications, anti-B lymphocyte agents, radiation therapy, and/or chemotherapy. However, a standardized stepwise approach to treatment has not been previously evaluated. In the present study, 19 consecutive patients presenting to a single institution with newly diagnosed PTLD were treated according to a sequential protocol that consisted of (1) a reduction in immunosuppressive medications plus, if feasible, resection or definitive radiation therapy of localized disease, (2) interferon-alpha, and (3) systemic chemotherapy. Of the 3 patients presenting exclusively with localized disease, two were treated with resection of pulmonary parenchymal nodules and one was treated with radiation therapy to a paraspinous mass, without evidence of recurrence at a mean follow-up of 31 months (range, 8 to 46 months). Sixteen patients presented with PTLD not amenable to local therapy, and they were treated daily with 3x10(6) units/m2 subcutaneous interferon-alpha. Total regression of PTLD (defined as disappearance of the tumor mass by physical examination or computed tomography scanning) was found in 8 of 14 patients who received at least 3 weeks of interferon therapy. Interferon-alpha therapy was continued for 6 to 9 months in the eight patients judged to be responders. None of these patients have relapsed to date with the same neoplastic clone. Two patients, however, developed new neoplastic clones. Seven patients received systemic chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) (n=1), EPOCH (etoposide, vincristine, and doxorubicin administered as a continuous infusion, with an intravenous bolus of cyclophosphamide and oral prednisone) (n=4), or EPOCH followed by DHAP (dexamethasone, cytarabine, and cisplatin) (n=2) after failure of interferon-alpha; five patients had a complete response. Only 1 of the 19 patients died of uncontrolled PTLD. These results suggest that the majority of solid organ transplant recipients who develop PTLD can be safely and successfully treated using a sequential approach to therapy.

Refrigerated storage improves the stability of the complete blood cell count and automated differential.

A CBC count was performed on 113 random patient and 21 control specimens before and after 24-hour room temperature (RT) storage; 98 random patient and 20 control specimens also were analyzed before and after 24 hour 4 degrees C storage. The Cell-Dyn 3500 (Abbott Laboratories, Abbott Park, IL) was used for analysis. RT storage showed a decline in WBC count using the optical but not the impedance method, resulting in a large number of WBC flags. An increase in mean corpuscular volume also was seen for patient specimens. The automated WBC differential showed a decrease in the percentage of neutrophils and an increase in the percentage of lymphocytes, owing primarily to neutrophil degeneration. These changes also were seen in the manual differential to a similar degree. Storage of specimens at 4 degrees C largely prevented all of these changes. The implementation of refrigerated specimen storage is a simple, inexpensive method to improve the accuracy of CBC results for aged specimens on automated hematology analyzers.

T-cell clonality determination using polymerase chain reaction (PCR) amplification of the T-cell receptor gamma-chain gene and capillary electrophoresis of fluorescently labeled PCR products.

We compared the effectiveness of polymerase chain reaction (PCR) and DNA blot analysis (DBA) for detecting clonal T-cell populations and investigated whether a nonradioactive PCR method could be used in routine clinical diagnosis. We analyzed DNA from 117 cases for T-cell clonality by PCR amplification. DBA was performed on 77 of these cases. Denaturing polyacrylamide gel electrophoresis (PCR-PAGE) of radiolabeled PCR products and capillary electrophoresis (PCR-CE) of fluorescently labeled PCR products were used for PCR product separation and quantitation. Complete agreement was obtained between PCR-PAGE and DBA in 67 of 77 cases. One case was positive by DBA and negative by PCR-PAGE, and 3 cases were positive by PAGE and negative by DBA. Five cases indeterminate by DBA were positive by PCR-PAGE, and 1 indeterminate case was negative by PCR-PAGE. In the comparison of PCR-PAGE and PCR-CE, of 63 cases with height ratios less than 2.0, all were negative by PCR-PAGE. Of 52 cases with height ratios of 2.0 or more, 50 were positive by PCR-PAGE. We conclude that PCR-CE is analytically equivalent to DBA and PCR-PAGE for detecting clonal T-cell populations. The PCR-CE method is semiquantitative and, therefore, may be more objective than gel-based methods.

Application of remote sensing to arthropod vector surveillance and control.

A need exists to further develop new technologies, such as remote sensing and geographic information systems analysis, for estimating arthropod vector abundance in aquatic habitats and predicting adult vector population outbreaks. A brief overview of remote sensing technology in vector surveillance and control is presented, and suggestions are made on future research opportunities in light of current and proposed remote sensing systems.

Landscape characterization of peridomestic risk for Lyme disease using satellite imagery.

Remotely sensed characterizations of landscape composition were evaluated for Lyme disease exposure risk on 337 residential properties in two communities of suburban Westchester County, New York. Properties were categorized as no, low, or high risk based on seasonally adjusted densities of Ixodes scapularis nymphs, determined by drag sampling during June and July 1990. Spectral indices based on Landsat Thematic Mapper data provided relative measures of vegetation structure and moisture (wetness), as well as vegetation abundance (greenness). A geographic information system (GIS) was used to spatially quantify and relate the remotely sensed landscape variables to risk category. A comparison of the two communities showed that Chappaqua, which had more high-risk properties (P < 0.001), was significantly greener and wetter than Armonk (P < 0.001). Furthermore, within Chappaqua, high-risk properties were significantly greener and wetter than lower-risk properties in this community (P < 0.01). The high-risk properties appeared to contain a greater proportion of broadleaf trees, while lower-risk properties were interpreted as having a greater proportion of nonvegetative cover and/or open lawn. The ability to distinguish these fine scale differences among communities and individual properties illustrates the efficiency of a remote sensing/GIS-based approach for identifying peridomestic risk of Lyme disease over large geographic areas.

Psychophysiologic reactivity in asthmatic children: a cholinergically mediated confluence of pathways.

OBJECTIVE: The purpose of this study was to determine the suitability of a newly developed experimental paradigm, designed to assess relationships among emotional responsivity, physiologic (autonomic) reactivity, airway reactivity, and pulmonary function in asthmatic children under controlled conditions of ecologically valid emotional stimulation. METHOD: Twenty-four children, aged 8 through 17, with moderate to severe asthma viewed the movie, E.T., the Extra-Terrestrial, while having their heart and respiration rate and oxygen saturation continuously measured and recorded. Airway reactivity was assessed by the methacholine challenge test, and pre- and postmovie pulmonary function by spirometry. Self-report of emotion was recorded for targeted scenes. RESULTS: Findings indicated that emotional responsivity and physiologic reactivity to the movie were associated with increased airway reactivity and with decreased pulmonary function. CONCLUSIONS: The pattern of results suggests cholinergically mediated psychophysiologic pathways of emotional influence in the asthmatic process for some asthmatic children. A heuristic biopsychosocial model of these pathways is presented.

Influence of specific emotional states on autonomic reactivity and pulmonary function in asthmatic children.

OBJECTIVE: Research relating depression/hopelessness to cholinergic activation suggests the hypothesis that sad emotional states evoke patterns of autonomic reactivity that predispose to cholinergically mediated airway constriction in asthma. A corollary hypothesis is that positive (e.g., happy) emotional states evoke opposing effects. The purpose of the current study is to assess whether specific emotional states (sadness and happiness) can be reliably induced, physiologically differentiated, and related to asthma-relevant physiologic (autonomic) reactivity and pulmonary function in asthmatic children. METHOD: Twenty-four children, aged 8 to 17 years, with moderate to severe asthma, viewed the movie E.T., The Extra-Terrestrial while having their heart and respiration rate and oxygen saturation continuously recorded. Specific scenes were identified and preselected to evoke sadness, happiness, and a mixture of happiness and sadness. Self-report of emotion and indices of physiologic response were analyzed for these targeted scenes. RESULTS: Sadness was associated with greater heart rate variability and instability of oxygen saturation compared with happiness, with mixed results for mixed happiness and sadness. CONCLUSION: Results support sadness as evoking patterns of autonomic influence consistent with cholinergically mediated airway constriction. Happiness appears to effect autonomic patterns that would tend to relieve airway constriction.

Flow cytometric diagnosis of myelodysplasia and myeloproliferative disorders.

The current diagnosis of both myelodysplastic syndromes and myeloproliferative disorders relies in large part on subtle and subjective morphologic findings and the presence of cytogenetic abnormalities. Consequently, diagnosis of these disorders is often difficult and tentative with diagnosis at early stages representing a particular challenge. There is a need for new diagnostic techniques to allow a more definitive and objective diagnosis for these diseases. The published literature relating to the potential diagnostic utility of flow cytometric immunophenotyping in the diagnosis of myelodysplastic syndromes and myeloproliferative disorders is reviewed, and the increasingly important contribution of this technique to the diagnosis of these disorders emphasized.

Physically manifested illness in children and adolescents. A biobehavioral family approach.

This article presents a family systems approach to the assessment and treatment of children and adolescents with physically manifested illness. A biobehavioral continuum of psychologically and physically manifested disease is offered to replace the false dichotomy of organic versus psychological illness. The Biobehavioral Family Model, an empirically validated model of the mutual influence of family relational patterns and childhood illness, organizes the treatment approach. The Family Process Assessment Protocol provides a method of diagnosing the child's illness in the context of family relational functioning. Two cases, a child with conversion disorder and a child with asthma, illustrate this approach. Additional family systems approaches are referenced in a table with citations.

Diagnosis and classification of lymphoma based on cytospin preparations: a comparison of hematopathologists and cytopathologists.

The diagnosis of malignant lymphoma based on cytologic preparations is a source of much debate. The purpose of this study was to assess the ability of a number of pathologists to diagnose and classify lymphoma using cytospin preparations, and to compare the rate of agreement between cytopathologists and hematopathologists. One hundred twenty-five cytospins prepared from histologically confirmed hematologic lesions were examined retrospectively and independently by four hematopathologists/fellows and two cytopathologists without knowledge of the final diagnosis; the results were compared with the final diagnoses derived from histology and immunophenotyping. Eighty-one cases were histologically diagnosed as lymphoma (including 67 cases of B-cell non-Hodgkin's lymphoma), and 44 cases represented a reactive process histologically. The distinction of a malignant from a benign process was made in 75% of the cases by cytospin examination, with cytopathologists correctly diagnosing 75% and hematopathologists 76% of the cases. The accuracy rate for subclassification of the lymphoma cases was 49% (46% for cytopathologists, 52% for hematopathologists). The cytopathologists correctly recognized large-cell lymphoma at an increased frequency compared with the hematopathologists (70% vs. 56%, P = 0.11), while the hematopathologists showed a greater ability to recognize and classify nonfollicle center low-grade B-cell lymphomas (57% vs. 28%, P = 0.01). We conclude that cytopathologists and hematopathologists generally achieve similar accuracy rates in the morphologic evaluation of cytologic preparations of lymphoid lesions, though some differences in their performance do exist.