Evidence of a clinical response at one yr after reduced-intensity allogeneic hematopoietic stem cell transplantation in heavily pretreated adolescents with aggressive refractory Hodgkin's lymphoma.

We report results of RIC AHSCT in four adolescents with aggressive refractory HL. They all received three or four lines of therapy prior to RIC-AHSCT including autografts. At the time of RIC, they were in partial response except for one patient who had progressive chemoresistant disease. The conditioning regimen consisted of fludarabin, busulfan and ATG. They all had a matched related donor. The median follow-up was 12-16-month post-allograft. All patient transplants engrafted rapidly. The median time of hospitalization was 35 days. The median time to neutrophil recovery (>or=500/muL) was 19 days. All the patients were in complete donor chimerism at day 60. Four patients developed skin (grade

[Implementation of quality assurance program ISO 9001 in a department of paediatric oncology]. / Mise en place d'un système d'assurance qualité ISO 9001 en cancérologie pédiatrique.

OBJECTIVE: Our objective was to improve the organization and management of care facilities for children suffering from cancer or leukaemia and to be aligned with the legislation in force in France. METHODS: Our report is on the successive steps for the implementation of a quality assurance system, methods used, motivations, cost, difficulties encountered as well as the advantages obtained. In the Regional Centre for Paediatric Oncology (CRCP) at the CHU in Clermont-Ferrand, we launched a quality programme based on ISO9001/2000 standards. The implementation of the quality assurance system was conducted as a research project and an established medical project with the support of the Management Team. The mission was divided into several "processes", an approach consisting of considering the clinical service in terms of flow and successions of transformations (reception, care, support, accompaniment, etc.) which produce added-value (services and products adapted to the needs of the "customers": children, families, correspondents). RESULTS: We singled out ten physical processes or "job specializations" such as "diagnosis", "care" or "project for the child". The cartography which is the systematic representation of the processes and the interactions between them made it possible to draw up a global vision of the CRCP "care" activity. CONCLUSION: The ISO9001/2000 standard is a tool designed to help organization and management. The benefit obtained in implementing it in a clinic was perceived in organisational terms and lead to a true team spirit, a standardization of the professional practices and the enhancement of the role of each person. The advantages appear at three levels: the child and his/her family, the medical and paramedical teams, and the administrative supervisory bodies.

Cutaneous leishmaniasis in a severely immunocompromised HIV patient in Kumbo, Northwest region of Cameroon: case report.

BACKGROUND: Leishmaniasis is a rising opportunistic infection in individuals with human immunodeficiency virus (HIV). Cases of leishmania and HIV co-infection have been documented in several countries in the world with most reporting on the association between visceral leishmaniasis (VL) and HIV. We herein report the case of cutaneous leishmaniasis (CL) occurring in an HIV seropositive patient. CASE PRESENTATION: A 28 year old Cameroonian female diagnosed with HIV for 6 months earlier, presented to our facility with a 3 months history of non-painful rash. Clinical examination revealed non prurigeneous papulo-nodular lesions on the face and thighs which later became crusty ulcerative lesions. Giemsa staining with examination under oil objective immersion identified amastigotes and a diagnosis of CL was made which was managed with amphotericine B (1 mg/kg of body weight) for 14 days with mild improvement of lesions. Patient developed hypokalemia due to the amphotericine B during admission which was corrected and died 1 month after discharge. CONCLUSIONS: Current evidence suggest higher incidence of VL in HIV, however we report the occurrence of CL in HIV. A high index of suspicion for CL is warranted among clinicians in Africa when faced with HIV patients with inconsistent cutaneous rash.

Update on extracorporeal photochemotherapy for graft-versus-host disease treatment.

Pediatric experience with extracorporeal photochemotherapy (ECP) for graft-versus-host disease (GvHD) has mainly been reported by Italian and French groups. Data concerning 41 children with acute GvHD and 63 children affected by chronic GvHD are available. In 73 and 63% of them, respectively, improvement was observed, with addition of ECP to their immunosuppressive regimen. Treatment with ECP was associated with minimal side effects, even in the smallest of patients. In all responded pediatric patients, both with acute and chronic GvHD, ECP allowed progressive reduction or discontinuation of the concomitant pharmacological immunosuppressive therapy without an increase in GvHD activity. These data show that ECP is a useful therapy for children affected by GvHD resistant to conventional treatment and can be safely used.

Using peripheral blood progenitor cells (PBPC) for transplantation in pediatric patients: a state-of-the-art review.

This paper presents a state-of-the-art review of using mobilized-peripheral blood progenitor cells (PBPC) for transplantation in children. Our own data and those from Medline searches and meeting reports, are analyzed and presented for the different sections that involve transplantation. Recommendations concerning the choice of mobilization regimens, venous access, priming of separator extracorporeal line, anticoagulation, and number of CD34+ cells to infuse for rapid engraftment are proposed. In the allogeneic setting, we analyze ethical and safety aspects of pediatric donor mobilization and collection. Data from the literature suggest that the use of cytokine-mobilized PBPC for allogeneic transplantation appears to be safe both for pediatric donors and patients leading a rapid hematopoietic engraftment with a similar incidence of acute graft-versus-host disease (GVHD). The high incidence of chronic GVHD and its management emerge as the most concerning aspect in allogeneic PBPC transplantation.

Ex vivo expansion of autologous PB CD34+ cells provides a purging effect in children with neuroblastoma.

Peripheral blood CD34+ cell samples from eight children with advanced neuroblastoma and from 10 healthy adult donors were seeded at 5 x 10(4) cells/ml in stroma-free, serum-free medium with FL, SCF, MGDF (100 ng/ml each), G-CSF, IL6 (10 ng/ml each) and IL3 (5 ng/ml), and incubated for 10 days. The levels of expansion of PBCD34+ cells observed in neuroblastoma patients, with up to 214-fold expansion for total nucleated cells, 39-fold for CD34+ cells, 79-fold for CFU-GM and nine-fold for LTC-IC were identical to those obtained with PBCD34+ cells of healthy donors (P>/=0.5). All samples from patients with neuroblastoma and five donor's PBCD34+ cell samples contaminated with IMR-32 neuroblasts, were screened for the number of tyrosine hydroxylase (TH) mRNA transcript using LightCycler software. In all samples, progressive 1.9-4.4 log decreases in the number of TH transcripts were observed between days 0 and 10 of expansion. Our results show that in extensively pretreated children with neuroblastoma, the culture conditions that were effective for BM and CB cell expansion can generate an expansion of PBCD34+ cells and provide a purge of tumour cells.

Kinetics of hematopoietic progenitor cell release induced by G-CSF-alone in children with solid tumors and leukemias.

The kinetics of peripheral blood progenitor cell (PBPC) release induced by G-CSF-alone at 10 microg/kg/day were monitored daily in 42 children with solid tumors and leukemias. Median 16- and 27-fold enrichment of circulating CD34+ cells and granulocyte-macrophage colony-forming units (CFU-GM) was noted with peak values occurring after the 4th or the 5th G-CSF dose. Individual values of PBCD34+ cell levels in patients with solid tumors were not significantly different after the 4th and after the 5th dose. The day-of-collection PBCD34+ cell concentration was related to the harvested CD34+ cell (P = 0.0001) and CFU-GM numbers (P = 0.0001). No correlations were found between PBPC enrichment and either patient age, body weight, diagnosis or pre-mobilization treatment duration. The median numbers of 1.1 x 10(6) CD34+ cells/kg and 28.1 x 10(4) CFU-GM/kg were derived from one patient's blood volume processed. Nineteen patients received G-CSF-alone primed grafts and had successful engraftment. Our data indicate that in 88% of children a single standard leukapheresis is sufficient to obtain a minimum graft (2 x 10(6) CD34+ cell and/or 10 x 10(4) CGU-GM per kg) whether undertaken after the 4th dose of G-CSF or the 5th.

Peripheral progenitor cells (CFU-GM, BFU-E, CD34) are increased in untreated chronic lymphocyte leukemia patients: stage B and C display a particularly high CD34+ cell count.

No treatment has proved its efficiency in CLL. Autologous transplantation is now under consideration for the youngest patients. We assayed progenitor cells (CFU-GM, BFU-E, CD34) in the peripheral blood of 28 untreated CLL patients and found an increase of all these progenitors in CLL compared to controls. There was no statistical difference between stage A versus stages B and C for CFU-GM and BFU-E. In contrast, CD34 cells were higher in stages B and C as compared to stage A. This finding could be explained by a high number of circulating clonal cells in advanced stages of the disease.

Processing of illegal consonant clusters: a case of perceptual assimilation?

Evidence is presented for a perceptual shift affecting consonant clusters that are phonotactically illegal, albeit pronounceable, in French. They are perceived as phonetically close legal clusters. Specifically, word-initial /dl/ and /tl/ are heard as /gl/ and /kl/, respectively. In 2 phonemic gating experiments, participants generally judged short gates--which did not yet contain information about the 2nd consonant /l/--as being dental stops. However, as information for the /l/ became available in larger gates, a perceptual shift developed in which the initial stops were increasingly judged to be velars. A final phoneme monitoring test suggested that this kind of shift took place on-line during speech processing and with some extratemporal processing cost. These results provide evidence for the automatic integration of low-level phonetic information into a more abstract code determined by the native phonological system.

[Cell therapy for cancer treatment in children]. / Thérapie cellulaire dans le traitement du cancer de l'enfant.

The cure rate for cancer in children is currently almost 75%. This rate has remained fairly constant over the past few years, which suggests that the limits of today's curative treatment potential have been reached. The development of cell therapy techniques opens up new therapeutic possibilities in paediatric oncology. Here, we deal both with a number of cell therapy techniques, which have already proved their efficacy in children, and other more innovative approaches, which require validation. Examples of the use of autologous and allogeneic cells are described. Clinical studies and their results, while often preliminary, are reported. The importance of well run clinical research, a clear and progressive legal framework and the necessary substantial economic support for the development of cell therapy are underlined.

[Extracorporeal photopheresis as an alternative therapy for drug-resistant graft versus host disease: three cases]. / Photochimiothérapie extracorporelle dans le traitement de la réaction chronique du greffon contre l'hôte: trois cas.

BACKGROUND: Graft versus host reaction is a life-threatening complication of allogenic bone marrow transplantation. Extracorporeal photopheresis has been used for some years in the treatment of graft versus host reaction. We report on three children treated with extracorporeal photopheresis for a graft versus host reaction resistant to immunosuppresive drugs. MATERIAL AND METHODS: Three children with a graft versus host reaction were submitted to 18, 30 and 46 extracorporeal photopheresis courses respectively. In the same time, the other immunosuppressive treatments were tapered or definitively stopped (ciclosporin). RESULTS: A dramatic improvement of cutaneous status and biological data was observed after the first courses. However, the extracorporeal photopheresis treatment did not improve the mucous lesions. No serious adverse effect was encountered. COMMENTS: As published elsewhere, extracorporeal photopheresis was effective on the graft versus host reaction lichenoid cutaneous lesions and in case of visceral involvement. In all of our cases, the immunosuppressive drug could have been tapered. No adverse event was observed. Thus, extracorporeal photopheresis should be indicated in case of resistance to immunosuppressive drugs.

Beginnings of prosodic organization: intonation and duration patterns of disyllables produced by Japanese and French infants.

In this study, some prosodic aspects of the disyllabic vocalizations (both babbling and words) produced by four French and four Japanese children of about 18 months of age, are examined. F0 contour and vowel durations in disyllables are found to be clearly language-specific. For French infants, rising F0 contours and final syllable lengthening are the rule, whereas falling F0 contours and absence of final lengthening are the rule for Japanese children. These results are congruent with adult prosody in the two languages. They hold for both babbling and utterances identified as words. The disyllables produced by the Japanese infants reflect adult forms not only in terms of global intonation patterns, but also in terms of tone and duration characteristics at the lexical level.

Impact of uncontrolled freezing and long-term storage of peripheral blood stem cells at - 80 °C on haematopoietic recovery after autologous transplantation. Report from two centres.

Controlled-rate freezing and storage in vapour phase nitrogen are used by most transplantation teams for the cryopreservation and storage of peripheral blood haematopoietic stem cells (PBSC). In this study, we analysed 666 autologous PBSC transplants after uncontrolled freezing and storage of PBSC at -80 °C. Statistical analysis showed that neutrophil recovery was associated with both the infused CD34(+) cell dose (P=0.01) and the post transplantation use of growth factors (P<0.001) and that platelet recovery was associated with the infused CD34(+) cell dose (P<0.001) and with the diagnosis (P=0.02). We analysed three groups according to the duration of the cryopreservation period (less than 6 months, between 6 and 12 months or more than 1 year). Haematopoietic recovery was not found to be adversely affected by longer storage at -80 °C. The haematopoietic recoveries of 50 pairs of sequential transplantations from the same PBSC mobilization were analysed. Despite prolonged cryopreservation, there were no statistically significant differences in neutrophil (P=0.09) or platelet (P=0.22) recovery in the second compared with the first transplant. In conclusion, the long-term storage of PBSC at -80 °C after uncontrolled-rate freezing is an easy and comparatively inexpensive cryopreservation method that leads to successful haematopoietic recovery even after prolonged storage.

Reduced-intensity conditioning followed by allogeneic transplantation in pediatric malignancies: a report from the Société Française des Cancers de l'Enfant and the Société Française de Greffe de Moelle et de Thérapie Cellulaire.

We report French prospective experience with reduced-intensity conditioning-allo-SCT in 46 patients (median age: 15.5 years, 4.8-20.2) presenting high-risk AL (n=11), Hodgkin's lymphoma (n=15) or solid tumors (n=20). Graft sources were BM (n=21), PBSC (n=20) and cord blood (CB; n=5) from related (n=20) or unrelated (n=26) donors. For CB grafts, only one patient out of five achieved sustained engraftment. For PBSC/BM grafts, engraftment rate was 95%, hematopoietic recovery times were not significantly different between BM, PBSC, sibling or unrelated grafts, day+100. Full donor chimerism was achieved in 94% of patients, and incidences of primary acute GVHD and chronic GVHD were 49% and 14%, respectively. Underlying disease was fatal in 39% of patients. TRM was 6.9%. Three-year OS was 49.15%. OS and EFS were not significantly different between patients transplanted with different grafts and with or without primary GVHD. Patients with solid tumor or measurable disease at transplant had poorer outcomes. Three-year EFS: 33.3% for ALL, 75.0% for AML, 51.8% for Hodgkin's lymphoma, 28.6% for neuroblastoma and 22.2% for sarcoma patients. This multicentre study concluded that Bu/fludarabine/anti-thymocyte globulin conditioning with PB or BM, related or unrelated grafts in patients with various malignancies at high-risk for transplantation toxicity results in high engraftment rates, low TRM and acceptable survival.

NK cytotoxicity and alloreactivity against neuroblastoma cell lines in vitro: comparison of Europium fluorometry assay and quantification by RT-PCR.

UNLABELLED: New therapies for children with high risk neuroblastoma are needed, and haploidentical stem cell transplantation with NK post-graft injections is a potential option. To develop this strategy, we compared and correlated two methods of NK cytotoxicity assay. The aim of this work is to optimize in vitro NK cytotoxicity assays, investigate the effect of interleukin stimulation on NK cells and use of antiGD2 antibodies against tumor target cells and finally establish an in vitro model for haploidentical stem cell transplantation. EXPERIMENTAL DESIGN: We evaluated NK cell cytotoxicity in vitro against NB cell lines (IMR-32 and SK-NSH) in different culture conditions using a Europium BATDA fluorescence test, and correlated the results with quantification of TH, Phox2B, and DCX transcripts evaluated by RT-PCR. RESULTS: Both IMR-32 and SK-N-SH neuroblastoma cell lines were sensitive to NK cells and particularly when NK cells were stimulated by interleukin IL-2 and IL-15 or when using anti-GD2 antibodies against tumor target cells. All these results were observed either with Europium fluorometry assay or with RT-PCR quantification. There is a clear correlation between the two methods, for the three transcripts at the ratio effector/target 50/1 (TH r=0.75, Phox2B r=0.79 and DCX r=0.8), for all the values whatever the cell line. Besides for all three transcripts, the correlations were significantly independent of the cell line and the ratio E/T (all p values non-significant) even if the best correlation was observed for the ratio 50/1. After prolonged incubation times of effector and target cells (24 h), which could be evaluated only by RT-PCR, all the transcripts clearly decreased, confirming the haploidentical effect of NK against the two neuroblastoma cell lines in our two in vitro haploidentical models but no advantage of mismatch. CONCLUSIONS: NK cytotoxicity against neuroblastoma cell lines can be evaluated by Europium assay and by RT-PCR with clear correlation for the three transcripts TH, Phox2B and DCX whatever the ratio E/T and cell line used. This new method of RT-PCR is simple and suitable for large-scale conditions like study of adherent tumor cells or prolonged incubations of target/effector cells which allowed us to observe haploidentical effect.

Hematopoietic progenitor cell mobilization and harvesting in children with malignancies: do the advantages of pegfilgrastim really translate into clinical benefit?

Our purpose was to assess success rates in children of achieving optimal hematopoietic progenitor cells (HPCs) harvest after mobilization with 300 microg/kg pegfilgrastim. Between January 2005 and January 2007, 26 children with solid malignancies who were referred for HPC collection were consecutively included. Hematopoietic progenitor cell mobilization consisted of one s.c. injection of 300 microg/kg body weight (BW) of pegfilgrastim. The success criterion was defined as at least 5 x 10(6) CD34+ cells/kg during the first standard apheresis (less than 3 blood volumes processed (BVP)). After 26 inclusions, the Bayesian analysis gave a mean estimated success rate of 60.7% (95% credibility interval: 42.0-78.0%). The first apheresis allowed the collection of 8.3 x 10(6) CD34+ cells/kg BW (range 0.6-37.8), with a median of 2.8 BVP (range 1.4-3.0). Overall, the median of CD34+ cells collected was 12.4 x 10(6)/kg (range 2.7-37.8). The cumulative dose of anthracyclin was the only variable associated with the total number of CD34+ collected cells (P<0.05). Mobilization was clinically well tolerated in 20 patients. No drug-related adverse events of grade > or =3 occurred. We conclude that a single injection of 300 microg/kg pegfilgrastim in the hematological steady state is an efficient and well-tolerated method of HPC mobilization in children with solid malignancies.

Intraperitoneal coagulation in chronic liver disease ascites.

Twenty patients with the ascites of chronic liver disease were investigated for in vivo evidence of active coagulation within ascites by detection of fibrin monomer. Increased levels of fibrin monomer, increased fibrin/fibrinogen degradation products, and absent or low levels of fibrinogen in the ascites of all patients tested confirmed the presence of intraperitoneal coagulation when ascites is present.