Allogeneic stem cell transplantation in children with acute lymphoblastic leukemia after isolated central nervous system relapse: our experiences and review of the literature.

The prognosis of patients with acute lymphoblastic leukemia (ALL) and central nervous system (CNS) relapse has historically been very poor. Although chemo-radiotherapy has improved outcomes, some patients still have a poor prognosis after CNS relapse. Therefore, allogeneic hematopoietic stem cell transplantation (allo-SCT) has recently become an option for treatment of CNS leukemia; however, information, particularly on the long-term outcome of transplant recipients, is limited. We performed allo-SCT in eight pediatric patients with ALL (n=7) or T-cell type non-Hodgkin's lymphoma (n=1), who had isolated CNS relapse. All patients survived for a median of 70.5 (range, 13-153) months after SCT. Sequelae developed late in some patients: mental retardation (IQ=47) in one patient, severe alopecia in two patients, limited chronic graft-versus-host-disease in three patients, and amenorrhea and/or hypothyroidism in three patients. Except for a pre-school child with post transplant CNS relapse, six out of seven patients show normal school/social performance. Our results clearly indicate a high cure rate of isolated CNS relapse by allo-SCT in pediatric lymphoid malignancies; however, there needs to be further studies to determine which are the appropriate candidates for transplantation and what is the best transplant regimen to achieve high cure rate and maintain good quality of life.

Induction of S 100 protein by 5-bromo-2'-deoxyuridine in human neuroblastoma cell lines.

The simultaneous effect of 5-bromo-2'-deoxyuridine (BrdUrd) on cell growth, morphological changes, and cellular contents of S 100 (S 100ao and S 100b) protein and neuron specific enolase was investigated in human neuroblastoma cells in culture. Among four cell lines (NCG, SK-N-DZ, GOTO, NB-1), GOTO was the most affected. With 5 micrograms/ml BrdUrd, the growth of this cell line was significantly inhibited to 14.5% of the control on day 6, in association with morphological changes into flat-type cells and an increase of S 100 protein. S 100ao protein was increased from 37 to 211,000 pg/mg protein (5,600-fold) and S 100b protein from less than 25 to 623 pg/mg protein. The induction of S 100 protein was also seen in SK-N-DZ but not in NCG and NB-1. In GOTO the induction of S 100 protein occurred in a dose- and time-dependent manner by the treatment with BrdUrd. On the other hand, after exposure to BrdUrd, neuron specific enolase decreased in NB-1 and SK-N-DZ and increased in GOTO. These results suggest that although heterogeneous certain neuroblastoma cell lines could be differentiated into S 100 protein-positive cells that may represent glial or Schwann cells and that the effect of BrdUrd is exerted bidirectionally in neuroblastoma differentiation.

Augmented MYCN expression advances the malignant phenotype of human neuroblastoma cells: evidence for induction of autocrine growth factor activity.

Amplification and enhanced expression of the MYCN oncogene are thought to contribute to the development and progression of human neuroblastomas. Here, we have transfected human neuroblastoma cells that harbor a single MYCN gene copy with the human MYCN gene driven by a viral enhancer/promoter, and we have compared the properties of the parental and the transfected cells. The transfected cells show an enhanced expression of the exogenous MYCN gene. Unlike the parental cells, they have acquired an increased proliferative potential, induce tumors in nude mice, grow in soft agar, and require low amounts of exogenous growth factors in order to proliferate. The MYCN-transfected, but not the parental, cells can synthesize and utilize autocrine growth factor activity. These results demonstrate that enhanced MYCN expression contributes to malignant progression of human neuroblastoma cells, conceivably by stimulating the expression of autocrine growth factor activity.

Numerous nonclonal chromosomal aberrations arising in residual recipient hematopoietic cells following allogeneic bone marrow transplantation.

A young female patient in a second remission of acute lymphoblastic leukemia underwent bone marrow transplantation after total body irradiation and high-dose cytarabine from her HLA-matched brother. Following successful engraftment, mixed chimerism was seen 75 days post transplant. The karyotype contained numerous abnormalities in residual recipient cells. Chromosomes 1, 7, 13, and X were significantly more affected than other chromosomes. The high-frequency breakpoints identified were 1p22.2, 5q31.2, and 13q14.2. Some karyotypes specific for leukemia, such as t(9;22)(q34.1;q11.2) and t(8;21)(q22.2;q22.2), not seen with the original disease, were also present. As the frequency of aberrant chromosomes increased markedly with time, donor leukocytes were infused 14 months after BMT, which effectively eradicated the abnormal karyotypes.

Donor lymphocyte infusion at unstable mixed chimerism in an allogeneic BMT recipient for chronic granulomatous disease.

We report a 14-year-old boy who had successfully received allogeneic BMT for chronic granulomatous disease and 3 years later was treated with donor lymphocyte infusion (DLI, 3.3 x 10(8) cells/kg) at unstable mixed chimerism in association with reduced neutrophil function. Following DLI, the patient developed transient acute hepatic GVHD, which was confirmed by liver biopsy and was manageable with cyclosporin A and prednisolone. The patient eventually attained complete chimerism with improved neutrophil function. At the time of writing (2.5 years from the DLI), the patient is doing well, free from infectious episodes and chronic GVHD. Our experience suggests that DLI could be a safe and effective strategy for dissolution of unstable mixed chimerism in BMT recipients for inherited disorders.

Chimerism analysis on mononuclear cells in the CSF after allogeneic bone marrow transplantation.

To evaluate the chimeric status of mononuclear cells in the CSF after allogeneic BMT, cells were analyzed by FISH using satellite DNA probes for human X and Y chromosomes. CSF cells were obtained from five pediatric ALL patients who received BMT from sex-mismatched donors. All patients received TBI-containing conditioning regimens. We found that CSF cells showed complete donor type in 19-97 days after BMT, when complete donor type hematopoiesis was observed. The rapid entry of the donor leukocytes into the brain may exert beneficial effects to eradicate the residual CNS leukemic cells and prevent a CNS relapse in ALL patients after BMT.

Successful allogeneic bone marrow transplantation in a case with myelodysplastic syndrome which developed following Fanconi anemia.

We report the case of a 14-year-old boy with myelodysplastic syndrome (MDS/RAEB) which developed following Fanconi anemia. The patient received BMT from an HLA-identical sister. Based on the in vitro CY-sensitivity test, 100 mg/kg of CY was administered for conditioning combined with 6 Gy TBI. Mucosal symptoms such as stomatitis, diarrhea and hematuria were severe, but manageable, and engraftment was successful. The patient has maintained normal trilineage hematopoiesis with > 90% Karnofsky score for 30 months with disappearance of a clonal chromosomal abnormality (47,XY, +i(lq)) which was detected before BMT.

Risk factors for cytomegalovirus retinitis following bone marrow transplantation from unrelated donors in patients with severe aplastic anemia or myelodysplasia.

Two cases of cytomegalovirus (CMV) retinitis following bone marrow transplantation (BMT) from unrelated donors are reported. 1 patient had been treated for severe aplastic anemia (SAA) and the other for hypoplastic myelodysplastic syndrome (MDS). Because first line therapy with antithymocyte globulin (ATG) and cyclosporin A (CsA) had failed, BMT was performed following a conditioning regimen of ATG, cyclophosphamide, and total lymphoid irradiation. Treatment for CMV retinitis was successfully carried out with gancyclovir (systemic and intraocular injection), foscarnet, and photocoagulation (Case 1) and gancyclovir and foscarnet (Case 2). Both patients also developed Epstein-Barr virus-associated lymphoproliferative disease (EBV-LPD). We compared these 2 cases with 14 SAA patients who did not develop CMV retinitis after BMT using marrow from either HLA-identical siblings (n = 9) or from unrelated donors (n = 5). Unlike the retinitis patients, the latter 5 patients received ATG only once. The retinitis patients had significantly lower CD4+ T-cell levels in their peripheral blood than the 14 patients who did not develop CMV retinitis. We believe that repeated treatment with ATG and transplantation from unrelated donors may lead to immune dysfunction that could increase the likelihood of CMV retinitis, as well as LPD. For such BMT patients, regular ophthalmic examinations and careful testing for CMV antigenemia are recommended.

Outcome of clonal hemophagocytic lymphohistiocytosis: analysis of 32 cases.

We studied the impact of clonality, determined by analysis of Epstein-Barr virus genome termini, T-cell receptor genes and clonal chromosomal abnormality, on the clinical outcome in 32 patients with hemophagocytic lymphohistiocytosis (HLH). Of the cases studied, 23 cases were EBV-clonal, 15 cases were TCR-clonal and 7 cases were cytogenetically clonal. Thirty patients were treated with immuno-chemotherapy and/or multiagents' chemotherapy and 4 received bone marrow transplantation. All 7 cases, in which cytogenetically abnormal clones were identified, were fatal (3-year survival by Kaplan-Meier analysis; 14%, 95%CI: 0-40%). None of these 7 cases received bone marrow transplantation. On the other hand, the 3-year survival of 23 clonal EBV-positive HLH cases including 4 cytogenetically abnormal cases was 64 % (95%CI: 42-84%), while that of 15 TCR-clonal cases was 53% (95%CI: 26-78%). Our observations suggest that cytogenetically abnormal cases are at extremely high risk, requiring intensive immuno-chemotherapy followed by prompt and timely allogeneic bone marrow transplantation.

Increased levels of alpha V-associated integrins in association with growth inhibition of cultured tumor cells by bromodeoxyuridine.

Treatment of three small-round-cell-tumor cell lines, TC-32 (peripheral neuroepithelioma), 6647 (Ewing's sarcoma), and GOTO (neuroblastoma), with bromodeoxyuridine (BrdU) (5 micrograms/ml) for 6 days markedly inhibited cell growth in both culture medium and soft agar and induced morphological alteration into large flat cells. These BrdU-treated cells showed markedly increased levels of alpha V-associated integrins, including alpha V beta 3, and no uniform changes in other beta 1 subfamilies (alpha 1-6). Cell attachment to vitronectin was found to be increased in these BrdU-treated cells. These results suggest that increased levels of alpha V-associated integrins are associated with growth inhibition of cultured tumor cells induced by BrdU.

[Neurofibroma-associated left peroneal nerve palsy in a patient with acute lymphoblastic leukemia].

Peroneal nerve palsy developed in a patient with T cell-type acute lymphoblastic leukemia (ALL) is reported. In the fifth month after starting of chemotherapy against ALL, the patient, a 7-year-old girl, developed drop foot on the left. Three possibilities were considered as its pathogenesis; (1) VCR neuropathy, (2) neurotoxicity of intrathecal MTX, (3) leukemic invasion to the spinal canal. However, there was no evidence of leukemic invasion in any lumbar taps, and no improvement was obtained by cessation of VCR and intrathecal MTX. Examination by CT scan revealed tumors in the intervertebral (L5-S2) region, which was diagnosed to be neurofibromas by biopsy. The tumors compressed the left peroneal nerve and neurotoxicity of antineoplastic agents for ALL could be the cause of her drop foot.

[Post-transplant EBV-associated lymphoproliferative disorders--report of two cases].

We report two cases of Epstein-Barr virus (EBV)-associated lymphoproliferative disorders (LPD) after allogenic bone marrow transplantation which were conditioned with regimens including antithymocyte globulin (ATG). The first case was a 31 year-old man which severe aplastic anemia who was transplanted from HLA-matched unrelated donor conditioned with total lymphoid irradiation (TLI)/ cyclophosphamide/ATG and prophylactic administration of ganciclovir Grade I acute GVHD improved in response to cyclosporine (CsA). LPD as a polyclonal epipharyngeal mass developed at day +53 and spontaneously regressed along with the withdrawal of CsA. Second case was a 11 year-old boy with acute myelomonocytic leukemia (FAB:M4E). He was transplanted from HLA B locus mismatched mother conditioned with total body irradiation (TBI)/busulfan/L-PAM/ATG. He showed grade IV acute GVHD, which was controlled by steroids and FK-506. LPD as a monoclonal intestinal lymphoma was diagnosed at day +82, and he was unsuccessfully treated with ganciclovir, acyclovir, chemotherapy and transfusions of EBV-specific cytotoxic lymphocytes in addition to discontinuation of immunosuppressants, and died at day +18 due to sepsis and multiple cerebral infarction. Early detection and introduction of appropriate treatment for post bone marrow transplantation LPD is necessary.

[AML(M7) associated with t(16;21)(p11;q22) showing relapse after unrelated bone marrow transplantation and disappearance of TLS/FUS-ERG mRNA].

A 3-year-old boy with poorly prognostic acute megakaryoblastic leukemia (AML M7) showing t(16;21)(p11;q22) karyotype underwent unrelated bone marrow transplantation (U-BMT) during his first hematological remission. The conditioning regimen consisted of BU, VP-16 and L-PAM. Engraftment was smooth, but the patient developed grade I acute GVHD. During hematological remission before U-BMT, the TLS/FUS-ERG chimeric transcript of t(16;21)(p11;q22) was consistently detectable as minimal residual disease (MRD) by RT-PCR. However, after U-BMT it soon became undetectable. There was no detectable MRD until 7 months after U-BMT, but bone marrow relapse occurred 10 months after U-BMT. We consider that U-BMT is a promising treatment for t(16;21)(p11;q22) AML. However, an intensified conditioning regimen or modification of GVHD prophylaxis is needed.

[Improved results of treatment in 30 cases of acute nonlymphocytic leukemia in childhood].

Thirty cases of childhood acute nonlymphocytic leukemia (ANLL) have been treated with intermittent, intensive multi-drug combinations during the past 5 years. Three patients never attained complete remission (CR) and 3 died of complications after less than one month of treatment. Twenty-four (86.7 %) attained CR with a median CCR of 26 months. The median for disease-free survival (DFS) among the total 30 cases was 15 months. Twelve out of the 24 CR patients have been disease-free for longer than 16 months, indicating significantly improved therapeutic results. Among the factors affecting prognosis, we found that patients with certain clonal abnormalities of leukemic cells and initial leukocytosis (greater than 40,000/microliter) had poor prognosis. Further revision of treatment should be considered for patients with high-risk ANLL.

[Therapeutic results in 22 cases of childhood non-Hodgkin's lymphoma treated by ACOP combination chemotherapy].

Twenty-two cases of childhood non-Hodgkin's lymphoma were treated during the past 8 years from 1979 to 1986. Median age was 7 years 4 months and the age range was from 2 years 4 months to 14 years 9 months, the male to female ratio being 18 : 4. Primary sites were common in the mediastinum (n = 7) and abdomen (n = 6) followed by submandibular lymph nodes (n = 3). According to Murphy's staging system, 7 were in stage I/II and 15 in stage III/IV. Histological studies of lymphoma tissues and blasts in the cerebrospinal fluid, pleural effusion or ascites revealed that 9 cases were lymphoblastic lymphoma while only 3 were defined as Burkitt's lymphoma. With our protocol of systemic combination chemotherapy (i.e. ACOP), intrathecal methotrexate and/or involved field irradiation, twenty-one out of the 22 cases (93%) attained complete remission and 14 patients are currently alive in continuous complete remission, with a median survival of 28+ months (range 6+ approximately 76+ months).