Tumor response and toxicity after single high-dose versus standard five-day divided-dose dactinomycin in childhood rhabdomyosarcoma.

This report deals with a randomized prospective multicentric clinical trial in childhood rhabdomyosarcoma (RMS) conducted to evaluate the toxicity and the effectiveness of dactinomycin (ACT-D) administered as high, single doses v five-day, divided doses administered in combination with vincristine (VCR) and cyclophosphamide (CYC). Fifty-five group III evaluable patients (pts) less than 15 years of age with tumor size greater than 5 cm in diameter, without high-risk features of CNS involvement, and 15 group IV RMS pts were randomized to receive VAC as primary chemotherapy (CT): VCR, 1.5 mg/m2 intravenously (IV) days 1 and 8; CYC, 275 mg/m2 IV days 1 through 5; and ACT-D, 0.45 mg/m2 IV days 1 through 5 every 28 days for three cycles (33 pts), or VAC-M: CYC, 150 mg/m2 intramuscularly (IM) days 1 through 7; VCR, 2.0 mg/m2 IV day 8; and ACT-D, 1.7 mg/m2 IV day 8 every 21 days for four cycles (37 pts). Major responses (complete plus partial responses [PR]) were obtained in 67% of the VAC pts and in 70% of the VAC-M pts. Toxic effects were low, and no increased toxicity was observed in pts treated with high, single-dose ACT-D. These results confirm the effectiveness and feasibility of single, high doses of ACT-D with the advantage of requiring less pt hospitalization.

Treatment of acute myelogenous leukemia in children: results of the Italian Cooperative Study AIEOP/LAM 8204.

One hundred thirty-three children with acute myelogenous leukemia (AML) entered the multicenter Pediatric Branch of the Italian Association Against Leukemia trial AIEOP/LAM 8204 between July 1982 and May 1986. Induction therapy consisted of two courses of daunomycin (DNM) plus cytosine arabinoside (Ara-C). Those patients who achieved remission were given four courses of consolidation with DNM, 6-thioguanine (6-TG) and escalated doses of Ara-C followed by six courses of sequential continuation therapy using monthly pairs: etoposide (VP-16)/Ara-C, Ara-C/6-TG, and DNM/Ara-C. Periodic intrathecal Ara-C was used for CNS prophylaxis. One hundred seven (80%) children achieved complete remission (CR). Kaplan-Meier estimates of 3-year disease-free survival (DFS) and event-free survival (EFS) are 41% and 33%, respectively. Relapses occurred in 34 patients after 5 to 97 weeks (32 marrow; 2 marrow plus CNS). Overall, 14 patients died of complications during treatment (nine during induction; five during the postremission phase), mostly from infection. Risk factor analysis showed that induction failures occurred predominantly in children with French-American-British (FAB) M5 and in those with elevated leukocyte counts; by step-up Cox analysis, only FAB subtype was predictive of remission success. None of the variables examined was significant for predicting the duration of remission. Hyperleukocytosis was predictive of a significantly worse EFS rate. These results are encouraging and further support the use of intensive chemotherapy programs for childhood AML.

Long-term results of the Italian Association of Pediatric Hematology and Oncology (AIEOP) acute lymphoblastic leukemia studies, 1982-1995.

The first multicentric approach to childhood acute lymphoblastic leukemia (ALL) treatment in Italy started in the early 1970s when the Associazione Italiana di Ematologia ed Oncologia Pediatrica (AIEOP) was founded. Since then the AIEOP has conducted nationwide chemotherapy protocols. Results obtained in three different periods (1982-1986, 1987-1990, 1991-1995) are reported here. Treatment schedules have been characterized by a progressive intensification of systemic therapy and by a progressive substitution of protracted intrathecal therapy for cranial irradiation as central nervous system (CNS) preventive therapy. In the third period cranial radiotherapy (CRT) has been administered only to patients at high risk of relapse or with CNS involvement at diagnosis (about 15% of the overall population). A progressive improvement of therapeutic results, with a steady reduction of isolated CNS relapse rates have been obtained in the three periods considered here. The AIEOP experience shows that CRT can be safely omitted in non-high risk patients, unless they are T-ALL patients with WBC count at the diagnosis > or =100,000/mm3, and that intensification of treatment allows the improvement of overall results with a reduction of the impact of NCI prognostic criteria. Over the years, AIEOP has also continued to foster active cooperation at an international level. In the ongoing AIEOP ALL 2000 study, conducted in cooperation with the BFM group, patients are stratified according to the presence of translocations t(9;22) and t(4;11) and to treatment response (either initial steroid therapy or induction) or minimal residual disease). This cooperation will allow an adequate recruitment of patients to answer relevant randomized questions in the context of a study in which patients are stratified according to minimal residual disease findings.

Long-term bone marrow cultures in Diamond-Blackfan anemia reveal a defect of both granulomacrophage and erythroid progenitors.

The hematopoietic defect of Diamond-Blackfan anemia (DBA) results in selective failure of erythropoiesis. Thus far, it is not known whether this defect originates from an intrinsic impediment of hematopoietic progenitors to move forward along the erythroid pathway or to the impaired capacity of the bone marrow (BM) microenvironment to support proliferation and differentiation of hematopoietic cells. Reduced longevity of long-term bone marrow cultures, the most physiologic in vitro system to study the interactions of hematopoietic progenitors and hematopoietic microenvironment, is consistent with a defect of an early hematopoietic progenitor in DBA. However, stromal adherent layers from DBA patients generated in a long-term culture system, the in vitro counterpart of BM microenvironment, did not show evidence of any morphologic, phenotypic, or functional abnormality. Our major finding was an impaired capacity of enriched CD34+ BM cell fraction from DBA patients, cultured in the presence of normal BM stromal cells, to proliferate and differentiate along the erythroid pathway. A similar impairment was observed in some DBA patients along the granulomacrophage pathway. Our result points to an intrinsic defect of a hematopoietic progenitor with bilineage potential that is earlier than previously suspected as a relevant pathogenetic mechanism of the disease. The finding of impaired granulopoiesis in some DBA patients underlines the heterogeneity of this rare disorder.

Hereditary thrombocytopenia due to reduced platelet production--report on two families and mutational screening of the thrombopoietin receptor gene (c-mpl).

Hereditary thrombocytopenias represent heterogeneous clinical and genetic syndromes. They include a consistent group of families which are considered as a separate clinical entity, characterized by autosomal dominant transmission, incomplete penetrance in females, chronic thrombocytopenia with early age of onset and frequently increased platelet volume, without any other hematologic abnormality. The molecular defect in these families is still unknown. We describe 2 families in 3 generations (10 patients), and report the first study of the TPO/c-mpl system in autosomal dominant thrombocytopenia. We performed mutational screening of c-mpl coding, flanking introns and promoter regions in 2 probands from the two families by DNA sequencing. The results do not provide evidence of c-mpl sequence alterations in either of the 2 families investigated. Moreover, the normal TPO serum levels detected in 5 patients from each family leads us to exclude the possibility of a defect in TPO production in our families. Finally, the involvement of both c-mpl and TPO genes in the pathogenesis of thrombocytopenia in these two families was excluded by negative results of linkage analysis.

Vindesine in the treatment of refractory hematologic malignancies: a phase II study.

A phase II evaluation of vindesine (VDS) was carried out in 46 patients with hematologic malignancies refractory to conventional chemotherapy. Two VDS schedules were employed (at random): (A) a weekly bolus (5 mg/m2 i.v. X 4); (B) fractionated daily injections (0.5 mg/m2 i.v. q.12 h X 10, course to be repeated after 10-15 days). Complete and partial remissions were observed in acute lymphocytic leukemia (3/14 patients), acute non-lymphocytic leukemia (2/12 patients), chronic myelocytic leukemia in blastic crisis (4/12 patients) and non-Hodgkin's lymphoma (4/8 patients). Responses were seen with higher frequency in patients treated with the weekly bolus (42.8 vs 16%). Myelosuppression was the most relevant side effect in both schedules. Neurotoxicity occurred infrequently and was generally mild in degree. Further trials with VDS in combination with other drugs are recommended in hematologic malignancies.

Chemical shift resolved photoionization cross sections of amorphous carbon nitride

The various components in the N 1s photoemission spectra of amorphous carbon nitride are identified by measuring their photon energy dependence and comparing the experimental results with ab initio multiple scattering calculations. The intensity modulations with photon energy are due to the extended x-ray absorption fine structure effects.

Current use and outcome of blood and marrow transplantation in childhood according to the Italian Registry.

Since 1985 data concerning patients affected by malignant and non-malignant diseases, aged <17 years, grafted in 16 centers nationwide, have been collected and stored in a central data base organized at the Associazione Italiana di Ematologia ed Oncologia Pediatrica (AIEOP) Operation Office within the AIEOP BMT Registry. The information, collected and structurally integrated with other specific disease-oriented national data bases, permitted the elaboration and the following publication of several analyses on survival, relapse probability and transplant-related mortality for the different diseases.

G-CSF in an infant donor: a method of reducing harvest volume in bone marrow transplantation.

We report the case of a 4-year-old female with high-risk ALL in first CR who received a BMT from an 11-month-old matched sibling treated with G-CSF in order to obtain an adequate number of mononuclear cells in a limited volume of bone marrow. The absence of toxicity, efficacy of the procedure and quality of the post-transplant clinical outcome suggest such treatments are feasible and useful to overcome problems caused by donor age and/or body weight. In view of this experience we demonstrate how such an approach leads to a notable reduction in risks and in bone marrow donation costs.

Cyclosporine-A as GVHD prophylaxis in allogeneic BMT for childhood acute leukemia. AIEOP-BMT group.

We report the preliminary results of a prospective randomized study on the impact of two different dosages of Cyclosporine A (Cs-A) on probability of development of acute and chronic GVHD, transplant-related mortality (TRM), relapse rate (RR) and event-free survival (EFS). Fifty-nine pediatric patients given BMT from an HLA-identical sibling were centrally randomized to receive either Cs-A at a dosage of 1 mg/kg/die (CsA1) or at a dosage of 3 mg/kg/die (CsA3) intravenously for the first 21 days after BMT. Patients given Cs-A at a dosage of 1 mg/kg/die had a higher probability of developing acute GVHD, but a lower relapse rate, which translated into a better probability of EFS. These preliminary results to be confirmed with a longer follow-up suggest that the use of low doses of CsA is feasible even though associated with a higher incidence of GVHD, but without any increment in TRM. The reduction of immunosuppressive treatment after BMT favoured the development of a graft-versus-leukemia effect, which seems to play a relevant role in preventing leukemia recurrence and in improving the cure rate.

Use of recombinant human granulocyte colony-stimulating factor in children given allogeneic bone marrow transplantation for acute or chronic leukemia.

The role of recombinant human granulocyte colony-stimulating factor (rHuG-CSF) in myeloid recovery of children given an allogeneic bone marrow transplant (BMT) from an HLA-identical sibling for acute leukemia was evaluated in a retrospectively historically controlled study, involving 20 consecutive treated patients and 30 historical controls. In order to investigate the efficacy of rHuG-CSF in patients given a matched unrelated BMT with methotrexate as part of graft-versus-host disease (GVHD) prophylaxis, we also analyzed the kinetics of engraftment in eight further children with acute or chronic leukemia, transplanted using a volunteer donor. Patients were treated with 5 micrograms/kg/day of rHuG-CSF by 1-h intravenous infusion from day +5 until the absolute neutrophil count (ANC) was > or = 2 x 10(9)/l. No adverse effect related to treatment was observed in any patients. Children transplanted from an HLA-identical sibling and treated with rHuG-CSF reached an ANC count greater than 0.5 x 10(9)/l, 1 x 10(9)/l and of 2 x 10(9)/l in a significantly shorter time than the control group (day +9, +10 and +12, vs day +15, +22 and +29, respectively). An accelerated granulocyte production was also observed in patients receiving an unrelated transplant after a GVHD prophylaxis schedule including methotrexate, the median time to neutrophil recovery above 0.5 x 10(9)/l, 1 x 10(9)/l and 2 x 10(9)/l being +14, +15 and +17 days, respectively. In comparison to historical controls, all rHuG-CSF-treated patients had fewer days of fever, of antibiotic therapy and, only for children with HLA-compatible siblings, of hospitalization, whereas in the three groups the duration and severity of mucositis were comparable. No difference between the rHuG-CSF-treated patients and the historical controls given BMT from HLA-identical sibling was seen with regard to incidence of acute or chronic GVHD, relapse rate and actuarial event-free survival at day +100 and 1 year after transplantation. Our data suggest that in children given allogeneic BMT for acute or chronic leukemia, rHuG-CSF reduces duration of neutropenia, without increasing the rate of relapse or the incidence and severity of GVHD.

Total parenteral nutrition and home parenteral nutrition: an effective combination to sustain malnourished children with cancer.

A patient with Wilms' tumor and severe failure to thrive required total parenteral nutrition (TPN) for "catch-up" growth. This case underscores how TPN might be useful in the management of a child with cancer. Cancer cachexia, chemotherapy, radiation, and infections caused by immune suppression can lead to potentially serious macro- and micronutrient deficiencies.

Chromosomal instability in multiple endocrine neoplasia type 1. Cytogenetic evaluation with DEB test.

Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal dominant condition with high penetrance and variable expressivity, in which tumors or hyperplasia occur in two or more endocrine organs. Some authors have investigated chromosomal instability in MEN 1 and MEN 2; the results are controversial. Chromosome analyses were performed on lymphocytes from seven patients with MEN 1, four healthy first-degree relatives (three of whom were children), six phenotypically normal volunteers, and three patients with Fanconi's anemia. To evaluate chromosomal instability we analyzed phytohemagglutinin-stimulated lymphocyte cultures with and without diepoxibutane. We observed an increase in the frequency of spontaneous chromosomal alterations in four patients. After the DEB test we found an increase in chromatid breakages, gaps, and exchange figures. These findings support the inclusion of the MEN 1 syndrome among the disorders with "chromosomal instability."

Neuronal cell differentiation of human neuroblastoma cells by inducing agents in combination.

The antineoplastic drug 4'-iodo-4'-deoxydoxorubicin (IDX), a new halogenated anthracycline (1), was examined as a differentiation inducing agent on the human neuroblastoma cell lines TS12 and SK-N-MC. IDX induced morphological and biochemical differentiation and growth inhibition. The effect of a combined treatment of IDX with retinoic acid (RA) and with nerve growth factor (NGF) respectively was then investigated. The responses of neuroblastoma cells to IDX alone and to these combined treatments were compared, with respect to neuritic outgrowth, acetylcholinesterase activity and cellular growth. The data obtained indicate that the combination of differentiation-inducing drugs may be able to enhance the effects of the same drugs given alone.

Different responsiveness of normal and leukemic hemopoietic cells to esorubicin.

The effect of different Esorubicin concentrations (10(-7) M to 10(-10) M) has been tested on the in vitro growth of human normal hemopoietic progenitor cells and of three leukemic cell lines (K562, U 937, HL60). The highest drug concentration completely abolished both normal and leukemic proliferation. Lower doses of Esorubicin failed to induce any morphological or phenotypic differentiation of leukemic cell lines. A 24h pretreatment of the cells with 10(-9) M Esorubicin enhanced the in vitro proliferation of normal early myeloid progenitor cells, whereas it did not affect leukemic, myelomonocytic cell proliferation.

Growth inhibitory and differentiating effects of sodium butyrate on human neuroblastoma cells in culture.

The effect of sodium butyrate (NaB) on cell growth and expression of morphological and biochemical properties was examined in the human neuroblastoma cell lines AF8 and SJ-N-KP. The obtained data show that NaB induced a marked growth inhibition and morphological differentiation, while it was ineffective in inducing biochemical differentiation.

Inhibitors of protein kinases induce differentiation in human neuroblastoma cell lines.

We investigated the effect on differentiation of genistein, an inhibitor of tyrosine protein kinase, and 1-(-5 isoquinolinylsulfonyl)-2-methylpiperazine (H7), an inhibitor of protein kinase C, in neuroblastoma cell lines. Growth inhibition and expression of morphological and biochemical properties were examined in the human neuroblastoma cell lines TS12 and SJNKP. Genistein and H7 induced neurite outgrowth, increased acetylcholinesterase activity and cell growth inhibition in both cell lines. These results underline that tyrosine protein kinase and protein kinase C may play a key role in the control of differentiation and proliferation of neural cells.

Effectiveness of differentiation inducers in combination on human neuroblastoma cells in vitro.

The effects of epirubicin and retinoic acid (RA) as differentiation inducing agents on human neuroblastoma cell lines were investigated. We have compared the response of neuroblastoma cells to epirubicin alone, to RA alone and to combined treatment, with respect to neuritic processes outgrowth, acethylcholinesterase activity, growth inhibition and antigenic expression. The obtained data indicate that the combination of the two agents is able to produce a synergistic effect on differentiation and on growth inhibition.

Gamma radiation-induced differentiation on human neuroblastoma cells in culture.

We have studied the effect of gamma radiation on differentiation in neuroblastoma cell lines AF8 and SJ-N-KP. Growth inhibition and morphological and biochemical differentiation have been examined following radiation exposure to 1-10 Gy. Gamma radiation induced marked growth inhibition and morphological differentiation in a dose-and time-dependent manner in both cell lines, and induced biochemical differentiation in AF8 cells.

Cruciate paralysis from a Jefferson's fracture. Report a case and review of the literature.

A case of post-traumatic cruciate paralysis with a Jefferson's fracture was observed in a 54-year-old patient who fell accidentally. Cruciate or Bell's paralysis is a condition caused by incomplete cervical spinal cord lesion linked to focal and reversible damage of the pyramidal tract at the level of the decussation. The patient was treated by S.O.M.I. brace and a Philadelphia collar with a complete neurological restitution.