[Hematopoietic stem cell transplantation with busulfanthiotepa-cyclophosphamide conditioning for pediatric patients with high-risk acute lymphoblastic leukemia].

Twelve children with high-risk acute lymphoblastic leukemia underwent stem cell transplantation (SCT) with a conditioning regimen consisting of busulfan, cyclophosphamide and thiotepa. Eight of them underwent SCT while in complete remission (CR) and the other 4 while not in CR. Three children underwent HLA-matched related bone marrow transplantation (BMT), 7 HLA-matched unrelated BMT, 1 HLA one-locus-mismatched unrelated cord blood cell transplantation, and 1 autologous peripheral blood stem cell transplantation. Grade II-IV acute GVHD was observed in 3 of the 11 allo-SCT cases, while chronic GVHD was seen in 3 of 9 evaluable cases. None of the 12 cases showed thrombotic microangiopathy, and veno-occlusive disease (VOD) was observed in 3. Nine of the patients are alive and disease-free 6-45 months after diagnosis. The event-free survival rate at 3 years was 72.2% for the 12 patients, including 8 of the 9 who received SCT during CR, and 2 of the 4 who did so while not in CR. The other 3 patients died: 2 of disease progression and 1 of VOD with pneumonia. All of those who died had undergone unrelated BMT.

[Childhood t(8;21) acute myelocytic leukemia: a comparison of clinical features and risk factors with adult cases].

Despite the abundance of reports describing adult cases of t(8;21) acute myelocytic leukemia (AML), childhood cases have received little attention. We retrospectively investigated 14 childhood cases of t(8;21) AML, and compared their clinical characteristics with those of adult cases, focusing on the risk factors for poor prognosis. Seventy-one percent of the patients had fever. Their mean leukocyte count was 12,700/microliter, and they showed decreased NAP activity. The cell surface showed positivity for CD13, 33, 19, 34, and HLA-DR. The complete remission rate was 100%, and relapse was observed in three of the patients. Bone marrow eosinophilia was present in a smaller proportion of the childhood cases than in the adult cases. Although an increased leukocyte count, tumor formation, and other risk factors have been reported in adults, there was no correlation between these factors and prognosis in our childhood cases. As children who showed AML relapse had TdT-positive blasts, detectable blast TdT activity may be a risk factor for relapse in childhood cases of t(8;21) AML. However, to confirm this, a study with a larger subject base should be conducted.

Prevention of etoposide-induced apoptosis by proteasome inhibitors in a human leukemic cell line but not in fresh acute leukemia blasts. A differential role of NF-kappab activation.

Recent research indicates that the proteasome is one of the non-caspase proteases involved in apoptotic signaling pathways. Nuclear factor-kappaB (NF-kappaB) activation, one of the key factors in apoptosis, can be prevented through abrogation of IkappaBalpha degradation by proteasome inhibition. We have investigated the effects of the proteasome inhibitors carbobenzoxyl-L-leucyl-L-leucyl-L-leucinal (MG132) and N-acetyl-L-leucinyl-L-leucinyl-L-norleucinal (LLnL) on apoptosis and NF-kappaB activation induced by etoposide, using a human leukemia cell line (U937) and leukemia blasts freshly isolated from patients with acute leukemia. Pretreatment of U937 cells with MG132 or LLnL inhibited etoposide-induced morphological apoptosis and caspase-3 activation. Furthermore, MG132 or LLnL prevented NF-kappaB activation and IkappaBalpha degradation, but not IkappaBalpha phosphorylation at Ser32. Other inhibitors of NF-kappaB activation, including pyrrrolidine dithiocarbamate (an antioxidant) and the peptide SN50 (an inhibitor of translocation of activated NF-kappaB into the nucleus), also attenuated etoposide-induced apoptosis. In leukemia blasts, although proteasome inhibitors suppressed NF-kappaB activation induced by etoposide, they were unable to prevent morphological apoptosis. Moreover, proteasome inhibitors by themselves caused apoptosis in leukemia blasts at the concentrations employed in this study. These results suggest that the role that NF-kappaB plays in apoptosis induced by etoposide in a human leukemia cell line may be different from the role it plays in freshly isolated leukemia blasts.

[Three pediatric cases of erythroleukemia: review of the literature on prognostic factors].

We encountered 3 patients with erythroleukemia who showed differing outcomes. The first patient was an 11-year-old girl who was treated with an ANLL 91 national protocol followed by bone marrow transplantation from an HLA-identical brother. She is still in complete remission after 6 years. The second patient was a 15-year-old girl. Treatment with low dose Ara-C was effective. She experienced a relapse once, but achieved her second remission with low dose-Ara-C plus vitamin D. Up to the present, she has maintained remission for 5 years. The third patient was a 1-month-old girl who initially presented with an increase of proerythroblasts with infiltration to the liver. Although her response to Ara-C and etoposide was favorable, she died of a generalized fungal infection in the leukopenic phase. Chromosomal analyses of bone marrow cells were normal for patients 1 and 2, but patient 3 had an abnormal complex karyotype. We think the prognosis for erythroleukemia in childhood is not necessarily poor in all cases. Appropriate treatment should be based on the patient's age, the proportion of proerythroblasts, and the presence of chromosomal abnormalities.

Acute pure red cell aplasia associated with allopurinol therapy.

Several investigators have reported patients with acute pure red cell aplasia (PRCA) caused by anticonvulsants, antibiotics, or antithyroid agents. Allopurinol is known to be a causative agent of aplastic anemia, but there have been few reports of acute PRCA induced by allopurinol. We describe here a 15-year-old boy who suffered from anemia 6 weeks after initiation of allopurinol therapy; his anemia immediately improved after cessation of the drug. His bone marrow showed severe erythroid hypoplasia with a myeloid/erythroid ratio of 18.6 and low expression of glycophorin A detected on cell-surface antigen analysis. No morphological abnormalities were observed in myeloid series and megakaryocytes. The prolonged plasma iron disappearance rate and the decreased plasma iron turnover rate also indicated erythroid hypoplasia. He had been free from any infections, including parvovirus B19, before manifestation of PRCA. Taken together, these results suggest a diagnosis of acute PRCA. This side effect of allopurinol should be taken into consideration.

Biomarkers in long survivors of pediatric acute lymphoblastic leukemia patients: late effects of cancer chemotherapy.

In order to elucidate the late effects of cancer chemotherapy, mutant frequencies (Mfs) at the hypoxanthine phosphoribosyl transferase (hprt) locus were evaluated in pediatric patients with early pre-B acute lymphoblastic leukemia (ALL). Hprt-Mfs were measured at least 2 years after completion of chemotherapy. Ten out of 15 patients were found to have hprt-Mfs exceeding the 99% confidence limits as calculated from observations of healthy controls. Although there was some intraindividual variation, serial measurements of hprt-Mfs with intervals of more than 6 months revealed that hprt-Mfs were fairly stable. Patients with high Mfs tended to have sibling clones as detected by clonality analysis using the T-cell receptor (TCR) rearrangement pattern, but clonality did not have a major effect on the Mfs. On the other hand, Mfs at the TCR locus and sister chromatid exchange frequency were within the normal range in all patients. These data suggest that chemotherapy can cause persistent genotoxicity in vivo in a subset of pediatric ALL patients and that the hprt-Mf is a useful method for measuring such an effect.

Analysis of mutations at the DNA repair genes in acute childhood leukaemia.

Deficiency in DNA repair capability is considered to be responsible for oncogenesis. Hereditary and sporadic cancers in various tissues have been reported to have mutations at the DNA repair genes. In this study we analysed two excision repair genes (ERCC1 and XPCC) and two mismatch repair genes (hMSH2 and hMTH1) in the leukaemic blasts of newly diagnosed paediatric patients by use of reverse transcriptase (RT)-polymerase chain reaction (PCR). Analysis of the leukaemic blasts from 15 patients demonstrated no alterations at the XPCC, hMSH2 or hMTH1 genes. Blasts from one patient with acute mixed lineage leukaemia revealed an abnormally migrated product of the ERCC1 gene by RT-PCR. His leukaemic blasts showed a reduced expression of ERCC1 protein by Western blotting. Since bone marrow cells at remission showed only normally migrated product, the ERCC1 gene mutation was considered to be specific for the leukaemic blasts. This is the first report describing a mutation at the ERCC1 gene in acute childhood leukaemia.

Second malignancy following treatment of acute lymphoblastic leukemia in children.

Second malignancy is one of the serious late effects among long-term survivors of acute lymphoblastic leukemia (ALL) in children. Of 83 newly diagnosed pediatric ALL patients at our hospital between January 1980 and December 1995, four patients were found to have second malignancies. These included MDS/AML after B-ALL, rhabdomyosarcoma after early pre-B ALL, ependymoma after B-ALL, and astrocytoma after early pre-B ALL. The mean duration from initial ALL to second malignancy was 5.2 years. The possible causes of second malignancy in these patients are discussed in this report, along with a review of recent literature.

Prospective study of mutant frequencies at the hprt and T-cell receptor gene loci in pediatric cancer patients during chemotherapy.

Mutant frequencies (MFs) at the hypoxanthine phosphoribosyl transferase gene and the T-cell receptor (TCR) gene loci were evaluated in nine pediatric cancer patients before and during anticancer chemotherapy. The study population consisted of three patients with Hodgkin's disease, four patients with neuroblastoma, and two patients with Wilms' tumor. Except for one patient with neuroblastoma and one patient with Wilms' tumor, MFs at the hypoxanthine phosphoribosyl transferase locus tended to increase during the early cycles of treatment. The elevation was most striking and persistent in patients with Hodgkin's disease. The clonal relationship was determined in mutant cells derived from Hodgkin's disease patients by TCR-gamma gene rearrangement pattern and showed that the elevation of MFs resulted from increased mutational events rather than from clonal expansion of mutants. An increase in TCR MF was also found during chemotherapy in most patients, but the time of TCR MF elevation was variable among patients. Among the chemotherapeutic agents used in this study, cyclophosphamide was considered to be the most mutagenic. Our present study clearly demonstrates that anticancer chemotherapy can induce mutagenesis in vivo in various pediatric cancer patients.

Evaluation of mutant frequencies at the hprt and the T-cell receptor loci in pediatric cancer patients before treatment.

Mutant frequencies (Mfs) at the two genetic loci, the hypoxanthine phosphoribosyl transferase (hprt) gene and the T-cell receptor (TCR) gene were evaluated in pediatric cancer patients before starting chemotherapy or radiotherapy. The study population consisted of 27 patients with various solid tumors (mean age +/- SD; 5.5 +/- 5.1 years, range; 0.2-14.5 years), 5 patients with acute leukemia (10.3 +/- 6.1, 1.3-17.0 years), and 26 healthy controls (11.6 +/- 4.0, 4.4-22.2 years). Although the age distributions were different, the mean Mf values of the hprt and the TCR loci were comparable among these three groups. On an individual basis taking the age factor into consideration, the hprt-Mfs of 3 patients with solid tumors, i.e., two patients with Hodgkin's disease and one patient with Askin tumor, were found to be well above the 95% confidence limit. There were no patients with a TCR-Mf exceeding the 95% confidence limit. These data suggest the possibility that some patients with solid tumors may be predisposed to mutational susceptibility before treatment. The assay of the hprt-Mf appears more sensitive than the TCR-Mf assay in distinguishing these patients.

Role of protein tyrosine phosphorylation in etoposide-induced apoptosis and NF-kappa B activation.

When a human myeloid cell line, U937, was incubated with etoposide (10 micrograms/mL), morphologically apoptotic cells first appeared at 3 hr and increased with time to 50% at 6 hr. Pretreatment of U937 cells for 30 min with a potent tyrosine kinase inhibitor, herbimycin A (10 microM), significantly suppressed the appearance of apoptotic morphological changes. Concomitantly, herbimycin A pretreatment prevented both high molecular weight and internucleosomal DNA fragmentation induced by etoposide. Two major bands at 30 and 66 kDa with enhanced tyrosine phosphorylation inhibited by herbimycin A were detectable after 30 min of incubation with etoposide. In addition, herbimycin A prevented etoposide-induced NF-kappa B activation. The expressions of Bcl-2 and Bax, on the other hand, were not affected by herbimycin A pretreatment. Herbimycin A was also found to inhibit 1-beta-D-arabinofuranosylcytosine-induced apoptotic changes and NF-kappa B activation. These results suggest that activation of tyrosine kinase(s) may play an important role in apoptotic processes induced by a variety of anti-cancer drugs.

NADH dehydrogenase deficiency in an apoptosis-resistant mutant isolated from a human HL-60 leukemia cell line.

An apoptosis-resistant mutant (VC-33) was selected from HL-60 by alternating exposure to camptothecin and etoposide. VC-33 cells demonstrated resistance to apoptosis as induced not only by camptothecin and etoposide but by a variety of other agents as well, including 1-beta-D-arabinofuranosylcytosine, hydroxyurea, calcium ionophore (A23187), cycloheximide, and UV irradiation. In an effort to identify the mechanism of such apoptosis resistance, a mRNA differential display analysis was used. Among a total of 12 bands with reduced expression in VC-33 cells, 1 cDNA clone was isolated that was hybridized to the wild-type transcript but not to the VC-33 transcript on Northern blotting. Partial sequence of this gene revealed 98% homology to mitochondrial NADH dehydrogenase subunit 5. When cell growth and intracellular ATP levels under glucose starvation were measured, VC-33 cells were found to be more sensitive than wild-type cells. Thus, NADH dehydrogenase deficiency may contribute, at least in part, to the mechanism of resistance to apoptosis in VC-33 cells.

Inhibition of superoxide production and chemotaxis by methotrexate in neutrophils primed by TNF-alpha or LPS.

We have demonstrated recently that methotrexate (MTX) inhibits superoxide generation and chemotaxis induced by N-formylmethionyl-leucyl-phenylalanine (fMLP) in neutrophils primed by granulocyte colony-stimulating factor (G-CSF). To extend these observations, we examined the in vitro effect of MTX on fMLP-stimulated superoxide generation and chemotaxis in neutrophils primed by either tumor necrosis factor alpha (TNF-alpha) or bacterial lipopolysaccharide (LPS). MTX inhibited superoxide generation and chemotaxis more efficiently in TNF-alpha- or LPS-primed neutrophils than in unprimed neutrophils. When either hypoxanthine or guanosine was added to the culture medium, the effects of MTX were partially counteracted. Furthermore, MTX caused a significant inhibition of both superoxide production induced by phorbol 12-myristate-13-acetate and chemotaxis induced by interleukin 8 in G-CSF-primed neutrophils. These results may support the hypothesis that neutrophils primed by different stimuli are more susceptible to the inhibitory effects of MTX on superoxide generation and chemotaxis irrespective of chemoattractants. Such an effect can be partly attributed to the perturbation of purine nucleotide biosynthesis.

Apoptosis-resistant phenotype selected by alternating exposure to camptothecin and etoposide.

We selected an apoptosis-resistant subline (VC-33) in a human promyelocytic leukemia cell line, HL-60, by alternating exposure to camptothecin (CPT) and etoposide (VP-16). When wild-type (WT) and VC-33 cells were incubated with various concentrations of either CPT or VP-16 for 4 h, VC-33 showed several-fold resistance to apoptosis induced by these agents in comparison with WT cells. VC-33 cells also exhibited cross-resistance to apoptosis induced by 1-beta-d-arabinofuranosylcytosine, hydroxyurea, a calcium ionophore (A23187), cycloheximide, or UV irradiation. The levels of protein-DNA cross-linking induced by CPT or VP-16, and the amounts of ara-CTP generation, tended to be smaller in VC-33 cells, but the difference was not sufficient to explain the difference in the sensitivity to apoptosis. The initial rise of intracellular calcium ions with A23187 and the expression of P-glycoprotein, Bcl-2, and Bcl-Xl were comparable between WT and VC-33 cells. This mutant may represent a new phenotype of resistance to apoptosis induced by a variety of agents, and may thus be useful in the study of the mechanisms of apoptosis.

Constitutive endonuclease to induce high molecular weight or internucleosomal DNA fragmentation in freshly isolated leukemia cells.

Using an autodigestion method, we investigated endogenous endonuclease(s) in leukemia cells freshly obtained from pediatric patients with various types of leukemia. Endonucleolytic activity was found to cause both high molecular weight and internucleosomal DNA fragmentation at a neutral pH in whole cell lysates of all common acute lymphoblastic leukemia (cALL) blasts, which was Mg2+-dependent and Ca2+-independent. Whole lysates from most acute myeloblastic leukemia (AML) cells possessed similar endonuclease activity, but both Mg2+ and Ca2+ were required for the activity. Our results suggest that leukemia cells of different lineages have distinct constitutive endonucleases, which may play a role in the occurrence of apoptosis in these cells.

Myelodysplastic syndrome presenting as third malignancy after non-Hodgkin's lymphoma and osteosarcoma.

The patient was initially diagnosed as having non-Hodgkin's lymphoma and was cured following treatment with prednisolone, vincristine, daunorubicin, 1-asparaginase, and cyclophosphamide. Seven years and two months later, he developed osteosarcoma in his right femur. He received chemotherapy consisting of methotrexate, carboplatin, etoposide, and ifosfamide and again obtained remission. After 2 years and 7 months, however, he was found to have pancytopenia with morphological abnormalities in the erythroid and myeloid series. Diagnosis of myelodysplastic syndrome (MDS) was made. Cytogenetic analysis of bone marrow cells revealed -5 and -7, which is typical for secondary MDS. This is a rare case of third malignancy presumably caused by alkylating agents.

Methotrexate inhibits superoxide production and chemotaxis in neutrophils activated by granulocyte colony-stimulating factor.

Treatment of circulating human neutrophils with recombinant human granulocyte colony-stimulating factor (rhG-CSF) for 30 min augmented superoxide generation and chemotaxis induced by N-formylmethionyl-leucyl-phenylalanine (fMLP) in a dose dependent manner. When neutrophils were treated with 1 microM of methotrexate (MTX) for 60 min after incubation with rhG-CSF (10 ng/ml), the effects of rhG-CSF on superoxide generation and chemotaxis were inhibited by approximately 49 and 29%, respectively. Although inhibitory effects of MTX were also seen in neutrophils not pretreated with rhG-CSF, the degree of inhibition was much less. The addition of either hypoxanthine or guanosine at a concentration of 100 microM to the culture medium significantly attenuated the effects of MTX. However, in neutrophils obtained from a patient with Lesch-Nyhan syndrome, which lacked hypoxanthine-guanine phosphoribosyl transferase activity neither hypoxanthine nor guanosine had any rescue effect. These results suggest that MTX inhibits superoxide generation and chemotaxis in rhG-CSF-activated neutrophils, at least in part, by disturbing purine nucleotide biosynthesis.

Treatment of children with congenital heart disease and growth retardation with recombinant human growth hormone.

Seven prepubertal short children with congenital heart disease were treated with recombinant human growth hormone (GH). Although complete surgical correction was performed for their heart disease at least 2 years before the start of GH therapy, improvement in growth was less than expected in these children. They received 0.5 IU kg-1 week-1 of GH daily for 2 years or more. The growth rate increased from a mean of 4.3 cm year-1 before treatment to a mean of 7.8 cm year-1 in the first year and to a mean of 6.3 cm year-1 in the second year of treatment. Their mean standardized height improved from -3.41 +/- 0.78 to -2.54 +/- 0.62 after 2 years. The mean height age difference minus the bone age difference became positive in these children. We conclude that recombinant GH increases the growth rate in children with congenital heart disease and prepubertal growth retardation.

Normal mutation frequencies of somatic cells in patients receiving growth hormone therapy.

The number of reported cases of malignancy developing in growth hormone (GH) users worldwide has increased to more than 40. However, the causal relationship between GH administration and the occurrence of malignancies is still uncertain. We investigated somatic cell mutation frequencies (Mfs) or variant frequency (Vf) at three gene loci in patients with pituitary dwarfism receiving GH therapy to clarify the genetic effect of GH. Eighty-eight patients receiving GH therapy for at least 3 months and 42 age-matched healthy controls were studied. Mfs at hypoxanthineguanine phosphoribosyltransferase (HPRT) and T-cell receptor (TCR) loci in GH users were not significantly higher than in the controls. Although a few patients seemed to have a slightly increased Vf at the glycophorin A (GPA) locus, the difference was not statistically significant. In addition, there was no tendency for the Mfs (Vf) at these loci to increase with the duration of the GH therapy. These data seem to exclude the possibility that GH induces genetic instability in patients with pituitary dwarfism who are receiving GH therapy.