Genomic profiling of Acute lymphoblastic leukemia in ataxia telangiectasia patients reveals tight link between ATM mutations and chromothripsis.

Recent developments in sequencing technologies led to the discovery of a novel form of genomic instability, termed chromothripsis. This catastrophic genomic event, involved in tumorigenesis, is characterized by tens to hundreds of simultaneously acquired locally clustered rearrangements on one chromosome. We hypothesized that leukemias developing in individuals with Ataxia Telangiectasia, who are born with two mutated copies of the ATM gene, an essential guardian of genome stability, would show a higher prevalence of chromothripsis due to the associated defect in DNA double-strand break repair. Using whole-genome sequencing, fluorescence in situ hybridization and RNA sequencing, we characterized the genomic landscape of Acute Lymphoblastic Leukemia (ALL) arising in patients with Ataxia Telangiectasia. We detected a high frequency of chromothriptic events in these tumors, specifically on acrocentric chromosomes, as compared with tumors from individuals with other types of DNA repair syndromes (27 cases total, 10 with Ataxia Telangiectasia). Our data suggest that the genomic landscape of Ataxia Telangiectasia ALL is clearly distinct from that of sporadic ALL. Mechanistically, short telomeres and compromised DNA damage response in cells of Ataxia Telangiectasia patients may be linked with frequent chromothripsis. Furthermore, we show that ATM loss is associated with increased chromothripsis prevalence in additional tumor entities.

Decrease in serum tacrolimus level and rise in serum creatinine under late addition of cinacalcet in a renal transplant recipient with hyperparathyroidism: a case report.

Cinacalcet is a calcimimetic drug that has been approved for treatment of secondary and tertiary hyperparathyroidism in patients with renal failure requiring renal replacement therapy. A few cases of successful treatment in renal transplant patients immunosuppressed with cyclosporine have been reported. Herein we have reported the case of a 48-year-old renal transplant recipient presenting with secondary hypercalcemic hyperparathyroidism (parathyroid hormone [PTH] 896 pg/mL; total calcium, up to 3.3 mmol/L) under immunosuppressive therapy with tacrolimus. Owing to substantial comorbidity and a high operative risk, we decided to initiate a therapeutic trial with cinacalcet. Using a daily dose of 30 mg of Cinacalcet, normal calcium levels and a mild fall in PTH levels (decline of 62 pg/mL) were achieved within the first week of treatment. At this point, we also observed a marked decrease in tacrolimus levels (from 6.3 to 2.6 mg/dL) without any change in concomitant medications. Thus, we adapted the tacrolimus dosage. Concurrent with cinacalcet therapy, there was a rise in serum creatinine levels (from 3.9 to 4.9 mg/dL before discontinuation of cinacalcet), which was not reversible after termination of 3 weeks of treatment with cinacalcet, but continued. Cinacalcet and tacrolimus are both metabolized via cytochrome P 450. The documented decrease in tacrolimus serum levels, suggested a drug-drug interaction between tacrolimus and cinacalcet. The irreversible deterioration in renal function may be attributed to nephrotoxic properties of cinacalcet, but may also indicate an acceleration of the natural course of chronic allograft nephropathy.

Results of the SIOP 93-01/GPOH trial and study for the treatment of patients with unilateral nonmetastatic Wilms Tumor.

BACKGROUND: The treatment of Wilms Tumor is integrated into clinical trials since the 1970's. In contrast to the National Wilms Tumor Study Group (NWTSG) the SIOP trials and studies largely focus on the issue of preoperative therapy to facilitate surgery of a shrunken tumor and to treat metastasis as early as possible. PATIENTS AND METHODS: In the SIOP 93-01/GPOH trial and study 1 020 patients with a newly diagnosed renal tumor were registered. 847 of them had a histological proven Wilms Tumor, of whom 637 were unilateral localized, and 173 tumors had an other histology [40 congenital mesoblastic nephroma (CMN), 51 clear cell sarcoma (CCSK), 24 rhabdoid tumor (RTK) and 58 other tumors]. Preoperative chemotherapy in benign tumors was given to 1.3 % of the patients. The main objective of the trial was the randomized question, if the postoperative two drug chemotherapy for stage I in intermediate risk or anaplasia can be reduced from conventional 3 courses to an experimental 1 course without loss of efficacy. RESULTS: 519 patients with unilateral nonmetastatic Wilms did receive preoperative chemotherapy. The histology in this group of patients was of intermediate risk in 469 (90 %) patients, 14 (3 %) tumors were low risk and 36 (7 %) high risk. The stage distribution of the tumors was stage I in 315 (61 %), stage II N- in 126 (24 %), stage II N+ in 25 (5 %) and stage III in 36 (7 %) patients. In 17 (3 %) patients the tumor stage remained unclear. Tumor volume was measured in 487 patients before and in 402 after preoperative chemotherapy. The median tumor volume did shrink from 353 to 126 ml. The amount of volume reduction depends on the histological subtype. The event free survival (EFS) after 5 years was 91 % for all patients with unilateral Wilms tumor without distant metastasis. Randomisation was done in 43.7 % for stage I patients and there was no difference in EFS for both treatment arms (90 versus 91 %). The EFS is identical for patients with stage I and II N- (0.92), as well as for stage II N+ and III (0.82). The tumor volume after chemotherapy is a prognostic factor for intermediate risk tumors with the exception of epithelial and stromal predominant tumors. These two subtypes often present as large tumors, they do not shrink during preoperative chemotherapy but they still have an excellent prognosis. On the other hand the prognosis of patients with blastemal predominant subtype after preoperative chemotherapy is worse than in any other patient group of intermediate risk tumors. There are less blastemal predominant tumors compared to primary surgery, but they are chemotherapeutic resistant selected by the preoperative chemotherapy. CONCLUSION: Patients with unilateral Wilms tumor without metastasis have an excellent prognosis. The post-operative chemotherapy in stage I can be reduced to 4 weeks without worsening treatment outcome. The reduction of the tumor volume could be identified as a helpful marker for stratification of post-operative treatment. Post-chemotherapy blastemal predominant subtype of Wilms tumor has to be classified as high risk tumor. Focal anaplasia has a better prognosis than diffuse anaplasia and will be classified as intermediate risk tumor.

Cytogenetic and molecular characterization of simultaneous chronic and acute myelocytic leukemia.

We describe a patient initially diagnosed with a chronic myeloproliferative disorder in the accelerated phase. Cytogenetic analysis showed the presence of two independent clones. One clone contained a typical Philadelphia (Ph) chromosome due to t(9;22)(q34;q11), as the sole abnormality which was proven molecularly to result in the b2a2-BCR/ABL fusion. The other clone displayed a complex karyotype with several structural and numerical aberrations including trisomy 11 and 22 but lacking a t(9;22) or any other structural abnormalities involving chromosomes 9 and 22. Fluorescence in situ hybridization demonstrated that the t(9;22) was present only in cells with two copies of chromosomes 11 and 22. In contrast, cells with trisomies 11 and 22 lacked evidence for a BCR/ABL fusion. Based on the genetic findings, simultaneous chronic and acute myelocytic leukemias were diagnosed rather than a blastic phase of a chronic myelocytic leukemia.

Pharmacokinetics of native Escherichia coli asparaginase (Asparaginase medac) and hypersensitivity reactions in ALL-BFM 95 reinduction treatment.

Repeated asparaginase treatment has been associated with hypersensitivity reactions against the bacterial macromolecule in a considerable number of patients. Immunological reactions may range from anaphylaxis without impairment of serum asparaginase activity to a very fast decline in enzyme activity without any clinical symptoms. Previous investigations on a limited number of patients have shown high interindividual variability of asparaginase activity time courses and hypersensitivity reactions in about 30% of patients during reinduction treatment. Therefore, monitoring of reinduction treatment was performed prospectively in 76 children with newly diagnosed acute lymphoblastic leukaemia (ALL). According to the ALL-Berlin-Frankfurt-Münster (BFM) 95 protocol, 10 000 U/m2 body surface area of native Escherichia coli asparaginase (Asparaginase medac) was given on d 8, 11, 15 and 18. In 45/76 children, trough and peak activities were determined with every dose, and also on d 4 and d 11 after the last administration. Data on asparaginase activity were not available from the remaining 31 patients, but information with regard to hypersensitivity reactions only was given. Eighteen out of 76 patients (24%) suffered a clinical hypersensitivity reaction; however, no silent inactivation was observed. Activity in the therapeutic range of greater than 100 U/l for at least 14 d was determined in 43 of the 45 patients who were analysed for enzyme activity.

Induction of immune tolerance with recombinant factor VIII in haemophilia A patients with inhibitors.

We report on 11 patients (nine unrelated and a brother pair) with severe haemophilia A and factor VIII (FVIII) inhibitor, in whom immune tolerance (IIT) was induced with recombinant FVIII (r-FVIII). Their age ranged from 11 months to 47 years. The number of exposure days (ED) at inhibitor detection varied from 11 to 130. Nine of the 11 patients were high responders ¿>10 Bethesda units (BU) with peak inhibitor levels ranging from 10 to 566 BU. The other two were low responders with peak levels between 0.7 and 2 BU. Before inhibitor detection, the patients had been receiving products of various purities. The IIT regimens were very heterogeneous, and the treatment schedule varied from a short period with 50 IU kg-1 every 2 days, followed by 100 IU kg-1 every 2 days and then 220 IU kg-1 daily. The outcome was considered successful when the inhibitor level fell to 0.6 BU or lower after IIT treatment. The outcome overall was successful in nine out of 11 patients (81.8%), with the nine successful cases comprising seven of the nine high responders (77.8%) and the two low responders. Definite failure of IIT was observed in one high responder after two different IIT regimens. A second high responder is still on IIT treatment. All patients in whom IIT was successful are currently receiving r-FVIII on demand or prophylactically at various dosages. Despite the variability of the patient characteristics and the IIT schedules, this study demonstrates that r-FVIII represents an effective alternative for the eradication of inhibitors through IIT.

Preradiation chemotherapy of children and young adults with malignant brain tumors: results of the German pilot trial HIT'88/'89.

BACKGROUND: Preradiation chemotherapy could be beneficial in malignant brain tumors, because the blood-brain tumor-barrier is disrupted after surgery, bone marrow recovery--essential for intense chemotherapy--is still intact, and CNS toxicity and ototoxicity of active drugs are lower before irradiation of a child's brain. PATIENTS AND METHODS: A neoadjuvant phase 2 and a single arm pilot trial were initiated to investigate the efficacy and toxicity of an intense multidrug regimen before radiotherapy in 147 patients aged between 3 and 29; 9 years with medulloblastoma (94), malignant glioma (22), ependymoma (21), and stPNET (10). They were treated with one or two cycles consisting of procarbazine, ifosfamide/mesna with etoposide, high dose methotrexate/CF, and cisplatin with cytarabine. RESULTS: Radiation therapy was delayed for 17-30 weeks (median 23 weeks) in 112 patients who received two cycles. Chemotherapy was well tolerated. Serious infections were observed in 20 patients, with one fatal fungal septicemia. In 69 high risk patients with a residual tumor and/or solid CNS metastases an objective response (CR plus PR) was achieved in 67% medulloblastoma, 57% stPNET, 55% anaplastic ependymoma and 25% malignant glioma. Progression-free survival (PFS) at 5 years was 57% in 14 high risk patients with medulloblastoma, who achieved a complete response (CR). After a less than CR the PFS was 20% (p = 0.01). Overall survival at 5 years was 57% in medulloblastoma, 62% in ependymoma, 36% in malignant glioma and 30% in stPNET. CONCLUSION: The HIT'88/'89 regimen was well tolerated and efficacious in regard to response rates and early PSF particularly in medulloblastoma and anaplastic ependymoma. Based on these results the prospectively randomized trial HIT'91 was designed to investigate the optimal timing of chemotherapy. Preradiation chemotherapy according to the HIT'88/'89 regimen was compared with the standard regimen using CCNU, cisplatin, and vincristine after radiation therapy. Additionally, strict quality control of the three treatment modalities was instituted to help improve the survival rates in both trial arms.

In-vivo evaluation of random donor platelet concentrates from pooled buffy coats.

Random-donor platelet concentrates (PC) prepared from pooled buffy coats have recently been described as an alternative method for platelet preparation. We evaluated such PCs in the clinical setting compared with a standard PC from platelet apheresis. PCs were prepared either from pools of buffy coats (BC-PC) or from single donors (SD-PC) with the cell separator CS-3000 plus. PCs were stored for up to 5 days before transfusion. We compared fresh PC (day 1) with stored (day 2-3) and long-stored PC (day 4-5). For analysis, platelet increment in the recipient was determined immediately and 16-22 h (mean 20 h) after transfusion, corrected for total body area and transfused platelets (CCI). A total of 316 PCs were administered to 36 thrombocytopenic patients suffering from various hematological disorders. Patients with detectable HLA or platelet-specific antibodies or splenomegaly were excluded from the study. Mean platelet content of the PC was 262 x 10(9) for BC-PC and 251 x 10(9) for SD-PC. The 20-h CCI after transfusion of fresh PC was slightly higher with BC-PC than with SD-PC (14.5 versus 11.9; p = 0.19), but values did not differ significantly between the two types of PC on any day of storage. For BC-PC, 20-h CCI decreased with further storage by 30% (10.2; p = 0.02). For SD-PC a decrease by 9% was not significant. In conclusion, platelet concentrates prepared from pools of buffy coats showed excellent transfusion results when administered fresh, but storage decreased the CCI by 30%. No significant difference from PCs from plateletpheresis was observed on any day of storage. Both types of platelet concentrates were capable of sufficient platelet increment even when stored for up to 5 days.

[Therapy-related pamphlet for patients in pediatric oncology]. / Therapiebegleitheft für Patienten der pädiatrischen Onkologie.

This notebook which is of postcard size contains important information in case of emergency and details about the current illness and treatment. It contains follow-up information about the pattern of growth, endocrinological development and assessment of renal tubular function. The necessary follow-up investigations and their frequency are summarized in a table as a guide for patients, parents and paediatricians.

Protection against UV-B by UV-A-induced tan.

Suntan is known to be protective against sunburn resulting from medium-wavelength ultraviolet radiation. Protection against UV-B by UV-A-induced pigmentation was studied by the evaluation of the erythema produced and by histologic alterations in the epidermis, including sunburn cell counts. Six subjects were deeply tanned with UV-A (mean cumulative dose, 700 joules/sq cm). The minimal erythemal dose to UV-B (300 +/- 5 nm) was established for each subject in normal skin and in UV-A-tanned areas. The UV-A tan provided measurable protection against UV-B-induced erythema. Following UV-B irradiation, 36 to 93 sunburn cells were counted per 10 mm of epidermal surface length in histologic sections of untanned skin as compared with four to seven sunburn cells in UV-A-tanned skin.

Polymorphous light eruption. Experimental reproduction of skin lesions.

The clinical features of polymorphous light eruption (PLE) are reviewed from the literature with special emphasis on the experimental reproduction of skin lesions. Our clinical experience with 180 patients is reported. In forty-three patients a newly developed UVA provocation test was performed. UVA, free of sunburn radiation (50-100 J/cm2), was administered, sometimes repeatedly up to four times, to large sites of previously involved skin. With this technic the reproduction of PLE lesions under laboratory conditions was possible in 90% of this group of forty-three patients. The diagnosis was substantiated by microscopic examination of genuine and experimentally induced lesions. Characteristic histologic features of PLE are described. Phototesting with large doses of UVA aids in confirming the diagnosis of PLE. Hitherto, this diagnosis depended often on exclusion of other dermatoses. Eusolex 8021, a UVA-effective sunscreen, blocked eruptions of PLE lesions under laboratory conditions. An effective means of treatment is offered by PUVA therapy.

[Varicose veins, chronic venous insufficiency, postthrombotic syndrome (author's transl)]. / Varizen - chronische venöse Insuffizienz - Postthrombotisches Syndrom.

A short review concerning definition, clinical relevance and therapy of varicose veins, chronic venous insufficiency and postthrombotic syndrome is given. It is proposed to define chronic venous insufficiency on a morphological base. Stage I is characterized by subfascial congestion, oedema and corona phlebectatica, stage II by induration and stasis dermatitis, stage III by the occurrence of venous ulcers. The postthrombotic syndrome is a special form of chronic venous insufficiency which can be distinguished by the clinical pattern alone.

Determination of 8-methoxypsoralen levels in plasma and skin suction blister fluid by a new sensitive fluorodensitometric method.

An improved fluorodensitometric assay for the determination of 8-methoxypsoralen (8-MOP) in plasma is described. Because of its low limit of detection (below 1 ng/spot) this method is suitable to determine the drug in skin suction blister fluid, too. The standard deviation of the procedure is 6.4% or less. Plasma and skin blister fluid levels of 8-MOP are determined 2 h following oral administration of 40-60 mg 8-MOP. They range from 0-239 ng/ml and 0-163 ng/ml, respectively. A rather close correlation (r = 0.91) between these two parameters could be observed. Thus, in cases with relatively high plasma levels sufficient skin levels can be predicted. If further investigations would prove, however, that a distinct concentration threshold required for therapeutic success exists--and recent experiments with fibroblast cultures imply that--skin blister fluid level determinations would seem highly desirable when plasma levels let us expect skin levels in the critical range. In general determination of 8-MOP skin blister fluid levels can be looked upon as a model for the evaluation of drug skin levels after systemic application in man.

[Detection of development of resistance in the short-term test (author's transl]. / Nachweis einer Resistenzentwicklung bei der Leukämie L 1210 mit dem in vitro-Kurzzeittest.

By treatment of the mouse leukemia L 1210 with cytosinarabinoside (120 mg/kg per week) a tumour cell line was developed which was resistant to this cytostatic agent. It is possible, using the short-term test, to follow the development of resistance to cytosinarabinoside.

[Exfoliative gastric cytology -- quality control (author's transl)]. / Die exfoliative Magenzytodiagnostik im Einsendelabor.

Results of exfoliative gastric cytology from two periods were compared (779 examinations in the first period, 598 in the second). In 85% of cytological examinations, a histologic diagnosis was available. 64% of histologically verified carcinoma were diagnosed by cytology, too. In the second period the percentage of false positive findings decreased from 4,7% to 1,1% and the rate of suspicious findings from 3,7% to 1,5%. The proportion of carcinomas not detected by cytology increased from 32% to 35%. The rate of correct diagnosis of two contributors remained constant (53% resp. 71%). Improvement of diagnostic accuracy depends upon better technique of yield of material by endoscopists.