Hodgkin's disease in Costa Rica: a report of 40 cases analyzed for Epstein-Barr virus.

We studied 40 cases of Hodgkin's disease (HD) from Costa Rica for evidence of Epstein-Barr virus (EBV) in the Reed-Sternberg and Hodgkin (RS-H) cells. We also compared the epidemiologic features of these patients with previous reports of HD in industrialized and developing nations. Because Costa Ricans enjoy a relatively higher standard of living than the residents of other developing Central American nations yet live in the same general geographic region and are genetically similar, we believed that this comparison might shed additional light on the hypothesis that the prevalence of EBV in HD and the epidemiologic factors of HD are influenced by socioeconomic factors. In 16 (40%) of 40 cases, immunohistochemical studies demonstrated that the RS-H cells were positive for EBV latent membrane protein (LMP), including 1 case of lymphocytic depletion analyzed, 12 (86%) of 14 cases of mixed cellularity, and 3 (15%) of 20 cases of nodular sclerosis. All five cases of lymphocytic predominance were negative. In the 16 EBV LMP-positive cases, polymerase chain reaction studies revealed that the virus was type A in 12 cases and type B in 4 cases. Nodular sclerosis was the most common type of HD, accounting for 20 cases (50%), followed by mixed cellularity, with 14 cases (35%). The relatively low prevalence of EBV in the RS-H cells of HD and the high incidence of nodular sclerosis in Costa Rica are similar to industrialized nations and are unlike HD in neighboring Central American countries. These findings further support the hypothesis that the prevalence of EBV in HD and the epidemiologic features of HD are most closely linked with socioeconomic conditions, and geographic location or ethnic heritage are of relatively less importance.

Subcutaneous tissue involvement by T-cell lymphoma. A report of 2 cases.

BACKGROUND: T-cell lymphomas may involve the subcutaneous tissue as a manifestation of generalized disease. However, T-cell lymphomas rarely present with extensive involvement of the subcutaneous fat without other sites of disease. OBSERVATIONS: We describe 2 women who presented with fever and subcutaneous nodules or masses. In case 1, the nodules were generalized and did not respond to chemotherapy. The patient died 2 months after diagnosis. In case 2, the mass was large but localized and responded to chemotherapy. The tumor subsequently recurred in a cervical lymph node 9 months later, and the patient was being treated with chemotherapy 15 months after initial diagnosis. Histologically, biopsy specimens from both patients revealed malignant lymphoma involving the subcutaneous tissue. The dermis and epidermis were not involved. At low power the lesions resembled panniculitis, but high-power examination revealed cytologic atypia of the malignant lymphoid cells. Immunohistochemical studies revealed T-cell lineage. In case 2, the neoplastic cells also expressed the CD30 antigen, were positive for Epstein-Barr virus RNA, and carried the t(2;5) (p23;q35) chromosomal translocation. We interpreted case 1 as an example of subcutaneous panniculitic T-cell lymphoma. We believe that case 2 is best classified as anaplastic large cell lymphoma of T-cell lineage. CONCLUSIONS: A variety of T-cell lymphomas rarely present with only subcutaneous tissue involvement. Knowledge of this phenomenon and recognition of the cytologic atypia of the lymphoid cells will help to prevent misdiagnosis.

Bone marrow transplantation from genetically HLA-nonidentical donors in children with fatal inherited disorders excluding severe combined immunodeficiencies: use of two monoclonal antibodies to prevent graft rejection.

OBJECTIVE: For children with life-threatening inborn errors of metabolism without a matched related bone marrow donor, transplantation from an HLA genetically nonidentical donor is the only therapeutic option. To reduce the high risk of graft rejection in this setting without increasing the conditioning regimen, a protocol based on the infusion of an antiadhesion antibody directed against the CD11a (leukocyte function-associated antigen 1 [LFA-1]) molecule was performed by the European Bone Marrow Transplantation-European Society for Immunodeficiency group with promising results. To optimize engraftment, and thereby survival, further, the additional blockade of a second important leukocyte adhesion and signalization pathway mediated by the CD2 and LFA-3 interaction was attempted in a multicenter protocol conducted by the European Bone Marrow Transplantation-European Society for Immunodeficiency group. Results of this study (ie, engraftment and survival) were compared with a historical control group that received the anti-LFA-1 antibody alone. Factors that may have affected engraftment and survival were also considered in this study. METHODS: Forty-four children with inborn errors, including inherited immunodeficiencies (excluding severe combined immunodeficiencies), Chédiak-Higashi syndrome, familial hemophagocytic lymphohistiocytosis, and malignant osteopetrosis, received bone marrow from HLA-nonidentical related donors or from HLA-identical unrelated donors at 13 European centers between August 1990 and June 1993. Bone marrow was depleted of T cells by use of either erythrocyte (E) rosetting or monoclonal antibodies (MoAbs) to prevent graft-versus-host disease. The conditioning regimen consisted of busulfan and cyclophosphamide for all patients plus etoposide for patients with osteopetrosis, familial hemophagocytic lymphohistiocytosis, and Chédiak-Higashi syndrome. Infusions of MoAbs specific for the CD11a and the CD2 molecules were started 4 and 3 days, respectively, before and continued through the first 10 and 11 days, respectively, after bone marrow transplantation (a total of 14 injections). RESULTS: The overall sustained engraftment rate was 69.8%, with full chimerism in 80.6% of patients and no late graft rejection with the use of two MoAbs versus 65.7% and 58.1%, respectively, in the control group, in which only one MoAb was infused. The overall actuarial survival rate with a functional graft was 40.9%, with a mean follow-up of 39.3 months with two MoAbs versus 37.8% with one. The engraftment rate was significantly influenced by the T-cell depletion method, with better results for recipients of E rosette- depleted marrow (78.6% vs 20% for Campath 1-M plus complement-depleted marrows). Graft-versus-host disease and the kinetics of immune reconstitution were similar in both groups. CONCLUSIONS: The overall engraftment rate and overall survival rate with engraftment in patients treated with anti-LFA-1 and anti-CD2 were similar to those in patients treated with anti-LFA-1 antibody alone. However, although the number of patients is too small to draw definitive conclusions, results from the combined use of the two MoAbs indicates a trend toward better engraftment and survival after infusion of E rosette-depleted marrow. Further improvement in survival would demand additional strategies to hasten immunologic recovery.

Transplanted sickle-cell disease patients with autologous bone marrow recovery after graft failure develop increased levels of fetal haemoglobin which corrects disease severity.

Bone marrow transplantation (BMT) is the only curative therapy for sickle-cell disease (SCD), but is not devoid of failure risk. Nine patients with severe SCD were grafted in our institution between 1988 and 1993. Six patients successfully engrafted, but three failed to engraft and had delayed autologous recovery. All patients had, prior to BMT, low levels of fetal haemoglobin (HbF < or = 3.5%). No change in HbF occurred in successfully grafted patients. In the three patients with graft failure HbF increased and remained persistently present at a high level (> or = 22%) 14 months, 16 months and 39 months post BMT, although two of the three patients were homozygous for either the Benin or the Central African Republic haplotype, a characteristic associated with low HbF level. Of interest, these three previously severely affected patients remain free of vaso-occlusive events. The mechanism responsible for the expression of high levels of HbF in our three patients with graft failure is not understood, but it protects them from the recurrence of severe vaso-occlusive crises.

Complete remission following donor leukocyte infusion in ALL relapsing after haploidentical bone marrow transplantation.

A 7-month-old boy with a high risk ALL harbouring the translocation (4;11) was grafted with an haploidentical bone marrow from paternal origin. At time of relapse, 11 months after BMT, he received donor leukocyte infusions (DLI) which put him in second CR. GVHD and pancytopenia occurred 2 weeks after DLI and were fully reversed with CsA + prednisolone. Six months later, the child continues to be in second CR, off steroid therapy, without any signs of GVHD. Our limited experience indicates that a second CR can be obtained with acceptable toxicity by DLI in very high risk ALL children who have been previously grafted with haploidentical bone marrow cells.

Effects of recombinant human granulocyte-colony stimulating factor on neutropenic mice infected with Candida albicans: acceleration of recovery from neutropenia and potentiation of anti-C. albicans resistance.

The treatment of systemic candidal infection in neutropenic patients continues to be a major problem, and only 20% of patients survive despite treatment with amphotericin B (Amph B). Granulocyte colony-stimulating factor (G-CSF) is a haemopoietic glycoprotein that appears to control the survival, cycle, activation, proliferation and maturation of neutrophil granulocytes and promoter recovery from neutropenia. Confirming previous results, we observed that subcutaneous (s.c.) injection of recombinant human (rh) G-CSF in mice (30 micrograms kg-1 daily) increased the circulating leucocyte count (fourfold) on day 5 of treatment, and led to an expansion of the bone marrow myeloid compartment. The in vivo effect of rhG-CSF on murine resistance to systemic Candida albicans infection was also studied in neutropenic mice. Neutropenia was induced by intraperitoneal injection of a single dose of cyclophosphamide (CPA, 200 mg kg-1) 4 days before C. albicans infection and 2 days before rhG-CSF treatment. rhG-CSF administration showed a protective role on mice infected intravenously (i.v.) with one million C. albicans spores; all the untreated control mice died within 8 days after infection, whereas about 40% of mice treated with rhG-CSF remained alive for the same period. Furthermore, the survival rate was greater in host animals treated with combined Amph B and rhG-CSF than in those treated with Amph B alone. The number of C. albicans colony-forming units (CFU-C. albicans) in the kidney of infected mice was lower in the rhG-CSF-treated group than in the non-treated control mice. This suggests that the severity of infection is decreased in rhG-CSF-treated host animals.

Long-term disease-free survival in a child with refractory metastatic malignant germ cell tumor treated by high-dose chemotherapy with autologous bone marrow rescues.

We report the case of a 8-month-old girl who presented with a metastatic malignant germ cell tumor (MGCT) that proved to be resistant to chemotherapy, including salvage platinum-based combination therapy, surgery, and metastatectomy. The child was then treated with high-dose carboplatin, etoposide, and cyclophosphamide with autologous bone marrow rescue (ABMR) for two courses, since the first course was well tolerated and resulted in serum alpha-f etoprotein normalisation. The child remains in complete remission 3 years post-ABMR and 4 years post-diagnosis, with no detectable treatment-related sequelae. Thus, as already reported in adults, dose-intensive chemotherapy with ABMR may have curative potential in children with refractory MGCT.

[Granulocytic sarcoma with mediastinal involvement]. / Sarcome granulocytaire avec atteinte médiastinale.

BACKGROUND: Granulocytic sarcoma is more frequent in adults; it can be a tumoral localization of acute non-lymphoblastic leukemia. This report describes an infantile case revealing an acute myeloid leukemia. CASE REPORT: A 14 month-old girl was admitted because of enlarged bilateral cervical lymph nodes. They had increased in volume over the past month and were accompanied by fever and anorexia. The liver and spleen were moderately enlarged. Hematologic data were: Hb = 7.5 g%; leucocytes = 14,900/mm3; platelets = 614,000/mm3. There were no abnormal cells. X-rays and MRI showed a mediastinal mass. Bone scintigraphy was normal but the myelogram showed a few atypical cells that were also seen in a biopsy of the cervical lymph node. Electron microscopic examination of these cells showed that they were myeloid in origin. This was confirmed by immunohistochemistry. The cytogenetic examination showed many chromosomal abnormalities in the lymph node and myelogram. The child is now recovered after nine months of chemotherapy. CONCLUSION: Diagnosis of acute myeloblastic leukemia in children is difficult when it is revealed by granulocytic sarcoma without major infiltration of bone marrow. The clinical presentation as a mediastinal mass is rare. The cytogenetic study was determinant for diagnosis.

Bone marrow transplantation corrects the splenic reticuloendothelial dysfunction in sickle cell anemia.

In sickle cell anemia (SCA), the loss of reticuloendothelial function is the result of vasoocclusive events occurring in the spleen. Such asplenia occurs early in the course of the disease and is considered to be permanent in late childhood. In this report, three patients 10, 11, and 14 years of age suffering from severe SCA and found to be asplenic were treated by bone marrow transplantation (BMT). Before transplantation, all three patients had loss of reticuloendothelial splenic function, as assessed by the presence of abundant Howell-Jolly bodies on blood smears and absence of technetium 99m (99mTc) splenic uptake. After BMT, Howell-Jolly bodies disappeared from blood smear, whereas 99mTc isotopic scan found normal isotope uptake. Our data indicate that BMT can correct "permanent asplenia" in SCA patients. However, it remains to be determined if such treatment can also correct other SCA-related organ dysfunctions.

[Indications for bone marrow graft in severe hemoglobinopathies]. / Indications des greffes de moelle dans les hémoglobinopathies graves.

Allogenic bone marrow transplantation (ABMT) is the only curative approach for sickle cell anemia and major beta-thalassemia. In sickle cell anemia, ABMT can be proposed for severe clinical disease. In major beta-thalassemia, it must be proposed to young patients who have an HLA identical familial donor.

[Bone marrow graft in hereditary diseases]. / La greffe de moelle dans les maladies héréditaires.

Since 1968, bone marrow transplantation became the first line therapy for selected metabolic and immunological hereditary disorders. Actually, advances in the supportive care in bone marrow transplantation and a better knowledge of the immunology of BMT complications has been associated with a better disease correction and an increase in long term survival. New approaches are under investigation and include: hematopoietic growth factors, enzymatic replacement and gene therapy. However at the present time BMT is still the only curative treatment for selected hereditary disorders.

[Autologous bone marrow graft in solid tumors in childhood]. / Greffe de moelle autologue dans les tumeurs solides des enfants.

Curability in children suffering from malignant solid tumor is 50%. Thus, high dose chemotherapy with or without total body irradiation followed by autologous bone marrow transplantation (ABMT) has been proposed to patients suffering from cancer either at initial diagnosis (poor prognosis tumor) or at relapse. Thanks to these studies, drugs having dose effects properties have been selected. In some tumors, ABMT has significantly improved patients median survival. It remains to be determined if: 1. high dose chemotherapy protocols with ABMT are superior to new aggressive chemotherapeutic protocol without ABMT. 2. ABMT increases the curability of high risk patients.

CD71 phenotype and the value of gallium imaging in lymphomas.

Tumor cells of 14 cases of non-Hodgkin lymphomas and 2 cases of Hodgkin disease were tested for the presence of the transferrin receptor (CD71) by flow cytofluorimetry before 67gallium imaging. It appeared that expression of CD71 phenotype was closely related to the positivity of gallium scan before therapy. We feel that this test is able to predict the avidity for 67gallium and the clinical implications are discussed.