Long-term results of Tokyo Children's Cancer Study Group trials for childhood acute lymphoblastic leukemia, 1984-1999.

We report the long-term results of Tokyo Children's Cancer Study Group's studies L84-11, L89-12, L92-13, and L95-14 for 1846 children with acute lymphoblastic leukemia, which were conducted between 1984 and 1999. The value of event-free survival (EFS)+/-s.e. was 67.2+/-2.2% at 10 years in L84-11, which was not improved in the following two studies, and eventually improved to 75.0+/-1.8% at 10 years in L95-14 study. The lower EFS of the L89-12 reflected a high rate of induction failure because of infection and delayed remission in very high-risk patients. The L92-13 study was characterized by short maintenance therapy; it resulted in poor EFS, particularly in the standard-risk (SR) group and boys. Females did significantly better than males in EFS in the early three studies. The gender difference was not significant in overall survival, partly because >60% of the males survived after the testicular relapse. Randomized studies in the former three protocols revealed that intermediate- or high-dose methotrexate therapy significantly reduced the testicular relapse rate. In the L95-14 study, gender difference disappeared in EFS. Contrary to the results of larger-scale studies, the randomized control study in the L95-14 reconfirmed with updated data that dexamethasone 8 mg/m(2) had no advantage over prednisolone 60 mg/m(2) in the SR and intermediate-risk groups. Prophylactic cranial irradiation was assigned to 100, 80, 44, and 44% of the patients in the studies, respectively. Isolated central nervous system relapse rates decreased to <2% in the last two trials. Secondary brain tumors developed in 12 patients at 8-22 years after cranial irradiation. Improvement of the remission induction rates and the complete omission of irradiation are currently main objectives in our studies.

Homeopathic treatment of Japanese patients with intractable atopic dermatitis.

The objective of the study was to evaluate the efficacy of homeopathic treatment of intractable atopic dermatitis (IAD). Seventeen IAD patients were given individualized homeopathic treatment in addition to conventional dermatological therapy from 6 months to 2 years and 7 months. Although all of the patients had previously been treated with conventional medicine and various psychological approaches, they had had severe conditions and shown no significant sign of improvement. The efficacy of homeopathic treatment was measured by objective assessments of the skin condition and the patients' own assessments, using a 9 point scale similar to the Glasgow Homeopathic Outcome Scale, was used. Over 50% improvement was reported in overall impression and in their skin conditions by all patients, in itchiness by 15 of the patients, in sleep disturbance by 10 out of 13 patients, in satisfaction in daily life by nine out of 12, in fulfillment at work by seven out of 11 and in satisfaction with human relations by 10 out of 14. Two detailed case histories are reported.

Homeopathic treatment of japanese patients with intractable atopic dermatitis

The objective of the study was to evaluate the efficacy of homeopathic treatment of intractable atopic dermatitis (IAD). Seventeen IAD patients were given individualized homeopathic treatment in addition to... (AU)

Growth of human T cell acute lymphoblastic leukemia lymphoblasts in NOD/SCID mouse fetal thymus organ culture.

The in vitro proliferation of T cell acute lymphoblastic leukemia (T-ALL) cells in its entirety has not been well delineated because of a lack of an appropriate culture system that mimics the growth pattern in a living body. We applied a NOD/SCID mouse fetal thymus organ culture (FTOC) for leukemic cells from fresh (one case) and frozen (seven cases) bone marrow (BM) samples of children with T-ALL. Cell growth was observed in all seven samples in the culture, reaching a proliferational peak at 4 weeks, and it was calculated that the proliferation potential was 212-to 319-fold. The FTOC-derived T-ALL cells showed similarity to the original cells morphologically and immunophenotypically, still possessed clonalities and were able to regenerate overt leukemia in NOD/SCID mice. These FTOC-derived T-ALL cells differed from ordinary cell lines because they always need FTOC support. Thus, we established a new in vitro culture for T-ALL cells. A comparison of the original and FTOC-derived T-ALL cells revealed that the proportion of cells expressing IL-7R increased in all seven cases. Sorting and re-seeding of FTOC-derived IL-7R+ and IL-7R- cells into secondary FTOC resulted in a predominant generation of IL-7R+ cells from both fractions, while IL-7R- cells proliferated more potently than did IL-7R+ cells, suggesting that a pathway for the conversion of IL-7R- to IL-7R+ exists during the proliferation of T-ALL lymphoblasts. Addition of exogenous IL-7 or neutralization with anti-IL-7 antibody did not influence the growth pattern of T-ALL cells in FTOC. The current study provides a unique assay system for the exploration of the hierarchy within human T-lymphoid leukemic cells, and should facilitate the establishment of novel therapeutic modalities.

Preparation of radioactive aldehyde-containing phosphatidylcholine.

Short-chain, aldehyde-containing phosphatidylcholine (PC), formed during the oxidation of PC, is thought to be involved in cellular responses in atherosclerosis and inflammation. Here we report a convenient procedure for a small-scale preparation of aldehyde-containing PC. PC containing an unsaturated fatty acyl chain was treated with osmium tetroxide followed by sodium periodate at room temperature. The reaction product was purified by TLC. This preparation showed a single peak on reverse-phase HPLC, and its identity was confirmed by fast atom bombardment mass spectrometry. This procedure does not require special equipment and is easily applicable for preparation of radioactive materials.

Six months of maintenance chemotherapy after intensified treatment for acute lymphoblastic leukemia of childhood.

PURPOSE: We postulated that intensification of chemotherapy immediately after remission induction might reduce the leukemic cell burden sufficiently to allow an abbreviated period of antimetabolite therapy. PATIENTS AND METHODS: Three hundred forty-seven children (ages 1 to 15 years) with previously untreated acute lymphoblastic leukemia (ALL) were enrolled onto the Tokyo L92-13 study, which excluded patients with mature B-cell ALL and patients less than 1 year old. One hundred twenty-four patients were classified as standard risk, 122 as high risk, and 101 as extremely high risk, according to age, peripheral-blood leukocyte count, selected genetic abnormalities, and immunophenotype. All subjects received four drugs for remission induction, followed by a risk-directed multidrug intensification phase and therapy for presymptomatic leukemia in the CNS. Maintenance chemotherapy with oral mercaptopurine and methotrexate was administered for 6 months, with all treatment stopped by 1 year after diagnosis. RESULTS: The mean (+/- SD) event-free survival (EFS) and overall survival rates for all patients were 59.5% +/- 3.4% and 81.5% +/- 2.2%, respectively, at 5. 5 years after diagnosis. EFS rates by risk category were similar (60. 2% +/- 6.0% for standard risk, 57.7% +/- 5.6% for high risk, and 62. 5% +/- 5.7% for extremely high risk), whereas overall survival rates differed significantly (91.2% +/- 2.7%, 80.0% +/- 4.1%, and 72.1% +/- 4.5%, respectively, P <.0001 by the log-rank test). There were 107 relapses. Eighty-five (79.4%) of these 107 patients achieved second complete remissions, with subsequent EFS rates of 61.5% +/- 7. 9% (standard risk), 42.6% +/- 8.1% (high risk), and 9.6% +/- 6.4% (extremely high risk). Of the five risk factors analyzed, only the response to prednisolone monotherapy among extremely high-risk patients proved important. CONCLUSION: Early treatment intensification did not compensate for a truncated phase of maintenance chemotherapy in children with standard- or high-risk ALL. However, 6 months of antimetabolite treatment seemed adequate for extremely high-risk patients who were good responders to prednisolone and received intensified chemotherapy that included high-dose cytarabine early in the clinical course.

Long-term follow-up of childhood acute lymphoblastic leukemia in Tokyo Children's Cancer Study Group 1981-1995.

The objectives were as follows: Firstly, to estimate the overall probability of event-free survival (EFS) and isolated CNS relapse in the studies for children with acute lymphoblastic leukemia (ALL) during the 1980s and 1990s. Secondly, to report the EFS according to presenting features and lineage. Thirdly, to evaluate the treatment results re-classified by the risks of NCI criteria. Four consecutive protocol studies were performed in the Tokyo Children's Cancer Study Group: L81-10 protocol (1981-1984, 189 patients), L84-11 (1984-1989, 484 patents), L89-12 (1989-1992, 418 patients) and L92-13 (1992-1995, 347 patients). Overall EFS at 5 years in each protocol was 56.5 +/- 3.8(1 s.e.)%, 71.0 +/- 2.1%, 67.8 +/- 2.3%, and 63.4 +/- 2.7%, respectively. The cumulative isolated CNS relapse rate at 5 years was 8.1 +/- 2.1%, 3.5 +/- 0.9%, 3.6 +/- 1.0%, 1.0 +/- 0.6. The EFS in SR/HR (standard risk/high risk) according to the NCI criteria in B-precursor ALL at 5 years was 61.9 +/- 4.3%/41.4 +/- 7.4% (lineage was not confirmed.), 72.5 +/- 2.6%/63.4 +/- 5.0%, 77.4 +/- 2.7%/56.3 +/- 4.7%, and 67.8 +/- 3.4%/56.7 +/- 5.4% in each protocol. Also EFSs according to NCI SR/HR at 5 years of T-ALL in protocols L84-11, L89-12 and L92-13 were 55.6 +/- 16.6%/60.9 +/- 10.1%, 72.7 +/- 13.4%/51.6 +/- 9.1%, and 77.1 +/- 14.4%/53.6/10.1%, respectively. The truncation of maintenance therapy to 6 months resulted in a decreased EFS in L92-13, particularly due to an increase of bone marrow relapse after cessation of therapy in SR and HR. The NCI risk criteria work properly even in the patients treated by different intensities, so that it makes the comparison possible among the patients in various groups. The overall EFSs in childhood ALL improved in 1980s, but it seemed stable or decreased in 1990s. The short maintenance therapy resulted in poor outcome in SR on the L92-13 protocol. Many of these late relapsers were effectively rescued and overall survival remained at a high level. The proportion of patients who received cranial irradiation reduced without any increase of the CNS events.

Metabolism of oxidized phosphatidylcholines formed in oxidized low density lipoprotein by lecithin-cholesterol acyltransferase.

The possible involvement of lecithin-cholesterol acyltransferase (LCAT) in the metabolism of oxidized phosphatidylcholine (PC) in plasma was investigated. A variety of oxidized products are formed from PC following oxidation of low density lipoproteins (LDL). A significant increase in LDL oxidation levels in patients with familial LCAT deficiency (FLD) has been previously demonstrated by a sensitive sandwich ELISA for oxidized LDL using the monoclonal antibody DLH3 which recognizes oxidized products of PC. In the present study, we found that LCAT produces various metabolites from oxidized PC and that oxidized PC molecules in LDL particles serve as substrates. When the neutral lipid fraction was separated by TLC after the incubation of oxidized 1-palmitoyl-2-[1-14C]linoleoyl PC with human plasma, a number of radioactive bands were formed in addition to cholesteryl ester. These products were not formed from native 1-palmitoyl-2-[1-14C]linoleoyl PC. Plasma from FLD patients also failed to form the additional products from oxidized PC. The addition of dithio-bis(nitrobenzoate) (DTNB), an LCAT inhibitor, or the inactivation of LCAT activity by treating the plasma at 56 degrees C for 30 min abolished the generation of these products from oxidized PC. The activity was recovered in the high density lipoprotein (HDL) fraction but not in the LDL fraction separated from normal plasma. When 1-palmitoyl-2-[1-14C](9-oxononanoyl) PC and 1-stearoyl-2-[1-14C](5-oxovaleroyl)PC, PC oxidation products that contain short chain aldehydes, were incubated with human plasma, radioactive products in the neutral lipid fraction were observed on TLC. LDL containing oxidized PC was measured by sandwich ELISA using an anti-apolipoprotein B antibody and DLH3. The reconstituted oxidized PC-LDL particles were found to have lost their ability to bind DLH3 upon incubation with HDL, while the reactivity of the reconstituted oxidized PC-LDL remained unchanged in the presence of DTNB. These results suggest that LCAT is capable of metabolizing a variety of oxidized products of PC and preventing the accumulation of oxidized PC in circulating LDL particles.

Characterization of leukemic cells in CD2/CD19 double positive acute lymphoblastic leukemia.

In the diagnosis of leukemia, CD2 which is a T-cell associated marker and CD19 which is a B-cell associated marker are widely used to determine the lineage of leukemic cells. It is known that the cells of acute lymphoblastic leukemia (ALL) express both CD2 and CD19 in some cases. The origins of these cells are generally thought to be a common precursor for T- and B-lymphocytes. However, cytoplasmic staining of CD3 which is a more specific marker for T-lineage and cytoplasmic staining of mb-1 (CD79a) which is more specific for B-lineage were not performed in previous reports and the determination of the cell lineages of these cells was unclear. We had two cases of ALL whose blasts were CD2/CD19 double positive. The first case was assessed as B-lineage because the cells expressed cytoplasmic CD79a and lacked cytoplasmic CD3. The immunoglobulin (Ig) heavy chain gene was rearranged. The other cell surface markers including CD22 and HLA-DR also suggested that these cells were B-lineage. The CD2 expression may be a coincidence and should not be taken as a T-cell marker in this case. It was difficult to determine the lineage in the second case because both cytoplasmic CD79a and cytoplasmic CD3 were expressed and neither TCR beta chain nor Ig heavy chain genes were rearranged. The other surface markers were not useful to determine the lineage. We concluded that this case was really an unclassified ALL. Accordingly, cytoplasmic staining of CD3 and CD79a should be carried out in the diagnosis of leukemia when it is difficult to determine the cell lineage.

[Phagocytosis of fungi in the peripheral blood neutrophils of two children with cancer during treatment with fluconazole].

We report on two children with malignancy who showed fungemia despite the antifungal treatment with fluconazole. Case 1 was a 7-year-old girl with a recurrence of stage IV neuroblastoma. She had profound neutropenia and fungemia developed after a month-long treatment with fluconazole. Her peripheral blood smear showed phagocytosis in the neutrophils and they were identified as fungi by immunofluorescence method (Fungi flora Y). She died two days after the diagnosis of fungemia. Rhodotorula rubra was isolated after her death. Case 2 was a 2-year-old boy with disseminated Langerhans cell histiocytosis. He had profound neuropenia and fungemia developed after treatment with fluconazole for 6 months. His peripheral blood smear also showed phagocytosis in the neutrophils and they were identified as fungi by Fungi flora Y. He was treated with intravenously administered amphotericin-B. However, he died 13 days after the diagnosis of fungemia. Candida guilliermondii was isolated after his death. Careful observation of the peripheral blood smear is important for early detection of fungi and Fungi flora Y is a quick and useful method to identify fungi. Fluconazole-resistant fungus should be considered when patients with neutorpenia are treated prophylactically with fluconazole for a long time.

[Terminal care at home].

When the fact that a cure is not now possible has been agreed by parents, treatment should focus on palliation. It may be better for families and patients to choose to give up second line or experimental therapy while the child is still relatively free from symptoms. Many families want to return to as normal life as possible. Pediatric oncology departments should do their best to support the patients and families under those circumstances. Our hospital has our own visiting nurse team. They are really a big help for the declining children who want to stay and die at home. Symptom management is essential. Pain should be managed after adequate diagnosis with analgesics, palliative radiation and chemotherapy. Emotional support for the child, parents, and siblings is also a critical part of terminal care.

A novel monoclonal antibody, KOR-SA3544 which reacts to Philadelphia chromosome-positive acute lymphoblastic leukemia cells with high sensitivity.

A monoclonal antibody which primarily reacted with Philadelphia chromosome (Ph1)-positive ALL cells was produced. The reactivity of a monoclonal antibody, KOR-SA3544 (IgG2a) was evaluated on normal hemopoietic cells, 68 leukemic cell lines and freshly obtained cells from 190 patients with leukemia and lymphoma. In cultured cells, KOR-SA3544 reacted with Ph1-positive ALL cell lines (5/5) and leukemic cell lines with 11q23 translocation (3/11). In lymphoid cells, KOR-SA3544 was reactive with all of Ph1-positive ALL (26/26), a part of common ALL (5/38) and one case of early B precursor leukemia with 11q23 translocation, but not with peripheral lymphocytes. Normal mature granulocytes were also strongly stained. In myeloid leukemias, KOR-SA3544 was positive (16/56) only in patients with acute myeloid leukemia with FAB-M2 and overt leukemia following myelodysplastic syndrome, but neither with other types of myeloid leukemias nor with blast crisis in chronic myelogenous leukemia. KOR-SA3544 recognized a 90 KDa protein on the membrane of a leukemic cell line, KOPN-57bi. In normal bone marrow, CD19+/KOR-SA3544+ cells were not identified, while Ph1-positive ALL cells were strongly positive for both antibodies. KOR-SA3544 is useful not only for making the diagnosis of Ph1-positive ALL but for detection of the minimal residual disease during remission.

The role of surgery in advanced neuroblastoma.

Recently we performed multi-modal therapy including chemotherapy with bone marrow transplantation (BMT), surgery, and local irradiation in the treatment of advanced neuroblastoma. As a result, all Stage III patients survived, and 4 out of 8 Stage IV patients who underwent our original systemic gross complete resection achieved long-term survival, 4y8m, 5y8m, 5y6m and 5y5m, respectively. Long-term survival patients were treated by local irradiation, brain surgery and intensive induction chemotherapy before primary site operation, and when resolution of distant metastases was obtained, the primary site was resected completely, followed by postoperative supralethal chemotherapy with BMT. The purpose of this report is to elucidate the role of surgery in advanced neuroblastoma based on our clinical results.

A case report of Stevens-Johnson syndrome with Mycoplasma pneumoniae infection.

We encountered an 8 year old boy who suffered from Stevens-Johnson syndrome with Mycoplasma pneumoniae infection. He had multiple erythema with vesicles in oral mucosa, and on his palms and feet, trunk and genital regions. We treated him with prednisolone (1 mg/kg per day) and antibiotics. His skin lesions improved dramatically, and a persistent fever and toxic general condition also showed dramatic improvement. Although the use of corticosteroids for Stevens-Johnson syndrome has recently been controversial, we thought that administration of corticosteroids was an effective treatment for some selective cases of Stevens-Johnson syndrome. The patient reported in this study had many beneficial effects in response to corticosteroid treatment.

Difficulty in removing a percutaneous central venous catheter inserted from a peripheral vein.

Two girls with acute lymphocytic leukemia (ALL) are reported. There were difficulties in removing their central venous catheters inserted from a peripheral vein. One girl required surgery under general anesthesia for the removal. The other patient received continuous infusion of low dose urokinase from a distal peripheral vein. The residual catheter was then removed successfully.

[Evaluation of modern therapy for neuroblastoma].

The clinical results were evaluated periodically in 50 cases of neuroblastoma, 4 survived cases out of 15 from 1965 to 1971, 6 survived of 16 (38%) from 1972 to 1982 and 11 survived of 19 (58%) after 1983. In the early period, before 1971, our systemic wide resection was not performed. From 1972, we operated on by our wide resection's technique which based on to preserve main vessels from tumor and lymph nodes. To separate the vessels from the lymph nodes was begun from both iliaca vessels to caeliac vessels. The systemic wide resection might contribute to improve survival rate from 1972 to 1982, however, all of 7 cases in stage IV did not survive. The best result after 1983, 58% survival rate, depends on new intensive chemotherapy accompanying with autologous bone marrow transplantation. All of 3 cases in stage III and 5 of 11 cases in stage IVA survived and better survival rates. Five alive cases in stage IVA received delayed wide resection after 3 or 4 cycles of new regimen A1, and then underwent bone marrow transplantation preconditioned by Melphalan .

Treatment of acute lymphoblastic leukemia in the Tokyo Children's Cancer Study Group--preliminary results of L84-11 protocol.

The Tokyo Children's Cancer Study Group (TCCSG) has performed prospective randomized controlled studies since 1984 for childhood acute lymphoblastic leukemia (ALL). Four hundred and ninety-eight newly diagnosed patients were treated with 5 different regimens designated as S1, S2 for a standard risk group (SRG), H1 and H2 for a high risk group (HRG) and HEX for an extremely high risk group of patients. We added intermediate-dose methotrexate as early intensification therapy in the S2 and H2 groups to reduce extramedullary and medullary relapses. Event-free survival of all patients at 4 years 6 months from the start of this regimen (median follow-up period 32 months) was 67.5%. The CNS relapse rate was significantly decreased to 2.2% compared to previously reported studies and our own experience. There were some unexpected complications of the CNS such as myelopathy and/or leukoencephalopathy. For the SRG early ID-MTX seemed to be useful to improve the prognosis, but triple intrathecal injections (TIT) should be limited in number. The 24Gy cranial irradiation (CRX) was effective but possibly excessive for the HRG. As evidenced by the success of the HEX group regimen, more intensive multi-drug consolidation in the early post-remission phase might be necessary to improve further the prognosis and to make it possible to shorten the treatment periods.

Late effects of childhood acute leukemia and its treatment.

Late effects of childhood acute leukemia and its treatment were studied in 776 patients (684 ALL, 73 ANLL, and 9 others) in Japan who had remained in remission for more than 1 year after their first complete remission. Delayed adverse sequelae involve a wide variety of organs and their functions. Short stature was present in 2.61%, obesity in 3.79%, abnormalities of growth hormone secretion in 1.5%, delayed secondary sex characteristics in 1.5% of males and 0.6% of females, motor disturbances in 1.17%, sensory disturbances in 0.91%, intellectual and learning disabilities in 2.48%, abnormal findings in routine neurologic examinations in 1.31%, EEG abnormalities in 4.30%, brain CT abnormalities in 5.09% and cardiac dysfunction in 1.07%. Various other disorders were seen in 20 patients. Many of these delayed adverse sequelae are caused by or related to central nervous system prophylaxis and systemic combination chemotherapy. The results suggest that it is needed to improve therapeutic methods through the stratification of patients by risk factors and detailed analysis of prognostic factors. Moreover it is important to render medical and psychosocial support to long-term survivors of childhood leukemia through interactions between the patient, parents and medical staff.

Principles of total care for children with leukemia--psychosocial interventions.

Today about 70% of children with leukemia are cured by intensive chemotherapy. Therefore how to deal with the children and their families before, during, and after the treatment has become a major concern for caregivers. And it is a fact that there are still a few patients who relapse and are destined to die. We are now taking care of two groups of patients. One group is truly cured and one group is dying. We have been trying to establish a good total care system that fits our society. We have formed medical teams which consist of doctors, nurses, and care workers. From our experience, we think the most important principle for the caregivers is frankness. Sometimes this is very difficult. Other important points of total care, especially from psychosocial aspects, are mentioned.