In vivo purging of bone marrow in children with poor-risk neuroblastoma for marrow collection and autologous bone marrow transplantation.

PURPOSE: To evaluate the following prospectively in poor-risk neuroblastoma (NBL) patients: (1) the feasibility and efficacy of in vivo purging of bone marrow; and (2) the outcome after autologous bone marrow transplantation (ABMT) when immunologically tumor-free, unpurged autografts were used. PATIENTS AND METHODS: Twenty-three children with poor-risk NBL were evaluated during induction chemotherapy by repeat bone marrow examinations, including aspirate, biopsy, and an immunofluorescence method using the anti-GD2 monoclonal antibody 3A7. Nineteen patients completed the program with surgery with or without local irradiation followed by ABMT. RESULTS: Autologous bone marrow grafts, both immunologically and cytologically clean, were obtained and used in 19 of 23 children. The overall 4-year disease-free survival of the 19 grafted children was 53%, with a toxic death rate of 16% and a posttransplant relapse rate of 37%. According to the in vivo purging efficacy of the 18 children with initial marrow disease, the following three groups were formed: patients with (1) perfect in vivo purging (n = 5); (2) eventually successful in vivo purging (n = 8); and (3) unsuccesful in vivo purging (n = 5). The 4-year DFS was 100%, 67%, and 0%, respectively (P < 0.001). The five patients with unsuccessful in vivo purging failed because of resistant/progressive bulky disease. CONCLUSION: In patients with poor-risk NBL, in vivo purging of bone marrow by conventional chemotherapy is feasible, can be monitored, and the purging efficacy during the first 3 months after diagnosis is a strong prognostic factor reflecting tumor responsiveness to therapy. Autografting with immunologically clean, unpurged marrows gives a DFS well comparable to previous studies using ex vivo purging.

Surgically treated patients with axial and peripheral Ewing's sarcoma family of tumours: A population based study in Finland during 1990-2009.

BACKGROUND: The surgical treatment of Ewing's sarcoma family tumours (ESFTs) is challenging especially with axial tumours. The aim of the study was to analyse surgical treatment and outcome in a nationwide, population-based material consisting of surgically treated axial and peripheral ESFTs of bone and soft tissue. METHODS: The data were collected from the Finnish National Cancer Registry and the medical records of patients diagnosed during 1990-2009. Fifty-seven patients with surgically treated ESFTs were included, 22 with an axial and 35 with a peripheral primary tumours. The surgical treatment, its complications, survival and prognostic factors were analysed. RESULTS: Fifty-four patients underwent surgery with a curative intent and three underwent de-bulking operations. Bone reconstruction was performed in six patients with an axial and 15 with a peripheral tumour. Positive resection margins were associated with a worse five-year local relapse-free survival (33% vs. 84% for those with resection margins free of tumour cells, p = 0.003). The five-year sarcoma-specific survival was affected only by an axial location of the primary (61% vs. 89% for those with a peripheral tumour, p = 0.031). The late complications were mainly associated with bone reconstruction and more frequent among patients with a peripheral compared to an axial tumour (p = 0.031). CONCLUSIONS: In the treatment of ESFTs, achieving adequate resection margins is crucial to avoid local relapses. Surgical complications are common particularly with bone reconstruction.

sIgA- and IgM-containing cells in the intestinal mucosa of iron-deficient rats.

The effect of iron deficiency on the jejunal mucosa was studied in postweaning rats that had received a 3-wk regimen of either iron-deficient or iron-sufficient diet (iron content 6 and 50 mg/kg diet) and in rats given the iron-sufficient diet for 1 wk after the initial 3-wk iron-deficient diet. Morphometric analysis showed little difference in villous height but a significant decrease in mitotic index of the crypt epithelial cells in the iron-deficient group. Direct immunoperoxidase studies showed that iron-deficient rats had substantially fewer sIgA- and IgM-containing cells than iron-sufficient rats. This abnormality was reversed after a 1-wk iron-sufficient diet. We conclude that iron deficiency may impair local immunity in the intestinal mucosa, sensitizing the surface epithelial cells to damage by noxious agents. Similar changes might lead to the syndrome of iron-deficiency anemia and hypoproteinemia in children.

Growth failure and growth hormone deficiency in children after bone marrow transplantation for leukemia.

Eleven patients between the ages of 6 and 18 years who had been treated for acute leukemia were investigated for growth and growth hormone (GH) secretion. All had undergone bone marrow transplantation (BMT) between 0.7 and 5.1 (median 2.0) years previously. Preparation of patients for BMT had included high-dose cyclophosphamide and total body irradiation. In the eight patients at risk of growth failure, the relative height decreased 0.5-2.5 SD units (median 1.0) during the follow-up period. Eight patients secreted subnormal amounts of GH as studied by measuring spontaneous pulsatile GH secretion overnight. The maximal nocturnal GH peak varied between 3.3 and 28.3 micrograms/l (median 9.3). The mean nocturnal GH concentration varied from 1.2 to 8.3 micrograms/l (median 2.3) and depended on the length of the follow-up period. We conclude that deficient GH secretion is one reason for poor growth after BMT. A good growth response to GH substitution would support the role of GH deficiency in the observed growth retardation after BMT.

Work performance in iron deficiency of increasing severity.

The effect of iron deficiency on work capacity was studied in groups of rats that had received diets with iron contents ranging between 9 and 50 mg/kg diet from 3 to 6 wk of age. Maximal O2 consumption (VO2max) declined only 16% with a decrease in hemoglobin (Hb) from 14 to 8 g/dl and fell sharply only below a Hb of 7 g/dl. Duration until exhaustion in a treadmill exercise of submaximal intensity (endurance) showed no significant depression between a Hb of 14 and 10 g/dl. However, endurance declined abruptly by 73% between a Hb of 10 and 8 g/dl. The VO2max results are in accord with known compensatory mechanisms that help to maintain delivery of O2 to tissues until anemia becomes severe. The sharp fall in endurance with relatively mild iron deficiency suggests a lack of similarly effective compensations for decreased oxidative capacity of muscle.

Chromosome abnormalities in 16 Finnish patients with Burkitt's lymphoma or L3 acute lymphocytic leukemia.

Eleven patients with Burkitt's lymphoma (BL), i.e., small noncleaved non-Hodgkin's lymphoma, and 5 patients with Burkitt-type acute lymphocytic leukemia (ALL-L3) were selected for chromosome study. Two of the 16 patients had no B-cell markers, but the erythrocyte marker--glycophorin A--was present on the surface of the leukemic blasts. The critical breakpoint at 8q24 was detected in 14 of the 16 patients, whereas this aberration was not detected in any of the 134 patients belonging to other subgroups of non-Hodgkin's lymphoma or ALL that we studied during the same period. In addition to the t(8;14)(q24;q32), the following translocations with the breakpoint at 8q24 were seen: t(2;8)(p11;q24), t(8;11)(q24;q13) in BL, and t(2;8;14)(p11 or p12;q24;q32) in ALL. Additional aberrations seen more than once were trisomy #7 and abnormalities in chromosomes #1, #11, and #13.

Cell differentiation in sacrococcygeal teratomas. An immunohistochemical and follow-up study.

The cell differentiation properties of thirty-four sacrococcygeal teratomas (SCT) and their five recurrences were immunohistochemically studied for the expression of different classes of intermediate filament proteins, muscle actin (MA) and S-100 protein. Out of thirty-nine tumors twenty-three were SCTs with only mature tissue elements, seven immature teratomas, five pure endodermal sinus tumors (EST) and four ESTs or embryonal carcinomas (EC) combined with mature components. Cytokeratin positivity was found in all epithelial structures and sometimes also in smooth muscle and primitive mesenchymal cells. An intense cytokeratin immunoreactivity was observed in EC and EST components. Muscle markers, desmin and MA were present in smooth and striated muscle cells. Focal desmin positivity was also found in some epithelial structures in two cases. Glial tissue positive for glial fibrillary acidic protein (GFAP) was found in twenty-eight out of thirty-nine tumors. Some cases with no apparent glial tissue in hematoxylin and eosin staining showed glial differentiation as proved by GFAP positivity. In six out of eleven choroid plexus-like tissues GFAP positive cells were observed. S-100 protein showed an intense distribution of immunoreactivity outside neural tissue, and focal positivity was observed in malignant epithelial structures. Immunohistochemical markers did not reveal any prognostic significance in teratomas. Our findings, however, showed some aberrant features of cell differentiation from normal mature tissue components but closely parallel to those found in normal fetal development.

Digital gene expression profiling of primary acute lymphoblastic leukemia cells.

We determined the genome-wide digital gene expression (DGE) profiles of primary acute lymphoblastic leukemia (ALL) cells from 21 patients taking advantage of 'second-generation' sequencing technology. Patients included in this study represent four cytogenetically distinct subtypes of B-cell precursor (BCP) ALL and T-cell lineage ALL (T-ALL). The robustness of DGE combined with supervised classification by nearest shrunken centroids (NSC) was validated experimentally and by comparison with published expression data for large sets of ALL samples. Genes that were differentially expressed between BCP ALL subtypes were enriched to distinct signaling pathways with dic(9;20) enriched to TP53 signaling, t(9;22) to interferon signaling, as well as high hyperdiploidy and t(12;21) to apoptosis signaling. We also observed antisense tags expressed from the non-coding strand of ~50% of annotated genes, many of which were expressed in a subtype-specific pattern. Antisense tags from 17 gene regions unambiguously discriminated between the BCP ALL and T-ALL subtypes, and antisense tags from 76 gene regions discriminated between the 4 BCP subtypes. We observed a significant overlap of gene regions with alternative polyadenylation and antisense transcription (P<1 × 10(-15)). Our study using DGE profiling provided new insights into the RNA expression patterns in ALL cells.

Immunohistochemical study of intestinal biopsies from children with atopic eczema due to food allergy.

In 18 patients with skin reactions after food challenge and in controls the numbers of immunoglobulin-containing cells in the intestinal mucosa were studied by the direct immunoperoxidase technique; IgE and C3 were studied by FITC-conjugated sera also. Serum immunoglobulins, complement fractions 3 and 4, and reaginic antibodies to the foods were measured during the provocation. None of the patients had any deficiency in the numbers of immunoglobulin-containing cells in the intestinal mucosa or in the serum immunoglobulin concentrations. The numbers of IgM- and IgA-containing cells were higher in the patients than in the controls. But patients and controls had equally low numbers of IgE-containing cells. No deposits of C3 were seen in any of the biopsy specimens. Serum IgE was increased in 13 cases. The presence of reaginic antibodies to cow's milk and cereals correlated well with the clinical reaction (12/15 and 5/7 of the cases). There was a negative correlation between the logarithm of serum IgE and the number of IgA-containing cells in the jejunal mucosa (P less than 0.01). High prechallenge counts of blood eosinophils were seen in seven cases and these showed a close correlation with the eosinophils in the jejunal mucosa (P less than 0.001).

Time of appearance of immunoglobulin-containing cells in the mucosa of the neonatal intestine.

In 46 intestinal specimens from infants 2 hr to 6 months old, the numbers of immunoglobulin-containing cells were counted by the direct immunofluorescent or direct immunoperoxidase technique. A restudy was made of biopsy specimens taken for diagnostic purposes, 34 from the rectum and 3 from the transverse colon of 30 infants at the Children's Hospital, Helsinki in 1971-1977, and in addition, of autopsy material recently collected from the intestines of 9 infants. Up to the age of 12 days, no immunoglobulin-containing cells were seen. A small number (1 to 2) of IgM-containing cells was seen in the lymph nodes of the 2 earlier specimens taken at the ages of 6 and 12 days. A rectal specimen from a 12-day-old infant showed 24 IgA- and 60 IgM-containing cells/mm2. In rectal specimens of infants less than 1 month old, the mean number of IgM-containing cells (26/mm2) was higher than that of IgA-containing cells (14/mm2), but older infants had a significantly higher mean number of IgA-containing cells (P < 0.01). The mean number of IgM-containing cells was the same in children 1 to 3 months (53 cells/mm2) and 3 to 6 months of age (59 cells/mm2), whereas the mean number of IgA-containing cells increased with age up to 6 months (112 and 163 cells/mm2). The youngest infant who had IgG-containing cells was 13 days old, although positive staining of intercellular spaces in the lamina propria and of the capillary endothelium by anti-IgG serum was observed in all specimens. The mean number of IgG-containing cells was low (5 cells/mm2) in all age groups. Sparse IgE-containing cells (less than 12 /mm2) were seen in 4 of the 46 specimens. In 5 patients, 2 or 3 consecutive specimens were available for the study; in these, the increase in the numbers of IgA- and IgM-containing cells was similar to the mean increase in cell numbers for the series as a whole.

Leukemic coronary artery occlusion in a child with acute lymphoblastic leukemia.

A 2-year-old boy with acute lymphoblastic leukemia initially experienced pericardial effusion during the maintenance treatment due to leukemic infiltration of the pericardium and cardiac muscle. He subsequently died suddenly owing to leukemic occlusion of the left coronary artery.

Prospective and randomized comparison of early versus delayed prophylactic administration of granulocyte colony-stimulating factor (filgrastim) in children with cancer.

BACKGROUND: The prophylactic use of hematopoietic growth factors has been shown to reduce the duration of neutropenia and related complications encountered after anticancer chemotherapy. However, the optimal timing for initiation of granulocyte colony-stimulating factor (G-CSF) has not been established. PROCEDURE: We evaluated the clinical parameters of the early versus delayed start (+1 day vs. +5 days postchemotherapy) of filgrastim (G-CSF; 5 micrograms/kg) after 36 courses of anticancer chemotherapy in 18 children with cancer in randomized fashion. Each child received two identical anticancer chemotherapeutic courses followed by one early (group 1) and one delayed (group 2) administration of G-CSF. Filgrastim was administered until absolute neutrophil count (ANC) exceeded 1.0 x 10(9)/l. RESULTS: The mean duration of G-CSF therapy was 8.6 (range, 5-14) days in group 1 and 5.4 (range, 3-10) days in group 2 (P = 0.001). The mean duration of neutropenia (ANC < 1.0 x 10(9)/l) did not differ between the study groups (7.8 vs. 8.2 days). Seven infection episodes occurred in group 1 and eight in group 2, respectively. The mean number of hospital days on broad-spectrum antibiotics was 2.3 (range, 0-8) in group 1 and 3.3 (range, 0-11) in group 2 (ns). CONCLUSIONS: We conclude that the delayed start of filgrastim reduced the costs of this treatment, but was not followed by more prolonged neutropenia or febrile neutropenias.

Semi-quantitative analysis of immunoglobulins and complement fractions 3 and 4 in the jejunal mucosa in coeliac disease and in food allergy in childhood. Immunohistochemical study by light and electron microscopy.

Immunoglobulins A, M, G and E and complement fractions 3 and 4 in jejunal biopsy specimens of 14 children were stained by the peroxidase-labelled antibody technique and studied in light and electron microscopy. In addition, cryostat sections were stained with FITC-conjugated anti-C3,-C4 and -IgE sera. Five patients had coeliac disease, three intestinal cow's milk or rye allergy, three eczema due to food allergy, and in three patients, who served as controls, intestinal and immunological diseases were excluded. This study showed that increased amounts of IgA and IgM both in coeliac disease and in food allergy are produced by the plasma cells in the lamina propria of the jejunum and are secreted into the gut through the epithelial cells in a similar manner as in the morphologically normal intestine. The amount of IgG produced locally or derived from serum, was increased in coeliac disease. IgE-producing cells were rare in all patients. No deposits of complement were seen in the basement membranes or epithelial cells.

Morphometric and immunohistochemical study of jejunal biopsies from children with intestinal soy allergy.

A morphometric and immunohistochemical restudy was made of jejunal biopsy specimens from 5 patients with soy allergy and the results obtained were compared to those from specimens taken before soy feeding and to those at a later time. All the patients had had previous cow's milk allergy with malabsorption. Gastrointestinal symptoms presented within two weeks of starting the soy based formula but in two patients the symptoms were mild and these patients were able to continue soy feeding. Jejunal biopsy specimens taken within 3 days from the reaction to soy showed villous atrophy associated with crypt hyperplasia and an increased cell renewal rate. Also, these specimens showed an inflammatory reaction in the lamina propria and in the epithelium, and the numbers of IgA- and IgM-containing cells were increased. Later, when the soy proteins were eliminated, the morphology of the jejunum improved and the cell numbers were reduced to normal. The intestinal damage and the local immune reaction caused by soy proteins are similar to those seen in cow's milk allergy with malabsorption. The immunological mechanisms operating in these diseases are thought to be the cause of these changes.

Infections occurring during the courses of anticancer chemotherapy in children with ALL: a retrospective analysis of 59 patients.

In a retrospective analysis we evaluated the occurrence of infections in 59 children with acute lymphoblastic leukemia (ALL) during the entire duration of their anticancer chemotherapy. We recorded a total of 245 infection episodes, 118 (50%) being during neutropenia and 119 (50%) during nonneutropenia. The infections most commonly detected during neutropenia were fevers of undetermined origin (36%), clinically or microbiologically defined focal infections (33%), and bacteremias (28%). During nonneutropenia, upper respiratory tract infections (55%) were the most common. Patients needed hospitalization for infections for a total of 1951 days (i.e., a mean of 33 days per patient) and the mean number of infection episodes was 4.2 per patient. Recurrent fever developed in 21% of the children with bacteremia. Mortality caused by bacteremias was 10%. Infections during the chemotherapy of ALL were a significant cause of morbidity in children, but mortality was low.

A child with esthesioneuroblastoma with metastases to the spinal cord and the bone marrow.

Esthesioneuroblastoma is a rare tumor in children, and the correct diagnosis may be difficult, as is demonstrated in this case report. A 5-year-old girl was diagnosed with this tumor, which was incurable and behaved like a neuroblastoma, sending metastases to the bone marrow and invading the cranium and the spinal canal.

Prophylactic administration of granulocyte colony-stimulating factor (filgrastim) after conventional chemotherapy in children with cancer.

We evaluated granulocyte colony-stimulating factor (G-CSF) as an adjunct to courses of conventional chemotherapy in 16 children with cancer. One course followed by G-CSF (20 episodes) was compared to identical courses without G-CSF (20 episodes) in the same patients. The mean duration of G-CSF therapy was 8.8 (5-13) days. The periods of neutropenia (4.8 days versus 16.5 days; p < 0.0001), days of hospitalization for febrile neutropenia (13 days versus 65 days; p = 0.02) and days on broad-spectrum antibiotics (13 days versus 95 days; p = 0.003) were significantly reduced. With the use of G-CSF the profound neutropenia could be prevented in 11 (55%) episodes. There were two episodes of fever and neutropenia in the G-CSF group as compared to 10 febrile neutropenias in the control group (p = 0.04). G-CSF was well tolerated and did not cause additional expenses when compared to the expenses needed for the treatment of febrile neutropenias. The cost benefit analyses showed that through using G-CSF a savings was realized in the amount of U.S. $20,650 for 20 cycles of chemotherapy, i.e., U.S. $1,033/chemotherapy cycle. We conclude that the use of G-CSF was efficacious and did not increase the total costs of therapy.

Iron deficiency anaemia with hypoproteinaemia.

Forty two children were admitted to this hospital between 1975 and 1980 with severe iron deficiency anaemia and 8 of them also had oedema caused by a low concentration of serum proteins. These 8 patients, aged 8-24 months, and 13 age matched controls were investigated. The patients had excessive faecal loss of 59FeCl or 51Cr-albumin, or both; their jejunal biopsy specimens showed little decrease in the ratio of villous height to crypt depth; and they had fewer intraepithelial lymphocytes and cells containing IgA than controls. They were all treated with an oral ferrous iron preparation and the oedema, hypoproteinaemia, and low haemoglobin concentrations rapidly resolved. These results show that immunologically mediated hypersensitivity is not implicated in iron deficiency anaemia associated with hypoproteinaemia.