Primary non-Hodgkin's lymphoma of the spleen presenting as space occupying lesion: a case report and review of literature.

Primary splenic lymphoma (PSL) is rare with a reported incidence of less than 1%. Diffuse large cell pathology has been reported in 22-23% of the cases and is felt to have poor outcome. This study reports a 50 year old male who presented with fever and weakness. He was found to have a mass lesion in the spleen documented by CT scan. A splenectomy was performed which showed non-Hodgkin's lymphoma. Immunohistological studies showed a positivity for CD20 and CD30.

Impaired cell motility in chronic myeloid leukemic granulocytes related to altered cytoskeletal pattern.

The bactericidal activity of polymorphonuclear leucocyte (PMNL) against infection stimulates cytoskeletal changes accompanied with alteration in adhesion and locomotion. Microfilaments, the motile apparatus is known to regulate these changes by polymerization of monomeric G-actin to fibrous F-actin. PMNL from chronic myeloid leukemia (CML) patients have been reported to be defective in locomotion in response to synthetic peptide, n-formyl-methionyl-leucyl-phenylalanine (fMLP) but the mechanism leading to defective locomotion and their spatial reorganization remains unclear. Therefore, in order to study the cause of defective motility of PMNL from CML patients the spatial distribution and reorganization of microfilaments and microtubules in response to fMLP have been examined by transmission electron (TEM) and scanning electron microscopy (SEM). Under SEM, the PMNL-CML surface appeared smoother with reduced ruffling resulting in rounding off cells with lesser polarized morphology. Unstimulated PMNL from normal as well as CML subjects showed shorter and fewer microtubules and evenly distributed microfilaments as compared to fMLP stimulated PMNL. It is proposed that the cause of defective locomotion was due to reduced surface activity as a consequence of altered cytoskeletal configuration. This phenomenon seems to be related to impaired functional appendages and as a whole led to the defective cell motility and hence reduced chemotaxis in PMNL from CML patients.

Myelomatous pleural effusion.

Serous effusions in multiple myeloma are uncommon but a myelomatous pleural effusion occurring in these patients is extremely rare. Here we report a rare case of a 38 years lady who was diagnosed to have multiple myeloma and subsequently developed pleural effusion. The myelomatous nature of the effusion was first diagnosed on cytology and subsequently confirmed by a pleural biopsy. The pleural effusion showed an initial response to chemotherapy but subsequently recurred.

Safe and efficacious use of procedural sedation and analgesia by non-anesthesiologists in a pediatric hematology-oncology unit.

BACKGROUND: Children often require relief of pain and anxiety while undergoing diagnostic and therapeutic procedures. Procedural sedation and analgesia (PSA) is the safe and effective control of pain, anxiety and motion so as to allow a necessary procedure to be performed and to provide an appropriate degree of memory loss or decreased awareness. OBJECTIVE: To prospectively describe procedural sedation and analgesia as performed in the pediatric oncology unit and to report the success of sedation and the incidence of complications. METHODS: IV Midazolam and IV Ketamine were used for PSA in pediatric oncology patients undergoing painful procedures. RESULTS: Between June 2004 and December 2004, 55 diagnostic and therapeutic procedures were performed using PSA in 16 children. There were 9 boys and 7 girls with a median age of 11 years. Twelve patients had hematolymphoid malignancies and 4 patients had solid tumors. The indication for PSA were bone marrow aspiration and or biopsy in 7 patients, therapeutic lumbar puncture in 43 patients, bone marrow aspiration and lumbar puncture in 4 patients and skin biopsy in 1 patient. All 55 procedures were successfully completed. Adverse events occurred in 15 (27%) episodes and included transient drop in oxygen saturation, vomiting, dizziness and disinhibition with crying spells. Average time to arousable state and full recovery was 22 minutes and 31 minutes respectively. None of the patients complained of post procedure pain nor recalled the procedure at the follow up visit. CONCLUSION: Procedural sedation and analgesia using midazolam and ketamine is a safe and efficient method of limiting anxiety and procedure related pain and can be successfully administered by non-anaesthesiologists. The complication rate is low and can be easily managed.

Total body irradiation in chronic myeloid leukemia.

Total body irradiation (TBI), given as 10 rad daily for five days a week for a total dose of 150 rad has been used in an attempt to control the chronic phase of chronic myeloid leukemia (CML). Thirteen patients with CML received fractionated TBI leading to rapid and good control of WBC count without any adverse reaction. The chronic phase of CML could also be controlled with TBI, even in three patients who were resistant to busulfan. Following TBI, WBC count remained under control for a period of 32 weeks as compared to 40 weeks following busulfan alone. Repeat TBI was also well tolerated with good response. It appears that TBI is an effective and safe therapy for controlling the chronic phase of CML.

Generation and characterization of lymphokine-activated killer cells from non-Hodgkin's lymphoma patients.

Lymphokine-activated killer cells generated from peripheral blood of Non-Hodgkin's lymphoma patients showed comparable levels of cytotoxicity. The patients with advanced disseminated disease displayed better augmentation with recombinant interleukin-2 (rIL-2) than the patients with localized disease. Thus, the defective cytotoxic potential of patients could be corrected in a culture of effector cells with IL-2. The indigenous ability to produce IL-2 in response to activation of peripheral blood mononuclear cells with phytohemagglutin showed slight depression and a positive correlation with the stage of the disease. Phenotypic analysis revealed a heterogenous population of cells involved in cytotoxic activity. Thus, IL-2 merits further evaluation in malignant lymphomas, particularly in relation to other variable therapies in conjunction with chemotherapy.

Growth factors in chronic myelogenous leukemia.

Transforming growth factors (TGFs) are implicated in malignancy, therefore qualitative and quantitative differences of these growth factors in chronic myelogenous leukemia (CML) in chronic phase has been investigated in this report. Induction of anchorage independent growth of BALB/c 3T3 and NRK-49F fibroblasts was used as an assay to detect TGF-beta activity in sera, serum free leukocyte and stromal conditioned medium of CML patients as well as normal subjects. The data shows that enhanced levels of transforming growth factor (type beta like activity) are detectable in the sera of chronic myelogenous leukemia patients. We believe that the enhanced levels of TGF-beta type activity may have a role in myeloid hyperplasia characteristic of CML patients in chronic phase of the disease.

Restriction fragment length polymorphism of the L-myc oncogene in non-Hodgkin's lymphoma patients from India.

We examined 89 non-Hodgkin's lymphoma (NHL) patients of Indian origin for EcoRI restriction fragment length polymorphism (RFLP) of the L-myc gene with a view to testing the hypothesis that the presence of the L-myc S-allele predisposes towards NHL. We found no significant difference either in the distribution of the LL, LS and SS genotypes or in the allelic frequencies between the patient group and the control group with the frequencies of L-myc alleles, L (10.0 kb) and S (6.6 kb), being 0.56 and 0.44, respectively, in the patient group and 0.54 and 0.46, respectively, in the control group. However, a higher proportion (70%) of the S-allele was observed in our control group of normal healthy volunteers. Thus, the presence of L-myc S-allele did not indicate increased susceptibility or predisposition to the malignancy.

Head and neck extranodal non-Hodgkin's lymphomas in Indian patients.

Though radiotherapy has traditionally been the treatment of the choice for the patients with localised extranodal lymphomas of the head and neck areas, its adequacy as the sole modality of treatment has come to be questioned. The disease is shown to relapse in other distant extranodal sites especially the gastrointestinal tract. The addition of systemic chemotherapy has been suggested. Fifty-five patients with localised head and neck extranodal lymphomas were treated at the Tata Memorial Hospital during the period 1976-1982, 35 with radiation therapy alone and 20 with combination therapy. The total survival at 5 years was 65% for patients treated with radiation alone and 85% for those treated with combination therapy. The 5 year disease-free survival dropped to 45% for the former group but was 74% for the latter group. This difference was statistically significant (p less than 0.01). We infer that localised extranodal lymphomas be regarded as a systemic disease and be treated by a multimodal approach.

Protein kinase C isoforms in normal and chronic myeloid leukemic neutrophils. Distinct signal for PKC alpha by immunodetection on PVDF membrane, decreased expression of PKC alpha and increased expression of PKC delta in leukemic neutrophils.

Neutrophils from patients with Chronic Myeloid Leukemia (CML) exhibit defects in several functions. They also show altered phosphorylation-dephosphorylation patterns of several proteins on stimulation with phorbol myristate acetate--a direct activator of protein kinase C (PKC). Since PKC mediates several functions of the neutrophil, in this study we investigate the PKC isoform profile and subcellular distribution in normal and CML neutrophils in an attempt to elucidate their role in CML signalling. Our results show the presence of PKC alpha, betaI, betaII and delta in both the cell types. A distinct and clear signal was obtained for PKC alpha, the isoform reported to be absent or present in very low amounts in normal neutrophils. In addition, PKC alpha was present in significantly lower levels in CML neutrophils while the PKC delta isoform was found in significantly higher amounts in the CML cytosol as compared to that in normal cells. PKC alpha, betaI, betaII and delta isoforms could not be detected in the nucleus of unstimulated normal and CML neutrophils. The altered levels of PKC alpha and delta may be one of the causes for the defects in function exhibited by the leukemic cells.

Chronic myeloid leukemia granulocytes have lower amounts of cytoplasmic actin.

Chronic myeloid leukemia (CML) granulocytes had earlier been shown to be defective in microfilament mediated phenomena such as chemotaxis and fluid phase pinocytosis when compared to normal granulocytes. The present studies were carried out to determine whether a quantitative alteration in actin or a change in isoform status could be responsible for some of the defects. Relative proportions of beta and gamma isoforms were found to be unaltered between normal and CML granulocytes. The amount of actin was significantly lower in CML cells. When the actin was expressed as percent of total protein in the granulocytes, it was found to be significantly lower in CML cells. The lower amount of actin may be responsible for some of the defects seen in CML cells.

Potentiation of hydroxyurea cytotoxicity in human chronic myeloid leukemia cells by iron-chelating agent.

The effect of hydroxyurea (HU) was studied in 15 cases of human chronic myeloid leukemia cells (CML) in combination with iron-chelating agent, 2,2-bipyridine (bipyridine). The extent of (3H)thymidine incorporation in CML cells in vitro was taken as an index for the measurement of cytotoxicity. In the present study, we observed a potentiation in HU cytotoxicity by hydrophobic iron-chelator bipyridine (p less than 0.001) resulting in complete DNA biosynthesis inhibition. Both HU and bipyridine were used at a relatively non-toxic concentrations of 10(-4) M and 10 micrograms/ml, respectively. This inhibition was found to be partially reversible and a partial protective action by iron is also demonstrated. The various other metal chelators failed to sensitise CML cells to HU cytotoxicity. Implications with respect to the efficacy in cancer treatment is discussed.

Flow cytometric studies on actin polymerization in PMN cells from chronic myeloid leukemia (CML) patients.

Studies in our laboratory have shown that polymorphonuclear leucocytes (PMNL) from chronic myeloid leukemia (CML) patients are defective in chemotaxis towards a synthetic peptide, n-formyl-methionyl-leucyl-phenylalanine (FMLP), during the active phases of the disease and in remission. Actin plays a major role in cellular movements and binding of chemo-attractant to cells induces polymerization of G-actin to F-actin. We have, therefore, compared polymerization of actin in FMLP stimulated PMNL from CML patients with those from normal subjects by fluorescence microscopy and flow cytometry, using F-actin specific probe, NBD-phallacidin. Our results show that binding of FMLP to normal PMNL induces rapid conversion of G-actin to F-actin followed by depolymerization to some extent. In CML PMNL, such a biphasic response is not seen. Conversion of G-actin to F-actin is slower and F-actin content is significantly lower than that in normal PMNL. Moreover, organization of F-actin is different in CML PMNL as compared to that in normal PMNL.

Chronic myeloid leukemic granulocytes exhibit decreased adhesion to fibronectin.

Extracellular matrix components are known to regulate the process of egress of granulocytes from the bone marrow and their emigration to inflammatory sites. In this study we have compared the adhesion of normal and chronic myeloid leukemic granulocytes to fibronectin. Adhesion of granulocytes from leukemic patients to all the different concentrations of fibronectin assessed was significantly lower than that of normal individuals. This observation suggests that the decreased adhesion of leukemic cells to fibronectin may be responsible for their early egress from the bone marrow and their delayed emigration to the sites of inflammation.

Fluid pinocytosis and esterase-oxidase in chronic myeloid leukemic granulocytes are differentially stimulated by chemotactic peptide.

Binding of a chemotactic peptide, n-formyl-methionyl-leucyl-phenylalanine (FMLP) to polymorphonuclear leukocytes (PMNL) leads to a series of biochemical and functional events. We have studied stimulation of fluid phase pinocytosis (FP), esterase and oxidase by FMLP in CML PMNL, by flow cytometry. Stimulation of FP in CML PMNL was lower than that in normal PMNL but, stimulation of esterase and oxidase was comparable to that in normal PMNL. Thus, early response to FMLP which is dependent on the integrity of actin network seems to be defective in CML PMNL.

PMN cells from chronic myeloid leukemia (CML) patients show defective chemotaxis in remission.

The chemotactic index (C.I.) of granulocytes from chronic myeloid leukemia (CML) patients at diagnosis and in subsequent remission was measured using different concentrations of the synthetic chemotactic peptide, N-formyl-methionyl-leucyl-phenylalanine (FMLP), by time lapse cinematography and compared with that of normal granulocytes. The C.I. of CML polymorphonuclear leucocytes (PMNL) at diagnosis and in remission was significantly lower than the C.I. of PMNL from normal subjects (p less than 0.001 and 0.05 greater than p greater than 0.02, respectively). PMNL from CML patients at diagnosis showed increased speed after stimulation with FMLP. In most of the CML patients, the highest values of C.I., speed and the number of motile cells were obtained at FMLP concentrations of 10-100-fold higher than those required for normal PMNL. These results suggest an alteration in the interaction between FMLP and its receptors and that events occurring after FMLP binding are also altered. It was earlier shown that PMNL from CML patients in the active stages of the disease show defective chemotaxis. Present studies show persistence of such defective cells in the peripheral blood of CML patients in remission. These results also suggest that defects in PMNL from CML patients in remission. These results also suggest that defects in PMNL from CML patients may be constitutional.

Chronic myeloid leukemic granulocytes exhibit reduced and altered binding to P-selectin: modification in the CD15 antigens and sialylation.

Granulocytes from patients with chronic myeloid leukemia (CML) egress from the bone marrow before they are functionally mature and exhibit delayed emigration to sites of infection. To understand these defects, we have compared the binding of normal and CML granulocytes to the 293 cell line transfected with cDNA for P-selectin. The CML granulocytes show significantly reduced binding to P-selectin relative to normal cells. The binding of normal granulocytes to P-selectin was significantly reduced when the cells were treated with anti CD15, polyclonal anti-P-selectin, monoclonal anti-P-selectin (G1) antibodies or neuraminidase. On average, only 8% of the CML granulocyte population bound to P-selectin. The antibodies and neuraminidase were ineffective in inhibiting the binding of this population of leukemic cells. These data show that the morphologically mature CML granulocytes consist of a heterogeneous population of cells, some of which do not bind to P-selectin and others which adhere to the molecule via modified sugars.

Heterogeneity in the expression of Fc gammaRIII in morphologically mature granulocytes from patients with chronic myeloid leukemia.

Morphologically mature granulocytes from patients with chronic myeloid leukemia exhibit a defect in receptor mediated endocytosis of FITC-conjugated heat-aggregated IgG. In our earlier studies, we have shown that transcripts for Fc gammaRII and Fc gammaRIII are lowered in CML granulocytes, while no such trend was seen for CD11b, CD18 and actin, the other molecules involved in this process. We have also shown by flow cytometry that the number of granulocytes expressing the Fc receptors on their surface is lowered in CML patients. In this report, we show that the lowered steady state level of the mRNA for the Fc receptors is due to their faster degradation and not due to any defect in transcription. A study of the expression of mRNA for Fc gammaRIII in morphologically mature CML granulocytes by in situ hybridization showed that there is heterogeneity in the expression of this receptor, with some cells positive for the message and some not. These results suggest that the Fc gammaRIII transcript reaches a stable RNA pool in only some of the granulocytes, whereas in the rest of the cells, it is probably degraded after it is transcribed and is therefore not detected. The Fc gammaRIII is probably one of the first antigens to be lost from the leukemic granulocyte surface during the transition of the disease from the chronic phase to the accelerated phase and finally to the blast crisis.

Actin mRNA is not lowered in chronic myeloid leukemic granulocytes.

Chronic myeloid leukemic (CML) granulocytes exhibit defects in several functions, some of which have been associated with changes in the expression of cell surface molecules, actin reorganization and lowered levels of total cellular actin. In this study, we show by northern blotting that the steady-state level of mRNA for actin is not decreased in the CML granulocyte. Our data suggest that the lowered levels of actin protein in the leukemic granulocyte may be due to altered control at the translational/post-translational step, rather than at the level of transcription/post-transcription, implicated in the regulation of expression of the surface molecules, Fc gamma RII, Fc gamma RIII and alkaline phosphatase.

Hepatitis B vaccination in acute lymphoblastic leukemia.

Active immunization against hepatitis B virus infection was carried out in 162 patients with acute lymphoblastic leukemia attending the Outpatient Department at Tata Memorial Hospital. Recombinant DNA vaccine was given in three doses at 0, 1 and 2 months followed by a booster 1 year after the first dose. Antibodies to hepatitis B surface antigen could be detected in 19.7% of patients following vaccination. Of these only 10.5% had titers in the protective range. Immunosuppression induced by both disease and treatment appears to diminish responsiveness to vaccination. Passive active prophylaxis with both vaccine and immunoglobulin may be a more effective alternative in these patients.