Posttranscriptional defects in beta-globin messenger RNA metabolism in beta-thalassemia: abnormal accumulation of beta-messenger RNA precursor sequences.

The production of beta-globin messenger RNA (mRNA) in beta-thalassemic erythroblasts was studied during pulse-chase incubations with [3H]uridine. Globin [3H]mRNA was quantitated by molecular hybridization to recombinant DNA probes complementary to globin mRNA and mRNA precursor sequences. Each of six patients with beta +-thalassemia produced normal amounts of globin alpha and beta [3H]mRNA during a 20-min pulse incubation, but the beta/alpha [3H]mRNA ratio declined to steady-state levels during a chase incubation, suggesting posttranscriptional defects in beta-globin mRNA metabolism. beta-globin mRNA precursor production was estimated by measurement of [3H]RNA sequences hybridizing to a pure DNA probe containing only the large intervening sequence (intron) of the beta-mRNA precursor. Four of the patients exhibited abnormal accumulation of 3H-beta-intron sequences (2-10 times normal), indicating abnormal posttranscriptional processing. In the remaining two patients, one of whom is known to carry a mutation in the small intron of the beta-globin gene, accumulation of large 3H beta-intron RNA and beta-globin [3H]mRNA was normal in nuclei, but the ratio of beta/alpha [3H]mRNA in cytoplasm was reduced, suggesting a different posttranscriptional defect in beta-mRNA processing. These findings imply the existence of heterogeneous posttranscriptional abnormalities in beta-globin mRNA metabolism in different patients with beta-thalassemia. The initial rates of gamma- and delta-mRNA synthesis were low in all patients, suggesting that the low level of expression of these genes in adults is mediated at the transcriptional level.

Improved survival of children with isolated CNS relapse of acute lymphoblastic leukemia: a pediatric oncology group study .

PURPOSE: Isolated meningeal relapse in children with acute lymphoblastic leukemia (ALL) usually has been followed by bone marrow relapse and limited survival. The purpose of this study was to prevent marrow relapse by administering intensive therapy before delayed craniospinal radiation. PATIENTS AND METHODS: Eighty-three patients with ALL in first bone marrow remission with an isolated CNS relapse were treated with systemic chemotherapy known to enter into the CSF and intrathecal chemotherapy for 6 months. Craniospinal irradiation (24 Gy cranial/15 Gy spinal) was then administered, followed by 1.5 years of maintenance chemotherapy. RESULTS: All 83 patients achieved a second remission. The 4-year event-free survival (EFS) rate was 71.1% +/- 5.3%. There was a fourfold increased risk of relapse for children whose initial remission was less than 18 months. The 4-year EFS rate for patients with a first complete remission >/= 18 months was 83.3% +/- 5.3%, and for those with a first complete remission less than 18 months, it was 46.2% +/- 10.2% (P =.0002.) There was a low incidence of neurologic toxicity and an unexpectedly high rate of allergic reactions to L-asparaginase. Five patients developed secondary malignancies: two with acute nonlymphoblastic leukemia during therapy, one with myelodysplasia after therapy, and two with brain tumors 1.5 to 2 years after cessation of therapy. CONCLUSION: For children with ALL and an isolated CNS relapse, treatment that delays definitive craniospinal irradiation by 6 months to allow for more intensive systemic and intrathecal chemotherapy results in better EFS than has been previously reported. Using this approach, the long-term prognosis for children with first complete remission >/= 18 months is comparable to that at the time of original diagnosis of ALL.

Treatment of occult or late overt testicular relapse in children with acute lymphoblastic leukemia: a Pediatric Oncology Group study.

PURPOSE: The Pediatric Oncology Group (POG) designed a randomized two-arm protocol (8304) to improve the survival of children with acute lymphoblastic leukemia (ALL) who experience an isolated testicular relapse and to evaluate the efficacy of teniposide (VM-26) and doxorubicin as intensification agents during second remission. The outcome and toxicity observed in 80 patients with isolated testicular leukemia treated on POG 8304 are presented. PATIENTS AND METHODS: The following are common features of POG 8304: (1) remission reinduction therapy with vincristine, prednisone, and doxorubicin; (2) bilateral testicular irradiation (2,600 cGy) during reinduction therapy; (3) CNS prophylaxis with intrathecal hydrocortisone, methotrexate (MTX), and cytarabine (Ara-C); and (4) continuation therapy (for 80 weeks) with alternating 6-week cycles of oral mercaptopurine (6-MP)/MTX and intravenous vincristine and cyclophosphamide. Treatment differences consisted of pulses (administered every 7 weeks) of either prednisone and doxorubicin (arm 1) or VM-26 and Ara-C (arm 2) during continuation therapy and a 4-week late intensification phase with either vincristine, prednisone, and doxorubicin (arm 1) or VM-26 and Ara-C (arm 2). RESULTS: Fifty-five boys with ALL had isolated microscopic testicular leukemia detected by an elective biopsy at completion of initial treatment, and 25 had a late (greater than or equal to 6 months off-therapy) isolated overt testicular relapse. All patients with overt testicular leukemia attained a second clinical remission, and no patient with microscopic testicular leukemia progressed during reinduction. Of 42 patients on arm 1, 11 have relapsed compared with 18 of 38 patients on arm 2 (log-rank analysis, P = .22), indicating no significant difference between an anthracycline and an epipodophyllotoxin-Ara-C combination in the treatment of testicular leukemia. The overall 4-year event-free survival (EFS) among boys with occult testicular relapse was 53% +/- 8%. Age greater than 10 years at initial diagnosis, a WBC count greater than 50,000/microL at diagnosis, and black race were associated with a worse outcome. The 4-year EFS for boys with a late overt testicular relapse was 84% +/- 10%, and these patients fared significantly better than patients with occult disease (P = .007). CONCLUSION: The treatment approach reported here can secure a prolonged second remission in many patients with occult or late overt testicular leukemia.

Improved diabetic control enhances erythroid stem cell proliferation in vitro.

Patients with type I diabetes mellitus treated with continuous sc insulin infusion (CSII) have improved glucose homeostasis, metabolic control, and linear growth. To determine the influence of CSII on cellular growth in vitro, we used a clonal stem cell assay for proliferation of erythroid progenitors, [burstforming units-erythroid (BFU-E)] in peripheral blood. Eight patients were studied before and after 1 week of CSII. Improvement in metabolic control was demonstrated by a decrease in mean 24-h plasma glucose from 232 +/- 29 (+/- SEM) mg/dl before treatment to 112 +/- 3 mg/dl after treatment (P = 0.01). Somatomedin-C levels increased from 1.1 +/- 0.4 to 1.4 +/- 0.4 U/ml (P less than 0.001). Numbers of BFU-E-derived colonies were not different from normal during conventional treatment, but increased 300% after 1 week of CSII. Our findings indicate that the acute metabolic and hormonal improvements that accompany short term CSII therapy in vivo are associated with a striking increase in the proliferation of erythroid committed stem cells in vitro.

Developmental pattern of splenic dysfunction in sickle cell disorders.

Splenic function in sickle hemoglobinopathy syndromes was assessed to determine the developmental pattern of splenic dysfunction. Nonvisualization of the spleen using technetium-99 metastable (99mTc) spleen scans correlated strongly with pocked (vesiculated) RBCs greater than or equal to 3.5%. Cross-sectional analysis of pocked RBC data from 2,086 patients showed differences in the developmental pattern of splenic dysfunction between several disorders. In hemoglobin SS disease (sickle cell anemia) and hemoglobin S beta(0) thalassemia, splenic dysfunction (greater than or equal to 3.5% pocked RBCs) often occurred in the first 6 to 12 months of life. In hemoglobin S beta(+) thalassemia, splenic dysfunction occurred less frequently and later. Splenic dysfunction in hemoglobin SC disease (sickle cell-hemoglobin C) was intermediate. The level of pocked RBCs was inversely associated with fetal hemoglobin (P less than .007) and directly associated with age (P less than or equal to .001). These patterns of splenic dysfunction reflect the known severity of hemolysis and intravascular sickling and are consistent with the epidemiology of severe bacterial meningitis and sepsis in these diseases. Serial measurement of pocked RBCs permits determination of the onset of splenic dysfunction and the time of increased susceptibility to severe bacterial infections.

An investigation of the validity of the quality of Well-Being Scale with pediatric oncology patients.

The usefulness of the Quality of Well-Being scale (QWB) in a sample of pediatric cancer patients was investigated. The parents of 30 children who were 4 to 18 years old and who were being treated for cancer, were administered the QWB. Performance status ratings from the parents and physician, toxicity ratings, treatment information, and routine laboratory values were also collected. Correlational analyses indicated that QWB scores were significantly related to ratings of performance status and that children who had experienced more surgeries and hospitalizations were assessed as more impaired on the QWB. The child's age, toxicity of treatment experience to date, and laboratory values were not significantly related to QWB findings. The potential utility of the QWB as a component of quality-of-life assessment is discussed.

Transient-evoked otoacoustic emissions in children after cisplatin chemotherapy.

Little is known about cisplatin ototoxicity in pediatric patients. Measurement of otoacoustic emissions is a rapid, reproducible, objective method of evaluating hearing. We examined whether transient-evoked otoacoustic emissions in pediatric patients exposed to cisplatin in the past correlated with audiographic findings. Twelve patients were entered into the study (mean age at treatment 7.8 years, mean cumulative dose 442.5 mg/mm2, mean 7.1 doses). Hearing at 3000 Hz was preserved in 82.6% of patients. In the higher frequencies significant sensorineural hearing loss was noted: 43.5% at 4 kHz; 81.0% at 6 kHz; and 90.5% at 8 kHz. Transient-evoked otoacoustic emissions were measurable in 11 of 12 patients. Middle ear disease accounted for abnormal otoacoustic emission seen in three patients (1 with effusion, 2 with significant negative middle ear pressure). When the middle ear was normal, a statistically significant correlation was seen between the transient-evoked otoacoustic emissions reproducibility and pure-tone threshold (correlation coefficient = -0.69, p = 0.008). Increased hearing loss was also associated with young age at first dose of cisplatin (p = 0.044), high number of chemotherapy cycles (p = 0.042), and high cumulative dose (p = 0.042).

Iron deficiency in children. Update on an old problem.

Over the past 25 years the incidence of iron deficiency anemia has decreased remarkably. This decline has resulted directly from a program of prevention that is based on a detailed understanding of iron lack in infants and children. However, iron deficiency without anemia--subtle iron deficiency--remains a problem. The negative impact of iron deficiency on brain function has recently been demonstrated in animal as well as human studies. The behavioral effects noted in infants and toddlers can be seen with subtle iron deficiency as well as with anemia. Although behavioral abnormalities in the very young appear to be correctable by iron treatment, prolonged iron deficiency may lead to irreversible effects on brain function. These recent findings should further encourage continued vigilance in preventing the old problem of iron deficiency.

Lymphadenopathy in children: a concise review.

Lymphadenopathy is commonly found in sick children and the cause of the enlarged nodes is usually evident. However, lymphadenopathy of a prolonged duration or with larger than anticipated nodes often presents a diagnostic dilemma. Knowledge of the normal pattern of lymph node size in children and the mechanisms of lymphadenopathy are prerequisites to approaching the diagnosis. Historical and physical clues help to guide the diagnostic evaluation and may indicate the need for certain laboratory tests, a trial of antibiotics, immediate biopsy, or simply close observation. If a biopsy is performed, comprehensive evaluation of the lymph node is critical to the diagnosis and subsequent treatment. Although most children with peripheral adenopathy have reactive hyperplasia of unknown etiology, it is important to monitor children with persistent lymphadenopathy until a diagnosis is made or the adenopathy resolves.

Hemophilia--an ancient disease with new problems and new solutions.

A bleeding disorder occurring in brothers was described by Talmudic rabbis in 500 A.D. Hemophilia A is now known to be due to a sex-linked deficiency of plasma factor VIII activity. The isolation of factor VIII from plasma in lyophilized concentrate has provided effective treatment and resulted in significant health and economic benefits for individuals with hemophilia. Treatment associated viral hepatitis and HIV infection have spurred the development of serologic screening of blood donors and viral inactivation techniques which have resulted in improved safety of plasma derived concentrate. Knowledge of the gene for factor VIII has led to development of recombinant factor VIII concentrate, and provides promise for gene replacement therapy in the future. The presence of the Human Immunodeficiency Virus (HIV) in plasma products exposed many individuals with hemophilia to the risk of developing the Acquired Immune Deficiency Syndrome (AIDS). Their medical care now includes testing for HIV exposure, AIDS risk reduction counseling, monitoring of immune parameters with prophylactic anti-HIV therapy for immunocompromised individuals, and treatment of opportunistic infections in those developing AIDS.

Curing children with leukemia in West Virginia.

Leukemia is the most common cancer in childhood with acute lymphoblastic leukemia (ALL) the most common subtype. While once uniformly fatal, today leukemia is a highly curable disease. To determine the outcomes of children with acute lymphoblastic leukemia in West Virginia, we performed a retrospective analysis of the results of treatment of children and adolescents with B-lineage ALL diagnosed between 2/86 and 1/91 and treated by the pediatric oncology teams at Morgantown or Charleston. Forty-one children with B-lineage ALL were identified and treated by a uniform protocol. Twenty-nine (71%) have remained disease-free for more than two years off therapy and are considered cured. Of the 10 patients who relapsed, five have now been off rescue therapy for greater than two years and are likely to be cured. Thirty-five of the original cohort of 41 children are alive and disease-free yielding an overall survival of 85%. The results of treatment of childhood leukemia in West Virginia are comparable to national data. Children with ALL diagnosed and treated by pediatric oncology teams in West Virginia have a very good chance of being cured.

A survey of pediatric malignancy in West Virginia.

The occurrence of malignancy in the pediatric age group is an uncommon but serious event. Since little data are available on the extent, nature or referral patterns of childhood cancer in West Virginia, we conducted a survey of 782 primary care physicians and 17 regional referral centers. The results showed that 249 cases of malignancy in the pediatric age group were reported and that 68% of children with newly diagnosed childhood malignancy were referred to institutions within West Virginia. We conclude that the incidence and distribution of types of malignancy in childhood in West Virginia parallels that of the nation, although there is some regional variation within the state.

Outcomes after HLA-matched sibling transplantation or chemotherapy in children with acute lymphoblastic leukemia in a second remission after an isolated central nervous system relapse: a collaborative study of the Children's Oncology Group and the Center for International Blood and Marrow Transplant Research.

In children with acute lymphoblastic leukemia (ALL) with isolated central nervous system (CNS) relapse and a human leucocyte antigen (HLA)-matched sibling, the optimal treatment after attaining second remission is unknown. We compared outcomes in 149 patients enrolled on chemotherapy trials and 60 HLA-matched sibling transplants, treated in 1990-2000. All patients achieved a second complete remission. Groups were similar, except the chemotherapy recipients were younger at diagnosis, less likely to have T-cell ALL and had longer duration (> or = 18 months) first remission. To adjust for time-to-transplant bias, left-truncated Cox's regression models were constructed. Relapse rates were similar after chemotherapy and transplantation. In both treatment groups, relapse rates were higher in older children (11-17 years; RR 2.81, P=0.002) and shorter first remission (< 18 months; RR 3.89, P<0.001). Treatment-related mortality rates were higher after transplantation (RR 4.28, P=0.001). The 8-year probabilities of leukemia-free survival adjusted for age and duration of first remission were similar after chemotherapy with irradiation and transplantation (66 and 58%, respectively). In the absence of an advantage for one treatment option over another, the data support use of either intensive chemotherapy with irradiation or HLA-matched sibling transplantation with total body irradiation containing conditioning regimen for children with ALL in second remission after an isolated CNS relapse.

Combined clotting factor deficiencies: experience at a single hemophilia treatment center.

We describe a series of patients with combined factor deficiencies and von Willebrand's disease (VWD) at one haemophilia treatment centre. Although the incidence of VWD is at least 1% in the general population, combined coagulation defects have been infrequently described in the medical literature and are likely under diagnosed. This entity should be considered in patients with a known factor deficiency and either an unexpectedly severe bleeding phenotype, or bleeding that is unresponsive to factor replacement.

Diagnostic problems in cerebrospinal fluid of children with lymphoid malignancies.

The interpretation of small numbers of lymphoblasts or of nonspecific pleocytosis in the cerebrospinal fluid (CSF) of children with lymphoid malignancies is difficult. In this prospective study of 204 patients, 15 had white cell chamber counts of less than or equal to 10 cells/microliter, with one or more blasts on a cytocentrifuged smear. Only 3/15 subsequently developed meningeal leukemia, and 4/15 remain in continuous complete remission. Among 53 patients with a chamber count greater than 10 WBC/microliter and no blasts, pleocytosis was associated with central nervous system (CNS) prophylaxis in half. Less common were viral syndromes, immune recovery, subsequent meningeal leukemia, active hematologic leukemia, the somnolence syndrome, leukoencephalopathy, or reaction to a previous traumatic lumbar puncture.

Fever of unknown origin and the value of gallium-67 and technetium-99M for defining abnormality of the spleen: a case report.

A three-year-old white female with acute promyelocytic leukemia developed persistent fever after successful induction-remission therapy; many large monilial abscesses were later found in the grossly enlarged spleen. Although the technetium-99M sulfur colloid scan prior to splenectomy suggested only a slight abnormality of the spleen, the gallium-67 citrate scintigraph showed a marked increase in gallium accumulation. The disparate results of the scanning techniques utilized in this patient suggest that it may be necessary to use more than one type of radiopharmaceutical to define an enlarged spleen, as well as the pathological process responsible for its enlargement.

Variable in vitro erythropoiesis in patients with transient erythroblastopenia of childhood.

Transient erythroblastopenia of childhood (TEC) is a pure red cell aplasia which primarily affects children in the infant and toddler age group. The clinical syndrome of TEC is well defined and is characterized by moderate to severe anemia with reticulocytopenia, selective aplasia of the erythroid bone marrow elements, and spontaneous recovery, usually within a month of presentation. We utilized the plasma clot tissue culture technique to explore the defect of erythropoiesis in seven patients with TEC. Culture of bone marrow at diagnosis in four patients revealed an increased erythroid proliferative capacity in one and a decreased capacity in three. The former patient plus three additional patients were found to have a transient serum inhibitor of erythroid colony formation in autologous and allogeneic systems. The three patients with diminished erythroid proliferative capacity had no demonstrable serum inhibitor, and in one patient studied the erythroid proliferative capacity became supernormal after recovery. We conclude that although TEC has a characteristic clinical picture, in vitro studies reveal a variable expression of the erythropoietic defect and support the hypothesis of a heterogeneous pathogenesis of this disorder.

Intracranial hemorrhage in children with sickle cell disease.

We treated two children with sickle cell disease and intracranial hemorrhage. The incidence of intracranial hemorrhage is increased in sickle cell disease, although not as markedly as that of cerebral infarction. Intracranial hemorrhage has a higher mortality, a lower rate of permanent neurologic impairment, and occurs more often in older patients than does cerebral infarction. Intracranial hemorrhage in adults is likely to be an intracerebral hemorrhage or a subarachnoid hemorrhage secondary to an aneurysm. Children, however, are more likely to have subarachnoid hemorrhage without an identifiable aneurysm. We hypothesize that both hemorrhages and infarcts are due to large-vessel cerebral vasculopathy secondary to the abnormal rheologic features of sickled cells.

In vitro steroid sensitivity testing: a possible means to predict response to therapy in primary hypoproliferative anemia.

We investigated the effects of various steroids on erythroid colony formation by normal human bone marrow and peripheral blood, and by marrow and peripheral blood from 18 patients with primary hypoproliferative anemia. These agents were variously found to enhance both CFU-E and BFU-E derived colony growth by normal human cells. Fluoxymesterone and dexamethasone were the most active inducers of CFU-E proliferation, and etiocholanolone and dexamethasone were the most potent burst augmenters. Androsterone did not significantly influence BFU-E proliferation in 66% of the marrow cultures from hematologically normal donors. Colony formation by erythroid progenitor cells of the patients with hypoproliferative anemia was reduce (20 +/- 10 CFU-E derived colonies/6 X 10(4) marrow cells; 12 +/- 5 BFU-E derived colonies/1 X 10(5) blood cells) when compared to growth by normal cells (65 +/- 14 CFU-E derived colonies/6 X 10(4) marrow cells; 21 +/- 9 BFU-E derived colonies/1 X 10(5) blood cells). Colony formation by marrow or peripheral blood cells of eight patients with steroid-responsive anemia was only moderately reduced (26 +/- 11 CFU-E derived colonies/6 +/- 10(4) marrow cells; 17 +/- 3 BFU-E derived colonies/1 X 10(5) blood cells) when compared to growth by marrow cells of three steroid-unresponsive patients (3 +/- 1.5 CFU-E derived colonies/6 X 10(4) cells). Whereas the addition of steroids of the same class to marrow and peripheral blood cultures of the steroid-responsive patients enhanced colony growth by 60-300%, their addition to marrow cultures of the steroid-unresponsive patients increased colony growth by less than 60%. It appears that further investigations using in vitro culture techniques as predictors of response to steroid therapy in patients with hypoproliferative anemia may be warranted.