Leukemic chromosome clone. I. Risk factor in the acute lymphatic leukemia of children]

As long as the aetiology of acute lymphatic leukaemia of children is not known its therapy is based on clinical experience. Among the values of experience those factors will play a part, the evidence of which during the ALL initial stage will be a risk for successful therapy and survival rate. This results in a choice of more aggressive variants of modern therapy schemes. In a cytogenetic study made in 35 children with ALL it was tested, whether even leukaemic chromosome clones will be a risk for the course of acute leukaemia. The duration of the first remission and survival rate were considered as criteria. The evidence of a leukaemic chromosome clone could be shown to be followed by a short survival rate, irrespective of the stage of the disease where the clone had been observed first. Thus, cytostatic therapy in those ALL patients who are affected with luekaemic chromosome aberration of stem line character should be aimed at the complete annihilation of the clone, irrespective of other remission criteria. The failure of blood and bone-marrow cultures as early as during the untreated initial stage indicated a primary cellular immuno-insufficiency. This combination of cell immuno-depression with high peripheral leukocytes connts and a primary mediastinal tumour or a generalizing lymphosarcoma respectively, was the highest risk up till now for the course of the disease. Judging from the duration of the first remission and the survival rates, the consecutive schemes of therapy did not differ in their effect on leukaemia with pathological stem lines. On the basis of the present study the impression could not be excluded that up till now long term survival rates could be attributed rather to individual manners of response than to the modern therapy scheme.     

Fibronectin and factor VIII-related antigen in acute leukaemia

The glycoprotein fibronectin is, as well as by various other cells, also produced in leucocytes and is said to play an important role in malignant transformation of cells. Therefore, the behaviour of plasma fibronectin and of factor VIII R:AG was investigated in acute leukaemia in order to prove their significance as prognostic and therapeutic markers (method: electroimmunoassay). In patients with acute myeloid leukaemia (n = 29) and acute lymphoblastic leukaemia (n = 11) no significant changes in fibronectin concentration could be evaluated. Fibronectin levels declined significantly only during therapy with asparaginase in patients with acute lymphoblastic leukaemia, probably as a result of disturbed synthesis in the liver. Using crossed immunoelectrophoresis against fibronectin antiserum, one normal and one slower migrating antigen (FN:C) could be observed in nearly all plasma samples in patients with acute leukaemia. By means of in vitro tests with highly purified substances and intermediate gel electrophoresis it could be shown that FN:C represents fibronectin which has bound fibrinogen, probably crosslinked by activated factor XIII. Factor VIII R:AG was found to be greatly raised in patients with acute leukaemia--up to 1400% of the normal level. Increased levels correlated well with a worsening of the disease. The protein seems to be suitable for estimating the activity and prognosis of acute leukaemia.     

Results of polychemotherapy and immunotherapy in acute leukemias]

For the purpose of evaluating the efficiency of an unspecific immunostimulation in acute leukaemias the results of treatment obtained from two groups of patients (a total of 55 children) were compiled. In the first group an unspecific immunostimulation with vaccination (BCG, diphtheria-tetanus-pertussis, measles) could be observed after the induction of remission during a cytostatic maintenance therapy. In the second group a polychemical therapy and the CNS-irradiation was applied according to the treatment scheme developed by the working team of Donald Pinkel. The group of patients treated with unspecific immunostimulation involved a high percentage of surviving children. In total there was no essential difference between the treatment results of both schemes of therapy during our period of observation. As before, the treatment of hyperleukocytic forms of leukaemias will cause particular difficulties.     

Detection of factor XIII deficiency in acute leukemia with resonance thrombography

In 16 patients affected with acute leukemia (7 patients with acute lymphatic leukemia and 9 patients with acute myeloid leukemia) the resonance thrombogramme was recorded during cytostatic induction therapy, coagulation factor XIII (subunit XIII-A, XIII-S) and further hemostasiological parameters were determined. Subunit XIII-A was lowered to 36%, subunit XIII-S to 65% and the fibrin formation time of the resonance thrombogramme was extended to 9 minutes. There exists a negative correlation between component XIII-A and fibrin formation time r = -0.48 (p less than 0.01). The influence exerted by diminishing factor XIII and fibrin(ogen) splitting products on the fibrin formation time was investigated in in-vitro tests. A diminution of factor XIII below 10% will extend the fibrin formation time to about 10 minutes, an increase of fibrin(ogen) splitting products to 100 micrograms/ml to about 3 minutes.     

Granulocytopoiesis in children with acute lymphoblastic leukaemia.

Numbers, proliferative potential, and differentiative capacity of bone marrow granulocyte-macrophage precursor cells were studied in 130 children with acute lymphoblastic leukaemia (ALL), including 77 children in an acute phase of the disease and 53 in remission. Bone marrow samples from 65 children without haematopoietic abnormalities were used as controls. The numbers of clonogenic precursors were found to be below normal in all phases of ALL, particularly during the acute period when the bone marrow was heavily infiltrated with leukaemic cells. It is shown that the decreases in the numbers and proliferative potential of the precursor cells during the acute phases was associated with the effects of leukaemic blast cells, but that in remission the observed reduction in the precursor cell pool was due to the cytostatic effect of therapy. The differentiative capacity of clonogenic granulocyte and macrophage precursors was not altered in children with ALL.     

OAP combination in the treatment of elderly leukaemic patients with preexisting severe internal disease

Sixteen elderly patients affected by acute non lymphoblastic leukaemia (ANLL) with a preexisting severe internal disease were treated with a low systemic toxicity drugs combination: OAP (Vincristine, Cytarabine and Prednisone). Complete remission was achieved in 5 patients (31%) after 2 OAP courses. The mean duration of remission was 18 weeks. Six patients were resistant to the therapy. Six patients died during the treatment: 5 in induction phase and 1 in consolidation phase. Even though the duration of remission was short we retain that OAP combination may be still considered a good therapeutical approach in elderly ANLL patients with associated severe internal disease.     

The appearance of immature cell leukemias after radiologic and cytostatic intensive therapy of Hodgkin's lymphoma]

Among 106 patients with Hodgkin's lymphoma in stage IIIB and IVB treated from September 1969 to June 1977 by a working team for hematology and oncology at the clinic and outpatients clinic of the Medical School of Erfurt, there were two cases (=1.9%) showing a final transition to leukaemia with immature cells. A third neoplasia which had developed in a former field of irradiation was additionally observed in one patient. The various possibilities arising from an oncologic effect of ionizing rays and those substances having a cytostatic effect are discussed. After frequent reports on the occurrence of secondary tumours following intensive radiological and cytostatic therapy of advanced Hodgkin's lymphoma the enhanced risk of a secondary tumour being induced by this combined therapy cannot be excluded. Various conclusions are drawn from that by the authors.     

Complete or partial trisomy for the long arm of chromosome 1 in patients with various hematologic malignancies

This study contains data obtained from a cytogenetic investigation of six patients with acute and chronic leukaemia. The karyotypes of bone marrow or blood cells of these patients showed a partial or complete trisomy for the long arm of chromosome 1. Three observations revealed a pronounced resistance of cell clones with 1q+ towards cytostatic therapy, and a comparatively short life span of patients after detection of 1q+. The importance of these changes for the role of some chromosomes and chromosome loci in leukaemogenesis is discussed.     

Prefinal clinical findings and results of autopsy in 82 children with acute lymphatic leuckemia (ALL) under various courses of therapy]

At present 80...90 % of the patients with acute lymphatic leukaemia die in the blastic crisis. About 10% will come ad finem during full remission caused by side effects of the treatment and their complication. The leukaemic terminal crisis may be accompanied or overlapped by a number of complications, the most frequent among own patients being acute bleeding in the terminal phase. First of all the source of bleeding is to be found in the gastro-intestinal tract (80%). Other authors found infections to be the most frequent final cause of death. It is only under autopsy that leukaemic infiltrates, infections and bleeding are completely recognized to their full extent. After polychemo-therapy the patients showed a significant increase of complications including pulmonary oedema and a marked insufficiency of the bone-marrow with leukocytopenia and granulocytopenia in the peripheral blood. Among the biochemical parameters only a generally significant increase of alpha2 and gamma globulins could be found in the serum. A correlation towards a form of therapy could not be ensured.     

Fibrinogen Manchester. Detection of a heterozygous phenotype in the intraplatelet pool.

Family members heterozygous for the congenitally abnormal fibrinogen designated fibrinogen Manchester, A alpha 16Arg----His, have previously been shown by h.p.l.c. and amino acid analysis to release a variant fibrinopeptide, [His16]fibrinopeptide A, from plasma fibrinogen after the addition of thrombin. The present study was designed to determine if the same abnormal phenotype was also present in the intraplatelet fibrinogen pool. Fresh platelets were washed in buffers containing EDTA until it could be shown that all washable plasma fibrinogen was removed. Normal platelets were then lysed by freezing and thawing to release their intracellular proteins, which were then treated with thrombin. The fibrinopeptides, cleaved from the intraplatelet fibrinogen, could be detected by an optimized h.p.l.c. technique. Quantification of the intraplatelet fibrinogen gave a result (means +/- S.D., n = 5) of 110 +/- 30 and 90 +/- 30 micrograms/10(9) platelets, when determined by h.p.l.c. quantification of fibrinopeptide B content and fibrinogen fragment E radioimmunoassay respectively. Examination of fibrinopeptides released from the platelet fibrinogen from the family with fibrinogen Manchester with the same techniques showed elution peaks in the same positions as both [His16]fibrinopeptide A and normal fibrinopeptide A. The identity of these peaks was further substantiated by analysis of the h.p.l.c. peaks by using specific radioimmunoassay to fibrinopeptide A. Our results therefore demonstrate that platelet fibrinogen expresses the heterozygous A alpha 16His phenotype. This supports the view that the A alpha chains of platelet and plasma fibrinogen are produced from a single genetic locus.     

Acyclovir given as prophylaxis against oral ulcers in acute myeloid leukaemia: randomised,double blind,placebo controlled trial.

OBJECTIVES--To evaluate (a) the prophylactic effect of the antiherpetic drug acyclovir on oral ulcers in patients with acute myeloid leukaemia receiving remission induction chemotherapy and thus (b), indirectly, the role of herpes simplex virus in the aetiology of these ulcers. DESIGN--Randomised, double blind, placebo controlled trial. SUBJECTS--74 herpes simplex virus seropositive patients aged 18-84. Thirty seven patients received acyclovir (800 mg by mouth daily) and 37 placebo. The patients were examined daily for 28 days. MAIN OUTCOME MEASURES--Occurrence of herpes labialis, intraoral ulcers, and acute necrotising ulcerative gingivitis. RESULTS--The two populations were comparable in age, sex, type of antineoplastic treatment, and history of herpes labialis. Acute oral infections occurred in 25 of the acyclovir treated patients and 36 of the placebo treated patients (relative risk 0.69 (95% confidence interval 0.55 to 0.87)). This difference was due to a reduction in the incidence of herpes labialis (one case versus eight cases; relative risk 0.13 (0.02 to 0.95)), intraoral ulcers excluding the soft palate (one case versus 13 cases; relative risk 0.08 (0.01 to 0.56)), and acute necrotising ulcerative gingivitis (one case versus eight cases; relative risk 0.13 (0.02 to 0.95)). However, ulcers on the soft palate were diagnosed with similar frequency in the two groups. Isolation of herpes simplex virus type 1 in saliva was reduced from 15 cases in the placebo group to one case in the acyclovir group (relative risk 0.07 (0.01 to 0.48)). CONCLUSION--Intraoral ulcers excluding the soft palate are most often due to infection with herpes simplex virus, whereas ulcers on the soft palate have a non-herpetic aetiology. The findings suggest that acute necrotising ulcerative gingivitis may also be due to herpes simplex virus. Prophylaxis with acyclovir should be considered for patients with acute myeloid leukaemia during remission induction therapy.     

Immunochemical studies of human fibrinopeptide A using synthetic peptide homologues.

Previous studies have indicated that rabbit antisera R2 and R33 to human fibrinopeptide A differ markedly in terms of cross-reactivity with fibrinogen and fibrinopeptide A-containing fragments of the fibrinogen molecule. Antiserum specificity was characterized by comparison of inhibition of binding to radiolabeled tyrosyl fibrinopeptide A produced by synthetic fragments and enzymatic digests of the fibrinopeptide A molecule vs. the complete fibrinopeptide sequence (Aalpha 1-16). Synthetic COOH-terminal homologues through the dodecapeptide (Aalpha 5-16) exhibited less than 16% immunoreactivity with R33 antiserum, which cross-reacts extensively with fibrinogen and fibrinopeptide A-containing fibrinogen fragments. In contrast, the synthetic COOH-terminal decapeptide (Aalpha 7-16) gave 100% immunoreactivity with R2 antiserum, which cross-reacts minimally with fibrinogen and fibrinopeptide A-containing fibrinogen fragments. Synthetic homologues smaller than Aalpha 7-16, such as Aalpha9-16 and Aalpha 7-11, reacted only minimally with R2 antiserum. Carboxypeptidase B digests of fibrinopeptide A retained less than 25% of their initial immunoreactivity with R2 antiserum. It is concluded that the antigenic determinants of R2 immunoreactivity reside entirely within the COOH-terminal ten-residue sequence of fibrinopeptide A, and that Phe-8, Asp-7, and Arg-16 contribute significantly to R2 immunoreactivity. The R2 antigenic determinants appear to be significantly less accessible to reaction with antibody than the R33 determinants when the fibrinopeptide is attached to its parent alpha chain (Canfield et al., 1976). A possible mechanism for the sequestration is discussed.     

Quantitative behavior of eosinophil granulocytes in the bone marrow of children with acute lymphoblastic leukemia]

Of 31 children affected with acute lymphoblastic leukaemia the quantitative behaviour of eosinophilie granulocytes was examined in the course of the disease. Nearly all patients were treated according to a chemotherapy scheme (Memphis IV). During this therapy the eosinophils greatly diminished initially increased significantly to subnormal values and to the values of healthy persons with persisting full remission. Another significant decrease occurred during the relapse and in the pre-final stage. During each following relapse a greater diminution of bone-marrow eosinophils could be observed. Simultaneously the decrease of eosinophils led to a shift in the degree of maturation. In this connection the similar behaviour of neutrophilic and eosinophilic granulocytes of the bone-marrow must be stressed. Eventually, the lbast excrescence in the bone-marrow and its therapy cannot solely be decisive for the findings made. Relations to the lymphocytic system can be referred to.     

Clinical and cell kinetic data on the combination of cytosine arabinoside with daunorubicin, isosfamide, thioguanine, and vincristine for remission induction and maintenance in patients with acute myelocytic leukaemia (author's transl)]

31 adult patients (study A) with acute myelocytic leukaemia were treated for remission induction with cytosine arabinoside (ARA-C, 100 mg/m2/day) by a 7 (5) day continuous infusion. 3 (2) doses of daunorubicin (DNR, 45 mg/m2 i.v.) were added at daily intervals. For maintenance 5 day ARA-C was given monthly in sequential combination with DNR, thioguanine (TG), or ifosfamide (IFOS). 16 (52%) patients achieved complete remission (C.R.) after 1.8 (1-3) courses and 6.7 (3-10) weeks from treatment start. The median survival for responders and non-responders was 11.5 months, early death rate within 6 weeks was 3 (10%). Median remission duration was 13.5 months. Among 11 patients surving for 7-22 months 7 patients are in first remission for 5.5-20.5 months. DNR, IFOS and TG were given before the 3rd day of ARA-C infusion. In a previous group of 34 leukaemic patients and in 44 therapy courses DNA histograms of bone marrow cells using pulse cytophotometry showed marked accumulation in S-phase for 75% of courses. Also (G2 + M)-cells in the DNA distribution and thymidine pulse labelling indices were markedly increased in most cases, whereas thymidine uptake by scintillation counter was diminished and mitotic indices had not changed significantly. In now 15 patients (study B) the induction regimen was intensified by adding vincristine (VCR, 2 mg i.v.) and 3 doses of IFOS (600 mg/m2 i.v.). Preliminary results are 50% C.R. after 1,7 (1-2) courses and 6.8 (5-10) weeks from initiation of therapy. 2 patients died in the first 6 weeks.     

Cytogenetic analysis and clinical significance of chromosome 7 aberrations in acute leukaemia

The analysis was performed on bone marrow cells derived from 96 patients with acute leukaemia (AL): 76 with acute myelogenous leukaemia (AML) and 20 with acute lymphoblastic leukaemia (ALL). Aberrations of chromosome 7 were revealed in 20 (21%) of 96 analysed cases: in 14 (18%) with AML and in six (30%) with ALL. Structural aberrations, present in 13 patients (eight with AML and five with ALL), were unbalanced and led to partial monosomy (12 cases) or trisomy (four cases) of chromosome 7. Twelve (86%) out of 14 AML and all the ALL patients with chromosome 7 aberrations had complex karyotypes in their bone marrow cells. Monosomy 7 and 7q losses were frequently observed in the AML group, whereas, in the ALL group, gains in 7q and losses in the short arms constituted most chromosome 7 aberrations. The occurrence of monosomy, or of losses in 7q, results in a worse response to induction therapy in AML patients. The complete remission (CR) rate was significantly lower in this group in comparison to the group of AML patients with a normal karyotype (p = 0.01) in bone marrow cells.     

Rubidomycin in Acute Leukaemia in Adults

In a preliminary study rubidomycin was found capable of inducing remission in adults with acute leukaemia, the remission rate in acute myeloblastic leukaemia comparing favourably with that achieved with previous forms of therapy. Marrow aplasia and cardio-toxicity occurred in a number of patients. Supportive measures during the former and early recognition by frequent electrocardiography can do much to mitigate these toxic effects.     

Fibrinolytic effect of a particular glycosaminoglycan (endoglycan) per os on normals and in patients with chronic artery disease.

Endoglycan, a heparan-dermatan sulphate association, is a highly purified heparinoid extracted from porcine intestinal mucosa. The aim of our study was to investigate the fibrinolytic system in a group of healthy controls and vascular disease patients, before and after endoglycan administration "per os". All the patients had a reduced basal fibrinolytic activity. The tests carried out were PT, PTT, FDP, Euglobulin Lysis Time (ELT), fibrinogen, plasminogen, alpha 2-antiplasmin, alpha 2-macroglobulin and t-PA activity assayed with a chromogenic method. After endoglycan administration, we have shown a significant shortening of ELT with complete normalization during the treatment. A fibrinogen decrease and either plasminogen or alpha 2-antiplasmin increase was seen. This was shown in normals too, however to a lesser extent. During therapy most of the healthy subjects, but only some patients, showed increased t-PA levels. Before and during treatment, significantly higher t-PA levels were seen in the control group as compared to the patients group. Reduced t-PA release was seen in our vascular disease patients. In conclusion, endoglycan "per os" appears to exert a stimulatory effect on the fibrinolytic system.     

An in vitro testing of chemoresistance in leukaemic patients

The fact that leukaemic cells are primarily or secondarily resistant to cytostatics is a serious phenomenon, which leads to the failure of chemotherapy of malignant diseases in clinical practise. Some detoxification and transporting systems are responsible for the generation of chemoresistance on the cellular level and the decrease of effectiveness in treatment. In vitro testing of chemoresistance of leukaemic cells is presently an inseparable component of “tailoring” therapy in the developing field of predictive oncology. The aim of this work was to estimate profiles of drug resistance, based on the predictive in vitro test, and to help in choosing the most effective cytostatic. The 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazoline (MTT) assay was used, based on the direct effect of cytostatics on the viability of leukaemic cells in vitro. The number of living leukaemic cells was evaluated by a computer program, where LC₅₀ (concentration of cytostatics lethal to 50% of leukaemic cells) was established from the achieved dose-relation curves. Seventy-one samples of leukaemic cells isolated from the patients’ peripheral blood or bone marrow were examined. All samples were tested to 3 cytostatics minimally. It was found by the in vitro assay, that resistance to dexamethasone, prednisolone, etoposide and vincristine is increased in patients with acute myeloid leukaemia disease, compared to the acute lymphoblastic leukaemia patients. In patients with a relapsed disease population, leukaemic cells are highly heterogeneous in the MTT assay. It was concluded that the MTT assay can be used to study drug interactions in vitro in leukaemia samples. The type of interaction was highly different between patients, and depended on drug concentrations.     

Remission-induction of acute lymphoblastic transformation of chronic myeloid leukaemia, followed by long-term maintenance therapy

Acute lymphoblastic transformation of chronic myeloid leukaemia (LT-CML) of 7 consecutive patients was treated according to a remission-induction and maintenance therapy used for de novo acute lymphoblastic leukaemia (ALL). All 7 patients achieved a second chronic phase with a median remission duration of 15 months. Two patients showed an isolated central nervous system (CNS) relapse. This did not occur in the 4 patients, who received prophylactic therapy with intrathecal methotrexate. The second transformation was nonlymphoblastic in nature in 4 out of the 5 patients. A treatment protocol similar to that of a bad risk ALL, including long-term maintenance therapy and CNS-prophylaxis is indicated in lymphoblastic transformation of CML.