Factors in Pathogenesis of Central-nervous-system Leukaemia

Eighty-three (50%) of 165 children with acute lymphoblastic or acute stem-cell leukaemia presenting during 1958-70 developed leukaemia of the central nervous system (C.N.S.). The rate of incidence of this complication is fairly constant throughout the first two-and-a-half years of the disease, but falls thereafter. The incidence of C.N.S. leukaemia is inversely correlated with the platelet count at the time of initial diagnosis of leukaemia, and directly correlated with the total leucocyte count and the presence of lymph-node enlargement. The major effect of initial leucocyte count is on the time of onset of clinical symptoms. It is suggested that leukaemic cells usually enter the C.N.S. from the blood as a result of intracranial petechial haemorrhage occurring around the time of initial diagnosis of leukaemia, and that the time for subsequent development of symptoms of C.N.S. disease is largely determined by the number and replication rate of leukaemic cells which gain access to the C.N.S. at that time. The increasing frequency of diagnosis of C.N.S. leukaemia in recent years is not wholly explained by increasing survival, and may in part be related to changes in the pattern of antileukaemic therapy.Prophylaxis for C.N.S. leukaemia should be instituted as early as practicable after diagnosis; the identification of a high-risk group may permit this to be done selectively.     

Electrocardiographic signs of pulmonary hypertension in children who snore.

Two children presented with sleep disturbances due to enlarged tonsils and adenoids. One child died during induction of anaesthesia, and postmortem examination showed hypertrophy of the right ventricle and atrium. As a result a prospective survey was carried out of children undergoing tonsillectomy or adenoidectomy, or both. During a nine-month period an electrocardiogram was taken in 92 children. Three electrocardiograms (3.3%) showed evidence of right heart strain. The children with abnormal electrocardiograms had symptoms of sleep disturbance with apnoea, snoring, and daytime somnolence. These symptoms and the electrocardiographic changes were reserved by adenotonsillectomy. The prevalence of pulmonary hypertension in children with enlarged tonsils and adenoids is still underestimated. When signs and symptoms of sleep disturbance, particularly snoring, are present an electrocardiogram should be obtained and a cardiologist''s opinion sought before embarking on routine surgery in view of the potentially fatal consequences.     

Radiation-induced growth hormone deficiency

Deficiency of one or more anterior pituitary hormones may follow treatment with external irradiation when the hypothalamic-pituitary axis falls within the fields of irradiation. Hypopituitarism occurs in patients who receive radiation therapy for pituitary tumours, nasopharyngeal cancer and primary brain tumours, as well as in children who undergo prophylactic cranial irradiation for acute lymphoblastic leukaemia, or total body irradiation for a variety of tumours and other diseases. The degree of pituitary hormonal deficit is related to the radiation dose received by the hypothalamic-pituitary axis. Thus, after lower radiation doses isolated growth hormone deficiency ensues, whilst higher doses may produce hypopituitarism. The timing of onset of the radiation-induced pituitary hormone deficit is also dose-dependent. The main site of radiation damage is the hypothalamus rather than the pituitary, although the latter may be affected directly.     

Cranial computertomography in children with acute lymphatic leukemia (ALL) and non Hodgkin-lymphoma (NHL) after different methods of CNS-treatment

42 children with acute lymphatic leukemia (ALL) or non-Hodgkin lymphoma (NHL) were subjected to cranial computer tomography (CT). 4 groups were formed according to CNS therapy. Group 1: 18 children in complete first remission after CNS prophylaxis with intrathecal 198 Au-colloid and methotrexate were examined between 3 1/2 and 7 1/3 years after beginning of therapy. 15 patients had normal computer tomograms, only 3 children had slight anomalies. The quantitative assessment of the computer tomograms yielded normal results for all 18 children. Group 2: 8 children were examined before CNS prophylaxis. 1 child had a connatal septum pellucidum cyst, 4 children had no anomalies and 3 children slight anomalies. The deviations from normal in groups 1 and 2 should be physiological variations. Group 3: 6 children were examined between 10 months and 8 1/4 years after termination of prophylactic CNS-irradiation (18-22.5 Gy) in combination with intrathecal methotrexate. Normal findings were obtained for 2 patients only. The other children had distinct cortical, subcortical or cerebellar atrophies and calcification of stem ganglia. Neurological complications had temporarily appeared in one child after skull irradiation. Group 4: A CT was made of 10 children during or after meningosis leukemia. The children who had received 198 Au-colloid for CNS prophylaxis yielded no pathological CT results. Distinct cortical, subcortical and cerebellar atrophies or calcification of stem ganglia were found in children after one or two CNS irradiations. These CT investigations confirm the results published by other authors, i.e. that owing to an irradiation--cytostatic therapy of the children's brains CNS lesions can be found in the CT. Their prognosis can only be determined by longterm observations. CNS prophylaxis by means of intrathecal 198 Au-colloid and methotrexate does not lead to any pathological CT anomalies.     

The cerebral sensitivity to "meningosis-prophylaxis" with 198Au radiogold according to EEG findings]

35 children (16 girls and 19 boys) at the age of 1 11/12 to 16 11/12 with acute leukaemia were injected intrathecally with 198Au-radiogold colloids (HOECHST-BEHRING) for "prophylaxis of meningosis". The colloid size of the isotope amounted to 5 or 30 nm, the applied activity lay between 1.4 and 3.12 mCi. According to a dosage estimation made with the help of LOEWINGERS formula 1 mCi of radiogold corresponds to approximately 1200 rad. Clinical observations, such as headaches, vomiting or fever up to 39 degrees C, could only be found in 6 children (17.1%) during the first 24 hours. All symptoms subsided quickly and without any sequels. Even retarded complications could not be detected. An electroencephalogram was made from all children before and after applying radiogold (1-8 d afterwards). After the injection of radiogold the majority of children had no change of findings in the electroencephalogram, 11 children even showed a tendency towards an improvement up to normalisation. Only 4 children had a deterioration of findings with unspecific disorders or appearances suspected of peak potential discharges. Simultaneously an accumulation of clinical complaints could be found. Judging from the clinical and electroencephalographic behaviour of our patients no absolute neurotoxity of radiogold could be ensured.     

Lack of extracellular superoxide dismutase (EC-SOD) in the microenvironment impacts radiation-induced changes in neurogenesis

Ionizing irradiation results in significant alterations in hippocampal neurogenesis that are associated with cognitive impairments. Such effects are influenced, in part, by alterations in the microenvironment within which the neurogenic cells exist. One important factor that may affect neurogenesis is oxidative stress, and this study was done to determine if and how the extracellular isoform of superoxide dismutase (SOD3, EC-SOD) mediated radiation-induced alterations in neurogenic cells. Wild-type (WT) and EC-SOD knockout (KO) mice were irradiated with 5 Gy and acute (8-48 h) cellular changes and long-term changes in neurogenesis were quantified. Acute radiation responses were not different between genotypes, suggesting that the absence of EC-SOD did not influence mechanisms responsible for acute cell death after irradiation. On the other hand, the extent of neurogenesis was decreased by 39% in nonirradiated KO mice relative to WT controls. In contrast, while neurogenesis was decreased by nearly 85% in WT mice after irradiation, virtually no reduction in neurogenesis was observed in KO mice. These findings show that after irradiation, an environment lacking EC-SOD is much more permissive in the context of hippocampal neurogenesis. This finding may have a major impact in developing strategies to reduce cognitive impairment after cranial irradiation.     

Spontaneous endocrine cure of gigantism due to pituitary apoplexy.

An 11 year old, tall boy presented with symptoms typical of pituitary apoplexy. A large necrotic and haemorrhagic tumour was removed, which was shown to be an adenoma secreting growth hormone and prolactin. Subsequent treatment comprised cranial irradiation and hormone replacement. Eighteen months after operation growth was static and plasma growth hormone and prolactin concentrations were undetectable. Treatment of pituitary apoplexy should comprise excision of the tumour and postoperative irradiation; such treatment after early recognition of the condition offers the best chance of preserving normal pituitary function in children with gigantism.     

Prospective study on the influence of radiochemotherapy on pituitary function in children with acute leukaemia and NHL.

To assess effects of chemo- and radiotherapy on the endocrine system 31 children with acute leukaemia and NHL (3 AML, 24 ALL, 4 NHL) were investigated. Children were treated according to modified BFM protocols. 25 patients were before, 5 during and one after puberty (2 to 16 y.). Before treatment, during induction therapy, during cranial irradiation, 4-6 weeks later and during maintenance therapy the following hormone values were estimated: TSH and prolactin basal and 30 min. after TRH (5 micrograms/kg i.v.), LH and FSH basal. Final investigations included total T4 and T3. In conclusion, chemo- und radiotherapy lead to transient elevations of TSH and prolactin in a few patients, but without proof for permanent disorders. Due to the fact all 3 patients with hyperprolactinaemia showed high prolactin levels (700 to 770 mU/l) already before treatment it is unlikely therapy was the main cause of these observed alterations. Although basal LH and FSH values were in normal ranges for age the increasing values after cranial irradiation in prepubertal children may reflect a possible initiation of early maturation, reported by others. Furthermore a retrospective growth study was performed in children treated with 2 different protocols. Protocol LSA2L2 used in the past before 1981 resulted in a permanent reduction of the height. In contrast, the mean SDS for height in children treated with protocol VII declined only during the intensive period of treatment. A catch-up growth occured already during maintenance therapy. Prophylactic cranial irradiation with 18 Gy in our patients under protocol LSA2L2 did not affect growth during the first 5 years after diagnosis.     

Fast repair of anoxic radiation damage in HeLa cells detected by antinucleoside antibodies

The influence of anoxia on X-ray damage in HeLa cells was studied by observing effects on nuclear immunoreactivity to antinucleoside antibodies and on the sedimentation in alkaline sucrose gradients of their DNA “complexes”. The fraction of G1 HeLa cells which was immunoreactive to fluorescein labeled antinucleoside antibodies increased from control levels of 11% ± 3.5 S.E. to 71% ± 5.7 S.E. after 1 000 rads in air. In anoxia 1 000 rads increased this fraction to only 42% ± 3.1 S.E. After 1 000 rads in air the return to normal G1 levels of immunoreactivity required 90 min, but it required only 30 min after radiation in anoxia. If cells were held at 0 °C for 35 min before anoxic irradiation the rapid return to control levels of immunoreactivity during postradiation incubation at 37 °C was not observed. Cold shock did not increase the proportion of cells initially made immunoreactive by 1 000 rads in anoxia. Anoxia reduced the effect of 1 000 rads on the sedimentation properties of the DNA complex. Cold shock prior to anoxic radiation retarded the faster reconstitution of the DNA complex otherwise observed after anoxic radiation.     

Mechanisms of action for an anti-radiation vaccine in reducing the biological impact of high dose and dose-rate, low-linear energy transfer radiation exposure

The development of an anti-radiation vaccine could be very useful in reducing acute radiation syndromes. Existing principles for the treatment of acute radiation syndromes are based on the amelioration of progressive pathophysiological changes, using the concept of replacement therapy. Active immunization by small quantities of the essential radiation-induced systemic toxins of what we call the Specific Radiation Determinant (SRD) before irradiation increased duration of life among animals that were irradiated by lethal or sub-lethal doses of gamma-radiation. The SRD toxins possess antigenic properties that are specific to different forms of acute radiation sickness. Intramuscular injection of larger quantities of the SRD toxins induce signs and symptoms in irradiated naive animals similar to those observed in acute radiation syndromes, including death. Providing passive immunization, at variable periods of time following radiation, with preparations of immune-globulins directed at the SRD molecules, can confer some protection in the development of clinical sequelae in irradiated animals. Improved survival rates and times were observed in animals that received lower, sublethal doses of the same SRDs prior to irradiation. Therefore, active immunization can be induced by SRD molecules as a prophylaxis. The protective effects of the immunization begin to manifest 15-35 days after an injection of a biologically active SDR preparation. The SRD molecules are a group of radiation toxins with antigenic properties that correlate specifically with different forms of radiation disease. The SRD molecules are composed of glycoproteins and lipoproteins that accumulate in the lymphatic system of mammals in the first hours after irradiation, and preliminary analysis suggests that they may originate from cellular membrane components. The molecular weight of the SRD group ranges from 200-250 kDa. The SRD molecules were isolated from the lymphatic systems of laboratory animals that were irradiated with doses known to induce the development of cerebral (SRD-1), non-specific toxic effects (SRD-2), gastrointestinal (SRD-3) and hematological (bone marrow) (SRD-4) syndromes. Our results suggest that an anti-radiation vaccine can be developed for prophylactic use against radiation damage induced by acute exposure to significant doses of low Linear Energy Transfer (LET) radiation for humans, including nuclear power workers, commercial and military pilots, cosmonauts/astronauts, nuclear-powered engine vessel operators and possibly even the civilian population in the case of a nuclear terrorism event.     

Increased radiosensitivity after irradiation of lymphocytes low adaptive doses

The variability of blood lymphocyte reaction on the adaptive irradiation (0.05 Gy at first, then 1.0 Gy 5 h later) was investigated by micronuclei assay. Blood samples were obtained from 700 children. It was shown that in all groups studied there were children with enhanced radiosensitivity ("radiosensitivity syndrome"-RS) after exposure to adaptive low dose of radiation. The radiosensitivity syndrome occurred more often in groups of ill children; part of them was characterized by the enhanced blood content of immunoglobulin E, enhanced level of T helpers and T suppressors. A high spontaneous level of lymphocytes with micronucleus is a factor of radiosensitivity formation. The possible factors resulted in radiosensitivity syndrome are discussed.     

Prevention and mitigation of acute radiation syndrome in mice by synthetic lipopeptide agonists of Toll-like receptor 2 (TLR2)

Bacterial lipoproteins (BLP) induce innate immune responses in mammals by activating heterodimeric receptor complexes containing Toll-like receptor 2 (TLR2). TLR2 signaling results in nuclear factor-kappaB (NF-κB)-dependent upregulation of anti-apoptotic factors, anti-oxidants and cytokines, all of which have been implicated in radiation protection. Here we demonstrate that synthetic lipopeptides (sLP) that mimic the structure of naturally occurring mycoplasmal BLP significantly increase mouse survival following lethal total body irradiation (TBI) when administered between 48 hours before and 24 hours after irradiation. The TBI dose ranges against which sLP are effective indicate that sLP primarily impact the hematopoietic (HP) component of acute radiation syndrome. Indeed, sLP treatment accelerated recovery of bone marrow (BM) and spleen cellularity and ameliorated thrombocytopenia of irradiated mice. sLP did not improve survival of irradiated TLR2-knockout mice, confirming that sLP-mediated radioprotection requires TLR2. However, sLP was radioprotective in chimeric mice containing TLR2-null BM on a wild type background, indicating that radioprotection of the HP system by sLP is, at least in part, indirect and initiated in non-BM cells. sLP injection resulted in strong transient induction of multiple cytokines with known roles in hematopoiesis, including granulocyte colony-stimulating factor (G-CSF), keratinocyte chemoattractant (KC) and interleukin-6 (IL-6). sLP-induced cytokines, particularly G-CSF, are likely mediators of the radioprotective/mitigative activity of sLP. This study illustrates the strong potential of LP-based TLR2 agonists for anti-radiation prophylaxis and therapy in defense and medical scenarios.     

Wilms' tumour: adjuvant treatment with actinomycin D and vincristine.

In an unselected series of 49 children with Wilms'' tumour treated in 1969-74 the 5-year relapse-free survival and survival rates were 78% and 81%, respectively, whereas in the series of children treated in 1963-68 the corresponding rates were 49% and 70%. The significant improvement in the relapse-free survival rate was a result of adjuvant treatment with actinomycin D and vincristine (AMD + VCR), which, in some patients, eradicated occult metastatic disease. In the treatment of lung metastases the combination of whole-lung irradiation and maintained chemotherapy with AMD + VCR proved excessively toxic: in 5 of 11 patients acute diffuse pneumonitis developed, and it was fatal in 3. Adjuvant AMD + VCR therapy is advocated in all patients with Wilms'' tumour except children less than 12 months old with a tumour of moderate size, limited to the kidney and completely resectable.     

Isolated nodal failure after chemo-radiotherapy in limited disease small cell lung cancer (LD-SCLC)

BackgroundThe irradiation volume for treatment of limited disease small cell lung cancer (LD-SCLC), are still controversial. One of the aspects of radiation volume is the use of elective nodal irradiation (ENI), which has never been subjected to randomized study in SCLC patients.AimTo review retrospectively patterns of failure in relation to the radiation field after chemoradiotherapy (CHT-RT) in patients with limited disease small cell lung cancer (LD-SCLC).Material and MethodsBetween 1997 and 2006, 117 consecutive patients with LD-SCLC received chemotherapy with sequential radiotherapy (70%) and concurrent or alternating CHT-RT (30%). All but one case had predefined elective nodal irradiation (ENI) without inclusion of supraclavicular regions. Prophylactic cranial irradiation (PCI) was administered to 39% of patients.ResultsThe median follow-up for the 20 living patients was 33 months. The overall survival at 2 years was 36% (median survival: 18 months). In-field locoregional progression was observed in 42 patients (36%). Distant metastases occurred in 71 patients (61%). Five patients (4%) developed isolated nodal failure (INF) without local progression in the supraclavicular region. Patients with INF had N3 disease more often than those without INF (60% vs 21%, p = 0.04). There was 5% RTOG grade 3 or higher early radiation toxicity.ConclusionsINF failures are rare; however, the need for extension of ENI to supraclavicular areas may be reconsidered in N3 patients.     

Medical cost of curing childhood acute lymphoblastic leukaemia

Between 1970 and 1979 acute lymphoblastic leukaemia was diagnosed in 378 children at this hospital. The outcome for the 181 survivors was examined six or more years after diagnosis to assess morbidity in an unselected group of long term survivors. One hundred and thirty seven of the survivors were in first remission and probably cured (group I). Forty four (group II) had had one or more relapses, some of whom, who had isolated extramedullary relapses, also have a good chance of cure.In group I 136 patients had prophylactic cranial or craniospinal irradiation, while patients in group II, in addition to having that treatment, received local testicular (17) or craniospinal radiation (seven) for testicular or central nervous system relapse. Eight had additional prophylactic cranial radiotherapy after bone marrow relapse, and six had total body irradiation before bone marrow transplantation. The incidence of clinically important growth and endocrine morbidity was 20% in group I and 68% in group II. The morbidity in patients in group I was mainly attributable to early pubertal maturation. In group II 30 patients had growth failure, of whom 19 had gonadal failure from testicular or total body irradiation, 14 had growth hormone deficiency after doses of cranial irradiation of over 2400 cGy, and 10 had spinal growth impairment after craniospinal irradiation. Two also had early pubertal maturation. Five out of six patients who received total body irradiation had multiple endocrine deficiency. Neuropsychological sequelae of treatment were seen in 40 (42%) of 96 schoolchildren in group I and in 12 (38%) of 32 schoolchildren in group II. Postinfective sequelae of treatment were found in patients in both groups.These results show that the survivors who were in their first remission had a 42% residual morbidity related to treatment compared with an 82% morbidity in the survivors of one or more relapses who had multiple treatments.     

Acute lymphoblastic leukaemia: cyclical chemotherapy with three combinations of four drugs (COAP-POMP-CART regimen).

Forty-two adults and children with previously untreated acute lymphoblastic leukaemia (ALL) were entered into a programme of chemotherapy in which three combinations, each of four drugs were administered in a predetermined cyclical rotation together with cranial irradiation and intrathecal injections of methotrexate. Forty-one patients (98%) entered remission and no patient developed neuroleukaemia. Relapse of ALL occurred in 10 patients, and three patients died during remission, while eight patients stopped treatment after two and a half years and have remained in remission for two to 26 months. Comparison of remission and survival experience in this mixed group of children and adults with the experience of children treated at Memphis and in the Medical Research Council''s UKALL-I trial showed no significant differences. On the other hand, analysis by prognostic factors showed that neither age nor blast cell count at presentation had any adverse effect in patients treated in this study. No relapses occurred in nine patients with blast cell counts greater than 20 x 109/1 at presentation. This regimen is effective treatment for ALL and may be of special value in patients with poor prognoses. The regiment has not as yet proved superior for the treatment of children with ALL who do not have adverse prognostic features.     

Controlled trial of budesonide given by the nebuhaler in preschool children with asthma.

OBJECTIVE--To determine whether the inhaled corticosteroid budesonide, given by a Nebuhaler spacing device, was effective in prophylaxis of asthma in preschool children. DESIGN--Double blind, placebo controlled, random order crossover trial with two week practice run in period. SETTING--Outpatient clinic referrals in secondary referral centre. PATIENTS--39 children aged 2-6 years selected for the following: able to use Nebuhaler; parents able to complete record card; poorly controlled asthma (defined); not already on systemic or inhaled steroids. Eleven withdrew for various reasons not connected with intolerance to budesonide. Age, sex, other atopies, and symptoms during run in period were similar in the 28 children who completed the trial and in the 11 who withdrew. INTERVENTIONS--Budesonide 200 micrograms or placebo (both one puff) given twice daily during 6-week treatment or control periods, using Nebuhaler after prior training. Three week "washout" at crossover. Compliance monitored by weighing canisters. Patients withdrawn if their acute attacks required treatment with systemic steroids. END POINT--Control of asthma. MEASUREMENTS AND MAIN RESULTS--Peak expiratory flow rate measured twice daily where cooperation allowed. Diary of symptoms and concomitant drug use kept daily. Results showed mean peak flow significantly higher (12% in mornings, 14% in evenings) in second three weeks of intervention compared with control period (95% confidence intervals 6.3-17.3% and 7.2-21.0%). Supplementary bronchodilator drugs reduced by 50% during intervention periods. CONCLUSIONS--Budesonide given by Nebuhaler is effective prophylaxis for preschool children with frequent asthma.     

Pituitary Hormone Dysfunction After Proton Beam Radiation Therapy in Children with Brain Tumors

Objectiveo characterize endocrine dysfunction in pediatric patients with brain tumors who received proton beam (PB) radiation therapy and to compare those treated with PB radiotherapy only versus combined conventional and PB irradiation.MethodsA retrospective review of medical records of patients ≤ 18 years of age who received PB radiation therapy for a brain tumor between 2000 and 2008 was performed. Variables analyzed included patient demographics, tumor type, therapeutic modalities, radiation doses, and types and timing of endocrine dysfunction.ResultsThirty-eight patients were identified, of whom 31 (19 boys and 12 girls; mean age, 11.9 ± 3.3 years) had undergone endocrine evaluation. Of these patients, 19 received PB radiotherapy only and 12 received conventional plus PB irradiation. Before irradiation, a cranial surgical procedure was performed in 28 study subjects, and 22 received chemotherapy. The mean duration of follow-up after radiation therapy was 1.8 ± 0.8 years. Nine patients (47%) in the PB only group and 4 (33%) in the conventional plus PB group developed endocrine dysfunction (no significant difference) after cranial irradiation. Children with endocrine sequelae treated with PB irradiation alone received fewer cobalt gray equivalents than those treated with conventional plus PB irradiation (5,384 ± 268 versus 5,775 ± 226, respectively; P < .02), and pituitary hormone deficiencies were detected later during follow-up in those who received PB radiotherapy only versus conventional plus PB irradiation (1.17 ± 0.4 years versus 0.33 ± 0.11 year, respectively; P < .01).ConclusionA high rate of endocrine sequelae was seen in our study. Children with brain tumors treated with conventional plus PB irradiation developed endocrine dysfunction faster and received a higher radiation dose than those receiving PB radiotherapy only. Prior surgical treatment and chemotherapy were additional risk factors. Large prospective studies are needed to evaluate further the incidence of endocrine sequelae after PB irradiation in children. (Endocr Pract. 2011;17:891-896)     

Characterization of the acute inflammatory response after irradiation in mice and its regulation by interleukin 4 (Il4)

The aim of this study was to determine the effects of total-body irradiation of mice on the acute release of a panel of several mediators of inflammation and to evaluate the efficacy of Il4 in regulating these radiation-induced modifications. We studied the effects of exposure of C57BL6/J mice to 8 Gy gamma rays on the early release of cytokines, chemokines, acute-phase proteins, prostaglandins and corticosterone in either plasma or tissues compared to those observed after intraperitoneal injection of lipopolysaccharide from 1 h to 3 days after stimulation. During the characterization of the acute inflammatory response induced by radiation or lipopolysaccharide, we observed differences both in the type of mediators produced and in the time course of release. We next determined the anti-inflammatory potential of Il4 in this model of total-body irradiation. We found that Il4 was able to down-regulate the radiation-induced production of mediators of inflammation such as Gro1 (also known as KC, N51) in plasma and lung, corticosterone in blood, Il1b in lung, and prostaglandin E(2) in colon, suggesting the anti-inflammatory potential of Il4 in regulating the radiation-induced response.