Hydroxyurea,Leucopheresis, and Splenectomy in Chronic Myeloid Leukaemia at the Problastic Phase

Forty-three patients with chronic myeloid leukaemia have been treated with hydroxyurea in order to be subjected to leucopheresis for white cell transfusions. Hydroxyurea decreases leucocytosis when it is administered and the blood granulocyte number increases soon after the drug is stopped. The survival of the patients is not different from the survival of the patients treated with conventional chemotherapy (busulphan, mitobronitol) and it is superior to the survival of patients treated with external radiotherapy or with ³²P. Half of the patients were subjected to splenectomy during first remission for a phase II trial. They were not randomized, but the distribution according to age was similar in the two groups. A slight difference appears in favour of splenectomy so far as survival is concerned, but there were three post-operative deaths out of 18 patients. We conclude that a phase II trial on the value of splenectomy is indicated ethically, but that the patients should be operated on and nursed in a microbiologically controlled environment.     

An apparent discrepancy between the number of colony forming units transplanted and survival of busulphan lethally treated rats

Conditions for keeping busulphan lethally treated rats alive by transplantation of bone marrow cells from syngeneic donors are described. After busulphan treatment of the donor rats with a dose which only reduces the colony forming units (CFU's) in the marrow (assayed by the spleen colony technique) to half the normal numbers, at least 100 times as many cells from these treated donors, compared to untreated rats, are required to produce an equivalent increase in survival of busulphan lethally treated recipients. In contrast, aminochlorambucil, despite producing a marked fall in bone marrow cellularity, has no effect on the number of CFU/femur, yet the marrow from these aminochlorambucil treated donors is no more effective in increasing the survival of busulphan lethally treated recipients than untreated marrow. Theories which may explain this apparent discrepancy and evidence which it affords on the mode of action of busulphan are discussed.     

Lung Function in Patients Receiving Busulphan

An attempt was made to achieve earlier detection of busulphan lung (fibrosing alveolitis) and to determine its incidence by means of serial studies during life, including measurement of the gas transfer factor. Twenty-three patients were investigated over an average period of nearly two years of busulphan treatment. One case of busulphan lung was detected and subsequently confirmed at necropsy, but in the remainder there was no clinical, radiological, or physiological evidence of fibrosing alveolitis. It is concluded that the development of fibrosing alveolitis may be related to individual genetic or immunological factors rather than to busulphan dosage.     

Acute leukaemia after busulphan.

During a double-blind study of two years'' cytotoxic chemotherapy with busulphan or cyclophosphamide in patients who had had resection of carcinoma of the bronchus the long-term effects of these two drugs were also studied. Four of the 243 patients treated with busulphan developed leukaemia compared with none of the 234 treated with cyclophosphamide and none of the 249 on placebo. None of these four patients received radiotherapy or other cytotoxic chemotherapy before leukaemia was diagnosed, and all four were among the 19 patients who developed pancytopenia while taking busulphan, five to eight years before leukaemia became clinically apparent. These findings suggest that busulphan is leukaemogenic, though its mode of action is uncertain.     

Pure red cell aplasia and thymoma associated with high levels of the suppressor/cytotoxic T lymphocyte subset.

A 64 year old man admitted to hospital with increasing effort dyspnoea and lethargy was found to have a thymoma and pure red cell aplasia. Lymphocytes accounted for 20-30% of marrow cells, and numbers of T8 suppressor/cytotoxic cells in peripheral blood were greatly increased. He remained anaemic after removal of the thymoma despite blood transfusions, and immunosuppression with prednisolone 60 mg and cyclophosphamide 50 mg daily was started. The dose of prednisolone was reduced to 15 mg owing to steroid myopathy and the risk of opportunistic infection. He went into remission, and the dose was further decreased to 10 mg daily.     

Central venous catheter related infections: Risk factors and the effect of glycopeptide antibiotics

Background

Invasive Aspergillus infections are frequently seen in immunocompromised patients but arthritis is a rare complication of Aspergillus infections in the absence of immune suppressive therapy, trauma or surgical intervention.

Case presentation

A 17 years old male patient with arthritis and patellar osteomyelitis of the left knee whose further investigations revealed chronic granulomatous disease as the underlying disease is followed. Aspergillus fumigatus was isolated from the synovial fluid and the tissue samples cultures. He was treated with Amphotericin B deoxicolate 0.7 mg/kg/day. Also surgical debridement was performed our patient. Amphotericin B nephrotoxicity developed and the therapy switched to itraconazole 400 mg/day. Itraconazole therapy were discontinued at the 6th month. He can perform all the activities of daily living including.

Conclusion

We think that, chronic granulomatous disease should be investigated in patients who have aspergillar arthritis and osteomyelitis.     

Chronic hypoplastic marrow failure and residual injury.

An experimental model of chronic marrow failure can be produced in mice by treatment with a short course of busulphan. This results in permanent partial marrow failure which may later progress and become complete. The underlying lesion appears to be stem cell damage which leads to failure of proliferation of stem cells and their progeny. Other drugs can produce the same lesion and alkylation of DNA may be the mechanism.     

Pure red cell aplasia: review of treatment and proposal for a treatment strategy.

The management of pure red cell aplasia (PRCA) continues to challenge clinical investigators because the pathophysiology is heterogeneous and poorly understood. There are five treatment regimens that have established efficacy for patients with chronic PRCA. In patients with congenital hypoplastic anemia the best results have been reported using corticosteroids. Cyclosporine A is recommended as the treatment of choice in acquired PRCA. High-dose intravenous immunoglobulin therapy is highly effective in PRCA associated with parvovirus B19 infections and impaired IgG-antibody response. Treatment failures may be successfully managed with horse anti-human thymocyte globulin or cyclophosphamide plus corticosteroids. The potential of hematopoietic growth factors in the treatment of PRCA awaits further studies.     

Varying course of pancytopenia after busulfan treatment of chronic myelocytic leukemia (CML)]

In 84 patients with chronic myeloid leukaemia receiving a cytostatic monotherapy with busulfan, an aplastic syndrome developed which was confirmed by a biopsy of the pelvis crest and examination of the sternal marrow. The time interval until pancytopenia was detected varied considerably in each case, ranging between 6 and 126 months. There are no correlations to the initial doses of busulfan. 3 patients died of the immediate effects of the bone-marrow damage caused by busulfan. In 4 from 6 of the following pancytopenic patients the leukocyte values lay between 12,800/microliter and 80,400 microliter when busulfan adminstration was interrupted. Thus, it is scarcely possible to give any reliable informations about a leukocyte limit value as a standard for an interruption of therapy in order to prevent bone-marrow aplasia. Taking this into account, the conclusion may be drawn that relatively short control intervals have to be made in this monochemotherapy of CML which often can be used successfully for many years.     

Novel PI3Kγ Mutation in a 44-Year-Old Man with Chronic Infections and Chronic Pelvic Pain

A 44-year-old man is presented here with 14 years of chronic purulent sinusitis, a chronic fungal rash of the scrotum, and chronic pelvic pain. Treatment with antifungal therapy resulted in symptom improvement, however he was unable to establish an effective long-term treatment regimen, resulting in debilitating symptoms. He had undergone extensive work-up without identifying a clear underlying etiology, although Candida species were cultured from the prostatic fluid. 100 genes involved in the cellular immune response were sequenced and a missense mutation was identified in the Ras-binding domain of PI3Kγ. PI3Kγ is a crucial signaling element in leukotaxis and other leukocyte functions. We hypothesize that his mutation led to his chronic infections and pelvic pain.     

Study of Cytotoxic Chemotherapy as an Adjuvant to Surgery in Carcinoma of the Bronchus

This report gives the findings after two years of a study of long-term oral cytotoxic chemotherapy with busulphan or cyclophoshamide in carcinoma of the bronchus compared with two placebos, identical in appearance to the drug-containing tablets. A total of 753 patients who had had a total resection of the tumour, who had no detectable extrathoracic metastasis, and who were able to attend chest clinics monthly were admitted to the study from January 1965 to January 1968. Twenty-seven patients were excluded from all the analyses.The 217 patients admitted up to December 1965 form the “early” intake, the remaining 509 the “late” intake. There were no significant differences between the series in either intake period in a number of pretreatment factors studied. At 24 months 46% of the busulphan, 44% of the cyclophosphamide, and 49% of the placebo series were alive in the early intake, as were 49%, 50%, and 50% respectively in the late intake. There were no important differences between the series in survival related to pretreatment condition, cause of death, time of detection of metastases, and condition of the survivors at 24 months. Maintenance chemotherapy was interrupted to a greater extent in the busulphan than in the cyclophosphamide series and least in the placebo series.In both intakes clinical toxicity was more frequent in the cyclophosphamide series and similar in frequency in the busulphan and placebo series. Haematological toxicity was particularly frequent and severe in the busulphan series, especially in the early intake, platelet depression being the predominant manifestation.It is concluded that there is no evidence that either of the two cytotoxic drugs in the dosage prescribed improved survival for the two-year period of observation, though a final evaluation of the adjuvant chemotherapy as studied in this investigation will have to await the results at five years.     

Granulopoiesis in long-term culture by marrow from mice with busulfan-induced chronic latent aplasia

Mice given high-dose busulfan therapy develop a chronic latent marrow aplasia characterized by normal peripheral blood neutrophil numbers, hematocrits and marrow cellularity but reduced numbers of pluripotent hemopoietic stem cells (CFU-s) and granulocyte-monocyte progenitor cells (CFU-gm). To study the pathogenesis of this lesion, bone marrow was propagated in long-term marrow cultures (LTMC). Small amounts of normal marrow readily established and sustained long-term granulopoiesis in vitro. In contrast, inocula of marrow from busulfan-treated animals containing three to five times as many stem and progenitor cells failed to establish long-term granulopoiesis in vitro. These results suggest that high-dose busulfan therapy produces a qualitative defect in either the hemopoietic stem cells, the stromal-forming elements, or both, rendering them incapable of establishing long-term granulopoiesis in vitro. Furthermore, mixing experiments employing normal and busulfan-damaged marrow demonstrate that this qualitative defect is not due to the emergence of a suppressor cell population. LTMC can show types of marrow damage not detectable by other techniques currently available and represent a powerful tool for studying latent bone marrow failure.     

Reproduction in a female patient with Down's syndrome. Case report of a 46, XY child showing slight phenotypical anomalies, born to a 47, XX, + 21 mother.

A non-mongoloid boy born to a mongoloid mother is described. He showed aplasia of the left 5th finger and some clinical and dermatoglyphic features frequently found in Down's syndrome. Chromosome analysis revealed few hyperdiploid but no G-trisomic cells. An undetected G-trisomy mosaic, or a mechanism of extrachromosomal inheritance, and an embryonic development in a pathological milieu are discussed.     

Reproduction in a female patient with Down's syndrome

Summary A non-mongoloid boy born to a mongoloid mother is described. He showed aplasia of the left 5th finger and some clinical and dermatoglyphic features frequently found in Down's syndrome. Chromosome analysis revealed few hyperdiploid but no G-trisomic cells. An undetected G-trisomy mosaic, or a mechanism of extrachromosomal inheritance, and an embryonic development in a pathological milieu are discussed.Supported by the Fritz-Thyssen-Stiftung     

The effects of busulphan on the chromosomes of normal human lymphocytes

In vitro exposure of human lymphocytes to busulphan (BUS) produced an increase in chromosome aberrations and in sister-chromatid exchange (SCE) frequency. The distribution of chromosome breaks throughout the karyotype was non-random and they occurred mainly in the G-negative bands. Certain bands had a marked susceptibility to BUS and comparisons with the human chromosome-break distributions reported for a number of drugs revealed that some of these bands were equally susceptible to other alkylating agents. Both the number of chromosome gaps and breaks and the SCE frequency increased with BUS concentration, but only the SCE dose-response was a clearly defined linear relationship. Therefore a standard SCE dose-response curve was constructed for future comparison with the results of similar investigations of patients on BUS therapy.     

Sister-chromatid exchanges and chromosal breakage in patients treated with cytostatics.

The frequency of structural chromosomal rearrangements and sister-chromatid exchanges (SCEs) was investigated in short-term phytohemagglutininstimulated lymphocyte cultures by means of bromodeoxyuridine substitution and fluorescence plus Giemsa (FPG) staining technique. Both these parameters were significantly increased in patients treated with comparatively low doses of cyclophosphamide, busulphan and adriamycin. The increased SCE rate was proportional to the number of chromosome breaks, the ratio of SCE to breaks being about 100:1. The increase in the SCE number was maintained for several months after the termination of cytostatic therapy, when the conventional analysis of chromosome breaks yielded normal results. Normal SCE values were obtained in two patients treated with low doses of fluorouracil.     

The effects of busulphan on the chromosomes of normal human lymphocytes

In vitro exposure of human lymphocytes to busulphan (BUS) produced an increase in chromosome aberrations and in sister-chromatid exchange (SCE) frequency. The distribution of chromosome breaks throughout the karyotype was non-random and they occurred mainly in the G-negative bands. Certain bands had a marked susceptibility to BUS and comparisons with the human chromosome-break distributions reported for a number of drugs revealed that some of these bands were equally susceptible to other alkylating agents. Both the number of chromosome gaps and breaks and the SCE frequency increased with BUS concentration, but only the SCE dose--response was a clearly defined linear relationship. Therefore a standard SCE dose--response curve was constructed for future comparison with the results of similar investigations of patients on BUS therapy.     

Treatment of Acute Myeloblastic Leukaemia with RP 22050

Fourty-four patients with acute myeloblastic leukaemia were treated with RP 22050, a new, semisynthetic derivative of daunorubicin. Complete remissions were achieved in 20 patients (45%). The median dose given was 23 mg/kg. The toxicity of RP 22050 is mainly haematological. Resistance rather than death in aplasia seemed to be the cause of failure of therapy.     

Clastogenic and aneuploidizing effects of antiblastic busulphan revealed by kinetochore immunofluorescence in CHO cells.

We utilized, in CHO cells, the cytoplasm preservation technique to evaluate the micronucleus frequency at different busulphan concentrations, and the indirect immunofluorescence technique, using sera obtained from patients with scleroderma (CREST variant), to analyze if busulphan-induced micronuclei have kinetochores. Results show that this alkylating agent is capable of causing a significant increase of micronuclei in vitro, a great part (40%) of them having CREST-positive kinetochores. These findings confirm the clastogenic effect of busulphan and reveal a considerable capability of this agent to induce aneuploidy. These results are examined taking into account the high incidence of secondary neoplasias induced by chemotherapy with alkylating agents utilized against primary neoplasias.