Noninvasive Assessment of Intracranial Pressure Status in Idiopathic Intracranial Hypertension Using Displacement Encoding with Stimulated Echoes (DENSE) MRI: A Prospective Patient Study with Contemporaneous CSF Pressure Correlation.

BACKGROUND AND PURPOSE: Intracranial pressure is estimated invasively by using lumbar puncture with CSF opening pressure measurement. This study evaluated displacement encoding with stimulated echoes (DENSE), an MR imaging technique highly sensitive to brain motion, as a noninvasive means of assessing intracranial pressure status. MATERIALS AND METHODS: Nine patients with suspected elevated intracranial pressure and 9 healthy control subjects were included in this prospective study. Controls underwent DENSE MR imaging through the midsagittal brain. Patients underwent DENSE MR imaging followed immediately by lumbar puncture with opening pressure measurement, CSF removal, closing pressure measurement, and immediate repeat DENSE MR imaging. Phase-reconstructed images were processed producing displacement maps, and pontine displacement was calculated. Patient data were analyzed to determine the effects of measured pressure on pontine displacement. Patient and control data were analyzed to assess the effects of clinical status (pre-lumbar puncture, post-lumbar puncture, or control) on pontine displacement. RESULTS: Patients demonstrated imaging findings suggesting chronically elevated intracranial pressure, whereas healthy control volunteers demonstrated no imaging abnormalities. All patients had elevated opening pressure (median, 36.0 cm water), decreased by the removal of CSF to a median closing pressure of 17.0 cm water. Patients pre-lumbar puncture had significantly smaller pontine displacement than they did post-lumbar puncture after CSF pressure reduction (P = .001) and compared with controls (P = .01). Post-lumbar puncture patients had statistically similar pontine displacements to controls. Measured CSF pressure in patients pre- and post-lumbar puncture correlated significantly with pontine displacement (r = 0.49; P = .04). CONCLUSIONS: This study establishes a relationship between pontine displacement from DENSE MR imaging and measured pressure obtained contemporaneously by lumbar puncture, providing a method to noninvasively assess intracranial pressure status in idiopathic intracranial hypertension.

Secuencia de disparo único eco de gradiente en fase y fase opuesta con preparación de la magnetización: descripción y optimización de la técnica con equipo de 1, 5 T / In-phase and out-of-phase single-shot magnetization-prepared gradient recalled echo: description and optimization of technique at 1.5T

Objetivo: Implementar técnicas en fase y en fase opuesta (EF/FO) con eco de gradiente con preparación de la magnetización (Magnetization-Prepared Gradient Recalled Echo [MP-GRE]) y evaluar la viabilidad y la calidad de imagen diagnóstica entre las secuencias MP-GRE antes y después de la optimización, incluyendo aquellos pacientes que no pueden colaborar manteniendo la apnea. Material y métodos: Para la realización del presente estudio retrospectivo, llevado a cabo de conformidad con la ley HIPPA de protección de datos médicos de EE.UU., se obtuvo la aprobación del Comité de Ética Institucional con exención de obtención del consentimiento informado. Se incluyeron 2 grupos de pacientes en el estudio, antes y después de la optimización de los parámetros MP-GRE, con 73 (24 no colaboradores/49 colaboradores) y 64 (22 no colaboradores/42 colaboradores) pacientes consecutivos, respectivamente. La secuencia no sensible al movimiento usada en este estudio fue 2D MP-GRE con técnica de disparo único. Dos radiólogos evaluaron cualitativamente las secuencias para identificar la presencia de artefactos de cancelación de fase en las imágenes en FO y para determinar la calidad de imagen, la extensión de los artefactos (artefacto de fantasma, artefacto de cancelación de señal, error de registro espacial y granulado de los píxeles) y la visibilidad de las lesiones en las diferentes secuencias. También se evaluó la capacidad para detectar visualmente esteatosis hepática y adenomas suprarrenales de contenido graso. Los análisis cualitativos se compararon mediante las pruebas de Wilcoxon y Mann-Whitney. Resultados: Hubo diferencias estadísticamente significativas entre todas las secuencias MP-GRE en lo relativo al artefacto de cancelación de fase (p < 0,0001), presente en las secuencias MP-GRE FO y despreciable o ausente en las secuencias MP-GRE EF, tanto antes (EF1) como después (EF2) de la optimización, en todos los pacientes. Los artefactos de cancelación de señal fueron significativamente más marcados en las secuencias in MP-GRE EF1 (p < 0,0001). El error de registro espacial fue ligeramente más marcado en las secuencias MP-GRE EF2 (p = 0,0027) en los pacientes no colaboradores. Las secuencias MP-GRE en FO y las secuencias MP-GRE EF2 mostraron una calidad de imagen significativamente mayor (p < 0,0001).En las secuencias MP-GRE se identificaron subjetivamente la esteatosis hepática (n = 20) y los adenomas suprarrenales (n = 5) basándose en la pérdida de señal desde la secuencia EF a la secuencia en FO. Conclusión: La técnica de disparo único MP-GRE EF/FO es una técnica viable que permite la obtención de imágenes resistentes al movimiento, ofreciendo una calidad de imagen diagnóstica adecuada. Esta técnica puede proporcionar información EF y en FO de pacientes que no son capaces de mantener la apnea (AU)

Purpose: To implement in-phase and out-of-phase (IP/OP) techniques with Magnetization-Prepared Gradient Recalled Echo (MP-GRE) and to evaluate the feasibility and diagnostic image quality among pre and post-optimized MP-GRE sequences, including patients unable to cooperate with breath-hold requirements. Materials and methods: Institutional review board approval with waiver of informed consent was obtained for this HIPAA-compliant retrospective study. Two groups of patients were included in the study, before and after optimization of MP-GRE parameters, with seventy-three (24 noncooperative/49 cooperative) and sixty-four (22 noncooperative/42 cooperative) consecutive patients, respectively. The motion-insensitive sequence used in this study was a single-shot 2D MP-GRE. Two radiologists qualitatively evaluated the sequences to identify the presence of phase cancellation artifact in OP images and to determine image quality, extent of artifacts (respiratory ghosting, bounce-point artifact, spatial misregistration and pixel graininess) and lesion conspicuity on the various sequences. The ability to visually detect liver steatosis and fatty adrenal adenomas was evaluated. Qualitative analyses were compared using the Wilcoxon and Mann-Whitney tests. Results: There were statistically significant differences between all MP-GRE sequences concerning phase cancellation artifact (P<.0001) which was present in MP-GRE OP sequences and negligible to absent in the pre (IP1) and post-optimized (IP2) MP-GRE IP sequences, respectively, in all patients. Bounce point artifacts were significantly more pronounced in MP-GRE IP1 (P<0.0001). Spatial misregistration was slightly more prominent in noncooperative patients with MP-GRE IP2 (P=0.0027). MP-GRE OP and MP-GRE IP2 showed significantly higher overall image quality (P<0.0001).MP-GRE sequences subjectively identified hepatic steatosis (n=20) and adrenal adenomas (n=5) based on signal loss from IP to OP sequence. Conclusion: Single shot IP/OP MP-GRE is feasible and allows motion resistant imaging with adequate diagnostic image quality. This technique is able to provide IP and OP information in patients unable to suspend respiration (AU)

[In-phase and out-of-phase single-shot magnetization-prepared gradient recalled echo: description and optimization of technique at 1.5 T]. / Secuencia de disparo único eco de gradiente en fase y fase opuesta con preparación de la magnetización: descripción y optimización de la técnica con equipo de 1,5 T.

PURPOSE: To implement in-phase and out-of-phase (IP/OP) techniques with Magnetization-Prepared Gradient Recalled Echo (MP-GRE) and to evaluate the feasibility and diagnostic image quality among pre and post-optimized MP-GRE sequences, including patients unable to cooperate with breath-hold requirements. MATERIALS AND METHODS: Institutional review board approval with waiver of informed consent was obtained for this HIPAA-compliant retrospective study. Two groups of patients were included in the study, before and after optimization of MP-GRE parameters, with seventy-three (24 noncooperative/49 cooperative) and sixty-four (22 noncooperative/42 cooperative) consecutive patients, respectively. The motion-insensitive sequence used in this study was a single-shot 2D MP-GRE. Two radiologists qualitatively evaluated the sequences to identify the presence of phase cancellation artifact in OP images and to determine image quality, extent of artifacts (respiratory ghosting, bounce-point artifact, spatial misregistration and pixel graininess) and lesion conspicuity on the various sequences. The ability to visually detect liver steatosis and fatty adrenal adenomas was evaluated. Qualitative analyses were compared using the Wilcoxon and Mann-Whitney tests. RESULTS: There were statistically significant differences between all MP-GRE sequences concerning phase cancellation artifact (P<.0001) which was present in MP-GRE OP sequences and negligible to absent in the pre (IP1) and post-optimized (IP2) MP-GRE IP sequences, respectively, in all patients. Bounce point artifacts were significantly more pronounced in MP-GRE IP1 (P<.0001). Spatial misregistration was slightly more prominent in noncooperative patients with MP-GRE IP2 (P=.0027). MP-GRE OP and MP-GRE IP2 showed significantly higher overall image quality (P<.0001). MP-GRE sequences subjectively identified hepatic steatosis (n=20) and adrenal adenomas (n=5) based on signal loss from IP to OP sequence. CONCLUSION: Single shot IP/OP MP-GRE is feasible and allows motion resistant imaging with adequate diagnostic image quality. This technique is able to provide IP and OP information in patients unable to suspend respiration.

Contrast-enhanced free-breathing 3D T1-weighted gradient-echo sequence for hepatobiliary MRI in patients with breath-holding difficulties.

OBJECTIVE: Evaluate the image quality and diagnostic performance of a free-breathing 3D-gradient-echo sequence with radial acquisition (rGRE) compared with a Cartesian breath-hold 3D-GRE (cGRE) sequence on hepatobiliary phase MRI in patients with breath-holding difficulties. METHODS: Twenty-eight consecutive patients (15 males; mean age 61 ± 11.9 years) were analysed in this retrospective IRB-approved study. Breath-holding difficulties during gadoxetate-disodium-enhanced liver MRI manifested as breathing artefacts during dynamic-phase imaging. MRI included axial and coronal cGRE and a radially sampled rGRE sequence during the hepatobiliary phase. Two radiologists independently evaluated cGRE and rGRE images for image quality, liver lesion detection and conspicuity, and bile duct conspicuity on a four-point scale. RESULTS: Liver edge sharpness was significantly higher on rGRE images (P < 0.001). Overall image quality was slightly but significantly higher for rGRE than for cGRE (P < 0.001 and P = 0.039). Bile duct conspicuity scores of rGRE and cGRE were not significantly different. Sensitivity for detection of the 26 liver lesions was similar for rGRE and cGRE (81-77 % and 73-77 %, P = 0.5 and 1.0). Lesion conspicuity scores were significantly higher for rGRE for one reader (P = 0.012). CONCLUSION: In patients with breath-holding difficulties, overall image quality and liver lesion conspicuity on hepatobiliary phase MRI can be improved using the rGRE sequence. KEY POINTS: • Patients with diminished breath-holding capacities present a major challenge in abdominal MRI. • A free-breathing sequence for hepatobiliary-phase MRI can improve image quality. • Further advances are needed to reduce acquisition time of the free-breathing gradient-echo sequence.

A regulatory role for Src homology 2 domain-containing inositol 5'-phosphatase (SHIP) in phagocytosis mediated by Fc gamma receptors and complement receptor 3 (alpha(M)beta(2); CD11b/CD18).

The Src homology 2 domain-containing inositol 5'-phosphatase (SHIP) is recruited to immunoreceptor tyrosine-based inhibition motif (ITIM)-containing proteins, thereby suppressing phosphatidylinositol 3-kinase (PI 3-kinase)-dependent pathways. The role of SHIP in phagocytosis, a PI 3-kinase-dependent pathway, is unknown. Overexpression of SHIP in macrophages led to an inhibition of phagocytosis mediated by receptors for the Fc portion of IgG (Fc gamma Rs). In contrast, macrophages expressing catalytically inactive SHIP or lacking SHIP expression demonstrated enhanced phagocytosis. To determine whether SHIP regulates phagocytosis mediated by receptors that are not known to recruit ITIMs, we determined the effect of SHIP expression on complement receptor 3 (CR3; CD11b/CD18; alpha(M)beta(2))-dependent phagocytosis. Macrophages overexpressing SHIP demonstrated impaired CR3-mediated phagocytosis, whereas macrophages expressing catalytically inactive SHIP demonstrated enhanced phagocytosis. CR3-mediated phagocytosis in macrophages derived from SHIP(-/-) mice was up to 2.5 times as efficient as that observed in macrophages derived from littermate controls. SHIP was localized to Fc gamma R- and CR3-containing phagocytic cups and was recruited to the cytoskeleton upon clustering of CR3. In a transfected COS cell model of activation-independent CR3-mediated phagocytosis, catalytically active but not inactive SHIP also inhibited phagocytosis. We conclude that PI 3-kinase(s) and SHIP regulate multiple forms of phagocytosis and that endogenous SHIP plays a role in modulating beta(2) integrin outside-in signaling.

Negative regulation of phagocytosis in murine macrophages by the Src kinase family member, Fgr.

Ingestion of opsonized pathogens by professional phagocytes results in the generation and release of microbicidal products that are essential for normal host defense. Because these products can result in significant tissue injury, phagocytosis must be regulated to limit damage to the host while allowing for optimal clearance and destruction of opsonized pathogens. To pursue negative regulation of phagocytosis, we assessed the effect of the Src kinase family member, Fgr, on opsonin-dependent phagocytosis by mouse macrophages. We chose Fgr because it is present in high concentrations in circulating phagocytes but is not essential for Fcgamma receptor-mediated ingestion by mouse macrophages. Although expression of Fgr both in a macrophage cell line and in primary macrophages significantly attenuates ingestion mediated by Fcgamma receptors and CR3, it does not affect macropinocytosis or receptor-mediated endocytosis. This selective effect of Fgr is independent of its tyrosine kinase function. After Fcgamma receptor cross-linking, Fgr becomes associated with the immunoreceptor tyrosine-based inhibition motif (ITIM)-containing receptor, SIRPalpha (a member of the signal-regulatory protein family, also known as Src homology 2 domain-containing protein tyrosine phosphatase [SHP] substrate 1 [SHPS-1], brain immunoglobulin-like molecule with tyrosine-based activation motifs [BIT], and P84) and potentiates the association of the phosphatase SHP-1 with SIRPalpha. This association is responsible, at least in part, for decreasing positive signaling essential for optimal phagocytosis. These data demonstrate an important negative regulatory role for this Src kinase family member and suggest that this homeostatic function must be overcome for optimal uptake and clearance of opsonized pathogens.

A Rab11-containing rapidly recycling compartment in macrophages that promotes phagocytosis.

Macrophages are specialized cells of the immune system that exhibit a prodigious capacity for phagocytosis. The ability of macrophages to internalize a substantial proportion of their plasma membrane during phagocytosis indicates that they possess a mechanism for the rapid renewal of plasma membrane. We examined the role of endocytic membrane recycling in promoting phagocytosis. In contrast to many other cell types, macrophages lack a morphologically distinct peri-centriolar recycling compartment but instead demonstrate an extensive network of transferrin receptor-positive tubules and vesicles that participated in recycling. The rate of transferrin recycling in thioglycollate-elicited murine peritoneal macrophages (thio-macrophages) was exceedingly rapid, with exocytic rate constants that were 2- to 3-fold higher than those of most other cells. Because the GTPase Rab11 has been implicated in transferrin recycling in other cells, we determined its role in transferrin recycling and phagocytosis in macrophages. Macrophages expressing epitope-tagged Rab11 demonstrated the presence of Rab11 in several intracellular membrane compartments, including endosomes and nascent phagosomes. Expression of Rab11 25N, a GTP binding-deficient allele of Rab11, led to a decreased rate of transferrin efflux and impaired Fc(gamma)R-mediated phagocytosis, where Fc(gamma)R is the receptor for the Fc portion of IgG. In contrast, expression of Rab11 70L, a GTPase-deficient allele of Rab11, led to an increased rate of transferrin efflux and enhanced phagocytosis. We conclude that macrophages have adapted a rapidly mobilizable, endocytic compartment to enhance phagocytosis. Rab11 participates in the recruitment of this compartment to the macrophage cell surface.

Effect of high-dose chemotherapy on intestinal permeability in humans.

1. Mucositis is a common side-effect of chemotherapy which is difficult to assess except by invasive means such as upper gastrointestinal endoscopy. Differential absorption of mono- and di-saccharides, such as rhamnose and lactulose, is a non-invasive measure of intestinal damage. 2. The purpose of the study was to assess the duration and severity of intestinal damage in patients undergoing high-dose chemotherapy and autologous blood stem-cell transplantation for malignant disease. 3. Thirty-five patients were studied before treatment and at 7, 28, 60 and 90 days after treatment. 4. The median lactulose/rhamnose ratios before treatment and at 7 and 90 days post-treatment were 0.09, 0.62 and 0.06 respectively. Altered permeability was due to both increased lactulose permeation and decreased rhamnose absorption. These abnormalities suggest a defect in tight-junction integrity as well as a decrease in surface area of small bowel. 5. We conclude that chemotherapy given for malignant disease is associated with a transient abnormality in intestinal sugar permeability, which peaks at 7 days after treatment and is composed of both mono- and di-saccharide absorption abnormalities.

Mobilization of predominantly Philadelphia chromosome-negative blood progenitors using cyclophosphamide and rHUG-CSF in early chronic-phase chronic myeloid leukaemia: correlation with Sokal prognostic index and haematological control.

Mobilization of Philadelphia chromosome (Ph) negative blood progenitors was attempted in 23 newly diagnosed chronic myeloid leukaemia (CML) patients using a regimen of cyclophosphamide (CY) 5 g/m2 and rHUG-CSF 150 microg/m2 daily. This regimen was well tolerated with no major adverse events reported. More than 2 x 10(6)/kg CD34+ cells were collected in 21 patients (91%). Predominantly Ph-negative mobilization (0-25% Ph-positive) was seen in 30% of cases overall and was confined to patients with a Sokal prognostic score < 1 (7/11 with Sokal score <1; 0/12 with Sokal score > or = 1). Within the low Sokal index group, a low WBC count pre-mobilization and a low WBC nadir both correlated strongly with Ph-negative mobilization (P = 0.006 and 0.02 respectively). Five of 19 patients receiving at least 6 months of Roferon A therapy post mobilization achieved a major cytogenetic response; all five patients were Ph-negative mobilizers. Therefore CML patients can be divided into a good-prognosis group in whom predominantly Ph-negative progenitors can be mobilized using a regimen of moderate intensity if haematological control is achieved pre-mobilization, and a poor-prognosis group for whom predominantly Ph-positive cells are mobilized with this regimen regardless of haematological control.

Significance of molecular marker-positive cells after autologous peripheral-blood stem-cell transplantation for non-Hodgkin's lymphoma.

PURPOSE: To evaluate the significance of molecular marker-positive cells in a cohort of non-Hodgkin's lymphoma (NHL) patients undergoing high-dose chemotherapy and autologous peripheral-blood stem-cell transplantation (PBSCT). PATIENTS AND METHODS: Twenty-eight PBSC transplants have been performed in 24 patients with poor-prognosis NHL. Molecular analysis of the t(14;18) (q32;q21) translocation (bcl-2/immunoglobulin [Ig] heavy-chain joining locus [JH] fusion) or antigen receptor gene rearrangements was performed to determine the presence of lymphoma cells at presentation, in PBSC harvests, and before and after autologous PBSCT. Kaplan-Meier estimates of survival and Cox regression analyses were used to test the effect of bone marrow involvement, tumor-cell contamination of PBSCs, disease stage, and chemotherapy sensitivity at transplantation, and presence of marker-positive cells post-PBSCT on disease-free and overall survival. RESULTS: Thirteen of 24 patients (54%) are alive following PBSCT at a median follow-up time of 654 days (range, 193 to 1,908). Nine patients are in complete remission (CR) at day 216 to 1,799 (median, 805) and four are alive following relapse (day 440, 573, 1,188, and 1,908). Eleven patients (46%) have died: three of transplant-related complications at day 0, 1, and 13, and eight of recurrent disease (day 132 to 1,330; median, 451). Longitudinal marker studies post-PBSCT showed that of 16 relapse events, 13 (81%) were positive for the lymphoma marker at or before clinically documented relapse. Marker studies became negative post-PBSCT in nine of nine patients who entered and remained in CR. Disease-free survival (DFS) was significantly shortened in patients in whom marker-positive cells were detected in serial samples posttransplantation (P = .006). Cox regression analysis showed that patients in this group had a 24 times higher risk of relapse (P = .03). CONCLUSION: The results show that the reappearance or persistence of marker-positive cells after autologous PBSCT is strongly associated with relapse.

Dose intensive therapy with autologous blood stem cell transplantation in breast cancer.

BACKGROUND: Breast cancer is the commonest form of cancer in Australian women. Although approximately 50% of women with breast cancer achieve long term survival by current management methods, recurrent or metastatic disease is generally incurable. In addition, women with Stage II disease with > 10 positive axillary lymph nodes and also women with locally advanced disease (Stage III) have a poor survival even with adjuvant therapy. AIMS: To assess the toxicity and efficacy of high-dose chemotherapy with autologous peripheral blood stem cell (PBSC) transplantation in women with both metastatic and poor prognosis primary breast cancer. METHODS: Twenty-eight women with either metastatic (15) or poor prognosis (13) primary breast cancer were enrolled in the study between November 1988 to January 1993. PBSC were harvested using high-dose cyclophosphamide (Cy) with or without granulocyte-colony stimulating factor (G-CSF) and a myeloablative regimen of Cy, melphalan and carboplatin (CMCp) was used in the transplantation phase. RESULTS: Optimum numbers of stem cells were harvested in 85% of patients. The use of five G/m2 Cy plus G-CSF resulted in better PBSC yields and a significant reduction in haematologic morbidity when compared to mobilisation with Cy alone. Twenty-two women underwent 23 PBSC transplants (PBSCT). There have been two early deaths due to sepsis. The predominant morbidities observed following high dose chemotherapy and transplantation have been nausea, mucositis and diarrhoea. The median number of days to discharge following infusion of PBSC was 15 (range 11-21). At a median follow up time of 1.1 years (range 0 months-3.6 years), 8/22 (36%) evaluable patients remain alive and disease free while 14/22 (64%) have relapsed or progressed or died. CONCLUSION: High-dose chemotherapy and autologous PBSCT is a potentially highly effective treatment of women with metastatic and poor prognosis primary breast cancer. Randomised studies are required to compare this form of therapy to more standard forms of treatment in breast cancer.

Molecular detection of residual lymphoma cells in peripheral blood stem cell harvests and following autologous transplantation.

Twenty-seven patients with non-Hodgkin's lymphoma (NHL) have undergone peripheral blood stem cell (PBSC) harvesting for autologous transplantation (Tx). A molecular marker was found at presentation in 23/27 patients. Immunoglobulin heavy chain (IgH) or T cell receptor beta (TCR beta) rearrangements were detected by Southern blotting or the polymerase chain reaction (PCR) in 13 patients; PCR detected the bcl-2/JH fusion in 10 patients. Fifteen autologous PBSC transplants have been performed in 11 patients. In 5/11 patients, the marker was present in at least one PBSC collection (in four patients, every PBSC collection was positive). Survival data are available for nine patients (two early deaths); three patients relapsed and died (221 - 930 d), one is alive and in relapse (354 + d) and five are alive and in complete remission (330 - 1290 + d). These findings suggest that tumour cell contamination of PBSC harvests is not uncommon. Whether these cells are clonogenic and contribute to disease relapse remains to be elucidated. The presence of residual disease at the time of transplantation and the reappearance (or persistence) of marker positive cells post-transplantation both appear to be poor prognostic factors for disease-free survival.

Factors affecting blood stem cell collections following high-dose cyclophosphamide mobilization in lymphoma, myeloma and solid tumors.

Sixty patients with malignancy were enrolled in a study of high-dose chemotherapy and peripheral blood stem cell transplantation (PBSCT). Stem cells were harvested prior to PBSCT using high-dose cyclophosphamide (CY) mobilization (4 or 7 g/m2) with collection of a median of 4.6 x 10(8)/kg mononuclear cells (range 0.2-9.5) and 21.6 x 10(4)/kg colony forming unit-granulocyte/macrophage (CFU-GM) (range 0.1-220). Forty-seven patients were mobilized once, 11 required two cycles and two required three cycles. Eight patients (13%) failed to reach the optimum CFU-GM target (greater than 15 x 10(4)/kg) following CY mobilization. A number of factors identified those patients who were likely to achieve optimum CFU-GM collections with CY mobilization. These included the use of the higher CY mobilization dose, a longer interval from last chemotherapy cycle to mobilization, and a higher premobilization bone marrow CFU-GM level. Patient's age, the degree of bone marrow infiltration, the nature of disease or the number of pre-mobilization chemotherapeutic cycles did not affect the ability to collect optimum CFU-GM numbers. Whilst the mobilization procedure was associated with moderate non-hematologic toxicity, significant hematological morbidity was observed primarily in patients mobilized using the 7 g/m2 dose. Refinements to the protocol, in particular the use of hematopoietic growth factors, are currently under investigation.

A rare translocation (4;11)(q21;p14-15) in an acute lymphoblastic leukemia expressing T-cell and myeloid markers.

A 21-year-old male presented with a large mediastinal mass and a white cell count of 420 x 10(9)/L. A diagnosis of acute lymphoblastic leukemia (ALL) was made, with 90% of cells in the bone marrow (BM) and 99% in the peripheral blood (PB) being lymphoblasts (FAB L1). Cytogenetic analysis of these cells revealed a rare variant of the t(4;11) translocation involving chromosome arm 11p rather than 11q, namely t(4;11)(q21;p14-15). The standard form of the (4;11) translocation has been associated with leukemias with mixed-lineage phenotypes. Three cases of ALL with t(4q;11p) have previously been reported. One of these cases showed phenotypic heterogeneity involving myeloid and lymphoid lineages. The leukemia reported here also exhibits lymphoid/myeloid features. Immunophenotyping of the blasts showed that most of the cells were positive for CD2, CD5, CD7, CD10 (CALLA), CD34, and HLA-DR. A significant proportion of the cells expressed CD33. These results suggest a biphenotypic rather than a biclonal disease. Molecular analysis showed rearrangement of both immunoglobulin heavy-chain genes (JH) and of a single allele of the T-cell receptor (TCR) gamma 1 gene, while retaining germline TCR beta genes.

Mobilization of haemopoietic stem cells by cyclophosphamide into the peripheral blood of patients with haematological malignancies.

Thirty one peripheral blood stem cell mobilizations using cyclophosphamide, followed by leucapheresis, were performed in 25 patients with a variety of haematological malignancies. Cyclophosphamide at doses ranging from 0.25 g/M2/day x 4 days to 4 g/M2 on one day were given. Total doses of cyclophosphamide less than 4 g/M2 failed to induce a significant mobilization of stem cells into the peripheral blood. This compares to cyclophosphamide doses of 4 g/M2 given over one or two days where 70%-75% of patients yielded adequate stem cells for transplantation (greater than 20 x 10(4) CFU-GM/kg). Both the presence of tumour cells in the bone marrow and previous chemotherapy within 12 months of cyclophosphamide infusion significantly diminished the patients stem cell mobilizations. The rate of recovery of the patient's leucocyte count following cyclophosphamide was highly correlated to the peak level of PB CFU-GM and is a good indicator of the total stem cell yield. Fever in 50% of patients during the period of cytopaenia was the only complication seen in our patients and thus high dose cyclophosphamide is a suitable and safe agent for mobilizing haemopoietic stem cells.

Single high doses of cyclophosphamide enable the collection of high numbers of hemopoietic stem cells from the peripheral blood.

We used single high doses of cyclophosphamide (4 g/m2) to produce rebound increases in peripheral blood (PB) stem cells (PBSC) during recovery from myelosuppression, enabling their collection by apheresis for later autotransplantation. Thirty-three courses of cyclophosphamide were given to 30 patients with malignant lymphoma, multiple myeloma, or solid tumors. The neutrophil count was less than 0.5 x 10(9)/liter for a mean of 6.9 days (median 7 days), and fever occurred in 17 of 33 courses. Positive blood cultures occurred in two patients, one of whom died. The mean peak level of PB granulocyte-macrophage colony-forming units (CFU-GM) was 1517 x 10(3)/liter (median 2447 x 10(3)/liter), a 14-fold increase above the mean in normal subjects. The peak occurred at a mean of 16.6 days (median 16 days) after cyclophosphamide, generally coinciding with the time to reach 1.0 x 10(9) neutrophils per liter. Normal or minimally involved bone marrow and a rapid rise in leukocyte count during recovery were independent variables correlated to the peak of the rebound increase in PB CFU-GM levels. Previous chemotherapy and the duration of neutropenia were additional independent variables in the group with peak PB CFU-GM levels of greater than 1000 x 10(3)/liter. The mean total CFU-GM collected after a mean of five aphereses was 43.8 x 10(4)/kg body weight (BW) (median 35.5 x 10(4)/kg BW), significantly correlated with the mononuclear cell yield. We conclude that single 4 g/m2 doses of cyclophosphamide effectively produce high levels of PBSC, particularly but not exclusively in patients with normal or minimally involved bone marrow and who have not had intensive recent chemotherapy.

Novel translocations in acute nonlymphocytic leukemia. Two cases involving chromosome 21, band q22.

We present two cases in which translocations involving 21q22 were found at presentation in acute nonlymphocytic leukemia (ANLL). The first of these translocations, t(3;21)(q26-q27;q22), is previously unknown in ANLL, but appears indistinguishable from that reportedly associated with Philadelphia-positive chronic myelogenous leukemia. The second case involves t(15;21)(q21-q22;q22), a translocation previously undescribed in ANLL. Both of these exchanges involve 21q22 plus another chromosome region associated with leukemogenesis. We attempted to interrelate these cytogenetic data with the oncogenic significance of 21q22.