Risk-adapted postremission therapy in acute myeloid leukemia: results of the German multicenter AML HD93 treatment trial.

The objective of the AML HD93 treatment trial was to evaluate the outcome in young adults with acute myeloid leukemia (AML) after postremission therapy was stratified according to cytogenetically defined risk. The rationales for the study design were based (i) on previous favorable results with high-dose cytarabine in AML with t(8;21), inv/t(16q22) and in AML with normal karyotype, and ii) on encouraging results obtained in several phase II trials using autologous stem cell transplantation (SCT). Between July 1993 and January 1998, 223 eligible patients, 16-60 years of age with newly diagnosed AML other than French-American-British type M3/M3v, were entered into the trial. Risk groups were defined as follows: low risk: t(8;21) or inv/t(16q22); intermediate risk: normal karyotype; high risk: all other chromosomal abnormalities. Following intensive double induction therapy with idarubicin, cytarabine and etoposide, all patients in complete remission (CR) received a first consolidation therapy with high-dose cytarabine and mitoxantrone (HAM). A second consolidation therapy was stratified according to the risk group: low risk: HAM; intermediate risk: related allogeneic SCT or sequential HAM; high risk: related allogeneic or autologous SCT. Double induction therapy resulted in a high CR rate of 74.5%, and 90% of the responding patients were eligible for consolidation therapy. Survival for all 223 trial entrants was 40%, and for the 166 patients who entered CR, disease-free (DFS) and overall survival were 40 and 51% after 5 years, respectively. Within the low-, intermediate- and high-risk groups, DFS and survival after 5 years were 62.5 and 87, 40 and 49 and 17 and 26% respectively, without advantage for allogeneic transplantation in the intermediate- and high-risk groups. Postremission therapy-related mortality was 0, 7 and 14%, respectively. This study demonstrates the feasibility of cytogenetically defined risk-adapted consolidation therapy. The overall trial results are at least equivalent to those of published trials supporting the risk-adapted treatment strategy.

Molecular epidemiology of Candida albicans isolates from AIDS and cancer patients using a novel standardized CARE-2 DNA fingerprinting technique.

A total of 277 Candida isolates from various body sites of 149 AIDS and cancer patients treated in four different university clinics in Würzburg, Germany were collected over a period of 27 months and phenotypically and genotypically characterized. The fingerprinting patterns of 194 Candida albicans isolates obtained with the moderately repetitive, C. albicans-specific DNA fragment CARE-2 were digitized and retrospectively compared with a highly accurate computer-assisted standardization method. A total of 168 different genotypic patterns (< 100% identity) could be differentiated using this technique. Although comparative analysis of C. albicans subsets revealed a pronounced tendency of C. albicans isolates from HIV patients to form clusters, the mean genetic variability in HIV and cancer patient isolates was virtually identical. Patients with a specific disease condition or in a certain age group were not found to harbour C. albicans isolates displaying a characteristic "signature genotype". Micro-evolutionary changes were detected by CARE-2 fingerprinting in temporal successive isolates of one patient, but nosocomial transmission of identical isolates between unrelated patients was never seen. Genotyping showed that patient isolates can replace one another; occasionally also species switches were observed. Secreted aspartic protease (SAP) production was not correlated with a specific C. albicans banding pattern; isolates obtained from HIV patients and from an internal control group secreted comparable amounts of SAP. Candida dubliniensis isolates in this study showed an elevated level of SAP production. When used under standardized conditions, CARE-2 fingerprinting is an efficient, reproducible and sensitive technique to characterize C. albicans isolates.

Successful collection of peripheral blood progenitor cells in patients with acute myeloid leukaemia following early consolidation therapy with granulocyte colony-stimulating factor-supported high-dose cytarabine and mitoxantrone.

We evaluated the feasibility of collecting peripheral blood progenitor cells (PBPC) in patients with acute myeloid leukaemia (AML) following two cycles of induction chemotherapy with idarubicin, cytarabine and etoposide (ICE), and one cycle of consolidation therapy with high-dose cytarabine and mitoxantrone (HAM). Thirty-six patients of the multicentre treatment trial AML HD93 were enrolled in this study, and a sufficient number of PBPC was harvested in 30 (83%). Individual peak concentrations of CD34+ cells in the blood varied (range 13.1-291.5/microl; median 20.0/microl). To reach the target quantity of 2.5 x 10(6) CD34+ cells/kg, between one and six (median two) leukaphereses (LP) were performed. The LP products contained between 0.2 x 10(6) and 18.9 x 10(6) CD34+ cells/kg (median 1.2 x 10(6)/kg). Multivariate analysis showed that the white blood cell count prior to HAM and the time interval from the start of HAM therapy to reach an unsupported platelet count > 20 x 10(9)/l were predictive for the peak value of CD34+ cells in the blood during the G-CSF stimulated haematological recovery. In 16 patients an intraindividual comparison was made between bone marrow (BM) and PBPC grafts. Compared to BM grafts, PBPC grafts contained 14-fold more MNC, 5-fold more CD34+ cells and 36-fold more CFU-GM. A CD34+ subset analysis showed that blood-derived CD34+ cells had a more immature phenotype as indicated by a lower mean fluorescence intensity for HLA-DR and CD38. In addition, the proportion of CD34+/Thy-1+ cells tended to be greater in the PBPC grafts. The data indicate that sufficient PBPC can be collected in the majority of patients with AML following intensive double induction and first consolidation therapy with high-dose cytarabine and mitoxantrone.

[The risk of splenectomy]. / Das Risiko der Splenektomie.

BACKGROUND: The controversely discussed effect of splenic loss and disturbances of the general state of health are to be reported by means of several check sheets. There is a control group for comparison and statistic evaluation. The results will be considered in relation to laboratory serum parameters. PATIENTS AND METHOD: 111 patients splenectomized for various reasons could be examined 3 to 17 years following surgery. We applied the depression check sheet by Beck, the Giessen complaint check sheet, and a specific splenectomy check sheet. The latter served to inquire an additional control group of statistic twins who underwent comparable upper abdominal surgery, but not splenectomy. Furthermore, 42 laboratory serum parameters were determined in every splenectomized patient. RESULTS: Compared to random tests with the Federal Republic's population, the Giessen complaint check sheet detected a more frequently disturbed state of health in "spleenless". An evaluation of the specific splenectomy check sheet detected an increased trend for infections after splenectomy (p = 0.0000001) compared to those after upper abdominal surgery. There was no statistical proof for other typical symptoms such as incompatibility with alcohol or vegetative dystonia. There was no significant anomaly in the 42 parameters measured. CONCLUSION: Every other splenectomized patient complained about frequent infections and, consequently, disturbed state of health (physical weakness, early exhaustion). These complaints did not correlate to the measured laboratory serum parameters.

The anaplastic variant of centrocytic lymphoma is marked by frequent rearrangements of the bcl-1 gene and high proliferation indices.

Ten cases of classic centrocytic lymphoma as defined in the Kiel classification system were investigated for their immunophenotype, their proliferation activity and by means of molecular diagnostics. The findings were compared to those obtained from a group of nine cases of anaplastic centrocytic lymphoma. Both groups showed virtually identical immunohistochemical characteristics with positivity for CD5 and negativity for CD10 and CD23. In the group of anaplastic centrocytic lymphoma, there were considerably higher proliferation indices as documented by staining for the Ki-67 antigen, up to 80% of the tumour cells being positive. Moreover, the cases of anaplastic centrocytic lymphoma had bcl-1 gene rearrangements in eight out of nine cases compared with three out of 10 cases of classic centrocytic lymphoma. DNA analysis was not able to detect bcl-2 gene rearrangement in any case, pointing to a difference compared with lymphomas of germinal centre origin. The coincidence of anaplastic and sometimes blast-like morphology of the tumour cells, high proliferation index and a rearranged bcl-1 gene in nearly all cases of anaplastic centrocytic lymphoma support their classification as high-grade malignant variants of centrocytic lymphoma and suggest a possible role for the bcl-1 locus not only in the origin but also in the progression of centrocytic lymphomas.

Malignancy-associated changes in monocytes and lymphocytes in acute leukemias measured by high-resolution image processing.

A number of methods are available for classifying lymphoid and myeloid leukemias in peripheral blood and bone marrow. However, in clinical diagnosis an initial and particularly important step is morphologic analysis. All the cells in this investigation were classified by two hematologic experts. In most cases, immunophenotyping and immunocytochemical analyses were performed. Routinely prepared Romanowsky-Giemsa-stained peripheral blood smears (approximately 23,000 cells) were scanned by a high-resolution color TV/microscope system and analyzed by color and texture algorithms. In addition to blast cells, lymphocytes and monocytes exhibited a leukemia-associated change in morphology. The calculated texture and color features were most significant for the subtyping performed by the statistical program. With multivariate statistical analysis, seven mathematical subtypes of lymphocytes and five of monocytes could be found over all the specimens. Acute myeloblastic leukemia (AML, M1-M2), acute myelomonocytic leukemia (AMMOL, M4) and acute monocytic leukemia (AMOL, M5) could be differentiated by their distributions of monocyte subtypes. However, this was impossible for the lymphocyte subtypes. Acute lymphoblastic leukemias (B-ALL and T-ALL) were discernible with the aid of lymphocyte subtypes and acute myeloid conditions from viral infections, such as with the Epstein-Barr virus. The method increased the relevance of image processing in clinical diagnosis of acute leukemias and showed that the "normal" cell populations were not really normal in malignant leukemias.

[The diagnostic assessment of enlarged lymph nodes by the qualitative and semiquantitative evaluation of lymph node perfusion with color-coded duplex sonography]. / Dignitätsbeurteilung vergrösserter Lymphknoten durch qualitative und semiquantitative Auswertung der Lymphknotenperfusion mit der farbkodierten Duplexsonographie.

Perfusion of enlarged lymph nodes by colour-coded sonography was studied prospectively in 105 benign and 115 malignant lymph nodes. The diagnosis was confirmed histologically in 158 and clinically in 62. Spectral analysis in the benign lymph nodes provided normal values for pulsatility and resistance indices. A pulsatility index greater than = 1.8, or a resistance greater than = 0.9 indicate lymph node metastases with positive prediction of 93% and specificity of 97%. In addition, subjective, semiquantitative classification of lymph node perfusion in relation to the surrounding fat or connective tissue improves the diagnosis of lymph node metastases and of malignant lymphomas.

[Therapeutic cytapheresis]. / Therapeutische Zytapheresen.

In myeloproliferative disorders many complications are caused by circulatory problems due to high leukocyte or platelet numbers and by hyperviscosity. With cytaphereses and mild cytostatics like Azathioprine, these problems are solved quickly and without major side effects. We report about plateletaphereses for polycythemia vera and megacaryocytic myelosis and leukocytaphereses for chronic myelogenous leukemia. In addition, erythrocytaphereses were carried out successfully in a patient with a combination of heterozygous sickle cell anemia and thalassemia minor.

Chronic Lymphocytic Leukemia (B-CLL) and Immunocytoma (LP-IC): Clinical and Prognostic Relevance of this Distinction.

The Kiel classification of non-Hodgkin lymphomas (NHL) has established chronic lymphocytic leukemia (B-CLL) and immunocytoma (LP-IC) as separate entities of low-grade malignant NHL by morphological and immunohistochemical criteria. The clinical and prognostic relevance of this discrimination was evaluated in a prospective multicenter observation study by the Kiel Lymphoma Study Group. From 1975 to 1980, 430 previously untreated patients with B-CLL (n = 217) and LP-IC (n = 213)a were recruited and followed for up to 14 years. While the age and sex distribution and the incidence of clinical stages were quite similar in both entities major differences between initial manifestations in B-CLL and LP-IC became evident, e.g. in the incidence of bone marrow infiltration (99.5 vs. 86%), peripheral blood lymphocytosis (99.5 vs. 60%), or monoclonal gammopathy (1 vs. 30%). A strictly localized tumor (Ann Arbor stage I/IE) was seen in only 1.5% of the LP-IC patients who were successfully treated by local radiotherapy. In all other patients an expectative-palliative treatment concept was pursued. Long-term survival data analysis revealed significant differences between B-CLL and LP-IC and identified the pseudofollicular in B-CLL and the lymphoplasmacytic in LP-IC as the most favorable histological subtypes. The discriminative prognostic potential of clinical stage (Rai or Binet classification) for B-CLL and LP-IC varied and the pattern of prognostic risk factors obtained by multivariate analysis was not identical. Thus, the morphological distinction between B-CLL and LP-IC correlates with characteristic differences between these entities both in their initial clinical presentation and long-term prognosis.

Multicentre randomized therapeutic trial for advanced centrocytic lymphoma: anthracycline does not improve the prognosis.

Within a multicentre observation study on non-Hodgkin lymphomas (NHL) diagnosed according to the Kiel classification advanced stages III and IV of centrocytic (CC) lymphoma exhibited the worst prognosis among lymphomas of low-grade malignancy with a 5-year survival probability of less than 10 per cent. Treatment had been solely expectative and palliative with treatment results showing a prognostic superiority of patients achieving partial and complete remissions over non-responders. Therefore, a randomized multicentre study was initiated to compare the remission-inducing potential of the COP regimen (Bagley et al., 1972) with that of the more intensive adriamycin-containing CHOP regimen (McKelvey et al., 1976). From 91 newly diagnosed CC lymphomas 63 fulfilled randomization criteria with 37 patients assigned to the COP regimen and 26 patients to the CHOP regimen. Between the COP- and CHOP-treated patients no significant differences could be demonstrated with respect to initial clinical parameters, rate of complete (41 per cent versus 58 per cent) or partial remissions (43 per cent versus 31 per cent), median overall survival probability (32 versus 37 months), relapse-free survival (10 versus 7 months) and rates of relapse (73 per cent versus 67 per cent) and death (57 per cent versus 50 per cent). It can be concluded that CC lymphoma is a typical lymphoma of low-grade malignancy with its inability to reach stable remissions while the demonstration of identical survival probabilities for patients with complete and partial remissions constitutes a unique feature of this lymphoma entity. These observations prove advanced CC lymphoma to represent an incurable neoplastic disease under conventional therapeutic approaches.

Preoperative chemotherapy in locally advanced and nonresectable gastric cancer: a phase II study with etoposide, doxorubicin, and cisplatin.

Thirty-four patients with locally advanced, nonresectable gastric cancer (staged by laparotomy) received etoposide, Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), and cisplatin (EAP). Thirty-three patients were evaluable for response and toxicity. Second-look surgery with removal of residual tumor by gastrectomy and lymphadenectomy was performed in case of complete/partial remission (CR/PR) after EAP. After successful resection (R0- and R1-resection), two cycles of EAP were administered for consolidation therapy. Patients refusing reoperation received up to six cycles of EAP. The response rate (CR/PR) after EAP was 70% (23/33), including a 21% (7/33) rate of clinical CRs (CCRs). Two patients had minor remission (MR)/no change and seven had progressive disease. There was one early death. Nineteen of 23 responders (5 CCRs, 14 clinical PRs [CPRs]) and one patient with MR underwent second-look surgery. Five CCRs were pathologically confirmed; 10 patients with CPR were without evidence of disease (NED) after resection. In three patients (CPR), R1-resections (microscopically tumor-cell positive proximal margin) were performed; two patients are disease-free, 22+ and 33+ months after consolidation chemotherapy. In two patients, the tumor was again considered nonresectable. Twenty patients were disease-free after EAP +/- surgery +/- consolidation chemotherapy. Toxicity was primarily hematologic. Leukopenia and thrombocytopenia of World Health Organization (WHO) grade 3 occurred in 30% and 9%, respectively and grade 4 in 18% and 9% of the patients, respectively. There was no increased peri- or postoperative morbidity. After a median follow-up of 20 months for disease-free patients, the relapse rate is 60% (12/20). The median survival time for all patients is 18 months and for disease-free patients 24 months. EAP is highly effective in locally advanced gastric cancer, and offers a chance for surgery with curative intention in patients with an otherwise fatal prognosis.

Etoposide and split-dose cisplatin in small-cell lung cancer.

Forty-seven untreated patients with small-cell lung cancer (SCLC) were treated with a combination of etoposide (170 mg/m2 intravenously, i.v., days 3-5) and cisplatin (50 mg/m2 i.v., days 1 and 7). Responding patients with limited disease received four cycles followed by irradiation (delivered to the primary site, mediastinum, and supraclavicular region) with 50 Gy. Prophylactic cranial irradiation (PCI) with 30 Gy was performed in patients who achieved complete remission. Responding patients with extensive disease received four to six cycles of chemotherapy. The overall objective response rate (complete response plus partial response, CR + PR) was 94% (44 of 47). CR rate (all patients) was 57% (27 of 47), 51% (19 of 37) in extensive disease and 80% (8 of 10) in limited disease. The median remission duration is 13 months (12 months in extensive disease and 26 months in limited disease). The median survival is 16 months for all patients (15 months in extensive disease, 28 months in limited disease). Mean follow-up is 13 months. Toxicity was primarily hematologic. Twelve of 47 patients had leukopenia of WHO grade 4, 30 of 47 of grade 3. Thrombocytopenia of WHO grade 3 and 4 occurred in 6 of 47 and 2 of 47 patients, respectively. There were four severe infections in neutropenic patients, but no chemotherapy-related lethal complications. The only treatment-related death was that of one patient who died in CR of progressive neurologic dysfunction 11 months after PCI. This schedule of etoposide and cisplatin induces high CR rates and a prolonged survival, especially in patients with extensive disease.

Segmentation of stained blood cell images measured at high scanning density with high magnification and high numerical aperture optics.

In hematological morphology, it is necessary to resolve and analyze the smallest possible cellular details appearing in the light microscope. A prerequisite for computer-aided analysis of subtle morphological features is measuring the cells at a high scanning density with high magnification and high numerical aperture optics. Contrary to visual observations, the information content in a measured picture can be increased by setting the condensor's numerical aperture (NA) greater than the objective's NA. The complexity and heterogeneity of such cell images necessitate a new segmentation method that conserves the morphological information required in the subsequent image analysis, feature extraction, and cell classification. In our segmentation strategy, characteristic color difference thresholds for each nucleus and cytoplasm are combined with geometric operations, probability functions, and a cell model. All thresholds are repeatedly recalculated during the successive improvements of the image masks. None of the thresholds are fixed. This strategy segments blood cell images containing touching cells and large variations in staining, texture, size, and shape. Biological inconsistencies in the calculated cell masks are eliminated by comparing each mask with the cell model criteria integrated into the entire segmentation process. All 20,000 leukocyte images from 120 smears in our leukemia project were segmented with this method.

Leukemia-related morphological features in blast cells.

This paper investigates the use of image-processing methods to detect leukemia-related morphological differences in mononuclear blast cells. Routinely prepared Pappenheim-stained blood smears were scanned in a high-resolution color TV-microscope system. Eleven blast-cell classes (OMSBC, T-ALL, OMS, ALL, LBL, IBL, AUL, AML, AMOL, AMMOL, and CML) were analyzed with the nonparametric statistical software program "Classification and Regression Trees" (CART). This paper documents the initial statistical evaluation of 62 leukemia-related morphological features that directly measure and analyze the cell-related quantifiable differences occurring in the various blast cells. The 62 cell image features include both common cytophotometric features, and new texture and color features developed for this project. This study found that each leukemia specimen contains a dominant class of blasts that correlates with the specific leukemia, plus a distribution of blasts from related diseases. The present data suggest the existence of a distribution fingerprint pattern for each leukemia.

[Clinical and prognostic relevance of the Kiel classification of non-Hodgkin lymphomas]. / Klinische und prognostische Relevanz der Kiel-Klassifikation der Non-Hodgkin-Lymphome.

The Kiel classification provides a new subdivision of non-Hodgkin lymphomas into distinct entities showing different clinical and prognostic properties. In comparison with earlier classifications this system defines additional types of lymphoma (e.g. CC lymphoma, LP immunocytoma) (for abbreviations see text) which are to be considered separate entities also from a clinical point of view. By data derived from a multicenter prospective observation study (1,127 patients recruited from 1975 to 1980, follow-up until 1985) a precise definition of the clinical features of each lymphoma entity (e.g. frequency, age and sex distribution, patterns of initial involvement and spread of disease) was possible. In addition, the effect of radio- and/or chemotherapeutic measures was evaluated. Strictly localized disease (stage I/IE according to the Ann Arbor classification) occurred in 1.5 to 8% of patients with NHL of low-grade malignancy (comprising 69.4% of cases studied) and in 8 to 17% of patients with high-grade malignant NHL (comprising 30.2% of cases studied). Loco-regional irradiation alone was able to induce complete remission in 86 to 89% (CB and IB lymphomas) and in 100% (LP immunocytoma, CB-CC and CC lymphomas), respectively, of stage I/IE patients. Only CC and IB lymphomas showed a relevant risk of relapse (40% and 50%, respectively). Total lymphoid irradiation as able to induce stable complete remissions in about 50% of patients with stage III of CB-CC lymphoma. Probabilities of survival of patients with initial stages III and IV treated by several types of chemotherapy reflect different prognostic features of individual lymphoma entities.(ABSTRACT TRUNCATED AT 250 WORDS)