Oral hairy leukoplakia in a patient with acute lymphocytic leukemia.

The first case of oral hairy leukoplakia (OHL) in an HIV-negative 56-year-old patient with acute lymphocytic leukemia (ALL) is reported. A white plaque was observed while the patient was in complete remission which followed the chemotherapeutic scheme. The clinical and histopathologic findings were typical for OHL and the polymerase chain reaction method was positive for Epstein-Barr virus DNA. Underdiagnosis and underreporting of OHL in patients with a malignant haematological disease and the apparent different environmental factors to which these non-AIDS patients have been exposed, probably constitute some of the reasons for the very few OHL cases reported in these patients.

Treatment with recombinant human erythropoietin in children with malignancies.

The effect of recombinant human erythropoietin (rHuEPO) on the anemia of cancer was examined in 15 children with hematologic malignancies (group I) and solid tumors (group II), whose hemoglobin (Hb) was under the third percentile for sex and age. The response to rHuEPO was defined as an increase of Hb to above the 10th percentile following 8 weeks of therapy. The rHuEPO caused an increase in the Hb and hematocrit (Hct) in 46% of children of both groups at a dose of 150 IU/L, in 28.5% of children at a dose of 250 IU/L and in 25.5% of children at a dose of 400 IU/L. Leukocyte and platelet counts were not influenced by the rHuEPO treatment. The red cell transfusion requirement decreased to 66% in both groups after rHuEPO treatment. Erythropoietin (EPO) levels were measured prior to the treatment and then every 4 weeks during rHuEPO treatment. Children who responded to EPO had an initial EPO level of < 100 IU/L, while those who did not respond had an initial EPO level of > 100 IU/L. Erythropoietin was well tolerated in all children, with no side effects.

Efficacy of recombinant human granulocyte colony-stimulating factor and recombinant human granulocyte-macrophage colony-stimulating factor in neutropenic children with malignancies.

The difference between the effects of administration of recombinant human granulocyte colony-stimulating factor (rhG-CSF) and recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) was studied in 39 children with neutropenia secondary to chemotherapy (absolute neutrophil count (ANC) less than 1,500/microliters. The children were divided into two groups. The first group (G-CSF) included 25 children (12 with acute lymphoblastic leukemia [ALL]-non-Hodgkin's lymphoma [NHL] and 13 with solid tumors) and the second group (GM-CSF) included 14 children (5 with ALL-NHL and 9 with solid tumors). All 39 children received of either G-CSF or GM-CSF (5 micrograms/kg/day) subcutaneously at the end of each chemotherapy course for a maximum duration of 14 days. The effect of G-CSF and GM-CSF on the ANC, the antibiotic therapy administration, and the length of hospital stay were studied for both groups at two cycles of chemotherapy. During both cycles a faster rise of ANC was observed in the children of the first group (G-CSF) compared with those of the second group (GM-CSF), but there was no difference in either the incidence of antibiotic therapy administration between the two groups (26% vs 25%) or the length of hospitalization. Both growth factors were well tolerated by all children studied with minimal side effects observed (including bone pain with G-CSF in 2 of 25 children and pruritus with GM-CSF in 1 of 14). We conclude that G-CSF reduces the duration of neutropenia more than does GM-CSF, but the incidence of severe infection and the duration of hospitalization do not differ between children receiving either G-CSF or GM-CSF.

Reverse transcription polymerase chain reaction for the diagnosis and molecular monitoring of the PML/RAR alpha fusion gene in acute promyelocytic leukemia.

Acute promyelocytic leukemia (APL) is characterized by a specific t(15;17) translocation and a high rate of response to all-trans retinoic acid. The translocation generates a PML/RAR alpha chimeric gene which is transcribed in a fusion PML/RAR alpha mRNA. In this study, by using RT-PCR, we examined 14 APL patients for PML/RAR alpha fusion gene transcripts. Eight patients were studied at diagnosis, 2 at relapse, 1 both at relapse and after reinduction, 1 both at diagnosis and after three cycles of consolidation chemotherapy, and 2 patients were examined for minimal residual disease (MRD) 4 months after completing treatment. A positive result was observed in all 14 cases. Two patients who were in complete hematologic remission had evidence of hematologic relapse soon after the positive test. We conclude that RT-PCR for APL yields important diagnostic and prognostic information for the APL patients.

Effect of granulocyte colony-stimulating factor on chemotherapy-induced neutropenia in children with cancer.

We investigated the effects of recombinant granulocyte colony-stimulating factor (G-CSF) administration on duration of neutropenia, antibiotic therapy, and hospitalization days in 25 children with malignancies (Group A: 12 leukemia and lymphoma; Group B: 13 tumors) who were undergoing chemotherapy. We compared the effect of G-CSF with a control group of 21 children with equivalent diseases and chemotherapy that did not receive G-CSF treatment. All 25 children received 5 micrograms/kg/day of G-CSF at the end of chemotherapy courses when absolute neutrophil counts were < or = 1000/mm3. The effect of G-CSF on median neutrophil profiles, antibiotic therapy, and hospitalization days was studied for both groups at the 1st and 4th cycle of chemotherapy. During both cycles, children who received G-CSF showed a faster rise of absolute neutrophil count (P < 0.001) and fewer hospitalization days (P < 0.05), and not as many received systemic antibiotic therapy (P < 0.0001). We conclude that G-CSF accelerates neutrophil recovery in chemotherapy-induced neutropenia in childhood malignancies.

Cord blood erythropoietin in the presence and absence of labor in normal infants.

To evaluate erythropoietin (Ep) levels in normal labor and cesarean section we studied the cord serum of 111 term pregnancies, divided into three groups: (i) those born by normal vaginal delivery (n = 69); (ii) those delivered vaginally from mothers who were smokers (n = 20); and (iii) those delivered by elective cesarean section (n = 22). The three groups did not differ in maternal age, gestational age, birthweight, infant sex and Apgar scores. No correlation was found between Ep and hematocrit in all three groups of normal terms studied. Although not statistically significant the lower mean Ep value observed in cesarean section compared with the values obtained from normal deliveries could suggest that the process of labor may be a cause of these differences.

Analysis of immunohistochemical results of the ras oncogene product p21 in myelodysplastic syndromes.

Mutation of the ras oncogenes is the most commonly detected molecular abnormality in acute myelogenous leukemia and myelodysplastic syndromes (MDS). This molecular event may either be acquired by different subclones or by all malignant cells. The availability of the ras p21 monoclonal antibody Y13 259 makes possible the direct study of the distribution of the ras gene product in human malignant cells. The bone marrow smears from 41 patients with MDS were analysed by two independent observers after treatment with MoAb Y13 259, biotinylated goat antirat IgG, streptavidin, peroxidase and staining with diaminobenzidine. A high proportion of strongly positive smears was found among patients with MDS. This positivity was found in 25% of refractory anemia, in 80% of the refractory anemias with excess of blasts, and in 90% of those in transformation, while all 7 cases with chronic myelomonocytic leukemia were found positive. The percentage of positivity may suggest that activation of ras oncogene in associated with disease progression.

Serum levels of tumor necrosis factor and soluble interleukin 2 receptor as markers of disease activity and prognosis in childhood leukemia and lymphoma.

The serum levels of soluble interleukin 2 receptor (SIL-2R) and tumor necrosis factor (TNF) were assessed in 69 children from 6 months to 14 years old who suffered from acute lymphoblastic leukemia (39), Hodgkin's disease (15), non-Hodgkin's lymphoma (15) and in 54 normal age-matched controls prior to any therapy and at remission. Both SIL-2R and TNF levels were significantly higher at diagnosis compared with normal controls (P < 0.001), but decreased significantly at remission. The SIL-2R and TNF levels were significantly higher in an advanced stage of lymphoma than in an early stage. In the patients with acute lymphoblastic leukemia (ALL) and lymphoma, higher levels of SIL-2R (> 1030 units/ml) and TNF (> 30 pg/ml) were associated with a poorer treatment outcome (P < 0.01). Our findings indicate that elevated TNF serum secretion together with SIL-2R are useful markers in childhood ALL and lymphoma and can be used to assess both disease activity and prognosis in this group of malignancies.

Correlation of in vitro enhancement of erythropoiesis and clinical response to steroids in Diamond-Blackfan anaemia.

To investigate whether the clinical response to steroids in Diamond-Blackfan anaemia (DBA) can be predicted in vitro, erythroid cultures from six patients was performed. The increment of burst forming unit erythroid (BFU-E) and colony forming unit erythroid (CFU-E) derived colonies had been studied with the in vitro addition of steroids. Our results showed: 1) a relative insensitivity to low and optimum concentration of erythropoietin (Epo) in cultures, and 2) lower CFU-E and BFU-E colony formation in all cases studied. (CFU-Es of normal controls/10(5) cells; were 85.6, BFU-Es 37.8, while the patients' CFU-E were 18.1 and BFU-E 7/10(5) cells with two IU of Epo) with poor or no growth in three cases, 3) increment up to 60-110% with in vitro addition of steroids in three cases, 4) high serum Epo levels in all Diamond-Blackfan anaemia patients, and 5) clinical response to steroids in the three patients who responded in vitro.

The expression of the ras p21 oncoprotein in the bone marrow smears of children with acute leukemia.

Point mutations of the ras genes have been detected in various hematologic malignancies. This genetic event may either occur in all malignant cells or be acquired by different subclones, which however, cannot be demonstrated adequately by analyzing only DNA derived from patient specimens. The availability of the ras p21 monoclonal antibody (MoAb) Y 13259 makes possible the direct study of the distribution of the ras gene product in human malignant cells. In this report the expression of the ras p21 oncoprotein in the bone marrow smears of 35 children with acute leukemia has been analyzed. The smears were treated with the MoAb Y 13259, biotinylated goat anti-rat IgG, streptavidin, peroxidase and stained with diaminobenzidine (DAB). The intensity of the staining was evaluated by two independent observers as negative or equivocal (-/+), moderate (+) or intense (++), by counting one thousand cells. Patients were also classified according to the percentage of the stained cells into four groups (0, I, II, III). It was found that 22/35 (63%) were (+) or (++) positive as follows: 11/21 (52%) with ALL CALLA (+), 2/2 ALL-B, 3/3 ALL-T and 6/9 AML. In Group 0 (none of the blasts was stained) were 13/35 (37%), as well as in Group I (1 to 25% of the blasts stained 1+ or 2+ positive), while in Group II (26 to 50% positive stained) 3/35 and in Group III (more than 51% stained) 6/35, all of which were AML (6/9). It is concluded that the immunohistochemical analysis of the ras p21 in blast cells of children with acute leukemia may demonstrate that ras gene expression in some subclones, the intensity and percentage of which may be of some clinical importance.

Proliferating cell nuclear antigen (PCNA) expression in childhood lymphomas.

Paraffin sections from 21 cases of Hodgkin's disease (HD) and 28 cases (26 high-grade and 2 low-grade) of non-Hodgkin's lymphomas (NHL) occurring in childhood were examined for the presence of proliferating cell nuclear antigen using an anti-PCNA antibody. All cases of HD and NHL showed PCNA reactivity. In HD 50.9% (mean value) of Hodgkin and Reed-Sternberg (HRS) cells were PCNA positive and judged to be proliferating. PCNA reactivity was also found in a varying number of cells of the background population in HD (mean value = 11.7%). In NHL 61.2% (mean value) of cells were PCNA positive. In the 26 high grade tumours 63.6% (mean value) of cells were PCNA positive while only 32% (mean value) of cells were PCNA positive in the 2 low-grade tumours. Our results show that the proliferation rate of tumour cells in high-grade NHL is higher than those of tumour cells in low-grade NHL and HRS cells in HD. Moreover, we found a considerable variation of proliferation rate among individual cases of HD (range 31%-68%) of NHL (range 31%-78%). This suggests that PCNA assessment can help in the individual approach of the proliferation rate of each tumour, and, in conjunction with other parameters of the cell proliferation, could be useful for the understanding of the biological behavior of childhood lymphomas.

Expression of the Epstein-Barr virus encoded latent membrane protein in tumor cells of Hodgkin's disease occurring in childhood.

Paraffin sections from 21 cases of Hodgkin's disease (HD), 28 cases of non-Hodgkin's lymphomas (NHL) and 34 cases of non-specific reactive lymphadenitides occurring in childhood were examined for the presence of the Epstein-Barr Virus (EBV)-encoded Latent Membrane Protein (LMP) using a double layer immunohistochemical method. LMP was detected in 12/21 (57%) cases of HD but not in NHL or reactive lymph nodes. LMP reactivity was restricted to Reed-Sternberg and Hodgkin's (HRS) cells in 4 of 9 (45%) cases of nodular sclerosis (NS), 6 of 9 (66%) cases of mixed cellularity (MC) and 2 of 2 (100%) cases of lymphocyte depletion (LD) while it was undetectable in the single case of lymphocyte predominance (LD) subtype. These results provide further evidence for an association between EBV and Hodgkin's disease, and they show that LMP expression occurs more frequently in the clinically more aggressive subtypes of HD. Furthermore, in view of the in vitro transforming potential of the LMP protein, the exclusive immunolocalization of LMP in HRS cells, suggests that EBV may be involved in the pathogenesis of a proportion of cases of HD.

Primary benign erythrocytosis with high erythropoietin levels and an early erythropoietin-sensitive population in the peripheral blood.

Primary erythrocytosis diagnosed in a 10-month-old female and followed for 12 years is described. The erythrocytosis was associated with an abnormally elevated set point of erythropoietin production in which the sensitivity fluctuated independently, but corresponded to the alterations in the oxygen-carrying capacity of the blood, when the hematocrit was lowered by phlebotomies. Extensive work for secondary erythrocytoses failed to demonstrate a recognizable cause for this abnormal erythropoietin production. Erythroid cell cultures from peripheral blood mononuclear cells showed the existence of at least two populations: one consistent with dramatic expansion of the erythron in keeping with enhanced sensitivity to endogenous erythropoietin, and the other consistent with the features of typical colonies derived from burst-forming units-erythroid (BFU-Es), seen in normal peripheral blood on days 12 to 14 of culture. The expanded population was characterized by the appearance of single colonies on days 4 to 6 and enormous response to the increasing amounts of erythropoietin, which enhanced their number, size, and maturation. The combination of clinical and in vitro data as well as the absence of any abnormality in the erythropoiesis of the parents and sibling suggest that the erythrocytosis in this child represents a new form with a benign course.

Ocular granulocytic sarcoma in childhood acute myelogenous leukemia.

We report two children of Greek origin with granulocytic sarcoma of the orbit and acute myelogenous leukemia. In the first case the orbital tumor was the initial manifestation of the disease, while the other occurred during hematological remission.

Serum erythropoietin in regularly transfused thalassemic patients.

Serum erythropoietin levels were measured in 67 regularly transfused thalassemic patients with pre-transfusion hematocrit ranging from 25-32% and in 40 normal individuals. In patients, mean erythropoietin levels were slightly increased (mean 91.5 miu/ml) as compared to normal individuals (mean 42 miu/ml). The distribution of erythropoietin (Ep) was wide in thalassemic patients. 40% had normal or decreased and 60% increased Ep levels. A reverse relation between pretransfusion Hct and erythropoietin activity was observed only among patients with normal erythropoietin levels and splenectomized patients with high erythropoietin titers suggesting that a normal feedback between tissue hypoxia and erythropoietin activity occurs in these groups. The effect of regular blood transfusions in reversing tissue hypoxia resulting from anemia in the majority of regularly transfused thalassemic patients seems to be satisfactory, as it is assessed by serum erythropoietin levels.

Committed erythroid progenitors and erythropoietin levels in anemic children with lymphomas and tumors.

In order to investigate the pathogenesis of anemia in childhood malignancy, we studied erythroid cell proliferation responses with bone marrow erythroid cultures and serum erythropoietin (Ep) levels in 32 children with lymphomas and malignant tumors. The erythroid colony formation from 20 normal controls (mean 68.8 colony-forming-unit erythroid [CFU-E] and 32 burst-forming-unit erythroid [BFU-E] derived colonies/10(5) mononuclear cells), was higher than that seen in children with lymphomas (mean 45.9 CFU-E and 20.7 BFU-E/10(5) cells, p less than 0.01) but similar to the values obtained from children with tumors (mean 65.1 CFU-E and 28.1 BFU-E/10(5) mononuclear cells). The degree of anemia in children with lymphomas correlated negatively (r = -0.7, p less than 0.01) with serum Ep levels. In contrast, a weak positive correlation (r = 0.3, p greater than 0.1) was observed between the degree of anemia and Ep values in the group with tumors. We suggest that the decreased number of committed erythroid progenitors in lymphomas may be the main factor for anemia in these patients, while the abnormal response of Ep to the degree of the anemia suggests a defect in erythropoiesis in children with tumors.