De novo acute myeloid leukaemia in patients over 55-years-old: a population-based study of incidence, treatment and outcome. Northern Region Haematology Group.

A 4-year prospective study of de novo acute myeloid leukaemia in patients aged 56 years and over was undertaken in the Northern Region of England (population 3.09 million). The study was conducted to assess the incidence and outcome of treatment in all elderly patients diagnosed between January 1, 1988 and December 31, 1991. Two hundred cases de novo AML were confirmed, giving an incidence of 6.05/10(5) per annum (age specific population) (95% Cl, 5.2-6.9). Acute promyelocytic leukaemia was rare. Erythroleukaemia, monocytic leukaemia and AML with trilineage myelodysplasia were more common than in younger patients. Karyotypic abnormalities classically associated with response to therapy were present in only six of 91 patients where cytogenetic data was available. Treatment was at the discretion of the physician in charge: if given, specific treatment was recorded and clinical outcome assessed. Only 84 (42%) of patients received treatment with curative intent. Forty-four of 84 achieved a complete remission, usually of brief duration. A normal karyotype in leukaemic cells was associated with a survival advantage in this group (p < 0.05). Actuarial overall survival at 4 years for the entire group was 2.5%. Even with aggressive treatment, the outcome is poor. The pattern of disease and its lack of response to conventional treatment would support the hypothesis that AML in the elderly may differ biologically from that observed in younger patients. Karyotyping appears to predict those patients likely to benefit from intensive therapy and decisions about management in otherwise fit patients should, if possible, be delayed until a result is obtained. Every effort should be made to give such patients optimal treatment. However, most patients are unsuitable for aggressive treatment and, since long-term survival is rare, cure should not be offered as an inducement to accept such treatment and improving quality of life outside hospital should be the aim of treatment in this group.

Diagnostic features and survival in typical and prolymphocytoid variants of chronic lymphocytic leukemia.

Diagnostic features were evaluated with regards to survival in 203 cases of typical and prolymphocytoid chronic lymphocytic leukemia. Excluding 27 (13 per cent) patients with second malignancies, survival analyses indicated that the prognostic factors with greatest significance were age at presentation (less than 65 years and 65 years or more: p = 0.0004), proportions of prolymphocytoid cells (less than 10 per cent and 10 per cent or more: p less than 0.0001 age corrected) and surface immunoglobulin (SIg) density (weak and more than weak: p = 0.001 age corrected). In contrast, sex, absolute numbers of prolymphocytoid cells, SIg light chain type and FMC7 expression were not prognostically significant. These observations suggest that the recognition and delineation of prolymphocytoid CLL variants by morphological and immunophenotypic criteria, although important in diagnostic terms, may have less relevance with respect to prognosis and patient management.

Severe renal toxicity due to intermediate-dose methotrexate.

Methotrexate (MTX) is a drug widely used in the treatment of patients with malignant disease. Its well-known side effects include myelosuppression, mucositis and renal damage. These problems are primarily dose-related, tending to occur more frequently when high doses (greater than 1 g/m2) are given. We present four cases in whom severe renal and mucosal toxicity occurred with intermediate doses (200 mg/m2) of MTX despite folinic acid rescue. Possible reasons for this occurrence are discussed and means of avoiding such toxicity are suggested. Three of four patients developed severe loin pain within a few hours of injection; the significance of this symptom in relation to subsequent renal toxicity has implications for early recognition of the problem.

Quantitative and qualitative enzyme studies of Hodgkin's disease-derived cell lines.

Any extensive analysis of Hodgkin (H) and Reed-Sternberg (RS) cells is limited by the scarcity of available material and by the common contamination with "by-stander" cells. The establishment of Hodgkin's disease-derived cell lines provides the opportunity to undertake studies in which large numbers of cells are required, as these cell lines are by definition monoclonal populations with unlimited cell growth. In this study, we analyzed the enzyme profiles of eight Hodgkin's disease cell lines (Co, Ho, Fox, HDLM-2, KM-H2, L428, L540, and L591) whereby cellular alpha-naphthyl acetate esterases, acid phosphatases, and dipeptidylpeptidase IV were examined quantitatively or qualitatively by IEF or chromatographic techniques. The results indicate that all of the H-RS cell lines examined had enzymatic features typical for lymphoid cells and, in particular, a monocyte/histiocyte origin of the cell lines could be excluded. Extrapolation of the available immunological, molecular biological, and enzymological evidence gained in vitro on cultured representatives of H-RS cells suggests a lymphoid origin for in vivo H-RS cells.

Diagnostic and prognostic factors in acute monocytic leukaemia: an analysis of 51 cases.

Diagnostic features (cytochemistry, immunophenotyping and serum biochemistry) were examined in 51 cases of acute monocytic leukaemia (AMoL). Peroxidase, Sudan black B and alpha naphthyl acetate esterase (ANAE) cytochemical reactions were unrelated to morphological (FAB groups M5a and M5b) or immunological subtype. ANAE cytochemistry, however, indicated that AMoL cases could be subdivided into those with typical (M-type) reactions and those with insignificant staining or monocytic ANAE isoenzymes (defined by IEF). All cases were phenotypically CD13/CD33 positive and, with one exception, had greater than 30% HLA-DR positive cells. Membrane CD14 expression was insignificant or variable in 33% of M5a cases in contrast to 23/24 M5b cases which showed high proportions of CD14-staining cells with at least two monoclonal antibodies. Serum lysozyme, LDH and beta-2 microglobulin (beta 2m) were increased in 88%, 68% and 81% of cases respectively but, with the exception of statistically higher lysozyme levels in CD14+ cases, were unrelated to the morphological, cytochemical or immunological diagnostic subgroups. Clinical and diagnostic features were also examined as possible prognostic indicators. The morphological, cytochemical and immunological subgroups of AMoL were not found to be of prognostic relevance but age (P = 0.004), renal failure (P = 0.005) and serum beta 2m levels (P = 0.002) were related to patient survival. Moreover, renal failure and serum beta 2m remained significant (P = 0.012 respectively) when age was taken into account and were shown to be independent prognostic variables.

TdT expression in acute myeloid leukaemia. Haemopoietic immaturity or maturational asynchrony?

A total of 412 cases of acute leukaemia were examined for the presence of nuclear terminal deoxynucleotidyl transferase (TdT) by indirect immunofluorescence. Of the 129 cases of acute myeloblastic leukaemia (AML FAB groups M1/M2) examined, 18% (n = 23) had significant proportions (greater than 10%) of TdT-positive blasts. Although most of these AML cases (n = 18) were of poorly differentiated (M1) type; 5 cases of AML showing features of granulocytic differentiation (M2) were also found to be TdT-positive. Even though TdT was generally more strongly expressed in the M1 group and associated with other markers of myeloid immaturity (Ia positive and lack of chloroacetate esterase), there was no inverse relationship with Sudan black or myeloperoxidase activity. In addition, although the proportion of AML-M1 cases with increased TdT-positive cells was slightly higher (18/95, 19%) than for the AML-M2 group (5/34, 15%) the results suggest that the presence of nuclear TdT in leukaemic myeloblasts may not only reflect cellular immaturity but may also be due to maturational asynchrony in otherwise well-differentiated blasts.

Quantitative and qualitative studies of leukaemic cell dipeptidylpeptidases II and IV.

Cellular concentrations of dipeptidylpeptidases (DAP) II and IV were determined by fluorimetric assay in 152 cases of leukaemia and 24 permanent T-cell lines. Whilst its estimation appears to have few diagnostic applications, it was found that DAPII levels were generally higher in prolymphocytoid CLL variants (CLL-Pro) compared with "typical" CLL cases. Qualitatively, DAPII extracted from leukaemic B- and T-cells did not differ significantly with respect to molecular weight (Mr 82 kD: FPLC gel filtration) or substrate affinity (Km). Similarly, a single molecular weight species (Mr 189 kD) of DAPIV was also detected in all leukaemic sonicates examined although, in quantitative terms, increased DAPIV levels were primarily associated with a subgroup of CD4-positive postthymic malignancies. Studies of immature T-cell proliferations however indicated that DAPIV expression was unrelated to either stage of immunological differentiation or CD4 expression. No evidence of lineage restriction was found for either enzyme and it is concluded that variations in DAP cytochemical staining patterns reflect quantitative rather than qualitative differences.

Prognostic factors and survival in chronic myelomonocytic leukaemia (CMML).

Ninety-seven cases of chronic myelomonocytic leukaemia (CMML) were examined retrospectively for survival and possible prognostic factors including age, total white cell count, peripheral blood and bone marrow monocyte counts, % double esterase (DE) positive cells in bone marrow and serum lysozyme. Age, absolute monocyte counts and serum lysozyme proved to be significant independent prognostic indicators but Cox model analyses showed serum lysozyme to be the most important factor whether taken as a continuous or discrete (two groups) variable. Twelve cases of second malignancy were found, including 2 cases of multiple myeloma, but this was not significantly greater than expected when compared with an age and sex matched group.

Cell surface expression of beta 2-microglobulin (beta 2m) correlates with stages of differentiation in B cell tumours.

Cell surface beta 2-microglobulin (beta 2m) densities of malignant B cells were determined by enzyme immunoassay in 97 cases of immunologically defined lymphoproliferative disease. Absolute beta 2m densities were found to depend on disease category with the lowest levels found on cells from chronic lymphocytic leukaemia (mean = 5.6 ng/10(6) cells, n = 27); atypical chronic lymphocytic leukaemia (mean = 5.9 ng/10(6) cells, n = 8); and prolymphocytoid chronic lymphocytic leukaemia variant (mean = 6.0 ng/10(6) cells, n = 16). beta 2m densities for B non-Hodgkin's lymphoma (n = 14) and B prolymphocytic leukaemia (n = 17) cases were 8.1 and 10.0 ng/10(6) cells, respectively, and the highest densities were found on cells from "late-B cell" tumours (mean = 14.3 ng/10(6) cells). Plasma cells from cases of Ig secreting tumours expressed unexpectedly low beta 2m densities (mean = 9.3 ng/10(6) cells; n = 6).

Serum enzyme and ferritin concentrations in acute leukaemia.

Serum ferritin concentrations were determined in 142 untreated cases of acute leukaemia. No correlation between type of leukaemia as defined by morphology and immunology and the level of serum ferritin was found. Samples were also tested for lactate dehydrogenase (LDH), phosphohexose isomerase (PHI), B-glucuronidase (B-gluc), leucine aminopeptidase (LAP), and C-reactive protein (CRP) levels. Serum ferritin was significantly correlated with serum PHI, LAP, and LDH concentrations but not with leukaemic mass as assessed by total white blood cell count (WBC). Ferritin and CRP levels were also significantly correlated suggesting that ferritin may behave to some extent like an acute phase reactant in acute leukaemia.

Diagnostic differentiation between reactive and malignant lymphoid cells in serous effusions.

Lymphoid cell components in a total of 34 pleural and ascitic aspirates were investigated immunologically. The results indicate that reactive lymphocytes predominate in effusions from non-haemopoietic malignancies and benign conditions, while a significant proportion of fluids from patients with non-Hodgkins lymphoma show unequivocal evidence of lymphomatous involvement. Immunological typing of lymphocytes in serous effusions is a valuable adjunct to conventional methods of diagnosis particularly in those patients in whom invasive procedures are undesirable.

Prolymphocytoid variants of chronic lymphocytic leukaemia: an immunological and morphological survey.

Of 417 cases of chronic lymphocytic leukaemia (CLL) examined morphologically, 346 (83%) showed low (less than 10%) numbers of cells with prolymphocytoid (PLC) morphology. Immunological studies in 267 of these cases, with particular reference to membrane surface immunoglobulin (SIg) densities and FMC7 expression, revealed that of 223 cases with insignificant prolymphocytoid components, 185 were phenotypically consistent with typical CLL whilst the other 38 cases showed significant (greater than 20% positive cells) FMC7 expression and/or increased SIg density. In contrast, 40 of the 44 cases with greater than 10% PLC showed atypical immunophenotypic features even though the expression of individual membrane components associated with B-cell differentiation appeared to be unrelated. MRBC receptor expression showed little correlation with the degree of prolymphocytoid change although all TU1- cases showed greater than 10% PLC. The results suggest that abnormal phenotypic features, similar to those observed in "prolymphocytoid" transformation, may be found in cases of CLL in the absence of morphological change.

Hairy cell leukaemia in two brothers.

Two cases of hairy cell leukaemia (HCL) presenting in brothers with a 14 year interval are described. Familial HCL has been described previously in two kinships but not in the UK. Both brothers had worked as car mechanics for some time but apart from this no other recognized shared environmental or genetic risk factors were identified.

Fast protein liquid chromatography (FPLC) of leukaemic cell N-acetyl beta-D hexosaminidases.

Leukaemic myeloid and lymphoid cell N-acetyl beta-D glucosaminidase (hexosaminidase) enzymes were fractionated by Fast Protein Liquid Chromatography (FPLC) using high-resolution ion exchange (Mono-S and Mono-Q), gel filtration (Superose-6) and chromatofocusing (Mono-P) columns. Although only one molecular weight species was detected in haemopoietic cells, with an apparent mass of 129 kD, "isoenzyme" variants defined by differences in molecular charge were considerably more diverse than previously thought. Separation of the major Hex forms (A and B) by chromatofocusing indicated that intermediate (I) components were present in most acute leukaemias irrespective of lineage supporting the concept that the I form is a non-specific marker of haemopoietic immaturity. Substrate and inhibitor studies further revealed that leukaemic cell hexosaminidases hydrolyse galactopyranosides at significantly lower rates than glucopyranosides and that the hydrolysis of N-acetyl beta-D glucosamine is inhibited by both glucosamine and galactosamine products.