Acute tumor lysis syndrome and treatment response in patients treated for refractory chronic lymphocytic leukemia with short-course, high-dose cytosine arabinoside, cisplatin, and etoposide.

Acute tumor lysis syndrome resulting from rapid neoplastic cell lysis after chemotherapy is an unusual event, generally seen in histological aggressive lymphatic tumors. The authors saw four patients who developed acute tumor lysis syndrome when treated for advanced-stage, refractory chronic lymphocytic leukemia (CLL) with an initial cycle of cytosine arabinoside (Ara-C) 2 g/m2 every 12 hours x 4, cisplatin 35 mg/m2 every 24 hours x 2, and etoposide 100 mg/m2 every 24 hours x 2 (ACE). With aggressive hydration, urine alkalinization, forced diuresis, and high-dose allopurinol, acute tumor lysis syndrome was not seen in three subsequent cases of CLL treated with ACE. Of a total of eight patients treated, seven patients had marked reductions in lymphocyte counts after the first course of ACE. Of the eight patients, three are alive: one in a complete remission greater than 2 years, one in partial remission after three cycles of ACE, and one in Richter's transformation to large cell lymphoma. The remaining patients died after one cycle of ACE chemotherapy, one as a direct complication of acute tumor lysis and pancytopenia, and four others from complications of severe pancytopenia and general debilitation. Therefore, ACE appears to cause a rapid dissolution of tumor cells in CLL, and with appropriate aggressive management of the tumor lysis and infectious complications may have a favorable impact on survival in advanced CLL.

Medulloblastoma metastatic to the marrow. Report of four cases and review of the literature.

Medulloblastoma is a malignant cerebellar tumor seen primarily in the pediatric age group that has a known ability to metastasize extraneurally. The skeleton is the most common site of extraneural metastases, but metastases to the bone marrow can also occur. Four cases of medulloblastoma metastatic to the marrow are reported. In addition, 31 cases from the medical literature are reviewed. Clinical features include bone tenderness, cytopenias and elevated serum alkaline phosphatase and lactic dehydrogenase levels. Skeletal involvement, especially of the pelvic bones, is frequently seen radiographically. Weight loss, soft tissue masses and a requirement for blood transfusion are also associated features. Marrow biopsy specimens are characterized by the presence of a small cell tumor often with fibrosis, necrosis and osteoblastic activity. The symptomatic response to chemotherapy is rapid, but chemotherapy resistance appears quickly. Only 1 in 4 cases diagnosed antemortem in this review lived for more than a year. We conclude that marrow aspiration and biopsy are indicated in the evaluation of patients with medulloblastoma and may serve to diagnose the cause of cytopenias, to verify extraneural spread and to provide prognostic information.

HMO development for primary care team teaching of medical and nursing students.

This article describes a three-year effort to facilitate the development of a university health maintenance organization (HMO) into an effective clinical teaching site for the team practice of primary care. Project staff initiated several activities to promote team development in the HMO. These included review and development of algorithms to guide physician/nurse teams in the care of patients with common problems, workshops on communication and role negotiating skills, and preceptor training. A variety of objective and subjective methods were employed to assess HMO team development and the effectiveness of the HMO as a primary care teaching site. Initial resistance to both team practice and teaching have been overcome. Students who were trained in the project not only acquired good clinical skills but also, perhaps more importantly, developed skills in professional role negotiation and communication as well.