Search

Purpose: To evaluate the prevalence of thyroid dysfunction and its association with possible contributing factors related to diagnosis and treatment in children who received hematopoietic stem cell transplantation (HSCT) in the only national transplant unit in Greece. Methods: This is an observational, retrospective, single center cohort study that included 194 patients (58.6% boys) who survived for at least 1 year following allogeneic HSCT. Conditioning regimens depended upon diagnosis and protocols active at the time of transplantation. Some patients received irradiation, either central nervous system prophylaxis (n= 20), or total body irradiation (TBI) (n= 8). Thyroid gland evaluation included thyroid-stimulating hormone, free thyroxine, thyroid autoantibodies, and sonogram. Univariate and multivariate logistic models were used to examine the association of the above-mentioned factors with hypothyroidism. Results: The mean age at diagnosis and at bone marrow transplant (BMT) in years was 7.51 ± 0.46 and 7.58 ± 0.36, respectively. The median follow-up time was 4.83 years. Hypothyroidism was detected in 33 cases (17.7%), four of those patients having received TBI. Factors contributing to hypothyroidism as per the multivariate analysis were male sex, [OR: 3.005, 95% CI (1.145–7.890)], irradiation, [OR: 2.876, 95% CI (1.120–7.386)], and years after HSCT [OR: 1.148, 95% CI (1.042–1.266)], while malignancy was identified only in the univariate analysis. The multivariate model presents a good class separation capacity [AUC = 72%, 95% CI (61.4%-82.4%)], Two patients had papillary thyroid cancer, both among children who had received TBI. Conclusion: These data highlight the fact that male sex and radiotherapy are two independent factors that lead to increased risk for hypothyroidism. Furthermore, the prevalence of hypothyroidism increases with time post HSCT.

Carbapenem resistance, most notably in Klebsiella pneumonia(KPC), results in infections associated with significant morbidity and mortality. Here we report 2 cases of adolescent patients with KPC infection after high-risk bone marrow transplantation, who eventually succumbed from other causes and review the epidemiology and treatment options for KPC infections in this vulnerable population.

We report the results of an analysis of unrelated allogeneic hematopoietic stem cell transplantations (HSCT) in 71 patients with sickle cell disease (SCD) transplanted in EBMT centers between 2005 and 2017. Median age was 9.3 years; graft type was bone marrow in 79% and peripheral blood in 21%. Recipient–donor HLA match at high resolution typing was 10/10 in 31, 9/10 in 20, and 8/10 in 4 patients; the other patients had intermediate resolution typing. The most frequent conditioning regimens were fludarabine–thiotepa–treosulfan (64%) or busulfan–cyclophosphamide (12%). Cumulative incidence of neutrophil engraftment was 92%; platelet engraftment was 90%. Eleven patients (15%) experienced graft failure. Grade II–IV acute graft-vs.-host disease (GvHD) was 23%; 3-year chronic GvHD was 23%. Three-year overall survival (OS) was 88 ± 4%. GRFS was 62 ± 6%. HLA matching was the most significant risk factor for OS: 3-year OS was 96 ± 4% in 10/10 group vs. 75 ± 10% in 9–8/10 (p= 0.042); GRFS was 69 ± 9% vs. 50 ± 12% (p= 0.114), respectively. In conclusion, unrelated donor HSCT is a valid option for SCD patients who lack an HLA-identical sibling donor, preferably in the context of clinical trials. Using a 10/10 HLA-matched unrelated donor yields better survival indicating that HLA matching is an important donor selection factor in this nonmalignant disease.

This paper discusses the implications of Guattari's concept of metamodeling, used to set up an emergent methods design, in a study on neighborhood images and urban development. Related to a theoretical background coming from Deleuzo-Guattarian philosophy, metamodeling is used as a conceptual tool that enables the creation of a flexible and adaptable methods design, which draws on methods that are not completely fixed at the beginning of the research but rather developed in an iterative way. By investigating the questions of how neighborhood images emerge and how they perform citizens’ everyday lives, we developed a methodological dispositive composed of four methods—one based on the use of photography, a second based on drawings, a third based on qualitative geographic information system (GIS), and a fourth that is a quantitative survey—that revealed multiple facets of neighborhood images.

This article presents the case of the New Acropolis Museum, one of the most important cultural works for contemporary urban development in Greece. We present a comparative study of the briefs and winning projects of the international architectural competition in 1989 and the tender for the architectural, engineering and electromechanical studies in 2000. We use assemblage theory as a theoretical basis for studying the two procurement processes. We illustrate how the diverse changes—changes related with costs, quality, technical complexity, and uncertainty—influenced directly the choice and the organization of the procedures. These different procedural organizations framed, in different ways, the selection of solutions, the project realization and thus the quality of urban space. By studying the links between the selection of procurement processes, their organization and their results, we shed light on the trajectories between the initial problems, the actors, and the priorities and we increase our understanding of the relation between the procurement process and the project realization.

AbstractIn the paper at hand, we study how the young Swiss republic in the late 19th century, which was in a political situation that objected to direct intervention and was deeply skeptical with regard to a centralized state in general, found a way to manifest itself in its major cities. We put forward the hypothesis that this process of manifestation relied on a powerful social technology: the architectural competition. Our argument will mainly trace the constitution of architectural competitions as a regulatory device, as an ensemble of “forces of becoming” constituted by the interplay between a specific constellation of discourses, knowledge-based practices, spatial settings, architectural expressions, and professional networks.By conceptualizing the agency of the processes studied as a Foucauldian dispositif, we also aim at contributing to the recent debate on alternative theoretical conceptions in research on architecture and planning. Empirically, we will focus on competitions for the federal post offices of Lucerne (i885), St.Gallen (1885), Geneva (1888), Zurich(1892), Neuchâtel (1892), Winterthur (1894), Lausanne (1894), Schaffhausen (1898), Berne (1898) and Chur (1899).

In this article we analyse how knowledge is generated in the design field of knowledge-based urban development (KBUD). Planners and urban designers, governments on various levels, or construction industry are dealing with complex urban realities in which places, discourses, but also specific spatio-temporal dynamics of economic, juridical and political systems come together. We approach the issue of planning by studying decision-making within juries of design competitions. Here knowledge is produced between actors from different professional and economic backgrounds, between global discourses and local specificities. In order to trace how knowledge creation takes place in decision-making – between various and heterogeneous types of knowledge, between global tendencies for innovation and local prerequisites and settings – we apply Amin and Roberts' concept of 'knowing in action'. We will elaborate on this model using ethnographic data on the work of a jury board in a design competition. As a result we propose a spatial conception that uses the modes of 'knowing in action' as its axes. This allows for the simultaneous positioning of activities and an understanding of the intertwining of different knowledge backgrounds.

Introduction:

No relevant conflicts of interest to declare.

Tsonis: Gilead: Other: Travel Grant; Astellas: Other: Travel Grants; Innovis: Other: Travel Grant; Pfizer: Other: Travel Grant; Takeda: Other: Travel Grant; Aenorasis: Other: Travel Grant.Tabl Ribavirin. Current indication: Treatment of active hepatitis C in combination with interferon-a.

Introduction

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

Introduction:Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative option for many children with various genetic or malignant diseases. However not all children in need for HSCT have a suitable donor available. For such cases in vitro fertilization (IVF) with pre-implantation genetic diagnosis (PGD) combined with human leukocyte antigen (HLA) tissue typing has been used to select an IVF healthy and HLA-matched embryo in order to give birth to a child who may serve as a stem cell donor. We report our experience with five children transplanted from HLA-matched siblings selected after IVF and PGD in our center.

No relevant conflicts of interest to declare.

Abstract 3547

Introduction: In TEL/AML1+ ALL, the formation of the fusion gene is frequently followed by clonal evolution, with the acquisition of additional aberrations, some involving the TEL and AML1 genes. The resulting variant subclones often coexist at diagnosis, but the clinical significance of this heterogeneity is unclear. Patients and Methods: The study included a group of 28 children with ALL, found TEL/AML1+ on interphase FISH. In all cases, 500 nuclei were assessed and all signal patterns indicative of a typical t(12;21) or any deviation were recorded. The patients were treated according to the BFM-95 protocol and followed-up for 5,3 to 101,10 (median 66,40) months. Results: In 19 cases, a single clone was found. In 12 of them (Group A), the typical pattern was obtained, while in 7 (Group B) there were additional aberrations (deletion of the non-rearranged TEL in 4; fusion duplication in 1; both in 2). In the rest 9 cases (Group C), we found coexistence of two (7) or three subclones (1). Certain variations (i.e. fusion triplication or AML1 deletion) were not seen in cases with a single clone, typical or variant. Epidemiological and biological variables and outcome were comparable between the three groups. However, 8 of the 9 children in Group C had residual disease detectable by flow cytometry on D15, versus only 2 and 1 patients in Group A and B respectively (p< 0,05). One patient in Group A relapsed and subsequently died with the same signal pattern as in diagnosis. There was another relapse in Group C, but the patient entered a second remission on re-induction. Interestingly, in this latter case, involving the only patient with three subclones seen on diagnosis, all three were also present on relapse, at comparable percentages as in diagnosis. Conclusions: Clonal heterogeneity is frequent in TEL/AML1+ ALL. It is associated with a slower clearance of the marrow on induction but not with the long-term outcome. However, this is unlikely to reflect the presence of a more resistant subclone with regard to additional aberrations of TEL and AML1 genes, since the presence of residual disease on day 15 was seen in similar frequency in patients with a typical t(12;21) and in those with a single variant clone. It is possible that patients with clonal heterogeneity may harbor other cytogenetic abnormalities involving other genes or chromosomes. Further study will be necessary to endorse this hypothesis and, perhaps, identify new pathways in the development of TEL/AML1+ ALL.

Clinical patient observations led to the hypothesis of increased ALL blast resistance in hyperglycemia (HG) states in pediatric ALL patients, either with preexisting diabetes mellitus (DM) or with steroid induced diabetes (SID). To evaluate the above, the chromometric MTT (methyl thiazole tetrazolium) assay was used Kaspers GJ et al, Leuk Res 1995; 19:175–81.Ficoll separated nucleated bone marrow cells from newly diagnosed pediatric ALL patients were cultured in usual conditions (NL) and in higher glucose levels (233–295 mg/dl), with the addition of titrated prednisolone (PDN) concentrations. The PDN concentration that lyses 50 % of the cultured blast cells (LD50) is the measure of PDN drug sensitivity. PDN concentrations of 0.02–2.0, 2.1–150, above 150 μg/uL indicate high, intermediate and low blast sensitivity to PDN, respectively. Hence, patient blasts with LD50at >150 μg/uL are resistant to PDN. The MTT assay results have been related to patient outcome (remission induction and event free survival, Pieters R et al Pediatr Oncol 1994; 22:299–308). Twelve newly diagnosed pediatric patients, with median age 6.4 years (range, 1.7 to 16.5 years) with common/CD10+ (N=8), pre-B (N=2), early pro-B (N=1) and maturing B (N=1) ALL were studied. All patients exhibited >80% ALL blast BM infiltration. Sensitivity (LD50< 150 μg/uL) in both NL and HG conditions was evident for 2 patients, while resistance to both conditions was seen in 3 patients. Patients resistant at NL conditions were resistant in HG, too. In contrast, 7 of 12 patients sensitive to PDN in NL conditions proved resistant in HG conditions (glucose 233–295 mg/dL). All 9 sensitive in NL conditions patients (in HG conditions 2 sensitive and 7 resistant) exhibited a median ×800 fold increase of the MTT LD50measured (range 6–29.000 fold). For all patients (N=12) median MTT LD50under NL conditions was 0.15 μg/uL and in HG conditions 167.5 μg/uL (× 116.6 fold increase). This change was statistically significant (Mc Nemar's test, p=0,016) and this change was not simply related to the change in glucose concentration. These findings of greatly increased ALL blast resistance in hyperglycemia environment, can support the notions given earlier (Weiser MA et al, Cancer 2004; 100:1179–85, Pieter's R EHA 2008) that hyperglycemia by itself can promote PDN resistance. Given that steroids is a mainstay in ALL treatment and that steroid induced hyperglycemia is a common occurrence, blood glucose monitoring and hyperglycemia correction appears to be of paramount significance in delivering an effective ALL treatment.

Acute myeloid leukemia (AML) accounting for approximately 17% of all childhood acute leukemias, arises either de novo or from a backround of myelodysplasia or previous chemotherapy. Cytogenetics is considered one of the most valuable prognostic determinants in AML while current risk–group classification in the limited cases of pediatric AML, is mainly based on cytogenetics and early treatment response. We reviewed the clinical and cytogenetic characteristics and the outcomes of 33 cases of childhood AML between 1997 and 2007 in order to investigate the incidence of the main FAB subtypes, the incidence of primary AML compared to secondary AML (s-AML) and the correlation between specific chromosome abnormalities and outcome in greek pediatric AML patients. Chromosome studies were performed on unstimulated bone marrow cells, derived from 33 pediatric AML patients, who were <18 years of age at the time of diagnosis. Eighteen patients were male and 15 were female. According to FAB classification one patient was classified as M0 (3%), 13 patients as M2 (39.4%), 4 as M3 (12.12%), 4 as M5 (12.12%), 2 as M6 (6.1%) and 4 as M7 (12.12%). No patient was classified as M4 while 5 patients with s-AML (15.15%) could not be classified. The median follow-up of all patients was 57.95 months (0.03–132.47). Overal survival and event free survival were 66,7% and 75,8% respectively. Eight patients with s-AML and 25 patients with primary AML were identified. The median age of patients with s-AML at diagnosis was 9.15 years while the median age of patients with primary AML was 7.2 years. Six out of 8 patients with s-AML died at a median follow up of 11.03 months. Nineteen out of 25 patients with primary AML are alive in complete remission (CR). Cytogenetic analysis was performed at diagnosis in 32 patients and results were obtained in 30 of them. The karyotype was abnormal in 21 out of 30 patients (70%). Normal karyotype was found in 9 patients, t(8;21)(q22;q22) in 5, t(15;17)(q22;q21) in 3, t(9;11)(p22;q23) in 3, −7/del(7q) in 5, del(9q) in 3, and complex karyotype in 4 patients. Three out of 4 patients with M3 are alive in CR with a median follow-up of 98.6 months while one with s-AML-M3 died 13 days post diagnosis. Three out of five patients with M2 and t(8;21), including 1 patient with s-AML, died at a median follow-up of 4.35 months. Three out of 5 patients with −7/del(7q) had s-AML and died in less than 4 years, while the two others are alive for more than 5 years, in CR. Although all patients with M7 had complex karyotypes, they are alive after a median follow-up of 96.73 months, 3 of them in CR and 1 in relapse. These results indicate that in greek patients, the main FAB subtypes show a distribution similar to that reported in the literature with the exception of M4 which is absent in our study but with a reported incidence of 20%. Pediatric patients with s-AML are older and their outcome is poor and is related to a higher probability of poor cytogenetic features compared to primary AML patients. Interestingly all patients with M7 had a good clinical course although they exhibited complex karyotypes.

Introduction:Deletions of the INK4 locus (on chromosomal region 9p21) are common in chALL. p16/14 and p15 genes lost with INK4 deletion are tumor suppressors, with a well-documented role in regulating cell cycle and chemosensitivity and in promoting apoptosis in vitro. However, the clinical significance of INK4 deletions remains unclear.

Aim: The aim of this study was the prospective evaluation of MRD during childhood ALL therapy and its correlation with specific prognostic criteria of ALL-BFM 95 protocol and with patient outcome.

Introduction: Deletions of the INK4 locus (on chromosomal region 9p21) are common in chALL. p16/14 and p15 genes lost with INK4 deletion are tumor suppressors, with a well-documented role in regulating cell cycle and chemosensitivity and in promoting apoptosis in vitro. However, the clinical significance of INK4 deletions remains unclear. Patients & Methods: The study included 78 children (49 boys and 29 girls) with ALL (medium age: 3,12, range:0,7 to 16,5 ). The disease was of B- and T-cell origin in 70 and 8 cases, respectively. INK4 deletion was investigated by interphase FISH on the diagnostic bone marrow samples and the result was correlated with the patients’ demographic data, biological and clinical parameters, and disease outcome. All patients were treated according to the ALL-BFM-95 protocol and followed-up for 11–105 (medium 41) months. Results: INK4 locus deletion was found in 24 cases (30.8%). The loss was hemizygous in 15 (19.2%) and homozygous in 9 cases (11.5%). A positive finding was strongly associated with disease of T-cell origin (p=0.008). Apart from a weak correlation between INK4 deletion and advanced age (p=0.068), there was no association with sex, initial leucocytosis level, cytogenetic category, risk group grade according to the ALL-BFM- 95 criteria or the presence of residual disease at days 15 and 33. Nevertheless, INK4 homozygous deletion was significantly associated with disease-free (p=0.004) and overall survival (p=0.002), while the respective associations for an hemizygous deletions were found insignificant (p=0.137 and p=0.131). Conclusions: The findings from this cohort of children suggest that INK4 homozygous deletion is an unfavorable prognostic factor in chALL, even for cases in which an aggressive course cannot be predicted by the conventional risk estimating criteria. Unclear results with regard to hemizygous deletion may be attributed to the functional state of remaining p16/p14 and p15 genes on the non-deleted chromosome 9. The study of a greater group of patients and the extension of the follow-up period will hopefully clarify whether INK4 deletion is an independent prognostic factor and whether it could be incorporated in risk evaluation guidelines, especially for cases which would otherwise be treated as chALL of standard or medium risk.

Aim: The aim of this study was the prospective evaluation of MRD during childhood ALL therapy and its correlation with specific prognostic criteria of ALL-BFM 95 protocol and with patient outcome. Patients/Methods: 127 children (49 girls) with ALL were studied during the period 1999–2008. The median age at diagnosis was 9,32 years (range, 0,6–16,48). All patients were diagnosed in the same center and treated uniformly with the ALL-BFM 95 protocol, modified in two therapeutic branches, medium and high risk, as we have published previously. We used three or five colours’ flow cytometric panels for MRD quantification at sequential standardized treatment time-points: at day 15 of induction (T1), at day 33 (T2) of induction, before consolidation (T3), before re-induction (T4), before maintenance (T5), at maintenance completion (T6). Additionally for the high risk patients, 6 more determinations before each consolidation treatment cycle were performed. The median follow-up time was 48,4 months (range, 1,7–110,3). For statistical analysis, descriptive statistics and Kaplan-Meier were used. Results: Immunophenotypical analysis resulted in 119 patients with ALL of B-origin and 8 of T-origin. Median WBC at diagnosis was 10×109/lt, while extra-BM infiltration was found in 9 children. According to ALL-BFM 95 protocol’s criteria: 40 patients were fulfilling the criteria of the standard risk (SR), 61 of medium (MR) and 26 of high risk (HR), respectively, and therapeutically were divided into two groups: A (101 patients, SR+MR) and B (26 patients, HR). MRD was detected in: 59/123 patients at treatment time-point (T1) (39/59 from group A, of which 26/39 with high MRD levels, and 20/59 from group B, all with high MRD levels). In time-point (T2), disease was detected in 19/124: 5/19 from group A (3/5 high MRD levels), 14/19 from group B (11/14 high MRD levels). At treatment-point (T3), 3/127 had detectable disease (all from group B). None of the patients of group A had minimal residual disease at the following time-points, while only 2 patients of group B had persistent presence of MRD. In total, 14/127 children relapsed (4/SR, 2/MR, 8/HR), with significant levels of MRD in 7 (6/7 HR) and 4 (all HR) patients, at time-point (T1) and (T2), respectively. Among all, 114 children survived (CR1: 110, CR2: 4), while 13 children died (9/disease, 4/therapy-related toxicity). Conclusions: Our results suggest that MRD detection in continuous standardized treatment time-points of childhood ALL correlates with shorter disease free (DFS) and overall survival (OS), however in our cohort there was no sufficient evidence of MRD independency as prognostic factor (cox-regression analysis) compared to the classical prognostic criteria of the ALL-BFM 95. The enlargement of the group of patients and the expansion of the follow-up period will lead to more reliable conclusions.

Acute myeloid leukemia (AML) accounting for approximately 17% of all childhood acute leukemias, arises either de novo or from a backround of myelodysplasia or previous chemotherapy. Cytogenetics is considered one of the most valuable prognostic determinants in AML while current risk–group classification in the limited cases of pediatric AML, is mainly based on cytogenetics and early treatment response. We reviewed the clinical and cytogenetic characteristics and the outcomes of 33 cases of childhood AML between 1997 and 2007 in order to investigate the incidence of the main FAB subtypes, the incidence of primary AML compared to secondary AML (s-AML) and the correlation between specific chromosome abnormalities and outcome in greek pediatric AML patients. Chromosome studies were performed on unstimulated bone marrow cells, derived from 33 pediatric AML patients, who were <18 years of age at the time of diagnosis. Eighteen patients were male and 15 were female. According to FAB classification one patient was classified as M0 (3%), 13 patients as M2 (39.4%), 4 as M3 (12.12%), 4 as M5 (12.12%), 2 as M6 (6.1%) and 4 as M7 (12.12%). No patient was classified as M4 while 5 patients with s-AML (15.15%) could not be classified. The median follow-up of all patients was 57.95 months (0.03–132.47). Overal survival and event free survival were 66,7% and 75,8% respectively. Eight patients with s-AML and 25 patients with primary AML were identified. The median age of patients with s-AML at diagnosis was 9.15 years while the median age of patients with primary AML was 7.2 years. Six out of 8 patients with s-AML died at a median follow up of 11.03 months. Nineteen out of 25 patients with primary AML are alive in complete remission (CR). Cytogenetic analysis was performed at diagnosis in 32 patients and results were obtained in 30 of them. The karyotype was abnormal in 21 out of 30 patients (70%). Normal karyotype was found in 9 patients, t(8;21)(q22;q22) in 5, t(15;17)(q22;q21) in 3, t(9;11)(p22;q23) in 3, −7/del(7q) in 5, del(9q) in 3, and complex karyotype in 4 patients. Three out of 4 patients with M3 are alive in CR with a median follow-up of 98.6 months while one with s-AML-M3 died 13 days post diagnosis. Three out of five patients with M2 and t(8;21), including 1 patient with s-AML, died at a median follow-up of 4.35 months. Three out of 5 patients with −7/del(7q) had s-AML and died in less than 4 years, while the two others are alive for more than 5 years, in CR. Although all patients with M7 had complex karyotypes, they are alive after a median follow-up of 96.73 months, 3 of them in CR and 1 in relapse. These results indicate that in greek patients, the main FAB subtypes show a distribution similar to that reported in the literature with the exception of M4 which is absent in our study but with a reported incidence of 20%. Pediatric patients with s-AML are older and their outcome is poor and is related to a higher probability of poor cytogenetic features compared to primary AML patients. Interestingly all patients with M7 had a good clinical course although they exhibited complex karyotypes.

Clinical patient observations led to the hypothesis of increased ALL blast resistance in hyperglycemia (HG) states in pediatric ALL patients, either with preexisting diabetes mellitus (DM) or with steroid induced diabetes (SID). To evaluate the above, the chromometric MTT (methyl thiazole tetrazolium) assay was used Kaspers GJ et al, Leuk Res1995;19:175–81.Ficoll separated nucleated bone marrow cells from newly diagnosed pediatric ALL patients were cultured in usual conditions (NL) and in higher glucose levels (233–295 mg/dl), with the addition of titrated prednisolone (PDN) concentrations. The PDN concentration that lyses 50 % of the cultured blast cells (LD50) is the measure of PDN drug sensitivity. PDN concentrations of 0.02–2.0, 2.1–150, above 150 μg/uL indicate high, intermediate and low blast sensitivity to PDN, respectively. Hence, patient blasts with LD50 at >150 μg/uL are resistant to PDN. The MTT assay results have been related to patient outcome (remission induction and event free survival, Pieters R et al Pediatr Oncol1994;22:299–308). Twelve newly diagnosed pediatric patients, with median age 6.4 years (range, 1.7 to 16.5 years) with common/CD10+ (N=8), pre-B (N=2), early pro-B (N=1) and maturing B (N=1) ALL were studied. All patients exhibited >80% ALL blast BM infiltration. Sensitivity (LD50 < 150 μg/uL) in both NL and HG conditions was evident for 2 patients, while resistance to both conditions was seen in 3 patients. Patients resistant at NL conditions were resistant in HG, too. In contrast, 7 of 12 patients sensitive to PDN in NL conditions proved resistant in HG conditions (glucose 233–295 mg/dL). All 9 sensitive in NL conditions patients (in HG conditions 2 sensitive and 7 resistant) exhibited a median ×800 fold increase of the MTT LD50 measured (range 6–29.000 fold). For all patients (N=12) median MTT LD50 under NL conditions was 0.15 μg/uL and in HG conditions 167.5 μg/uL (× 116.6 fold increase). This change was statistically significant (Mc Nemar’s test, p=0,016) and this change was not simply related to the change in glucose concentration. These findings of greatly increased ALL blast resistance in hyperglycemia environment, can support the notions given earlier (Weiser MA et al, Cancer2004;100:1179–85, Pieter’s R EHA 2008) that hyperglycemia by itself can promote PDN resistance. Given that steroids is a mainstay in ALL treatment and that steroid induced hyperglycemia is a common occurrence, blood glucose monitoring and hyperglycemia correction appears to be of paramount significance in delivering an effective ALL treatment.

Introduction:In TEL/AML1+ ALL, the formation of the fusion gene is frequently followed by clonal evolution, with the acquisition of additional aberrations, some involving the TEL and AML1 genes. The resulting variant subclones often coexist at diagnosis, but the clinical significance of this heterogeneity is unclear.

The extensive use of etoposide has been implicated in the development of secondary acute myelogenous leukemia (AML) with unfavorable prognostic characteristics and most often involvement of the 11q23 locus. The case herein being presented exhibits favorable characteristics and poses the question whether it represents a secondary malignancy or a second primary event. A five year old boy was diagnosed with a mass of the posterior fossa representing anaplastic ependymoma of the brain stem (medulla oblongata) without CNS nor distant metastases. After partial resection of the tumor, the patient received 53 Gy to the tumor bed and 30 Gy to the neuroaxis followed by temozolamide p.o. for 4 cycles. Following this treatment, symptoms improved, he was ambulatory and back to school. Two years later he relapsed with unresectable tumor and received etoposide (VP-16) at 100 mg/m2/day for 21 days of 28 cycles, with a palliative intent. The treatment proved efficacious to him and he continued to receive VP-16 for 3 years in total. Six years after initial diagnosis and 3 years on VP-16, he developed ecchymoses, with thrombocytopenia (PLT: 15 k/uL) and leukocytosis (WBC: 25.8 k/uL). Bone marrow evaluation revealed infiltration with AML M2 blasts (>80%), MPO+ (93%), CD 34+ (58%), CD15+ (19%), CD71+ (33%), CD38+ (87%), CD33+ (47%) and CD123+ (52%), karyotype with detection of t(8;21). Bone marrow RT-PCR confirmed the presence of AML1-ETO hybrid gene, the absence of the MLL-AF4 product, and the absence of 11q23 involvement. Results were also confirmed by FISH technique. The patient was started on chemotherapy according to the AML-BFM 98 protocol. Disease remission was rapidly achieved (day +15 BM with no blasts) and treatment schedule was prompt, for the first 4 months of treatment. Severe, long-lasting marrow aplasia followed and pulmonary Aspergillosis was evident (compatible findings on CT and detection of Aspergillus specific proteins in the plasma by PCR), requiring assisted ventilation. However the patient succumbed 5 months following the diagnosis of AML. Childhood ependymomas have a dismal prognosis despite intensive treatment. This child exhibited a similarly good treatment response either to the ependymoma or to the later evolved AML. This AML1-ETO positive AML either representing a second primary malignancy or a rare type of secondary, therapy induced leukemia, is not a common and well described event and it certainly did not present, in our case, the usual dismal course of a secondary AML. Of importance our patient achieved and remained in remission with minimal treatment, for over 5 months, verifying the good prognosis of AML1-ETO positive AML either as a primary or a secondary event.

T-ALL has increasing incidence during adolescence and it is rarely associated with Philadelphia chromosome positivity. Moreover, extremely rare is the event of Philadelphia chromosome negativity at diagnosis and leukemia clone evolution with t(9;22) at relapse. Such a patient is being described and relevant issues are being raised. A 14 year old boy was diagnosed with leukemia due to malaise and ecchymoses. CBC revealed: WBC 170 k/uL (80% blasts), Hb 13.1 gr/dL, Ht 37.7% and PLT of 26 k/uL. Bone marrow confirmed the diagnosis of ALL (L2 morphology). Bone marrow flow cytometry depicted a T II ALL by EGIL classification (Tdt 54%, cCD3 99%, CD7 96%, CD2 96%, CD4 0%, CD8 2%, CD5 75%, TCRαβ 0%, CD1α 0%, sCD3 31%). Karyotype with G-banding, technically failed. By PCR, blasts were negative for TEL-AML1, E2A-PBXand MLL-AF4 while RNA coding for proteins p190 and p210 was also negative. Additionally, the 9 chromosome was evaluated by FISH technique (centromere and 9p21 areas/genes p16/p14 and p15- Vysis) and an homozygous deletion of 9p16 area was detected in the great majority of the blasts tested. The patient was treated according to the ALL-BFM-95 protocol and proved to be a poor prednisone responder, with residual disease detected on day +15 bone marrow and remission on day +33. He proceeded to the High Risk arm of the protocol. Thirteen months from diagnosis and 5 months on maintenance treatment, the patient suffered a bone marrow relapse. CBC revealed: WBC 30 k/uL (25% blasts), Hb 13.8 gr/dL, Ht 40.9 % and PLT of 201 k/uL. Bone marrow confirmed the relapse (L2 blast morphology) with a more mature T-cell type (cCD/TdT coexpression, with CD3 87% and TCRαβ 53.3% expression). Five of 25 metaphases revealed the following complex karyotype: 46,XY,del(6)(q21),?del(7)(q36), -9, t(9;22)(q34;q11),+mar1. By FISH , monosomy of 9 chromosome was not proved , while homozygous deletion of 9p16 area was again documented and t(9;22) was clearly evident. By PCR, there was no detection of RNA coding for proteins p190 and p210 with standard commercially available probes. The patient is treated with a fludarabine based regimen and imatinib, with the prospective of stem cell transplantation. In conclusion, at diagnosis, T-ALL without t(9;22) but with an homozygous deletion of chromosome 9, was documented. At relapse, there is clone evolution with a more mature T-origin blast detection of a complex karyotype with t(9;22). Ph+ T-ALL is rare, as well as rare is the event of ALL clone evolution, with emergence of Ph+ at relapse. This patient’s data are being completed and there is prospective of further illuminating the underlying pathogenesis. Chromosome 9 deletions are under investigation for contributing in genetic instability. Homozygous 9p16 deletion of ALL blasts at diagnosis and relapse might play a key role in these events.

The extensive use of etoposide has been implicated in the development of secondary acute myelogenous leukemia (AML) with unfavorable prognostic characteristics and most often involvement of the 11q23 locus. The case herein being presented exhibits favorable characteristics and poses the question whether it represents a secondary malignancy or a second primary event. A five year old boy was diagnosed with a mass of the posterior fossa representing anaplastic ependymoma of the brain stem (medulla oblongata) without CNS nor distant metastases. After partial resection of the tumor, the patient received 53 Gy to the tumor bed and 30 Gy to the neuroaxis followed by temozolamide p.o. for 4 cycles. Following this treatment, symptoms improved, he was ambulatory and back to school. Two years later he relapsed with unresectable tumor and received etoposide (VP-16) at 100 mg/m2/day for 21 days of 28 cycles, with a palliative intent. The treatment proved efficacious to him and he continued to receive VP-16 for 3 years in total. Six years after initial diagnosis and 3 years on VP-16, he developed ecchymoses, with thrombocytopenia (PLT: 15 k/uL) and leukocytosis (WBC: 25.8 k/uL). Bone marrow evaluation revealed infiltration with AML M2 blasts (>80%), MPO+ (93%), CD 34+ (58%), CD15+ (19%), CD71+ (33%), CD38+ (87%), CD33+ (47%) and CD123+ (52%), karyotype with detection of t(8;21). Bone marrow RT-PCR confirmed the presence of AML1-ETO hybrid gene, the absence of the MLL-AF4 product, and the absence of 11q23 involvement. Results were also confirmed by FISH technique. The patient was started on chemotherapy according to the AML-BFM 98 protocol. Disease remission was rapidly achieved (day +15 BM with no blasts) and treatment schedule was prompt, for the first 4 months of treatment. Severe, long-lasting marrow aplasia followed and pulmonary Aspergillosis was evident (compatible findings on CT and detection of Aspergillus specific proteins in the plasma by PCR), requiring assisted ventilation. However the patient succumbed 5 months following the diagnosis of AML. Childhood ependymomas have a dismal prognosis despite intensive treatment. This child exhibited a similarly good treatment response either to the ependymoma or to the later evolved AML. This AML1-ETO positive AML either representing a second primary malignancy or a rare type of secondary, therapy induced leukemia, is not a common and well described event and it certainly did not present, in our case, the usual dismal course of a secondary AML. Of importance our patient achieved and remained in remission with minimal treatment, for over 5 months, verifying the good prognosis of AML1-ETO positive AML either as a primary or a secondary event.

T-ALL has increasing incidence during adolescence and it is rarely associated with Philadelphia chromosome positivity. Moreover, extremely rare is the event of Philadelphia chromosome negativity at diagnosis and leukemia clone evolution with t(9;22) at relapse. Such a patient is being described and relevant issues are being raised. A 14 year old boy was diagnosed with leukemia due to malaise and ecchymoses. CBC revealed: WBC 170 k/uL (80% blasts), Hb 13.1 gr/dL, Ht 37.7% and PLT of 26 k/uL. Bone marrow confirmed the diagnosis of ALL (L2 morphology). Bone marrow flow cytometry depicted a T II ALL by EGIL classification (Tdt 54%, cCD3 99%, CD7 96%, CD2 96%, CD4 0%, CD8 2%, CD5 75%, TCRαβ 0%, CD1α 0%, sCD3 31%). Karyotype with G-banding, technically failed. By PCR, blasts were negative for TEL-AML1, E2A-PBXand MLL-AF4 while RNA coding for proteins p190 and p210 was also negative. Additionally, the 9 chromosome was evaluated by FISH technique (centromere and 9p21 areas/genes p16/p14 and p15- Vysis) and an homozygous deletion of 9p16 area was detected in the great majority of the blasts tested. The patient was treated according to the ALL-BFM-95 protocol and proved to be a poor prednisone responder, with residual disease detected on day +15 bone marrow and remission on day +33. He proceeded to the High Risk arm of the protocol. Thirteen months from diagnosis and 5 months on maintenance treatment, the patient suffered a bone marrow relapse. CBC revealed: WBC 30 k/uL (25% blasts), Hb 13.8 gr/dL, Ht 40.9 % and PLT of 201 k/uL. Bone marrow confirmed the relapse (L2 blast morphology) with a more mature T-cell type (cCD/TdT coexpression, with CD3 87% and TCRαβ 53.3% expression). Five of 25 metaphases revealed the following complex karyotype: 46,XY,del(6)(q21),?del(7)(q36), -9, t(9;22)(q34;q11),+mar1. By FISH , monosomy of 9 chromosome was not proved , while homozygous deletion of 9p16 area was again documented and t(9;22) was clearly evident. By PCR, there was no detection of RNA coding for proteins p190 and p210 with standard commercially available probes. The patient is treated with a fludarabine based regimen and imatinib, with the prospective of stem cell transplantation.