Search

Background Early cancer detection could identify tumors at a time when outcomes are superior and treatment is less morbid. This prospective case-control sub-study (from NCT02889978 and NCT03085888) assessed the performance of targeted methylation analysis of circulating cell-free DNA (cfDNA) to detect and localize multiple cancer types across all stages at high specificity. Participants and methods The 6689 participants [2482 cancer (>50 cancer types), 4207 non-cancer] were divided into training and validation sets. Plasma cfDNA underwent bisulfite sequencing targeting a panel of >100 000 informative methylation regions. A classifier was developed and validated for cancer detection and tissue of origin (TOO) localization. Results Performance was consistent in training and validation sets. In validation, specificity was 99.3% [95% confidence interval (CI): 98.3% to 99.8%; 0.7% false-positive rate (FPR)]. Stage I–III sensitivity was 67.3% (CI: 60.7% to 73.3%) in a pre-specified set of 12 cancer types (anus, bladder, colon/rectum, esophagus, head and neck, liver/bile-duct, lung, lymphoma, ovary, pancreas, plasma cell neoplasm, stomach), which account for ∼63% of US cancer deaths annually, and was 43.9% (CI: 39.4% to 48.5%) in all cancer types. Detection increased with increasing stage: in the pre-specified cancer types sensitivity was 39% (CI: 27% to 52%) in stage I, 69% (CI: 56% to 80%) in stage II, 83% (CI: 75% to 90%) in stage III, and 92% (CI: 86% to 96%) in stage IV. In all cancer types sensitivity was 18% (CI: 13% to 25%) in stage I, 43% (CI: 35% to 51%) in stage II, 81% (CI: 73% to 87%) in stage III, and 93% (CI: 87% to 96%) in stage IV. TOO was predicted in 96% of samples with cancer-like signal; of those, the TOO localization was accurate in 93%. Conclusions cfDNA sequencing leveraging informative methylation patterns detected more than 50 cancer types across stages. Considering the potential value of early detection in deadly malignancies, further evaluation of this test is justified in prospective population-level studies.

CCGA [NCT02889978] is the largest study of cfDNA-based early cancer detection; the first CCGA learnings from multiple cfDNA assays are reported here. This prospective, multi-center, observational study has enrolled 10,012 of 15,000 demographically-balanced participants at 141 sites. Blood was collected from participants with newly diagnosed therapy-naive cancer (C, case) and participants without a diagnosis of cancer (noncancer [NC], control) as defined at enrollment. This preplanned substudy included 878 cases, 580 controls, and 169 assay controls (n=1627) across 20 tumor types and all clinical stages. All samples were analyzed by: 1) Paired cfDNA and white blood cell (WBC)-targeted sequencing (60,000X, 507 gene panel); a joint caller removed WBC-derived somatic variants and residual technical noise; 2) Paired cfDNA and WBC whole-genome sequencing (WGS; 35X); a novel machine learning algorithm generated cancer-related signal scores; joint analysis identified shared events; and 3) cfDNA whole-genome bisulfite sequencing (WGBS; 34X); normalized scores were generated using abnormally methylated fragments. In the targeted assay, non-tumor WBC-matched cfDNA somatic variants (SNVs/indels) accounted for 76% of all variants in NC and 65% in C. Consistent with somatic mosaicism (i.e., clonal hematopoiesis), WBC-matched variants increased with age; several were non-canonical loss-of-function mutations not previously reported. After WBC variant removal, canonical driver somatic variants were highly specific to C (e.g., in EGFR and PIK3CA, 0 NC had variants vs 11 and 30, respectively, of C). Similarly, of 8 NC with somatic copy number alterations (SCNAs) detected with WGS, 4 were derived from WBCs. WGBS data revealed informative hyper- and hypo-fragment level CpGs (1:2 ratio); a subset was used to calculate methylation scores. A consistent “cancer-like” signal was observed in 99% specificity for invasive cancer, and support the promise of cfDNA assay for early cancer detection. Additional data will be presented on detected plasma:tissue variant concordance and on multi-assay modeling. Citation Format: Alexander A. Aravanis, Geoffrey R. Oxnard, Tara Maddala, Earl Hubbell, Oliver Venn, Arash Jamshidi, Ling Shen, Hamed Amini, John A. Beausang, Craig Betts, Daniel Civello, Konstantin Davydov, Saniya Fazullina, Darya Filippova, Sante Gnerre, Samuel Gross, Chenlu Hou, Roger Jiang, Byoungsok Jung, Kathryn Kurtzman, Collin Melton, Shivani Nautiyal, Jonathan Newman, Joshua Newman, Cosmos Nicolaou, Richard Rava, Onur Sakarya, Ravi Vijaya Satya, Seyedmehdi Shojaee, Kristan Steffen, Anton Valouev, Hui Xu, Jeanne Yue, Nan Zhang, Jose Baselga, Rosanna Lapham, Daron G. Davis, David Smith, Donald Richards, Michael V. Seiden, Charles Swanton, Timothy J. Yeatman, Robert Tibshirani, Christina Curtis, Sylvia K. Plevritis, Richard Williams, Eric Klein, Anne-Renee Hartman, Minetta C. Liu. Development of plasma cell-free DNA (cfDNA) assays for early cancer detection: first insights from the Circulating Cell-Free Genome Atlas Study (CCGA) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-343.

LBA8501 Background: Plasma cfDNA genomic analysis is used widely for the care of advanced lung cancer, but its suitability for early stage lung cancer detection is not well established. CCGA (NCT02889978) is a prospective, multi-center, observational study launched for the development of a noninvasive assay for cancer detection. Methods: Blood was prospectively collected (N = 1627) from 749 controls (no cancer diagnosis) and 878 participants (pts) with newly-diagnosed untreated cancer in this preplanned substudy, including 127 pts with lung cancer. Three prototype sequencing assays were performed: paired cfDNA and white blood cell (WBC) targeted sequencing (507 genes, 60,000X) for single nucleotide variants/indels; paired cfDNA and WBC whole genome sequencing (WGS) for copy number variation (30X); and cfDNA whole genome bisulfite sequencing (WGBS) for methylation (30X). For each assay, a classification model using 10-fold cross-validation was developed for all pts with cancer, then evaluated in the pts with lung cancer; sensitivity was estimated at 95% specificity. Results: We evaluated pts with lung cancer (127) and a subset of controls (580) with similar ages (mean±SD yrs: 67±9, 60±13), 85% and 43% were ever-smokers, and 46% and 22% were men, respectively. Of 3055 nonsynonymous mutations detected across 122 evaluable pts with lung cancer, > 50% were detected in WBC consistent with clonal hematopoiesis (CH). Accounting for CH, sensitivity in 63 stage I-IIIA pts evaluable across all 3 assays was 48% (35-61, targeted), 54% (41-67, WGS), and 56% (43-68, WGBS); in 54 stage IIIB-IV pts it was 85% (73-93, targeted), 91% (80-97, WGS), and 93% (82-98, WGBS) . Similar sensitivities were observed across histological subtypes (adenocarcinoma, squamous cell, small cell). Comparison to tumor WGS and multi-assay classification will be reported. Conclusions: Early stage lung cancers are detectable in cfDNA using a genome-wide sequencing approach. For lung cancer detection using targeted assays, CH must be accounted for to minimize false positives. Assay optimization is ongoing to allow further clinical development in the intended use population. Clinical trial information: NCT02889978.

Between November 1990 and March 1993, nine pediatric patients with newly diagnosed brain tumors having a high risk of failure with standard treatment received high-dose thiotepa/cyclophosphamide chemotherapy followed by autologous bone marrow infusion and involved-field hyperfractionated radiation therapy. The presenting diagnoses were brainstem glioma (BSG) [6], parietal mixed high-grade oligodendro-glioma-astrocytoma [1], thalamic anaplastic astrocytoma [1], and high-grade parietal glioma [1]. Following chemotherapy there were two partial responses, one minor response, three with stable disease, and one with progressive disease. Responses were not evaluated in two patients who had toxic deaths. Following radiation two patients, one with brainstem glioma and one with anaplastic mixed glioma, achieved complete remission. The overall survival is no better than conventional therapy. © 1994 Wiley-Liss, Inc.

Patients with chronic renal disease in whom erythropoietin production is inadequate invariably experience moderate to severe debilitation-induced fatigue. Unlike the direct humeral control of erythropoiesis, neutropenia in the same cohort of patients appears to be under indirect control, very likely brought about by the suppressive effect of increased levels of low-density lipoprotein (LDL) on granulocyte-monocyte colony formation. Markedly elevated LDL levels were identified in plasma samples obtained from a study population of 179 chronic renal disease patients. The effect of the elevated LDL levels in the plasma of these patients resulted in a greater than 60% decrease in granulocyte-macrophage colony-forming unit in comparison with age-matched plasma from normal individuals. Careful review of all nutritional and therapeutic events in these patients did not offer any evidence, other than the elevated LDL levels, in support of the etiology of the chronically low absolute neutrophil counts.

We conducted a pilot protocol at seven Pediatric Oncology Group (POG) institutions to examine the feasibility, toxicity, and efficacy of using a common regimen of high-dose chemoradiotherapy (HD CT/RT) supported by autologous or allogeneic marrow infusions in children with metastatic neuroblastoma (NBL) in first or second remission. During a 57-month period, we accrued 101 patients. We report here results for the 81 who completed treatment at least 2 years ago. The HD CT/RT regimen consisted of melphalan 60 mg/m2/d for three doses, and total body irradiation (TBI) either 1.5 Gy (n = 27) or 2.0 Gy (n = 54) twice daily for six doses. Twenty-three patients also received irradiation consisting of 1.2 Gy twice daily for 10 doses to persisting disease sites. Seventy-four were given autologous and seven allogeneic marrow, 64 autologous marrows being purged immunomagnetically. Fifty-four children were in first complete (CR) or partial (PR) remission and 27 in second CR or PR. As of October 1, 1990, follow-up was from 32 to 72 months. Forty-seven of these 81 children relapsed, 10 died of complications, one of unknown cause, and 23 continue in remission, including 21 of the 54 treated in first remission, and 16 who completed treatment more than 3 years ago. The 2-year actuarial event-free survival (EFS) probabilities are first CR (CR1) 32% (SE 10%), first PR (PR1) 43% (SE 9%), second CR (CR2) 33% (SE 27%), and second PR (PR2) 5% (SE 5%). Probability of EFS correlated with remission number (first better than second, P less than .001), with interval from diagnosis to HD CT/RT (greater than 9 months better than less than 9 months, P = .055), and with TBI dose (12 Gy better than 9 Gy, P = .031). These encouraging results may partly reflect selection for this treatment of patients with NBL who have a slower disease pace.

A Phase I1 study of the combination of etoposide (VP-16) and cyclophosphamide (CPM) was conducted in an attempt to identify active and potentially less toxic agents for treating patients with osteogenic sarcoma (0s). VP-16 was given as a 72-hour infusion for a total dose of 600 mg/m2. CPM was given as six pulses of 300 mg/m2 every 12 hours for a total dose of 1800 mg/m2. Seventeen newly diagnosed patients, including five (29%) with metastatic disease, were evaluated before and after two courses of VP16 and CPM for clinical, radiologic, and biochemical (serum alkaline phosphatase [SAP]) responses of the primary tumor and metastases. Fifteen (88%) patients achieved complete or partial clinical responses. Fourteen (82%) patients achieved radiologic responses. Thirteen (87%) of 15 patients with higher than normal SAP levels for their age showed partial or complete responses. Three (60%) of the five patients with metastatic disease achieved complete or partial responses. The only major toxicity was myelosuppression, which led to 21 (62%) brief admissions after 34 courses of chemotherapy for intravenous antibiotic therapy for fever and neutropenia, without associated mortality. It was concluded that the combination of VP-16 and CPM is effective chemotherapy for lboth primary and metastatic 0s. Although myelosuppression is inevitable, it is rapidly reversible in the drug dosages used. Further studies are needed to evaluate the effect of these drugs in combination with established agents in improving the disease-free survival of patients with 0s. Cancer 65:861-865, 1990.

Erythrocyte binding and plasma protein binding of codeine in sickle cell patients and healthy controls were determined. A reversed-phase HPLC procedure was used for codeine analysis. Codeine was extracted from alkalinized plasma, separated on a CN column, and assayed by fluorescence detection. The erythrocyte-buffer partition coefficient was significantly higher in sickle cell patients (1.72 +/- 0.21) than in healthy controls (1.25 +/- 0.14). No time dependence of partitioning was observed. The fraction of codeine bound to plasma proteins, determined by ultrafiltration, was significantly higher in sickle cell patients (66.0% +/- 8.6%) than in healthy controls (30.5% +/- 2.7%). No concentration dependence of erythrocyte or protein binding was observed. Further studies were performed to elucidate the binding mechanisms. From a ghost cell binding study it was concluded that the major binding sites for codeine are in the cell membrane. A decrease in codeine binding was observed in the presence of bilirubin. Codeine binding to alpha 1-acid glycoprotein was found to be minimal. The levels of alpha 1-acid glycoprotein and other glycoproteins in sickle cell patients and healthy controls were measured by glycoprotein electrophoresis. The results showed no significant difference between the two groups. Plasma protein electrophoresis was performed for the two groups. The results showed a significant difference in gamma-globulin levels between sickle cell patients and healthy controls. Codeine is known to bind to gamma-globulin, a fact that may explain in part the observed increase in the plasma protein binding of codeine in sickle cell patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The pharmacokinetics of codeine were determined after oral administration of codeine sulfate (60 mg) with sickle cell patients (SCPs) and healthy controls (HCs). Plasma concentrations of codeine were measured by reversed-phase high-pressure liquid chromatography with fluorescence detection. Pharmacokinetic parameters were calculated using both compartmental and noncompartmental analysis. No significant differences were observed in time to reach maximum peak plasma concentration (tmax) (1.0 +/- 0.4 versus 1.4 +/- 1.0 hours), maximum peak plasma concentration (Cmax) (172 +/- 25 versus 225 +/- 97 ng/mL), area under the curve (AUC infinity) (590 +/- 96 versus 779 +/- 234 ng*h/mL), and Cl/F (104 +/- 17 versus 89 +/- 27 L/h) between SCPs and HCs. Conversely, significant differences were observed in mean residence time (MRT) (3.7 +/- 0.3 versus 4.7 +/- 0.3 hours) and half-life (t1/2) (1.7 +/- 0.2 versus 2.8 +/- 0.3 hours). In a separate study, significant differences were observed in the in vitro plasma protein binding of codeine in SCPs (66.0 +/- 8.6%) and HCs (30.5 +/- 2.7%) as well as in vivo binding (68.4 +/- 11.1% for SCPs versus 29.2 +/- 3.4% for HCs). Codeine is a relatively high-extraction drug that is primarily eliminated by metabolism in the liver. Generally, the clearance of such drugs is approximately equal to hepatic blood flow and is not affected by changes in protein binding. Therefore, the change in t1/2 observed in SCPs can be attributed to changes in volume of distribution rather than clearance.

This study was undertaken to test the effects of certain arachidonate derivatives, PGF2 alpha, PGI2 and TxB2 on in vitro bone marrow granulocyte colony growth (CFU-C) in leukemia patients receiving maintenance chemotherapy and in normal controls. The addition of PGF2 alpha did not result in increased numbers of colonies, but it did cause a shift in the size of the colonies so that there was a significant increase in larger colonies (P less than 0.001) and significantly fewer small colonies (P less than 0.05) as compared to untreated samples. Of the prostenoids tested in a Tris-buffered system, PGI2 affected the greatest increase in CFU-C (P less than 0.01) followed by PGF2 alpha (P less than 0.05) whereas 6-keto-PGF1 alpha (the stable hydrate of PGI2) did not affect colony growth. Time-response curves revealed a linear growth pattern for PGF2 alpha with a peak at 10 days, whereas there was a 6-day growth lag with PGI2 followed by linear growth with a peak at 13 days. TxB2 added to cultures significantly reduced the number of bone marrow CFU-C at all doses tested. The prostanoid effects on CFU-C derived from leukemic patients on maintenance chemotherapy and from normal individuals were identical in every respect.

This study was undertaken to better define the relationship between catecholamine (CAT) metabolism within the malignant neuroblast and other factors known to influence clinical outcome in neuroblastoma (NB). Several CATs and their metabolites were measured in 32 tumors and 47 urines from 60 newly diagnosed children with neurogenic tumors. Absolute and relative CAT concentrations were correlated with age, clinical stage, histologic differentiation and survival duration. The major findings are: (1) urinary CAT excretion patterns often differ markedly from tumor CAT patterns in the same child, which may be explained by the continuous nature of tumor metabolism, hepatic and renal catabolism, and sampling errors; (2) definite patterns of biochemical maturation are apparent in tumors and urines, but standard light microscopy is insufficient to correlate this with degree of histologic differentiation; (3) more differentiated patterns of CAT metabolism, both in tumor and urine, are significantly associated with age less than 1 year at diagnosis, and with more favorable clinical Stage (I, II, IVS). Tumor NE was increased relative to DM and DA, and urine NMN and VMA were increased relative to DM and HVA, in these patients. (4) this more differentiated CAT pattern in infants and in less advanced stages was reflected in their better survival. Greater maturity of tumor enzyme systems is the probable reason for the better prognosis of NB in infants less than 1 year. Individual enzymes should be measured in fresh tumor tissues, and related to relative and absolute CAT concentrations in tumor and urine, to try to categorize patients on the basis of clearcut biological differences when planning new treatment strategies for NB.

Studies on serum tocopherol levels, hematopoietic responses, and erythrocyte phospholipid fractions were carried out in agroup of low-birth-weight (mean, 1,530 gm) premature infants whose diets were supplemented with either water-soluble (TPGS) or fat-soluble (TA) forms of d-alpha tocopheryl (25 IU/day). Significantly higher serum tocopherol levels and early maintenance of higher hemoglobin values were observed in the infants who received the water-soluble tocopheryl preparation. Comparable but less marked differences in these values were identified in similarly paired groups fed lower concentrations of the tocopheryls in combination with iron. The lowest hemoglobin levels were recorded in the infants fed formulas containing TA and iron. Among a selected group of vitamin E-deficient infants, evidence of lipid instability in the erythrocyte membrane was manifested by decreased values of phosphatidyl ethanolamine.

Nine children underwent ten bone marrow transplants for malignancies and were supported by parenteral alimentation administered in cyclic fashion 18 hours daily. Children received cyclic parenteral nutrition for an average of 29 days, which provided a caloric intake (mean +/- SD) of 55.9 +/- 18.1 Kcal/kg/day, and a nitrogen intake of 0.28 +/- 0.08 g/kg/day. Nutritional status was assessed using nitrogen balance, creatinine-height index, and visceral protein concentrations including serum albumin, transferrin, and prealbumin. Minimal transient elevation in tests of liver function were observed without marked derangement in blood glucose, electrolytes, or osmolality. Unlike prealbumin, determinations of nitrogen balance, creatinine-height index, serum albumin and transferrin concentrations did not parallel changes in clinical status. Cyclic parenteral alimentation is a practical approach to the maintenance of nutrition during intensive antitumor therapy and provides an infusion-free period for the administration of drugs and blood transfusions without interfering with nutritional support. Prealbumin accurately reflects changes in the patient's clinical status at any point and is easily and reliably determined.

Increased in vitro erythrocyte sensitivity to the hemolytic effects of hydrogen peroxide (H2O2) in the H2O2 fragility test has been widely associated with vitamin E deficiency. In the present study, H2O2 red cell fragility was abnormally elevated in many types of acquired and congenital anemias in children who were tocopherol sufficient. In addition to abnormal red cell H2O2 sensitivity known to occur in vitro in conditions involving defects in cellular devices for disposal of peroxides, it is likely that a wide variety of erythrocyte dysfunctions result in increased in vitro H2O2 hemolysis even in situations where the usually adequate mechanisms for peroxide detoxification are present.

Central nervous system infiltration was studied in a group of 47 children with acute leukemia. CNS involvement was found to occur more frequently and appear more rapidly in patients who presented with elevated peripheral WBC counts. CNS infiltration not suspected clinically was identified by spinal fluid examination in a significant minority of children at the time of the initial diagnosis of leukemia, indicating that lumbar puncture should be a routine part of the initial evaluation of patients with acute leukemia. Intrathecal amethopterin administered "prophylactically" at the time of initial diagnosis of leukemia did not prevent or decrease the frequency of occurrence of CNS infiltration. However, it did delay the onset of CNS involvement in patients with elevated WBC counts. Intrathecal amethopterin administered before the onset of CNS infiltration appears to be useful in delaying morbidity resulting from CNS involvement in children who present with elevated peripheral WBC counts.

The hematologic and serologic data of 87 cystic fibrosis patients, between the ages of 5 and 16 years, showed the following characteristics as compared with a group of age-matched normal control children: The cystic fibrosis patients were shorter, weighed less, and had lower pO 2 values than the control group. Although moderately polycythemic, they had lower MCHC's lowe serum-bound iron values, and higher iron-binding capacities. However, both BI and TIBC values were low in the group with the klowest pO 2 values. The blood vlumes, based upon height, were normal. Iron absorption, particularly in thosse with low iron values, was increased. Whereas the level of serum-bound iron was the major factor in regulation iron absorptioin, the red cell mass was, directly related to the degree of hypoxia. Pancreatic extract impeded absorption of iron, but to a lesser extent than it did in the control group.

Two adolescents who underwent successful allogeneic bone marrow transplantation were nutritionally managed on a fat-free cyclic parenteral nutrition (PN) regimen. Serum concentrations of prealbumin, albumin, and transferrin were prospectively evaluated to assess the efficacy of nutritional therapy. Both patients tolerated the cyclic PN metabolically. Serial albumin and transferrin concentrations varied slightly and were less sensitive indices of changing nutritional status. In contrast, prealbumin concentrations decreased uniformly during periods of metabolic stress. At the cessation of Pn therapy, all serum proteins were within the normal range. Cyclic PN appears to be a safe, practical approach to the nutritional management of patients undergoing bone marrow transplantation.

Studies on 41 healthy preterm infants and 53 term infants revealed that almost 70% of the total folate is present in the bound form. Beyond the neonatal period the fraction of bound folate drops to that observed in normal adults: approximately 30%. The increase in bound folate with increasing gestational maturity reflects fetal demands placed on folate transport and affords an explanation for the loss of folate and corresponding increase in unsaturated binder during pregnancy. With the knowledge of folate biology gained from radioligand data, it is reasonable to postulate that effective folate metabolism depends upon a metabolically active transport mechanism.

A presumed cimetidine-induced granulocytopenia in a 6-year-old male with acute lymphocytic leukemia (ALL) prompted an investigation of the effects of cimetidine on in vitro bone marrow granulocyte colony growth (CFU-C) in normal individuals and ALL patients either on maintenance chemotherapy or off all therapy for at least 1 year. The addition of cimetidine resulted in a significant reduction of colony numbers as compared to untreated controls beginning at 1 x 10(-6) M (P less than 0.05) and increasing in significance as the concentration of cimetidine increased. Analysis of sex differences showed that CFU-C derived from females were not adversely affected by the addition of cimetidine (except at levels far in excess of recommended dosages) whereas CFU-C in males declined significantly from controls beginning at 1 x 10(-7) M (P less than 0.05) and became of greater significance as the concentration of cimetidine increased. These findings were identical for both normal individuals and ALL patients either receiving maintenance chemotherapy or off all therapy.

We determined lymphocyte aryl hydrocarbon hydroxylase (AHH) inducibility for members of 13 families with one or more children with acute lymphoblastic leukemia (ALL) and 12 control families. Pedigree analysis suggested that aromatic hydrocarbon responsiveness (i.e. inducibility) is a codominant trait. Heterozygotes were found to be moderately responsive with IR values intermediate between homozygous minimally responsive and homozygous highly responsive individuals. Homozygous recessive and heterozygous genotypes accounted for 54% and 36% of ALL children respectively. The risk of ALL among minimally aromatic hydrocarbon responsive children was twice that of highly responsive children.

In summary, it appears that thrombocytosis frequently accompanies the less severe anemia of iron deficiency and may be related to platelet stimulation in a manner analogous to the erythropoietin increase seen in many of the anemic states. In some of the severely anemic individuals, thrombopenia has been observed related suggestively to several factors, including severe depletion of iron as iron enzymes, a folate deficiency or a transient thrombopoietin deficit. In order to determine with any degree of certainty the etiology of the thrombocytopenia, one would have to evaluate the platelet response in a similarly afflicted group of infants treated with folic acid or simply thrombopoietin rich plasma prior to iron therapy. In regard to the intriguing difference in the platelet response to oral and parenteral iron, subsequent studies, using either extremely small amounts of parenteral iron or large amounts of oral iron, regardless of the initial platelet and hemoglobin values, might cast light on the etiology of this occurrence.

The association of vitamin E deficiency and hemolytic anemia in small premature infants prompted study of intestinal absorption of vitamin E in infants of various gestational and chronologic ages. A direct relationship was found between the gestational age of the premature infant and his ability to maintain vitamin E sufficiency during the first 3 months of life; infants of lowest gestational age were least able to achieve vitamin E sufficiency, even when receiving a vitamin E supplement. In infants whose gestational age was less than 32 weeks, progressive improvement in the intestinal absorption of the vitamin was seen as the chronologic equivalent of a full-term gestational age was approached. Oral administration of iron is implicated as interfering with the intestinal absorption of vitamin E. Since maintenance of vitamin E sufficiency appears to be nutritionally important in the premature infant, the efficacy of other routes of administration of the vitamin should be explored.

Studies of red cell hydrogen peroxide hemolysis and intestinal absorption of vitamin E were conducted in 21 infants whose major presenting symptom was jaundice, in order to evaluate the efficacy of these simple laboratory techniques in differentiation of their disease conditions. The peroxide hemolysis test is based upon the assumptions that the intestinal absorption of fat-soluble vitamin E requires adequate amounts of bile salts and that vitamin E deficiency is reflected by abnormal sensitivity of the red cell membrane to hydrogen peroxide. Ultimate diagnoses in the infants studied, 14 of whom underwent open liver biopsy and operative cholangiogram, included biliary atresia, neonatal hepatitis, and primary congenital hemolytic processes. Although a single red cell hydrogen peroxide hemolysis test did not clearly differentiate between the various conditions studied, peroxide hemolysis used in combination with vitamin E absorption curves showed distinctly different patterns for each group of diseases. The information gained thus enabled prediction of the jaundice with accuracy and indicates that these laboratory techniques can be of great value in guiding the decisions regarding the necessity and timing of surgical exploration in jaundiced infants.

Normal white blood cells were cultured in plasma obtained from leukemic subjects during active disease and during remission. No mitotic activity was discernible with “remission” plasma, whereas normal cells cultured in “active” plasma showed considerable mitotic activity. Conversely, leukemic cells cultured in normal plasma showed no mitotic activity. It is proposed that there is present in leukemic plasma, during the active stages of the disease, a factor(s) capable of inducing mitoses in normal white cells.

In the report entitled, "High-Dose Chemoradiotherapy Supported by Marrow Infusions for Advanced Neuroblastoma: A Pediatric Oncology Group Study" by Graham Pole et al (J Clin Oncol 9:152–158, 1991), Cook Children's Hospital, Fort Worth, TX was omitted from the list of institutions participating in this study.

The cardiac status of 36 children with sickle cell anemia, aged two to 17 years, was evaluated, by means of physical examination, phonocardiogram, chest roentgenogram, electrocardiogram, and Frank vectorcardiogram. Their hemoglobins were from 3.6 to 10.8 gm per cent. Pertinent physical and phonocardiographic findings were: (a) suprasternal notch thrill in 15 children, (b) abnormally loud third sound in 19, (c) prominent systolic ejection murmurs in all, with one having an apical holosystolic murmur, and (4) apical mid-diastolic rumble in 11. Chest roentgenograms revealed cardiac enlargement in 32 children, of which, ten showed marked cardiomegaly. The aortic arch was unduly prominent in 17 children. Of the 15 with suprasternal notch thrills, 11 had a prominent aortic arch. The electrocardiograms were normal in four children, showed LVH in 22, and CVH in two. Of the 30 vectorcardiograms, five were normal, 14 had LVH, three had RVH, and eight had CVH. The explanation for the inability of the electrocardiogram to detect right ventricular hypertrophy was usually the masking of a large terminal rightward force by a large posterior vector. There were certain significant differences in the magnitude of vector projections and of the timed, maximum and one-half area QRS vectors, as well as the T vectors between the children with sickle cell anemia and the normal. The hemoglobins of the children with cardiovascular abnormalities were significantly lower than those without these abnormalities.

The extent of leukemic marrow (BM) involvement in children with ALL is often unrelated to the degree of anemia. This serial study was carried out to correlate marrow CFU-E with stages of disease. BMs from 35 normal children served as controls. In 29 ALL patients 64 cultures were done; 14 newly diagnosed and untreated; 32 in remission; 18 in relapse. BM cells were cultured with and without erythropoletin (EPO) and included EPO dose response curve. CFU-E at diagnosis was significantly lower than controls, and despite complete remission, values did not reach the normal range. The mean value of cultures obtained during remission (166 ± 47 S.E./106 nucleated cells) was markedly higher than the newly diagnosed (17 ± 8 S.E.) or relapse patients (25 ± 13 S.E., p

Leukocytosis with predominance of polymorphonuclear leukocytes occurs in a variety of primary or metastatic hepatic tumors without apparent explanation. A 17-year-old male with lymphoepithelioma developed marked leukocytosis following the onset of liver metastases. In order to gain insight into the origin of the leukocytosis, granulopoietic colony stimulating activity (CSA) of patient's plasma and leukocytes were examined and compared to control. Leukocyte conditioned media (LCM) was prepared by the double layer culture method. The assay consisted of non-adherent marrow cells from normal individuals cultured in methylcellulose, fetal calf serum and α-media. With the various CSA sources in this system, the number of granulocytic colony forming units (CFU-C) is proportional to the amount of CSA present and therefore allows for quantitative comparisons. The number of CFU-C produced with the patient's plasma was significantly higher (P

668 RECURRENCE OF PNEUMOCYSTIS CARINII PNEUMONIA IN PATIENTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA

New treatments are urgently needed for stage IV NB, which becomes resistant to chemotherapy (CT) in 75% of cases. We have treated 6 children (ch) with refractory NB with HD L-PAM, either 120 mg/m2 (4 ch) or 180 mg/m2 (2 ch), in 3 divided doses, followed by reinfusion of bone marrow (BM) previously frozen in liquid N2 during BM remission. The ch were isolated during the neutropenic phase and supported with red cells and platelets, and hyperalimentation via Broviac catheters. Toxicity: all 6 recovered hemopoietic function, in median periods of 28 days (neutrophils 500), 34 days (retics 1%), and 35 days (platelets 50,000). Gastrointestinal side effects were severe but short-lived. 1 ch developed hepatic venocclusive disease, which regressed completely with supportive measures. 3 ch developed sepsis while neutropenic. 1 ch died after 3 mo complete response (CR) from complications of prior abdominal surgery and had no tumor at autopsy. Responses: 120 mg/m2 (4 ch)--1 CR (6 mo), 1 PR (1 mo), 2 NR. 180 mg/m2 (2 ch)--2 CR (3 mo and 4+ mo). Conclusions: 1. HD L-PAM is clearly active against NB. 2. Autologous BM reinfusions protect against severe myelosuppression. 3. BM autografting may uncover other dose-limiting toxicities of L-PAM. 4. L-PAM should be combined with other agents in further phase II and III studies.