Paraffin section immunophenotyping of acute leukemias in bone marrow specimens

The immunohistochemical evaluation of acute leukemia specimens has been limited in the past due of the inability to detect many lineage-related antigens in paraffin sections. With the improvement in immunohistochemical methods as well as the introduction of new antibodies, these limitations are now reduced. To evaluate the diagnostic utility of paraffin section immunohistochemistry in the lineage determination of acute leukemias, 77 previously immunophenotyped acute leukemias were studied with a panel of antibodies that included antibodies directed against CD3, CD20, CD34, CD43, CD68, CD79a, HLA-DR, myeloperoxidase (MPX), and terminal deoxynucleotidyl transferase (TdT). The cases included 48 acute myeloid leukemias, 18 precursor B-cell acute lymphoblastic leukemias, 6 T-cell acute lymphoblastic leukemias, and 5 mixed precursor B/myeloid leukemias. This immunohistochemical panel correctly identified the lineage of 96% of both acute myeloid leukemias and acute lymphoblastic leukemias and identified evidence of mixed lineage in 60% of mixed lineage leukemias. Antibodies directed against CD3, CD79a, MPX, and TdT were found to be the most useful, although the latter three alone were not entirely lineage specific. These findings suggest a role for paraffin section immunohistochemistry in the lineage determination of some cases of acute leukemia.     

Epidemiology and therapy of malignant hemopathies in Senegal

Rupture of the pericardium due to blunt thoracic trauma is a rare pathology with a range of mortality between 30 and 64% according to different authors. We review 40 cases which have been reported in the literature in the last decade and report a case of our own. We have found that 82% of the patients with traumatic rupture of the pericardium were men with a mean age of 45 years. In 80% of the cases the cause was a motor vehicle accident, 17% were due to falls and only 1 case was associated with a crush. The commonest location of the tear was the left pleuropericardium (62%) followed by the diaphragmatic portion of the pericardium (22%). In 80% of the cases the diagnosis was achieved in the course of a surgery performed for associated lesions. None of the cases was diagnosed in a post-mortem study. The traumatic rupture of the pericardium is a disease which often remains undiagnosed, especially when one does not have a high index of suspicion. Nevertheless, this is a disease which can threaten the life of the patient and we should keep it in mind to diagnose and treat it as soon as possible. It is known that an early and aggressive management of these patients implies a much better prognosis with a significant reduction of the mortality. In this article we want to give useful clues to allow a preoperative diagnosis and an early and adequate management.     

Economic analyses of bone marrow and blood stem cell transplantation for leukemias and lymphoma: what do we know?

The use of blood and/or bone marrow stem cell transplantation (SCT) grew extensively in the last decade as technological advances led to improved outcomes and wider availability. The first study of SCT costs, however, was not published until 1989. This paper summarizes current knowledge about costs and cost-effectiveness of allogeneic and autologous SCT for leukemias and lymphoma. Methodological issues in cost studies such as types of costs, methods of data collection, and time horizons are discussed, and studies are evaluated with regard to these issues. Considerations specific to economic analyses of SCT are considered, including the potential impact of technological changes, learning curve effects, and inter-institutional differences.     

Allogenic bone marrow transplantation in the treatment of malignant hematologic disease

We have treated 28 patients (pts) with malignant hematological diseases with allogeneic bone marrow transplantation (BMT). 18 pts had acute lymphoblastic (ALL) and non lymphoblastic leukemia (ANLL), 5 chronic myeloid leukemia (CML), 2 severe aplastic anemia (SAA), 1 myelodisplasia, 1 Fanconi's anemia and 1 advanced Non Hodgkin's lymphoma. All but three received the graft from HLA identical sibling donors. We used conditioning with total body irradiation and chemotherapy (cyclophosphamide, cytarabine and etoposide) in 17 pts and chemotherapy alone in 11. 24 pts had full hematological recovery 18 to 25 days post BMT. 15 pts died after BMT as a consequence of toxicity or early infection (4), graft failure (2), graft versus host disease (4) or relapse (5). Actuarial event free survival for the group with favorable prognosis (SAA, ALL and ANLL in first or second remission and CML in chronic phase) is 57% at 36 months. Allogeneic BMT is an effective and feasible therapeutic procedure for selected patients with hematological malignancies.     

Combining morphology and flow cytometric immunophenotyping to evaluate bone marrow specimens for B-cell malignant neoplasms

We studied the evolutionary history of two homologous proteins of the human complement system, factor H (FH) and the alpha chain of the C4b binding protein (C4bpalpha), and included in this study the related proteins from the barred sand bass (P. nebulifer) and the nematode C. elegans. Phylogenetic trees inferred from individual short consensus repeats (SCRs) and divergence among repeats from different genes suggest that human FH has a much closer evolutionary relationship to putative complement components from P. nebulifer and C. elegans than does the C4bpalpha. This indicates that a member of the alternative pathway of the complement system (FH) has an ancient origin, while a homologous member of the classical pathway (C4bpalpha) appeared later in evolutionary history as a result of gene duplication. The ancient evolutionary position of FH is in agreement with the suggestion that the alternative pathway of the complement system is older than the classical pathway. Phylogenetic analysis also shows that the sand bass cofactor protein SBP1 and cofactor related protein SBCRP-1 have diverged very recently.     

Connexin43 gap junctions in normal, regenerating, and cultured mouse bone marrow and in human leukemias: their possible involvement in blood formation

Communicating channels called gap junctions are thought to play a ubiquitous part in cell growth and development. Based on earlier work, we have recently found functional evidence of their presence in human and mouse bone marrow. In this study we studied the cell-type association of the gap junction channel-forming protein, connexin, in mouse and human bone marrow under different physiological and pathological conditions and tested the pathway of communication in bone marrow cultures. For high-resolution antigen demonstration we took advantage of semi-thin resin sections, antigen retrieval methods, immunofluorescence, and confocal laser scanning microscopy. Connexin43 (Cx43) and its mRNA were consistently expressed in human and rodent marrow. Cx37 was found only in the arteriolar endothelium, but neither Cx32 nor -26 were expressed. In tissue sections, the immunostained junctions appeared as dots, which were digitally measured and counted. Their average size was 0.40 mm in human and 0.49 mm in mice marrow. There were at least twice as many gap junctions in the femoral midshaft of 6-week-old mice (1.75 x 10(5)/mm3) as in those older than 12 weeks (0.89 x 10(5)/mm3). Most Cx43 was associated with collagen III+ endosteal and adventitial stromal cells and with megakaryocytes. Elsewhere, they were few and randomly distributed between all kinds of hematopoietic cells. In the femoral epiphysis of juvenile mice, stromal cell processes full of Cx43 enmeshed three to six layers of hematopoietic cells near the endosteum. The same pattern was seen in the midshaft of regenerating mouse marrow 3 to 5 days after cytotoxic treatment with 5-fluorouracil. Functional tests in cultures showed the transfer of small fluorescent dyes, Lucifer Yellow and 2',7'-bis-(2-carboxyethyl)-5, 6-carboxyfluorescein, between stromal cells and in rare cases between stromal and hematopoietic cells too. The stromal cells were densely packed with Cx43 and we found aggregates of connexon particles in their membrane replicas. In normocellular human bone marrow, gap junctions were as rare as in adult mouse and similarly distributed, except that they were also on adipocytic membranes. In a few leukemic samples, characterized by an increased stromal/hematopoietic cell ratio, there were two- to fourfold more Cx43 (2.8 x 10(5) to 3.9 x 10(5)/mm3) than in the normal (1.0 x 10(5) to 1.2 x 10(5)/mm3). The cases included a hypoplastic acute lymphoblastic leukemia, an acute myeloid leukemia (French-American-British classification M4-5), a case of myelodysplastic syndrome with elevated number of megakaryocytes, and a CD34+ acute hemoblastosis, probably acute myeloid leukemia (French-American-British classification M7). Taken together, our results indicate that direct cell-cell communication may be involved in hematopoiesis, ie, in developmentally active epiphyseal bone marrow and when there is a demand for progenitors in regeneration. However, gap junctions may not play as important a role in resting adult hematopoiesis and in leukemias.     

Endothelium and bone marrow transplantation

Thrombotic complications may occur early after marrow transplantation and many data suggest that endothelial injury plays a pivotal role in their pathogenesis. Since plasma thrombomodulin and P-selectin are thought to be of value as markers of vascular endothelial cell membrane injury, we investigated their plasma concentration in bone marrow transplant patients aiming better to clarify the degree of endothelial involvement. Plasma thrombomodulin and P-selectin were monitored in 25 patients without thrombotic complications before transplant, on day 0 and weekly for 1 month thereafter, while in three patients who developed VOD monitoring continued until day +52. These proteins were in the normal range in all the uncomplicated patients and in two with reversible VOD, while they were always very high in the only patient who developed very severe and lethal VOD. In conclusion, we suggest that endothelial activation/damage occurs rarely in the course of BMT for hematological malignancies; we were able to document endothelial injury in only one patient with very severe thrombotic complication.     

Visceral leishmaniasis: II. Histiocyte ultrastructure in bone marrow associated with low level of parasitaemia and mimicking malignant histiocytosis

The ultrastructural features of histiocytes in the bone marrow (BM) were studied in a febrile, splenomegalic and pancytopenic Sudanese patient who was diagnosed by one of us as visceral leishmaniasis (VL) associated with low level of parasitaemia and mimicking malignant histiocytosis (MH). Serial thick (STS) and ultrathin (SUT) sections showed that the BM was hypercellular and markedly infiltrated by large histiocytes with prominent phagocytosis. A thorough examination of various ST and UT section revealed only a single, typical Leishman-Donovan body. At transmission electron microscopy (TEM) level, two principal types of histiocytic cells were identified: Type I, subdivided into two subtypes, were actively phagocytic histiocytes (PH) with large digestive vacuoles and primary lysosomes; type II were nonphagocytic histiocytes (nPH) with primary lysosomes only. The rate of PH to nPH ws 7:2 in plastic STS. The interaction between the PH and ingested cells is described. Both types of cell were morphologically similar to previously described malignant histiocytic cells. However, this study showed a better characterization of PH during VL.     

Normal bone marrow: signal characteristics and fatty conversion

Understanding the dynamic MR appearance of normal bone marrow during childhood is essential. This article reviews normal bone marrow structure and development, especially the process of fatty conversion, laying the cornerstone for accurate interpretation of marrow MR imaging.     

Acute neurologic dysfunction associated with high-dose chemotherapy and autologous bone marrow rescue for primary malignant brain tumors

Acute neurologic complications occurred 103 times in 50 (54%) of 92 patients (primarily children) treated with high-dose chemotherapy and autologous bone marrow rescue for primary central nervous tumors. Different types of neurologic compromise occurred during the chemotherapy infusion as compared to the first 100 days after the chemotherapy and the greater-than-100-day time period. The causes of the neurologic compromise were also time sensitive. BACKGROUND: Results of treatment for children with primary brain tumors using high-dose chemotherapy with autologous marrow rescue (ABMR) have been encouraging. However, the neurotoxicity associated with this technique remains a major concern. We reviewed the records of 92 patients who underwent ABMR for malignant brain tumors between 1986 and 1992 for the occurrence and timing of acute neurologic dysfunction (AND). METHODS: Individual investigators at the participating institutions retrospectively completed standardized forms on each patient. The manner in which the distribution of AND versus time of treatment emerged led to the establishment of distinct time periods for data analysis and discussion. The pre-ABMR period included those events that occurred during the chemotherapy infusion, the early posttreatment period included the first 100 days following bone marrow rescue, and the late posttreatment period was greater than 100 days following bone marrow rescue. RESULTS: Fifty patients (54%) had 103 episodes of AND. AND included encephalopathies with or without hallucinations or coma (32), seizures (23), headaches (9), ataxia-tremor-dysarthria syndrome (7), anorexia and nausea syndrome (7) and others (25). During the chemotherapy infusion, encephalopathies and seizures were most common. Hallucinations occurred primarily related to drug infusion, while encephalopathies without hallucinations were usually due to demonstrable dysmetabolic states. In the 100 days following ABMR, dysmetabolic states and iatrogenic factors caused 45% and progressive disease caused 33% of AND. Greater than 100 days from ABMR, progressive disease caused 55% of AND; 7 patients were noted to develop chronic anorexia and nausea of unclear etiology. The occurrence of neurologic compromise was not related to the chemotherapy regimens, tumor histology, tumor location, patient age, prior treatment, or the amount of tumor at time of treatment. Dexamethasone use was the only clinical factor associated with AND (p < 0.004). CONCLUSIONS: The cause of AND was definable for 95% of instances that occurred within 100 days of ABMR. Early AND was often iatrogenic and reversible. The greater the time from ABMR the more likely AND was due to progressive disease. Clinical factors could not predict the occurrence of AND as only the concurrent use of dexamethasone at the time of treatment proved significant. Although frequent, AND should not be considered a limiting toxicity of this approach or preclude the use of this technique.     

Allogeneic bone marrow transplantation

Allogeneic bone marrow transplantation (BMT) after high-dose, marrow-ablative chemoradiotherapy has been established as the treatment of choice for various hematologic, neoplastic, and congenital disorders. The most common type of marrow graft is an allogeneic one from a sibling donor who has compatible human leukocyte antigen (HLA). Only 30% of patients requiring allogeneic BMT have an HLA-compatible sibling donor. Over the past few years, marrows from unrelated HLA-compatible donors have been used with increasing frequency and promising outcome in certain hematologic malignancies. Despite the morbidity and mortality associated with this treatment modality, allogeneic BMT may provide a 20% to 90% chance of long-term, disease-free survival to patients with a wide variety of neoplastic and abnormal marrow disorders.     

Factors affecting bone graft incorporation

Successful graft incorporation requires that an appropriate match be made among the biologic activity of a bone graft, the condition of the perigraft environment, and the mechanical environment. The authors have studied, in a wide variety of animal models, the factors that affect the main components of bone graft incorporation: revascularization, new bone formation, and host-graft union. The principal determinant of the rate, pattern, and amount of revascularization is the presence or absence of a vascular pedicle. The nonvascularized bone graft is entirely dependent on the surrounding tissue for its revascularization, which results in a noticeable delay in vessel ingrowth. The principal determinant of the rate and amount of new bone formation on, in, or about a bone graft is the presence or absence of living, histocompatible, committed bone-forming cells. When living cells are not part of the graft at the time of implantation, the cells that form new bone are derived from host tissues, and new bone formation is delayed. The principal determinants of host-graft union are stability of the construct and contact between host bone and the graft. Factors that slow or inhibit all of these processes are reduction of the biologic activity of the graft by freezing or some other treatment, histocompatibility antigen disparities between donor and recipient, mechanical instability between the graft and the perigraft environment, and local and systemic interference with the biologic activity of the graft and surrounding tissue, for example, by irradiation or the administration of cisplatin. The task of the clinician who does a bone grafting procedure is to choose the right graft or combination of grafts for the biologic and mechanical environment into which the graft will be placed.     

Granulocyte-macrophage colony stimulating factor in autologous bone marrow transplantation: augmentation of graft versus tumor effect via antibody dependent cellular cytotoxicity

Several immunomodulatory approaches have been explored with the aim of inducing a graft versus tumor effect (GVT) in autologous bone marrow transplantation (ABMT). Granulocyte-macrophage colony stimulation factor (GM-CSF) has been reported to induce antibody dependent cellular cytotoxicity (ADCC) via stimulation of peripheral blood neutrophils, lymphocytes, and monocytes. We investigated the role of GM-CSF in inducing ADCC via bone marrow (BM) macrophages against murine and human tumor cells both in vitro and vivo. Our data shows that stimulation of murine BM macrophages with GM-CSF induced a potent ADCC against a murine melanoma in vitro. Treatment of tumor bearing mice with a combination of GM-CSF and antibody against melanoma resulted in a significant reduction in the dissemination of melanoma both in a nontransplant as well as in a transplantation setting. Adoptive transfer of BM macrophages obtained from animals undergoing treatment with GM-CSF plus antibody significantly reduced the spread of tumor in secondary recipients; this effect was seen only in mice undergoing bone marrow transplantation. GM-CSF treatment of human BM macrophages induced a significant ADCC against a human melanoma and a lymphoma in vitro, as well as against a human lymphoma implanted in nude mice. Treatment with GM-CSF alone or with antibody alone was ineffective in controlling the dissemination of tumors both in transplantation as well as in nontransplant situations. These observations indicate that treatment with GM-CSF plus tumor specific monoclonal antibodies after ABMT may induce a GVT effect and bring about the eradication of residual disease.