- Email: [email protected]
DIFFERENTIATION OF AUER-ROD POSITIVE LEUKÆMIC CELLS IN DIFFUSION CHAMBER CULTURE
267
"This letter has been shown
to
Dr
RESULT OF PLATELET THERAPY
Gale, whose reply fol-
lows.-ED. L.
SIR,-I should like
to several important points the M.R.C. Leukaemia Unit. 2 of colleagues the long-term survivors had A.L.L. 1 was transplanted after a second relapse. The second failed to achieve an initial remission. Thus, transplantation of less-resistant A.L.L. does not seem a likely explanation of our results. Since our approach was to perform transplants only in patients unresponsive to intensive chemotherapy, those transplanted after a first relapse may have had more resistant dosage than those transplanted after a second or subsequent relapse. The 3 twins fared similarly to the 30 allograft recipients; 1 is a long-term survivor and 2 died, 1 of recurrent leukaemia and 1 of a late interstitial
raised by
our
to
respond
at
pneumonitis (day +224). The question of whether the transplant cohort received more intensive therapy than the non-transplant cohort is not easily answered. Non-transplant patients received maximally tolerated conventional and experimental chemotherapy and the vast majority died of marrow aplasia with and without residual leukaemia. 3 patients who received SCARI without total-body irradiation also failed to achieve a remission and died of marrow aplasia. The 5 long-term survivors reported by Dr Catovsky and his colleagues are of interest. Unfortunately, our experience has been less favourable. As Catovsky et al. point out, the diseasefree survival in the long-term was less than that of the transplant cohort. The object of our study was to determine the feasibility of achieving long-term disease-free survival in "resistant" acute leukaemia using intensive chemoradiotherapy and bone-marrow transplantation. I should like to re-emphasise the experimental nature of this approach. It is noteworthy that resistant leukaemia was responsible for treatment failure in only 24% of patients while immunological problems (graft-versus-host disease and interstitial pneumonitis) accounted for three-quarters of late deaths. Inroads into these immunological problems could significantly improve long-term survival. U.C.L.A. Bone Marrow Transplant Team, Department of Microbiology and Immunology, Center for the Health Sciences, Los Angeles, California 90024, U.S.A.
ROBERT PETER GALE
PLATELET PROPHYLAXIS IN ACUTE NON-LYMPHOBLASTIC LEUKÆMIA many treatment centres, the thrombocytopenia patients with acute leukaemia by induction chemotherapy is routinely managed by the transfusion of platelets when the platelet-count falls below a predetermined level. Since platelets are expensive and often difficult to obtain, we have compared the effect of this routine platelet prophylaxis with the effect of giving platelets for specific indications onlynamely, clinically significant bleeding and a very rapid decline in the platelet-count. Of 31 successive patients, 17 randomly selected patients were given platelet transfusions from random donors whenever the platelet-count was <20 000/1 and they had clinically significant bleeding (prophylactic group); 12 patients (specific indications group) were given platelets only when clinically significant bleeding or a platelet-count <20 000/1 was preceded by a decline of 50% in the plateletcount during the preceding 24 h. Induction chemotherapy was
SiR,-In
induced in
either D.A.P.T.o.l or C.O.D.A.; D.A.P.T.O. consists of dau’norubicin, 1.5 mg/kg/day for 3 days; cytarabine, 2 mg/kg every 12 h for 14 doses; 6-thioguanine, 2 mg/kg every 12 h for 14 doses; prednisone, 1 mg/kg daily for 7 days; and vincristine, 1 mg/m2 1.Glocksberg, H., Buckner,
C. D., Fefer, A., De Marsh, Q., Coleman, D., Dobrow, R. B., Huff, J., Kjobech, C., Hill, A. S., Dittman, W., Neiman, P. E., Cheever, M. A., Einstein, A. B. Jr., Thomas, E. D. Cancer Chemother. Rep. 1975, 59, 1131.
*1
patient excluded because granulocyte transfusions were given.
body
surface
on
day
1 and
day
7. C.O.D.A. consists of cytara-
bine, 1.5mg/kg daily for 6 doses; vincristine, 1.5mg on days 1 and 4; daunorubicin, 0.75 mg/kg/day for 6 days; and 5-aza150 mg/m2 daily for 6 days. Since these two programmes-to which patients were assigned at random-are approximately equally myelosuppressive and produce similar remission-rates, the data have been pooled. Only previously untreated patients with non-lymphoblastic acute leukaemia were investigated. Patients with promyelocytic leukaemia were excluded because of their well-known severe
cytidine,
2 patients assigned to the prophylactic group died of cerebral haemorrhage on the first day of treatment and were excluded. All other patients completed at least one course of therapy and those who did not achieve a complete remission were generally given a second course with the same combination of drugs. The average age of the patients entering the study was 43 (range 16-71). The patients in the prophylactic group received 22 courses of chemotherapy and those in the specific indications group received 17 courses. Although the specific indications group required only approximately half as many units of platelets as the prophylactic group, the results of therapy were much the same (see table). Indeed, the only 2 deaths which could clearly be ascribed to bleeding occurred in the group of patients receiving platelet prophylaxis. If the 2 patients dying on the first day of therapy had not been excluded, there would have been 4 deaths due to bleeding in this group. Although the 2 patients in the specific indications group who died after induction therapy had some signs of haemorrhage at necropsy, both deaths seemed clearly attributable to sepsis, not bleeding. Thus, giving platelets for specific indications may protect patients with acute leukaemia on acute induction therapy as effectively as does giving platelets at predetermined platelet levels and has the advantage of greatly decreasing the use of platelets.
h2emorrhagic tendency.
JOEL SOLOMON City
of Hope Medical
Center,
Duarte, California 91010, U.S.A.
THOMAS BOFENKAMP JOHN L. FAHEY RAM K. CHILLAR ERNEST BEUTLER
DIFFERENTIATION OF AUER-ROD POSITIVE LEUKÆMIC CELLS IN DIFFUSION CHAMBER CULTURE
StR, —If, in myeloid leukaemia, functional rather than struchave occurred in the genes controlling cell differmicroenvironmental factors might determine entiation, whether gene expression is leukxmic or occurs in a manner appropriate for normal granulopoietic differentiation. Evidence in favour of such a view has come from the work of
tural
changes
268
Mintz, Sachs, and their colleagues.’-4 Studies of untreated human leukaemias in vitro have shown some degree of differentiation both in agar colonies5-7 and in liquid culture.8.9 Hoelzer et al. 10 reported non-proliferating granulocytes from mouse leukaemia blood-cells cultured in diffusion chambers far exceeding that observed in normal blood cultures. These workers could not, however, exclude differentiation of normal stem cells. Auer rods are markers of acute myeloid leukaemia,l1 and, on rare occasions, may be observed even in leukxmic pseudo-
Fig. 2 —Ceil numbers in relation to time in culture. Leuksemic bone-marrow cells obtained from patient with acute untreated promyelocytic leukaemia were cultured in diffusion chambers, which were implanted into the of irradiated NMRI mice (750 r 6OCo one day before chamber implantation) and reimplanted on day 8. Results as mean cell numbers for six diffusion chambers.
peritoneum
Pelger cells.’2 For our study of leukaemic cell differentiation in diffusion chambers we selected bone-marrow from a patient with untreated acute promyelocytic leukaemia characterised by an abundance of Auer rods (fig. 1). Leukaemic cells were separated by the ’Ficoll’ gradient methodl3 and cultured in diffusion chambers.14,15 Fig. 2 shows the result. From day 1 to day 6, blasts and promyelocytes increased in numbers without apparent differentiation. However, after day 7 in culture, the peak and concomitant decrease of cell numbers in the blast-promyelocyte compartment was followed by a sequential rise and peak in the myelocyte compartment, which again was followed by a steady increase of non-proliferating granulocytes. Thus, a sequential increase in cell numbers through the different granulopoietic compartments was observed, beginning in the most immature and terminating in the non-proliferative cell pool. This suggests regular proliferation and differentiation of these leukeemic bone-marrow cells in the environment of heterologous diffusion chamber culture in vivo, which is known to support normal granulopoiesis.14 The crucial question -whether the mature cells observed were indeed derived from leukxmic cells and not from normal stem cells-is answered by the demonstration of Auer rods, ‘
Mintz, B., Illmensee, K., Gearhart, J. D. in Teratomas and Differentiation (edited by M. I. Sherman and D. Solter); p. 59. New York, 1975. 2. Mintz, B., Illmensee, K. Proc. natn. Acad. Sci. U.S.A. 1975, 72, 3585. 3. Sachs, L. Harvey Lect. 1974, 68, 1. 4. Sachs, L. Israel J. med. Sci. 1977, 13, 654. 5. Paran, M., Sachs, L., Barak, Y., Resnitzky, P. Proc. natn. Acad. Sci. U.S.A. 1970, 67, 1542. 6. Duttera, M. J., Whang-Peng, J., Bull, J. M. C., Carbone, P. P. Lancet, 1972, i, 715. 7. Moore, M. A. S., Metcalf, D. Int. J. Cancer, 1973, 11, 143. 8. Golde, D. W., Cline, M. J. Blood, 1973, 41, 45. 9. Gallagher, R. E., Salahuddin, S. Z., Hall, W. T., McCredie, K. B., Gallo, R. C. Proc. natn. Acad. Sci. U.S.A. 1975, 72, 4137. 10. Hoelzer, D., Kurrle, E., Schmücker, H., Harriss, E. B. Blood, 1977, 49, 729. 11. Freeman, J. A. ibid. 1966, 27, 499. 12. Leder, L. D. Acta hœmat. 1969, 42, 58. 13. Boyum, A. Scand. J. clin. Lab. Invest. 1968, suppl. no. 97. 14. Boyum, A., Boecker, W. R., Carsten, A. L., Cronkite, E. P. Blood, 1972, 40, 1.
Fig. I-Photomicrographs showing differentiation
of leutcaentie
bone-marrow cells. Auer rods in the original blasts and promyelocytes (A,B) and in matured cells after 13 (C-E) and 28 days (F,G) in diffusion chamber culture. (May-Grunwald-Giemsa.)
163. 15. Boecker, W. R.,
Hossfeld, D. K., Gallmeier, W. M., Schmidt, C. G. Nature, 1975, 258, 235.
269 were found in several non-proliferative granulocytes after 13 and 28 days in diffusion chamber culture (fig. 1). Thus, in this case of acute promyelocytic leukaemia, continuation of cell maturation was made possible by a change in the microenvironment, which released the leukaEmic cells from a blockage of differentiation within 7 days of culture.
which
This work was
supported by grants from
Landesamt fur
Forschung,
Nordrhein-Westfalen.
Innere Universitätsklinik (Tumorforschung), Westdeutsches Tumorzentrum, D-4300 Essen 1, West Germany
W. R. BOECKER S. ÖHL D. K. HOSSFELD C. G. SCHMIDT.
HODGKIN’S DISEASE DURING ACUTE LEUKÆMIA IN REMISSION
SIR,-We were interested in the paper by Dr Woodruff and his
colleagues’ because we had just diagnosed Hodgkin’s disduring remission of acute lymphoblastic leukaemia (A.L.L.). We could find only one previously published case of this.2 In two reviews3,4 108 children with second malignant neoplasms were found, but none was A.L.L. the first and Hodgease
kin’s disease the second. A boy born in August, 1971, was admitted to hospital in December, 1975, with a 2 week history of fever, abdominal pain, and malaise. Laboratory tests showed leukopenia, anaemia, and mild thrombocytopenia. A.L.L. was diagnosed. The boy was treated with vincristine and prednisolone. Complete remission was achieved after 4 weeks. Prophylactic central-nervous-system therapy consisted of cranial irradiation (2400 rad) and five intrathecal methotrexate injections. Thereafter the patient received a maintenance chemotherapy with daily 6-mercaptopurine and weekly methotrexate and cyclo-
phosphamide. In
September, 1977, a symptomatic upper left cervical lym-
phadenopathy
was
noticed. Penicillin had
no
effect. Fine-
aspiration biopsy showed no signs of leukaemia. Serological tests for infectious mononucleosis, toxoplasmosis, cytomegalovirus disease, and ornithosis were all negative. Thelymphnode grew to approximately 2-5x3-5cm and it was removed. The nodal structure was severely deranged with marked infiltration of eosinophils, plasma cells, and numerous Hodgkin cells including typical Reed-Sternberg cells. Thus all the criteria for Hodgkin’s disease, mixed cellular type, were met. A bone-marrow aspiration showed continuous remission of the leukaemia (22 months after diagnosis). Further investigations included surgical biopsy of bone-marrow and Waldeyer’s ring, percutaneous fine-needle aspiration biopsies of liver and spleen, and a staging laparotomy with splenectomy. In all these specimens there was no evidence of Hodgkin’s disease or A.L.L. Abdominal lymph-nodes were lymphocyte depleted for a patient of this age. The patient thus had stage IA Hodgkin’s disease during complete remission of leukaemia. Both diseases have been treated conventionally and independently-the upper mantle technique for Hodgkin’s disease and maintenance chemotherapy for A.L.L. Leukaemia complicating Hodgkin’s disease is well known and has usually been of the acute myelocytic type (A.M.L.). In all such cases studied cytogenetically, chromosome changes have been seen; these are much less common in "spontaneous" A.M.L.6 This may well be an expression for different mechanisms behind the two forms of A.M.L. The one complicating needle
1. Woodruff, R. K., and others Lancet, 1977, ii, 900. 2. Grant, M. D., Coleman, M. J. J. Am. med. Ass. 1975, 231, 623. 3. Li, F. P. Cancer, 1977, 40, 1899. 4. Meadows, A. T., D’Angio, G. J., Miké, V., Banfi, A., Harris, C., Jenkin, R. D. T., Schwartz, A. ibid. p. 1903. 5. Coleman, C. N., Williams, C. J., Flint, A., Glatstein, E. J., Rosenberg, S. A., Kaplan, H. S. New Engl. J. Med. 1977, 297, 1249. 6. Cavallin-Ståhl, E., Landberg, T., Ottow, Z., Mitelman, F. Scand. J. Hœmat.
1977, 19, 273.
Hodgkin’s disease develops in patients treated with both largetarget-volume, high-absorbed-dose radiotherapy and intensive chemotherapy, both modalities being potential carcinogens. However, in studies on second malignant neoplasms in children3.4 most second cancers were in the field of prior radiotherapy and were attributable to the oncogenic effect of radiation. Direct oncogenic effect of chemotherapy or its enhancing effect on radiation oncogenesis was not noted. All patients who have had Hodgkin’s disease during remission of
A.L.L.
have received cranial irradiation and combined
chemotherapy. The xtiological relation, if any, between the two diseases or the treatment remains purely speculative. It is, nevertheless, striking that the histology of Hodgkin’s disease occurring in patients with leukaemia does not reflect the usual incidence of different histological types in this disease. The three young adult patients showed lymphocyte depletion and the two children showed mixed cellularity type. In our case undiseased lymph-nodes were relatively depleted of lymphocytes. We believe that this histological appearance is caused by chemotherapy for leukxmia. Therefore, the histological appearance may not have the same prognostic significance as in "naturally" occurring Hodgkin’s disease. Until further knowledge about Hodgkin’s disease complicating leukaemia has been collected, it may be warranted to evaluate and treat the two diseases independently. STANISLAW GARWICZ STEFAN ARONSON BENGT ANDRÉASSON TORSTEN LANDBERG Departments of Pædiatrics, Oncology, and Pathology, EVA CAVALLIN-STÅHL University Hospital, HANS HENRIKSON S-221 85 Lund, Sweden
INTRAVENOUS VERSUS INHALED SALBUTAMOL
SIR,-Your editorial (Jan. 14,
p. 80) appeared on the same trial was published.’ Using a double-blind randomised allocation of treatment, we concluded that wet nebulised salbutamol given with spontaneous respiration was as effective in severe asthma as intravenous salbutamol and was free from the side-effects of the latter. The paper2 on which your editorial was based concluded that in severe asthma the intravenous route was the method of choice. Patients in this trial were all first given nebulised salbutamol by intermittent positive-pressure ventilation (I.P.P. v.) followed by intravenous salbutamol. Peak flow rates showed greater improvement after intravenous salbutamol. However, the results could equally well indicate that the second dose of salbutamol, by whatever route, was more effective than the first since no crossover or alternative order of dosage was attempted. Also, since no attempt was made to make the trial blind, the beneficial psychological effect of an intravenous in’ jection compared with the possible unpleasant effect of the LP.P.V. mask or mouthpiece could easily account for the
day
as our
results. There is evidence that I.P.P.V., especially in obstructive airways disease, increases the maldistribution of the inspired air. Nebulised drugs given by i.P.P.v. may thus be less effective than when given with spontaneous ventilation.3 This may partly explain the results obtained by Williams and Seaton with nebulised salbutamol. We suggest that nebulised salbutamol has a place in the management of acute severe asthma and is best given using a simple nebuliser with spontaneous breath-
ing. Northwick Park Hospital, Middlesex HA1 3UJ
1. 2. 3.
P. LAWFORD
J. S. MILLEDGE
Lawford, P., Jones, B. J. M., Milledg&ebreve;, J. S. Br. med. J. 1978, i, 84. Williams, S., Seaton, A. Thorax, 1977, 32, 555. Dolovich, M. B., and others. Am. Rev. resp. Dis. 1977, 115, 397.
"This letter has been shown
to
Dr
RESULT OF PLATELET THERAPY
Gale, whose reply fol-
lows.-ED. L.
SIR,-I should like
to several important points the M.R.C. Leukaemia Unit. 2 of colleagues the long-term survivors had A.L.L. 1 was transplanted after a second relapse. The second failed to achieve an initial remission. Thus, transplantation of less-resistant A.L.L. does not seem a likely explanation of our results. Since our approach was to perform transplants only in patients unresponsive to intensive chemotherapy, those transplanted after a first relapse may have had more resistant dosage than those transplanted after a second or subsequent relapse. The 3 twins fared similarly to the 30 allograft recipients; 1 is a long-term survivor and 2 died, 1 of recurrent leukaemia and 1 of a late interstitial
raised by
our
to
respond
at
pneumonitis (day +224). The question of whether the transplant cohort received more intensive therapy than the non-transplant cohort is not easily answered. Non-transplant patients received maximally tolerated conventional and experimental chemotherapy and the vast majority died of marrow aplasia with and without residual leukaemia. 3 patients who received SCARI without total-body irradiation also failed to achieve a remission and died of marrow aplasia. The 5 long-term survivors reported by Dr Catovsky and his colleagues are of interest. Unfortunately, our experience has been less favourable. As Catovsky et al. point out, the diseasefree survival in the long-term was less than that of the transplant cohort. The object of our study was to determine the feasibility of achieving long-term disease-free survival in "resistant" acute leukaemia using intensive chemoradiotherapy and bone-marrow transplantation. I should like to re-emphasise the experimental nature of this approach. It is noteworthy that resistant leukaemia was responsible for treatment failure in only 24% of patients while immunological problems (graft-versus-host disease and interstitial pneumonitis) accounted for three-quarters of late deaths. Inroads into these immunological problems could significantly improve long-term survival. U.C.L.A. Bone Marrow Transplant Team, Department of Microbiology and Immunology, Center for the Health Sciences, Los Angeles, California 90024, U.S.A.
ROBERT PETER GALE
PLATELET PROPHYLAXIS IN ACUTE NON-LYMPHOBLASTIC LEUKÆMIA many treatment centres, the thrombocytopenia patients with acute leukaemia by induction chemotherapy is routinely managed by the transfusion of platelets when the platelet-count falls below a predetermined level. Since platelets are expensive and often difficult to obtain, we have compared the effect of this routine platelet prophylaxis with the effect of giving platelets for specific indications onlynamely, clinically significant bleeding and a very rapid decline in the platelet-count. Of 31 successive patients, 17 randomly selected patients were given platelet transfusions from random donors whenever the platelet-count was <20 000/1 and they had clinically significant bleeding (prophylactic group); 12 patients (specific indications group) were given platelets only when clinically significant bleeding or a platelet-count <20 000/1 was preceded by a decline of 50% in the plateletcount during the preceding 24 h. Induction chemotherapy was
SiR,-In
induced in
either D.A.P.T.o.l or C.O.D.A.; D.A.P.T.O. consists of dau’norubicin, 1.5 mg/kg/day for 3 days; cytarabine, 2 mg/kg every 12 h for 14 doses; 6-thioguanine, 2 mg/kg every 12 h for 14 doses; prednisone, 1 mg/kg daily for 7 days; and vincristine, 1 mg/m2 1.Glocksberg, H., Buckner,
C. D., Fefer, A., De Marsh, Q., Coleman, D., Dobrow, R. B., Huff, J., Kjobech, C., Hill, A. S., Dittman, W., Neiman, P. E., Cheever, M. A., Einstein, A. B. Jr., Thomas, E. D. Cancer Chemother. Rep. 1975, 59, 1131.
*1
patient excluded because granulocyte transfusions were given.
body
surface
on
day
1 and
day
7. C.O.D.A. consists of cytara-
bine, 1.5mg/kg daily for 6 doses; vincristine, 1.5mg on days 1 and 4; daunorubicin, 0.75 mg/kg/day for 6 days; and 5-aza150 mg/m2 daily for 6 days. Since these two programmes-to which patients were assigned at random-are approximately equally myelosuppressive and produce similar remission-rates, the data have been pooled. Only previously untreated patients with non-lymphoblastic acute leukaemia were investigated. Patients with promyelocytic leukaemia were excluded because of their well-known severe
cytidine,
2 patients assigned to the prophylactic group died of cerebral haemorrhage on the first day of treatment and were excluded. All other patients completed at least one course of therapy and those who did not achieve a complete remission were generally given a second course with the same combination of drugs. The average age of the patients entering the study was 43 (range 16-71). The patients in the prophylactic group received 22 courses of chemotherapy and those in the specific indications group received 17 courses. Although the specific indications group required only approximately half as many units of platelets as the prophylactic group, the results of therapy were much the same (see table). Indeed, the only 2 deaths which could clearly be ascribed to bleeding occurred in the group of patients receiving platelet prophylaxis. If the 2 patients dying on the first day of therapy had not been excluded, there would have been 4 deaths due to bleeding in this group. Although the 2 patients in the specific indications group who died after induction therapy had some signs of haemorrhage at necropsy, both deaths seemed clearly attributable to sepsis, not bleeding. Thus, giving platelets for specific indications may protect patients with acute leukaemia on acute induction therapy as effectively as does giving platelets at predetermined platelet levels and has the advantage of greatly decreasing the use of platelets.
h2emorrhagic tendency.
JOEL SOLOMON City
of Hope Medical
Center,
Duarte, California 91010, U.S.A.
THOMAS BOFENKAMP JOHN L. FAHEY RAM K. CHILLAR ERNEST BEUTLER
DIFFERENTIATION OF AUER-ROD POSITIVE LEUKÆMIC CELLS IN DIFFUSION CHAMBER CULTURE
StR, —If, in myeloid leukaemia, functional rather than struchave occurred in the genes controlling cell differmicroenvironmental factors might determine entiation, whether gene expression is leukxmic or occurs in a manner appropriate for normal granulopoietic differentiation. Evidence in favour of such a view has come from the work of
tural
changes
268
Mintz, Sachs, and their colleagues.’-4 Studies of untreated human leukaemias in vitro have shown some degree of differentiation both in agar colonies5-7 and in liquid culture.8.9 Hoelzer et al. 10 reported non-proliferating granulocytes from mouse leukaemia blood-cells cultured in diffusion chambers far exceeding that observed in normal blood cultures. These workers could not, however, exclude differentiation of normal stem cells. Auer rods are markers of acute myeloid leukaemia,l1 and, on rare occasions, may be observed even in leukxmic pseudo-
Fig. 2 —Ceil numbers in relation to time in culture. Leuksemic bone-marrow cells obtained from patient with acute untreated promyelocytic leukaemia were cultured in diffusion chambers, which were implanted into the of irradiated NMRI mice (750 r 6OCo one day before chamber implantation) and reimplanted on day 8. Results as mean cell numbers for six diffusion chambers.
peritoneum
Pelger cells.’2 For our study of leukaemic cell differentiation in diffusion chambers we selected bone-marrow from a patient with untreated acute promyelocytic leukaemia characterised by an abundance of Auer rods (fig. 1). Leukaemic cells were separated by the ’Ficoll’ gradient methodl3 and cultured in diffusion chambers.14,15 Fig. 2 shows the result. From day 1 to day 6, blasts and promyelocytes increased in numbers without apparent differentiation. However, after day 7 in culture, the peak and concomitant decrease of cell numbers in the blast-promyelocyte compartment was followed by a sequential rise and peak in the myelocyte compartment, which again was followed by a steady increase of non-proliferating granulocytes. Thus, a sequential increase in cell numbers through the different granulopoietic compartments was observed, beginning in the most immature and terminating in the non-proliferative cell pool. This suggests regular proliferation and differentiation of these leukeemic bone-marrow cells in the environment of heterologous diffusion chamber culture in vivo, which is known to support normal granulopoiesis.14 The crucial question -whether the mature cells observed were indeed derived from leukxmic cells and not from normal stem cells-is answered by the demonstration of Auer rods, ‘
Mintz, B., Illmensee, K., Gearhart, J. D. in Teratomas and Differentiation (edited by M. I. Sherman and D. Solter); p. 59. New York, 1975. 2. Mintz, B., Illmensee, K. Proc. natn. Acad. Sci. U.S.A. 1975, 72, 3585. 3. Sachs, L. Harvey Lect. 1974, 68, 1. 4. Sachs, L. Israel J. med. Sci. 1977, 13, 654. 5. Paran, M., Sachs, L., Barak, Y., Resnitzky, P. Proc. natn. Acad. Sci. U.S.A. 1970, 67, 1542. 6. Duttera, M. J., Whang-Peng, J., Bull, J. M. C., Carbone, P. P. Lancet, 1972, i, 715. 7. Moore, M. A. S., Metcalf, D. Int. J. Cancer, 1973, 11, 143. 8. Golde, D. W., Cline, M. J. Blood, 1973, 41, 45. 9. Gallagher, R. E., Salahuddin, S. Z., Hall, W. T., McCredie, K. B., Gallo, R. C. Proc. natn. Acad. Sci. U.S.A. 1975, 72, 4137. 10. Hoelzer, D., Kurrle, E., Schmücker, H., Harriss, E. B. Blood, 1977, 49, 729. 11. Freeman, J. A. ibid. 1966, 27, 499. 12. Leder, L. D. Acta hœmat. 1969, 42, 58. 13. Boyum, A. Scand. J. clin. Lab. Invest. 1968, suppl. no. 97. 14. Boyum, A., Boecker, W. R., Carsten, A. L., Cronkite, E. P. Blood, 1972, 40, 1.
Fig. I-Photomicrographs showing differentiation
of leutcaentie
bone-marrow cells. Auer rods in the original blasts and promyelocytes (A,B) and in matured cells after 13 (C-E) and 28 days (F,G) in diffusion chamber culture. (May-Grunwald-Giemsa.)
163. 15. Boecker, W. R.,
Hossfeld, D. K., Gallmeier, W. M., Schmidt, C. G. Nature, 1975, 258, 235.
269 were found in several non-proliferative granulocytes after 13 and 28 days in diffusion chamber culture (fig. 1). Thus, in this case of acute promyelocytic leukaemia, continuation of cell maturation was made possible by a change in the microenvironment, which released the leukaEmic cells from a blockage of differentiation within 7 days of culture.
which
This work was
supported by grants from
Landesamt fur
Forschung,
Nordrhein-Westfalen.
Innere Universitätsklinik (Tumorforschung), Westdeutsches Tumorzentrum, D-4300 Essen 1, West Germany
W. R. BOECKER S. ÖHL D. K. HOSSFELD C. G. SCHMIDT.
HODGKIN’S DISEASE DURING ACUTE LEUKÆMIA IN REMISSION
SIR,-We were interested in the paper by Dr Woodruff and his
colleagues’ because we had just diagnosed Hodgkin’s disduring remission of acute lymphoblastic leukaemia (A.L.L.). We could find only one previously published case of this.2 In two reviews3,4 108 children with second malignant neoplasms were found, but none was A.L.L. the first and Hodgease
kin’s disease the second. A boy born in August, 1971, was admitted to hospital in December, 1975, with a 2 week history of fever, abdominal pain, and malaise. Laboratory tests showed leukopenia, anaemia, and mild thrombocytopenia. A.L.L. was diagnosed. The boy was treated with vincristine and prednisolone. Complete remission was achieved after 4 weeks. Prophylactic central-nervous-system therapy consisted of cranial irradiation (2400 rad) and five intrathecal methotrexate injections. Thereafter the patient received a maintenance chemotherapy with daily 6-mercaptopurine and weekly methotrexate and cyclo-
phosphamide. In
September, 1977, a symptomatic upper left cervical lym-
phadenopathy
was
noticed. Penicillin had
no
effect. Fine-
aspiration biopsy showed no signs of leukaemia. Serological tests for infectious mononucleosis, toxoplasmosis, cytomegalovirus disease, and ornithosis were all negative. Thelymphnode grew to approximately 2-5x3-5cm and it was removed. The nodal structure was severely deranged with marked infiltration of eosinophils, plasma cells, and numerous Hodgkin cells including typical Reed-Sternberg cells. Thus all the criteria for Hodgkin’s disease, mixed cellular type, were met. A bone-marrow aspiration showed continuous remission of the leukaemia (22 months after diagnosis). Further investigations included surgical biopsy of bone-marrow and Waldeyer’s ring, percutaneous fine-needle aspiration biopsies of liver and spleen, and a staging laparotomy with splenectomy. In all these specimens there was no evidence of Hodgkin’s disease or A.L.L. Abdominal lymph-nodes were lymphocyte depleted for a patient of this age. The patient thus had stage IA Hodgkin’s disease during complete remission of leukaemia. Both diseases have been treated conventionally and independently-the upper mantle technique for Hodgkin’s disease and maintenance chemotherapy for A.L.L. Leukaemia complicating Hodgkin’s disease is well known and has usually been of the acute myelocytic type (A.M.L.). In all such cases studied cytogenetically, chromosome changes have been seen; these are much less common in "spontaneous" A.M.L.6 This may well be an expression for different mechanisms behind the two forms of A.M.L. The one complicating needle
1. Woodruff, R. K., and others Lancet, 1977, ii, 900. 2. Grant, M. D., Coleman, M. J. J. Am. med. Ass. 1975, 231, 623. 3. Li, F. P. Cancer, 1977, 40, 1899. 4. Meadows, A. T., D’Angio, G. J., Miké, V., Banfi, A., Harris, C., Jenkin, R. D. T., Schwartz, A. ibid. p. 1903. 5. Coleman, C. N., Williams, C. J., Flint, A., Glatstein, E. J., Rosenberg, S. A., Kaplan, H. S. New Engl. J. Med. 1977, 297, 1249. 6. Cavallin-Ståhl, E., Landberg, T., Ottow, Z., Mitelman, F. Scand. J. Hœmat.
1977, 19, 273.
Hodgkin’s disease develops in patients treated with both largetarget-volume, high-absorbed-dose radiotherapy and intensive chemotherapy, both modalities being potential carcinogens. However, in studies on second malignant neoplasms in children3.4 most second cancers were in the field of prior radiotherapy and were attributable to the oncogenic effect of radiation. Direct oncogenic effect of chemotherapy or its enhancing effect on radiation oncogenesis was not noted. All patients who have had Hodgkin’s disease during remission of
A.L.L.
have received cranial irradiation and combined
chemotherapy. The xtiological relation, if any, between the two diseases or the treatment remains purely speculative. It is, nevertheless, striking that the histology of Hodgkin’s disease occurring in patients with leukaemia does not reflect the usual incidence of different histological types in this disease. The three young adult patients showed lymphocyte depletion and the two children showed mixed cellularity type. In our case undiseased lymph-nodes were relatively depleted of lymphocytes. We believe that this histological appearance is caused by chemotherapy for leukxmia. Therefore, the histological appearance may not have the same prognostic significance as in "naturally" occurring Hodgkin’s disease. Until further knowledge about Hodgkin’s disease complicating leukaemia has been collected, it may be warranted to evaluate and treat the two diseases independently. STANISLAW GARWICZ STEFAN ARONSON BENGT ANDRÉASSON TORSTEN LANDBERG Departments of Pædiatrics, Oncology, and Pathology, EVA CAVALLIN-STÅHL University Hospital, HANS HENRIKSON S-221 85 Lund, Sweden
INTRAVENOUS VERSUS INHALED SALBUTAMOL
SIR,-Your editorial (Jan. 14,
p. 80) appeared on the same trial was published.’ Using a double-blind randomised allocation of treatment, we concluded that wet nebulised salbutamol given with spontaneous respiration was as effective in severe asthma as intravenous salbutamol and was free from the side-effects of the latter. The paper2 on which your editorial was based concluded that in severe asthma the intravenous route was the method of choice. Patients in this trial were all first given nebulised salbutamol by intermittent positive-pressure ventilation (I.P.P. v.) followed by intravenous salbutamol. Peak flow rates showed greater improvement after intravenous salbutamol. However, the results could equally well indicate that the second dose of salbutamol, by whatever route, was more effective than the first since no crossover or alternative order of dosage was attempted. Also, since no attempt was made to make the trial blind, the beneficial psychological effect of an intravenous in’ jection compared with the possible unpleasant effect of the LP.P.V. mask or mouthpiece could easily account for the
day
as our
results. There is evidence that I.P.P.V., especially in obstructive airways disease, increases the maldistribution of the inspired air. Nebulised drugs given by i.P.P.v. may thus be less effective than when given with spontaneous ventilation.3 This may partly explain the results obtained by Williams and Seaton with nebulised salbutamol. We suggest that nebulised salbutamol has a place in the management of acute severe asthma and is best given using a simple nebuliser with spontaneous breath-
ing. Northwick Park Hospital, Middlesex HA1 3UJ
1. 2. 3.
P. LAWFORD
J. S. MILLEDGE
Lawford, P., Jones, B. J. M., Milledg&ebreve;, J. S. Br. med. J. 1978, i, 84. Williams, S., Seaton, A. Thorax, 1977, 32, 555. Dolovich, M. B., and others. Am. Rev. resp. Dis. 1977, 115, 397.