Martha F. Greenwood

Chlorhexidine prophylaxis for chemotherapy-and radiotherapy-induced stomatitis: A randomized double-blind trial

Patients receiving cytotoxic antineoplastic therapy often have treatment-associated stomatitis. A 0.12% chlorhexidine digluconate mouthrinse was evaluated (15 ml, three times a day) in a prospective, double-blind randomized trial as prophylaxis against cytotoxic therapy-induced damage to oral soft tissues. Seventy subjects, forty inpatients receiving high-dose chemotherapy and thirty outpatients receiving high-dose head and neck radiation therapy, were evaluated. Chlorhexidine mouthrinse significantly reduced the incidence of oral mucositis in the chemotherapy group on day 14 (p less than 0.02) and at 1 week follow-up on day 28 (p less than 0.002). Mucositis in the patients undergoing chemotherapy who received chlorhexidine also resolved more rapidly. Mucositis severity was significantly less compared to the control chemotherapy group on day 14 (p less than 0.03), day 21 (p less than 0.04), and on 1 week follow-up (p less than 0.02). Concomitant trends in the reduction in oral streptococci and yeast were noted in the chemotherapy group receiving chlorhexidine mouthrinse. Although no differences were observed in oral mucositis between the control and chlorhexidine groups of patients undergoing high-dose radiotherapy, similar reductions of oral microflora to those seen in the chemotherapy population were also noted for patients undergoing radiation therapy who received chlorhexidine. Although generally not significant, some increase in gram-negative bacilli was noted in the chlorhexidine-treated patients in both the chemotherapy and radiotherapy groups, but there was no correlation with increased systemic infection. Prophylactic chlorhexidine mouthrinse reduces oral mucositis and microbial burden in patients with cancer undergoing intensive chemotherapy.

Successful treatment of inflammatory myofibroblastic tumor with malignant transformation by surgical resection and chemotherapy.

Inflammatory myofibroblastic tumor (IMT) is a tumor composed of myofibroblasts and a mixed inflammatory infiltrate that rarely undergoes malignant transformation. The authors present the case of a 7-year-old boy with an abdominal mass diagnosed as IMT with malignant transformation. The tumor recurred twice after attempts at resection and was initially treated with vincristine and etoposide. After a third recurrence and incomplete resection, he was treated with cisplatin, Adriamycin, and methotrexate. He is disease-free after 2 years, representing successful combined surgery and chemotherapy in the treatment of malignant IMT. The use of chemotherapy for aggressive myofibroblastic tumors is reviewed.

Terminal deoxynucleotidyltransferase distribution in neoplastic and hematopoietic cells.

In the present study, terminal deoxynucleotidyltransferase was examined in the peripheral blood and (or) bone marrow of 115 children with a variety of neoplastic, hematologic, and other unrelated disorders. Terminal deoxynucleotidyltransferase activity was present at 4.08+/-0.74 U/108 cells in 23 morphologicall normal bone marrow samples from childhood controls. Terminal transferase was present at greater than 23 U/108 nucleated cells and at greater than31 U/108 blasts in the bone marrow of all children with acute lymphoblastic leukemia studied at initial diagnosis and at disease relapse. Terminal deoxynucleotidyltransferase was detectable at low levels, less than 7.5 U/108 cells, in all remission marrow smaples. Bone marrow terminal transferase activity was markedly elevated in all untreated acute lymphoblastic leukemia patients, whereas low levels which were difficult to interpret were present in the peripheral blood samples of two patients at diagnosis and six patients at relapse who had low absolute lymphoblast counts. Because of greater variation in the lymphoblast content of peripheral blood, bone marrow assays are more reliable in detecting disease activity. Marrow terminal deoxynucleotidyltransferase values obtained during the active phase of acute lymphoblastic leukemia were significantly greater than those found in other types of leukemia, bone marrow malignancies, and hematologic disorders. Terminal transferase determinations in blast cells of two patients with leukemic conversion of non-Hodgkins lymphoma and in tumor cells from one patient with Burkitts lymphoma were within the control range. These dat further define the usefulness of terminal deoxynucleotidyltrnasferase assay in the differentiation and classication of hematologic malignancies.

Late Echocardiographic Findings Following Childhood Chemotherapy with Normal Serial Cardiac Monitoring

Purpose Late development of myocardial dysfunction years following successful treatment of childhood malignancy with anthracyclines is well documented. There have been few studies of late cardiac performance in children in whom serial monitoring during treatment suggested normal cardiac performance, and those studies that do exist rely on the results of extensive evaluation. It was our purpose to determine whether findings consistent with known late cardiac changes could be discovered in these patients by echocardiographic monitoring similar to that routinely performed during treatment. Patients and Methods A total 28 consecutive asymptomatic patients who had completed anthracycline therapy at least 3 years previously, had been free of malignant disease since the completion of therapy, and who had had normal serial echocardiographic studies during and at completion of treatment were restudied by echocardiography. Of these 28, 12 had undergone mediastinal radiation as part of their acute treatment. Results Four patients (14%) of the study group were found to have abnormally low values for left ventricular shortening and ejection fractions. All four had also received mediastinal radiation. The remaining 24 patients, while having values for shortening fraction within the normal range, had, as a group, experienced a significant decrease in echocardiographic left ventricular shortening since completion of treatment. In these patients, left ventricular wall thickness had not increased commensurate with growth in body size and left ventricular cavity dimension. Conclusions The known incidence of late asymptomatic cardiac dysfunction is confirmed despite the presence of persistently normal echocardiographic monitoring studies during and at completion of anthracycline treatment. Additionally, as a population, these patients show impaired myocardial growth over time, placing them at risk for future myocardial failure. Normal echocardiographic monitoring studies during antineoplastic treatment in children may not necessarily predict that patients will be free of the development of late cardiac dysfunction. Routine serial echocardiographic monitoring can, however, be helpful in the long-term management of these patients.

Lymphocyte Infusion for Delayed Extramedullary Relapse of Acute Leukemia Following Bone Marrow Transplantation

We report a case of extramedullary relapse of acute myelogenous leukemia twelve years after allogeneic bone marrow transplantation. Due to the localized nature of the relapse, we were able to eliminate a majority of the tumor burden, utilizing local irradiation. Destined with eventual systemic leukemia relapse, further therapy utilizing donor lymphocytes was given at a time of minimal disease burden. The patient remains in a state of complete remission.

Langerhans cell histiocytosis after therapy for a malignant germ cell tumor of the central nervous system.

Langerhans cell histiocytosis (LCH) is a clonal neoplastic disorder that results in a spectrum of clinical manifestations. Known to be associated with a variety of malignant diseases, LCH may precede, coincide with, or develop after the diagnosis of cancer. A child with a malignant germ cell tumor of the brain who subsequently experienced LCH is reported. The 8-year-old boy was treated for an immature teratoma of the posterior fossa with gross total resection and craniospinal irradiation preceding bleomycin, etoposide, and vinblastine chemotherapy for four cycles. Seven months after completion of therapy, he experienced multifocal bone disease with LCH.

Resolution of Ga-67 citrate uptake in the left neck mass of Hodgkin's disease and reversion of double scoliosis of cervical-thoracic and lower lumbar vertebrae

A 6-yr-old boy underwent a total body Ga-67 citrate imaging study because of a large mass of Hodgkins lymphoma in the left neck and the left anterior chest wall region. The images showed intense uptake in the left neck extending anteroinferiorly to the left upper chest wall corresponding to the left neck and chest region. In addition, there was mild cervical-upper thoracic scoliosis with convexity to the right and mild scoliosis of the lower lumbar scoliosis with concavity to the left. After three cycles of chemotherapy, in the follow-up Ga-67 citrate total body images seven months after his first Ga-67 citrate imaging, the intense uptake in the left neck and the left upper chest wall had been resolved and the scoliosis of the cervical-thoracic and lower lumbar spine had also been reversed to normal. This case shows that a Ga-67 citrate imaging study is useful for first diagnosis and subsequent monitoring of the therapeutic effects in a follow-up imaging. Also Ga-67 citrate imaging provided evidence that the scoliosis had been reversed.

PLASMA MEMBRANE ULTRASTRUCTURE OF HUMAN LEUCOCYTES

The surface of human blood neutrophils (PMN), monocytes, B and T lymphocytes, lymphoblasts from acute lymphoblastlc leukemia (ALL) and macrophages transformed in-vitro from blood monocytes was compared using critical point drying and scanning electron microscopy (SEM). Elongated, veillike extensions of the plasma membrane cover the entire surface of the monocyte and macrophage and are characteristic of the mononuclear phagocyte cell line. In contrast, numerous short microvilli and serpentine ridges cover the surface of the PMN. Following PMN attachment to glass the central portion of the cell becomes smooth and microundulations of plasma membrane activity are noted only at the cell periphery. Numerous microvillous projections on the normal human B lymphocyte surface in contrast to the smooth surface and receptors for sheep erythrocytes (SRBC) on the normal blood T lymphocyte surface, as previously reported, were confirmed. SEM offers an additional tool for characterization of each of the normal blood leucocyte cell types. SEM observations of blood lymphoblasts in 3 children with ALL prior to treatment revealed greater than 90% of cells with a smooth surface identical to normal T lymphocytes. However, SRBC rosette formation was present in 6%, 7% and 91% respectively. Correlation of membrane ultrastructure and SRBC receptor sites appears less consistent following malignant lymphoid transformation.