Perry Cook

Incidence and Treatment of Tumor Lysis Syndrome in Patients with Acute Leukemia

Tumor lysis syndrome (TLS) is a complication associated with electrolyte abnormalities that is observed in patients with acute leukemia who are receiving intense doses of chemotherapy. Forty-one patients with acute leukemia were treated with high-dose combination chemotherapy and were evaluated for TLS. A grading system developed for the evaluation of these patients was applied. Grade I tumor lysis was observed in 22 patients, grade II TLS in 2 patients and grade III in 1 patient. All patients were treated with intravenous fluids, mannitol, allopurinol and in some patients, aluminum-based antacids. Treatment for TLS prior to intensive chemotherapy reduced morbidity and mortality associated with high-dose chemotherapy for acute leukemias.

Amsacrine is safe and effective therapy for patients with myocardial dysfunction and acute leukemia

The role of amsacrine in inducing remission in patients with cardiac disease and acute leukemia was evaluated. There were 17 patients with acute myelogenous leukemia (AML), six with acute lymphocytic leukemia (ALL), and one with biphenotypic leukemia. In this series of 24 patients whose disease had relapsed and who had reduced left ventricular ejection fraction, nine had a complete remission, seven with AML and two with ALL. In addition, four of six with newly diagnosed acute leukemia and reduced left ventricular ejection fraction also responded. Among nine patients who underwent endomyocardial biopsy, none had morphologic changes of sufficient degree to account for drug‐induced heart failure. Patients with preexisting arrhythmias received amsacrine without incident if their serum potassium level was higher than 4.0 mEq/1 at the time of drug administration. Amsacrine is safe and effective therapy for patients with acute leukemia and cardiac disease.

Treatment of Gancyclovir Resistant Cytomegalovirus with Foscarnet: a Report of Two Cases Occurring After Bone Marrow Transplantation

Cytomegalovirus (CMV) infection is common in patients who undergo allogeneic bone marrow transplantation. Gancyclovir is useful in treating CMV infections. Resistance to gancyclovir is rare and has, thus far, not been reported in the setting of BMT. Two patients with CMV infections unresponsive to gancyclovir were successfully treated with foscarnet. 10-15% of CMV infections are resistant initially or develop resistance to gancyclovir. Both patients had an adequate trial of gancyclovir and resistance developed over time. While we did not document resistance in the laboratory there was dramatic clinical improvement with foscarnet.

Allogeneic marrow transplantation for myelodysplastic syndrome complicating autologous bone marrow transplantation.

A patient with refractory relapsed Hodgkins disease underwent an autologous bone marrow transplant in July 1987 and achieved remission of Hodgkins disease. He had complete hematological recovery but developed pancytopenia 3 years post bone marrow transplantation with morphological evidence of myelodysplasia. High-dose cyclophosphamide, 200 mg/kg, chemotherapy followed by an allogeneic bone marrow transplant from a HLA-matched sibling was performed in April 1991 with complete hematological recovery. Allogeneic bone marrow transplantation was thus used successfully to treat a potential complication of autologous bone marrow transplantation.

Higher cure rates in acute leukemia: now more probable with increasingly effective induction therapy.

SummaryTraditional therapy of acute myelogenous leukemia has not cured more than 10% of patients and, of acute lymphoblastic leukemia not more than 30% of adults. In part, this is due to the lack of agents effective enough to induce remissions of such quality that cure is possible. The introduction of mitoxantrone and its use in high dose with high-dose cytarabine for induction therapy, raises the possibility of an increased cure rate of acute myelogenous leukemia and acute lymphoblastic leukemia.

Improving the Remission Quality in Acute Myelogenous Leukemia (AML) by Increasing Cytoreduction During Induction Therapy

Induction of remission in AML has, for many years, been achieved by the administration of daunorubicin with cytarabine [1]. With traditional doses of these drugs, approximately two-thirds of the patients treated have gone into remission. Roughly two-thirds of these have achieved their remission after the first cycle of therapy and one-third required additional treatment. Although physicians have consistently tried to increase the cure rate of patients with AML achieving CR by the administration of subsequent therapy, the “quality” of CR has never been thought to be vital, since post-induction chemotherapy was considered the most important aspect of treatment. Because of this, consolidation therapy has gone from gentle to very intense and has been given for as little as 1–2 months to as long as 1 year or more. Death, associated with delivery of this therapy, has varied between 0% and 40% [2, 3]. The therapy reported here is based on the presumption that, at the time of diagnosis or at relapse, with fully evident disease, the normal stem cells are asleep and somewhat protected from the chemotherapy that is administered. Therefore, induction treatment with high-dose cytarabine, mitoxantrone, and etoposide can be administered with less risk than previously expected. Indeed, it may be that, in most protocols, what is accomplished during “induction” therapy may be the most important element of treatment.