Shuwen Shi

Early diagnostic and prognostic significance of a specific Th1/Th2 cytokine pattern in children with haemophagocytic syndrome

The haemophagocytic syndrome (HPS) is a rare but frequently fatal disorder of immune regulation caused by hypercytokinemia. Using cytometric bead array technique, the serum T‐helper cell type 1 (Th1) and 2 (Th2) cytokines including interferon‐γ (IFN‐γ), tumour necrosis factor (TNF), interleukin (IL)‐10, IL‐6, IL‐4 and IL‐2 were determined in 24 children with de novo HPS and 87 children as control. The median levels of serum IFN‐γ, IL‐10 and IL‐6 in the acute phase of HPS were 901·7, 879·0 and 63·8 pg/ml, respectively, significantly higher than those after remission, and in the healthy volunteers and patients with viral infection. IL‐4 was slightly elevated while IL‐2 and TNF were within normal range in acute phase. Patients with bacterial sepsis showed an extremely high level of IL‐6 and moderate level of IL‐10, whereas IFN‐γ was only slightly elevated. Five patients were diagnosed with HPS according to the Th1/Th2 cytokine pattern 3–13 d earlier than they fulfilled the relevant diagnostic criteria. IL‐10 level >2000 pg/ml was an unfavorable prognostic factor for HPS treatment response (P = 0·033) and outcome (P = 0·009). We conclude that the significant increase of IFN‐γ and IL‐10 and a slightly increased level of IL‐6 is an early, specific and prognostic cytokine pattern for childhood HPS.

Diagnostic Accuracy of a Specific Cytokine Pattern in Hemophagocytic Lymphohistiocytosis in Children

OBJECTIVE The study goal was to determine the diagnostic accuracy of a specific cytokine pattern including interferon-gamma (IFN-γ), interleukin (IL)-10, and IL-6 for hemophagocytic lymphohistiocytosis (HLH) in febrile children. STUDY DESIGN In this prospective study, 756 patients with fever admitted to a hematology-oncology unit were enrolled. The causes of fever were documented and the serum cytokines, including IFN-γ, tumor necrosis factor-alpha (TNF-α), IL-10, IL-6, IL-4, and IL-2, were determined using cytometric bead array techniques. RESULTS Of 1474 episodes of fever that were analyzed, 71 episodes of HLH manifested a specific cytokine pattern of highly increased levels of IFN-γ (median level: 1088.5 pg/mL) and IL-10 (623.5 pg/mL) but a moderately increased level of IL-6 (51.1 pg/mL). IL-6 was predominantly increased to varied extents in patients in the sepsis group (244.6 pg/mL) and the nonsepsis infection group (34.7 pg/mL). The diagnostic accuracy of IFN-γ and IL-10 for HLH was 99.5% and 92.8%, respectively. By applying the cutoff point of 100 pg/mL, IFN-γ had a sensitivity of 94.4% and a specificity of 97.2% for HLH. When using the criteria of IFN-γ >75 pg/mL and IL-10 >60 pg/mL, the specificity reached 98.9% and the sensitivity was 93.0%. CONCLUSIONS The specific cytokine pattern of markedly elevated levels of IFN-γ and IL-10 with only modestly elevated IL-6 levels has high diagnostic accuracy for HLH and may be a useful approach to differentiate HLH from infection.

Long-term outcome of childhood acute lymphoblastic leukemia treated in China.

To retrospectively determine the treatment outcome and causes of treatment failure of ALL children treated in a single institution at East China.

Evaluation of Th1/Th2 cytokines as a rapid diagnostic tool for severe infection in paediatric haematology/oncology patients by the use of cytometric bead array technology

Haematology/oncology children are usually at risk for various infections after intensive chemotherapy. We evaluated the quantification of Th1/Th2 cytokines with a flow cytometric bead array (CBA) in 795 hospitalized haematology/oncology children (309 febrile and 486 afebrile patients) to seek for a diagnostic method for determination of the type and the severity of infection. Three hundred and nine febrile patients developed a total of 505 febrile episodes. Microbiological examination demonstrated a positive blood culture (microbiologically documented infection (MDI)) in 145/505 febrile episodes. The controls included 550 healthy children, 43 haemophagocytic lymphohistiocytosis (HLH) patients, 35 cytomegalovirus infection patients and 19 Epstein-Barr virus infection patients. Interleukin (IL)-4, IL-6, IL-10, tumour necrosis factor (TNF)-α and interferon (IFN)-γ levels in febrile episodes were significantly higher than those in healthy children, and the cytokine profile was different from that of the HLH controls or the viral infection controls. IL-6 levels were much higher in MDI patients (usually >1000.0 pg/mL, 60/145) than in HLH patients (2/43); however, IFN-γ levels were only slightly increased in MDI patients, rarely being more than 100.0 pg/mL (8/145 vs. 39/43 in HLH patients). The median levels of IL-4, IL-6, IL-10, TNF-α and IFN-γ in febrile patients before antibiotic therapy were 3.9, 660.1, 122.7, 6.9 and 11.4 pg/mL, respectively, and returned to 3.3, 22.8, 9.6, 4.1 and 6.4 pg/mL, respectively, after infection was controlled. IL-6 and IL-10 levels were positively associated with septic shock and mortality rates. In conclusion, our results have demonstrated the usefulness of IL-6/IL-10/TNF-α/IFN-γ determination with CBA technology for the early rapid diagnosis, severity evaluation and assessment of therapy effect in febrile haematology/oncology children.

Long-term outcome of childhood acute myeloid leukemia in a developing country: experience from a children's hospital in China

Data on childhood acute myeloid leukemia (AML) in developing countries are limited. Herein we report the outcome of childhood AML treated with modified NPCLC-AML97 in our institution from 1997 to 2005. One hundred and eighty-five children with newly diagnosed AML were admitted. The 7-year overall survival (OS) and event free survival (EFS) rates for the whole cohort were 33.1 ± 4.1% and 31.2 ± 3.7%, respectively. Sixty patients (32.4%) refused chemotherapy and 123 were eligible for protocol evaluation. Among eligible patients, 111 (90.2%) achieved complete remission (CR). The estimated 7-year OS and EFS rates were 50.2 ± 5.5% and 46.9 ± 5.1%, respectively. APL was more curable than non-APL (7-year EFS: 63.5 ± 7.9% vs. 35.9 ± 6.3%, p = 0.005). Thirty-one patients (25.2%) relapsed, but no central nervous system leukemia was observed. Although the cure rate of childhood AML in China was low, the treatment outcome for patients who could adhere to the treatment protocol was satisfactory.

Th1/Th2 cytokine profiles in G+/G- bacteremia in pediatric hematology/oncology patients.

Early diagnosis of infection and appropriate choice of antibiotics are essential not only to improve the prognosis of the patients but also to prevent from the abuse of the antibiotics in hematology/oncology children at the time of neutropenia after intensive chemotherapy.

A multiplex cytokine score for the prediction of disease severity in pediatric hematology/oncology patients with septic shock.

Although many inflammatory cytokines are prognostic in sepsis, the utility of cytokines in evaluating disease severity in pediatric hematology/oncology patients with septic shock was rarely studied. On the other hand, a single particular cytokine is far from ideal in guiding therapeutic intervention, but combination of multiple biomarkers improves the accuracy. In this prospective observational study, 111 episodes of septic shock in pediatric hematology/oncology patients were enrolled from 2006 through 2012. Blood samples were taken for inflammatory cytokine measurement by cytometric bead array (CBA) technology at the initial onset of septic shock. Interleukin (IL)-6 and IL-10 were significantly elevated in majority of patients, while tumor necrosis factor (TNF)-α and interferon (IFN)-γ were markedly increased in patients with high pediatric index of mortality 2 (PIM2) score and non-survivors. All the four cytokines paralleled the PIM2 score and differentially correlated with hemodynamic disorder and fatal outcomes. The pediatric multiplex cytokine score (PMCS), which integrated the four cytokines into one score system, was related to hemodynamic disorder and mortality as well, but showed more powerful prediction ability than each of the four cytokines. PMCS was an independent predictive factor for fatal outcome, presenting similar discriminative power with PIM2, with accuracy of 0.83 (95% CI, 0.71-0.94). In conclusion, this study develops a cytokine scoring system based on CBA technique, which performs well in disease severity and fatality prediction in pediatric hematology/oncology patients with septic shock.

Absolute lymphocyte count is associated with minimal residual disease level in childhood B-cell precursor acute lymphoblastic leukemia.

The prognostic value of absolute lymphocyte count (ALC) has been a recent matter of debate in childhood acute lymphoblastic leukemia (ALL). In the current study, ALCs at the time of diagnosis (ALC-0), after 7 days of initial therapy (ALC-8) and at interim of the induction therapy (ALC-22) were examined in Chinese children with B-cell precursor (BCP) ALL and correlated with the level of minimal residual disease (MRD) at day 22 of induction therapy. Medical and laboratory records of 140 patients diagnosed with childhood BCP ALL were retrieved and analyzed. ALC-22 is significantly correlated with MRD level at day 22 of therapy and can be a good prognostic factor for childhood BCP-ALL. Furthermore, lymphocyte count at initial diagnosis is correlated with MRD level at day 22 in childhood BCP-ALL with the immnunophenotype of CD19(pos)/CD10(pos)/CD34(pos)/CD45(neg) and role as a new prognostic factor was determined.

Day 22 of induction therapy is important for minimal residual disease assessment by flow cytometry in childhood acute lymphoblastic leukemia

This study was aimed to illustrate the significance of minimal residual disease (MRD) assessment on day 22 in childhood acute lymphoblastic leukemia. MRD were measured on day 22, day 36, week 12, month 6 and month 12 by four-color flow cytometry. The 5-year cumulative incidence of relapse was significantly different for patients with MRD levels of <0.01%, 0.01-0.1%, 0.1-1.0% and ≥ 1.0% on day 22: 6.9 ± 2.6%, 16.7 ± 5.5%, 25.8 ± 6.2% and 58.4 ± 13.4% (P < 0.001). MRD on day 22 was more powerful than other parameters including NCI risk. However, other time points after induction, although predictive as well, were not accurate enough due to false positivity.

Prognostic significance of flow cytometric minimal residual disease assessment after the first induction course in Chinese childhood acute myeloid leukemia.

Flow cytometry based minimal residual disease (MRD) was evaluated for outcome prediction in childhood acute myeloid leukemia (AML). The median levels of MRD in relapsed and nonrelapsed patients were different after the first induction (0.64% vs. 0.18%, P=0.030). A cutoff level of ≥ 0.25% after the first course of induction was correlated with a high risk of relapse in both univariate analysis (5-year cumulative incidence of relapse: 66.8% vs. 21.2%, P=0.002) and multivariate analyses (hazard ratio: 3.70, 95% CI, 1.23-11.08, P=0.020). Our results showed that MRD level after the first induction therapy provides important information for risk assessment in childhood AML.