Academic Appointments

Current Research and Scholarly Interests

Hematology/Oncology, Phase I drug studies for childhood cancer, overcoming multidrug resistance in leukemia and solid tumors, biology and treatment of acute nonlymphocytic leukemia, early detection of central nervous system leukemia by measuring growth, factor binding proteins.

Clinical Trials

  • Phase I Dose Escalation Study of CD19/CD22 Chimeric Antigen Receptor (CAR) T Cells in Children and Young Adults With Recurrent or Refractory B Cell Malignancies Recruiting

    This phase I trial studies the best dose and side effects of CD19/CD22 chimeric antigen receptor (CAR) T cells when given together with chemotherapy, and to see how well they work in treating children or young adults with CD19 positive B acute lymphoblastic leukemia that has come back or does not respond to treatment. A CAR is a genetically-engineered receptor made so that immune cells (T cells) can attack cancer cells by recognizing and responding to the CD19/CD22 proteins. These proteins are commonly found on B acute lymphoblastic leukemia. Drugs used in chemotherapy, such as fludarabine phosphate and cyclophosphamide, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving CD19/CD22-CAR T cells and chemotherapy may work better in treating children or young adults with B acute lymphoblastic leukemia.

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  • A Study of Clofarabine in Combination With Etoposide and Cyclophosphamide in Children With Acute Leukemias. Not Recruiting

    Clofarabine (injection) is approved by the Food and Drug Administration (FDA) for the treatment of pediatric patients 1 to 21 years old with relapsed or refractory acute lymphoblastic leukemia (ALL) who have had at least 2 prior treatment regimens. This use is based on the induction of complete responses. Randomized trials demonstrating increased survival or other clinical benefit have not been conducted. The purpose of the phase 1 portion of this study was to determine if clofarabine added to a combination of etoposide and cyclophosphamide is safe in children with relapsed or refractory acute lymphoblastic leukemia (ALL) or acute myelogenous leukemia (AML). The purpose of the phase 2 portion of the study was to measure the effectiveness of the combination therapy in children with ALL.

    Stanford is currently not accepting patients for this trial. For more information, please contact Min Wang, (650) 736 - 4281.

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  • A Study of Venetoclax in Combination With Navitoclax and Chemotherapy in Subjects With Relapsed/Refractory Acute Lymphoblastic Leukemia or Relapsed/Refractory Lymphoblastic Lymphoma Not Recruiting

    This dose-escalating study is to determine the safety, pharmacokinetics, and preliminary efficacy of venetoclax in combination with navitoclax and chemotherapy in adult and pediatric participants with relapsed/refractory acute lymphoblastic leukemia (ALL) or relapsed/refractory lymphoblastic lymphoma. A safety expansion cohort of approximately 20 patients may be enrolled in addition to the 50 participants in dose-escalation cohort.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

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  • Clofarabine Plus Cytarabine Versus Conventional Induction Therapy And A Study Of NK Cell Transplantation In Newly Diagnosed Acute Myeloid Leukemia Not Recruiting

    The purpose of this study is to assess the feasibility and efficacy of a novel form of therapy-haploidentical NK cell transplantation-in patients with standard-risk AML. In addition, we will investigate the efficacy of clofarabine + cytarabine (Clo/AraC) in newly diagnosed patients with AML and attempt to optimize outcome through the use of MRD-adapted therapy and further improvements in supportive care.

    Stanford is currently not accepting patients for this trial. For more information, please contact Peds Hem Onc CRAs, 650-723-5535.

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  • Combination Chemotherapy Plus PSC-833 in Treating Children With Refractory or Relapsed Acute Leukemia Not Recruiting

    Phase I trial to study the effectiveness of PSC-833 plus etoposide and mitoxantrone in treating children who have refractory or relapsed acute leukemia. Drugs used in chemotherapy use different ways to stop cancer cells from dividing so they stop growing or die. Some cancers become resistant to chemotherapy drugs. Combining PSC-833 with chemotherapy may reduce resistance to the drug and allow more cancer cells to be killed.

    Stanford is currently not accepting patients for this trial.

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  • Dasatinib in Treating Young Patients With Recurrent or Refractory Solid Tumors or Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia or Chronic Myelogenous Leukemia That Did Not Respond to Imatinib Mesylate Not Recruiting

    This phase I trial is studying the side effects and best dose of dasatinib in treating young patients with recurrent or refractory solid tumors or Philadelphia chromosome-positive acute lymphoblastic leukemia or chronic myelogenous leukemia that did not respond to imatinib mesylate. Dasatinib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth

    Stanford is currently not accepting patients for this trial. For more information, please contact Neyssa Marina, (650) 723 - 5535.

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  • Genome, Proteome and Tissue Microarray in Childhood Acute Leukemia Not Recruiting

    We will study gene and protein expression in leukemia cells of children diagnosed with acute leukemia. We hope to identify genes or proteins which can help us grade leukemia at diagnosis in order to: (a) develop better means of diagnosis and (b) more accurately choose the best therapy for each patient.

    Stanford is currently not accepting patients for this trial. For more information, please contact Norman J Lacayo, 650-723-5535.

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  • hu14.18-Interleukin-2 Fusion Protein in Treating Young Patients With Recurrent or Refractory Neuroblastoma Not Recruiting

    RATIONALE: Biological therapies such as hu14.18-interleukin-2 fusion protein work in different ways to stimulate the immune system and stop tumor cells from growing. PURPOSE: This phase II trial is studying how well hu14.18-interleukin-2 fusion protein works in treating young patients with recurrent or refractory neuroblastoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact LPCH New Patient Coordinator, (650) 725 - 1072.

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  • Intensive Neoadjuvant Chemotherapy in Treating Young Patients Undergoing Surgical Resection for High-Risk Hepatoblastoma Not Recruiting

    RATIONALE: Drugs used in chemotherapy work in different ways to stop tumor cells from dividing so they stop growing or die. Giving chemotherapy drugs before surgery may shrink the tumor so that it can be removed. PURPOSE: This phase II trial is studying how well neoadjuvant chemotherapy works in treating young patients who are undergoing surgical resection for high-risk hepatoblastoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact Nadeem Mukhtar, (650) 725 - 1662.

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  • Lenalidomide in Treating Young Patients With Relapsed or Refractory Solid Tumors or Myelodysplastic Syndromes Not Recruiting

    This phase I trial is studying the side effects and best dose of lenalidomide in treating young patients with relapsed or refractory solid tumors or myelodysplastic syndromes. Lenalidomide may stop the growth of solid tumors or myelodysplastic syndromes by blocking blood flow to the cancer. It may also stimulate the immune system in different ways and stop cancer cells from growing.

    Stanford is currently not accepting patients for this trial. For more information, please contact LPCH New Patient Coordinator, (650) 725 - 1072.

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  • Rasburicase Treatment for Chemotherapy or Malignancy-Induced Hyperuricemia in Asthma/Allergy Patients Not Recruiting

    This is a multi-center trial for rasburicase in children at high risk of tumor lysis syndrome who have a history of asthma/atopy. The main purpose of this study is to establish the safety of this drug in patients with a history of asthma or severe allergies.

    Stanford is currently not accepting patients for this trial. For more information, please contact LPCH New Patient Coordinator, (650) 725 - 1072.

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  • Repeat-Dose of Forodesine Hydrochloride (BCX-1777) Infusion in Patients With Advanced T-Cell Leukemia Not Recruiting

    BCX-1777 may stop the growth of cancer cells by blocking the enzymes necessary for their growth. The Phase II trial is designed to study the effectiveness of BCX-1777 in treating patients who have recurrent or refractory advanced T-cell leukemia. Patients will receive an infusion of BCX-1777 on days 1-5. Treatment may be repeated every week for up to six courses. Patients are not required to be hospitalized for the administration of BCX-1777. Some patients may continue to receive an infusion of BCX-1777 twice a week for 6 weeks.

    Stanford is currently not accepting patients for this trial. For more information, please contact Nadeem Mukhtar, (650) 497 - 8815.

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  • T-cell Minimal Residual Disease (MRD) Evaluation Using Flow Cytometric Analysis Not Recruiting

    To determine if MRD (minimal residual disease) can be found in the blood (only) as opposed to bone marrow in children with ALL (acute lymphoblastic leukemia).

    Stanford is currently not accepting patients for this trial. For more information, please contact Nadeem Mukhtar, (650) 497 - 8815.

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  • Temozolomide, Vincristine, and Irinotecan in Treating Young Patients With Refractory Solid Tumors Not Recruiting

    RATIONALE: Drugs used in chemotherapy, such as temozolomide, vincristine, and irinotecan, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Giving more than one drug (combination chemotherapy) may kill more tumor cells. PURPOSE: This phase I trial is studying the side effects and best dose of irinotecan when given together with temozolomide and vincristine in treating young patients with refractory solid tumors.

    Stanford is currently not accepting patients for this trial. For more information, please contact Nadeem Mukhtar, (650) 497 - 8815.

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  • Treatment of Patients With Newly Diagnosed Acute Myeloid Leukemia or Myelodysplasia Not Recruiting

    The purpose of this study is to compare the effectiveness of two multi-agent chemotherapy regimens using different dosages of cytarabine to eliminate all detectable leukemia.

    Stanford is currently not accepting patients for this trial. For more information, please contact LPCH New Patient Coordinator, (650) 725 - 1072.

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  • Valproic Acid in Treating Young Patients With Recurrent or Refractory Solid Tumors or CNS Tumors Not Recruiting

    RATIONALE: Drugs used in chemotherapy, such as valproic acid, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Valproic acid may also stop the growth of solid tumors or CNS tumors by blocking blood flow to the tumor. PURPOSE: This phase I trial is studying the side effects and best dose of valproic acid in treating patients with recurrent or refractory solid tumors or CNS tumors.

    Stanford is currently not accepting patients for this trial. For more information, please contact LPCH New Patient Coordinator, (650) 725 - 1072.

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  • Vorinostat With or Without Isotretinoin in Treating Young Patients With Recurrent or Refractory Solid Tumors, Lymphoma, or Leukemia Not Recruiting

    This phase I trial is studying the side effects and best dose of vorinostat when given together with isotretinoin in treating young patients with recurrent or refractory solid tumors, lymphoma, or leukemia. Drugs used in chemotherapy, such as vorinostat, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Vorinostat may also stop the growth of cancer cells by blocking some of the enzymes needed for cell growth and by blocking blood flow to the cancer. Isotretinoin may cause cancer cells to look more like normal cells, and to grow and spread more slowly. Giving vorinostat together with isotretinoin may be an effective treatment for cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Min Wang, (650) 736 - 4281.

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2023-24 Courses

Graduate and Fellowship Programs

  • Pediatric Hem/Onc (Fellowship Program)

All Publications

  • Base-Editing as a Safe and Highly Effective Alternative Treatment for X-SCID Compared to CRISPR-Cas9 Nuclease Editing with an AAV Donor Bzhilyanskaya, V., Brault, J., Liu, S., Kozhushko, N., Lawson, A., Pavel-Dinu, M., Clark, A. B., Meis, R. J., Ma, M., Lazzarotto, C. R., Tsai, S. Q., Wu, X., Dahl, G., Kleinstiver, B. P., Porteus, M. H., Malech, H. L., De Ravin, S. CELL PRESS. 2023: 572
  • "You don't accept he's completely ok": a reflexive thematic analysis of parents' roles in monitoring their child's health and symptoms after finishing childhood cancer treatment. Journal of cancer survivorship : research and practice Loecher, N., Jordan, A., Spunt, S. L., Simon, P., Simons, L. E., Dahl, G., Kosyluk, K., Heathcote, L. C. 2023


    OBJECTIVES/PURPOSE: Childhood cancer survival brings continued mental and physical health challenges both for the child and for the family. In this study, we investigated how parents viewed their roles in their child's health and symptom monitoring during the survivorship period.METHODS: Twenty-one parents of childhood cancer survivors (n=18 mothers; parent mage=49.78years, child mage=18.50years; range=12-25years), whose children were at least one year off-treatment (m=3.67years; SD=2.25; various diagnoses), completed semi-structured interviews. Interviews were recorded, transcribed, and analyzed using reflexive thematic analysis.RESULTS: Analyses generated three themes which reflect roles that parents may adopt in the context of monitoring symptoms in their childhood cancer survivor. "Vigilant Mama and Papa" (theme 1) described parents who expressed a strong sense of responsibility for protecting their child's health during survivorship resulting in careful monitoring of their child's symptoms and health. "Pragmatic Mamas and Papas" (theme 2) described parents who adopted an approach to symptom and health monitoring that emphasized moving past cancer and focusing on the future. Finally, "Encouraging Mamas and Papas" (theme 3) described parents who focused on educating and preparing their child to develop an autonomous approach to health and symptom self-monitoring as they transitioned to survivorship and adulthood.CONCLUSION: Parents take on varying roles in monitoring their child's symptoms and health after finishing childhood cancer treatment.IMPLICATIONS FOR CANCER SURVIVORS: Understanding the ways in which parents continue to be involved in their child's cancer journey helps researchers develop interventions to support dyadic coping in survivorship.

    View details for DOI 10.1007/s11764-023-01353-w

    View details for PubMedID 36821041

  • Smartphone-Based Ecological Momentary Assessment to Study "Scanxiety" among Adolescent and Young Adult Survivors of Childhood Cancer: A Feasibility Study. Psycho-oncology Heathcote, L. C., Cunningham, S. J., Webster, S. N., Tanna, V., Mattke, E., Loecher, N., Spunt, S. L., Simon, P., Dahl, G., Walentynowicz, M., Murnane, E., Tutelman, P. R., Schapira, L., Simons, L. E., Mueller, C. 2022


    OBJECTIVE: Scan-related anxiety ("scanxiety") refers to the fear, stress, and anxiety in anticipation of tests and scans in follow-up cancer care. This study assessed the feasibility of Ecological Momentary Assessment (EMA) for real-world, real-time capture of scanxiety using patients' personal smartphone.METHODS: Adolescent and Young Adult (AYA) survivors of childhood cancer were prompted to complete EMA surveys on a smartphone app three times per day for 11 days (33 surveys total) around their routine surveillance scans. Participants provided structured feedback on the EMA protocol.RESULTS: Thirty out of 46 contacted survivors (65%) enrolled, exceeding the preregistered feasibility cutoff of 55%. The survey completion rate (83%) greatly exceeded the preregistered feasibility cutoff of 65%. Participants generally found the smartphone app easy and enjoyable to use and reported low levels of distress from answering surveys. Participants reported significantly more daily fear of cancer recurrence (FCR) and negative affect in the days before compared to the days after surveillance scans, aligning with the expected trajectory of scanxiety. Participants who reported greater FCR and scanxiety using comprehensive measures at baseline also reported significantly more daily FCR around their surveillance scans, indicating validity of EMA items. Bodily threat monitoring was prospectively and concurrently associated with daily FCR, thus warranting further investigation as a risk factor for scanxiety.CONCLUSIONS: Findings indicate the feasibility, acceptability, and validity of EMA as a research tool to capture the dynamics and potential risk factors for scanxiety. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/pon.5935

    View details for PubMedID 35411626

  • Therapy-related myeloid neoplasms resembling juvenile myelomonocytic leukemia: a case series and review of the literature. Pediatric blood & cancer Wintering, A., Smith, S., Fuh, B., Rangaswami, A., Dahl, G., Chien, M., Gruber, T. A., Dang, J., Li, L. S., Lenzen, A., Savelli, S., Dvorak, C. C., Agrawal, A. K., Stieglitz, E. 1800: e29499


    Therapy-related myeloid neoplasms (t-MN) are a distinct subgroup of myeloid malignancies with a poor prognosis that include cases of therapy-related myelodysplastic syndrome (t-MDS), therapy-related myeloproliferative neoplasms (t-MPN) and therapy-related acute myeloid leukemia (t-AML). Here, we report a series of patients with clinical features consistent with juvenile myelomonocytic leukemia (JMML), an overlap syndrome of MDS and myeloproliferative neoplasms that developed after treatment for another malignancy.

    View details for DOI 10.1002/pbc.29499

    View details for PubMedID 34939322

  • Comparison of the Transcriptomic Signatures in Pediatric and Adult CML. Cancers Youn, M., Smith, S. M., Lee, A. G., Chae, H., Spiteri, E., Erdmann, J., Galperin, I., Jones, L. M., Donato, M., Abidi, P., Bittencourt, H., Lacayo, N., Dahl, G., Aftandilian, C., Davis, K. L., Matthews, J. A., Kornblau, S. M., Huang, M., Sumarsono, N., Redell, M. S., Fu, C. H., Chen, I., Alonzo, T. A., Eklund, E., Gotlib, J., Khatri, P., Sweet-Cordero, E. A., Hijiya, N., Sakamoto, K. M. 1800; 13 (24)


    Children with chronic myeloid leukemia (CML) tend to present with higher white blood counts and larger spleens than adults with CML, suggesting that the biology of pediatric and adult CML may differ. To investigate whether pediatric and adult CML have unique molecular characteristics, we studied the transcriptomic signature of pediatric and adult CML CD34+ cells and healthy pediatric and adult CD34+ control cells. Using high-throughput RNA sequencing, we found 567 genes (207 up- and 360 downregulated) differentially expressed in pediatric CML CD34+ cells compared to pediatric healthy CD34+ cells. Directly comparing pediatric and adult CML CD34+ cells, 398 genes (258 up- and 140 downregulated), including many in the Rho pathway, were differentially expressed in pediatric CML CD34+ cells. Using RT-qPCR to verify differentially expressed genes, VAV2 and ARHGAP27 were significantly upregulated in adult CML CD34+ cells compared to pediatric CML CD34+ cells. NCF1, CYBB, and S100A8 were upregulated in adult CML CD34+ cells but not in pediatric CML CD34+ cells, compared to healthy controls. In contrast, DLC1 was significantly upregulated in pediatric CML CD34+ cells but not in adult CML CD34+ cells, compared to healthy controls. These results demonstrate unique molecular characteristics of pediatric CML, such as dysregulation of the Rho pathway, which may contribute to clinical differences between pediatric and adult patients.

    View details for DOI 10.3390/cancers13246263

    View details for PubMedID 34944883

  • Cytokine levels at birth in children who developed acute lymphoblastic leukemia. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology Whitehead, T. P., Wiemels, J. L., Zhou, M., Kang, A. Y., McCoy, L. S., Wang, R., Fitch, B., Petrick, L. M., Yano, Y., Imani, P., Rappaport, S. M., Dahl, G. V., Kogan, S. C., Ma, X., Metayer, C. 2021


    BACKGROUND: Prenatal immune development may play an important role in the etiology of childhood acute lymphoblastic leukemia (ALL).METHODS: Seven cytokines - interleukin 1beta (IL1beta), IL4, IL6, IL8, granulocyte-macrophage colony-stimulating factor (GM-CSF), tumor necrosis factor alpha (TNFalpha), and vascular endothelial growth factor (VEGF) - were analyzed in blood spots collected at birth from 1,020 ALL cases and 1,003 controls participating in the California Childhood Leukemia Study. Odds ratios (ORs) and 95% confidence intervals (95% CI) associated with an interquartile range increment in cytokine levels were calculated using logistic regression adjusting for sociodemographic and birth characteristics.RESULTS: We found that ALL patients were born with higher levels of a group of correlated cytokines than controls [IL1beta: OR of 1.18 (95% CI: 1.03, 1.35); IL8: 1.19 (1.03, 1.38); TNFalpha: 1.15 (1.01, 1.30); VEGF: 1.16 (1.01, 1.33)], especially among children of Latina mothers (ORs from 1.31 to 1.40) and for ALL with high hyperdiploidy (ORs as high as 1.27). We found that neonatal cytokine levels were correlated with neonatal levels of endogenous metabolites which had been previously associated with ALL risk; however, there was no evidence that the cytokines were mediating the relationship between these metabolites and ALL risk.CONCLUSIONS: We posit that children born with altered cytokine levels are set on a trajectory towards an increased risk for subsequent aberrant immune reactions that can initiate ALL.IMPACT: This is the first study to evaluate the interplay between levels of immunomodulatory cytokines at birth, prenatal exposures, and the risk of childhood ALL.

    View details for DOI 10.1158/1055-9965.EPI-20-1704

    View details for PubMedID 34078642

  • Symptom monitoring and the uncertain threat of disease recurrence: A deductive thematic analysis with adolescent and young adult (AYA) cancer survivors. Heathcote, L. C., Loecher, N., Spunt, S. L., Simon, P., Dahl, G., Moiceanu, S., Cruanes, G., Tutelman, P., Schapira, L., Mueller, C., Chiu, B., Simons, L. AMER SOC CLINICAL ONCOLOGY. 2019
  • Comparison of the Transcriptomic Signature of Pediatric Vs. Adult CML and Normal Bone Marrow Stem Cells Chae, H., Murphy, L. C., Donato, M., Lee, A. G., Sweet-Cordero, E., Abidi, P., Bittencourt, H., Lacayo, N. J., Dahl, G., Aftandilian, C., Davis, K. L., Huang, M., Sumarsono, N., Redell, M., Fu, C. H., Chen, I. L., Alonzo, T. A., Eklund, E. A., Gotlib, J. R., Khatri, P., Hijiya, N., Sakamoto, K. M. AMER SOC HEMATOLOGY. 2018
  • Chromation Remodeling Therapy and Capizzi Methotrexate in Treatment-Related MDS/AML Aftandilian, C., Sakamoto, K. M., Davis, K. L., Dahl, G., Lacayo, N. J. AMER SOC HEMATOLOGY. 2018
  • Effect of Fitbit and iPad Wearable Technology in Health-Related Quality of Life in Adolescent and Young Adult Cancer Patients. Journal of adolescent and young adult oncology Yurkiewicz, I. R., Simon, P., Liedtke, M., Dahl, G., Dunn, T. 2018


    PURPOSE: Adolescent and young adult (AYA) patients with cancer face significant challenges with regard to fatigue, reduced physical activity, and social isolation, which may negatively impact quality of life. This study investigated whether the use of digital wearable technology (Fitbits, along with synced iPads) can affect health-related quality of life (HRQOL) in AYA aged patients with cancer.MATERIALS AND METHODS: This was a prospective cohort study that offered Fitbits and iPads to all AYA patients aged 15 to 29 at an academic medical center at the time of cancer diagnosis. Patients completed the Short Form Health Survey developed by RAND (RAND-36) assessing eight dimensions of HRQOL on entering the study and at the time of their 6-month follow-up or the end of treatment, whichever occurred first. At the time of follow-up, patients also completed a questionnaire that assessed user experience, including frequency of wearable device use, enjoyment, challenges, and participation, in online communities.RESULTS: Thirty-three patients participated in the study. Most patients reported enjoying the digital technology and using the devices to track multiple aspects of their health (85%). Most also reported a subjective increase in physical activity (79%). After the intervention, participants demonstrated significant improvements across all eight dimensions of HRQOL measured by the RAND-36 (p<0.00 to 0.01).CONCLUSION: Distributing wearable technology at the time of diagnosis may provide an avenue for improving HRQOL in adolescents and young adults with cancer.

    View details for PubMedID 29924668

  • Effect of Fitbit and iPad Wearable Technology in Health-Related Quality of Life in Adolescent and Young Adult Cancer Patients JOURNAL OF ADOLESCENT AND YOUNG ADULT ONCOLOGY Yurkiewicz, I. R., Simon, P., Liedtke, M., Dahl, G., Dunn, T. 2018; 7 (5): 579–83
  • Niclosamide suppresses acute myeloid leukemia cell proliferation through inhibition of CREB-dependent signaling pathways ONCOTARGET Chae, H., Cox, N., Dahl, G. V., Lacayo, N. J., Davis, K. L., Capolicchio, S., Smith, M., Sakamoto, K. M. 2018; 9 (4): 4301–17


    CREB (cAMP Response Element Binding protein) is a transcription factor that is overexpressed in primary acute myeloid leukemia (AML) cells and associated with a decreased event-free survival and increased risk of relapse. We recently reported a small molecule inhibitor of CREB, XX-650-23, which inhibits CREB activity in AML cells. Structure-activity relationship analysis for chemical compounds with structures similar to XX-650-23 led to the identification of the anthelminthic drug niclosamide as a potent anti-leukemic agent that suppresses cell viability of AML cell lines and primary AML cells without a significant decrease in colony forming activity of normal bone marrow cells. Niclosamide significantly inhibited CREB function and CREB-mediated gene expression in cells, leading to apoptosis and G1/S cell cycle arrest with reduced phosphorylated CREB levels. CREB knockdown protected cells from niclosamide treatment-mediated cytotoxic effects. Furthermore, treatment with a combination of niclosamide and CREB inhibitor XX-650-23 showed an additive anti-proliferative effect, consistent with the hypothesis that niclosamide and XX-650-23 regulate the same targets or pathways to inhibit proliferation and survival of AML cells. Niclosamide significantly inhibited the progression of disease in AML patient-derived xenograft (PDX) mice, and prolonged survival of PDX mice. Niclosamide also showed synergistic effects with chemotherapy drugs to inhibit AML cell proliferation. While chemotherapy antagonized the cytotoxic potential of niclosamide, pretreatment with niclosamide sensitized cells to chemotherapeutic drugs, cytarabine, daunorubicin, and vincristine. Therefore, our results demonstrate niclosamide as a potential drug to treat AML by inducing apoptosis and cell cycle arrest through inhibition of CREB-dependent pathways in AML cells.

    View details for PubMedID 29435104

  • A germ-line deletion of APOBEC3B does not contribute to subtype-specific childhood acute lymphoblastic leukemia etiology HAEMATOLOGICA Wallace, A. D., Francis, S. S., Shao, X., de Smith, A. J., Walsh, K. M., Mckean-Cowdin, R., Ma, X., Dahl, G., Barcellos, L. F., Wiemels, J. L., Metayer, C. 2018; 103 (1): e29–e31

    View details for PubMedID 29025908

  • In utero cytomegalovirus infection and development of childhood acute lymphoblastic leukemia BLOOD Francis, S. S., Wallace, A. D., Wendt, G. A., Li, L., Liu, F., Riley, L. W., Kogan, S., Walsh, K. M., de Smith, A. J., Dahl, G. V., Ma, X., Delwart, E., Metayer, C., Wiemels, J. L. 2017; 129 (12): 1680-1684
  • Correlates of prenatal and early-life tobacco smoke exposure and frequency of common gene deletions in childhood acute lymphoblastic leukemia. Cancer research de Smith, A. J., Kaur, M., Gonseth, S., Endicott, A. A., Selvin, S., Zhang, L., Roy, R., Shao, X., Hansen, H. M., Kang, A. Y., Walsh, K. M., Dahl, G. V., McKean-Cowdin, R., Metayer, C., Wiemels, J. L. 2017


    Tobacco smoke exposure has been associated with risk of childhood acute lymphoblastic leukemia (ALL). Understanding the relationship between tobacco exposures and specific mutations may yield etiologic insights. We carried out a case-only analysis to explore whether prenatal and early-life tobacco smoke exposure influences the formation of leukemogenic genomic deletions. Somatic copy number of 8 genes frequently deleted in ALL (CDKN2A, ETV6, IKZF1, PAX5, RB1, BTG1, PAR1 region, and EBF1) was assessed in 559 pretreatment tumor samples from the California Childhood Leukemia Study. Parent and child's passive tobacco exposure was assessed using interview-assisted questionnaires as well as DNA methylation in aryl-hydrocarbon receptor repressor (AHRR), a sentinel epigenetic biomarker of exposure to maternal smoking during pregnancy. Multivariable Poisson regressions were used to test the association between the smoking exposures and total number of deletions. Deletion burden varied by subtype, with a lower frequency in high-hyperdiploid and higher frequency in ETV6-RUNX1 fusion ALL. The total number of deletions per case was positively associated with tobacco smoke exposure, in particular for maternal ever-smoking (ratio of means, RM, 1.31; 95% CI, 1.08-1.59), maternal smoking during pregnancy (RM, 1.48; 95% CI, 1.12-1.94), and during breastfeeding (RM, 2.11; 95% CI, 1.48-3.02). The magnitude of association with maternal ever-smoking was stronger in male children compared with females (Pinteraction = 0.04). The total number of deletions was also associated with DNA methylation at the AHRR epigenetic biomarker (RM, 1.32; 95% CI, 1.02-1.69). Our results suggest that prenatal and early-life tobacco smoke exposure increase the frequency of somatic deletions in children who develop ALL. Cancer Res; 77(7); 1674-83. ©2017 AACR.

    View details for DOI 10.1158/0008-5472.CAN-16-2571

    View details for PubMedID 28202519

    View details for PubMedCentralID PMC5380517

  • In utero cytomegalovirus infection and development of childhood acute lymphoblastic leukemia. Blood Francis, S. S., Wallace, A. D., Wendt, G. A., Li, L., Liu, F., Riley, L. W., Kogan, S., Walsh, K. M., de Smith, A. J., Dahl, G. V., Ma, X., Delwart, E., Metayer, C., Wiemels, J. L. 2016


    It is widely suspected, yet controversial, that infection plays an etiologic role in the development of acute lymphoblastic leukemia (ALL), the most common childhood cancer and a disease with a confirmed prenatal origin in most cases. We investigated infections at diagnosis and then assessed the timing of infection at birth in children with ALL and age, gender, and ethnicity matched controls to identify potential causal initiating infections. Comprehensive untargeted virome and bacterial analyses of pretreatment bone marrow specimens (n = 127 ALL in comparison with 38 acute myeloid leukemia cases in a comparison group) revealed prevalent cytomegalovirus (CMV) infection at diagnosis in childhood ALL, demonstrating active viral transcription in leukemia blasts as well as intact virions in serum. Screening of newborn blood samples revealed a significantly higher prevalence of in utero CMV infection in ALL cases (n = 268) than healthy controls (n = 270) (odds ratio [OR], 3.71, confidence interval [CI], 1.56-7.92, P = .0016). Risk was more pronounced in Hispanics (OR=5.90, CI=1.89-25.96) than in non-Hispanic whites (OR=2.10 CI= 0.69-7.13). This is the first study to suggest that congenital CMV infection is a risk factor for childhood ALL and is more prominent in Hispanic children. Further investigation of CMV as an etiologic agent for ALL is warranted.

    View details for PubMedID 27979823

  • Childhood Leukemia: A Preventable Disease PEDIATRICS Metayer, C., Dahl, G., Wiemels, J., Miller, M. 2016; 138: S45-S55


    In contrast to most pediatric cancers, there is a growing body of literature, nationally and internationally, that has implicated the role of several environmental indoor and outdoor hazards in the etiology of childhood leukemia. For example, exposures to solvents, traffic, pesticides, and tobacco smoke have consistently demonstrated positive associations with the risk of developing childhood leukemia. Intake of vitamins and folate supplementation during the preconception period or pregnancy has been demonstrated to have a protective effect. Despite the strength of these findings, the dissemination of this knowledge to clinicians has been limited. Some children may be more vulnerable than others as documented by the high and increasing incidence of childhood leukemia in Hispanics. To protect children's health, it is prudent to establish programs to alter exposure to those factors with well-established associations with leukemia risk rather than to suspend judgment until no uncertainty remains. This is particularly true because other serious health outcomes (both negative and positive) have been associated with the same exposures. We draw from historical examples to put in perspective the arguments of association versus causation, as well as to discuss benefits versus risks of immediate and long-term preventive actions.

    View details for DOI 10.1542/peds.2015-4268H

    View details for Web of Science ID 000389414300007

    View details for PubMedID 27940977

    View details for PubMedCentralID PMC5080868

  • Small molecule inhibition of cAMP response element binding protein in human acute myeloid leukemia cells. Leukemia Mitton, B., Chae, H., Hsu, K., Dutta, R., Aldana-Masangkay, G., FERRARI, R., Davis, K., Tiu, B. C., Kaul, A., Lacayo, N., Dahl, G., Xie, F., Li, B. X., Breese, M. R., Landaw, E. M., Nolan, G., Pellegrini, M., Romanov, S., Xiao, X., Sakamoto, K. M. 2016


    The transcription factor CREB (cAMP Response-Element Binding Protein) is overexpressed in the majority of acute myeloid leukemia (AML) patients, and this is associated with a worse prognosis. Previous work revealed that CREB overexpression augmented AML cell growth, while CREB knockdown disrupted key AML cell functions in vitro. In contrast, CREB knockdown had no effect on long-term hematopoietic stem cell activity in mouse transduction/transplantation assays. Together, these studies position CREB as a promising drug target for AML. To test this concept, a small molecule inhibitor of CREB, XX-650-23, was developed. This molecule blocks a critical interaction between CREB and its required co-activator CBP (CREB Binding Protein), leading to disruption of CREB-driven gene expression. Inhibition of CBP-CREB interaction induced apoptosis and cell-cycle arrest in AML cells, and prolonged survival in vivo in mice injected with human AML cells. XX-650-23 had little toxicity on normal human hematopoietic cells and tissues in mice. To understand the mechanism of XX-650-23, we performed RNA-seq, ChIP-seq and Cytometry Time of Flight with human AML cells. Our results demonstrate that small molecule inhibition of CBP-CREB interaction mostly affects apoptotic, cell-cycle and survival pathways, which may represent a novel approach for AML therapy.

    View details for DOI 10.1038/leu.2016.139

    View details for PubMedID 27211267

  • The genomic landscape of juvenile myelomonocytic leukemia NATURE GENETICS Stieglitz, E., Taylor-Weiner, A. N., Chang, T. Y., Gelston, L. C., Wang, Y., Mazor, T., Esquivel, E., Yu, A., Seepo, S., Olsen, S. R., Rosenberg, M., Archambeault, S. L., Abusin, G., Beckman, K., Brown, P. A., Briones, M., Carcamo, B., Cooper, T., Dahl, G. V., Emanuel, P. D., Fluchel, M. N., Goyal, R. K., Hayashi, R. J., Hitzler, J., Hugge, C., Liu, Y. L., Messinger, Y. H., Mahoney, D. H., Monteleone, P., Nemecek, E. R., Roehrs, P. A., Schore, R. J., Stine, K. C., Takemoto, C. M., Toretsky, J. A., Costello, J. F., Olshen, A. B., Stewart, C., Li, Y., Ma, J., Gerbing, R. B., Alonzo, T. A., Getz, G., Gruber, T. A., Golub, T. R., Stegmaier, K., Loh, M. L. 2015; 47 (11): 1326-?


    Juvenile myelomonocytic leukemia (JMML) is a myeloproliferative neoplasm (MPN) of childhood with a poor prognosis. Mutations in NF1, NRAS, KRAS, PTPN11 or CBL occur in 85% of patients, yet there are currently no risk stratification algorithms capable of predicting which patients will be refractory to conventional treatment and could therefore be candidates for experimental therapies. In addition, few molecular pathways aside from the RAS-MAPK pathway have been identified that could serve as the basis for such novel therapeutic strategies. We therefore sought to genomically characterize serial samples from patients at diagnosis through relapse and transformation to acute myeloid leukemia to expand knowledge of the mutational spectrum in JMML. We identified recurrent mutations in genes involved in signal transduction, splicing, Polycomb repressive complex 2 (PRC2) and transcription. Notably, the number of somatic alterations present at diagnosis appears to be the major determinant of outcome.

    View details for DOI 10.1038/ng.3400

    View details for PubMedID 26457647

  • Dust metal loadings and the risk of childhood acute lymphoblastic leukemia JOURNAL OF EXPOSURE SCIENCE AND ENVIRONMENTAL EPIDEMIOLOGY Whitehead, T. P., Ward, M. H., Colt, J. S., Dahl, G., Ducore, J., Reinier, K., Gunier, R. B., Hammond, S. K., Rappaport, S. M., Metayer, C. 2015; 25 (6): 593-598

    View details for DOI 10.1038/jes.2015.9

    View details for PubMedID 25736162

  • Children's Cancer and Environmental Exposures: Professional Attitudes and Practices. Journal of pediatric hematology/oncology Zachek, C. M., Miller, M. D., Hsu, C., Schiffman, J. D., Sallan, S., Metayer, C., Dahl, G. V. 2015; 37 (7): 491-497


    Epidemiologic studies worldwide have provided substantial evidence of the contributions of environmental exposures to the development of childhood cancer, yet this knowledge has not been integrated into the routine practice of clinicians who care for children with this disease. To identify the basis of this deficit, we sought to assess the environmental history-taking behavior and perceptions of environmental health among pediatric hematologists and oncologists.A web-based survey was sent from June to October 2012 to 427 pediatric oncologists, fellows, and nurse practitioners from 20 US institutions, with an overall response rate of 45%.Survey responses indicated that environmental exposures are of concern to clinicians. The vast majority of respondents (88%) reported receiving questions from families about the relationship between certain environmental exposures and the cancers they regularly treat. However, a lack of comfort with these topics seems to have limited their discussions with families about the role of environmental exposures in childhood cancer pathogenesis. Although 77% of respondents suspected that some of the cases they saw had an environmental origin, their methods of taking environmental histories varied widely. Over 90% of respondents believed that more knowledge of the associations between environmental exposures and childhood cancer would be helpful in addressing these issues with patients.Although limited in size and representativeness of participating institutions, the results of this survey indicate a need for increased training for hematology/oncology clinicians about environmental health exposures related to cancer and prompt translation of emerging research findings in biomedical journals that clinicians read.

    View details for DOI 10.1097/MPH.0000000000000416

    View details for PubMedID 26334434

    View details for PubMedCentralID PMC4571458

  • Cytogenetic Variation of B-Lymphoblastic Leukemia With Infrachromosomal Amplification of Chromosome 21 (iAMP21) A Multi-Institutional Series Review AMERICAN JOURNAL OF CLINICAL PATHOLOGY Johnson, R. C., Weinberg, O. K., Cascio, M. J., Dahl, G. V., Mitton, B. A., Silverman, L. B., Cherry, A. M., Arber, D. A., Ohgami, R. S. 2015; 144 (1): 103-112


    B-lymphoblastic leukemia (B-ALL) with intrachromosomal amplification of chromosome 21 (iAMP21) is a relatively uncommon manifestation of acute leukemia and limited predominantly to the pediatric population. Case-specific information regarding flow cytometric, morphologic, and laboratory findings of this subtype of leukemia is currently lacking.We searched the databases of three large institutions for lymphoblastic leukemia with iAMP21 from 2005 through 2012 and analyzed the clinicopathologic features.We identified 17 cases with five or more RUNX1 signals on interphase nuclei, 14 of which were consistent with the Children's Oncology Group (COG) definition for iAMP21—namely, the presence of three or more RUNX1 signals on one marker chromosome. These cases showed a statistically significant lower peripheral WBC count and older age at diagnosis compared with all pediatric cases of B-ALL. We also identified three cases with increased RUNX1 signals scattered on multiple marker chromosomes that did not meet the COG definition of iAMP21 but showed similar 21q instability and older age at presentation.Our findings not only demonstrate that B-ALL with iAMP21 is truly a distinct clinicopathologic entity but also suggest that a subset of cases of B-ALL with iAMP21 can show variable cytogenetic features.

    View details for DOI 10.1309/AJCPLUYF11HQBYRB

    View details for PubMedID 26071468

  • What causes leukemia? Pediatric blood & cancer Dahl, G., Wiemels, J. 2015; 62 (7): 1123-1124

    View details for DOI 10.1002/pbc.25526

    View details for PubMedID 25894591

  • Prognostic factors in children with acute myeloid leukaemia and excellent response to remission induction therapy BRITISH JOURNAL OF HAEMATOLOGY Karol, S. E., Coustan-Smith, E., Cao, X., Shurtleff, S. A., Raimondi, S. C., Choi, J. K., Ribeiro, R. C., Dahl, G. V., Bowman, W. P., Taub, J. W., Degar, B., Leung, W., Downing, J. R., Pui, C., Rubnitz, J. E., Campana, D., Inaba, H. 2015; 168 (1): 94-101


    Minimal residual disease (MRD) is a strong prognostic factor in children and adolescents with acute myeloid leukaemia (AML) but nearly one-quarter of patients who achieve MRD-negative status still relapse. The adverse prognostic factors among MRD-negative patients remain unknown. We analysed the AML02 study cohort to identify demographic and genetic prognostic factors. Among the presenting features, certain 11q23 abnormalities, such as t(6;11) and t(10;11), acute megakaryoblastic leukaemia without the t(1;22), and age ≥10 years were associated with inferior outcome in patients who had MRD-negative status after either remission induction I or II. By contrast, those with rearrangement of CBF genes had superior outcome. Our study identifies patient populations for whom close post-remission MRD monitoring to detect and treat emerging relapse and adjustment in treatment intensity might be indicated.

    View details for DOI 10.1111/bjh.13107

    View details for Web of Science ID 000346151600012

    View details for PubMedID 25164427

    View details for PubMedCentralID PMC4262553

  • Residential Levels of Polybrominated Diphenyl Ethers and Risk of Childhood Acute Lymphoblastic Leukemia in California ENVIRONMENTAL HEALTH PERSPECTIVES Ward, M. H., Colt, J. S., Deziel, N. C., Whitehead, T. P., Reynolds, P., Gunier, R. B., Nishioka, M., Dahl, G. V., Rappaport, S. M., Buffler, P. A., Metayer, C. 2014; 122 (10): 1110-1116


    House dust is a major source of exposure to polybrominated diphenyl ethers (PBDEs), which are found at high levels in U.S. homes.We studied 167 acute lymphoblastic leukemia (ALL) cases 0-7 years of age and 214 birth certificate controls matched on date of birth, sex, and race/ethnicity from the Northern California Childhood Leukemia Study. In 2001-2007, we sampled carpets in the room where the child spent the most time while awake; we used a high-volume small-surface sampler or we took dust from the home vacuum. We measured concentrations of 14 PBDE congeners including penta (28, 47, 99, 100, 153, 154), octa (183, 196, 197, 203), and decaBDEs (206-209). Odds ratios (ORs) were calculated using logistic regression, adjusting for demographics, income, year of dust collection, and sampling method.BDE-47, BDE-99, and BDE-209 were found at the highest concentrations (medians, 1,173, 1,579, and 938 ng/g, respectively). Comparing the highest to lowest quartile, we found no association with ALL for summed pentaBDEs (OR = 0.7; 95% CI: 0.4, 1.3), octaBDEs (OR = 1.3; 95% CI: 0.7, 2.3), or decaBDEs (OR = 1.0; 95% CI: 0.6, 1.8). Comparing homes in the highest concentration (nanograms per gram) tertile to those with no detections, we observed significantly increased ALL risk for BDE-196 (OR = 2.1; 95% CI: 1.1, 3.8), BDE-203 (OR = 2.0; 95% CI: 1.1, 3.6), BDE-206 (OR = 2.1; 95% CI: 1.1, 3.9), and BDE-207 (OR = 2.0; 95% CI: 1.03, 3.8).We found no association with ALL for common PBDEs, but we observed positive associations for specific octa and nonaBDEs. Additional studies with repeated sampling and biological measures would be informative.

    View details for DOI 10.1289/ehp.1307602

    View details for Web of Science ID 000343136200024

    View details for PubMedID 24911217

  • Altered resting state functional connectivity in young survivors of acute lymphoblastic leukemia. Pediatric blood & cancer Kesler, S. R., Gugel, M., Pritchard-Berman, M., Lee, C., Kutner, E., Hosseini, S. M., Dahl, G., Lacayo, N. 2014; 61 (7): 1295-1299


    Chemotherapy treatment for pediatric acute lymphoblastic leukemia (ALL) has been associated with long-term cognitive impairments in some patients. However, the neurobiologic mechanisms underlying these impairments, particularly in young survivors, are not well understood. This study aimed to examine intrinsic functional brain connectivity in pediatric ALL and its relationship with cognitive status.We obtained resting state functional magnetic resonance imaging (rsfMRI) and cognitive testing data from 15 ALL survivors age 8-15 years and 14 matched healthy children. The ALL group had a history of intrathecal chemotherapy treatment but were off-therapy for at least 6 months at the time of enrollment. We used seed-based analyses to compare intrinsic functional brain network connectivity between the groups. We also explored correlations between connectivity and cognitive performance, demographic, medical, and treatment variables.We demonstrated significantly reduced connectivity between bilateral hippocampus, left inferior occipital, left lingual gyrus, bilateral calcarine sulcus, and right amygdala in the ALL group compared to controls. The ALL group also showed regions of functional hyperconnectivity including right lingual gyrus, precuneus, bilateral superior occipital lobe, and right inferior occipital lobe. Functional hypoconnectivity was associated with reduced cognitive function as well as younger age at diagnosis in the ALL group.This is the first study to demonstrate that intrinsic functional brain connectivity is disrupted in pediatric ALL following chemotherapy treatment. These results help explain cognitive dysfunction even when objective test performance is seemingly normal. Children diagnosed at a younger age may show increased vulnerability to altered functional brain connectivity.

    View details for DOI 10.1002/pbc.25022

    View details for PubMedID 24619953

    View details for PubMedCentralID PMC4028071

  • Genomic ancestry and somatic alterations correlate with age at diagnosis in Hispanic children with B-cell acute lymphoblastic leukemia. American journal of hematology Walsh, K. M., de Smith, A. J., Welch, T. C., Smirnov, I., Cunningham, M. J., Ma, X., Chokkalingam, A. P., Dahl, G. V., Roberts, W., Barcellos, L. F., Buffler, P. A., Metayer, C., Wiemels, J. L. 2014; 89 (7): 721-725


    Hispanic children have a higher incidence of acute lymphoblastic leukemia (ALL) than non-Hispanic whites but tend to be diagnosed at older ages. In genome-wide association studies, Native American ancestry and polymorphisms in six genes have been associated with ALL risk. In multivariable regression models, we investigated whether genomic ancestry, inherited risk SNPs, or acquired somatic alterations were associated with differences in age at diagnosis in Hispanic children with B-cell ALL. Genome-wide array data were used to estimate each participant's percent membership in the three Hispanic ancestral populations: Native American, African, and European. Each 20% increase in European ancestry was associated with a six month younger age at diagnosis (95% CI = 0.36-11.6 months, P = 0.037). Correspondingly, each 20% increase in Native American ancestry was associated with a six-month older age at diagnosis (P = 0.037). Both the TEL-AML1 translocation and high-hyperdiploidy were associated with younger age at diagnosis (24.4 months, P = 2.0 x 10(-4) and 12.4 months, P = 0.011, respectively), while CDKN2A and IKZF1 deletions were associated with older age at diagnosis (19.7 months, P = 7.0 x 10(-4) and 18.1 months, P = 0.012, respectively). No associations with age at diagnosis were observed for RAS mutation, PAX5 deletion or for known heritable risk alleles in IKZF1, CDKN2A, PIP4K2A, GATA3, ARID5B, or CEBPE. Because younger age at diagnosis is associated with improved treatment outcomes for children with ALL, the effect of European ancestry on ALL survival may be mediated by its effect on age at diagnosis, or by proxy, its association with more treatable molecular subtypes of ALL.

    View details for DOI 10.1002/ajh.23727

    View details for PubMedID 24753091

  • Genomic ancestry and somatic alterations correlate with age at diagnosis in Hispanic children with B-cell acute lymphoblastic leukemia AMERICAN JOURNAL OF HEMATOLOGY Walsh, K. M., de Smith, A. J., Welch, T. C., Smirnov, I., Cunningham, M. J., Ma, X., Chokkalingam, A. P., Dahl, G. V., Roberts, W., Barcellos, L. F., Buffler, P. A., Metayer, C., Wiemels, J. L. 2014; 89 (7): 721-725

    View details for DOI 10.1002/ajh.23727

    View details for Web of Science ID 000338029300010

  • Safety Profile of Asparaginase Erwinia chrysanthemi in a Large Compassionate-Use Trial PEDIATRIC BLOOD & CANCER Plourde, P. V., Jeha, S., Hijiya, N., Keller, F. G., Silverman, L. B., Rheingold, S. R., Dreyer, Z. E., Dahl, G. V., Mercedes, T., Lai, C., Corn, T. 2014; 61 (7): 1232-1238


    L-Asparaginase is an integral component of standard chemotherapy regimens for the treatment of acute lymphoblastic leukemia (ALL). Clinical hypersensitivity, a common reason for treatment discontinuation, has been reported in 10-30% of patients receiving Escherichia coli-derived asparaginase. After hypersensitivity, E. coli-derived asparaginase should be discontinued and an alternative asparaginase preparation, such as asparaginase Erwinia chrysanthemi, may be initiated. We conducted a compassionate-use study to collect additional safety information on asparaginase Erwinia chrysanthemi and to support FDA approval of the product.Patients with ALL or lymphoblastic lymphoma (LBL; N = 1368) who developed a hypersensitivity reaction (grade ≥2) to an E. coli-derived asparaginase participated in this trial. The recommended asparaginase Erwinia chrysanthemi dose was 25,000 IU/m(2) three days per week (Monday/Wednesday/Friday) for two consecutive weeks for each missed pegylated E. coli-derived asparaginase dose and 25,000 IU/m(2) for each missed nonpegylated asparaginase dose for the completion of their planned asparaginase treatment.Adverse event reports and/or case report forms were completed for 940 patients. The most common adverse event (AE) was hypersensitivity (13.6%). Eighteen patients (1.9%) died during the study. Most patients (77.6%) completed their planned asparaginase treatment with asparaginase Erwinia chrysanthemi. There was no apparent difference in the incidence of the most commonly reported AEs with asparaginase treatment by age, administration, or disease state.This study further established the safety profile of asparaginase Erwinia chrysanthemi in patients with ALL or LBL who had a hypersensitivity reaction to an E. coli-derived asparaginase.

    View details for DOI 10.1002/pbc.24978

    View details for Web of Science ID 000335198400021

    View details for PubMedID 24436152

  • Gemtuzumab Ozogamicin Can Reduce Minimal Residual Disease in Patients With Childhood Acute Myeloid Leukemia CANCER O'Hear, C., Inaba, H., Pounds, S., Shi, L., Dahl, G., Bowman, W. P., Taub, J. W., Pui, C., Ribeiro, R. C., Coustan-Smith, E., Campana, D., Rubnitz, J. E. 2013; 119 (22): 4036-4043


    Gemtuzumab ozogamicin (GO) is an active agent for the treatment of CD33-postive acute myeloid leukemia (AML) and may improve the outcome of specific patient subgroups when combined with conventional chemotherapy. However, to the best of the authors' knowledge, the effects of GO on levels of minimal residual disease (MRD) are unknown.Pediatric patients with AML who received GO, either alone or in combination with chemotherapy on the AML02 multicenter trial, were analyzed to determine the effects of GO on MRD and outcome.Among 17 patients who received GO alone because of persistent leukemia, 14 had a reduction in their MRD level and 13 became MRD negative. Of the 29 who received chemotherapy in combination with GO after responding poorly to chemotherapy, 28 demonstrated reduced MRD and 13 became MRD negative. Treatment with GO effectively reduced MRD before hematopoietic stem cell transplantation and was not found to be associated with increased treatment-related mortality after transplantation.GO is effective in reducing MRD levels in pediatric patients with AML and may improve the outcome of those patients at high risk of disease recurrence.

    View details for DOI 10.1002/cncr.28334

    View details for Web of Science ID 000326418500022

    View details for PubMedCentralID PMC4271731

  • Development and validation of a single-cell network profiling assay-based classifier to predict response to induction therapy in paediatric patients with de novo acute myeloid leukaemia: a report from the Children's Oncology Group BRITISH JOURNAL OF HAEMATOLOGY Lacayo, N. J., Alonzo, T. A., Gayko, U., Rosen, D. B., Westfall, M., Purvis, N., Putta, S., Louie, B., Hackett, J., Cohen, A. C., Cesano, A., Gerbing, R., Ravindranath, Y., Dahl, G. V., Gamis, A., Meshinchi, S. 2013; 162 (2): 250-262


    Single cell network profiling (SCNP) is a multi-parameter flow cytometry technique for simultaneous interrogation of intracellular signalling pathways. Diagnostic paediatric acute myeloid leukaemia (AML) bone marrow samples were used to develop a classifier for response to induction therapy in 53 samples and validated in an independent set of 68 samples. The area under the curve of a receiver operating characteristic curve (AUCROC ) was calculated to be 0·85 in the training set and after exclusion of induction deaths, the AUCROC of the classifier was 0·70 (P = 0·02) and 0·67 (P = 0·04) in the validation set when induction deaths (intent to treat) were included. The highest predictive accuracy was noted in the cytogenetic intermediate risk patients (AUCROC 0·88, P = 0·002), a subgroup that lacks prognostic/predictive biomarkers for induction response. Only white blood cell count and cytogenetic risk were associated with response to induction therapy in the validation set. After controlling for these variables, the SCNP classifier score was associated with complete remission (P = 0·017), indicating that the classifier provides information independent of other clinical variables that were jointly associated with response. This is the first validation of an SCNP classifier to predict response to induction chemotherapy. Herein we demonstrate the usefulness of quantitative SCNP under modulated conditions to provide independent information on AML disease biology and induction response.

    View details for DOI 10.1111/bjh.12370

    View details for Web of Science ID 000321211300012

    View details for PubMedID 23682827

  • Pediatric Acute Myeloid Leukemia as Classified Using 2008 WHO Criteria: A Single-Center Experience. American journal of clinical pathology Davis, K. L., Marina, N., Arber, D. A., Ma, L., Cherry, A., Dahl, G. V., Heerema-McKenney, A. 2013; 139 (6): 818-825


    The classification of acute myeloid leukemia (AML) has evolved to the most recent World Health Organization (WHO) schema, which integrates genetic, morphologic, and prognostic data into a single system. However, this system was devised using adult data and how this system applies to a pediatric cohort is unknown. Performing a retrospective chart review, we examined our single-center experience with AML in 115 children and classified their leukemia using the WHO 2008 schema. We examined patient samples for mutations of FLT3, NPM1, and CEBPA. Overall survival was calculated within categories. In our pediatric population, most cases of AML had recurrent genetic abnormalities of favorable prognosis. More than 10% of patients in our series were categorized as AML, with myelodysplasia-related changes, an entity not well-described in pediatric patients. In addition, a large proportion of patients were categorized with secondary, therapy-related AML. To our knowledge, this is the first application of the WHO 2008 classification to a pediatric cohort. In comparison to adult studies, AML in the pediatric population shows a distinct distribution within the WHO 2008 classification.

    View details for DOI 10.1309/AJCP59WKRZVNHETN

    View details for PubMedID 23690127

  • Prognostic features in acute megakaryoblastic leukemia in children without Down syndrome: a report from the AML02 multicenter trial and the Children's Oncology Group Study POG 9421 LEUKEMIA O'Brien, M. M., Cao, X., Pounds, S., Dahl, G. V., Raimondi, S. C., Lacayo, N. J., Taub, J., Chang, M., Weinstein, H. J., Ravindranath, Y., Inaba, H., Campana, D., Pui, C. H., Rubnitz, J. E. 2013; 27 (3): 731-734

    View details for DOI 10.1038/leu.2012.223

    View details for Web of Science ID 000316587300031

    View details for PubMedID 22918081

  • Treatment Outcome in Older Patients With Childhood Acute Myeloid Leukemia CANCER Rubnitz, J. E., Pounds, S., Cao, X., Jenkins, L., Dahl, G., Bowman, W. P., Taub, J. W., Pui, C., Ribeiro, R. C., Campana, D., Inaba, H. 2012; 118 (24): 6253-6259


    Older age has historically been an adverse prognostic factor in pediatric acute myeloid leukemia (AML). To the authors' knowledge, the impact of age relative to that of other prognostic factors on the outcome of patients treated in recent trials is unknown.Clinical outcome and causes of treatment failure of 351 patients enrolled on 3 consecutive protocols for childhood AML between 1991 and 2008 were analyzed according to age and protocol.The more recent protocol (AML02) produced improved outcomes for patients aged 10 years to 21 years compared with 2 earlier studies (AML91 and AML97), with 3-year rates of event-free survival (EFS), overall survival (OS), and cumulative incidence of refractory leukemia or recurrence (CIR) for this group being similar to those of patients aged birth to 9 years: EFS: 58.3% ± 5.4% versus 66.6% ± 4.9% (P = .20); OS: 68.9% ± 5.1% versus 75.1% ± 4.5% (P = .36); and CIR: 21.9% ± 4.4% versus 25.3% ± 4.2% (P = .59). The EFS and OS estimates for patients aged 10 to 15 years overlapped those for patients aged 16 to 21 years. However, the cumulative incidence of toxic death was significantly higher for patients aged 10 to 21 years compared with younger patients (13.2% ± 3.6% vs 4.5% ± 2.0%; P = .028).The survival rate for older children with AML has improved on the results of a recent trial and is now similar to that of younger patients. However, deaths from toxicity remain a significant problem for patients in the older age group. Future trials should focus on improving supportive care while striving to develop more effective antileukemic therapy.

    View details for DOI 10.1002/cncr.27659

    View details for Web of Science ID 000311911600031

    View details for PubMedID 22674050

  • Effect of body mass index on the outcome of children with acute myeloid leukemia CANCER Inaba, H., Surprise, H. C., Pounds, S., Cao, X., Howard, S. C., Ringwald-Smith, K., Buaboonnam, J., Dahl, G., Bowman, W. P., Taub, J. W., Campana, D., Pui, C., Ribeiro, R. C., Rubnitz, J. E. 2012; 118 (23): 5989-5996


    The effect of body mass index (BMI) on the treatment outcomes of children with acute myeloid leukemia (AML) is unclear and needs further evaluation.Children with AML (n = 314) who were enrolled in 4 consecutive St. Jude protocols were grouped according to BMI (underweight, <5th percentile; healthy weight, 5th to 85th percentile; and overweight/obese, ≥ 85th percentile).Twenty-five patients (8%) were underweight, 86 patients (27.4%) were overweight/obese, and 203 patients (64.6%) had healthy weight. The 5-year overall survival rate of overweight/obese patients (46.5% ± 7.3%) was lower than the rate of patients with healthy weight (67.1% ± 4.3%; P < .001); underweight patients also tended to have lower survival rates (50.6% ± 10.7%; P = .18). In a multivariable analysis that was adjusted for age, leukocyte count, French-American-British classification, and study protocols, patients with healthy weight had the best survival rate among the 3 groups (P = .01). When BMI was considered as continuous variable, patients with lower or higher BMI percentiles had worse survival (P = .03). There was no difference in the occurrence of induction failure or relapse among BMI groups, although underweight and overweight/obese patients had a significantly higher cumulative incidence of treatment-related mortality, especially because of infection (P = .009).An unhealthy BMI was associated with worse survival and more treatment-related mortality in children with AML. Meticulous supportive care with nutritional support and education, infection prophylaxis, and detailed laboratory and physical examination is required for these patients. These measures, together with pharmacokinetics-guided chemotherapy dosing, may improve outcome.

    View details for DOI 10.1002/cncr.27640

    View details for Web of Science ID 000311306000033

    View details for PubMedID 22648558

  • Massive evolution of the immunoglobulin heavy chain locus in children with B precursor acute lymphoblastic leukemia BLOOD Gawad, C., Pepin, F., Carlton, V. E., Klinger, M., Logan, A. C., Miklos, D. B., Faham, M., Dahl, G., Lacayo, N. 2012; 120 (22): 4407-4417


    The ability to distinguish clonal B-cell populations based on the sequence of their rearranged immunoglobulin heavy chain (IgH) locus is an important tool for diagnosing B-cell neoplasms and monitoring treatment response. Leukemic precursor B cells may continue to undergo recombination of the IgH gene after malignant transformation; however, the magnitude of evolution at the IgH locus is currently unknown. We used next-generation sequencing to characterize the repertoire of IgH sequences in diagnostic samples of 51 children with B precursor acute lymphoblastic leukemia (B-ALL). We identified clonal IgH rearrangements in 43 of 51 (84%) cases and found that the number of evolved IgH sequences per patient ranged dramatically from 0 to 4024. We demonstrate that the evolved IgH sequences are not the result of amplification artifacts and are unique to leukemic precursor B cells. In addition, the evolution often follows an allelic exclusion pattern, where only 1 of 2 rearranged IgH loci exhibit ongoing recombination. Thus, precursor B-cell leukemias maintain evolution at the IgH locus at levels that were previously underappreciated. This finding sheds light on the mechanisms associated with leukemic clonal evolution and may fundamentally change approaches for monitoring minimal residual disease burden.

    View details for DOI 10.1182/blood-2012-05-429811

    View details for Web of Science ID 000313111300023

    View details for PubMedID 22932801

    View details for PubMedCentralID PMC3507147

  • Concurrent cyclophosphamide and craniospinal radiotherapy for pediatric high-risk embryonal brain tumors JOURNAL OF NEURO-ONCOLOGY Campen, C. J., Dearlove, J., Partap, S., Murphy, P., Gibbs, I. C., Dahl, G. V., Fisher, P. G. 2012; 110 (2): 287-291


    Embryonal tumors are an aggressive subtype of high-grade, pediatric central nervous system (CNS) tumors often with dismal survival rates. The 5-year survival for highest-risk embryonal tumors may be as low as 10 %. We report feasibility and efficacy from our experience using intravenous (IV) cyclophosphamide concurrently with craniospinal radiation (CSI) in high-risk embryonal CNS tumors of childhood. Ten consecutive children (aged: 3.5-15.5 years, median: 10.2 years, six male) with high-risk embryonal tumors, including: large cell/anaplastic medulloblastoma (6), atypical teratoid rhabdoid tumor (1), and leptomeningeal primitive neuroectodermal tumor (3), were treated with IV cyclophosphamide 1 g/M(2) on days 1 and 2 of CSI. Following a median of 36 Gy CSI plus tumor boosts, adjuvant treatment consisted of 21 doses of oral etoposide (7) and alkylator based chemotherapy from five to eight cycles in all. Of the ten patients thus treated, six remain alive with no evidence of disease and four are deceased. Median survival was 3.3 years, with a 3-year progression-free survival of 50 % (5/10). Median follow-up was: 3.3 years (range: 5 months-12.9 years) in the five patients with progression, median time-to-progression was: 1.3 years (range: 1 month-3 years). Median follow-up in the patients without progression is 8.8 years (range: 3-12.9 years). Complications due to adjuvant chemotherapy were typical and included myelosupression (10), necessitating shortened duration of chemotherapy in three, and hemorrhagic cystitis (1). In high-risk embryonal CNS tumors, cyclophosphamide given concurrently with CSI is well tolerated. Early results suggest that a phase II trial is warranted.

    View details for DOI 10.1007/s11060-012-0969-2

    View details for Web of Science ID 000311208100017

    View details for PubMedID 22941430

  • HLA-DP genetic variation, proxies for early life immune modulation and childhood acute lymphoblastic leukemia risk BLOOD Urayama, K. Y., Chokkalingam, A. P., Metayer, C., Ma, X., Selvin, S., Barcellos, L. F., Wiemels, J. L., Wiencke, J. K., Taylor, M., Brennan, P., Dahl, G. V., Moonsamy, P., Erlich, H. A., Trachtenberg, E., Buffler, P. A. 2012; 120 (15): 3039-3047


    The human leukocyte antigen (HLA) genes are candidate genetic susceptibility loci for childhood acute lymphoblastic leukemia (ALL). We examined the effect of HLA-DP genetic variation on risk and evaluated its potential interaction with 4 proxies for early immune modulation, including measures of infectious exposures in infancy (presence of older siblings, daycare attendance, ear infections) and breastfeeding. A total of 585 ALL cases and 848 controls were genotyped at the HLA-DPA1 and DPB1 loci. Because of potential heterogeneity in effect by race/ethnicity, we included only non-Hispanic white (47%) and Hispanic (53%) children and considered these 2 groups separately in the analysis. Logistic regression analyses showed an increased risk of ALL associated with HLA-DPB1*01:01 (odds ratio [OR] = 1.43, 95% CI, 1.01-2.04) with no heterogeneity by Hispanic ethnicity (P = .969). Analyses of DPB1 supertypes showed a marked childhood ALL association with DP1, particularly for high-hyperdiploid ALL (OR = 1.83; 95% CI, 1.20-2.78). Evidence of interaction was found between DP1 and older sibling (P = .036), and between DP1 and breastfeeding (P = .094), with both showing statistically significant DP1 associations within the lower exposure categories only. These findings support an immune mechanism in the etiology of childhood ALL involving the HLA-DPB1 gene in the context of an insufficiently modulated immune system.

    View details for DOI 10.1182/blood-2012-01-404723

    View details for Web of Science ID 000311619300021

    View details for PubMedID 22923493

  • Comparative Analysis of Different Approaches to Measure Treatment Response in Acute Myeloid Leukemia JOURNAL OF CLINICAL ONCOLOGY Inaba, H., Coustan-Smith, E., Cao, X., Pounds, S. B., Shurtleff, S. A., Wang, K. Y., Raimondi, S. C., Onciu, M., Jacobsen, J., Ribeiro, R. C., Dahl, G. V., Bowman, W. P., Taub, J. W., Degar, B., Leung, W., Downing, J. R., Pui, C., Rubnitz, J. E., Campana, D. 2012; 30 (29): 3625-3632


    In acute myeloid leukemia (AML), initial treatment response by morphologic analysis of bone marrow predicts long-term outcome. Response can now be assessed by minimal residual disease (MRD) monitoring with flow cytometry or polymerase chain reaction (PCR). We determined the relation among the results of these approaches and their prognostic value.In the multicenter AML02 study, follow-up bone marrow samples from 203 children and adolescents with newly diagnosed AML were examined by flow cytometry (n = 1,514), morphology (n = 1,382), and PCR amplification of fusion transcripts (n = 508). Results were correlated with treatment outcome.Among 1,215 samples with less than 5% leukemic myeloblasts by morphology, 100 (8.2%) were MRD positive (≥ 0.1%) by flow cytometry, whereas 96 (57.5%) of the 167 samples with ≥ 5% blasts were MRD negative. Virtually all (308 of 311; 99.0%) MRD-negative samples by PCR were also MRD negative by flow cytometry. However, only 19 (9.6%) of the 197 PCR-positive samples were flow cytometry positive, with analyses of AML1-ETO and CBFβ-MYH11 accounting for most discrepancies, whereas eight of 13 MLL-positive samples had detectable MRD by flow cytometry. MRD by flow cytometry after induction 1 or 2 predicted lower event-free survival and higher relapse rate (P < .001) and was an independent prognostic factor in a multivariable analysis; prediction was not improved by morphologic information or molecular findings.In childhood AML, morphologic assessment of treatment response has limited value if MRD is measured by flow cytometry. MLL fusion transcripts can provide prognostic information in some patients, whereas monitoring of AML1-ETO and CBFβ-MYH11 transcripts is largely uninformative.

    View details for DOI 10.1200/JCO.2011.41.5323

    View details for Web of Science ID 000309653600013

    View details for PubMedID 22965955

  • Variation in xenobiotic transport and metabolism genes, household chemical exposures, and risk of childhood acute lymphoblastic leukemia CANCER CAUSES & CONTROL Chokkalingam, A. P., Metayer, C., Scelo, G. A., Chang, J. S., Urayama, K. Y., Aldrich, M. C., Guha, N., Hansen, H. M., Dahl, G. V., Barcellos, L. F., Wiencke, J. K., Wiemels, J. L., Buffler, P. A. 2012; 23 (8): 1367-1375


    Recent studies suggest that environmental exposures to pesticides, tobacco, and other xenobiotic chemicals may increase risk of childhood acute lymphoblastic leukemia (ALL). We sought to evaluate the role of genes involved in xenobiotic transport and metabolism in childhood ALL risk, both alone and in conjunction with household chemical exposures previously found to be associated with childhood ALL risk.We conducted a population-based epidemiologic study of 377 cases and 448 controls in California, utilizing a haplotype-based approach to evaluate 42 xenobiotic transport and metabolism genes in conjunction with data on self-reported household chemical exposures.We identified significant associations of childhood ALL risk with haplotypes of ABCB1, ARNT, CYP2C8, CYP1A2, CYP1B1, and IDH1. In addition, certain haplotypes showed significant joint effects with self-reported household chemical exposures on risk of childhood ALL. Specifically, elevated risks associated with use of paints in the home (ever) and indoor insecticides (pre-birth) were limited to subjects carrying specific haplotypes of CYP2C8 and ABCB1, respectively.Our results provide support for a role of xenobiotic transport and metabolism pathways in risk of childhood ALL and indicate that genes in these pathways may modulate the risk of disease associated with use of common household chemicals. Additional studies are needed to confirm these findings and localize specific causal variants.

    View details for DOI 10.1007/s10552-012-9947-4

    View details for Web of Science ID 000306122300016

    View details for PubMedID 22674224

  • Phase II study of 2-chlorodeoxyadenosine plus idarubicin for children with acute myeloid leukaemia in first relapse: a Paediatric Oncology Group study BRITISH JOURNAL OF HAEMATOLOGY Chaleff, S., Hurwitz, C. A., Chang, M., Dahl, G., Alonzo, T. A., Weinstein, H. 2012; 156 (5): 649-655


    Relapse remains the leading cause of death in patients with acute myeloid leukaemia (AML). Relatively few new chemotherapy agents have been proven to be effective in this population. We report on a Phase 2 clinical trial using the novel combination of 2-chlorodeoxyadenosine (2-CDA) (8 mg/m² per d x 5 d) plus idarubicin (Ida) (10 mg/m² per d x 3 d). The study involved 109 paediatric patients with AML at first relapse, of whom 104 were available for analysis. The overall response rate was 51% (complete response [CR] + partial response) with a CR rate of 46%. 2-year event-free survival (EFS) and overall survival (OS) were 20% and 26%. The only significant variable in determining response, EFS and OS was duration of initial remission, with patients who had an initial remission >1 year having much worse outcomes overall (response rate 74% vs. 25%, EFS 8% vs. 37% and OS of 16% vs. 39%, P < 0.01 for all). There was an acceptable toxicity profile with one neurological event and no cardiac events observed. The most common grade 3-4 toxicities observed were neutropenia (59%) and thrombocytopenia (68%). This study demonstrated that the novel combination of 2-CDA/Ida was effective and should be considered for incorporation in front line therapy for children with AML.

    View details for DOI 10.1111/j.1365-2141.2011.08976.x

    View details for Web of Science ID 000300971800010

    View details for PubMedID 22512017

  • Therapeutic Complications in a Patient With High-Risk Acute Lymphoblastic Leukemia and Undiagnosed Hereditary Hemochromatosis PEDIATRIC BLOOD & CANCER Balagtas, J. M., Dahl, G. V. 2012; 58 (1): 101-103


    Hereditary hemochromatosis (HH) is an autosomal-recessive disorder of iron metabolism that most commonly manifests in the fourth or fifth decade of life. Here, we describe a 14-year-old male who presented with high-risk acute lymphoblastic leukemia and previously undiagnosed HH. His treatment course was remarkable for significant therapeutic complications, including iron overload, hepatic failure, cardiac dysfunction, and death. Postmortem testing revealed homozygosity for the C282Y mutation, confirming the diagnosis of HH. Since HH mutations occur commonly in select populations, screening patients with leukemia for HH may better inform treatment decisions regarding chemotherapy, transfusions, and/or iron chelation therapy.

    View details for DOI 10.1002/pbc.22829

    View details for Web of Science ID 000297641300020

    View details for PubMedID 22076832

  • Phase 2 trial of clofarabine in combination with etoposide and cyclophosphamide in pediatric patients with refractory or relapsed acute lymphoblastic leukemia BLOOD Hijiya, N., Thomson, B., Isakoff, M. S., Silverman, L. B., Steinherz, P. G., Borowitz, M. J., Kadota, R., Cooper, T., Shen, V., Dahl, G., Thottassery, J. V., Jeha, S., Maloney, K., Paul, J., Barry, E., Carroll, W. L., Gaynon, P. S. 2011; 118 (23): 6043-6049


    The outcomes in children with refractory/relapsed (R/R) acute lymphoblastic leukemia (ALL) are dismal. The efficacy and safety of intravenous clofarabine 40 mg/m(2) per day, cyclophosphamide 440 mg/m(2) per day, and etoposide 100 mg/m(2) per day for 5 consecutive days in pediatric patients with R/R ALL was evaluated in this phase 2 study. The primary endpoint was overall response rate (complete remission [CR] plus CR without platelet recovery [CRp]). Among the 25 patients (median age, 14 years; pre-B cell ALL, 84%; ≥ 2 prior regimens: 84%; refractory to previous regimen: 60%), the overall response rate was 44% (7 CR, 4 CRp) with a 67.3-week median duration or remission censored at last follow-up. Most patients proceeded to alternative therapy, and 10 patients (40%) received hematopoietic stem cell transplantation. Six patients (24%) died because of treatment-related adverse events associated with infection, hepatotoxicity, and/or multiorgan failure. The study protocol was amended to exclude patients with prior hematopoietic stem cell transplantation after 4 of the first 8 patients developed severe hepatotoxicity suggestive of veno-occlusive disease. No additional cases of veno-occlusive disease occurred. The regimen offered encouraging response rates and sustained remission in R/R patients. Future investigation should include exploration of patient selection, dosing, and supportive care. This trial was registered at as #NCT00315705.

    View details for DOI 10.1182/blood-2011-08-374710

    View details for Web of Science ID 000297757700013

    View details for PubMedID 21967976

  • Langerhans cell histiocytosis in a 5-month-old presenting with biparietal masses Case report JOURNAL OF NEUROSURGERY-PEDIATRICS Pricola, K. L., Karamchandani, J., Vogel, H., Dahl, G. V., Yeom, K. W., Edwards, M. S., Guzman, R. 2010; 6 (4): 393-397


    Langerhans cell histiocytosis (LCH) is a rare proliferative disorder that occurs most commonly in the pediatric population as a result of pathological clonal proliferation of Langerhans cells with subsequent damage and destruction to surrounding tissue. Clinically, LCH presents in a variety of ways, which often results in prolonged time to diagnosis and subsequently poorer outcomes. In this case report, the authors describe an unusually early presentation of multisystem LCH in a patient at birth, which resulted in a 5-month delay to diagnosis and treatment. This patient presented both atypically young and with an uncommon initial manifestation of multisystem disease with multiple soft-tissue swellings rather than early skin involvement. Additionally, this patient had an unusual radiographic appearance with biparietal skull destruction on initial skull radiographs and biparietal soft-tissue lesions on CT resembling cephalohematoma at 3 months of age. The clinical and radiological evaluation, pathology, and treatment strategies are discussed, with particular attention paid to the importance of further workup of atypical nonresolving cephalohematomas to prevent disease progression and poorer outcomes.

    View details for DOI 10.3171/2010.7.PEDS10149

    View details for PubMedID 20887116

  • Minimal residual disease-directed therapy for childhood acute myeloid leukaemia: results of the AML02 multicentre trial LANCET ONCOLOGY Rubnitz, J. E., Inaba, H., Dahl, G., Ribeiro, R. C., Bowman, W. P., Taub, J., Pounds, S., Razzouk, B. I., Lacayo, N. J., Cao, X., Meshinchi, S., Degar, B., Airewele, G., Raimondi, S. C., Onciu, M., Coustan-Smith, E., Downing, J. R., Leung, W., Pui, C., Campana, D. 2010; 11 (6): 543-552


    We sought to improve outcome in patients with childhood acute myeloid leukaemia (AML) by applying risk-directed therapy that was based on genetic abnormalities of the leukaemic cells and measurements of minimal residual disease (MRD) done by flow cytometry during treatment.From Oct 13, 2002, to June 19, 2008, 232 patients with de-novo AML (n=206), therapy-related or myelodysplasia-related AML (n=12), or mixed-lineage leukaemia (n=14) were enrolled at eight centres. 230 patients were assigned by block, non-blinded randomisation, stratified by cytogenetic or morphological subtype, to high-dose (18 g/m(2), n=113) or low-dose (2 g/m(2), n=117) cytarabine given with daunorubicin and etoposide (ADE; induction 1). The primary aim of the study was to compare the incidence of MRD positivity of the high-dose group and the low-dose group at day 22 of induction 1. Induction 2 consisted of ADE with or without gemtuzumab ozogamicin (GO anti-CD33 monoclonal antibody); consolidation therapy included three additional courses of chemotherapy or haematopoietic stem-cell transplantation (HSCT). Levels of MRD were used to allocate GO and to determine the timing of induction 2. Both MRD and genetic abnormalities at diagnosis were used to determine the final risk classification. Low-risk patients (n=68) received five courses of chemotherapy, whereas high-risk patients (n=79), and standard-risk patients (n=69) with matched sibling donors, were eligible for HSCT (done for 48 high-risk and eight standard-risk patients). All 230 randomised patients were analysed for the primary endpoint. Other analyses were limited to the 216 patients with AML, excluding those with mixed-lineage leukaemia. This trial is closed to accrual and is registered with, number NCT00136084.Complete remission was achieved in 80% (173 of 216 patients) after induction 1 and 94% (203 of 216) after induction 2. Induction failures included two deaths from toxic effects and ten cases of resistant leukaemia. The introduction of high-dose versus low-dose cytarabine did not significantly lower the rate of MRD-positivity after induction 1 (34%vs 42%, p=0.17). The 6-month cumulative incidence of grade 3 or higher infection was 79.3% (SE 4.0) for patients in the high-dose group and 75.5% (4.2) for the low-dose group. 3-year event-free survival and overall survival were 63.0% (SE 4.1) and 71.1% (3.8), respectively. 80% (155 of 193) of patients achieved MRD of less than 0.1% after induction 2, and the cumulative incidence of relapse for this group was 17% (SE 3). MRD of 1% or higher after induction 1 was the only significant independent adverse prognostic factor for both event-free (hazard ratio 2.41, 95% CI 1.36-4.26; p=0.003) and overall survival (2.11, 1.09-4.11; p=0.028).Our findings suggest that the use of targeted chemotherapy and HSCT, in the context of a comprehensive risk-stratification strategy based on genetic features and MRD findings, can improve outcome in patients with childhood AML.National Institutes of Health and American Lebanese Syrian Associated Charities (ALSAC).

    View details for DOI 10.1016/S1470-2045(10)70090-5

    View details for Web of Science ID 000279019500026

    View details for PubMedID 20451454

  • Concurrent Treatment of Steroid-Related Mood and Psychotic Symptoms With Risperidone PEDIATRICS Ularntinon, S., Tzuang, D., Dahl, G., Shaw, R. J. 2010; 125 (5): E1241-E1245


    Corticosteroid treatment is an important therapeutic modality for many pediatric medical conditions including acute lymphoblastic leukemia. However, steroid-induced behavioral and mood abnormalities are common and potentially disabling adverse effects that have been widely reported in the pediatric literature. From this case series, we report the efficacy of risperidone in 3 children with acute lymphoblastic leukemia who developed steroid-related mood and psychotic symptoms during treatment with prednisone and dexamethasone. Risperidone is an effective short-term pharmacologic agent for controlling steroid-related psychiatric adverse effects when cessation or dose reduction of steroid therapy is not an option.

    View details for DOI 10.1542/peds.2009-1815

    View details for Web of Science ID 000277232800060

    View details for PubMedID 20385646

  • Phase I Study of Valspodar (PSC-833) With Mitoxantrone and Etoposide in Refractory and Relapsed Pediatric Acute Leukemia: A Report From the Children's Oncology Group PEDIATRIC BLOOD & CANCER O'Brien, M. M., Lacayo, N. J., Lum, B. L., Kshirsagar, S., Buck, S., Ravindranath, Y., Bernstein, M., Weinstein, H., Chang, M. N., Arceci, R. J., Sikic, B. I., Dahl, G. V. 2010; 54 (5): 694-702


    Valspodar, a non-immunosuppressive analog of cylosporine, is a potent P-glycoprotein (MDR1) inhibitor. As MDR1-mediated efflux of chemotherapeutic agents from leukemic blasts may contribute to drug resistance, a phase 1 study of valspodar combined with mitoxantrone and etoposide in pediatric patients with relapsed or refractory leukemias was performed.Patients received a valspodar-loading dose (2 mg/kg) followed by a 5-day continuous valspodar infusion (8, 10, 12.5, or 15 mg/kg/day) combined with lower than standard doses of mitoxantrone and etoposide. The valspodar dose was escalated using a standard 3 + 3 phase I design.Twenty-one patients were evaluable for toxicity and 20 for response. The maximum tolerated dose (MTD) of valspodar was 12.5 mg/kg/day, combined with 50% dose-reduced mitoxantrone and etoposide. The clearance of mitoxantrone and etoposide was decreased by 64% and 60%, respectively, when combined with valspodar. Dose-limiting toxicities included stomatitis, ataxia, and bone marrow aplasia. Three of 11 patients with acute lymphoblastic leukemia (ALL) had complete responses while no patient with acute myeloid leukemia (AML) had an objective response. In vitro studies demonstrated P-glycoprotein expression on the blasts of 5 of 14 patients, although only 1 had inhibition of rhodamine efflux by valspodar.While this regimen was tolerable, responses in this heavily pretreated population were limited to a subset of patients with ALL.

    View details for DOI 10.1002/pbc.22366

    View details for Web of Science ID 000275935700009

    View details for PubMedID 20209646

    View details for PubMedCentralID PMC2838930

  • Prevalence and prognostic significance of KIT mutations in pediatric patients with core binding factor AML enrolled on serial pediatric cooperative trials for de novo AML BLOOD Pollard, J. A., Alonzo, T. A., Gerbing, R. B., Ho, P. A., Zeng, R., Ravindranath, Y., Dahl, G., Lacayo, N. J., Becton, D., Chang, M., Weinstein, H. J., Hirsch, B., Raimondi, S. C., Heerema, N. A., Woods, W. G., Lange, B. J., Hurwitz, C., Arceci, R. J., Radich, J. P., Bernstein, I. D., Heinrich, M. C., Meshinchi, S. 2010; 115 (12): 2372-2379


    KIT receptor tyrosine kinase mutations are implicated as a prognostic factor in adults with core binding factor (CBF) acute myeloid leukemia (AML). However, their prevalence and prognostic significance in pediatric CBF AML is not well established. We performed KIT mutational analysis (exon 8 and exon 17) on diagnostic specimens from 203 pediatric patients with CBF AML enrolled on 4 pediatric AML protocols. KIT mutations were detected in 38 (19%) of 203 (95% CI, 14%-25%) patient samples of which 20 (52.5%) of 38 (95% CI, 36%-69%) involved exon 8, 17 (45%) of 38 (95% CI, 29%-62%) involved exon 17, and 1 (2.5%; 95% CI, 0%-14%) involved both locations. Patients with KIT mutations had a 5-year event-free survival of 55% (+/- 17%) compared with 59% (+/- 9%) for patients with wild-type KIT (P = .86). Rates of complete remission, overall survival, disease-free survival, or relapse were not significantly different for patients with or without KIT mutations. Location of the KIT mutation and analysis by cytogenetic subtype [t(8;21) vs inv(16)] also lacked prognostic significance. Our study shows that KIT mutations lack prognostic significance in a large series of pediatric patients with CBF AML. This finding, which differs from adult series and a previously published pediatric study, may reflect variations in therapeutic approaches and/or biologic heterogeneity within CBF AML. Two of 4 studies included in this analysis are registered at as NCT00002798 (CCG-2961) and NCT00070174 (COG AAML03P1).

    View details for DOI 10.1182/blood-2009-09-241075

    View details for Web of Science ID 000275981900010

    View details for PubMedID 20056794

  • WT1 Expression at Diagnosis Does Not Predict Survival in Pediatric AML: A Report From the Children's Oncology Group PEDIATRIC BLOOD & CANCER Noronha, S. A., Farrar, J. E., Alonzo, T. A., Gerbing, R. B., Lacayo, N. J., Dahl, G. V., Ravindranath, Y., Arceci, R. J., Loeb, D. M. 2009; 53 (6): 1136-1139


    WT1 is a transcription factor that is aberrantly overexpressed in acute and chronic leukemias. Overexpression of WT1 in pediatric acute myeloid leukemia has been reported, but the prognostic significance is unclear because sample sizes in these studies have been relatively small. WT1 expression was measured by quantitative RT-PCR in samples obtained at diagnosis from 155 pediatric AML patients treated on a cooperative group protocol. Neither overall survival nor event-free survival was correlated with WT1 expression.

    View details for DOI 10.1002/pbc.22142

    View details for Web of Science ID 000270440900043

    View details for PubMedID 19618455

  • Molecular inversion probes reveal patterns of 9p21 deletion and copy number aberrations in childhood leukemia CANCER GENETICS AND CYTOGENETICS Schiffman, J. D., Wang, Y., McPherson, L. A., Welch, K., Zhang, N., Davis, R., Lacayo, N. J., Dahl, G. V., Faham, M., Ford, J. M., Ji, H. P. 2009; 193 (1): 9-18


    Childhood leukemia, which accounts for >30% of newly diagnosed childhood malignancies, is one of the leading causes of death for children with cancer. Genome-wide studies using microarray chips to identify copy number changes in human cancer are becoming more common. In this pilot study, 45 pediatric leukemia samples were analyzed for gene copy aberrations using novel molecular inversion probe (MIP) technology. Acute leukemia subtypes included precursor B-cell acute lymphoblastic leukemia (ALL) (n=23), precursor T-cell ALL (n=6), and acute myeloid leukemia (n=14). The MIP analysis identified 69 regions of recurring copy number changes, of which 41 have not been identified with other DNA microarray platforms. Copy number gains and losses were validated in 98% of clinical karyotypes and 100% of fluorescence in situ hybridization studies available. We report unique patterns of copy number loss in samples with 9p21.3 (CDKN2A) deletion in the precursor B-cell ALL patients, compared with the precursor T-cell ALL patients. MIPs represent an attractive technology for identifying novel copy number aberrations, validating previously reported copy number changes, and translating molecular findings into clinically relevant targets for further investigation.

    View details for DOI 10.1016/j.cancergencyto.2009.03.005

    View details for Web of Science ID 000268922900002

    View details for PubMedID 19602459

    View details for PubMedCentralID PMC2776674

  • Tissue microarrays from bone marrow aspirates for high-throughput assessment of immunohistologic markers in pediatric acute leukemia PEDIATRIC AND DEVELOPMENTAL PATHOLOGY Hazard, F. K., Zhao, S., Schiffman, J. D., Lacayo, N. J., Dahl, G. V., Natkunam, Y. 2008; 11 (4): 283-290


    Gene expression profiling studies have been employed to investigate prognostic subgroups in pediatric acute leukemia. Tissue microarrays (TMAs) are useful for high-throughput analysis of protein expression of target genes in acute leukemia samples and for validation of gene microarray analysis. Using cryopreserved samples of pediatric acute leukemia bone marrow aspirates, we constructed TMA from as few as 1 million cells. Bone marrow core biopsies from the same patients were included on the same TMA for comparison. A panel of 15 immunohistochemical markers typically used for diagnosis as well as those targeting recently characterized, prognostically relevant molecules of interest in pediatric acute leukemia was used to evaluate protein expression. Staining results confirm that suspension cells from bone marrow aspirates can be effectively used to derive protein expression data from multiple cases simultaneously with comparable efficacy to that of biopsy tissue. This method allows for new markers of diagnostic, prognostic, or therapeutic importance to be screened on large numbers of study patients. Furthermore, this technique may facilitate the inclusion of small samples, aspirates, and body fluids in large-scale studies of protein expression in clinical trials and protocols in which tissue biopsies are often unavailable.

    View details for DOI 10.2350/07-04-0253.1

    View details for PubMedID 17990919

  • Hematopoietic stem cell transplant for pediatric acute promyelocytic leukemia BIOLOGY OF BLOOD AND MARROW TRANSPLANTATION Dvorak, C. C., Agarwal, R., Dahl, G. V., Gregory, J. J., Feusner, J. H. 2008; 14 (7): 824-830


    The optimal form of treatment for children with relapsed or refractory acute promyelocytic leukemia (APL) is unclear. We retrospectively analyzed the results of 32 (11 autologous, 21 allogeneic) hematopoietic stem cell transplants (HSCT) performed for children originally treated on either the Eastern Cooperative Group E2491 Trial or the Cancer and Leukemia Group B C9710 Trial and subsequently diagnosed with relapsed or refractory APL. For autologous HSCT, the incidence of treatment-related mortality (TRM) and relapse was 0% (95% confidence interval [CI], 0%-30%) and 27% (95% CI, 9%-57%), respectively. The 5-year event-free survival (EFS) and overall survival (OS) following autologous HSCT was 73% (95% CI, 43%-91%) and 82% (95% CI, 51%-96%), respectively. For allogeneic HSCT, the incidence of TRM and relapse was 19% (95% CI, 7%-41%) and 10% (95% CI, 2%-30%), respectively. The 5-year EFS and OS following allogeneic HSCT was 71% (95% CI, 50%-86%) and 76% (95% CI, 55%-90%), respectively. There was no significant difference in EFS or OS between autologous and allogeneic HSCT. This data demonstrates that autologous and allogeneic HSCT are both effective therapies for treatment of children with relapsed or refractory APL. Autologous HSCT is associated with a low incidence of TRM, whereas allogeneic HSCT is associated with a low incidence of relapse, suggesting a strong GVL effect against residual APL.

    View details for DOI 10.1016/j.bbmt.2008.04.015

    View details for Web of Science ID 000256971000013

    View details for PubMedID 18541203

    View details for PubMedCentralID PMC2796449

  • Comparison of antitumor effects of multitargeted tyrosine kinase inhibitors in acute myelogenous leukemia MOLECULAR CANCER THERAPEUTICS Hu, S., Niu, H., Minkin, P., Orwick, S., Shimada, A., Inaba, H., Dahl, G. V., Rubnitz, J., Baker, S. D. 2008; 7 (5): 1110-1120


    We compared the antitumor activities of the multitargeted tyrosine kinase inhibitors imatinib, sorafenib, and sunitinib to determine which inhibitor is best suited to be used for the treatment of acute myelogenous leukemia (AML). In nine human AML cell lines, sorafenib and sunitinib were more potent inhibitors of cellular proliferation than imatinib (IC50, 0.27 to >40, 0.002-9.1, and 0.007-13 micromol/L for imatinib, sorafenib, and sunitinib, respectively). Sorafenib and sunitinib were potent inhibitors of cells with fms-like tyrosine kinase 3 internal tandem duplication (IC50, 2 and 7 nmol/L) and c-KIT N822K mutations (IC50, 23 and 40 nmol/L). In four cell lines (MV4-11, Kasumi-1, KG-1, and U937) that spanned a range of drug sensitivities, sorafenib and sunitinib had similar activity in apoptosis and cell cycle assays, except that sunitinib did not promote apoptosis in U937 cells. Both drugs inhibited mitogen-activated protein kinase signaling but had no effect on AKT signaling in most of the cell lines tested. Sorafenib was substantially more bound than sunitinib in human plasma (unbound fraction, 0.59% versus 8.4%) and cell culture medium (unbound fraction, 1.3% versus 39%), indicating that sorafenib was more potent than sunitinib and that unbound sorafenib concentrations with activity against most AML cell lines are achievable in vivo. There was more intracellular accumulation of sorafenib than of sunitinib and imatinib in AML cells. Between 1 and 10 micromol/L, sorafenib inhibited the proliferation of six of nine primary AML blast samples by > or =50%. Our results highlight the pharmacologic features of sorafenib that may provide it an advantage in the treatment of AML.

    View details for DOI 10.1158/1535-7163.MCT-07-2218

    View details for Web of Science ID 000255913900012

    View details for PubMedID 18483300

  • Identification of a novel p53 in-frame deletion in a Li-Fraumeni-like family PEDIATRIC BLOOD & CANCER Schiffman, J. D., Chun, N., Fisher, P. G., Dahl, G. V., Ford, J. M., Eggerding, F. A. 2008; 50 (4): 914-916


    We describe a 2-year-old female with a completely resected cerebral pilocytic astrocytoma who subsequently developed B-progenitor acute lymphoblastic leukemia (ALL). Her father and paternal uncle were previously diagnosed with glioblastoma multiforme. Sequence analysis of the patient's p53 gene revealed a novel germline three base-pair deletion (339_341delCTT) in exon 4, resulting in removal of an evolutionarily conserved phenylalanine amino acid residue at codon 113. The same mutation was found in the patient's two clinically unaffected siblings. The in-frame deletion we describe has not previously been reported and adds to our understanding of the biologic effects of p53 gene mutation in Li-Fraumeni syndrome (LFS).

    View details for DOI 10.1002/pbc.21247

    View details for PubMedID 17554785

  • In cyclosporine-induced neurotoxicity, is tacrolimus an appropriate substitute or is it out of the frying pan and into the fire? Response PEDIATRIC BLOOD & CANCER Minn, A. Y., Fisher, P. G., Barnes, P. D., Dahl, G. V. 2008; 50 (2): 427-427

    View details for DOI 10.1002/pbc.21210

    View details for Web of Science ID 000252006000062

  • Cardiomyopathy in children with down syndrome treated for acute myeloid leukemia: A report from the children's oncology group study POG 9421 48th Annual Meeting of the American-Society-of-Hematology O'Brien, M. M., Taub, J. W., Chang, M. N., Massey, G. V., Stine, K. C., Raimondi, S. C., Becton, D., Ravindranath, Y., Dahl, G. V. AMER SOC CLINICAL ONCOLOGY. 2008: 414–20


    To determine the outcomes, with particular attention to toxicity, of children with Down syndrome (DS) and acute myeloid leukemia (AML) treated on Pediatric Oncology Group (POG) protocol 9421.Children with DS and newly diagnosed AML (n = 57) were prospectively enrolled onto the standard-therapy arm of POG 9421 and were administered five cycles of chemotherapy, which included daunorubicin 135 mg/m(2) and mitoxantrone 80 mg/m(2). Outcomes and toxicity were evaluated prospectively and were compared with the non-DS-AML cohort (n = 565). A retrospective chart review was performed to identify adverse cardiac events.In the DS-AML group, 54 patients (94.7%) entered remission. One experienced induction failure and two died. Of the 54 who entered remission, three relapsed and six died as a result of other causes. The remission induction rate was similar in the non-DS-French-American-British (FAB) M7 (91.7%) and non-DS-non-M7 (89.3%) groups. The 5-year overall survival was significantly better in the DS-AML group (78.6%) than in the non-DS-M7 (36.3%) or the non-DS-non-M7 (51.8%) groups (P < .001). No age-related difference in 5-year, event-free survival was seen between patients younger than 2 years (75.8%) and those aged 2 to 4 years (78.3%). Symptomatic cardiomyopathy developed in 10 patients (17.5%) with DS-AML during or soon after completion of treatment; three died as a result of congestive heart failure.The POG 9421 treatment regimen was highly effective in both remission induction and disease-free survival for patients with DS-AML. However, there was a high incidence of cardiomyopathy, which supports current strategies for dose reduction of anthracyclines in this patient population.

    View details for DOI 10.1200/JCO.2007.13.2209

    View details for Web of Science ID 000254177200015

    View details for PubMedID 18202418

  • Concerns about infertility risks among pediatric oncology patients and their parents PEDIATRIC BLOOD & CANCER Oosterhuis, B. E., Goodwin, T., Kiernan, M., Hudson, M. M., Dahl, G. V. 2008; 50 (1): 85-89


    Given pediatric cancer patients are living into adulthood, parents and patients need to be informed about fertility-related side effects of their particular treatment.We surveyed 97 parents of pediatric patients of all ages as well as 37 adolescent patients of 14 years or older who were presented for care at the Lucile Packard Children's Hospital (LPCH) at the Stanford University Medical Center. We estimated the potential infertility risk (low, intermediate, and high) based on the child's treatment regimen.In contrast to our hypothesis, the majority of parents in all three risk categories were concerned about fertility-related side effects of cancer treatment. Many parents with children at low risk were concerned (58.3%) whereas not all parents with children at intermediate or high risk were concerned, 61.5% and 73.3% respectively, P = 0.43. Indeed, over 50% of all parents were erroneously concerned that cancer therapies cause DNA damage to their child's eggs (or sperm). Only 29.9% of parents were satisfied with the amount of information received. Similar patterns were seen among the adolescent patient sample.Parents of pediatric cancer patients and teenage patients have concerns about fertility-related side effects regardless of treatment received. Targeted education about infertility risk before and after treatment can address these gaps.

    View details for DOI 10.1002/pbc.21261

    View details for Web of Science ID 000251410400015

    View details for PubMedID 17514741

  • Outcomes of transplantation in children with primary hepatic malignancy PEDIATRIC TRANSPLANTATION Beaunoyer, M., Vanatta, J. M., Oyihara, M., Strichartz, D., Dahl, G., Berquist, W. E., Castillo, R. O., Cox, K. L., Esquivel, C. O. 2007; 11 (6): 655-660


    HBL and HCC are the most common hepatic malignancies in children. The role of OLT in children with HCC is still a matter of debate. The aim of this study was to review our experience of OLT for HCC. Medical records of patients (<18 yr) who underwent OLT for HCC were reviewed and compared to children who underwent OLT for HBL and for indications other than malignancy. There were 25 patients: HCC (10 cases) and HBL (15 cases). The actuarial patient survival for HCC at one and five yr was 100% and 83.3%, for the HBL group the survival was 86.7% at both one and five yr, and for indications (n=377) other than malignancy the patient survival for pediatric OLT at our center was 87.7% and 84.7% at one and five yr, respectively. The actuarial recurrence free survival at five yr was 83.3% for HCC and 66.8% for HBL. In conclusion, OLT is a good therapeutic modality for children with HCC and HBL.

    View details for DOI 10.1111/j.1399-3046.2007.00751.x

    View details for Web of Science ID 000249004000015

    View details for PubMedID 17663690

  • The incidence and clinical significance of nucleophosmin mutations in childhood AML BLOOD Brown, P., McIntyre, E., Rau, R., Meshinchi, S., Lacayo, N., Dahl, G., Alonzo, T. A., Chang, M., Arceci, R. J., Small, D. 2007; 110 (3): 979-985


    Frameshift mutations in exon 12 of the nucleophosmin gene (NPM1) result in aberrant cytoplasmic localization of the NPM protein (NPMc(+)) and occur in 25% to 35% of adult acute myeloid leukemia (AML). In adults with AML, NPMc(+) has been associated with normal karyotype, FLT3/ITD mutations, high remission induction rates, and improved survival (particularly in patients lacking FLT3/ITD). NPMc(+) has not been well characterized in childhood AML. This study examines the incidence and clinical significance of NPMc(+) in 295 children with newly diagnosed AML treated on a large cooperative group clinical trial (POG-9421). We find that NPMc(+) is relatively uncommon in childhood AML (23 of 295 patients, 8%); and is significantly associated with FLT3/ITD mutations (P = .046), female sex (P = .029), older age (P = .047), and normal cytogenetics (P < .001). There is a favorable impact of NPMc(+) on survival in children lacking FLT3/ITD (5-year EFS, 69% vs 35%; hazard ratio, 0.39; P = .051), which is similar in magnitude to the favorable impact of t(8;21) and inv(16). We conclude that NPMc(+) is relatively rare in childhood AML, particularly in younger children. NPMc(+) does not abrogate the negative prognostic influence of FLT3/ITD mutations, but may contribute to risk stratification in children who lack FLT3/ITD mutations by identifying a group with superior prognosis.

    View details for DOI 10.1182/blood-2007-02-076604

    View details for Web of Science ID 000248514700035

    View details for PubMedID 17440048

    View details for PubMedCentralID PMC1924773

  • Reinduction of relapsed acute promyelocytic leukemia with ATRA and low dose anti metabolite-based chemotherapy PEDIATRIC BLOOD & CANCER Dvorak, C. C., Sanders, R. P., Dahl, G. V., Donaldson, S. S., Razzouk, B. I. 2007; 48 (5): 582-585


    While the disease-free survival of acute promyelocytic leukemia (APML) now approaches 75%, some children continue to experience relapses, and questions remain as to the optimal management of these patients. We describe two young children who experienced combined relapses in the bone marrow and extramedullary locations following hematopoietic stem cell transplantation (HSCT). An induction regimen, consisting of all-trans retinoic acid (ATRA), methotrexate, and 6-mercaptopurine (6MP), successfully and safely achieved hematologic remission in one patient and molecular remission in the other. These cases demonstrate that there is a role for ATRA plus differentiating chemotherapy other than arsenic trioxide in the treatment of relapsed APML.

    View details for DOI 10.1002/pbc.20592

    View details for Web of Science ID 000245195200019

    View details for PubMedID 16123994

  • Vinblastine and methotrexate for desmoid fibromatosis in children: Results of a Pediatric Oncology Group phase II trial JOURNAL OF CLINICAL ONCOLOGY Skapek, S. X., Ferguson, W. S., Granowetter, L., Devidas, M., Perez-Atayde, A. R., Dehner, L. P., Hoffer, F. A., Speights, R., Gebhardt, M. C., Dahl, G. V., Grier, H. E. 2007; 25 (5): 501-506


    To determine the efficacy and safety of using vinblastine (Vbl) and methotrexate (Mtx) in children with desmoid-type fibromatosis that is recurrent or not amenable to treatment with radiation or surgery.A phase II study was conducted within the Pediatric Oncology Group. Patients were treated using Vbl (5 mg/m2/dose) and Mtx (30 mg/m2/dose), both administered by intravenous injection weekly for 26 weeks and every other week for an additional 26 weeks. Response was assessed by bidimensional measurements of tumor on axial imaging (magnetic resonance imaging or computed tomography).Over 35 months, 28 patients were enrolled; 27 were eligible, and 26 were assessable for response. A measurable response was documented in eight patients (31%), and 10 patients had stable disease documented as the best response to treatment. Eighteen patients had disease progression at a median time of 9.1 months. Eight patients remain free of disease progression at a median of 43.4 months from study entry. Nine patients reported no to moderate toxicity. Neutropenia was the most common toxicity (n = 22) and the most common grade 4 toxicity (n = 5). Anemia, nausea, vomiting, and elevations in hepatic transaminases were also common and were reversible with interruption of chemotherapy.Vbl and Mtx are well tolerated in children with desmoid-type fibromatosis. Furthermore, this combination can promote tumor regression or block tumor growth in most children.

    View details for DOI 10.1200/JCO.2006.08.2966

    View details for Web of Science ID 000244176000007

    View details for PubMedID 17290057

  • A syndrome of irreversible leukoencephalopathy following pediatric allogeneic bone marrow transplantation PEDIATRIC BLOOD & CANCER Minn, A. Y., Fisher, P. G., Barnes, P. D., Dahl, G. V. 2007; 48 (2): 213-217


    Despite decreases in overall mortality following bone marrow transplantation (BMT), a number of complications such as neurotoxicity have been described and often associated with immunosuppressive agents. The syndrome of reversible posterior leukoencephalopathy has been described in patients receiving cyclosporin and FK-506. We report here a subset of children who developed a syndrome of previously undescribed irreversible leukoencephalopathy following allogeneic BMT.Between 1996 and 2002, 138 pediatric patients received an allogeneic BMT at Lucile Salter Packard Children's Hospital at Stanford. Six cases of irreversible leukoencephalopathy were observed. Cases were defined as children who exhibited progressive and continued, severe neurologic deterioration lasting greater than 2 weeks and consistent with non-localizing, central nervous system abnormalities. Medical records and magnetic resonance images (MRIs) were reviewed.Median age of the affected patients at BMT was 7.8 years. All six received cyclosporine, and [corrected] one had elevated drug levels. Encephalopathy occurred at a median of 53 days (range 14-77) following BMT. Symptoms at onset of leukoenceophalopathy included confusion and altered mental status, sluggish pupillary responses, abnormal movements, and seizures. Two patients died during their neurologic decline. Four patients remain alive with persistent encephalopathy. MRI showed abnormalities in all patients including periventricular or subcortical white matter involvement in all, and basal ganglia lesions in three.We report a syndrome of irreversible neurologic deficits and cerebral white matter abnormalities following allogeneic BMT, yet not associated with elevated cyclosporin levels. A precise mechanism for this syndrome is lacking and warrants further consideration.

    View details for DOI 10.1002/pbc.20731

    View details for Web of Science ID 000242875800016

    View details for PubMedID 16365853

  • Attitudes and practices of pediatric oncology providers regarding fertility issues PEDIATRIC BLOOD & CANCER Goodwin, T., Oosterhuis, B. E., Kiernan, M., Hudson, M. A., Dahl, G. V. 2007; 48 (1): 80-85


    Given the higher survival rates of childhood cancer, health care providers must be aware of the side effects of cancer therapies to educate patients and provide appropriate interventions to reduce cancer-related morbidity. To understand the current practices and attitudes in a pediatric hematology/oncology clinic, health care providers were surveyed regarding fertility issues pertinent to their patient care. PARTICIPANTS AND INSTRUMENTS: In this study, 93.8% (30/32) health care providers in one pediatric hematology/oncology department completed a 44-item survey assessing knowledge, current practices, obstacles to current practices, perceptions of patient differences, and improvements to future practice.The majority of health care providers were aware of the adverse effects of alkylating agents (90.7%) and of abdominal and pelvic radiation (100.0%) on fertility. However, only half were aware of gender differences in gonadotoxicity (50.0%) or knowledgeable of current research and technology in fertility preservation (53.3%). While only 34.6% of providers currently consulted with specialists, nearly all (92.8%) indicated a desire to do so in the future, but 64.3% indicated difficulties in finding proper facilities and specialists for their patients. Almost all (96.6%) agreed that providers and patient families need more information regarding the effects of cancer therapy on fertility.Surveyed pediatric oncology providers considered fertility to be an important issue for childhood cancer patients and desired more resources regarding effects on fertility and fertility preservation. Greater communication needs to be established between pediatric oncology providers and specialists in reproductive medicine and endocrinology to ensure adequate professional collaboration and patient referrals.

    View details for DOI 10.1002/pbc.20814

    View details for Web of Science ID 000242425000015

    View details for PubMedID 16572406

  • CpG island methylator phenotype and childhood leukemia CLINICAL CANCER RESEARCH Lacayo, N. J., Di Martino, J. F., Wei, M. C., Dahl, G. V. 2006; 12 (16): 4787-4789

    View details for DOI 10.1158/1078-0432.CCR-06-0651

    View details for PubMedID 16914562

  • A prospective study of the natural history of transient leukemia (TL) in neonates with Down syndrome (DS): Children's Oncology Group (COG) study POG-9481 BLOOD Massey, G. V., Zipursky, A., Chang, M. N., Doyle, J. J., Nasim, S., Taub, J. W., Ravindranath, Y., Dahl, G., Weinstein, H. J. 2006; 107 (12): 4606-4613


    A unique transient leukemia (TL) has been described in newborns with Down syndrome (DS; or trisomy 21 mosaics). This leukemia has a high incidence of spontaneous remission; however, early death and subsequent development of acute megakaryoblastic leukemia (AMKL) have been reported. We prospectively evaluated 48 infants with DS and TL to determine the natural history and biologic characteristics of this disease, identify the clinical characteristics associated with early death or subsequent leukemia, and assess the incidence of subsequent leukemia. Blast cells associated with TL in DS infants exhibited FAB M(7) morphology and phenotype. Most infants (74%) had trisomy 21 (or mosaicism) as the only cytogenetic abnormality in the blast cells. Most children were able to spontaneously clear peripheral blasts (89%), normalize blood counts (74%), and maintain a complete remission (64%). Early death occurred in 17% of infants and was significantly correlated with higher white blood cell count at diagnosis (P < .001), increased bilirubin and liver enzymes (P < .005), and a failure to normalize the blood count (P = .001). Recurrence of leukemia occurred in 19% of infants at a mean of 20 months. Development of leukemia was significantly correlated with karyotypic abnormalities in addition to trisomy 21 (P = .037). Ongoing collaborative clinical studies are needed to determine the optimal role of chemotherapy for infants at risk for increased mortality or disease recurrence and to further the knowledge of the unique biologic features of this TL.

    View details for DOI 10.1182/blood-2005-06-2448

    View details for Web of Science ID 000238305400013

    View details for PubMedID 16469874

  • Low or absent SPARC expression in acute myeloid leukemia with MLL rearrangements is associated with sensitivity to growth inhibition by exogenous SPARC protein LEUKEMIA DiMartino, J. F., Lacayo, N. J., Varadi, M., Li, L., Saraiya, C., Ravindranath, Y., Yu, R., Sikic, B., Raimondi, S. C., Dahl, G. 2006; 20 (3): 426-432


    Secreted protein, acidic and rich in cysteine (SPARC), is a matricellular glycoprotein with growth-inhibitory and antiangiogenic functions. Although SPARC has been implicated as a tumor suppressor in humans, its function in normal or malignant hematopoiesis has not previously been studied. We found that the leukemic cells of AML patients with MLL gene rearrangements express low to undetectable amounts of SPARC whereas normal hematopoietic progenitors and most AML patients express this gene. SPARC RNA and protein levels were also low or undetectable in AML cell lines with MLL translocations. Consistent with its tumor suppressive effects in various solid tumor models, exogenous SPARC protein selectively reduced the growth of cell lines with MLL rearrangements by inhibiting cell cycle progression from G1 to S phase. The lack of SPARC expression in MLL-rearranged cell lines was associated with dense promoter methylation. However, we found no evidence of methylation-based silencing of SPARC in primary patient samples. Our results suggest that low or absent SPARC expression is a consistent feature of AML cells with MLL rearrangements and that SPARC may function as a tumor suppressor in this subset of patients. A potential role of exogenous SPARC in the therapy of MLL-rearranged AML warrants further investigation.

    View details for DOI 10.1038/sj.leu.2404102

    View details for Web of Science ID 000235537800007

    View details for PubMedID 16424866

  • Anthracyclines cause endothelial injury in pediatric cancer patients: A pilot study 37th Annual Congress of the International-Society-of-Pediatric-Oncology Chow, A. Y., Chin, C., Dahl, G., Rosenthal, D. N. AMER SOC CLINICAL ONCOLOGY. 2006: 925–28


    The vascular endothelium plays a central role in the regulation of arterial vasomotor tone, releasing nitric oxide for vasodilation. Endothelial-dependent vasodilation can be assessed in vivo, using high resolution ultrasound to measure changes in diameter of the brachial artery. Animal studies have demonstrated that anthracyclines can damage the endothelium and impair the vasodilatory response of arteries; however, there are no comparable data in humans. This is a pilot study assessing endothelial toxicity from anthracyclines in pediatric cancer patients.Fourteen control patients and 14 cancer patients (4 to 21 years) were studied. Cancer patients had completed chemotherapy containing no less than 300 mg/m2 of anthracyclines 2 to 60 months before study. Brachial artery diameters were measured at rest and 1 minute after blood pressure cuff occlusion. Brachial artery reactivity (BAR) was calculated as percent change between baseline and after cuff deflation measurements. Results were compared using unpaired, two-tailed t-test.Baseline characteristics, including age, percentage of females, blood pressure, and resting vessel diameters were similar between the two groups. BAR in the controls averaged 6.7% with a standard deviation (SD) of 3.3%, while BAR in patients receiving anthracyclines averaged 3.8% with an SD of 3.4%, demonstrating a significant decrease (P < .05) in vasomotor reactivity in the treated group.These results suggest that anthracyclines cause impaired endothelial function, an important and newly recognized toxicity. Since endothelial dysfunction is an early event in atherogenesis, there may be important clinical implications from these findings. Further study is required to confirm these preliminary results in a larger cohort.

    View details for DOI 10.1200/JCO.2005.03.5956

    View details for Web of Science ID 000235469700017

    View details for PubMedID 16484703

  • Randomized use of cyclosporin A (CsA) to modulate P-glycoprotein in children with AML in remission: Pediatric Oncology Group Study 9421 BLOOD Becton, D., Dahl, G. V., Ravindranath, Y., Chang, M. N., Behm, F. G., Raimondi, S. C., Head, D. R., Stine, K. C., Lacayo, N. J., Sikic, B. I., Arceci, R. J., Weinstein, H. 2006; 107 (4): 1315-1324


    Relapse is a major obstacle in the cure of acute myeloid leukemia (AML). The Pediatric Oncology Group AML Study 9421 tested 2 different strategies to improve event-free survival (EFS) and overall survival (OS). Patients were randomized to receive standard-dose DAT (daunorubicin, cytarabine, and thioguanine) or high-dose DAT during induction. To interfere with P-glycoprotein (P-gp)-dependent drug efflux, the second randomization tested the benefit of cyclosporine (CsA) added to consolidation chemotherapy. Of the 282 children randomly assigned to receive standard DAT induction, 248 (87.9%) achieved remission compared to 253 (91%) of the 278 receiving high-dose DAT (P = ns). Children with HLA-identical sibling donors who achieved a complete remission received an allogeneic bone marrow transplant as consolidation. For the 83 patients receiving a matched related donor bone marrow transplantation (BMT), the 3-year disease-free survival (DFS) is 67%. Of the 418 children who achieved remission and went on to consolidation with and without CsA, the DFS was 40.6% and 33.9%, respectively (P = .24). Overexpression of P-gp was infrequent (14%) in this pediatric population. In this study, intensifying induction with high-dose DAT and the addition of CsA to consolidation chemotherapy did not prolong the durations of remission or improve overall survival for children with AML.

    View details for DOI 10.1128/blood-2004-08-3218

    View details for Web of Science ID 000235296100018

    View details for PubMedID 16254147

    View details for PubMedCentralID PMC1895393

  • Pediatric Oncology Group (POG) studies of acute myeloid leukemia (AML): a review of four consecutive childhood AML trials conducted between 1981 and 2000 LEUKEMIA Ravindranath, Y., Chang, M., Steuber, C. P., Becton, D., Dahl, G., Civin, C., Camitta, B., Carroll, A., Raimondi, S. C., Weinstein, H. J. 2005; 19 (12): 2101-2116


    From 1981 to 2000, a total of 1823 children with acute myeloid leukemia (AML) enrolled on four consecutive Pediatric Oncology Group (POG) clinical trials. POG 8101 demonstrated that the induction rate associated with the 3+7+7 combination of daunorubicin, Ara-C, and 6-thioguanine (DAT) was greater than that associated with an induction regimen used to treat acute lymphoblastic leukemia (82 vs 61%; P=0.02). Designed as a pilot study to determine the feasibility of administration of noncross-resistant drug pairs and later modified to assess the effect of dose intensification of Ara-C during the second induction course, POG 8498 confirmed the high initial rate of response to DAT (84.2%) and showed that dose intensification of Ara-C during the second induction course resulted in a trend toward higher event-free survival (EFS) estimates than did standard-dose DAT (2+5) during the second induction course (5 year EFS estimates, 22 vs 27%; P=0.33). Age <2 years and leukocyte count <100 000/mm3 emerged as significantly good prognostic factors. The most significant observation made in the POG 8498 study was the markedly superior outcome of children with Down's syndrome who were treated on the high-dose Ara-C regimen. POG 8821 compared the efficacy of autologous bone marrow transplantation (BMT) with that of intensive consolidation chemotherapy. Intent-to-treat analysis revealed similar 5-year EFS estimates for the group that underwent autologous BMT (36+/-4.7%) and for the group that received only intensive chemotherapy (35+/-4.5%) (P=0.25). There was a high rate of treatment-related mortality in the autologous transplantation group. The study demonstrated superior results of allogeneic BMT for patients with histocompatible related donors (5-year EFS estimate 63+/-5.4%) and of children with Down's syndrome (5-year EFS estimate, 66+/-8.6%). The POG 9421 AML study evaluated high-dose Ara-C as part of the first induction course and the use of the multidrug resistance modulator cyclosporine. Preliminary results showed that patients receiving both high-dose Ara-C for remission induction and the MDR modulator for consolidation had a superior outcome (5-year EFS estimate, 42+/-8.2%) than did patients receiving other treatment; however, the difference was not statistically significant. These four studies demonstrate the importance of dose intensification of Ara-C in the treatment of childhood AML; cytogenetics as the single most prognostic factor and the unique curability of AML in children with Down's syndrome.

    View details for DOI 10.1038/sj.leu.2403927

    View details for Web of Science ID 000233462300009

    View details for PubMedID 16136167

  • Gene expression profiling and FLT3 status correlate with outcome in de novo acute myeloid leukemia (AML) with normal karyotype: Results of children's oncology group (COG) study POG #9421. 47th Annual Meeting of the American-Society-of-Hematology Lacayo, N., Meshinchi, S., Raimondi, S., Saraiya, C., O'Brien, M., Yu, R., Juric, D., Chang, M., Willman, C., Tibshirani, R., Ravindranath, Y., Sikic, B., Weinstein, H., Dahl, G. V. AMER SOC HEMATOLOGY. 2005: 667A–667A
  • Proteomic analysis of childhood leukemia LEUKEMIA Hegedus, C. M., Gunn, L., Skibola, C., Zhang, L., Shiao, R., Fu, S., Dalmasso, E. A., Metayer, C., Dahl, G. V., Buffler, P. A., Smith, M. T. 2005; 19 (10): 1713-1718


    Childhood acute lymphoblastic and myeloid leukemias are stratified into molecular and cytogenetic subgroups important for prognosis and therapy. Studies have shown that gene expression profiles can discriminate between leukemia subtypes. Thus, proteome analysis similarly holds the potential for characterizing different subtypes of childhood leukemia. We used surface-enhanced laser desorption/ionization time-of-flight mass spectrometry to analyze cell lysates from childhood leukemia cell lines as well as pretreatment leukemic bone marrow derived from childhood leukemia cases. Comparison of the acute myeloid leukemia (AML) cell line, Kasumi, and the biphenotypic myelomonocytic cell line, MV4;11, with the acute lymphoblastic leukemia (ALL) cell lines, 697 and REH, revealed many differentially expressed proteins. In particular, one 8.3 kDa protein has been identified as a C-terminal truncated ubiquitin. Analysis of childhood leukemia bone marrow showed differentially expressed proteins between AML and ALL, including a similar peak at 8.3 kDa, as well as several proteins that differentiate between the ALL t(12;21) and hyperdiploid subtypes. These results demonstrate the potential for proteome analysis to distinguish between various forms of childhood leukemia. Future analyses are warranted to validate these findings and to investigate the role of the C-terminal truncated ubiquitin in the etiology of ALL.

    View details for DOI 10.1038/sj.leu.2403897

    View details for Web of Science ID 000232204000001

    View details for PubMedID 16136170

  • Profile of daily life in children with brain tumors: An assessment of health-related quality of life 39th Annual Meeting of the American-Society-of-Clinical-Oncology (ASCO) Bhat, S. R., Goodwin, T. L., Burwinkle, T. M., Lansdale, M. F., Dahl, G. V., Huhn, S. L., Gibbs, I. C., Donaldson, S. S., Rosenblum, R. K., Varni, J. W., Fisher, P. G. AMER SOC CLINICAL ONCOLOGY. 2005: 5493–5500


    The survival of children with CNS tumors approaches 70%, yet health-related quality of life (HRQOL) has not been investigated rigorously in this population. We aimed to show that universal assessment of HRQOL could be obtained easily by using the PedsQL 4.0 and to provide a composite profile of their daily lives.The PedsQL was administered to all patients seen in the neuro-oncology clinic at Lucile Packard Children's Hospital (Palo Alto, CA) from December 2001, to September 2002. Patients were compared with healthy controls by using two-sided t tests to evaluate statistically significant differences.One hundred thirty-four patients (73 male; mean age +/- standard deviation, 11.8 +/- 5.4 years; 55 had low-grade glioma, 32 had medulloblastoma/primitive neuroectodermal tumor/embryonal tumor, 17 had malignant astrocytoma, nine had germ-cell tumor, and 21 had other types of tumors) were assessed, each in less than 20 minutes. Scores on both child and parent-proxy reports for the total HRQOL, psychosocial, physical, emotional, social, and school-functioning scales were all significantly lower than controls (P < .01). Patients with low-grade glioma were reported to have the highest total HRQOL. Children receiving radiation therapy (XRT) but no chemotherapy had significantly lower total, psychosocial, emotional, and social functioning than those receiving other treatments, including XRT plus chemotherapy.The PedsQL can be used to assess HRQOL rapidly and easily in children with CNS tumors, who have significantly worse HRQOL than healthy children. Children receiving XRT fare worse overall; chemotherapy added to XRT does not seem to worsen HRQOL. Assessment of HRQOL should be included as an outcome in future clinical trials.

    View details for DOI 10.1200/JCO.2005.10.190

    View details for Web of Science ID 000231371700020

    View details for PubMedID 16110009

  • Osteonectin/SPARC is epigenetically silenced in AML with MLL gene rearrangements and selectively inhibits the growth of MLL rearranged cell lines 46th Annual Meeting of the American-Society-of-Hematology DiMartino, J. F., Lacayo, N. J., Varadi, M., Ravindranath, Y., Yu, R., Sikic, B., Raimondi, S. C., Dahl, G. V. AMER SOC HEMATOLOGY. 2004: 314A–314A
  • Gene expression profiles at diagnosis in de novo childhood AML patients identify FLT3 mutations with good clinical outcomes BLOOD Lacayo, N. J., Meshinchi, S., Kinnunen, P., Yu, R., Wang, Y., Stuber, C. M., Douglas, L., Wahab, R., Becton, D. L., Weinstein, H., Chang, M. N., Willman, C. L., Radich, J. P., Tibshirani, R., Ravindranath, Y., Sikic, B. I., Dahl, G. V. 2004; 104 (9): 2646-2654


    Fms-like tyrosine kinase 3 (FLT3) mutations are associated with unfavorable outcomes in children with acute myeloid leukemia (AML). We used DNA microarrays to identify gene expression profiles related to FLT3 status and outcome in childhood AML. Among 81 diagnostic specimens, 36 had FLT3 mutations (FLT3-MUs), 24 with internal tandem duplications (ITDs) and 12 with activating loop mutations (ALMs). In addition, 8 of 19 specimens from patients with relapses had FLT3-MUs. Predictive analysis of microarrays (PAM) identified genes that differentiated FLT3-ITD from FLT3-ALM and FLT3 wild-type (FLT3-WT) cases. Among the 42 specimens with FLT3-MUs, PAM identified 128 genes that correlated with clinical outcome. Event-free survival (EFS) in FLT3-MU patients with a favorable signature was 45% versus 5% for those with an unfavorable signature (P = .018). Among FLT3-MU specimens, high expression of the RUNX3 gene and low expression of the ATRX gene were associated with inferior outcome. The ratio of RUNX3 to ATRX expression was used to classify FLT3-MU cases into 3 EFS groups: 70%, 37%, and 0% for low, intermediate, and high ratios, respectively (P < .0001). Thus, gene expression profiling identified AML patients with divergent prognoses within the FLT3-MU group, and the RUNX3 to ATRX expression ratio should be a useful prognostic indicator in these patients.

    View details for DOI 10.1182/blood-2004-12-4449

    View details for PubMedID 15251987

  • Phase I trial of intrathecal liposomal cytarabine in children with neoplastic meningitis JOURNAL OF CLINICAL ONCOLOGY Bomgaars, L., Geyer, J. R., Franklin, J., Dahl, G., Park, J., Winick, N. J., Klenke, R., Berg, S. L., BLANEY, S. M. 2004; 22 (19): 3916-3921


    We performed a phase I trial of intrathecal (IT) liposomal cytarabine (DepoCyt; Enzon Pharmaceuticals, Piscataway, NJ and SkyePharma Inc, San Diego, CA) to determine the maximum-tolerated dose, the dose-limiting toxicities, and the plasma and CSF pharmacokinetics of IT lipsomal cytarabine in children >/= 3 years of age with advanced meningeal malignancies.Eighteen assessable patients received IT liposomal cytarabine through either an indwelling ventricular access device or via lumbar puncture. Liposomal cytarabine was given once every 2 weeks during induction, once every 4 weeks during consolidation, and once every 8 weeks during the maintenance phase of treatment. The initial dose was 25 mg, with subsequent escalations to 35 and 50 mg. CSF pharmacokinetic samples were obtained in a subset of patients.Arachnoiditis, characterized by fever, headache, nausea, vomiting, and back pain was noted in the first two patients at the 25 mg dose level. Therefore, subsequent patients were treated with dexamethasone, beginning the day of liposomal cytarabine administration and continuing for 5 days. Headache (grade 3) was dose limiting in two of eight patients enrolled at the 50 mg dose level. Eight of the 14 patients assessable for response demonstrated evidence of benefit manifest as prolonged disease stabilization or response.The maximum-tolerated dose and recommended phase II dose of liposomal cytarabine in patients between the ages of 3 and 21 years is 35 mg, administered with dexamethasone (0.15 mg/kg/dose, twice a day for 5 days). A phase II trial of IT liposomal cytarabine in children with CNS leukemia in second or higher relapse is in development.

    View details for DOI 10.1200/JCO.2004.01.046

    View details for Web of Science ID 000224281600013

    View details for PubMedID 15459213

  • Critical windows of exposure to household pesticides and risk of childhood leukemia ENVIRONMENTAL HEALTH PERSPECTIVES Ma, X. M., Buffler, P. A., Gunier, R. B., Dahl, G., Smith, M. T., Reinier, K., Reynolds, P. 2002; 110 (9): 955-960


    The potential etiologic role of household pesticide exposures was examined in the Northern California Childhood Leukemia Study. A total of 162 patients (0-14 years old) with newly diagnosed leukemia were rapidly ascertained during 1995-1999, and 162 matched control subjects were randomly selected from the birth registry. The use of professional pest control services at any time from 1 year before birth to 3 years after was associated with a significantly increased risk of childhood leukemia [odds ratio (OR) = 2.8; 95% confidence interval (CI), 1.4-5.7], and the exposure during year 2 was associated with the highest risk (OR = 3.6; 95% CI, 1.6-8.3). The ORs for exposure to insecticides during the 3 months before pregnancy, pregnancy, and years 1, 2, and 3 were 1.8 (95% CI, 1.1-3.1), 2.1 (95% CI, 1.3-3.5), 1.7 (95% CI, 1.0-2.9), 1.6 (95% CI, 1.0-2.7), and 1.2 (95% CI, 0.7-2.1), respectively. Insecticide exposures early in life appear to be more significant than later exposures, and the highest risk was observed for exposure during pregnancy. Additionally, more frequent exposure to insecticides was associated with a higher risk. In contrast to insecticides, the association between herbicides and leukemia was weak and nonsignificant. Pesticides were also grouped based on where they were applied. Exposure to indoor pesticides was associated with an increased risk, whereas no significant association was observed for exposure to outdoor pesticides. The findings suggest that exposure to household pesticides is associated with an elevated risk of childhood leukemia and further indicate the importance of the timing and location of exposure.

    View details for Web of Science ID 000177893800039

    View details for PubMedID 12204832

  • Pharmacokinetic interactions of cyclosporine with etoposide and mitoxantrone in children with acute myeloid leukemia LEUKEMIA Lacayo, N. J., Lum, B. L., Becton, D. L., Weinstein, H., Ravindranath, Y., Chang, M. N., Bomgaars, L., Lauer, S. J., Sikic, B. I., Dahl, G. V. 2002; 16 (5): 920-927


    The purpose of this study was to assess the effect of the multidrug resistance modulator cyclosporine (CsA) on the pharmacokinetics of etoposide and mitoxantrone in children with de novo acute myeloid leukemia (AML). Serial blood samples for pharmacokinetic studies were obtained in 38 children over a 24-h period following cytotoxin treatment with or without CsA on days 1 and 4. Drug concentrations were quantitated using validated HPLC methods, and pharmacokinetic parameters were determined using compartmental modeling with an iterative two-stage approach, implemented on ADAPT II software. Etoposide displayed a greater degree of interindividual variability in clearance and systemic exposure than mitoxantrone. With CsA treatment, etoposide and mitoxantrone mean clearance declined by 71% and 42%, respectively. These effects on clearance, in combination with the empiric 40% dose reduction for either cytotoxin, resulted in a 47% and 12% increases in the mean AUC for etoposide and mitoxantrone, respectively. There were no differences in the rates of stomatitis or infection between the two groups. CsA treatment resulted in an increased incidence of hyperbilrubinemia, which rapidly reversed upon conclusion of drug therapy. The variability observed in clearance, combined with the empiric 40% dose reduction of the cytotoxins, resulted in statistically similar systemic exposure and similar toxicity.

    View details for DOI 10.1038/sj/leu/2402455

    View details for Web of Science ID 000175631200020

    View details for PubMedID 11986955

  • Letter to the editor: Recurrent mercaptopurine-induced acute pancreatitis: A rare complication of chemotherapy for acute lymphoblastic leukemia in children MEDICAL AND PEDIATRIC ONCOLOGY Willert, J. R., Dahl, G. V., Marina, N. M. 2002; 38 (1): 73-74
  • Surveillance neuroimaging to detect relapse in childhood brain tumors: A pediatric oncology group study JOURNAL OF CLINICAL ONCOLOGY Minn, A. Y., Pollock, B. H., Garzarella, L., Dahl, G. V., Kun, L. E., Ducore, J. M., Shibata, A., Kepner, J., Fisher, P. G. 2001; 19 (21): 4135-4140


    To investigate the prognostic significance of surveillance neuroimaging for detection of relapse among children with malignant brain tumors.A historical cohort study examined all children who experienced relapse from 1985 to 1999 on one of 10 Pediatric Oncology Group trials for malignant glioma, medulloblastoma, or ependymoma.For all 291 patients (median age at diagnosis, 8.2 years), median time to first relapse was 8.8 months (range, 0.6 to 115.6 months). Ninety-nine relapses were radiographic, and 192, clinical; median time to relapse was 15.7 versus 6.6 months, respectively (P = .0001). When stratified by pathology, radiographic and clinical groups showed differences in median time to relapse for malignant glioma (7.8 v 4.3 months, respectively; P = .041) and medulloblastoma (23.6 v 8.9 months, respectively; P = .0006) but not ependymoma (19.5 v 13.3 months, respectively; P = .19). When stratified by early (< 8.8 months) or late (> or = 8.8 months) time to relapse, 115 early relapses were clinical, and 32, radiographic; for late relapses, 77 were clinical, and 67, radiographic (P = .001). Overall survival (OS) from relapse was significantly longer for radiographic compared with clinical detection (median, 10.8 months; 1-year OS, 46% v median, 5.5 months; 1-year OS, 33%; P = .002), but this trend did not retain significance when analyzed by pathology subgroups.Surveillance neuroimaging detects a proportion of asymptomatic relapses, particularly late relapses, and may provide lead time for other therapies on investigational trials. During the first year after diagnosis, radiographic detection of asymptomatic relapse was infrequent. A prospective study is needed to formulate a rational surveillance schedule based on the biologic behavior of these tumors.

    View details for Web of Science ID 000171901100006

    View details for PubMedID 11689581

  • Modified cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone therapy for posttransplantation lymphoproliferative disease in pediatric patients undergoing solid organ transplantation JOURNAL OF PEDIATRIC HEMATOLOGY ONCOLOGY Suryanarayan, K., Natkunam, Y., Berry, G., Bangs, C. D., Cherry, A., Dahl, G. 2001; 23 (7): 452-455


    The authors report the use of a cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone (CHOP)-based chemotherapy regimen in treating six children with posttransplantation lymphoproliferative disorder (PTLD) that developed after solid organ transplantation.The chemotherapy regimen consisted of a 29-day induction with CHOP and then as many as 15 cycles of maintenance therapy using methotrexate and cytarabine alternating with vincristine, adriamycin, mercaptopurine, and prednisone.All patients attained remission. One patient died of sepsis while in remission. Four of the five remaining patients have been followed-up in remission for as long as 8 years without losing the graft. One of the patients experienced relapse after completing therapy and subsequently died with disease.The authors conclude that pediatric patients with PTLD after solid organ transplantation that fails conservative management can be treated successfully with CHOP-based chemotherapy.

    View details for Web of Science ID 000171516000011

    View details for PubMedID 11878581

  • Weekly dosing of carboplatin increases risk of allergy in children 36th Annual Meeting of the American-Society-of-Clinical-Oncology Yu, D. Y., Dahl, G. V., Shames, R. S., Fisher, P. G. LIPPINCOTT WILLIAMS & WILKINS. 2001: 349–52


    Carboplatin (CBDCA) has been used increasingly to treat pediatric low-grade gliomas. Allergic reactions to CBDCA have been reported in 2% to 30% of children. The reason for this high incidence of allergy is unclear.To determine the risk factors for CBDCA allergy, an historic cohort study was conducted for all children who received the drug during a 6-year period at the Lucile Salter Packard Children's Hospital at Stanford. The patients' medical records were reviewed for data on age, tumor type, CBDCA dose schedule, total number of doses, cumulative dosage, dose per treatment, other chemotherapy administered, and allergic reaction.Fifty-four children (mean age 7.2 years, 35 boys) were identified. Six children (11.1%) had an allergic reaction to CBDCA. All reactors had low-grade gliomas treated with weekly CBDCA and vincristine, with a dosage per treatment <500 mg/m2. Overall, six (75%) of eight children administered weekly CBDCA, 6 (46.2%) of 13 children with brain tumors, and 6 (40%) of 15 administered CBDCA dosage <500 mg/m2 manifested allergic reactions. Patients receiving more than five doses had significant risk for CBDCA allergy (relative risk [RR] = 11.8; 95% confidence interval [CI]: 1.5-94.1). Using logistic regression with multiple variables, weekly dose schedule was the most predictive covariate for allergic reaction (P < 0.000 1), and other factors were unrelated or redundant.Children with low-grade gliomas receiving CBDCA weekly are at significantly increased risk for CBDCA allergy. The repetitive, weekly dosing schedule of CBDCA appears to be a key risk factor for allergic reaction in brain tumor patients. The high frequency of allergy with weekly CBDCA warrants further consideration when planning future trials.

    View details for Web of Science ID 000170884300006

    View details for PubMedID 11563768

  • Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Howard, S. C., Gajjar, A., Ribeiro, R. C., Rivera, G. K., Rubnitz, J. E., Sandlund, J. T., Harrison, P. L., de Armendi, A., Dahl, G. V., Pui, C. H. 2000; 284 (17): 2222-2224


    Patients with thrombocytopenia are at risk for spontaneous or procedure-related hemorrhage. Whether such patients can safely undergo lumbar puncture (LP) without prophylactic platelet transfusion is unknown.To determine whether an association exists between thrombocytopenia and LP complications among children with acute lymphoblastic leukemia.Retrospective review of the records of 958 consecutive children (median age, 5.5 years) with newly diagnosed acute lymphoblastic leukemia who were treated at a pediatric cancer center between February 1984 and July 1998.All patients underwent a diagnostic LP followed by a median of 4 LPs to instill intrathecal chemotherapy.Serious complications of LP occurring during the remission induction and consolidation treatment periods (when thrombocytopenia is likely to occur), defined as any neurologic, infectious, or hemorrhagic problems related to the procedure, reported by platelet count at the time of the procedure.Of the 5223 LPs evaluated, 29 were performed at platelet counts of 10 x 10(9)/L or less, 170 at platelet counts of 11 to 20 x 10(9)/L, and 742 at platelet counts of 21 to 50 x 10(9)/L. No serious complications were encountered, regardless of the platelet count. The 95% confidence interval for the proportion of serious complications in the 199 patients with platelet counts of 20 x 10(9)/L or less was 0% to 1.75% and that for the 941 patients with platelet counts of 50 x 10(9)/L or less was 0% to 0.37%.In our study of children undergoing remission induction or consolidation therapy for acute lymphoblastic leukemia, serious complications of LP were not observed, regardless of platelet count. Prophylactic platelet transfusion is not necessary in children with platelet counts higher than 10 x 10(9)/L. Due to the small number of patients in our study with platelet counts of 10 x 10(9)/L or less, conclusions cannot yet be drawn for such patients. JAMA. 2000;284:2222-2224.

    View details for Web of Science ID 000090052600031

    View details for PubMedID 11056594

  • Management of children with metastatic spinal myxopapillary ependymoma using craniospinal irradiation MEDICAL AND PEDIATRIC ONCOLOGY Chinn, D. M., Donaldson, S. S., Dahl, G. V., Wilson, J. D., Huhn, S. L., Fisher, P. C. 2000; 35 (4): 443-445

    View details for Web of Science ID 000089577700013

    View details for PubMedID 11025481

  • Mitoxantrone, etoposide, and cyclosporine therapy in pediatric patients with recurrent or refractory acute myeloid leukemia JOURNAL OF CLINICAL ONCOLOGY Dahl, G. V., Lacayo, N. J., Brophy, N., Dunussi-Joannopoulos, K., Weinstein, H. J., Chang, M. R., Sikic, B. I., Arceci, R. J. 2000; 18 (9): 1867-1875


    To determine the remission rate and toxicity of mitoxantrone, etoposide, and cyclosporine (MEC) therapy, multidrug resistance-1 (MDR1) status, and steady-state cyclosporine (CSA) levels in children with relapsed and/or refractory acute myeloid leukemia.MEC therapy consisted of mitoxantrone 6 mg/m(2)/d for 5 days, etoposide 60 mg/m(2)/d for 5 days, and CSA 10 mg/kg for 2 hours followed by 30 mg/kg/d as a continuous infusion for 98 hours. Because of pharmacokinetic interactions, drug doses were decreased to 60% of those found to be effective without coadministration of CSA. MDR1 expression was evaluated by reverse transcriptase polymerase chain reaction, flow cytometry, and the ability of CSA at 2.5 micromol/L to increase intracellular accumulation of (3)H-daunomycin in blasts from bone marrow specimens.The remission rate was 35% (n = 23 of 66). Overall, 35% of patients (n = 23) achieved complete remission (CR), 12% of patients (n = 8) achieved partial remission, and 9% of patients (n = 6) died of infection. Exposure to CSA levels of greater than 2,400 ng/mL was achieved in 95% of patients (n = 56 of 59). Toxicities included infection, cardiotoxicity, myelosuppression, stomatitis, and reversible increases in serum creatinine and bilirubin. In most who had relapsed while receiving therapy or whose induction therapy had failed, response was not significantly different for MDR1-positive and MDR1-negative patients.Serum levels of CSA capable of reversing multidrug resistance are achievable in children with acceptable toxicity. The CR rate of 35% achieved in this study is comparable to previously reported results using standard doses of mitoxantrone and etoposide. The use of CSA may have improved the response rate for the MDR1-positive patients so that it was not different from that for the MDR1-negative patients.

    View details for Web of Science ID 000086873900008

    View details for PubMedID 10784627

  • A multi-institutional retrospective study of intracranial ependymoma in children: Identification of risk factors JOURNAL OF PEDIATRIC HEMATOLOGY ONCOLOGY Horn, B., Heideman, R., Geyer, R., Pollack, I., Packer, R., Goldwein, J., Tomita, T., Schomberg, P., Ater, J., Luchtman-Jones, L., Rivlin, K., Lamborn, K., Prados, M., Bollen, A., Berger, M., Dahl, G., McNeil, E., Patterson, K., Shaw, D., Kubalik, M., Russo, C. 1999; 21 (3): 203-211


    The goal of this multi-institutional retrospective study of children with intracranial ependymoma was to identify risk factors associated with unfavorable overall survival (OS) and event-free survival (EFS).Clinical data, including demographics, tumor location, spread, histology, details of surgery, radiation treatment, and chemotherapy were collected. Clinical characteristics and univariate and multivariate analyses of risk factors for OS and EFS are presented.Eleven U.S. institutions contributed 83 patients treated from 1987 to 1991. The OS at 5 and 7 years was 57% and 46%, and EFS at 5 and 7 years was 42% and 33%. Patients 3 years of age or younger differed from the older group by more common infratentorial location, less common gross total resection (GTR), and postoperative use of chemotherapy rather than radiation. This younger group of patients had worse survival (P < 0.01) than the older age group. Other than young age, less than GTR and World Health Organization (WHO) II grade 3 histology were significant adverse risk factors for EFS in univariate and multivariate analyses. OS shared the same adverse risk factors except for histology in multivariate analysis, which was only of borderline significance (P = 0.05). Progression at the original tumor location, present in 89% of patients, was the major pattern of tumor recurrence. Adjuvant chemotherapy in the group older than 3 years or craniospinal radiation in M0 patients did not significantly change EFS.Adverse outcome in childhood intracranial ependymoma is related to age (3 years or younger), histology (grade 3), and degree of surgical resection (less than GTR). New approaches, particularly for local tumor control in younger patients, are needed to improve survival.

    View details for Web of Science ID 000080625600007

    View details for PubMedID 10363853

  • Combination chemotherapy using vinblastine and methotrexate for the treatment of progressive desmoid tumor in children JOURNAL OF CLINICAL ONCOLOGY Skapek, S. X., Hawk, B. J., Hoffer, F. A., Dahl, G. V., Granowetter, L., Gebhardt, M. C., Ferguson, W. S., Grier, H. E. 1998; 16 (9): 3021-3027


    We report the treatment of 10 children for progressive desmoid tumor not amenable to standard surgical or radiation therapy with the use of vinblastine (VBL) and methotrexate (MTX).Ten patients aged 6.4 to 18 years with primary (two patients) or recurrent (eight patients) desmoid tumor were treated with VBL and MTX for 2 to 35 months. Patients with recurrent tumors had been previously treated with surgical resection with (two patients) or without (five patients) radiation therapy or with radiation therapy alone (one patient). No patient had previously received cytotoxic chemotherapy. The tumor response was assessed at routine intervals by physical examination and magnetic resonance imaging (MRI).Five patients had clinical evidence of response to therapy with complete resolution (three patients) or partial resolution (two patients) of physical examination and radiographic abnormalities. Three patients had stable disease during 10 to 35 months of treatment. Two of these patients had progressive disease 9 and 37 months after treatment stopped; one patient had no progression 16 months after therapy. Two additional patients with stable disease had chemotherapy discontinued after 2 and 3 months. Common side effects included mild alopecia and myelosuppression and moderate nausea and vomiting. In patients with responding tumors, MRI showed decreased tumor size and, in two patients, changes consistent with fibrosis and decreased cellularity of the tumor.Combination chemotherapy with VBL and MTX appears to control desmoid tumor without significant acute or long-term morbidity in most children. This may allow for further growth and development in these patients, which may decrease the morbidity of subsequent definitive therapy.

    View details for Web of Science ID 000075734800017

    View details for PubMedID 9738571

  • Bcl-2 expression does not correlate with patient outcome in pediatric acute myelogenous leukemia LEUKEMIA RESEARCH Naumovski, L., Martinovsky, G., Wong, C., Chang, M., Ravendranath, Y., Weinstein, H., Dahl, G. 1998; 22 (1): 81-87


    Although the Bcl-2 protein inhibits apoptosis (programmed cell death) of lymphoid cells induced by a variety of stimuli, its effects on myeloid cell short- and long-term survival after chemotherapy are less defined. We sought to elucidate the short- and long-term effect of Bcl-2 in a well-studied myeloid cell line (HL-60) treated with specific anti-AML chemotherapy. HL-60 cells overexpressing Bcl-2 (HL-60/BCL-2) were more resistant than parental HL-60 cells to multiple chemotherapeutic agents in short-term apoptosis and viability assays. Significantly, HL-60/BCL-2 cells retained greater long-term proliferative capacity than HL-60 cells when treated with low doses of doxorubicin. To assess the importance of Bcl-2 expression in pediatric AML we correlated clinical outcome and levels of Bcl-2 protein in 22 patient specimens. The correlation did not achieve statistical significance with patient response to chemotherapy or long-term outcome, suggesting that analysis of larger numbers of patient samples would not be useful. Our study suggests that although Bcl-2 clearly promotes short and long-term survival in a myeloid cell line, measurement of Bcl-2 levels alone are not sufficient to be of prognostic significance in pediatric AML.

    View details for Web of Science ID 000073169100013

    View details for PubMedID 9585084

  • Congenital myelomonocytic and pre-B leukemias with t(11;19)(q23;p13): Relation of phenotype to HRX fusion partner. DiMartino, J., MILATOVICH, A., Bangs, D., CORNBLEET, J., Marina, N., Cleary, M. L., Dahl, G. V. AMER SOC HEMATOLOGY. 1997: 3763–63
  • CHROMOSOME-ABERRATIONS IN 4 HEPATOBLASTOMAS Neidich, J. A., Bangs, C. D., Hsieh, C. L., Donlon, T. A., Dahl, G. CELL PRESS. 1995: 393–93
  • Neoplastic disorders after pediatric heart transplantation. Circulation Bernstein, D., Baum, D., Berry, G., Dahl, G., Weiss, L., Starnes, V. A., Gamberg, P., Stinson, E. B. 1993; 88 (5): II230-7


    Because of their life-long requirement for immunosuppressive therapy, neoplastic disorders could represent a significant threat to long-term survival in infants and children after heart transplantation. This study determined the incidence and clinical spectrum of neoplastic disorders in 80 pediatric patients who underwent heart transplantation between 1974 and 1992.Follow-up ranged from 6 to 189 months (mean, 50.0 months). Tumors occurred in 10 patients (12.5%). Time to detection ranged from 3.3 to 139.2 months (mean, 52.7 months). Tumor incidence was greatest in 9 patients transplanted before the cyclosporine era (44%) compared with the subsequent 71 patients (8.5%, P < .05). There was no increase in risk related to sex, age, underlying disease, or blood type; however, patients with tumors received higher initial doses of cyclosporine and prednisone and had more rejection episodes in the first 3 months (P < .05). There was an increased risk associated with anti-thymocyte globulin (33%, P < .05) but not with OKT3 (6%, P = NS). There were eight lymphoproliferative disorders (four B-cell, one T-cell, three not determined) and one hepatocellular and one squamous cell carcinomas. Six cases of lymphoproliferative disorder had in situ evidence of Epstein-Barr virus. Patients were treated by reducing immunosuppression (7), radiotherapy (2), and chemotherapy (1). There were five deaths: two tumor related and the others due to rejection, renal failure, and infection. Of 5 survivors, 1 had tumor recurrence 4 years after diagnosis, and 4 are disease free.Tumors represent a small but serious long-term risk to pediatric heart transplant recipients. The incidence in children transplanted in the cyclosporine era is similar to that in adults, and the majority of tumors are lymphoproliferative disorders that often regress by reducing immunosuppression.

    View details for PubMedID 8222159

  • NEOPLASTIC DISORDERS AFTER PEDIATRIC HEART-TRANSPLANTATION CIRCULATION Bernstein, D., Baum, D., Berry, G., Dahl, G., Weiss, L., Starnes, V. A., Gamberg, P., Stinson, E. B. 1993; 88 (5): 230-237
  • NEOPLASTIC DISORDERS AFTER PEDIATRIC HEART-TRANSPLANTATION (HTX) Bernstein, D., Berry, G., Dahl, G., Weiss, L., Gamberg, P., Starnes, V. A., Baum, D. LIPPINCOTT WILLIAMS & WILKINS. 1992: 238–38
  • IMPACT OF 3 METHODS OF TREATMENT INTENSIFICATION ON ACUTE LYMPHOBLASTIC-LEUKEMIA IN CHILDREN - LONG-TERM RESULTS OF ST-JUDE TOTAL THERAPY STUDY-X LEUKEMIA Pui, C. H., Simone, J. V., Hancock, M. L., Evans, W. E., Williams, D. L., Bowman, W. P., Dahl, G. V., Dodge, R. K., Ochs, J., Abromowitch, M., Rivera, G. K. 1992; 6 (2): 150-157


    Long-term follow-up observations are reported on 427 patients who received one of three different intensified therapies in total therapy study X for acute lymphoblastic leukemia (ALL). In the trial for 'standard-risk' ALL, 154 of 309 patients in complete remission were randomized to receive high-dose methotrexate (HDMTX, 1 g/m2) periodically during the first 72 of 120 weeks of standard continuation therapy with 6-mercaptopurine and oral MTX; the remaining 155 patients received 1800 cGy cranial irradiation and intrathecal MTX, followed by 6-mercaptopurine/MTX therapy interrupted from week 36-71 for substitution of two other pairs of drugs. At 9 years of follow-up, significantly higher proportions of patients in the HDMTX group have maintained complete remissions (64 +/- 7%, SE, vs. 52 +/- 6%, p = 0.03), hematologic remissions (73 +/- 6% vs. 62 +/- 6%, p = 0.03), and testicular remissions (94 +/- 5% vs. 80 +/- 8%, p = 0.03); however, the proportion continuing in central nervous system remission has been lower (84 +/- 5% vs 93 +/- 4%, p = 0.02). In the evaluation of teniposide/cytarabine and delayed cranial irradiation for 'high-risk' ALL, 36 +/- 9% of 101 patients are predicted to be event-free survivors at 9 years. Altogether, 217 (51%) of the 427 patients are event-free survivors after at least 7 years of follow-up (median, 9 years); an additional 75 patients are alive and free of leukemia for a median of 6.4 years after successful remission retrieval therapy, boosting the total number of long-term survivors to 292 (68%). These results establish the efficacy of HDMTX for patients with standard-risk ALL and indicate the potential of teniposide/cytarabine for use in multiagent regimens for patients with high-risk disease. The overall survival figure, 68%, affords a benchmark for other studies assessing long-term outcome in ALL.

    View details for Web of Science ID A1992HP85300010

    View details for PubMedID 1552746

  • THE T(1-22)(P13-Q13) IS NONRANDOM AND RESTRICTED TO INFANTS WITH ACUTE MEGAKARYOBLASTIC LEUKEMIA - A PEDIATRIC ONCOLOGY GROUP-STUDY BLOOD Carroll, A., Civin, C., Schneider, N., Dahl, G., Pappo, A., Bowman, P., Emami, A., Gross, S., Alvarado, C., Phillips, C., Krischer, J., Crist, W., Head, D., Gresik, M., Ravindranath, Y., Weinstein, H. 1991; 78 (3): 748-752


    We report the nonrandom occurrence and frequency of the t(1;22)(p13;q13) in acute myeloid leukemia (AML) and its close association with the French-American-British M7 subtype of AML in infants (less than 1 year). This chromosomal abnormality occurred in 6 of 252 (2.4%) children and adolescents with AML (6 of 28 infants, 22%; 6 of 18 M7 AML cases overall, 33%; and 6 of 6 M7 cases in infants). Infants with AML of M7 subtype and the t(1;22) often presented with prominent abdominal masses. Two of these infants were not treated and died early. Three of four treated infants entered complete remission with therapy for AML; the remaining infant died of hemorrhage on day 8. Of the three infants who entered remission, only one remains alive and disease free at 5+ months. The other two infants relapsed in the bone marrow at 5 and 2 months from the start of therapy, respectively. We conclude that M7 AML with the t(1;22) usually presents in infants with extensive infiltration of abdominal organs by leukemic cells and may confer a poor prognosis despite intensive AML-directed treatment. Identification of this nonrandom translocation exclusively in infants with acute megakaryoblastic leukemia (AMkL) implies that it may serve as an additional diagnostic marker for this disease and links it to the pathogenesis of AMkL in infants.

    View details for Web of Science ID A1991FZ56600028

    View details for PubMedID 1859887

  • IMPROVED OUTCOME IN CHILDHOOD ACUTE LYMPHOBLASTIC-LEUKEMIA WITH REINFORCED EARLY TREATMENT AND ROTATIONAL COMBINATION CHEMOTHERAPY LANCET Rivera, G. K., Raimondi, S. C., Hancock, M. L., Behm, F. G., Pui, C. H., Abromowitch, M., Mirro, J., Ochs, J. S., Look, A. T., Williams, D. L., Murphy, S. B., Dahl, G. V., Kalwinsky, D. K., Evans, W. E., Kun, L. E., Simone, J. V., Crist, W. M. 1991; 337 (8733): 61-66
  • TESTICULAR RELAPSE IN CHILDREN WITH ACUTE NONLYMPHOBLASTIC LEUKEMIA CANCER Furman, W. L., Fontanesi, J., HUSTU, O., Dahl, G. V., Kalwinsky, D. K., Pui, C. H. 1990; 66 (10): 2095-2098


    The clinical course and other distinctive features of five children who developed a testicular relapse 4 months to 25 months after the diagnosis of acute nonlymphoblastic leukemia (ANLL) are described. The chief presenting feature at relapse was painless testicular enlargement, as is also seen in children with acute lymphoblastic leukemia who relapse in the testes. By French-American-British convention, the malignant cells were classified as M4 (myelomonoblastic) in four cases and M2 (myeloblastic) in one. All children received a course of multiagent reinduction chemotherapy and all but one received local irradiation to the testes. Only one of these children, whose relapse was a late event after elective cessation of therapy, is a long-term survivor. A comparison with six previously published cases shows similar clinical characteristics and outcome. Given the poor responses of such patients to conventional treatment, it seems worthwhile to consider the use of intensive reinduction chemotherapy with concomitant bilateral testicular irradiation followed by remission intensification and an autologous or allogenic marrow transplant.

    View details for Web of Science ID A1990EH74500008

    View details for PubMedID 2224763



    Forty-one children with refractory acute nonlymphocytic leukemia (ANLL) were treated from March 1975 to February 1979 with a schedule-dependent combination of methotrexate (MTX) and L-asparaginase. Intravenous (IV) MTX was followed 24 hours later by IV L-asparaginase (10,000 units [U]/m2). The MTX dose was started at 60 to 100 mg/m2 and was escalated by 20 to 40 mg/m2 as tolerated. This sequence was repeated every 7 to 10 days. Eight patients (20%) achieved a complete remission (CR) and six others had a partial response (PR), with clearance of blasts from the peripheral blood and reduction of bone marrow blasts to less than 25% of nucleated marrow cells. Responding patients received a median maximum MTX dose of 120 mg/m2 (range, 60 to 220 mg/m2). The median number of courses required to achieve a CR was 6 (range, 2 to 13 courses). Toxicity consisted of allergic reactions to L-asparaginase (n = 12), stomatitis (n = 6), minimal elevation of hepatic enzymes (n = 2), and hyperglycemia (n = 1). Treatment was given on an outpatient basis in 95% of all courses. The data indicate that this combination therapy has antileukemic activity and is relatively nontoxic in childhood ANLL.

    View details for Web of Science ID A1990DH06600001

    View details for PubMedID 2340462



    Eighty-seven consecutive children and young adults with acute nonlymphocytic leukemia (ANLL) were treated uniformly with induction chemotherapy based on daunorubicin and cytarabine (ara-C), with the addition of etoposide (VP-16) and azacytidine (5-Az) for refractory patients. Of the 65 patients who entered complete remission, 42 were eligible for assessment of response to intensive chemotherapy consisting of four pairs of drugs administered in sequential fashion. Nineteen others with available histocompatibility locus antigen (HLA)-compatible donors were assigned to receive allogeneic bone marrow transplants within 16 weeks from their dates of complete remission. Durations of continuous complete remission (CCR) in the two groups were not significantly different at a median follow-up time of 6 years (P = .30 by log-rank analysis). Kaplan-Meier estimates of CCR probabilities (+/- SE) at 6 years were 43% +/- 13% (transplantation) and 31% +/- 7% (sequential chemotherapy). Postremission failures in the sequential chemotherapy group resulted from bone marrow relapse in 23 of 29 patients (79%), whereas in the transplantation group, failures were equally divided between marrow relapse and transplantation-related complications of graft-versus-host disease (GVHD) or infection due to the immunosuppressive effects of ablative chemotherapy. Comparison of hematologic remission curves indicated a significant advantage for marrow transplantation in terms of systemic leukemia control (P = .06). Thus, in programs of intensive chemotherapy of the type described here, allogeneic marrow transplantation should be seriously considered as alternative therapy for patients in first remission who have an HLA-matched sibling donor, provided that effective methods for control of transplant-related complications are available.

    View details for Web of Science ID A1990CK91000016

    View details for PubMedID 2299372



    Reports of close associations between recurring chromosomal abnormalities and the clinical behavior of acute nonlymphocytic leukemia (ANLL) have stimulated efforts to define this disease in cytogenetic terms. Here we report on the leukemic cell karyotypes of 155 children with ANLL who were treated from 1980 to 1987 in consecutive programs of chemotherapy at this institution. Of 121 cases with adequate banding, 20% were normal, 30% had miscellaneous clonal abnormalities, and 50% were classified into known cytogenetic subgroups: inv(16)/del(16q) (n = 15), t(8; 21) (n = 14), t(15;17) (n = 9), t(9;11) (n = 9), t(11;V)/del(11q) (n = 7) and -7/del(7q) (n = 6). The inv(16)/del(16q) cases showed a nearly equal distribution of myelocytic and monocytic French-American-British (FAB) subtypes; only four of these patients presented with M4Eo morphology. Despite a 100% remission induction rate, patients with inv(16)/del(16q)-positive ANLL fared no better overall than the entire group; only 40% of this subgroup were event-free survivors at 2 years from diagnosis (P = .23). Patients with inv(16)/del(16q) frequently had CNS involvement at diagnosis (eight of 15) or initially relapsed in this site (three of eight). Event-free survival (EFS) was clearly superior for young patients with FAB M5 leukemia and the t(9;11) (P = .041). These patients were clinically indistinguishable from others with the FAB disease subtype, yet their responses to etoposide-containing therapies were noteworthy. By contrast, children with structural abnormalities involving 11q23, other than t(9;11), were infants (median age, 6 months) with FAB M4 or M5 leukemia, hyperleukocytosis, and frequent coagulation abnormalities. Patients with such changes [t(11;V) or del(11q)] relapsed early during postremission therapy: none remained disease-free more than 16 months from diagnosis. Because of resistant leukemia, patients with monosomy 7/del(7q) had a poor remission induction rate (17%; P = .0015); patients with the t(15;17) were also poor responders to induction therapy (44%; P = 0.02) because of hemorrhagic deaths. These results identify several cytogenetic subtypes of pediatric ANLL that may represent unique disease processes for which more effective early cytoreduction [-7/del(7q), t(11;V)], better supportive care measures [t(15;17)], or more effective CNS prophylaxis [inv(16)/del(16q)] would be warranted.

    View details for Web of Science ID A1990CG70400012

    View details for PubMedID 2295913

  • SECONDARY ACUTE MYELOID-LEUKEMIA IN CHILDREN TREATED FOR ACUTE LYMPHOID LEUKEMIA NEW ENGLAND JOURNAL OF MEDICINE Pui, C. H., Behm, F. G., Raimondi, S. C., Dodge, R. K., George, S. L., Rivera, G. K., Mirro, J., Kalwinsky, D. K., Dahl, G. V., Murphy, S. B., Crist, W. M., Williams, D. L. 1989; 321 (3): 136-142


    We studied the risk of the development of acute myeloid leukemia (AML) during initial remission in 733 consecutive children with acute lymphoid leukemia (ALL) who were treated with intensive chemotherapy. This complication was identified according to standard morphologic and cytochemical criteria in 13 patients 1.2 to 6 years (median, 3.0) after the diagnosis of ALL. At three years of follow-up, the cumulative risk of secondary AML during the first bone marrow remission was 1.6 percent (95 percent confidence limits, 0.7 and 3.5 percent); at six years, it was 4.7 percent (2 and 10 percent). The development of secondary AML was much more likely among patients with a T-cell than a non-T-cell immunophenotype (cumulative risk, 19.1 percent [6 and 47 percent] at six years). Sequential cytogenetic studies in 10 patients revealed entirely different karyotypes in 9, suggesting the induction of a second neoplasm. In eight of these patients, the blast cells had abnormalities of the 11q23 chromosomal region, which has been associated with malignant transformation of a pluripotential stem cell. There was no evidence of loss of DNA from chromosome 5 or 7, a karyotypic change commonly observed in cases of AML secondary to treatment with alkylating agents, irradiation, or both. We conclude that there is a substantial risk of AML in patients who receive intensive treatment for ALL, especially in those with a T-cell immunophenotype, and that 11q23 chromosomal abnormalities may be important in the pathogenesis of this complication.

    View details for Web of Science ID A1989AG03900002

    View details for PubMedID 2787477



    Of 251 consecutive cases of childhood acute nonlymphocytic leukemia (ANLL) seen at St. Jude Children's Research Hospital over a 12-year period, 16 (6.4%) were classified as promyelocytic according to the French-American-British definition. Patients with this form of leukemia were older at diagnosis than the group representing all other ANLL subtypes (median age, 14.8 vs. 9.0 years); they had lower leukocyte counts (median, 4.5 vs. 25.9 x 10(9)/liter), and a higher percentage were girls (68% vs. 44%). They also were much more likely to have a coagulation abnormality (75% vs. 13%). Only 44% of the promyelocytic group achieved complete remission, compared with 79% of the remaining patients (p = 0.001); however, after a median follow-up of 3.5 years, all but two of the responding patients with promyelocytic leukemia remain in complete remission. The majority of induction failures in the promyelocytic group (six of nine) resulted from complications that developed during periods of marrow hypoplasia or before hypoplasia was induced; whereas in the comparison group, more than half of the patients who failed had evidence of absolute or relative drug resistance. It is concluded that acute promyelocytic leukemia in children differs sufficiently from other subtypes of childhood ANLL to justify clinical trials of selective therapy. Recommendations for the use of heparin and blood component support in these patients are given.

    View details for Web of Science ID A1989T821800009

    View details for PubMedID 2927178

  • A PROSPECTIVE-STUDY OF HICKMAN BROVIAC CATHETERS AND IMPLANTABLE PORTS IN PEDIATRIC ONCOLOGY PATIENTS JOURNAL OF CLINICAL ONCOLOGY Mirro, J., Rao, B. N., Stokes, D. C., Austin, B. A., Kumar, M., Dahl, G. V., COLTEN, M., Balas, L., Rafferty, M., Hancock, M., Fairclough, D. 1989; 7 (2): 214-222


    We prospectively studied the continuous function and complication rates of 286 central venous catheters consecutively placed in 264 children and young adults at a single institution over a 19-month period (median follow-up, 376 days). Externalized catheters (91 Hickman [H], 113 Broviac [B]) and implantable ports (n = 82) were compared for complications, including infection and thrombosis. The most frequent major complication of all catheters was infection, although the rates of infection varied with the duration of catheter use and were generally lower than reported by others. Overall, when catheter failures (removal) for infection, obstruction, or dislodgement were considered, ports had a significantly longer failure-free duration of use (P = .0024) than did externalized catheters. Likewise, ports had a significantly longer infection-free (P less than .01) duration of use than H and B catheters. However, differences in patient age and clinical characteristics among the three catheter groups may have affected the outcome. In analysis of pairs matched for diagnosis, therapy, and age, ports had lower infection rates than did B catheters after 100 days (P = .053). This difference became significant at 400 days of catheter use (P = .029). Although there was a trend toward lower rates of infections for ports v H catheters, this difference was not significant. In view of our results in matched pairs, selection of catheter type based on clinical characteristics and patient preferences remains a reasonable therapeutic approach despite the apparent advantages of ports. The superiority of ports for long-term use (greater than 100 days) needs to be confirmed in a large randomized clinical trial.

    View details for Web of Science ID A1989R975600011

    View details for PubMedID 2915237



    The combination of teniposide (VM-26) and amsacrine (AMSA) was evaluated in a dose-finding and efficacy study in 58 patients with relapsed or refractory acute leukemia. Both agents were given as simultaneous continuous infusions for 72 h through separate i.v. lines. All patients were evaluable for toxicity and 57 were evaluable for response; only 2 of 20 with acute lymphoblastic leukemia (ALL), acute mixed-lineage leukemia, or chronic myelogenous leukemia in blast crisis achieved a complete remission (CR). More encouraging was a second-remission rate of 43% (13 complete and 3 partial) in the 37 patients with acute nonlymphoid leukemia (ANLL). Responses occurred only in patients who received VM-26 doses of greater than or equal to 200 mg/m2 per day and AMSA doses of greater than or equal to 100 mg/m2 per day. Thus, the CR rate for relapsed ANLL patients who received the higher doses of both agents was 40% (13 of 33). All responders had previously received epipodophyllotoxin therapy and 40% had also received AMSA. All but one patient had severe leukopenia (less than 2.0 x 10(9) leukocytes/l) and thrombocytopenia (less than 50.0 x 10(9) platelets/l) as a results of therapy. Severe mucositis (grade 3 or 4) was the dose-limiting toxicity. Our results indicate that VM-26 plus AMSA, given by continuous infusion, is effective in the treatment of ANLL. Further phase II studies should consider using VM-26 at 200 mg/m2 per day and AMSA at 100 mg/m2 per day, but the best administration schedule remains unclear.

    View details for Web of Science ID A1989U881200010

    View details for PubMedID 2731312



    Serum concentrations of CD8 antigen were measured at diagnosis with an enzyme-linked immunoassay in children with acute lymphoblastic leukemia (n = 344) or non-Hodgkin's lymphoma (n = 65). All patients had detectable levels of the serum antigen, which in its soluble nonreduced form appeared to be a 52-Kd homodimer as compared with the 66-Kd surface membrane component on most thymocytes and on a subset of functionally distinct T cells (suppressor/cytotoxic). Increased serum levels of CD8 in leukemia patients were significantly related to recognized high-risk prognostic features: high leukocyte count, large liver and spleen size, high serum lactic dehydrogenase level, T-cell immunophenotype, presence of a mediastinal mass, pseudodiploid karyotype, DNA index less than 1.16, and chromosomal translocation. Children with serum CD8 levels greater than or equal to 450 U/mL were more likely to fail treatment than were those with lower levels (P = .002), even in the group with non-T-cell leukemia (P = .003). In a multivariate analysis, serum CD8 antigen contributed independent prognostic information beyond that conveyed by age, leukocyte count, and race (P = .02). High serum CD8 antigen levels also correlated with advanced stages of disease in children with non-Hodgkin's lymphoma or B-cell leukemia. Children with higher serum CD8 antigen levels (greater than or equal to 700 U/mL) had a poorer treatment outcome (P = .003), even after results were adjusted for disease stage and serum lactic dehydrogenase level (P = .05). Measurement of serum levels of CD8 antigen not only has important prognostic value in childhood lymphoid malignancies but also could be useful in assessing the immunoregulatory role of T cells in patients with cancer.

    View details for Web of Science ID A1988Q102800029

    View details for PubMedID 2970871



    We tested the value of early intensification of chemotherapy in 68 consecutive children with acute nonlymphocytic leukemia (ANLL) who were admitted to St. Jude Children's Research Hospital from November 1983 through March 1987. Fifty-eight patients (85%) entered complete remission after treatment with etoposide (VP-16)/cytarabine (ara-C) (A), followed by daunorubicin (Dauno)/ara-C/thioguanine (6-TG) (B) and then VP-16/azacytidine (5-AZ) (C). Thirty percent of the complete responders, mainly those with an M4 or M5 leukemia subtype, attained M1 marrow status after component A, 60% after A + B, and 10% after A + B + C. Induction failures resulted primarily from absolute or relative drug resistance; there was only one death during this phase of therapy. Postremission treatment consisted of three pairs of drugs (vincristine [VCR]/amsacrine [m-AMSA], or doxorubicin [Doxo]/6-TG/ara-C, and VP-16/cyclophosphamide [CTX]) administered sequentially in 6-week cycles for 22 months. Despite the high rate of remission induction, only 33% +/- 7% SE of the patients are expected to be failure-free survivors at 2 years. Remission durations were not significantly affected by the majority of factors examined in this study, with the exception of marrow cellularity after VP-16/ara-C induction therapy. Patients with less than or equal to 5% leukemic cells survived relapse-free for a median of 36.1 months, compared with 11.3 months for the group with a larger infiltrate (P = .01). Although postremission therapy did not improve the percentage of long-term failure-free survivors, the induction regimen we used appears highly effective, and its components should be considered for inclusion in other treatment programs.

    View details for Web of Science ID A1988P260200009

    View details for PubMedID 3292713



    The presenting features and clinical outcome of acute nonlymphoblastic leukemia (ANLL) in infants and older children were compared to identify any differences that might suggest methods to improve therapy. Twelve of the 29 infants were boys and 17 were girls, with ages ranging from two days to 12 months (median, 7 months). By comparison with 222 patients greater than 1 year of age, infants were significantly more likely to have monoblastic or myelomonoblastic leukemia (P less than .0001), chloroma (P less than .0001), marked hepatomegaly (P = .001), and high leukocyte count (P = .005) and were less likely to have Auer rods (P less than .001). Each of these features except leukocyte count showed an association with infant ANLL in a multivariate analysis. Twenty-four (83%) of the infants attained a complete remission, a rate that was not significantly different from that of the older children. Even though infants had a significantly higher CNS relapse rate (P = .003), their event-free survival times were no different than those of older children (P = .74). Ten of the infants remain in initial complete remission for 5+ to 112+ months (median, 52+ months). Infants with ANLL did not have a poorer prognosis than older patients in our study; future protocols for this age group should emphasize more effective systemic therapy, preferably including an epipodophyllotoxin, as well as improved treatment for subclinical CNS leukemia.

    View details for Web of Science ID A1988N737700014

    View details for PubMedID 3373258



    Childhood nonlymphocytic leukemia comprises a minority (25%) of pediatric leukemia cases, yet contributes a significant proportion of overall leukemia mortality. Improvements in supportive care (antibiotics, antifungals, nutrition, and blood products) along with aggressive induction therapies have significantly improved remission induction rates over the past two decades. Ideal treatment to completely eliminate residual disease following remission is not yet known. In most series, only one out of three patients are long-term survivors of this disease. Recent advances in allogeneic bone marrow transplantation and improved techniques for autologous engraftment leave promise for significant improvements in postinduction disease control. Biologic studies of surface immunophenotype have contributed to our understanding of the heterogeneity of this family of disorders and allowed identification and characterization of leukemias of mixed myeloid/lymphoid lineage. Karyotype studies have identified important subsets of ANLL with distinctive clinical and biologic properties, for which tailored therapies someday may be developed. In addition, studies of oncogenes provide insight into regulation of leukemic hematopoiesis with potential of identifying future methods to regulate proliferation of the leukemic clone.

    View details for Web of Science ID A1988M438400004

    View details for PubMedID 3281104

  • HIGH-DOSE METHOTREXATE IMPROVES CLINICAL OUTCOME IN CHILDREN WITH ACUTE LYMPHOBLASTIC-LEUKEMIA - ST-JUDE TOTAL THERAPY STUDY MEDICAL AND PEDIATRIC ONCOLOGY Abromowitch, M., Ochs, J., Pui, C. H., Kalwinsky, D., Rivera, G. K., Fairclough, D., Look, A. T., HUSTU, H. O., Murphy, S. B., Evans, W. E., Dahl, G. V., Bowman, W. P. 1988; 16 (5): 297-303


    Childhood acute lymphoblastic leukemia with an initial leukocyte count greater than or equal to 100 X 10(9)/L responds poorly to conventional chemotherapy. To extend event-free survival (EFS) in this disease, we devised a protocol that specifies intensive 2-week courses of teniposide (VM-26, 165 mg/m2) plus cytarabine (ara-C, 300 mg/m2), before and immediately after standard 4-week remission induction therapy with prednisone, vincristine, and L-asparaginase. The VM-26 and ara-C combination was also administered intermittently for the first year of continuation treatment with oral 6-mercaptopurine and methotrexate. CNS prophylaxis consisted of periodic intrathecal (IT) injections of methotrexate and delayed cranial irradiation. At a median follow-up of 4 years, the estimated EFS rate for 57 consecutive patients with leukocyte counts of 100 to 1,000 X 10(9)/L was 44%, compared with 10% for matched controls (P less than .001). Remission induction rates in the two groups were similar (82% v 72%, P = .16). Twenty-five patients in the VM-26/ara-C group have survived without adverse events for 2.7 to 6.8 years, whereas only nine of the controls achieved more than a year of EFS. The most common complications during early treatment were acute hyperkalemia from rapid tumor cell lysis and infections due to prolonged marrow aplasia. Continuation chemotherapy was well tolerated. We conclude that VM-26 plus ara-C, added to each phase of an otherwise basic regimen of chemotherapy, will substantially improve prognosis in this high-risk form of childhood leukemia.

    View details for Web of Science ID A1987J134800006

    View details for PubMedID 3474355



    The clinical significance of a low percentage of myeloperoxidase-positive blast cells in childhood acute nonlymphoblastic leukemia was determined. Of 155 consecutive cases studied by cytochemical staining methods, 14 were characterized by 4% to 15% (median 6%) myeloperoxidase-positive blasts. All 14 cases showed reactivity to Sudan black B stain, and 7 had Auer rods. The morphological subtypes of leukemia were M1 (8 cases), M2 (3), M4 (1), and M5 (2). Immunological marker studies disclosed the lymphoid-associated T11 antigen on cells from 8 of the 11 cases tested. Other lymphoid-related findings in these 8 cases included the T3 antigen and E rosette formation in 1 case each. Among cases that were prospectively studied for the expression of lymphoid-associated markers, 6 of 8 with low levels of myeloperoxidase positivity compared with only 1 of 44 with higher levels (greater than 15%) possessed such features (P less than 0.001). We conclude that low levels of myeloperoxidase reactivity distinguish cases of acute leukemia in which the blast cells coexpress lymphoid (T11 antigen) and myeloid markers.

    View details for Web of Science ID A1987J078000007

    View details for PubMedID 3036278

  • AN ANALYSIS OF LEUKEMIC-CELL CHROMOSOMAL FEATURES IN INFANTS BLOOD Pui, C. H., Raimondi, S. C., Murphy, S. B., Ribeiro, R. C., Kalwinsky, D. K., Dahl, G. V., Crist, W. M., Williams, D. L. 1987; 69 (5): 1289-1293


    Leukemic cell chromosomal findings in 27 infants were analyzed. Among the 18 cases of acute nonlymphoblastic leukemia (ANLL), all but two were classified as monocytic or myelomonocytic. The remaining nine cases were acute lymphoblastic leukemia (ALL), seven lacking the common ALL antigen and two having cytoplasmic immunoglobulin (pre-B phenotype). Twenty-five cases (93%) had an abnormal karyotype, 21 (84%) being pseudodiploid. Chromosomal translocations were detected in 67% of the ANLL cases and in 78% of the ALL cases. Nonrandom chromosomal abnormalities included the t(9;11)(p21-22;q23) in three cases of monocytic leukemia, inversion of chromosome 16 in three cases of myelomonocytic leukemia with bone marrow eosinophilia, and t(4;11)(q21;q23) in one case of ALL. Chromosomal regions preferentially involved in infant leukemia included 11q23-25 (13 cases), 9p21-22 and 10p11-13. All but one of the 24 cases with chromosomal breakage or rearrangement had breakpoints that corresponded to known fragile sites, half of which were at 11q23-25, a finding that may have pathogenetic importance. The CALLA- or pre-B phenotype and the presence of chromosomal translocations in most infants with ALL provide a biological explanation for their poor prognosis.

    View details for Web of Science ID A1987H128300003

    View details for PubMedID 2952182

  • CHILDHOOD MONOSOMY-7 SYNDROME - CLINICAL AND INVITRO STUDIES LEUKEMIA Weiss, K., Stass, S., Williams, D., Kalwinsky, D., Dahl, G. V., Wang, W., Johnson, F. L., Murphy, S. B., DOW, L. W. 1987; 1 (2): 97-104


    The clinical and cell growth characteristics of 11 children with monosomy 7 presenting as preleukemia (eight cases) or acute nonlymphoblastic leukemia (three cases) were studied. Anemia was common to all patients, with nine showing leukocytosis, seven thrombocytopenia, and one thrombocytosis. There was a striking predominance of males (M/F ratio, 10:1) and a young median age (3 years). Preleukemia evolved to acute nonlymphoblastic leukemia in five patients and to myelofibrosis in one. In vitro studies of bone marrow progenitor cells cultured in leukocyte feeder-stimulated agar revealed abnormal cell proliferative patterns, most often an increased number of small clusters, for all 11 subjects. The cells of some preleukemic patients showed increased growth even in the absence of an exogenous source of colony-stimulating factor, suggesting autonomous growth or possibly autocrine stimulation. Combination chemotherapy or bone marrow transplantation failed to induce complete remission in the seven patients who were treated. Our findings in these 11 cases confirm the poor prognosis of monosomy 7 presenting as preleukemia in children. The in vitro studies suggest an association between altered cell growth in vitro and clinical evolution to frank leukemia.

    View details for Web of Science ID A1987J471400001

    View details for PubMedID 3669740

  • Limiting toxicities during intensified remission induction chemotherapy for childhood acute lymphocytic leukemia. Haematology and blood transfusion Rivera, G. K., Kovnar, E., Pui, C. H., Dahl, G. V., Abromowitch, M., Ochs, J. J., Look, A. T., Kalwinsky, D. K., Mirro, J., DOW, L. W. 1987; 30: 156-160

    View details for PubMedID 3476354



    Bone marrow cells from 99 patients with acute myeloid leukemia were cloned in either agar stimulated by leukocyte feeder layers (AG/F) or methylcellulose supplemented with medium conditioned by phytohemagglutinin stimulation of leukocytes (MC/P). Although cell growth in the two systems was correlated (r = 0.74, p less than 0.0001), there was increased formation and size of clusters and colonies in AG/F, suggesting that the clonogenic cells from children with AML are more readily assayed in AG/F. The number and size of clones in either system did not show a relationship to the morphologic subtype of leukemia. Depending on the scoring system used, increased growth in MC/P was related to abnormal karyotype. Also dependent on scoring system, the ability of leukemic cells to form small clusters in AG/F was associated with resistance to induction therapy: cells of patients with resistant disease were more likely to produce small clusters (p = 0.02). Our results suggest that clonogenic cells from children with AML grow more readily in AG/F than in MC/P, but that neither culture system supports the growth of cells from all patients. Depending on scoring criteria, in-vitro growth patterns in AG/F correlate with response to induction therapy.

    View details for Web of Science ID A1987J158400010

    View details for PubMedID 3474483

  • A comparison of cytokinetically based versus intensive chemotherapy for childhood acute myelogenous leukemia. Haematology and blood transfusion Dahl, G. V., Kalwinsky, D. K., Mirro, J., Look, A. T. 1987; 30: 83-87

    View details for PubMedID 3305227



    Clonogenic cells from 41 children with newly diagnosed acute myeloid leukemia (AML) were tested in vitro for their sensitivity to cytarabine (Ara-C) and daunorubicin (DNR). The findings were then compared with the patients' responses to induction chemotherapy that uniformly included Ara-C and DNR. Light-density marrow cells were incubated with either or both drugs for one hour and cultured over leukocyte feeder layers; clusters and colonies were scored on days 7, 10, and 14. Only the percentage of cell kill in the presence of 1.8 mumol/L DNR was significantly associated with responses to induction therapy: median of 45% (range, 0% to 98%) for patients achieving complete remission v 16% (range, 4% to 23%) for nonresponders (P = .007). The relationship between clonogenic cell kill less than or equal to 23% and clinical responses was striking. Of the 11 evaluable patients with in vitro findings in this category, ten either failed induction therapy or relapsed within 1 year after attaining remission. Kaplan-Meier analysis of relapse-free survival times indicated longer durations of remission for patients whose blast cells showed increased sensitivity in vitro to Ara-C alone, DNR alone, or a combination of the two agents. Seven of 11 patients with cell kills of greater than or equal to 49% in the presence of 1.25 mumol/L Ara-C remain free of leukemia, compared with only one of 12 whose cells were less sensitive to the drug (P = .006). We conclude that the in vitro sensitivity of clonogenic leukemic progenitors to DNR and Ara-C correlates with treatment outcome in children with newly diagnosed AML.

    View details for Web of Science ID A1986D504100012

    View details for PubMedID 3460647

  • CHROMOSOMAL TRANSLOCATIONS PLAY A UNIQUE ROLE IN INFLUENCING PROGNOSIS IN CHILDHOOD ACUTE LYMPHOBLASTIC-LEUKEMIA BLOOD Williams, D. L., Harber, J., Murphy, S. B., Look, A. T., Kalwinsky, D. K., Rivera, G., Melvin, S. L., Stass, S., Dahl, G. V. 1986; 68 (1): 205-212


    Certain types of chromosomal abnormalities have been shown to exert strong independent influence on treatment outcome in acute lymphoblastic leukemia (ALL). To identify the changes most closely associated with prognosis, we analyzed the completely banded blast cell karyotypes of 161 children with this disease. One hundred twenty-five cases had one or more chromosomal abnormalities, with 45 showing translocations. The frequency of translocations was highest (58%) among patients with pseudodiploid karyotypes and lowest (0%) in the hyperdiploid group defined by 51 or more chromosomes. During the maximum 6-year follow-up period, 30 of the 45 patients with a translocation failed therapy, compared with only 27 of the 116 who lacked this feature. Life-table estimates of event-free survival indicate that only 14% of the translocation group will be in complete remission at 3 years. The percentages of failures associated with random and nonrandom translocations were virtually identical (68% v 65%). When entered in a Cox proportional hazards model with seven other types of chromosomal abnormalities, and then with 11 clinical and laboratory variables of known prognostic value in ALL, translocation emerged as the strongest single predictor of treatment outcome (P less than 0.0001). The model indicated that translocation increases the risk of treatment failure six times by comparison with the absence of this feature. These findings offer an explanation for the majority of early treatment failures in childhood ALL, including those previously attributed to ploidy classification.

    View details for Web of Science ID A1986D052700029

    View details for PubMedID 3459555

  • CYTOGENETIC FEATURES AND SERUM LACTIC-DEHYDROGENASE LEVEL PREDICT A POOR TREATMENT OUTCOME FOR CHILDREN WITH PRE-B-CELL LEUKEMIA BLOOD Pui, C. H., Williams, D. L., Kalwinsky, D. K., Look, A. T., Melvin, S. L., Dodge, R. K., Rivera, G., Murphy, S. B., Dahl, G. V. 1986; 67 (6): 1688-1692


    Leukemic cells from 89 (24%) of 369 children with newly diagnosed acute lymphoblastic leukemia (ALL) were found to have a pre-B immunophenotype. By comparison with blasts having the common ALL phenotype, the pre-B cells were more likely to have a DNA index less than 1.16 (P = 0.02), a pseudodiploid karyotype (P less than 0.001), and a chromosomal translocation (P = 0.001). Increased serum lactic dehydrogenase levels (P = 0.001) were also characteristic of pre-B ALL; otherwise, the clinical and laboratory features of the two groups were similar. A nonrandom chromosomal translocation, t(1;19)(q23;p13.3), was identified in blast cells from 16 (23%) of the 70 patients with pre-B ALL and adequate chromosome banding studies; different translocations were found in 11 of the remaining patients. The presence of any chromosomal translocation in the pre-B group was significantly related to a higher leukocyte count, an increased level of serum lactic dehydrogenase, an increased percentage of S-phase cells, black race, and a blast cell DNA index less than 1.16. Four presenting features were found to confer an increased risk of treatment failure among pre-B patients: pseudodiploidy, chromosomal translocation, black race, and higher serum lactic dehydrogenase level. In a multivariate analysis, pseudodiploidy emerged as the strongest factor for predicting relapse in pre-B ALL. The frequent association of chromosomal abnormalities of known adverse prognostic significance and high serum lactic dehydrogenase levels with pre-B-cell ALL explains, at least in part, the poor treatment outcome reported for children with this subtype of leukemia.

    View details for Web of Science ID A1986C606500024

    View details for PubMedID 2939898



    Twelve pediatric patients with nonlymphocytic leukemia were treated for 10 days with high-dose (15, 20, or 30 million U/m2/day) human lymphoblastoid interferon (Wellferon) administered by continuous iv infusion. Nine children had acute nonlymphocytic leukemia (ANLL) in relapse, two had Philadelphia chromosome-positive chronic myelocytic leukemia in myeloblastic crisis, and one had juvenile chronic myelocytic leukemia. Blast cell counts in the peripheral blood decreased in five patients with ANLL treated with the higher interferon doses; however, there was no evidence of an antileukemic effect in the marrow. Dose-limiting toxicity, which included malaise, hepatotoxicity, and coagulation abnormalities, was observed in patients given 20 or 30 million U/m2/day. Studies of the growth of leukemic progenitor cells in vitro in the presence of interferon disclosed a concentration-related inhibition of colony formation. Patients who had a decrease in peripheral blast cell counts demonstrated greater in vitro inhibition of clonogenic leukemic progenitors than patients whose blast cell counts did not decrease. However, the serum interferon concentrations in patients given clinically tolerable doses were lower than those concentrations which inhibited leukemic cell growth in vitro by a median of 42% (1000 U/ml). This study failed to demonstrate clinically significant antileukemic activity against nonlymphocytic leukemia in patients given high-dose constant-infusion interferon, and the toxicity of this approach was prohibitive.

    View details for Web of Science ID A1986A824000008

    View details for PubMedID 3456833

  • EARLY RESULTS OF INTENSIFIED REMISSION INDUCTION CHEMOTHERAPY FOR CHILDHOOD ACUTE LYMPHOCYTIC-LEUKEMIA MEDICAL AND PEDIATRIC ONCOLOGY Rivera, G. K., George, S. L., Williams, D., Look, A. T., Abromowitch, M., Pui, C. H., Ochs, J. J., Dahl, G. V., Kalwinsky, D. K., Mirro, J., DOW, L. W., Raimondi, S., Murphy, S. B. 1986; 14 (3): 177-181

    View details for Web of Science ID A1986D758100012

    View details for PubMedID 3462464



    Treatment with a combination of daunorubicin (45 mg/m2 IV, days 1-3) and cytarabine (100 mg/m2 continuous IV infusion, days 4-10) failed to induce complete remission in 31 of 87 children (36%) with acute nonlymphocytic leukemia (ANLL). Six patients with monocytic or promyelocytic leukemia died before day 14 of therapy from complications of hyperleukocytosis and coagulopathy; an additional 10 failed because of fatal infections associated with drug-induced marrow hypoplasia, and the remaining 15 had residual leukemia despite receiving two courses of daunorubicin and cytarabine. Alternative therapy with etoposide (250 mg/m2, IV, days 1-3, 7-9) and 5-azacytidine (300 mg/m2 IV, days 4, 5, 9, 10) induced complete remission in nine (60%) of the 15 patients with resistant leukemia. Among the six children who failed to respond to either regimen, three had cytochemical and immunophenotypic features indicative of acute mixed-lineage leukemia, and one had monosomy 7 syndrome. Our findings suggest that the addition of etoposide and 5-azacytidine to a basic daunorubicin-cytarabine regimen would increase remission induction rates in childhood ANLL. Careful determination of pretreatment characteristics, including blast cell immunophenotype and cytogenetic properties, are needed to identify unusual cases of ANLL that may require selective therapy.

    View details for Web of Science ID A1986F211000001

    View details for PubMedID 2431255

  • UNFAVORABLE PRESENTING CLINICAL AND LABORATORY FEATURES ARE ASSOCIATED WITH CALLA-NEGATIVE NON-T, NON-B LYMPHOBLASTIC-LEUKEMIA IN CHILDREN LEUKEMIA RESEARCH Pui, C. H., Williams, D. L., Raimondi, S. C., Melvin, S. L., Behm, F. G., Look, A. T., Dahl, G. V., Rivera, G. K., Kalwinsky, D. K., Mirro, J., Dodge, R. K., Murphy, S. B. 1986; 10 (11): 1287-1292


    Twenty-four (5.7%) of 424 children with newly diagnosed acute lymphoblastic leukemia (ALL) were found to have blast cells that expressed HLA-DR antigens but not the common ALL antigen (CALLA), E-rosette receptors, T-cell antigens, or cytoplasmic or surface immunoglobulins. Each of the eight cases tested expressed the B-cell associated antigen B4, but not B1 or B2 antigen. Myeloid-associated antigens were not present in any of the 10 cases tested. By comparison with common (CALLA+ B-cell precursor) ALL, patients having this immunophenotype were more likely to be children less than 2 yr of age (p less than 0.001), to have higher initial leukocyte counts (p less than 0.001), and to have blast cells with a DNA index less than 1.16 (p = 0.05), a pseudodiploid karyotype (p = 0.01) and a chromosomal translocation (p = 0.003). The presence of any chromosomal translocation in these CALLA- ALL was related to measures of increased leukemic cell burden including higher leukocyte counts, larger liver and spleen sizes and higher serum lactic dehydrogenase levels. While the patients were entered into several treatment arms of two protocols, the CALLA- cases appeared to have lower remission rate (p = 0.06) and shorter event-free survival time (p = 0.05) than did those with common ALL. The association with clinical and laboratory features of known adverse prognostic significance provides some explanation for the poor treatment outcome of CALLA- ALL.

    View details for Web of Science ID A1986F595200005

    View details for PubMedID 2948078

  • ELECTIVE TESTICULAR BIOPSY DURING CHEMOTHERAPY FOR CHILDHOOD LEUKEMIA IS OF NO CLINICAL-VALUE LANCET Pui, C. H., Bowman, W. P., Abromowitch, M., Dahl, G. V., Rao, B. N., Ochs, J., Rivera, G. 1985; 2 (8452): 410-412


    The clinical value of early detection of testicular leukaemia was assessed by elective wedge biopsy during the 12th or 18th month of therapy in children with acute lymphoblastic leukaemia. Biopsy samples were taken in 106 of 238 consecutively treated boys who attained complete remission; only 1 had occult disease. Samples were also taken in 2 boys with testicular leukaemia at diagnosis as soon as they achieved complete remission, and in 14 others at the end of therapy; none showed evidence of leukaemic infiltration. 13 boys, including the 1 with biopsy-confirmed occult disease, had a testicular relapse; 6 of these patients had had negative biopsy findings 12-28 months before relapse. These results indicate that elective testicular biopsy during therapy for childhood leukaemia is of no benefit clinically. They also suggest that routine use of end-of-therapy testicular biopsy should be re-evaluated, since frequency of testicular relapse is low, therapy is effective, and negative biopsy findings do not preclude eventual relapse.

    View details for Web of Science ID A1985APH3400003

    View details for PubMedID 2863443

  • Recent results from Total Therapy Study X for standard and high risk acute lymphoblastic leukemia in children: recognition of new clinical and biologic risk features. Haematology and blood transfusion Murphy, S. B., Dahl, G. V., Look, A. T., Ochs, J., Abromowitch, M., Pui, C. H., Bowman, W. P., Simone, J. V., Kalwinsky, D. K., Evans, W. E. 1985; 29: 78-81

    View details for PubMedID 3861494


    View details for Web of Science ID A1985ALQ2800030

    View details for PubMedID 3159943

  • SERUM LACTIC-DEHYDROGENASE LEVEL HAS PROGNOSTIC VALUE IN CHILDHOOD ACUTE LYMPHOBLASTIC-LEUKEMIA BLOOD Pui, C. H., Dodge, R. K., Dahl, G. V., Rivera, G., Look, A. T., Kalwinsky, D., Bowman, W. P., Ochs, J., Abromowitch, M., Mirro, J., Murphy, S. B. 1985; 66 (4): 778-782


    Serum lactic dehydrogenase (LDH) levels were measured at diagnosis in 293 children with "standard-risk" acute lymphoblastic leukemia (ALL) to determine the prognostic value of this biologic feature. Standard risk assignment was based on an initial leukocyte count of less than 100 X 10(9)/L, the absence of a mediastinal mass, the absence of meningeal involvement, and the presence of lymphoblasts lacking sheep erythrocyte receptors or surface immunoglobulin. Serum LDH levels ranged from 97 to 6,595 U/L, with a mean of 547 U/L. Higher LDH levels were associated with higher leukocyte counts, lower blast cell DNA indices, lower platelet counts, a larger spleen size, and nonwhite race. LDH levels were not related to the percentage of marrow S-phase cells, liver size, French-American-British (FAB) classification, hemoglobin levels, age, sex, or the presence of the common ALL antigen on marrow blasts. Patients with the highest LDH levels (greater than 1,000 U/L) were most likely to fail treatment, whereas those with the lowest levels (less than 300 U/L) had the lowest risk of failure (P less than .0001). The prognostic significance of serum LDH level was retained in a subset of patients that included only those with leukocyte counts less than 25 X 10(9)/L (P = .0018). When 11 presenting characteristics were subjected to multivariate analysis, serum LDH level was found to have independent prognostic strength, contributing clinically important information to that gained from leukocyte count. Early measurement of serum LDH could be useful in identifying a group of standard-risk ALL patients with a high relapse hazard.

    View details for Web of Science ID A1985AST4400005

    View details for PubMedID 3862434

  • A NOVEL TREATMENT OF CHILDHOOD LYMPHOBLASTIC NON-HODGKINS LYMPHOMA - EARLY AND INTERMITTENT USE OF TENIPOSIDE PLUS CYTARABINE BLOOD Dahl, G. V., Rivera, G., Pui, C. H., Mirro, J., Ochs, J., Kalwinsky, D. K., Abromowitch, M., Look, A. T., Murphy, S. B. 1985; 66 (5): 1110-1114


    We treated 24 children and adolescents with stage III or IV lymphoblastic non-Hodgkin's lymphoma, using a protocol designed for patients with poor-prognosis acute lymphoblastic leukemia (ALL). Early therapy consisted of teniposide plus cytarabine administered before and immediately after prednisone, vincristine, and asparaginase. The two-drug combination was also given intermittently with continuous 6-mercaptopurine and methotrexate during the first year of continuation chemotherapy. Periodic intrathecal methotrexate and delayed cranial irradiation were used to prevent central nervous system involvement. Anthracycline compounds, alkylating agents, high-dose methotrexate, and involved-field irradiation were not used in any phase of treatment. Twenty-two (96%) of the 23 evaluable patients achieved complete remission. With a median follow-up of 2 1/2 years, only four patients have relapsed; the remainder have been disease-free for eight months to more than five years. The projected four-year continuous complete remission rate is 73% for all patients and 79% for the 19 with mediastinal involvement at diagnosis. These results demonstrate that use of teniposide plus cytarabine with an otherwise conventional plan of ALL therapy is an effective approach to the treatment of childhood lymphoblastic lymphoma.

    View details for Web of Science ID A1985AUP7600017

    View details for PubMedID 3840395

  • UNEXPECTEDLY SEVERE TOXICITY FROM INTENSIVE EARLY TREATMENT OF CHILDHOOD LYMPHOBLASTIC-LEUKEMIA JOURNAL OF CLINICAL ONCOLOGY Rivera, G. K., Evans, W. E., Kalwinsky, D. K., Mirro, J., Ochs, J., DOW, L. W., Abromowitch, M., Pui, C. H., Dahl, G. V., Look, A. T., Crone, M., Murphy, S. B. 1985; 3 (2): 201-206


    In early 1984, we treated 13 consecutive patients with acute lymphoblastic leukemia (ALL) using an induction regimen of rapidly rotated combinations of prednisone, vincristine, asparaginase, teniposide (VM-26), cytosine arabinoside, and high-dose methotrexate (MTX) followed by leucovorin rescue. The intent of this clinical trial, designated Total Therapy Study XI, is to test the hypothesis that greater initial leukemia cell kill will decrease opportunities for the development of drug-resistant mutants, with resultant improvement in the length of disease-free survival. Five patients experienced life-threatening gastrointestinal toxicity within three weeks of the start of treatment. One died. Three other patients had severe abdominal pain, abdominal distention, diarrhea, and weight loss, but not gastrointestinal bleeding. In the remaining five patients, toxicity was rapidly reversible, and each child was able to complete the planned course of chemotherapy. The study was then amended to switch high-dose MTX from the induction phase to the consolidation phase, allowing at least one week for mucosal recovery. Among the next 28 patients who were treated, none showed evidence of severe gastrointestinal toxicity. Patients now receive high-dose MTX alone as consolidation therapy and are tolerating it adequately. Drug timing should be examined critically when intensified multiple-agent regimens are being devised for initial treatment of ALL.

    View details for Web of Science ID A1985ABH2600010

    View details for PubMedID 3918144

  • PROGNOSTIC IMPORTANCE OF BLAST CELL-DNA CONTENT IN CHILDHOOD ACUTE LYMPHOBLASTIC-LEUKEMIA BLOOD Look, A. T., Roberson, P. K., Williams, D. L., Rivera, G., Bowman, W. P., Pui, C. H., Ochs, J., Abromowitch, M., Kalwinsky, D., Dahl, G. V., George, S., Murphy, S. B. 1985; 65 (5): 1079-1086


    Using flow cytometric techniques, we determined the pretreatment distribution of DNA content in propidium iodide-stained leukemic blasts from 205 children with "standard-risk" acute lymphoblastic leukemia (ALL). Risk assignment was based on an initial WBC count less than 100 X 10(9)/L, no thymic mass, no meningeal leukemia, and lymphoblasts lacking sheep erythrocyte receptors or surface immunoglobulin. A single aneuploid leukemic line was detected in 74 cases (36.1%): 70 hyperdiploid and four hypodiploid. For hyperdiploid cases, the DNA index (DI, or ratio of the DNA content of leukemic v normal G0/G1 cells) ranged from 1.06 to 2.0 (median, 1.20). A secondary leukemic line with hyperdiploid cellular DNA content was identified in 21 cases with diploid primary lines. Children whose primary leukemic line showed a DI greater than or equal to 1.16 (n = 57) had significantly better responses to treatment than did those with either a diploid DI (n = 130; P = .002) or values in the range of 1.01 to 1.15 (n = 14; P = .001). The relative risk of failure for hyperdiploid cases with DI greater than or equal to 1.16, corresponding to greater than or equal to 53 chromosomes, was one-third that of the other two groups. Treatment responses of patients with both diploid and hyperdiploid lines were identical to those associated with single diploid lines, but significantly worse than those associated with single hyperdiploid lines with DI greater than or equal to 1.16 (P = .016). The most favorable prognostic variables selected by a Cox proportional hazards model were: DI greater than or equal to 1.16 (P = .001), white race (P = .022), WBC less than or equal to 25 X 10(9)/L (P = .032), age between 2 and 9 years (P = .075), and hemoglobin less than 7.0 g/dL (P = .094). DNA index greater than or equal to 1.16 retained its significant prognostic impact even after adjustment for other variables (P = .001). With the combination of DI greater than or equal to 1.16 and WBC less than or equal to 25 X 10(9)/L, one can identify a group of children with ALL who have a low probability of relapse when treated with current therapy. If they remain disease-free after longer follow-up, it may be advisable to treat them with less intensive, hence less toxic, chemotherapy than patients with higher WBC counts or lower DI values.

    View details for Web of Science ID A1985AGW2900006

    View details for PubMedID 3158360

  • CLINICAL RELEVANCE OF LYMPHOBLAST BIOLOGICAL FEATURES IN CHILDREN WITH ACUTE LYMPHOBLASTIC-LEUKEMIA JOURNAL OF CLINICAL ONCOLOGY Kalwinsky, D. K., Roberson, P., Dahl, G., Harber, J., Rivera, G., Bowman, W. P., Pui, C. H., Ochs, J., Abromowitch, M., COSTLOW, M. E., Melvin, S. L., Stass, S., Williams, D. L., Murphy, S. B. 1985; 3 (4): 477-484


    Improvements in therapy for childhood acute lymphoblastic leukemia (ALL) have led us to reevaluate the prognostic significance of lymphoblast characteristics at diagnosis. From application of univariate and multivariate statistical methods, we determined the relationship of five blast cell features to treatment outcome in 250 patients who were enrolled in two clinical trials at this center from May 1979 through April 1982. Karyotype ploidy, lymphoblast morphology, and immunophenotype were each significantly related to prognosis as measured by time to failure, while periodic acid-Schiff reactivity and glucocorticoid receptor number lacked prognostic implication for this patient population. In addition, clinical features of initial WBC count, age, and race were also significant independent variables in predicting treatment response. By multivariate analysis, both ploidy and morphology contributed prognostic information to a clinical model based on WBC count, age, and race. If the model was adjusted for impact of ploidy, however, French-American-British morphology no longer contributed additional prognostic information. Our findings suggest that many traditional biological features used to estimate prognosis in ALL can be discarded in favor of clinical features (leukocyte count, age, and race) and cytogenetics (ploidy) for planning of future clinical trials.

    View details for Web of Science ID A1985AFP3500005

    View details for PubMedID 3872347

  • CENTRAL NERVOUS-SYSTEM LEUKEMIA IN CHILDREN WITH ACUTE NONLYMPHOBLASTIC LEUKEMIA BLOOD Pui, C. H., Dahl, G. V., Kalwinsky, D. K., Look, A. T., Mirro, J., Dodge, R. K., Simone, J. V. 1985; 66 (5): 1062-1067


    Factors contributing to the development of central nervous system (CNS) leukemia, and the impact of leukemic involvement of this site on subsequent remission length, were determined in 184 children with acute nonlymphoblastic leukemia who had been treated in two successive clinical trials. Preventive CNS therapy in both studies consisted of intrathecal methotrexate (12 mg/m2) given monthly during the first six months of therapy and then every three months until all treatment was stopped. Children with CNS leukemia at diagnosis or relapse were given intrathecal chemotherapy weekly for four weeks and then monthly throughout the remainder of the treatment course. Those continuing in complete remission received 2,400 rad cranial irradiation plus five doses of intrathecal methotrexate before cessation of therapy. The 38 children (20.7%) with CNS leukemia at diagnosis were more likely to have an initial leukocyte count greater than or equal to 25 X 10(9)/L (P = .01) and age less than 2 years (P = .03). The presence of CNS leukemia at diagnosis did not adversely affect the remission induction rate (P = .13) or the length of complete remissions (P = .73). CNS relapse ended initial remissions in 11 patients only and did not preclude subsequent long-term survival, as four of these children are off therapy and in second complete remission for 33+ to 78+ months. Three features at diagnosis were predictive of CNS relapse: monocytic or myelomonocytic leukemia (P = .002); age less than 2 years (P = .0001); and leukocyte count greater than or equal to 25 X 10(9)/L (P = .012). By stepwise Cox regression analysis, each factor was found to have independent predictive value. Despite the apparent effectiveness of intrathecal methotrexate as preventive CNS treatment, our findings indicate that more effective prophylaxis is needed for patients with features predisposing to CNS relapse.

    View details for Web of Science ID A1985AUP7600009

    View details for PubMedID 3840394



    Of 263 children with glucocorticoid receptor (GR) levels measured at diagnosis of acute lymphoblastic leukemia (ALL), 27 received single-agent glucocorticoid before combination induction chemotherapy and were evaluable for in vivo clinical response to steroid. Twenty-one were glucocorticoid-responsive and 6 were resistant. There was no difference between the two groups in the distribution of age, sex, white blood cell count, immunophenotype of blasts, initial central nervous system disease or mediastinal mass. The median GR level, however, was appreciably lower in the group of patients with resistant disease (6250 vs 17,800 sites/cell, p = 0.06). Five of 12 patients with GR levels of less than 10,000 sites/cell compared to 1 of 15 with higher levels had glucocorticoid-resistant ALL (p = 0.03). All 21 patients with glucocorticoid-sensitive disease achieved a complete remission after combination induction chemotherapy, but only 3 of 5 evaluable patients in the other group did (p less than 0.04). Two patients were studied both at diagnosis and at relapse; both had decreased GR levels at relapse (below detection in one) and failed to respond to glucocorticoid. We conclude that a lower GR level is associated with glucocorticoid resistance and furthermore that a decrease in the level of GR is a mechanism of acquiring steroid resistance.

    View details for Web of Science ID A1984TH80400006

    View details for PubMedID 6590931

  • TENIPOSIDE (VM26) DISPOSITION IN CHILDREN WITH LEUKEMIA CANCER RESEARCH SINKULE, J. A., Stewart, C. F., Crom, W. R., MELTON, E. T., Dahl, G. V., Evans, W. E. 1984; 44 (3): 1235-1237


    The clinical pharmacokinetics of teniposide (VM-26, NSC 122819) has been studied in 21 children (median age, 4.7 years) with acute lymphocytic leukemia. Teniposide was administered at a dosage of 165 mg/sq m as a 30- to 60-min i.v. infusion. Patients were studied either on the first or second dosage of the drug. Plasma samples were assayed for teniposide and metabolites by high-performance liquid chromatography with electro-chemical detection. Both compartmental and noncompartmental pharmacokinetic analyses were performed. Systemic clearance and apparent volume of distribution of steady state averaged 13.82 +/- 6.0 ml/min/sq m (S.D.) and 7.9 +/- 4.0 liter/sq m, respectively. Univariate and multivariate stepwise regression analyses were used to construct mathematical models to describe the relationships between certain patient-specific demographic and laboratory values and the pharmacokinetic parameters, systemic clearance, elimination rate constant, and area under the concentration-time curve. A significant relationship between serum alkaline phosphatase and systemic clearance, elimination rate constant, and area under the concentration-time curve was found, suggesting that liver function influences the disposition of this anticancer drug in humans.

    View details for Web of Science ID A1984SE34000066

    View details for PubMedID 6581866



    The authors observed Auer rods in mature neutrophils, bands, and metamyelocytes in two children with AML with maturation (FAB M2). In order to determine if this rare finding was characteristic of AML M2, the authors reviewed the bone marrows and peripheral blood smears of 50 children with AML M2 and 50 children with other AML subtypes (FAB M1, M3, M4, and M5). They found Auer rods in mature neutrophils and band forms in 10 of 50 patients (20%) with AML M2 but in none of 50 patients with non-M2 AML. This finding was not related to the frequency of mature cells in the specimen or to the frequency of Auer rods in blasts. Cytogenetics did not show a consistent abnormality. The presence of Auer rods in mature granulocytes is unique to FAB M2 AML in the authors' series and supports the concept that in AML at least some of the mature myeloid cells are involved in the leukemic process.

    View details for Web of Science ID A1984SQ88200020

    View details for PubMedID 6586071

  • HEAVY-CHAIN IMMUNOGLOBULIN GENE REARRANGEMENT IN ACUTE NONLYMPHOCYTIC LEUKEMIA BLOOD Rovigatti, U., Mirro, J., Kitchingman, G., Dahl, G., Ochs, J., Murphy, S., Stass, S. 1984; 63 (5): 1023-1027


    Samples of leukemic cell DNA from 14 children with acute nonlymphocytic leukemia (ANLL) and 4 human myeloid leukemia cell lines were analyzed for rearrangement in the heavy chain region of the immunoglobulin gene. The diagnosis of ANLL was confirmed in all patients by morphological, cytochemical, and immunologic studies. By restriction endonuclease digestion and hybridization with cloned heavy chain immunoglobulin gene probes for the constant (Cmu) and joining (JH) regions, the DNA of 2 patients and 1 cell line (ML-1) was found to contain rearrangements. The DNA from the remaining 12 patients and 3 cell lines was not rearranged (germline configuration). Both patients with apparent immunoglobulin gene rearrangement achieved complete remission on therapy for ANLL. Immunoglobulin gene rearrangement in phenotypically defined ANLL suggests (1) that such changes may not be limited to lymphoid leukemia of B cell lineage, or (2) that, in some patients, the leukemic transforming event may involve stem cells capable of both B cell and myeloid differentiation.

    View details for Web of Science ID A1984SQ45700007

    View details for PubMedID 6324925



    Cytogenetic analysis of leukemic cells obtained at diagnosis from 122 patients with childhood acute lymphoblastic leukemia (ALL) disclosed chromosomal translocations in 36 cases. Two new nonrandom translocations were identified and found to be associated with specific immunophenotypes of the disease. The first, identified in 4 of 16 cases of T-cell ALL positive for sheep erythrocyte receptors (E+), involved the short arm (p) of chromosome 11 and the long arm (q) of chromosome 14 and was designated t(11;14) (p13;q13). The second, found in 7 of 23 cases with a pre-B-cell phenotype, involved the long arm of chromosome 1 and the short arm of chromosome 19; it was designated t(1;19) (q23;p13.3). A third abnormality involving a common breakpoint on chromosome 12 (band p 12) was also identified. These two new differentiation-specific translocations suggest a mechanism for aberrant expression of genes that influence lymphoid cell growth and development, as well as leukemogenesis.

    View details for Web of Science ID A1984SA85800011

    View details for PubMedID 6607116

  • ACUTE-LEUKEMIA WITH MIXED LYMPHOID AND MYELOID PHENOTYPE BRITISH JOURNAL OF HAEMATOLOGY Pui, C. H., Dahl, G. V., Melvin, S., Williams, D. L., Peiper, S., Mirro, J., Murphy, S. B., Stass, S. 1984; 56 (1): 121-130


    Three children with acute leukaemia had blasts that expressed both lymphoid and myeloid markers. The blasts met immunological criteria for acute lymphoblastic leukaemia (ALL)--common ALL antigen+, HLA-DR+, terminal deoxynucleotidyl transferase+--but their cytochemical features, including positive myeloperoxidase and Sudan black B, were those of acute nonlymphoblastic leukaemia (ANLL) as defined by the French-American-British Group. 30% of the blasts from one of two patients tested reacted with a monoclonal antibody specific for nonlymphoid cells (MCS-2). The wide overlap in the percentages of blasts expressing lymphoid or myeloid markers indicates that some leukaemic cells in each child had a mixed phenotype. There were no consistent cytogenetic findings, and the Philadelphia chromosome was not present. Complete remission was induced by treatment effective for either ALL (two patients) or ANLL. These three cases appear to represent a rare leukaemia subtype that we have designated acute leukaemia with mixed lymphoid and myeloid phenotype. Its recognition may be important in treatment, since two patients achieved remission with standard therapy for ALL. These cases demonstrate further the phenotypic heterogeneity that may be seen in leukaemic cell differentiation.

    View details for Web of Science ID A1984RY55300012

    View details for PubMedID 6584167

  • SUDAN BLACK-B POSITIVE ACUTE LYMPHOBLASTIC-LEUKEMIA BRITISH JOURNAL OF HAEMATOLOGY STASS, S. A., Pui, C. H., Melvin, S., Rovigatti, U., Williams, D., MOTRONI, T., Kalwinsky, D., Dahl, G. V. 1984; 57 (3): 413-421


    The presence of greater than 3% Sudan black B (SBB) positivity in leukaemic blasts has been considered diagnostic of acute non-lymphocytic leukaemia (ANLL). A rare report has indicated that this finding may not be specific for ANLL. In order to determine whether SBB could be found in acute lymphoblastic leukaemia (ALL) the data on 350 patients with newly diagnosed ALL were reviewed. Six patients (1.6%) were found to have 5% or greater SBB positive blasts. The diagnosis of ALL was supported by morphology, cytochemistries, immunologic markers, therapeutic response, and in one case immunoglobulin gene rearrangement. It is important to recognize the fact that SBB is not specific for AML and may be found in the blasts of patients with ALL.

    View details for Web of Science ID A1984SZ56000007

    View details for PubMedID 6204679

  • FAILURE OF LATE INTENSIFICATION THERAPY TO IMPROVE A POOR RESULT IN CHILDHOOD LYMPHOBLASTIC-LEUKEMIA CANCER RESEARCH Pui, C. H., AUR, R. J., Bowman, W. P., Dahl, G. V., Dodge, R. K., George, S. L., Ochs, J., Kalwinsky, D. K., Abromowitch, M., HUSTU, H. O., Simone, J. V. 1984; 44 (8): 3593-3598


    This clinical study, begun in 1975, tested the efficacy of early and delayed intensification treatments in children with acute lymphoblastic leukemia. Regardless of presenting features, all patients received 4 weeks of conventional induction therapy with daily prednisone and weekly vincristine and daunorubicin. One-third were randomized to receive, in addition, two doses of asparaginase during induction therapy, while another one-third received four doses of both asparaginase and cytarabine after remission induction. Preventive central nervous system therapy uniformly included 2400 rads cranial irradiation and five doses of intrathecal methotrexate. Remissions were maintained with daily p.o. mercaptopurine and weekly i.v. methotrexate. Of the 277 assessable patients, 254 (92%) entered complete remission, and 102 (37%) remain clinically free of leukemia for 4.6 to 8.0 years (median, 6.3 years). The three treatment groups showed no significant differences in either remission induction rate or outcome, even when the analysis was based on risk assignment. A "late intensification" phase of therapy, added to the maintenance protocol for 65 patients who had been in continuous complete remission for 14 to 30 months, failed to extend remission durations, as judged from statistical comparison with matched controls (p = 0.84). When tested as a time-dependent covariate in the Cox proportional-hazards model, delayed intensification again showed no important effect on duration of complete remission. We conclude that limited early or aggressive late intensification of therapy, as described here, does not improve outcome in childhood acute lymphoblastic leukemia.

    View details for Web of Science ID A1984TB82500068

    View details for PubMedID 6589042



    The sensitivity of relapsed acute lymphoblastic leukemia (ALL) to treatment with steroids was assessed by measuring bone marrow blast, whole-cell glucocorticoid receptor (GR) levels and serial cytokinetic and clinical responses to steroids, both as single agents and in combination reinduction chemotherapy. GR levels ranged widely, from 1800 to 47,800 sites/cell (median 16,000), and did not differ significantly from levels measured in newly diagnosed patients (p = 0.50). Nineteen of the 48 children studied had GR levels measured both at diagnosis and relapse, and in 14 the values at relapse were either decreased or increased by more than 25%. For nine children, the sensitivity to a three-day oral course of dexamethasone alone (6 mg/m2 per day) was estimated from daily leukocyte counts and serial bone marrow cytokinetic studies. A clinical oncolytic effect of dexamethasone was associated with a reduction in the marrow cell proliferating compartment, as judged from labeling indices, mitotic indices and percent S + G2 + M in five patients. We found, however, that GR levels either alone or combined with clinical or cytokinetic responses to dexamethasone as a single agent did not reliably identify patients who were likely to respond favorably to reinduction with steroid-containing combination chemotherapy. The 35 children who successfully attained subsequent remissions had GR levels similar to those who failed (p = 0.35). While not statistically significant, two observations suggest an association between lower receptor content and drug resistance. Receptor levels from patients with ALL who relapsed while on chemotherapy were appreciably lower (median 15,700, n = 31) than GR levels from patients who relapsed off therapy (median 20,300, n = 17) (p = 0.08). Moreover, three of seven patients with serial studies, whose GR levels at relapse were lower than at diagnosis, failed reinduction--compared to only one of twelve whose levels were either increased or remained unchanged (p = 0.11). Although not having any obvious clinical utility, studies of GR at diagnosis and at relapse may aid in clarifying mechanisms of drug resistance in leukemic blasts.

    View details for Web of Science ID A1983SA34400006

    View details for PubMedID 6582341



    Small megakaryocytes are frequently seen in patients with acute nonlymphocytic leukemia (ANLL). In this study, median megakaryocyte diameters were determined in marrow biopsy specimens of 32 children at diagnosis of ANLL and related to platelet count and chemotherapeutic response. The association between median megakaryocyte size and time-to-failure was striking. Seven of 9 patients with median megakaryocyte diameters greater than 20 microns remain in continuous complete remission for more than 3 yr, whereas 20 of 23 patients with smaller median megakaryocyte diameters failed therapy within 15 mo (p = 0.002). By Cox-regression analysis, megakaryocyte size had independent prognostic value (p less than 0.001), surpassing that of spleen size, the only other feature having significant association with time-to-failure. Megakaryocyte size at diagnosis may be useful for predicting the likelihood of prolonged complete remission in ANLL.

    View details for Web of Science ID A1983QN28600007

    View details for PubMedID 6831047



    Two cases of Pseudomonas aeruginosa infection, with hemograms and marrow aspirates simulating acute promyelocytic leukemia, are presented. The absence of either Auer rods or abnormal granulation, as well as the clinical history of infection, are important clues to the benign nature of the process. Experimental and clinical evidence to support the role of Pseudomonas endotoxin in myeloid suppression and maturation arrest is reviewed.

    View details for Web of Science ID A1983RF23800025

    View details for PubMedID 6410907



    We examined the leukemia cells of 81 consecutively admitted children and adolescents with acute nonlymphoblastic leukemia (ANLL) to determine the frequency and specificity of chromosomal abnormalities. Karyotypes were obtained for 73 (90%) of the 81 children, and 36 (49%) were abnormal. The modal karyotypes for the cases were tightly clustered in the diploid range; only 5 (7%) were hypodiploid, with 45 chromosomes each, and only 2 (3%) had greater than 50 chromosomes. Specific chromosomal abnormalities in the abnormal karyotypes were compared to morphologic subgroups of ANLL. An 8;21 translocation was found in 6 of 9 cases with M2 morphology but was also found in 1 case with M1 morphology. One of 4 with M3 (progranulocytic) morphology had a 15;17 translocation, and another had a 17q deletion. A structural abnormality in 11q was found in 3 of 7 patients with M5 (monoblastic) morphology, 2 of whom had a 9;11 translocation. The only case of M6 had a 22q-or Philadelphia chromosome in addition to other abnormalities. Statistical analysis of 27 abnormal karyotypes showed preferential structural rearrangement of 8q and 21q. We conclude that, in children as well as adults, specific structural abnormalities are correlated with certain morphologic subgroups of ANLL. However, other chromosomal changes associated with prior mutagenic exposure of adult ANLL were uncommon in children, which may suggest a difference in pathogenesis.

    View details for Web of Science ID A1983QR89100001

    View details for PubMedID 6825064



    A treatment plan to achieve better disease control in patients with acute lymphoblastic leukemia (ALL) who relapse after elective cessation of therapy was assessed. The principal modifications were (1) a second preventive treatment of the central nervous system (CNS) at relapse and every six weeks throughout therapy, using intrathecal methotrexate with cytosine arabinoside, and (2) a four-week course of systemic chemotherapy given immediately before therapy was stopped a second time. Twenty-four patients were studied. There have been no meningeal relapses, in contrast to seven among 16 similar patients who were retreated without CNS prophylaxis. Although the median length of second hematologic remission was not significantly different from the outcome in the comparison group, a much higher proportion of patients (eight of 24 versus zero of 17) remain in prolonged reinduced complete remission (48-79 months). Children whose first relapse occurred later than six months after cessation of therapy had significantly longer subsequent remissions. These end results establish the value of intrathecal CNS prophylaxis in relapsed ALL and suggest that a late intensive phase of therapy will extend remissions in a substantial proportion of patients.

    View details for Web of Science ID A1983RJ76300003

    View details for PubMedID 6583322



    Using a whole-cell assay, we found glucocorticoid receptors (GR) in all 43 consecutive assessable children with newly diagnosed acute non-lymphocytic leukemia (ANLL). The receptor levels ranged from 2146 to 81,308 sites/cell (median = 18,105); these results were similar to those for acute lymphocytic leukemia. Receptor levels were not related to any of these clinical or biological features at diagnosis: age, sex, race, initial leukocyte count, liver or spleen size, presence of CNS disease or Auer rods, [3H] thymidine ( [3H]TdR) labelling index, French-American-British morphology or terminal deoxynucleotidyl transferase activity. Receptor levels also were not related to the initial treatment response or remission duration after therapy that did not include a glucocorticoid. We conclude that GR level has no clinical utility as a marker protein in childhood ANLL.

    View details for Web of Science ID A1983QN25700002

    View details for PubMedID 6834883


    View details for Web of Science ID A1982PG90600008

    View details for PubMedID 6181873

  • ANAPHYLACTOID REACTIONS TO ESCHERICHIA-COLI AND ERWINIA ASPARAGINASE IN CHILDREN WITH LEUKEMIA AND LYMPHOMA CANCER Evans, W. E., Tsiatis, A., Rivera, G., Murphy, S. B., Dahl, G. V., Denison, M., Crom, W. R., Barker, L. F., Mauer, A. M. 1982; 49 (7): 1378-1383


    The incidence and clinical characteristics of anaphylactoid reactions to intravenous asparaginase were assessed in 196 patients given E. coli asparaginase and 49 patients given Erwinia asparaginase. All patients were given a 50 IU intravenous test dose followed in 30 min by the full dosage (10,000 IU/m2), if no reaction occurred to the test dose. Twenty-nine of 196 patients (14.8%) given E. coli asparaginase had an anaphylactoid reaction, occurring after their first through 12th doses. The probability of an anaphylactoid reaction was significantly greater in those patients not receiving concomitant prednisone-vincristine and patients with a hiatus between courses of asparaginase therapy. By logistic regression analysis, other variables such as age, sex, race, diagnosis, total number of doses and concurrent methotrexate or arabinosylcytosine did not contribute significantly to the probability of a reaction. Twenty-three of the patients who had reacted to E. coli asparaginase and 26 patients who had not reacted to E. coli asparaginase were subsequently given Erwinia asparaginase. Seven of these 49 patients (14%) had an anaphylactoid reaction. The probability of a reaction to Erwinia asparaginase was significantly related to a prior reaction to E. coli asparaginase, concomitant prednisone-vincristine therapy, total number of asparaginase doses, number of prior E. coli asparaginase doses, and diagnosis, when assessed by a logistic regression model. However, after adjusting for prior reaction to E. coli asparaginase and the total number of asparaginase doses given, the other variables did not contribute significantly to the probability of a reaction. Only 5/29 patients reacting to E. coli asparaginase and 1/7 reacting to Erwinia asparaginase had a reaction to the test dose. None of the reactions were fatal.

    View details for Web of Science ID A1982NF56800012

    View details for PubMedID 7037164


    View details for Web of Science ID A1982NN92700017

    View details for PubMedID 6177437

  • ANEUPLOIDY AND PERCENTAGE OF S-PHASE CELLS DETERMINED BY FLOW-CYTOMETRY CORRELATE WITH CELL PHENOTYPE IN CHILDHOOD ACUTE-LEUKEMIA BLOOD Look, A. T., Melvin, S. L., Williams, D. L., Brodeur, G. M., Dahl, G. V., Kalwinsky, D. K., Murphy, S. B., Mauer, A. M. 1982; 60 (4): 959-967


    Cellular DNA content distributions of propidium-iodide-stained bone marrow blasts were determined by flow cytometry (FCM) for 225 untreated children with acute leukemia and were correlated with leukemia cell phenotype and karyotype. Aneuploidy of the primary malignant stem line was detected in 54 cases (24%): 51 hyperdiploid and 3 hypodiploid. A second stem line with approximately twice the DNA content of the primary stem line was recognized by FCM in 28 cases (23 ALL, 5 ANLL) and may be an important source of leukemia cell heterogeneity. The degree of DNA content abnormality detected by FCM was highly correlated (r = 0.98) with the number of whole chromosome gains or losses in the leukemia karyotype. Aneuploidy detectable by FCM was more frequent in acute lymphoblastic leukemia (ALL) (52 of 173, 30.1%) than in acute nonlymphoblastic leukemia (2 of 52, 3.8%) (p less than 0.001). In the ALL group, aneuploidy was significantly correlated with the cell surface expression of common ALL antigen: 46 of 127 antigen-positive cases were aneuploid compared to 6 of 46 antigen-negative cases (p less than 0.003). Only 2 of 21 cases of T-cell ALL without common ALL antigen had detectable aneuploidy, which was significantly less than in the common ALL group (p = 0.02). The median percentage of cells in S-phase was significantly greater for B-cell and erythrocyte rosette-positive T-cell ALL, than for the other phenotypic subgroups. We conclude that aneuploidy and S-phase cell percentage are correlated with the state of leukemia cell differentiation. The biologic basis for the correlation is not established, but may be linked to the process of malignant transformation.

    View details for Web of Science ID A1982PL33300022

    View details for PubMedID 7115962

  • CYTOKINETICALLY BASED INDUCTION CHEMOTHERAPY AND SPLENECTOMY FOR CHILDHOOD ACUTE NONLYMPHOCYTIC LEUKEMIA BLOOD Dahl, G. V., Kalwinsky, D. K., Murphy, S., Look, A. T., Amadori, S., Kumar, M., Novak, R., George, S. L., Mason, C., Mauer, A. M., Simone, J. V. 1982; 60 (4): 856-863


    A four-drug regimen, based on cell kinetic principles, induced complete remissions in 68 of 95 children (72%) with acute nonlymphocytic leukemia (ANLL). Patients entered remission after 2-5 weekly cycles of vincristine-daunorubicin (day 1) followed by sequential cytosine arabinoside and 6-azauridine (days 4-7). With continuation therapy of monthly vincristine-doxorubicin-cyclophosphamide, weekly cytosine arabinoside, and daily 6-mercaptopurine, the median duration of complete remission was 10 mo and the median survival time 21 mo. Portal triaditis, evident in 11 of 23 patients with liver biopsies, was associated with long remissions. A larger spleen size (greater than 5 cm) and a higher myeloblast labeling index (greater than 10%) at diagnosis were clearly related to shorter durations of remission. Splenectomy within 1 mo of remission had no statistically significant effect on the frequency of relapse or length of remission. Patients without central nervous system (CNS) leukemia at diagnosis, all treated prophylactically with intrathecal methotrexate, had a low frequency of initial CNS relapse (3/56, 5%). The 2-yr disease-free survival rate is 29% (20 of 68 patients attaining complete remission). fifteen patients have completed 2.5 yr of therapy, and each remains in continuous complete remission, off treatment, for 1+ -36+ mo. This induction chemotherapy was as effective as more intensive regimens, with the advantage of less toxicity and shorter periods of hospitalization.

    View details for Web of Science ID A1982PL33300009

    View details for PubMedID 6896834

  • PROGNOSTIC IMPORTANCE OF CHROMOSOME-NUMBER IN 136 UNTREATED CHILDREN WITH ACUTE LYMPHOBLASTIC-LEUKEMIA BLOOD Williams, D. L., Tsiatis, A., Brodeur, G. M., Look, A. T., Melvin, S. L., Bowman, W. P., Kalwinsky, D. K., Rivera, G., Dahl, G. V. 1982; 60 (4): 864-871


    Leukemia cell karyotypes were determined at diagnosis for 136 of 159 consecutive patients with acute lymphoblastic leukemia (ALL) who were followed for up to 35 mo. Ninety patients (67%) had abnormal karyotypes. Five chromosome categories were designated, based on the distribution of modal numbers: hyperdiploid greater than 50 (n = 41), hyperdiploid 47-50 (n = 18), pseudodiploid (n = 28), normal (n = 46), and hypodiploid (n = 3). Treatment response was assessed for the categories in terms of time to failure (induction failure, first relapse, or death). Children in the hyperdiploid greater than 50 category had the best responses to treatment, with only 2 failures, and those in the pseudodiploid category had the poorest (p less than 0.001). The remaining 3 chromosome categories had intermediate responses and formed a third prognostic group. This same influence of chromosome number on time to failure was evident within the 2 clinical prognostic groups: high risk, signified by a leukocyte count greater than 100 X 10(9)/liter, meningeal leukemia, mediastinal mass, or the presence of blasts that formed rosettes with sheep erythrocytes at 37 degrees C, and standard risk, indicated by the absence of these features. The influence of chromosome number on time to failure was also the same within the historically favorable prognostic group that had common ALL. Results of a multivariate analysis indicated that chromosome number was the strongest single predictor of outcome (p less than 0.001) and was the only variable that added significant prognostic information to leukocyte count (p less than 0.001). The combination of chromosome number and leukocyte count should more clearly distinguish patients with ALL at low or high risk of relapse.

    View details for Web of Science ID A1982PL33300010

    View details for PubMedID 6956375


    View details for Web of Science ID A1982NN92700018

    View details for PubMedID 7083458



    Fifty-six children with refractory acute lymphocytic leukemia (ALL) were assessed for remission-induction responses to VM-26 (250 mg/m2 per week) in combination with prednisone (40 mg/m2 per day) and vincristine (1.5 mg/m2 per week). Each child had been treated intensively with steroids, vincristine, daunorubicin and L-asparaginase. In fact, all patients had failed to respond to previous reinduction therapy with prednisone-vincristine or had relapsed while receiving vincristine. Our intent in this study was to test whether or not addition of VM-26 to prednisone-vincristine would overcome clinical resistance to these established agents. Complete remissions were induced in 17 patients (0.30) over 4 to 6 weeks. Five of these children, all clinically unresponsive to prednisone-vincristine alone, had complete remissions that lasted longer than 1 year; two remain in remission for 2 1/2 years and both are now off therapy. Myelosuppression, the most serious treatment complication, was documented in 20 of 26 evaluable patients. The median time to recovery of normal marrow function was 15 days. These results demonstrate further the potential of VM-26 in combined-drug treatment of refractory ALL. Whether the effectiveness of this combination represents potentiation of prednisone and vincristine activity by VM-26 or some other, as yet unidentified interaction, remains to be determined.

    View details for Web of Science ID A1982PS88100002

    View details for PubMedID 6958957


    View details for Web of Science ID A1982PM03100079

    View details for PubMedID 6957262


    View details for Web of Science ID A1982PU30900002

    View details for PubMedID 7154706

  • Effective remission induction of refractory childhood acute nonlymphocytic leukemia by VP-16-213 plus azacitidine. Cancer treatment reports Look, A. T., Dahl, G. V., Kalwinsky, D., Senzer, N., Mason, C., Rivera, G. 1981; 65 (11-12): 995-999


    Thirty-eight children and young adults with advanced acute nonlymphocytic leukemia (ANLL) in relapse were treated with VP-16-213 plus azacitidine (5AZ). Each patient had previously received many chemotherapeutic drugs, including anthracyclines and cytarabine. Initially, 16 patients received a 5-day course of VP-16-213 (100 mg/m(2)) daily x 3 days and 5AZ 9150 mg/m(2)) daily x 2 days, repeated after 9-16 days. Since this treatment produced marrow hypoplasia and complete remission (CR) in only one of 16 patients, a more intensive regimen was devised: the remaining 22 patients received a course of VP-16-213 (200 mg/m(2)) daily x 3 days, followed by 5AZ (300 mg/Fm(2)) daily x 2 days, repeated after 1-2 days until the bone marrow became hypoplastic. After two to four courses, 18 patients had marrow hypoplasia and ten of these achieved CR. The proportion of patients achieving CR with the higher doses was significantly greater than that with the initial doses )P less than or equal to 0.05). The toxicity also increased with the higher doses, with major problems due to prolonged pancytopenia. Supportive therapy was required for severe bleeding and infections. We conclude that the intensive treatment with VP-16-213 plus 5AZ can effectively induce remission in patients with refractory advanced acute nonlymphocytic leukemia.

    View details for PubMedID 6170431



    Terminal deoxynucleotidyl transferase (TDT) activity was measured in bone marrow lymphoblasts obtained at diagnosis from 168 consecutive patients with childhood acute leukemia. Absolute concentrations of TDT were increased (greater than or equal to 20 units/10(8) blasts) in samples from 98 of 112 assessable patients with acute lymphocyte leukemia (ALL). The values ranged from less than 1 to 1502 units/10(8) blasts with a median of 90 units contrasted with less than 1 to 219 units (median, 2.6 units) in studies of children without leukemia. Results of an immunofluorescence assay were in good agreement with enzymatic detection of the polymerase. Among 115 patients with adequate marrow smears, 105 had TDT-positive blasts. By contrast, in most children with acute myelogenous leukemia, TDT activity was either undetectable or less than 10 units/10(8) blasts. Although the highest levels of TDT were found in blasts with the common ALL phenotype, quantitative determinations were not significantly related to the major immunological subtypes of ALL or to morphological features or periodic acid-Schiff reactivity of the lymphoblasts. The probability that a newly diagnosed case of leukemia would be ALL was 90% if TDT levels were greater than 20 units/10(8) blasts. We conclude that absolute concentrations of TDT, as determined in this study, are of little value in identifying subclasses of ALL. The immunofluorescence assay, which is much less expensive and easier to perform than the enzyme assay, should prove useful for confirming the diagnosis of ALL and for detecting extramedullary sites of leukemic infiltration.

    View details for Web of Science ID A1981LV66400051

    View details for PubMedID 7018672



    Combination chemotherapy with VM-26 and ara-C was given to 14 children with acute lymphocytic leukemia who had not responded to initial treatment with prednisone, vincristine, daunomycin, and asparaginase. Nine of these patients had also received ara-C. At diagnosis, five children were classified as having standard prognostic features and nine as being at high risk for treatment failure. The drug combination was administered by vein twice a week for four weeks at dosages of 165 mg/m2 for VM-26 and 300 mg/m2 for araC. Nine complete remissions, five in patients with high-risk leukemia, were induced with acceptable toxicity; all 9 subsequently were given continuation therapy with oral mercaptopurine and methotrexate. Four of the 9 patients have relapsed at 2--21 months. All treatment was stopped in 2 patients after 30 months of complete remission. Combinations of VM-26 and ara-C represent an alternative remission induction treatment for patients who fail to attain initial remission with agents of established effectiveness. These agents may especially benefit patients with prognostic features indicating a high risk of treatment failure.

    View details for Web of Science ID A1980KL60000003

    View details for PubMedID 6932995



    On the basis of previous findings at this institution, VM-26 and Cytosine Arabinoside (ara-C) were used in combination to treat 33 children with refractory acute lymphocytic leukemia (ALL). Chemotherapy was given by vein twice a week for four weeks at dosage of 300 mg/m2 for ara-C and 50, 75, 110, 165, or 200 mg/m2 for VM-26. Ten marrow remissions (nine complete and one partial) were induced, with hypotension (2/33) and bone marrow hypoplasia (20/33) the most significant side effects observed. Therapeutic responses were obtained with each dosage of VM-26 except 75 mg/m2; myelosuppression developed at all dosages, being most prolonged at 200 mg/m2. Ten of the 23 non-responders did not complete their planned courses of therapy. The significance of this information is that combinations of VM-26 and ara-C were effective in patients who were either in late stages of their leukemia or had never achieved an initial remission. All had been previously treated with prednisone, vincristine, daunomycin and L-asparaginase. In addition, seven of the 10 responders had previously received ara-C in other drug combinations. The use of VM-26 and ara-C in combination may be warranted for newly diagnosed patients who are at high risk for treatment failure with first-line drugs.

    View details for Web of Science ID A1980JN23500003

    View details for PubMedID 7357520

  • TRANSIENT LEUKEMOID REACTION AND TRISOMY-21 MOSAICISM IN A PHENOTYPICALLY NORMAL NEWBORN BLOOD Brodeur, G. M., Dahl, G. V., Williams, D. L., Tipton, R. E., Kalwinsky, D. K. 1980; 55 (4): 691-693


    Transient leukemoid reactions that resemble acute leukemia have been well described for infants with trisomy 21 (Down syndrome). We report a phenotypically normal 3-day-old boy with hepatosplenomegaly, leukocytosis, and circulating myeloblasts. On chromosome analysis, trisomy 21 was found in all blood and bone marrow cells. However, only 4% of cultured skin fibroblasts were trisomic and the other 96% were normal, thus indicating mosaicism. Without treatment, the leukocyte count gradually returned to normal and the organomegaly diminished. Subsequently, chromosome analysis of blood and bone marrow disclosed a predominance of cells with a normal karyotype. These findings suggest that mosaicism could be responsible for the transient leukemoid reactions in some newborns--i.e., the trisomic cells may temporarily gain a proliferative advantage over the normal cells, perhaps by inhibiting their growth. Serial cytogenetic studies, as well as chromosome analysis of more than one tissue, may help to distinguish transient leukemoid reactions from acute leukemia in infants.

    View details for Web of Science ID A1980JN35100027

    View details for PubMedID 6444534



    Forty-one pediatric patients with advanced cancer (24 with acute leukemia and 17 with diverse solid tumors) received 74 courses of therapy with a new chemotherapeutic agent, 4'-(9-acridinylamino)methanesulfon-m-anisidide (AMSA: NSC 249992). Treatments were given by slow i.v. injection daily for five days every two to three weeks. In patients with leukemia: (a) dosages were escalated from 1.3 to 150 mg/sq m/day; (b) toxicity in the form of stomatitis, vomiting, and phlebitis occurred at dosage levels of 125 to 150 mg/sq m/day; and (c) oncolytic effects were observed in 13 of 24 patients. In patients with solid tumors: (a) dosages were escalated from 5 to 50 mg/sq m/day; (b) toxicity (stomatitis, myelosuppression, and phlebitis) occurred at the dosage level of 50 mg/sq m/day; and (c) no oncolytic responses were noted. Serum concentrations of total and free AMSA were assayed by a fluorescence technique and declined in a biphasic manner with free AMSA declining more rapidly than total AMSA. Dosages of greater than 100 mg/sq m/day were required to maintain serum concentrations of total and free AMSA greater than 0.2 microM for the entire five-day schedule. The results suggest that maximum tolerated dosages of AMSA may differ in children with leukemia and solid tumors; however, hematopoietic toxicity could not be fully evaluated in the patients with leukemia. AMSA has clear antileukemic activity that warrants future Phase II trials.

    View details for Web of Science ID A1980KM86800062

    View details for PubMedID 6258775

  • 2ND CESSATION OF THERAPY IN CHILDHOOD LYMPHOCYTIC-LEUKEMIA BLOOD Rivera, G., AUR, R. J., Dahl, G. V., Pratt, C. B., HUSTU, H. O., George, S. L., Mauer, A. M. 1979; 53 (6): 1114-1120

    View details for Web of Science ID A1979GZ26200011

    View details for PubMedID 444653

  • ["Total therapy" for localized and regional malignant non-Hodgkin's lymphoma of children. A second look (author's transl)]. Sangre AUR, R. J., HUSTU, H. O., Verzosa, M., Johnson, W. W., Simone, J., Rivera, G., Dahl, G. V., Bowman, W. P. 1979; 24 (6): 1031-1042

    View details for PubMedID 538556


    View details for Web of Science ID A1978GD92700002

    View details for PubMedID 282003

  • CHILDHOOD ACUTE LYMPHOCYTIC-LEUKEMIA - STUDY-VIII CANCER AUR, R. J., Simone, J. V., VERZOSA, M. S., HUSTU, H. O., Barker, L. F., PINKEL, D. P., Rivera, G., Dahl, G. V., Wood, A., STAGNER, S., Mason, C. 1978; 42 (5): 2123-2134


    This controlled study of children with ALL was designed to test the efficacy and toxicity of one-, two-, three- and four-drug therapy during remission and whether more aggressive therapy in the first eight weeks prolongs remission in patients with features associated with a particularly poor prognosis. After inducing remission with prednisone, vincristine and asparaginase, patients received cranial irradiation and IT methotrexate and were randomized to receive: 1--methotrexate alone; 2--methotrexate plus mercaptopurine; 3--same as in group 2 plus cyclophosphamide; and 4--same as in group 3 plus arabinosyl cytosine. Patients with CNS leukemia at diagnosis received IT methotrexate weekly during the induction period and a higher dose of CNS irradiation. Patients with anterior mediastinal enlargement at diagnosis received radiotherapy to the mass during the induction period. Patients who failed to attain bone marrow remission after four weeks of therapy were given daunorubicin and prednisone for 2--4 additional weeks. Of the 282 patients entering this study between January 1972 and November 1975, 268 (95%) attained complete remission and 228 (85%) were randomized to receive continuation chemotherapy with 1, 2, 3 or 4 drugs. In Group 1 (methotrexate alone), 14 of 20 patients relapsed and 9 developed leukoencephalopathy without antecedent CNS leukemia apparently due to higher doses of intravenous methotrexate; in Groups 2, 3 and 4 the results were equivalent, but without leukoencephalopathy in initial CR. The addition of cyclophosphamide and arabinosyl cytosine increased toxicity and complications without demonstrably increasing the leukemocidal effect. In the 40 patients given additional early therapy, the modalties employed in this study did not prolong remission.

    View details for Web of Science ID A1978FY61800006

    View details for PubMedID 363252



    In this study of children with acute nonlymphocytic leukemia an attempt was made to prevent central nervous system relapse and to determine whether this therapy, coupled with multiagent chemotherapy, would be successful in prolonging durations of complete remission. Central nervous system relapses were prevented by irradiation, although patients who received this therapy did no better than those who did not receive irradiation. A small group of patients received irradiation to the liver and spleen, but this modality also failed to improve the duration of remission. Control of extramedullary leukemia, in this study, failed to improve remission duration because bone marrow relapse was not prevented or delayed. It is unlikely that focal therapy will have a significant impact in acute nonlymphocytic leukemia until longer marrow remissions are achieved.

    View details for Web of Science ID A1978FY61800015

    View details for PubMedID 102418