No abstract

Subintimal recanalization is beneficial in selected patients with peripheral chronic total occlusions (CTO). However, in complex cases, re‐entry into the true arterial lumen may prove to be unsuccessful with a conventional guidewire or a re‐entry catheter when using standard femoral artery access. Our case series describes these technical dilemmas along with strategies that can be utilized to overcome these challenges. © 2011 Wiley‐Liss, Inc.

To describe the clinical and biologic features of pediatric acute megakaryoblastic leukemia (AMKL) and to identify prognostic factors, experience at St Jude Children's Research Hospital was reviewed. Of 281 patients with acute myeloid leukemia treated over a 14-year period, 41 (14.6%) had a diagnosis of AMKL. Six patients had Down syndrome and AMKL, 6 had secondary AMKL, and 29 had de novo AMKL. The median age of the 22 boys and 19 girls was 23.9 months (range, 6.7-208.9 months). The rate of remission induction was 60.5%, with a 48% rate of subsequent relapse. Patients with Down syndrome had a significantly higher 2-year event-free survival (EFS) estimate (83%) than did other patients with de novo AMKL (14%) or with secondary AMKL (20%; P < .038). Among patients who had de novo AMKL without Down syndrome, 2-year EFS was significantly higher after allogeneic bone marrow transplantation (26%) than after chemotherapy alone (0%; P ‫؍‬ .019) and significantly higher when performed during remission (46%) than when performed during persistent disease (0%; P ‫؍‬ .019). The 5-year survival estimates were significantly lower for de novo AMKL (10%) than for other forms of de novo AML (42%; P < .001). Treatment outcome is very poor for patients with AMKL in the absence of Down syndrome. Remission induction is the most important prognostic factor. Allogeneic transplantation during remission offers the best chance of cure; in the absence of remission, transplantation offers no advantage over chemotherapy alone. IntroductionAcute megakaryoblastic leukemia (AMKL) is a biologically heterogeneous form of acute myeloid leukemia (AML) and is recognized as the seventh subtype of AML (M7) within the FrenchAmerican-British (FAB) cooperative group classification system. 1 AMKL has a bimodal age distribution that peaks in early childhood (age Ͻ 3 years) and adulthood. [2][3][4][5][6] Between 1% and 10% of cases of AML in adults are identified as AMKL. 2,7 Although initially thought to be rare among children, AMKL has been diagnosed with increasing frequency in this age group, largely because of improvements in immunophenotyping. 5 Contemporary cooperative group studies have found that 3.1% to 10% of all cases of childhood AML are AMKL. [8][9][10][11] However, the exact incidence of AMKL in children remains undetermined.Acute megakaryoblastic leukemia is the most common form of AML in children with Down syndrome (DS), and its prognosis is excellent in this group of patients. 6,8,[12][13][14] AMKL in other children appears to be more heterogeneous, and its prognostic factors have not been well defined. 5,6 Since 1984, our institution has used systematic criteria to establish the diagnosis of AMKL. We reviewed the clinical and biologic characteristics and the outcomes of all 41 cases of childhood AMKL diagnosed at our institution since that time. Patients, materials, and methods PatientsAll cases of AMKL diagnosed between January 1985 and December 1998 at St Jude Children's Research Hospital were reviewed. Details of clinical presentation...

Little is known about the factors that affect treatment outcome in very young children with acute myeloid leukemia (AML). We therefore analyzed the prognostic impact of various presenting clinical and laboratory features by discrete age group in 299 children with AML treated in four consecutive clinical trials between 1980 and 1997. Differences in presenting features, as well as treatment outcome, were compared between children aged 12 months or less (n = 28) or 13 to 24 months (n = 28) and those more than 24 months of age (n = 243). Children in the two youngest groups (24 months of age or less) had similar presenting features and treatment outcome. Collectively, these 56 children were significantly more likely than the 243 older patients to have M4 or M5 leukemia (70% vs 30%), CNS leukemia (33% vs 22%), the t(9;11) (p22;q23) (18% vs 6%) or other 11q23 translocations (23% vs 3%), and less likely to have Auer rods (2% vs 54%) or the t(8;21) (q22;q22) (0% vs 17%). Among patients aged 24 months or less, two factors independently predicted a favorable prognosis: FAB M4 or M5 leukemia (relative risk of relapse, 0.4; 95% confidence interval, 0.2-0.9) and the t(9;11) (relative risk, 0.3; 95% confidence interval , 0.1-1.0). Leukocyte count and 11q23 translocations other than the t(9;11) lacked prognostic significance. Among older patients, a leukocyte count Ͻ50 × 10 9 /l and the presence of the t(9;11) conferred a favorable prognosis. Leukemia (2000) 14, 684-687.

Adolescents undergoing treatment for cancer rate fatigue as their most prevalent and intense cancer- and treatment-related effect. Parents and staff rate it similarly. Despite its reported prevalence, intensity, and distressing effects, cancer-related fatigue in adolescents is not routinely assessed during or after cancer treatment. We contend that the insufficient clinical attention is primarily due to the lack of a reliable and valid self-report instrument with which adolescent cancer-related fatigue can be measured. Our aim was to determine the reliability and construct validity of a new instrument and its ability to measure change in fatigue over time. Initial testing involved 64 adolescents undergoing curative treatment of cancer who completed the Fatigue Scale-Adolescent (FS-A) at two to four key points in treatment in one of four studies. Internal consistency estimates ranged from 0.67 to 0.95. Validity estimates involving the FS-A with the parent version ranged from 0.13 to 0.76; estimates involving the staff version and the Reynolds Depression Scale were 0.27 and 0.87, respectively. Additional validity findings included significant fatigue differences between anemic and nonanemic patients (P=0.042) and the emergence of four factors in an exploratory factor analysis. Findings further indicate that the FS-A can be used to measure change over time (t=2.55, P<0.01). In summary, the FS-A has moderate to strong reliability and impressive validity coefficients for a new research instrument.

Summary:Our purpose was to evaluate frequency and severity of bone mineral decrements and frequency of osteonecrosis in survivors of pediatric allogeneic bone marrow transplantation (alloBMT). We retrospectively reviewed demographic information, treatment, magnetic resonance (MR) imaging studies (hips and knees), and bone mineral density (BMD) studies of 48 patients as measured by quantitative computed tomography (QCT). In all, 24 patients were male; 37 were Caucasian. Median age at alloBMT was 10.3 years (1.6-20.4 years). Of the 48 patients, 43 underwent QCT. Median time between alloBMT and imaging was 5.1 years (1.0-10.2 years). Median BMD Z-score was À0.89 (À4.06 to 3.05). BMD Z-score tended to be associated with female sex (P ¼ 0.0559) but not with age at BMT, race, primary diagnosis, time from alloBMT, T-cell depletion of graft, total-body irradiation, or acute/chronic graft-versus-host disease (GVHD). MR showed osteonecrosis in 19 of 43 (44%). We found no associations between osteonecrosis and sex, race, diagnosis, age at BMT, history of GVHD, time from BMT, or T-cell depletion. Seven patients (15%) had MR changes of osteonecrosis and BMD Z-scores of less than -1 s.d. We conclude that pediatric alloBMT survivors have decreased BMD and are at risk of osteonecrosis. They should be monitored to assure early intervention that may ameliorate adverse outcomes.

This agent was well tolerated, and its toxicity was acceptable. Future trials should examine the effectiveness of 2-CDA given in combination with other agents effective against AML.

To determine the clinical significance of central nervous system (CNS) involvement at the time of diagnosis of pediatric acute myeloid leukemia (AML), we analyzed clinical features and outcomes of 290 patients treated consecutively on four institutional trials (AML80, AML83, AML87, and AML91). CNS status was classified as CNS1 (no blast cells in CSF; n ¼ 205), CNS2 (o5 WBC/ll CSF with blast cells; n ¼ 37), or CNS3 (X5 WBC/ll CSF with blast cells, or signs of CNS involvement; n ¼ 48). Patients with CNS3 status were significantly younger than others (P ¼ 0.016) and significantly more likely to have the favorable cytogenetic features t(9;11), t(8;21), or inv(16) (Po0.001). The CNS3 group had a significantly greater probability (7s.e.) of 5-year event-free survival (43.777.0%) than did the CNS1 (27.873.2%, P ¼ 0.015) and CNS2 (24.377.5%, P ¼ 0.032) groups. However, after adjustment for favorable genetic features, there was no significant difference in EFS between the CNS3 and the combined CNS1 þ CNS2 groups (P ¼ 0.075). In all, 10 of 151 patients treated on AML80 and AML83, but none of 139 treated on AML87 and AML91, had primary CNS relapse. CNS involvement had no adverse prognostic significance, and patients with CNS2 status had similar outcome to CNS1 patients in this large group of pediatric patients with AML, treated at a single institution.