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Introduction: Granulocyte sarcoma (GS), also known as chloroma, is a localized malignant tumor composed of myeloid cells, the diagnosis of which is difficult. The pancreatic location and recurrence, aside from any context of malignant hemopathy, are exceptional., Observation: A 31-year-old woman developed an isolated and recurrent granulocyte sarcoma of the pancreas, without any context of a malignant hemopathy. The diagnosis retained on extemporaneous examination was an adenocarcinoma of the pancreas, because of the non-specific necrotic nature of the tumor. The immuno-histochemical exploration corrected the diagnosis. Despite local surgery, an isolated tumor recurred 6 months later. This relapse was treated with radiotherapy followed by heavy chemotherapy, identical to that applied in acute myeloblastic leukemia (AML). Ten months later, remission was stable and complete., Comments: Isolated granulocyte sarcomas located in the pancreas are exceptional and have often led to initial erroneous diagnosis. Immuno-histochemical methods are essential in order to obtain correct diagnosis. Despite the localized nature of the tumor, intensive AML-type chemotherapy is necessary.

A cost-effectiveness analysis was carried out from a randomized placebo-controlled protocol of GM-CSF during and after remission induction treatment for elderly patients with acute myeloid leukemia (AML). A retrospective economic analysis was carried out from the hospital perspective. A total of 240 patients with de novo AML and aged 55 to 75 years were enrolled. Overall survival and disease-free survival were analysed for efficacy within five years and expressed in gained life-years. Analysis was also conducted according to the protocol stratification: 55-64-year-old and 65-75-year-old patients. Global costs were estimated on the basis of patient medical records from inclusion to death or relapse. In all, 83 patients were evaluated from three centres, Besançon, Nancy and Nantes. Costs are expressed in French francs. Overall, total cost per patient amounted to FF 641,778 for placebo patients and to FF 587,048 for GM-CSF patients. For disease free-survival, costs were FF 357,167 for placebo patients and FF 320,736 for GM-CSF patients. For overall survival and disease free-survival the cost savings by GM-CSF were, respectively, FF 54,730 and FF 36,431. In the younger patient group savings were synonymous with GM-CSF. In all cases GM-CSF strategy induced benefit expressed as savings as well as efficacy.

We retrospectively studied 32 patients treated with the m-BACOD regimen in a single institution between January 1988 and December 1991. After four to seven courses, four patients presented severe acute pneumonitis (PaO2 < 55 mmHg in room air), with diffuse bilateral interstitial syndrome. Broncho-alveolar lavage displayed increased lymphocyte count (> 45%) with inversion of CD4/CD8 in two cases and no evidence of parasitic, bacterial or viral infection. All patients received methyl-prednisolone (0.5 to 1 mg/kg/d x 1 week) with both complete clinical and radiological recovery within a week. The m-BACOD regimen was continued without bleomycine for four patients and without bleomycine plus methotrexate for two patients, until the completion of eight courses, without recurrence of pneumonitis. Drug-exclusion decisions were made empirically because the exact nature of the pneumonitis was not recognized at the time of diagnostic. Because of the regular administration in the m-BACOD regimen, methotrexate leads to an increased risk of pneumonitis. We concluded that the use of the m-BACOD regimen should henceforth be discontinued.

The follow-up of patients treated with sequential chemotherapy in internal medicine departments with special interest in haematology imposes a heavy burden on the entire treating staff. The chances of errors, notably in medical prescriptions and care, are not negligible, and these errors result in iatrogenic complications, readmissions and prolonged stays in hospitals. Designing a medical decision and therapeutic follow-up aid system should be time-saving for the staff and ensure good quality and safe prescriptions as well as reliable therapeutic evaluations and better hospital management. The system described here is developed on 4D Macintosh computer which handles a relational data-base. It includes the data-base, i.e. a knowledge-based system devised by the expert clinician containing "declarative" data and deduced rules which represent the expert's reasoning and determine the action to be taken, and the interface between them. The system easily accepts many parameters, thereby enabling medical knowledge and therapeutic attitudes to be updated.

In order to study the importance of atrial systole, the authors used different stimulus modalities at the same rate; they stimulated the right ventricle, the right atrium, and the two. The haemodynamic parameters were monitored by microcatheterisation of both right and left sides. A comparative study using controls and patients with left ventricular failure showed the improvement in the haemodynamic picture which was obtained in the latter group when the atrio-ventricular sequence was correct.

The authors report on two cases of Hodgkin's disease with muscular involvement. This exceptional complication occurred during the terminal phase of a stage IV disease in one case and during remission of a stage III disease in the other case, where it responded to combined chemotherapy. Muscular lesions in Hodgkin's disease may be due to extension from adjacent tissues or from dissemination through the blood stream. They do not necessarily indicate a more severe prognosis.

A case of acute monoblastic leukemia in a 68-year-old man is reported in which one of the presenting manifestations was a pericardial effusion. A blood-stained fluid was removed from the pericardium. The pericardial fluid showed blast cells on microscopical examination. The patient was treated with 6-Mercaptopurine and Methotrexate and achieved a short partial remission. He died of general infection, 4 months after the start of his illness. We found in the medical literature 30 additional cases with a mean age of 24 +/- 16 years and a striking male predominance (68. p. 100). We found 15 acute lymphoid leukemias, 9 acute myeloid leukemias, 4 acute indifferentiated leukemias, and 2 acute nontyped leukemias. The leukemic pericardial involvement is often associated with splenomegaly, adenopathy and pleural effusion. The management procedures include pericardiocentesis, general of local chemotherapy, irradiation of the cardiac area. The prognosis is generally poor, with a mean survival of 5 months.

A new case is reported here of acute myeloid leukemia after chlorambucil therapy for multiple sclerosis. This is the sixth case seen at our institution during the period 1978 to 1984. The leukemogenic potential of the immunosuppressive cytotoxic drugs in patients with multiple sclerosis is emphasized.

We studied the action of cimetidine at various concentrations on human hematopoeitic colony and cluster forming cells "in vitro" (CFUc). Bone marrow samples obtained from 31 patients with various hematological and neoplastic diseases were cultured in semisolid agar. When cimetidine was added to cultures there was a reduction of colony and macrocluster formation. At the concentration used in our study (20 micrograms/ml, 30 micrograms/ml, 40 micrograms/ml) these effects were not dose-related. We did not find any significant reduction of microcluster formation. These results are relevant with the hypothesis that histamine H2 receptors antagonists may have an inhibiting action on bone marrow CFUc proliferation. They point out the need for hematological surveillance during long-term cimetidine therapy.

The authors report a case of acute myeloid leukemia in a thirty-four-year-old man who had been under lithium carbonate for the last six months for manic-depressive psychosis. One year after treatment with cytosine-arabinoside, 6-thioguanine and daunorubicin, the patient is still in complete remission. In the medical literature we found seven additional reports of acute or chronic myeloid leukemia after lithium therapy. Lithium was found to enhance granulopoiesis. Our findings suggest that lithium may initiate or promote leukemia.

The hematologic immediate toxicity during radiotherapy for Hodgkin's disease was studied from a series of 72 patients with stage IIB or III who received 3 courses or more of chemotherapy before radiotherapy. The toxicity in the group of 36 of them who received total nodal irradiation (TNI) was the most important. Sixteen of the 28 TNI had irradiation interrupted, 12 of them began with inverted Y type. The blood cells count at the beginning of the treatment was crucial; only 16% of the patients had interruption of irradiation when the blood cells count was normal; on the other side, 63% had interruption when the blood cells count was abnormal (P less than 0.05). Toxicity was due to the daily destruction of the dividing bone marrow stem cells located in the irradiated area, from the first day of treatment; there was a progressive decrease in the pool of these stem cells within a late resaturation. The absence of resaturation of this pool after initial chemotherapy and after the first part of irradiation explained the immediate and durable toxicity; in the same way, inverted Y irradiation destroyed a great part of active bone marrow (40%) and the pool of remaining stem cells with high mitotic index would be located in areas irradiated subsequently. So, waiting for the absolute normalisation of blood cells count before beginning irradiation and start irradiation by mantle field (rather than inverted Y) seem to be the 2 measures able to reduce the number of interruptions of irradiation due to hematotoxicity.

Sixty-one patients with refractory or relapsed or secondary acute leukemia were treated with high-dose cytosine arabinoside (2-3 g/sq m in intravenous infusion every 12 hr to a 12-36 g/sq m total dose). m-Amsa or another antileukemic drug was given with cytosine arabinoside to 20 patients. Complete remission was achieved in 12 of 27 patients with acute myeloid leukemia, 5 of 8 patients with chemotherapy-induced leukemia, 3 of 7 patients with hematologic disorders in blastic crisis and 5 of 17 acute lymphoblastic leukemia patients. A similar response rate (6/16) was obtained when m-Amsa was given with cytosine-arabinoside. The median duration of remission was short (4 months in acute myeloid leukemia). Bone marrow transplantation was performed in 10 patients during the remission time. This regimen has acceptable toxicity; severe neurologic or hepatic disorders occurred in 18% of patients. These data suggest that high-dose cytosine arabinoside is an effective alternative in the treatment of resistant acute leukemia.

The effects of i.v. cytomegalovirus (CMV) immunoglobulin given for prophylaxis of CMV infections in recipients of allogeneic and autologous marrow transplants were evaluated in a randomized trial: 60 patients were randomly assigned to receive (30 patients) or not to receive (30 patients) CMV immunoglobulin for a period of 90 days after transplantation. As to the allografted patients, the cumulative incidence of asymptomatic and symptomatic CMV infections was significantly reduced in the CMV immunoglobulin-treated group as compared to the control group (56.5% versus 92.9%, P less than 0.05). No other statistically significant effect of CMV immunoglobulin could be found. In particular, the incidence of symptomatic CMV infections (including interstitial pneumonia), the mean delay of post-transplant viraemia and haematopoietic recovery were similar in the control and CMV immunoglobulin-treated groups. We conclude that prophylactic CMV immunoglobulin administration, as designed in our study, is no more than marginally effective and cannot be recommended without additional trials.