Negative Bone Marrow Biopsy Research Articles

New response criteria for lymphomas in clinical trials

Standardized staging and response assessment are critical to the successful conduct of clinical trials. In turn, clinical trials are essential to the development of new and more effective therapy for patients with lymphomas. In the absence of effective agents, response criteria are almost irrelevant. However, with the increasing number of effective therapies, standardized criteria are necessary to reliably assess and compare results of studies. Variability in how patients were evaluated led to an International Working Group (IWG) that developed guidelines to standardize normal lymph node size, when and how responses are assessed, and definitions for response categories and endpoints [1]. These recommendations were widely adopted by clinical trials groups and regulatory agencies. However, with their application over time, it became clear that revisions were indicated. For example, the IWG criteria relied on physical examination, with its marked interand intraobserver variability, CT scans and SPECT gallium scans, the latter no longer being widely used. A major problem with the original IWG criteria was the misinterpretation of the term complete remission/unconfirmed (CRu). CRu was originally proposed to designate patients with curable histologies, such as Hodgkin’s lymphoma or diffuse large B-cell lymphoma, with a large mass prior to therapy for whom treatment eradicated all detectable tumor except for persistence of the single mass, which had decreased by at least 75% on CT scan, recognizing that these lesions are scar tissue or fibrosis in >90% of cases [2, 3]. Instead, CRu was often applied to situations in which the sum of the product of the diameters (SPD) of multiple nodes decreased by at least 75%, which would more appropriately designated partial response (PR). A second type of CRu indicated patients who fulfilled all of the conditions for a CR following therapy except that the bone marrow was considered morphologically indeterminate. Instead, the term was also assigned to patients who did not undergo a repeat biopsy to confirm response. FDG-PET has resulted in a major shift in lymphoma patient management. PET is not useful for diagnosis because it lacks specificity. However, it has been considered for staging, prognosis, directing therapy, restaging and post-treatment surveillance. The strongest evidence for the usefulness of PET is in post-treatment restaging [4–27]. The Ann Arbor system most commonly used was based on physical examination and bone marrow assessment, with CT scans subsequently incorporated. PET is highly sensitive in detecting nodal and extranodal involvement by most histologic subtypes of lymphoma and may provide complementary information to the Ann Arbor staging system [4, 8, 10, 11, 16, 21, 28–38]. Most common lymphoma histologies are routinely FDG avid with a sensitivity and specificity that is superior to CT [28, 29, 32, 38]. Whereas PET and CT are 80–90% concordant in staging of diffuse large B-cell lymphoma, follicular lymphoma and mantle cell lymphoma [10, 32], PET results in upstaging by identifying additional sites of disease. Concordance of PET and CT is lower in Hodgkin’s lymphoma [4, 8, 16, 21, 34–36]. PET can detect bone or bone marrow involvement in lymphoma patients with a negative iliac crest bone marrow biopsy [39–41], although being more sensitive with diffuse disease and less reliable with limited involvement [41]. Thus, PET cannot substitute for bone marrow biopsy in lymphoma staging. PET is currently not part of standard lymphoma staging primarily because of its expense and the generally small percentage of patients ( 15–20%) where PET modifies clinical stage, with a change in management in only 10–15% [11, 32, 42]. Thus, at present PET alone should not replace CT for staging [4, 8, 16, 35]. PET/CT offers important advantages compared with contrast-enhanced, full-dose diagnostic CT or PET alone [37, 43, 44]. The CT portion of the PET/CT exam for initial staging using i.v. contrast may permit a more accurate assessment of liver and spleen compared with unenhanced CT [25]. PET/ CT may be valuable in patients with clinical stage I or II disease who are being considered for local radiation therapy. Numerous studies have demonstrated that PET scans performed after one or more cycles of chemotherapy predict progression-free and overall survival [5–7, 20, 21, 23, 24, 45–47]. Unfortunately, no available data demonstrate that altering treatment on the basis of PET results improves patient outcome. This critically important issue is currently being addressed in a number of clinical trials.

Use of PCR for BCL2/IgH + cells in stage I/II follicular lymphoma to identify positive cells in bone marrow and peripheral blood that can be cleared by lymph-node irradiation

8571 Background: Stage I/IIA follicular lymphoma (FL) is considered a localized disease that can be adequately treated with radiotherapy alone. Minimal NHL contamination in peripheral blood (PB) or bone marrow (BM) can be detected by qualitative and quantitative PCR. Aim of this study was to evaluate the role of PCR, the impact of radiotherapy and prognosis in localized FL. Methods: BM and PB involvement in FL was investigated by PCR in a series of 25 consecutive patients with histologically revised diagnosis and treated with involved field radiotherapy alone. Results: Despite a negative BM biopsy, Bcl-2/IgH+ cells were found at diagnosis in the PB and/or BM of 17 patients (68%). After lymph-node involved field radiotherapy, in 10/16 Bcl-2/IgH positive, valuable patients, a disappearance of Bcl-2/IgH+ cells was observed, which persisted after a median follow-up of 42 months (range 5–79) in all but 2 patients.. Quantitative PCR demonstrated the feasibility of clearing PB and BM Bcl-2+ cells after local irradiation of the primary site of the disease only when the basal number of lymphoma cells was <1:100 000. Two patients had a molecular relapse only and were reinduced into a negative PCR status after rituximab treatment. Clinical relapse was observed in 4/25 patients, all of them had Bcl-2/IgH+ cells in the PB and/or BM at diagnosis. After radiotherapy 3 of them persisted bcl2 positive in BM and/or PB and one became negative. Conclusions: In the majority of localized FL, Bcl-2/IgH+ cells could be found in the PB and BM despite a negative BM biopsy. Lymphoma cells can thus reversibly spread from the affected lymph node (s) to PB and BM and durably disappear after lymph node irradiation. Patients with Bcl-2/IgH+ cells at diagnosis or after treatment had a higher likelihood of relapse. The possibility of a persistent lymphoma cell clearance is proportional to the amount of cells detected at presentation by quantitative PCR. Rituximab can reverse molecular relapses. No significant financial relationships to disclose.

Cementoplasty for the treatment of a painful lytic lesion

PURPOSE: Anesthesiologists working in interventional pain management frequently care for cancer patients with uncontrolled pain due to lytic lesions. We report a patient who obtained substantial pain relief from cementoplasty, the injection of methylmetacrylate into a lytic lesion, to her pelvis. CLINICAL FEATURES: An 89 year old female complained of a six month history of insidious left hip pain that increased to ‘9/10’ following a fall two months prior to presentation. She had a vague history of fatigue and radiographic investigation revealed lytic lesions in the left pubic ramus and left ischium. A diagnosis of plasmocytoma was made based on a monoclonal gammopathy and negative bone marrow biopsy, and the patient was treated with five fractions of 20 Gy radiation. There was no change in pain and the patient was referred to the Pain Center. The patient's pain was described as 'excruciating', incidental and localized to the left hip and groin. It was unrelieved by analgesics, strong opioids and cannabinoids (acetaminophen 3g/day, fentanyl 50ug/hr patch and nabilone 1mg HS). She was depressed with only partial response to citalopram. Based on the size of the pubic/ischial ramus lesion (3 x 1 x 1cm) and tenderness to palpation, it was determined to be the main cause of pain. The patient was explained the benefits and risks of cementoplasty and consented. Patient was placed in prone position and two 2mm diameter guidewires were inserted under CT guidance. The first entered at the ischial tuberosity and was advanced into the inferior ramus of the pubis. The second entered at the same point, but was advanced towards the ischium posterior to the acetabulum. Each guidewire followed a track anesthetized with lidocaine 1%. With Seldinger technique, 14G trochars were placed over the guidewires directly into the lytic lesion of the rami. A total of 3.5cc of methylmetacrylate (Vertebroplastic®) was injected and the trochars were removed. The patient noted an immediate reduction in pain and went home 90 minutes post procedure. Following cementoplasty, the patient's average pain decreased to 3.5/10. Her subjective report of walking better was confirmed by MD examination. Her mood improved, attributed to both medication and the procedure-related pain relief, and she began socializing again. The patient consented to the publication of this case report. CONCLUSIONS: Cementoplasty provided this patient with artificial bone casting, as well as immediate and substantial analgesia, and should be considered for the treatment of painful lytic lesions. Incidental pain secondary to bone fracture is difficult to control with medication and cementoplasty represents an alternative to surgery. Anesthesiologists involved in interventional pain may consider adding this technique to their armamentarium. Its use requires experience with radiology-guided procedures and methylmetacrylate injection.

Stage I/II follicular lymphoma: spread of bcl‐2/IgH+ cells in blood and bone marrow from primary site of disease and possibility of clearance after involved field radiotherapy

Stage I/IIA follicular lymphoma (FL) is considered a localised disease that can be adequately treated with radiotherapy alone. Bone marrow (BM) and peripheral blood (PB) involvement in FL was investigated by polymerase chain reaction (PCR) in a series of 24 consecutive patients with histologically revised diagnosis and treated with involved field radiotherapy. Despite the limited stage, Bcl-2/IgH+ cells were found at diagnosis in PB and/or BM of 16 patients (66.6%). After treatment, in 9/15 Bcl-2/IgH positive evaluable patients, a disappearance of Bcl-2/IgH+ cells was observed, which persisted after a median follow-up of 43.5 months (range 11-70) in all but one patient. Quantitative PCR demonstrated the feasibility of clearing PB and BM Bcl-2+ cells after local irradiation of the primary site of the disease only when the basal number of lymphoma cells was <1:100 000. Patients with Bcl-2/IgH+ cells at diagnosis or after treatment had a higher likelihood of relapse. Thus, despite a negative BM biopsy, the majority of localised FL Bcl-2/IgH+ cells were found in the PB and BM. Lymphoma cells can reversibly spread from the affected lymph node to PB and BM and, in a proportion of cases, durably disappear after irradiation. The possibility of a persistent lymphoma cell clearance is proportional to the amount of cells detected at presentation by quantitative PCR.

Role of JAK 2 Mutation Detection in Budd-Chiari Syndrome (BCS) and Portal Vein Thrombosis (PVT) Associated to MPD.

Background: MPD is found in up to 50% of BCS and 30% of PVT, but its diagnosis is often difficult, bone marrow biopsy (BMB) and endogenous erythroid colony (EEC) formation being the most reliable tests in our experience (Br J Haematol , 2005; 129:553) and that of others. We assessed the diagnostic and prognostic value of V617F JAK2 detection in this situation.Methods: Underlying prothrombotic factors were studied in 241 pts (104 BCS, 137 PVT) from 3 centers (Paris, Barcelona, Rotterdam). Based on BMB results (blindly reviewed), 31% of patients had MPD, 67% no-MPD, and 2% were uncertain. Based on combined BMB+EEC results, 29% had MPD, 41% no-MPD and 31% had discordant features. V617F JAK2 mutation was studied in all patients by quantitative RT-PCR.Results: V617FJAK2 was detected in 45% of BCS and 34% of PVT (p=.08). Mean % circulating V617F allele was 37% and 28% in BCS and PVT pts, respectively (p<.04). In pts diagnosed with MPD using conventional criteria, V617F mutation was found in 84% pts with positive BMB, and in 97% pts with concordant BMB+EEC results (table). In pts previously diagnosed as no-MPD, V617F was present in 19% pts with negative BMB and in 7% pts with both negative BMB and EEC. This discrepancy was greater in BCS patients, where V617F was found in 25% pts previously not diagnosed with MPD. V617F was also found in 58% of pts with discordant BMB and EEC results, allowing to increase the rate of definite MPD diagnosis. On the other hand, 16% pts with wild type JAK2 had MPD features on BMB and 20% had positive EEC. Taking into account V617F JAK2 in addition to BMB and EEC, definite MPD incidence increased from 30 to 49% overall; from 32% to 60% in BCS patients; and from 29% to 49% in PVT patients. V617F JAK2 was significantly associated with higher Hb, WBC, and platelet counts, larger spleen size, lower serum EPO, and higher red cell mass. Other prothrombotic states were found in 19/92 V617F patients and 29/144 wtJAK2 patients (NS). Baseline BCS prognostic scores (Child Pugh, Clichy and Rotterdam scores) did not significantly differ between V617F and wtJAK2 patients. BCS and PVT survival was not affected by the presence of V617F JAK2.Conclusion: Detection of V617FJAK2 (1) is almost as common in PVT as in BCS but the % of mutant allele is higher in BCS; (2) is not fully redundant with EEC or BMB findings and increases the diagnosis of underlying MPD by 28% in BCS and by 20% in PVT; (3) has no discernible impact on medium term outcome of BCS or PVT. (Supported by EU: QLG1-CT-2002-01686).% of V617F JAK2 positiveAll patientsBCSPVTBMB / EEC+ / +9710094− / −7250Discordant585362BMB+847592−192712EEC+778472−253818inconclusive333630

Can [18F]fluorodeoxyglucose positron emission tomography imaging complement biopsy results from the iliac crest for the detection of bone marrow involvement in patients with malignant lymphoma?

To assess the usefulness of [18F]fluorodeoxyglucose positron emission tomography in the detection of bone marrow involvement in malignant lymphoma, and its impact in clinical management. One hundred and six consecutive patients with a confirmed diagnosis of lymphoma, referred for staging or restaging of Hodgkin's lymphoma (n=18) or non-Hodgkin's lymphoma (n=88), were reviewed retrospectively. A positron emission tomography scan and bone marrow biopsy of the iliac crest were performed in all patients. The assessment of bone marrow involvement by lymphoma was confirmed by histology and/or progression of bone marrow lesions in clinical follow-up. In 28 of 106 patients, bone marrow involvement was found. Positron emission tomography was more sensitive (86%) than bone marrow biopsy (57%). Positron emission tomography and bone marrow biopsy were concordant by positive correlation in 12 of 28 cases (43%) and by negative correlation in 77 of 78 cases (99%). Ten cases of non-Hodgkin's lymphoma and two cases of Hodgkin's lymphoma with positive positron emission tomography results and an initial negative bone marrow biopsy showed clinical progression of the bone marrow lesions and/or subsequent positive histology. These were considered as false-negative results for bone marrow biopsy. In seven of the 12 positive cases with negative bone marrow biopsy, positron emission tomography uptake distant from the site of the biopsy was seen. In four cases of follicular lymphoma, the bone marrow biopsy was positive and the positron emission tomography scan was normal. Positron emission tomography and bone marrow biopsy are complementary in assessing the presence of bone marrow involvement in patients with malignant lymphoma. In our series, positron emission tomography was more sensitive than bone marrow biopsy in Hodgkin's and non-Hodgkin's lymphoma, except in follicular lymphoma.

Rituximab Monotherapy Is an Effective Treatment for Splenic Marginal Zone B-Cell Lymphomas (SMZL).

Splenectomy has traditionally been considered as standard treatment for SMZL conferring a survival advantage over chemotherapy. However it carries significant complications, especially in elderly patients. The purpose of the present study is to evaluate the safety and efficacy of Rituximab for the treatment of SMZL. Fourteen patients with SMZL, diagnosed in our Department were treated with Rituximab. Diagnosis was established using standard criteria. Twelve received Rituximab as first line treatment at a median time of 2 months (1–120) after diagnosis. The remaining two received Rituximab after splenectomy. Four patients were symptomatic. Patients' median age was 68 yrs (range 50–78) and four were male. All non-splenectomized patients had palpable splenomegaly before treatment. The median size of the spleen was 10 cm blcm (3–20 cm). 12/14 patients had anemia, 6/14 leukocytosis, 9/14 lymphocytosis, 4/14 leukopenia and 5/14 thrombocytopenia prior to treatment initiation. Rituximab was administered for six weekly cycles of 375mg/m2. 6/13 patients received maintenance treatment, starting at a median time of four months (range 2–7) after the completion of the six cycles. Maintenance was given as 375mg/m2 every two months. Complete clinical response was defined as disappearance of palpable splenomegaly. Complete hematologic response was defined as the restoration of all hematologic parameters to normal values and partial hematologic response as an improvement of abnormal values without complete normalization. Molecular remission was defined as PCR negativity for IgH rearrangement in patients with negative bone marrow biopsy. 11 of 11 non-splenectomized patients achieved a complete clinical response (the 12th patient is still under treatment and response cannot be evaluated). Symptomatic patients had resolution of disease/splenomegaly related symptoms. 8/13 (62%) patients achieved a complete hematologic response, including the two previously splenectomized patients and 5/13 (38%) a partial hematologic response. Anemia was resolved in 8/11 patients, leukocytosis in 6/6, leukopenia in 1/3 and thrombocytopenia in 4/4 patients. Bone marrow biopsy after treatment disclosed persistent but reduced infiltration in 6/10, disappearance of lymphomatous infiltration in 3/10 and remained unchanged in a single patient. 2/3 patients with negative bone marrow biopsy were in molecular remission, while one patient remained PCR positive after treatment. He subsequently received a second course of four weekly cycles and became PCR negative. No patient presented infectious complications after Rituximab administration. Infusion related side effects were easily treated with steroids, antihistamines and paracetamol. Two patients, who did not receive maintenance treatment progressed with reappearance of splenomegaly both at 7 months after completion of treatment and were retreated with six cycles of Rituximab. One of them had a second response and the other remained with stable disease. All patients are alive. Median follow up after treatment initiation is 16 months (range 1–22) and median response duration has not been reached. In conclusion, Rituximab is a safe and effective treatment for SMZL and can be considered an alternative to splenectomy as first line therapy. Maintenance may be important for consolidation of response.

Case 38-2004

A 40-year-old man noted a lump on the top of his head. Imaging studies showed a dural-based tumor invading bone and soft tissue. The lesion was excised and a diagnosis of plasmacytoma was made. Additional staging studies disclosed multiple lytic bone lesions, with no paraprotein and a negative bone marrow biopsy and aspirate. The discussants review recent advances in the management of multiple myeloma.

TECHNITIUM-99m-SESTAMIBI SCANNING (MIBI) CORRELATES WITH DISEASE ACTIVITY IN PATIENTS (PTS) WITH MULTIPLE MYELOMA UNDERGOING AUTOLOGOUS PERIPHERAL BLOOD STEM CELL TRANSPLANTATION (PBSCT).

Traditional radiographs are often used to establish a diagnosis of MM, as over 80% of patients will have some form of bone disease, including osteolysis and osteopenia. However, radiographs offer incomplete and sometimes misleading information regarding an individual patient's progress. Pace et al (Eur J Nuc Med, 1998) initially reported the use of MIBI scans to examine bone disease in pts with MM. We hypothesized that MIBI scans could provide a convenient, reproducible method to track pts with MM. We therefore investigated the ability of MIBI scans, in comparison with radiographs and dual energy x-ray absorptiometry (DEXA) to diagnose and follow MM disease progression, as assessed by clinical criteria.Methods: Patients were subjects enrolled in an autologous PBSCT protocol using escalating doses of busulfan and melphalan. Pts received a complete bone survey, DEXA scanning and MIBI scanning prior to PBSCT. Pts able to return for follow up received all 3 tests at various time intervals. MIBI scans consisted of the injection of 30 mCi of technietium-99m-sestamibi followed by immediate scanning with a dual headed gamma camera to produce whole body images. Spot films were made of areas of increased activity. Two radiologists blinded to clinical outcomes reviewed and scored the MIBI films based on scan intensity rated as 0–4 in each of five areas. Scores were averaged, then summed and reported as a total score for each pt. Interrater reliability was determined by using Cohen's kappa statistic.Results: 31 pts were enrolled on the PBSCT protocol, with 29 pts receiving baseline MIBI scanning. The initial total MIBI scores ranged from 2.5 to 16.5 with a mean score of 11 out of a possible 20. Of note, pts categorized as having either a complete remission (CR) or near complete remission (nCR) (n=4, mean score 6.1) had significantly lower (p=.02) MIBI scores in comparison to pts graded as either stable or progressive disease (n=12, mean score 11.5) prior to PBSCT . Eleven pts had serial scans performed at intervals of 6 to 12 months. Of these, 6 pts with stable/progressive disease had pre PBSCT MIBI scores ranging from 9 to 16.5 with a median score of 12. The single pt with nCR had a MIBI score of 5.5. At the first follow up, pts in stable/PD group had MIBI scores that significantly improved, ranging from 1.5 to 5.5 (median=3.3) with concomitant laboratory and marrow improvement (near CR-3, PR-3) but no change in their xray or DEXA scans. The pt with a nCR also showed improvement in protein and marrow findings to a CR with follow up MIBI score of 1.5. Two of 11 pts classified before PBSCT as "non secretory" MM with negative bone marrow biopsies had prePBSCT MIBI scores of 10.5 and 12, which improved post PBSCT to 3 and 6, respectively and corresponded to subjective improvement in bone pain and anemia. With median follow up of 30 mos for these 11 patients, 2 pts have relapsed by standard criteria, with corresponding increase in MIBI score, but no new lytic lesions documented by radiographs or DEXA.Conclusions: Technitium-99m-sestamibi scans provide a simple, inexpensive method (average cost per MIBI $175) to follow the clinical course of MM patients, especially those with nonsecretory disease, and may prove more cost effective and accurate than other imaging methods for tracking total disease burden. We believe that further investigation of MIBI scanning for this indication is warranted.

Absence of Breast Cancer Cells in a Single-Day Peripheral Blood Progenitor Cell Collection After Priming With Cyclophosphamide and Granulocyte-Macrophage Colony-Stimulating Factor

The effect of priming on occult tumor cell involvement of peripheral blood (PB) and PB progenitor cell (PBPC) collections is poorly characterized. Using sensitive immunocytochemistry (ICC) and tumor clonogenic assays (TCA) specific for epithelial-derived tumor cells, hematopoietic specimens were analyzed for PBPC and occult tumor cell involvement in 28 patients with chemotherapy-sensitive stage IIIB or IV breast cancer. Before PBPC priming, tumor was detected by ICC in PB of 1 of 23 (4%) patients and in bone marrow (BM) harvests of 4 of 27 (15%) patients. Fifteen days after cyclophosphamide and granulocyte-macrophage colony-stimulating factor (GM-CSF) priming, 2 of 28 (7%) patients had ICC-positive PBPC collections. The median amplification of CD34+ PBPC during this time was over 19-fold (range, < 1 to 199). One patient had pretreatment tumor involvement of both PB and BM. One patient grew tumor colonies in TCA; the PB and BM were ICC- and TCA-positive, but the PBPC collection was ICC-positive and TCA-negative. After cytoreduction with conventional-dose chemotherapy, patients with advanced breast cancer and histologically negative BM biopsy specimens have rare tumor cell involvement of PB and BM. Despite effective PBPC priming with cyclophosphamide and GM-CSF, clonogenic breast cancer cells were not found in the PBPC collection performed on day 15.

Bone marrow involvement in anaplastic large cell lymphoma. Immunohistochemical detection of minimal disease and its prognostic significance.

Bone marrow involvement by anaplastic large cell anaplastic large cell (ALC) lymphoma can be difficult to detect on routine morphologic examination alone. In a series of 42 patients with ALC lymphoma, the authors analyzed: (1) the usefulness of a limited panel of monoclonal antibodies directed against CD30 (Ber-H2, HRS4) and epithelial marrow involvement on routinely processed biopsy specimens; and (2) the prognostic significance of bone marrow involvement as detected on both morphologic and immunohistochemical grounds. On conventional examination, 17% of the patients were found to have bone marrow involvement at diagnosis. However, after immunohistochemical analysis, occult malignant cells were detected in 23% of the patients with negative bone marrow biopsy on routine histology. The low percentage of positive cases on routine morphologic examination compared to immunohistochemical examination was related to: (1) the scarcity of neoplastic cells which were scattered among hematopoietic cells; (2) the difficulty of distinguishing malignant cells from immature hematopoietic elements; and (3) the absence of alteration of the reticulin network. The authors observed a significant association between marrow infiltration and the presence of hematologic abnormalities (mostly anemia or cytopenias) at diagnosis, both in children and adult patients. More importantly, a significant lower survival was seen in patients with bone marrow involvement compared to those without bone marrow involvement. Immunohistochemistry with anti-CD30 and anti-EMA antibodies should be performed systematically in bone marrow biopsies from patients with ALC lymphoma to reliably identify the presence of bone marrow involvement that appears to carry a poor prognosis.

Sensitive detection of occult breast cancer by the reverse-transcriptase polymerase chain reaction.

Detection of occult carcinoma in patients with breast cancer may aid the establishment of prognosis and development of new therapeutic approaches. To improve on existing methods of detection, we have developed a reverse-transcriptase polymerase chain reaction (RT-PCR) assay for keratin 19 (K19) transcripts to identify mammary carcinoma cells in the peripheral blood and bone marrow of patients with breast cancer. Peripheral-blood or bone marrow samples obtained from 34 patients with stages I to IV breast cancer and 39 control subjects without breast cancer were screened for K19 mRNA by nested primer PCR. In reconstitution experiments, K19 RT-PCR reliably detected 10 mammary carcinoma cells in 1 million normal peripheral-blood mononuclear (PBMN) cells. Four of 19 patients with stage IV breast cancer had detectable K19 transcript in peripheral blood. Five of six patients with histologically negative bone marrow biopsies following preablative chemotherapy and before autologous bone marrow transplant (BMT) were positive by this assay. Stem-cell apheresis harvests obtained from one of these patients and three additional patients immediately before BMT were all K19-negative. K19 RT-PCR analysis of CSF from a breast cancer patient with known carcinomatous meningitis was also positive. Thirty-eight of 39 non-breast cancer patients had negative K19 RT-PCR assays. The one exception was a patient with chronic myelogenous leukemia. RT-PCR of K19 is a sensitive, specific, and rapid method for detection of occult mammary carcinoma cells in the peripheral blood and bone marrow of patients with breast cancer. The presence of residual breast cancer cells in histologically normal bone marrow aspirates but not in stem-cell apheresis harvests is a frequent finding. This assay may be useful in diagnosing metastatic disease, as well as in monitoring the effectiveness of systemic therapy.

Methods and prognostic value of bone marrow examination in small cell carcinoma of the lung

The technique and predictive value for survival of initial and restaging bone marrow examinations in small cell carcinoma (SCC) of the lung were evaluated by 76 examinations of 72 patients. In 76 examinations, only 2 (2.6%) of the bilateral iliac crest bone marrow examinations revealed tumor cells unilaterally and these two were restaging examinations. If SCC was found in the marrow, bone marrow biopsy was always positive. In no instance was an aspirate positive with a negative bone marrow biopsy. Thus a unilateral bone marrow biopsy is an adequate technique for the initial staging of the bone marrow in SCC of the lung. Survival of patients with or without positive initial bone marrow examinations was not significantly different.

Leukocyte Glucocerebrosidase Deficiency Diagnostic in Adult Gaucher's Disease with Negative Bone Marrow Biopsy. Some Properties of the Enzyme in Leukocytes and Spleen

Abstract. A sixty‐one year‐old man with Gaucher's disease is described. The disease was manifested by splenomegaly, hypersplenism and elevations of serum acid phosphatase and immunoglobulin but no bone lesions were roentgenologically demonstrable and bone marrow biopsy failed to reveal Gaucher cells. The diagnosis was established prior to splenectomy by the finding of decreased β‐D‐glucoside glucohydrolase (β‐D‐GGH) activity in his peripheral leukocytes. Examination of the surgically removed spleen revealed Gaucher cells, a large excess of glucocerebroside and decreased β‐D‐GGH activity. Splenectomy was followed by normalization of haemoglobin, white cell and platelet counts and of the serum acid phosphatase and immunoglobulin levels. The patient's leukocyte β‐D‐GGH activity showed an optimum pH similar to that of normal leukocyte enzyme, about 5.4, using both glucocerebroside (Glc‐Cer) and 4‐methylumbelliferyl‐β‐D‐glucopyranoside (MU‐Glc) as substrate. The patient's spleen β‐D‐GGH activity showed a pH optimum of about 4.5, which differed slightly from that of normal spleen enzyme. The Km values of β‐D‐GGH in the patient's leukocytes for Glc‐Cer and MU‐Glc were 1.35 × 10−4 M and 3.6 × 10−3 M, respectively, i.e. in the normal range. The patient's splenic tissue Km values were for Glc‐Cer and MU‐Glc 0.52 × 10−4 M and 5.8 × 10−3 M, respectively, as compared to 0.30 × 10−4 M and 5.0 × 10−3 M in a normal control.