The traditional methods to detect anti-platelet antibodies were diminished in value because of low sensitivity and reproducibility after the introduction of the measurement of platelet-associated IgG for immune thrombocytopenias. In this literature, the methodological problems of a number of PAIgG assays were commented upon. The measurement of PAIgG is very useful for the diagnosis and follow-up studies of immune thrombocytopenic disorders, although this assay is not always specific for idiopathic thrombocytopenic purpura. The introduction of PAIgG assay in clinical medicine can produce invaluable information for clarifying the cause of thrombocytopenias, including unknown thrombocytopenias.

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Monitoring the 48-hour serum methotrexate (MTX) concentration is essential for predicting and avoiding the fatal clinical toxicity after the high dose infusion. The enzyme, dihydrofolate reductase (DHFR) inhibition assay (EIA) is the most widely used method to determine the serum MTX level due to its simplicity. However, this method is affected by other substances in serum which inhibit the DHFR. In this paper, the influence of sulfamethoxazole (SMX) and trimethoprim (TMP) on the EIA was investigated. Two patients with non-Hodgkin's lymphoma who received MTX (1400 and 3000 mg/m²), SMX (40 mg/kg), and TMP (8 mg/kg) concomitantly were investigated. MTX was intravenously infused for 24 hour with citrovorum factor rescue. The serum MTX concentrations at 48 hour measured by EIA were 1.3×10^-6M in Case 1, and 7.8 × 10^-7 M in Case 2, which were higher than the mean +2SD of that observed at our institute. The same sample reanalyzed by HPLC revealed MTX 4.5 × 10^-7 M, 7-OH-MTX 6.0 × 10^-6 M, SMX 3.5 × 10^-5 M, TMP 7.0 × 10^-6 M in Case 1, and MTX 3.5 × 10^-7 M, 7-OH-MTX 6.1 × 10^-7 M, SMX 2.5 × 10^-5 M, TMP 3.5 × 10^-6 M in Case 2. The in vitro DHFR inhibitory activity of TMP was 14.3% of that imposed by MTX. The apparent higher result measured by EIA was considered to be due to the cross-inhibition of DHFR by TMP. For precise monitoring of the serum MTX concentrations it is important to avoid taking the TMP preparation during treatment of MTX.

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Cytosine arabinoside (Ara-C) is the major drug in the treatment of acute nonlymphocytic leukemia, but human leukemic cells are heterogenous with respect to their response to the drug. We measured in vitro suppression by Ara-C of ³H-thymidine incorporation into leikemic cells which were obtained from children with relapsed or induction-failure acute leukemia. Leukemic cells (1-2 × 10⁵) suspended in RPMI 1640 with 25 mm Hepes buffer and 30% patient's serum were placed in wells of microtiter plates with Ara-C at final concentration of 30 ng/ml. After 5 and 24 hours of incubation, 0.2 μCi of ³H-thymidine were added to each well and, after a 3-hour labelling period, counts of ³H-thymidine uptake were made on aliquots of cells drawn from the well with an automated cell harvester. In the leukemic cells of 3 children who achieved complete remission by low dose Ara-C therapy, the degree of suppression of ³H-thymidine incorporation at 5 hours after incubation with Ara-C remained until 24 hours. In contrast, the patients whose cells showed the recovery ³H -thymidine uptake at 24 hours, though revealing the the suppression at 5 hours, did not achieve remission.

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Total decontamination was used for 22 children who underwent bone marrow transplantation. In order to give oral antimicrobial drugs completely, nasogastric tubes were inserted in stomach and remained there for approximately 1 month. There was no sign of mechanical failures, such as mucosal bleeding or perforation. Routine microbiological examination revealed that Pseudomonas spp and Candida spp were isolated from throat, frequently accompanied by fever. Five patients (23%) suffered oral infections by Pseudomonas aeruginosa or Staphylococcus aureus. Therefore, more intensive oral decontamination should be applied when drugs are given through nasogastric tubes.

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Whether childhood 7 monosomy syndrome and juvenile chronic myelogenous leukemia (JCML) are the same disease or not has continued to be a subject of controversy. A clinical study of 4 patients with childhood 7 monosomy syndrome and 6 patients with JCML was described. The two diseases were considered to be different disease entity because of the different findings in sex distribution, the platelet count, neutrophil alkaline phosphatase score, HbF, serum lysozyme and colony-forming capacity. Previously some patients with 7 monosomy syndrome were possibly diagnosed as having J CML without chromosome analysis. High resolution chromosome analysis and molecular genetics may shed some light on the mechanism of these diseases.

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Hemolytic anemia was induced in rats by injecting acetylphenylhydradine (APH) intraperitoneally. Various erythropoietic parameters were measured daily from the beginning of hemolysis to the recovery from anemia. From the result, the sequence of erythropoiesis was discussed. Erythrocyte glutamic oxaloacetic transaminase (E-GOT) activities were also assayed in patients with iron deficiency anemia, hemolytic anemia, aplastic anemia, and acute leukemia. E-GOT activities were elevated in a condition with increased production of erythrocytes.

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We studied the recovery of in peripheral blood cells after allogeneic bone marrow transplantation (allo-BMT) and autologous bone marrow transplantation (auto-BMT). Twelve patients were studied, six allo-BMT and six auto-BMT. The basic diseases in the allo-BMT were ALL (4 cases), AML (1 case), and NHL (1 case) those in the auto-BMT were ALL (1 case), NHL (3 cases), and yolk sac tumor (2 cases). All twelve patients were treated with intensive chemotherapy and 12 Gy total body irradiation followed by BMT. As a result we found that the recovery of lymphocyte count in the auto-BMT was faster than in the allo-BMT. However, the recovery of neutrophil count and platelet count in the auto-BMT was slower than that of allo-BMT. Recovery of reticulocyte count and monocyte count did not show any significant difference between the two groups. Our results suggest that the standard methods of cryopreservation of bone marrow may be suboptimal.

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The Bone Marrow Transplantation Committee of the Society has conducted an annual registry of bone marrow transplantation in children in Japan since 1983. As of June 30, 1987, 326 patients had received transplants and were registered from 45 institutes. Bone marrow transplantation was performed in 92 cases of acute lymphoblastic leukemia (37 alive), 64 cases of acute non-lymphocytic leukemia (38 alive), 11 cases of chronic myelocytic leukemia (9 alive), 21 cases of non-Hodgkin's lymphoma (12 alive), 60 cases of malignant solid tumors (30 alive), 45 cases of aplastic anemia (40 alive), 21 cases of severe combined immune deficiency (6 alive), and 12 other cases (10 alive). The details are reported in this paper.

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We have successfully reconstituted a 3-year-old boy with stage IV_A neuroblastoma whose marrow was treated in vitro by monoclonal antibodies/magnetic immunobeads. The induction regimen included cyclophosphamide, vincristine, THP-adriamycin, and cisplatin. After four courses of the induction therapy, the primary tumor (ls-adrenal gland) was completely removed and the unresectable residual mass of lymph node was irradiated with 15 Gy. The tumor tissue had 30 copies of N-myc. Bone marrow cells were harvested, treated in vitro by using magnetic immunobeads method and cryopreserved. After the conditioning regimen with modified VAMP-TBI (teniposide, doxorubicin, L-phenylalanine mustard, cisplatin-total body irradiation) the purged marrow cells were transplanted on July 17th, 1986. He is disease free more than 1 year after transplantation. The intensive chemoradiotherapy and purged autologous marrow transplant, if carried out before development of progressive disease, will improve the outcome of patients with poor prognosis neuroblastoma.

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During the past 23 years (1965-1987), 120 Children with idiopathic thrombocytopenic purpura (ITP) were treated in our hospital. We analyzed clinical features of these patients and evaluated the efficacy of corticosteroid therapy on the course of acute ITP and on the long-term prognosis of chronic ITP. The patients were classified according to three types of ITP as follows : 81 cases of acute ITP, 31 cases of chronic ITP, and 2 cases of recurrent type ITP. Two cases could not be classified because of their early death. No difference was observed in incidence between male and female (62 : 58). Twenty-three patients were younger than one year old, and the number of patients tended to decrease with increasing age. Preceding infection was noted in about a half of all patients, and all cases after acute exanthematous disease were acute type. In cases with acute ITP, there was no significant difference in the duration of thrombocytopenia between the corticosteroid-treated and non-treated groups. However, two cases in the non-treated group died of intacranial bleeding in the early stage. Corticosteroid therapy should be recommended for the cases with severe bleeding tendency. Seventeen of 26 patients with chronic ITP achieved spontaneous remission (platelet counts in excess of 100, 000/mm3) from 8 months to 12 years (mean : 38 months) after diagnosis. Because of the possibility of late spontaneous remission, splenectomy should be indicated for only serious cases. Splenectomy was performed in seven cases. Five of them had sustained remission, and the remaining 2 patients obtained clinical improvement. High dose gammaglobulin therapy was performed in 4 cases and was effective in 3 patients with a rapid increment of the platelet number, but it should be recommended for selected cases.

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Although there is widespread use of 6-mercaptopurine (6-MP) and 6-thioguanine (6-TG) in the treatment of acute leukemia, knowledge of the pharmacological mechanism of these drugs is limited. To clarify the cytotoxic mechanism of 6-MP and 6-TG in ML-1 cells and CCRF-CEM cells, intracellular active metabolites were analyzed with HPLC. Intracellular active metabolites of thiopurines were extracted with TCA and neutralized with freon-alamine and analyzed with Waters' HPLC equipped with SAX-10 anion exchange column. The 6-TG was activated to thioguanine mono-, di-, and triphosphate. The intracellular major metabolite of 6-MP was 6-thioinosine monophosphate. No 6-thioinosine di-and triphosphate were detected in cells even at 6-MP concentration up to 1 × 10^-4 M. We suggested that the cytotoxic mechanism of 6-TG includes inhibition of both purine pathway and DNA synthesis, and that 6-MP inhibits only the purine pathway.

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A multi-institute group retrospective analysis was performed on the efficacy of BH-AC for the treatment of acute leukemia in children. One hundred and thirty-nine children with various types of acute leukemia were treated with regimen including BH-AC; in 69 cases (49.6%), complete remission (CR) was successfully induced. Among them, CR was induced in 36 out of 48 (75.0%) previous untreated patients with ANLL and in 24 out of 58 (42.9%) refractory ALL. We retrospectively compared the treatment results between the regimens with cytosine arabinoside (AraC) and those with BH-AC in the initial remission induction phase of childhood ANLL. Complete remission rates were 22 out of 27 cases (81.5%) in the group of BH-AC.AMVP therapy, and 13 out of 17 cases (70.5%) in the Ara C·AMVP therapy group. Five-year CR rates were 51% in the BH-AC.AMVP therapy group, and 19% in Ara C.AMVP therapy group. Five-year survival rates were 43% and 33%, respectively. There were fewer toxicities in the patients treated with BH-AC·AMVP therapy than in those with Ara C·AMVP therapy. From this study, it is concluded that BH-AC was as effective as Ara C, and it seemed to be the more advantageous drug for the children because of its less severe toxicities.

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Transient erythroblastopenia in childhood (T.E.C.) may occur in association with virus infection, bacterial infection, or drug. Differential diagnosis of T.E.C. from congenital pure red cell anemia is very important, especially for its treatment. A female child's course of T.E.C. and treatment is reported. She was treated twice with blood transfusions and she has been free of anemia since two months after onset.

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A case of juvenile rheumatoid arthritis (JRA) arising after the cessation of the therapy for acute lymphoblastic leukemia (ALL) was reported. A 6-year-old girl was admitted to the hospital because of anorexia, hepatosplenomegaly, lymphadenopathy and severe anemia. The WBC count was 25, 000/mm³ with 92% blasts. Bone marrow examination showed 92.3% blasts which were negative both for peroxidase and PAS. From these data she was diagnosed as having ALL. She was treated with the high-risk ALL protocol 821A from CCLSG. A complete remission was obtained and the schedule of the therapy was completed in April, 1985. She had no joint symptom during the clinical course. In October, 1985, she developed pain and swelling of bilateral foot and knee joints and was admitted to our hospital in December. No evidence of ALL relapse was shown. A definite diagnosis of JRA was obtained by blood examination, arthroscope and synovial biopsy. A test for RA was positive and a high serum level of ANA was demonstrated. The authors are very interested in a possible relationship between ALL and JRA although the precise mechanism (s) remains to be elucidated.

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This infant girl was admitted for anemia and jaundice at 5 months of age. Her clinical symptoms and laboratory findings confirmed the diagnosis of autoimmune hemolytic anemia (AIHA) associated with IgA deficiency. She received transfusions with red cells in addition to corticosteroids therapy. The improvement of anemia was observed 3 weeks after treatment but the direct Coombs test was still positive. After discharge she showed reticulocytosis and anemia at 1 year and 1 year, 5 months of age, which improved with short-period corticosteroid therapy. Thereafter she has had no episode of AIHA relapse. At 3 years of age she began having increased episodes of upper respiratory tract infection and otitis media. Besides IgA deficiency, IgG and IgM level decreased gradually. At 6 years of age agammaglobulinemia (common variable immunodeficiency) developed and then the Coombs test became negative. Pancytopenia also developed. Immunological evaluation suggested T-cell abnormalities. She has received periodically the intravenous immunoglobulin therapy and has markedly decreased incidence of infections. Hematological findings remain pancytopenia. Follow-up of clinical course and further immunological studies are continuing.

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A five-month-old boy with autoimmune hemolytic anemia (AIHA) is reported. The patient visited our hospital because of pale face. The diagnosis of AIHA was made based on severe anemia (hemoglobin 2.6 g/dl), hyperbilirubinemia (total bilirubin 6.2 mg/dl), and positive direct Coombs' test. There was a potent anti-D both in his serum and in an eluate from his red blood cells. At the initiation of therapy, RhD negative packed red cells were transfused, and prednisolone therapy was followed. We tried two courses of pulse infusion of methylprednisolone (mPSL), high-dose intravenous immuno-globulin infusion (IVIgG) and low-dose prednisolone therapy. The patient has been successfully treated by this combination therapy. The anti-D specificity in AIHA is extremely rare, and clinical course was reported to be difficult. The result of our therapy should be encouraging for a treatment of infantile AIHA with a poor prognosis.

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A 13-year-old male was admitted with anemia and mediastinal mass ; 95% T-lymphoblasts were seen in the bone marrow, but none in the peripheral blood. Patient was diagnosed T-cell lymphoma/leukemia syndrome ; complete remission was achieved at the 24th day with multiple drug chemotherapy. At day 52, the initial course of high-dose methotrexate (MTX) therapy was started at the dose of 50 mg/kg with 6 hr continuous infusion. The citrovorum factor (CF) rescue was started at 36 h after initiation of MTX infusion which these refer to 6 h interval with the dose of 12 mg/m² CF rescue. On the next day of the second high-dose MTX infusion at the dose of 100 mg/kg, acute renal failure occurred showing oliguria, hypertension, high serum creatinine level (2.0 mg/dl). Because serum MTX concentration level at 48 h after infusion was high (22×10^-6 mol/l), charcoal hemoperfusion and 160 mg/m²/day CF rescue were given every 6 h. Initial creatinine clearance level was below 10 ml/min/ 1.6 m²; this level gradually recovered to 60 ml/min on the 17th day. Side effects such as mucositis, and bone marrow suppression were moderate. We could not find any causative factors related to the renal failure.

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