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  246 Correspondence REFERENCES zyxwvutsrq lvarex-Sala, J.L., Villegas. zyxwvutsr . Alarccin. C. zyxwvutsrq   Espinos. D. (1983) Intraerythrocytic adaptation to anaemia in thalassaemia. zyxwvutsr uuvelle Revue Frunpise d Hemuiulugiu, 25, 267-2658. Fessas. Ph. Tassiopoulos, Th. (1983) On the 'anaemia' of heterozygous thalassaemia and on the possible relation zyxwvuts f micro- cytosis to haemoglobin concentration. Biomedica Biuchimica Acta. Fiorelli, C., Gerli. G.C.. Bernasconi. C.. Bianchi, C. zyxwvuts : Matuonto, V. 1 97 zyxwvutsrq   L'afinita dell'emoglobina per I'ossigeno in sindromi talasse- niiche: Interaxione tra 2,3-difosfoglicerato ed emoglobina fetale. Atti Vu Congressu Sulk Micrucitemie, pp. 145-1 54. Edit. Inst. Ital. di Medicina Sociale. de Furia. F.G.. Miller, D.R. Canale, V.C. (1974) Red blood cell metabolism and function in transfused P-thalassemia. Annals ufthe New York Academy of Sciences, 232, 323-332. Pearson. HA.. Motoyama. E., Genel. M.. Kramer. M. Zigas, C.J. 1 977) Intraerythrocytic adaptation (2,3-DPG,P50) in thalasse- mia minor. Blood, 49, 463465. 42,258-262. Ricci. G.. Castaldi. G., Zavagli. 2.. Lupi, G., Turati, A. Rezzi, T. (1982) Red cell 2.3-diphosphoglycerate contents and oxygen affinity in heterozygous beta-thalassaemia. Acta Haemato~ogicu. Tassiopoulos, Th.. Kaltsoya-Tassiopoulos. A.. Alchanati, N.. Rom- bos, J., Rournaras. N. Fessas, Ph. (1982) Anemie, 2,3-DPG et oxygenation tissulaire chez les hetkozygotes de P-thalassemie. Nuuvelle Revue Franpise d Himatulogir, 24, 359-362. Tassiopoulos, Th., Fessas, Ph., Pangalis, G., Andreopoulos. A. Loukopoulos, D. (1983) Volume des erythrocytes et concentration en 2.3-DPG. Etude sur le modkle de la polyglobulie primitivc. Nouvelle Revue Frunquise d Himatologie, 25, 263-266. Tassiopoulos, Th., Stamatelos, G., Filippidou, E., Filippidis, F., Laoutaris. N. Fessas, Ph. (1987) The anemia of childhood revisited. Blut 54, 147-1 52. Weatherall, D.J. Clegg, J.B. (198 1) The Thulassuemiu Syndromes, 3rd edn. p. 240. Blackwell Scientific Publications, Oxford. 68, 63-64. AGGRESSIVE CHEMOTHERAPY IN THE TREATMENT OF SUBACUTE MYELOMONOCYTIC TXUKAEMIA WITH SKIN INFILTRATION In a recent paper Fenaux et al (1987) reported 60 cases of chronic CMML) and subacute SMML) myelomonocytic leukaemia. Media survival of the CMML subjects was 49 months but for the SMML subjects was 8.5 months. At diagnosis the mean percentage of blast cells in the marrow was 6.8 in CMML and 15.5 in SMML. The mean haemoglobin levels were 10.6 g/dl in CMML and zyxwvut  0 g/dl in SMML arid the mean blood monocytoid cells were 3.6 x 10y/l in CMML and 7.6 x 1OY/1 in SMML. Duguin et al (1983) reported four cases of CMML who during the course of the disease developed skin infiltration by monocytoid cells. At the appearance of skin lesions the disease evolved rapidly and all Table I. Clinical and laboratory features at the onset of leukaemia Peripheral blood Hb (g/W WBC (x 1OY/1) Monocytoid cells ( ) Blasts ( ) Platelets ( x loy/l Bone marrow Blasts ( ) Monocytoid cclls ( ) Hepatomegaly Splenomegaly Lymphadenopathy Run S.I. units) Creatinine (S.I. units) Case 1 Case Case 3 8.9 59.9 67 11 112 30 50 2 cm 1 cm 13.209 25752 6.6 17.2 45 25 90 35 27 2 cm 16.065 256.36 6.5 65.4 7 0 10 140 40 40 12.852 229.84 Fig 1. Skin biopsy (case 1) (haematoxylin and eosin x 200).  Correspondence 24 7 aggressive chemotherapy. The results obtained by these authors are disappointing. Our patients had all the bad prognostic signs reported by Fenaux, furthermore they presented skin and, presumably, kidney leukaemic involve- ment. The aggressive treatment we have given caused not only the reduction of the WBC count but also the improve- ment of the other haematological parameters and the disappearance of skin and renal lesions, so that the CK was achieved in a few weeks. Even though we have treated only three patients the results we have obtained seem to be very promising and we suggest that this protocol might be used in all patients affected by zyxw MMT, with skin involvement. patients died within a short time. Treatment with steroids alkylating agents or with vincristine and bleomycin low- ered the peripheral white blood cell (WBC) count but had no effect on the skin lesions. For these reasons Duguin concluded that the appearance of skin lesions in CMML was a grim prognostic sign. Over the last years we have observed three patients, aged 63-6h. withSMMLasdefined byFenauxetal(l987). Clinical and laboratory findings of the patients are summarized in Table I. All patients developed skin eritaematosus papular lesions at the onset of haematological disease. Biopsies showed skin infiltration by monocytoid cells (Pig 1). The subjects also presented with renal failure. They were started on aggressive induction chemotherapy according to the following protocol: daunoblastin 60 mg/m2 i.v. day 1; bleomycin 15 mg i.v. days 1 and 5; aracytin 100 mg/mL .v. days 1-5; etoposide 100 mg/m2 i.v. days 1-5. Complete remission CK) was obtained after the first chemotherapeutic cycle in all patients and the skin lesions disappeared and renal function was restored. Afterwards a consolidation therapy consisted of two courses of the same treatment, every zyxwv   weeks. and maintenance therapy was a sequence of three courses of TRAP combination and three courses of POMP combination, according to Spiers’ protocol (Spiers zyxwvut t al, 1 zyxwvutsrqp   77), and three courses of etoposide 1 00 mg/mL i.v. days 1-3) plus aracytin (150 mgjm2/12 h S.C. days 1-3) was administered. The first two patients relapsed after 18 and 9 months and died within a short time, surviving 20 and 12 months. The last patient is still alive in CR after zyxwvuts   months. Both Duguin and Fenaux treated their patients with a non- RING NEUTROPHILS IN MEGALOBLASTIC ANAEMIA King ncutrophils occur in rodents and other animals but are infrequently seen in man. Recent reports have described ring neutrophils in the peripheral blood of patients with myelodys- plastic disorders, chronic granulocytic leukaemia, and infec- tions (Langenhuijsen, 1984; Peichev. 1986). King cells were also seen in two of 20 ‘healthy controls’ (Langcnhuijsen, 1984). A patient presenting to this laboratory with megaloblastic anaemia due to folate deficiency was noted to have occasio- nal ring neutrophils in peripheral blood and bone marrow smears. A subsequent review of 20 cases of rnegaloblastic anaemia diagnosed on bone marrow aspirate revealed occasional (less than l x) ing neutrophils in the marrows of eight. None had ring cells in the peripheral blood. The patients rrpresented a heterogeneous group with vitamin Blr or folic acid deficiency and none had evidence of haematolo- gical malignancy. King neutrophils, or ‘doughnut cells’, were reported in lnstituto zyxwv i Semeioficu Medica Universita Cattoloca drd KOBERTO MARRA Sacro Cuorr Roma. ltaiia LIVIO PACANO SLKGIO TORTI SALVATORE AOLFTTI GIITSEPPE EONE REFERENCES Duguin. J.K.M.. Mackie. M.J. &McVerry. B.A. (1983) kin infiltration associated with chronic myelomonocytic leukaemia. British lour nal of Huemutology, 53, 257-254. Fenaux. P., Jounet, .P., Zandecki. M.. Lai. J.L., Simon, L.. Pollet. J.P. Hauters, F. (1987) Chronic and subacute myelomonocytic leuke- mi in the adult: a report of 60 cases with special references to prognostic factors. British Journal of Hnemntology. 65, 101 1 06. Spiers. A.S.D., Goldman, J.M., Catowsky, D., Costello. C.. Galton, D.A.G. &Pitcher. C.S. (19773 Prolonged remission maintenance in acute myeloid leukemia. British Medical Journal, ii, 544-547. megaloblastic anaemia in 1936 by 0 P. Jones, but seem recently to have been overlooked. They are uncommon but easy to over-identify, and must be distinguished from giant metamyelocytes with overlapping arms (Fig 1 ). Although ring cells may have a significant association with chronic granulocytic leukaemia (Langenhuijsen, 1984), they occur occasionally in a variety of conditions. Their incidence in the general population is unknown and their significance in disease states therefore remains obscure. Department of Haematoiogy. A4anchester Royal Infirmary, Oxford Road. Munchester M13 9WL A. CRAIG
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