749

the auricle and that an absence or dysfunction of thismuscle allows the auricle to protrude. It follows that theprotruding auricle should be interpreted as a sign of amuscular or neurological deficiency of the posterior aur-icular muscle rather than as a sign of dysmorphogenesisof the auricular cartilage. Thus a protruding auricle canbe expected in patients with muscular’disorders such asmyotonic dystrophy,4 and there is an obvious relation ofprotruding auricles with the Moebius anomalad,4 inwhich there is congenital seventh nerve paralysis, sinceit is the seventh nerve which innervates the posteriorauricular muscle. The absence of the posterior auricularmuscle in two patients with protruding auricles andsevere defects of brain development (anencephaly andholoprosencephaly) should not necessarily be taken asevidence of a primary muscle deficiency, since a defectof the functional innervation of a muscle early in its de-velopment will usually result in hypoplasia, or evenabsence, of the non-innervated muscle.6 We favour a pri-mary neurological deficiency as the cause of the absenceof the posterior auricular muscle in our patients withsevere defects of early brain development and protrud-ing auricles. Protruding auricles are associated with anumber of disorders in which multiple defects includecentral nervous-system dysfunction (see accompanyingtable). The list includes disorders in which the clinical

DISORDERS IN WHICH A PROTRUDING AURICLE MAY BE A FEATURE

*++= frequent, 20% or more; += occasional, less than 20%.

features do not readily suggest a neural or muscularbasis for the protruding auricle, but protruding auriclesmay be present in an otherwise normal individual andtheir familial occurrence has been reported. 7A protruding auricle is like ptosis of the eyelid, which

may be due to a muscular or a neurological deficiencyof the levator palpebrae superioris muscle, may occur byitself or as part of a generalised muscular disorder, ormay be a consequence of brain dysfunction. A protrud-ing auricle and ptosis of the eyelid may be present in thesame patient. In myotonic dystrophy8 both signs relateto muscle dysfunction. However, whether protrudingauricles and/or the ptosis of the eyelids are due primar-ily to muscular or to neurological abnormalities remains

Fig. 4—Girt with XO Turner syndrome, protruding auricles, andptosis of the left eyelid.Courtesy of Dr Judith G. Hall, Division of Medical Genetics, University of

Washington School of Medicine.

uncertain in disorders such as the XO Turner syndrome(fig. 4).

Defects of development and/or function of the othertwo extrinsic auricular muscles and of the six intrinsicauricular muscles also need to be studied in relation toother defects of the auricle.

We thank Dr Thomas H. Shepard, of the Central Laboratory forHuman Embryology, for the fetal material; and the department ofmedical photography and the nursing staff of the University Hospitalnewborn nursery, Mrs Lyle Harrah (research librarian), and Ms JaneFowler (secretary) for their help. The work was supported by: the U.S.Bureau of Community Health Services, Health Services Administra-tion, Public Health Service, the Department of Health, Education andWelfare, and the National Institutes of Health; and by Yoshida’sScience and Technology Foundation, Japan.

Requests for reprints should be addressed to D. W. S., Departmentof Pediatrics, RD-20, University of Washington School of Medicine,Seattle, Washington 98195.

REFERENCES

1. Thomson, D’Arcy. On Growth and Form. Cambridge, 1942.2. Moss, M. L. Birth Defects orig. Article Ser. 1975, 11, 283.3. Seiler, R. Gegenbaurs morphol. Jahrb. (Leipzig) 1974, 120, 78.4. Smith, D. W. in Recognizable Patterns of Human Malformation; p. 485,

Philadelphia, 1976.5. Ek, J. I. Acta pædiat. scand. 1958, 47, 302.6. Eastlick, H. L. J. exp. Zool. 1973, 93, 27.7. Becker, O. J. Archs Otolar. 1949, 50, 541.8. Dodge, P. R., Gamstop, I., Byers, R. K., Russell, P. Pediatrics, 1965, 35, 3.

ACID-PHOSPHATASE REACTION IN ACUTELYMPHOBLASTIC LEUKÆMIA

D. CATOVSKYM. F. GREAVES

C. PAIN

M. CHERCHI

G. JANOSSYH. E. M. KAY

M.R.C. Leukæmia Unit, Royal Postgraduate Medical School,London W12; Membrane Immunology Laboratory, ImperialCancer Research Fund, London WC2; and M.R.C. Leukæmia

Trials Office, Royal Marsden Hospital, London SW3

Summary The diagnostic value of the acid-phos-phatase reaction was assessed double-

blind in 148 cases of acute lymphoblastic leukæmia

(A.L.L.) classified by surface-membrane markers andentered into the M.R.C. U.K. A.L.L. trials. 90% of casesof T-A.L.L. showed a positive reaction in the majority ofblast cells, while only 2% of common-A.L.L. and 10% of

750

null-A.L.L. were positive. This cytochemical reaction dis-tinguishes the more aggressive form of A.L.L. and mayaid the choice of therapy.

Introduction

BLAST cells in acute lymphoblastic leukaemia (A.L.L.)carry several combinations of cell surface markersl-4which allow the division of A.L.L. cases into four distinct

subgroups.2 In the T-A.L.L. and B-A.L.L. subgroups thelymphoblasts have the surface markers of T and B lym-phocytes, respectively; non-T, non-B lymphoblastseither react with a specific anti-A.L.L. serum (common-A.L.L. subgroup) or they do not (null-A.L.L. subgroup).T-A.L.L. has the worst prognosis, 1,3,4-6 Early work sug-gested that in T-A.L.L. the majority of blast cells fre-quently had a strong acid-phosphatase reaction7,8 whichmight provide a useful, independent, non-immunologicalmeans of diagnosis. The M.R.C. United Kingdom A.L.L.(U.K.A.L.L.) trials have provided the opportunity to test,double-blind, the diagnostic value of this cytochemicalreaction in a large series.

Materials and Methods

Patient SamplesPretreatment samples of bone-marrow and/or blood from

148 patients with A.L.L. were collected by participants in theU.K.A.L.L. trials. Freshly made, unfixed films were sent to D.C.and samples of the same material in anticoagulant to M.F.G.

Immunological Tests

Viable cells were separated from samples of marrow and/orblood by centrifugation through ’Ficoll-Triosil’ and tested witha panel of membrane markers2.9-the binding of sheep F(ab’)2anti-human Ig serum, rabbit anti-A.L.L. serum, in some casesrabbit anti-p28,33 (anti-Ia) serum and rabbit anti-human T-cell serum, and sheep-erythrocyte (E) rosette-formation. Theanti-human Ig serum was fluoresceinated; the binding of theother antisera was detected with fluorescein-labelled goatanti-rabbit Ig antibodies. A Zeiss photomicroscope with inci-dent illumination was used.

CytochemistryThe acid-phosphatase reaction of Goldberg and Barka 10 was

assessed in slides reaching the laboratory not later than 4weeks after they were made. Romanowsky stained films werelooked at in all cases, and in most the myeloperoxidase reac-tion was also investigated. As a result the diagnosis waschanged to acute myeloid leukaemia in 5 cases which wereexcluded from the study.

Cases were initially scored as acid-phosphatase positivewhen >65% of blasts showed a characteristic strong reaction,usually localised to the area of cytoplasm corresponding to theGolgi apparatus,’ and negative when the blast cells were nega-tive or up to 30% of them showed only a weak or moderatereaction.

5 cases showed a moderately strong reaction in 40%-50% ofcells, outside the limits of the groups described above, but theywere included in the positive group in the results.

Results

Lymphoblasts from the A.L.L patients were subdi-vided into four groups using the panel of membranemarkers (table i). 6 additional caes had an intermediatemembrane phenotype. Only 2 of 97 cases of commonA.L.L. were acid-phosphatase positive; the rest were

negative. Most cases of null-A.L.L. and both cases of

TABLE I-RESULTS OF THE ACID-PHOSPHATASE REACTION IN

A.L.L.

*T=Anti-T-cell serum; E=Sheep-erythrocyte rosette-formation;Ia=Anti-p28,33 serum; A.L.L.=anti-A.L.L. serum; SmIg=Anti-humanIg serum.tSignificantly different from T-A.L.L. (r<0001, xz test).

B-A.L.L. were negative. In contrast, 90% of cases ofT-A.L.L. were positive. The difference between T-A.L.L.and the common and null subgroups was significant(P<O .001, X2 test). In 15 of the 18 cases of positive-acid-phosphatase T-A.L.L. the reaction was found in mostblast cells and in the other 3 it was found in 50% of thecells.A group of 6 A.L.L. cases showed intermediate results

with the various surface markers (table n). All of them

TABLE II-INTERMEDIATE TYPE OF A.L.L.

&plusmn;=very weak staining compared with typical common-A.L.L.;..= notdone.

showed some staining with the anti-A.L.L. serum andwere positive with one or both of the T-lymphocytemarkers. The acid-phosphatase reaction was negative in5 and positive in 1 case. 3 patients (nos. 2, 5, and 6) hadan anterior mediastinal mass.

18 of an additional 120 A.L.L. cases in which surfacemarkers were not studied were acid-phosphatase posi-tive. The clinical features in this group were similar tothose of the acid-phosphatase-positive T-A.L.L. cases-boys predominated (M : F ratio 2.2 : 1), there was ahigh leucocyte count at presentation, and frequently ananterior mediastinal mass. These features are character-istic ofT -A.L.L.l.3-6

Discussion

This study shows that the acid-phosphatase reactioncorrelates well with the subtypes of A.L.L. defined bymembrane phenotype. Only 2% of cases of common-A.L.L. (anti-A.L.L.-serum reactive) and 10% of cases ofnull-A.L.L. showed a positive reaction, while 90% ofT-A.L.L. were positive. This finding confirms our pre-vious small series4 and those of others.3,6,8 The close cor-relation between the specific pattern of enzyme activityand T-A.L.L. shows that the cytochemical reaction canbe useful for the diagnosis of T-A.L.L. Although in mostcases the cytochemical reaction was seen in more than80% of T-lymphoblasts, clearly satisfying the first criter-ion of positivity, in some a lower percentage of cells

751

showed the reaction. 50% of acid-phosphatase-positivecells may still be consistent with a diagnosis of T-A.L.L.Rare cases of common-A.L.L. and null-A.L.L. also

showed a strong acid-phosphatase reaction. The 6 cases(table 11), 3 of them with a mediastinal mass, in whichthe membrane phenotype was intermediate suggest thatthe different forms of A.L.L. may represent the prolifer-ation of cells arrested at different stages of differentia-tion and maturation from a prelymphoid precursor orstem cell to a thymus-derived cell similar to that whichproliferates in T-A.L.L.

Null-A.L.L. is a less well defined category which mayinclude both prelymphoid stem cells and leukaemias ofthe T-cell lineage. This is supported by the high inci-dence of mediastinal mass (4 of 10 A.L.L. cases) reportedby Chessells et al. and may account for the strong acid-phosphatase reaction in the only case with a mediastinalmass tested in that study. Since not all their null A.L.L.cases were tested with anti-T and anti-Ia sera it is pos-sible that some belong more correctly in the interme-diate group with an incomplete T-cell phenotype. Thisis supported by Thiel et al.11 who have shown a positiveacid-phosphatase reaction in 7 of 9 cases with an E-rosette-negative T-A.L.L. surface phenotype. The localised acid-phosphatase reaction in fetal thymocytes suggests thatthis marker is acquired early in the ontogeny of Tlymphocytes. 12

T-A.L.L. accounts for 15-25% of childhood A.L.L. andthere is increasing evidence that it has a worse prognosisthan common-A.L.L.l,3-6 As shown in this study, itsrecognition is helped by a positive acid-phosphatasereaction. The addition of this cytochemical reaction tothe battery of surface markers used to classify A.L.L.may also help to define cases which, on clinical or im-munological grounds, are closer to T-A.L.L. than to com-mon-A.L.L. The value of such a distinction will dependon whether such cases respond clinically as T-A.L.L. oras common-A.L.L.6 and may aid a more rational alloca-tion of cases in therapeutic trials. More intensive ther-apy could then be tried in T-A.L.L., without the risk oftoxicity for those with less aggressive forms of A.L.L.We thank the members of the M.R.C. Working Party on Leukaemia

in Childhood for supplying the material with which we carried out ourstudies: Prof. J. H. Hutchison (chairman); Prof. R. M. Hardisty (sec-retary) ; Dr P. Barbor; Dr N. D. Barnes; Dr J. M. Bridges; Dr J. M.Chessells; Dr P. F. Deasy; Dr P. Emerson; Dr D. I. K. Evans; DrN. E. M. Harker; Dr E. M. Innes; Dr E. Jones; Dr J. S. Lilleyman;Dr J. Mann; Dr J. Martin; Dr T. J. McElwain; Dr M. Mott; Dr M.Radford; Dr E. N. Thompson; Dr M. L. N. Willoughby.

Requests for reprints should be addressed to D. C., M.R.C. Leukae-mia Unit, Royal Postgraduate Medical School, London W12 OHS.

REFERENCES

1. Sen, L., Borella, L. New Engl. J. Med. 1975, 292, 828.2. Greaves, M. F. Prog. H&aelig;mat. 1975, 9, 255.3. Brouet, J. C., Valensi, F., Daniel, M.-T., Flandrin, G., Preud’homme, J. L.,

Seligmann, M. Br. J. H&aelig;mat. 1976, 33, 319.4. Catovsky, D. in Recent Advances in H&aelig;matology, (edited by A. V. Hoff-

brand, M. C. Brain, J. Hirsh); p. 201. Edinburgh, 1977.5. Belpomme, D., Math&eacute;, G., Davies, A. J. S. Lancet, 1977, i, 555.6. Chessells, J. M., Hardisty, R. M., Rapson, N. T., Greaves, M. F. ibid. ii,

1307.7. Catovsky, D., Galetto, J., Okos, A., Miliani, E., Galton, D. A. G. J. clin.

Path. 1974, 27, 767.8. Stein, H., Peterson, N., Gaedicke, G., Lennert, K., Landbeck, G. Int. J.

Cancer, 1976, 17, 292.9. Greaves, M. F. et al. in H&aelig;matology and Blood Transfusion. Vol. xx (edited

by S. Thierfelder, H. Rodt and E. Thiel); p. 61. Berlin, 1977.10. Goldberg, A. F., Barka, T. Nature, 1962, 195, 297.11. Thiel, E., Rodt, H., Netzel, B., Huhn, D., Wundisch, G. F., Thierfelder, S.

in Abstracts of the 2nd International Symposium on Therapy of AcuteLeuk&aelig;mias; p. 259. Rome, 1977.

12. Stem, H., M&uuml;ller-Hermelink, H. K. Br. J. H&aelig;mat. 1977, 36, 225.

Reviews of Books

THIs book, written by a cardiac surgeon and a group of car-diologists, gives a balanced and reasoned picture of coronary-artery bypass surgery in a clear and concise manner. It con-tains sections which make the book interesting not only for thecardiologist and the surgeon but also for the general practi-tioner, who must consider referring patients for such surgery.The text is comprehensive yet does not exhaust the reader withminutiae. Adequate references are given at the end of eachchapter. A short account of the evolution of coronary-arterysurgery is followed by chapters on the clinical course of pa-tients with coronary-artery disease and the risks and benefitsof such surgery. A rational approach to the preoperative eval-uation is discussed and the indications for coronary angiogra-phy reviewed. There are chapters on operative technique andon the problems encountered by the anaesthetist. Consideringthe impact that coronary-artery bypass surgery has on medi-cine and the economic resources of the community, an impor-tant chapter for health-care planning is that on the economicsof such surgery. This book can be recommended as one of thebest up-to-date reviews on this subject.

Principles of Family MedicineROBERT E. RAKEL, M.D. Philadelphia and London: Saunders.1977.Pp.336. ;12.

THE emphasis in this book, by the professor of family prac-tice in the University of Iowa College of Medicine, is almostentirely on psychosocial aspects of practice, family dynamics,and interpersonal relationships (including the doctor-patientrelationship); it also gives details of record-keeping, includingfamily and genetic charting. Social and cultural factors areclassified and categorised in detail. It would be easy to be

flippantly critical of some of the results of such categorisation,for instance that "the number of interpersonal relationships ina family has been depicted mathematically by the formula

x=yy2

where y is the number of persons involved and x the resultingnumber of interpersonal relationships". Try it out on yourfamily and then on the largest family you know (unless theyare one and the same) and see if you feel much the wiser. Onealso questions the value of describing in detail and illustratingcommon nervous habits such as sniffing, rubbing the nose, andclearing the throat as examples of the "respiratory avoidanceresponse". If these aspects are a bit leaden, there is neverthe-less much pertinent observation in the book, particularly in thecentral chapter on the impact of illness on the family and theinfluence of the family upon illness. The main interest of thebook, however, lies in the comparison between primary care inthe U.S.A. and the U.K. There is much in common, but oneof the main differences is in the personnel of the primary-careteam. Comparing the U.S.A. with the U.K., the authorremarks that "organizational efficiency [of the primary-careteam] has not progressed this far in the United States" and "aunified system of community health services is sorely needed inthis country". Conversely, there are aspects of family practicein the U.S.A. from which U.K. doctors can learn, and we canenvy the American family practitioner the time he can allocateto each patient and to record-keeping. The end of each chapterhas excellent references with notes by the author. There arenumerous diagrams and tables in this well printed and pro-duced book. Those interested in the development of primarycare on both sides of the Atlantic, especially the psychosocialaspects, will find this book a valuable source of information onthe present state of family medicine in the U.S.A.