bluuebunny/crossref_metadata_2025 huggingface dataset:
Acute Kidney Injury in Patients Receiving Subcutaneous Deferoxamine Therapy.
Authors: Ponnampalam Arjuna , Houston Donald S
Published: April 2020

Iron chelation is an important modality in treating patients with iron overload syndromes to minimize end-organ damage. The greatest experience has been in young patients with thalassemia, but there is growing use of chelation therapy in patients with acquired transfusion-dependent disorders such as myelodysplastic syndrome. Deferoxamine is a clinically proven and effective therapy for long term chelation, but the standard mode of administration by subcutaneous pump-driven infusion is burdensome for patients and leads to poor adherence. Intermittent bolus injection (1g in 10ml of water injected subcutaneously twice daily) has been advocated as an alternative protocol that may facilitate compliance. Acute kidney injury has been described previously in patients receiving high dose intravenous deferoxamine, but not in patients receiving subcutaneous therapy, and nephrotoxicity is not listed as an adverse effect in the product monograph. Here we report a series of three patients who developed acute kidney injury when receiving subcutaneous deferoxamine by intermittent bolus injection.

CASES: All three patients were elderly adults. The first was a 64 year old man who developed iron overload secondary to hemoglobin H disease, the second was a 78 year old woman with transfusion-dependent myelodysplastic syndrome (refractory anemia with ring sideroblasts), and the third was an 83 year old man with transfusion-dependent smoldering multiple myeloma. These patients had preexisting mild renal impairment: the first was a kidney transplant recipient taking cyclosporine, the second had a prior nephrectomy for renal carcinoma, and the third had longstanding renal impairment from renovascular disease. All three patients had resolution of their acute kidney injury on discontinuation of therapy and have had stable creatinine values subsequently. Rechallenge with deferoxamine led again to a reversible rise in creatinine in the first patient. The most striking effect was in the second patient: her creatinine level rose from a baseline of 154μmol/l to 280μmol/l one month after starting deferoxamine, and fell to 138μmol/l two weeks after discontinuing the drug.

DISCUSSION: We conclude that renal dysfunction can be an important side effect of deferoxamine chelation. The toxicity appears to be reversible on discontinuation of therapy. Older patients and patients with pre-existing renal impairment may be more susceptible to this effect, and subcutaneous bolus dosing may increase the risk, possibly due to higher peak drug levels. Careful monitoring of creatinine values and minimization of other nephrotoxic agents is appropriate and prudent when managing iron overload syndromes with deferoxamine chelation therapy.
Bone Marrow Necrosis: Clinical and Pathological Characteristics of 30 Patients
Authors: Sanchez-Guerrero Sergio , Agreda Gladys , Gutiérrez Ruth , Buitrón Nathalie , Montante Daniel , Lome Carmen
Published: April 2020

Background: Bone marrow necrosis (BMN) affects both stromal tissue and hematopoietic precursors and its prevalence ranges from 0.3–37%, being the hematologic malignancies the most frequent cause.

Aim: To describe the clinical and pathological characteristics of 30 patients with BMN diagnosed and treated at our institution.

Methodology: We included all adult patients diagnosed during the last 8 years (2000– 2007) via bone marrow aspiration and biopsy.

Results: Median age was 44 years (range 14–78); 53.3% were females. 42.2% of the patients died within a month mainly due to adult respiratory distress syndrome (ARDS) and septic shock. Just 5 (16.7%) of them are still alive. In all cases, BMN was of coagulative type, and extense in 23 (76.6%) of the patients. The main symptoms were: bone pain (53%), anemia (53%) and fever (50%), whereas the main underlying diseases were: acute lymphoblastic leukemia (ALL) in 26.7%, non-Hodgkin lymphoma (NHL) in 13.3% and multiple myeloma (MM) in 10% of the patients.

Conclusions: BMN is associated to a fatal course and to hematologic malignancies in most of our patients.
Investigation of Epidemiologic Factors in Children with Acute Lymphoblastic Leukemia
Authors: Yilmaz Oznur , Timur Cetin , Yoruk Asim , Erguven Muferet , Aktekin Elif , Kavakli Kaan
Published: April 2020

In this study, we aimed to investigate epidemiologic factors in children with Acute Lymphoblastic leukemia (ALL). The parents of 105 children diagnosed and treated as ALL between the years 1997 –2007 in our Clinic of Pediatric Hematology-Oncology were questioned and results were compared with control group that consisted of 102 healthy children with similar age and gender. The mean age of the patients was 8.57 ± 3.95 years. The mean age at diagnosis was 5.87 ± 3.73 years. There was no significant difference between the groups in terms of type of delivery, birth weight, asphyxia at birth, resuscitation with high-concentration oxygen and ventilatory support (p>0.05). There was also no significant difference between the groups in terms of duration of breast feeding. The rate of exposure to infections prior to diagnosis was higher in control group (p:0.003). Besides that, the rate of going to nursery was also significantly higher in control group (p:0.014). There was no difference between the groups in terms of X-ray exposure (p>0.05). In conclusion over-protection from infectious agents in and delay in meeting with some specific agents seems to increase ALL risk. Infections in early infantile period can be protective against leukemia. There has to be more extended studies on this subject.
GST T1 and GST M1 Polymorphisms Are Associated with the Risk of Acute Myeloid Leukemia
Authors: Kim Hee Nam , Yu Li , Kim Nan Young , Lee Il-Kwon , Kim Yeo-Kyeoung , Yang Deok-Hwan , Lee Je-Jung , Kim Hee-Je , Min Woo- Sung , Park Moo-Rim , Jo Deog-Yeon , Won Jong-Ho , Kwak Jae-Yong , Kim Hyeoung Joon
Published: April 2020

Xenobiotic-metabolizing enzymes influence the susceptibility to malignancies as well as prognosis by causing chemotherapy resistance. We analyzed genetic polymorphisms of glutathione S-transferases T1 and M1 (del GSTT1 and del GSTM1) and NAD(P)H quinone-oxoreductase (NQO1 C609T) to evaluate the association and risk of acute myeloid leukemia (AML). A large-scale population-based, case-control study of 1700 controls and 663 cases was conducted in Chonnam National University Hwasun Hospital, Korea.

GST T1 null genotype was associated with increased risk for AML [odds ratio (OR) = 1.20; 95% confidence interval (CI) = 1.003–1.45, p=0.047]. GST M1 null genotype was highly associated with a decreased risk for AML (OR= 0.38; 95%CI = 0.31–0.46, p< 0.0001). Analysis of the NQO1 C609T polymorphism failed to show an association with AML, although a near significant increase was also found in NQO1 609GG genotype (OR= 1.30; 95%CI = 0.54–4.77, p=0.06)

Our results suggest an association of extensive GST with an increased or decreased risk for AML, possibly by an increase in the metabolic activation of chemical carcinogens or linkage to another cancer-causing gene. Inconsistent result in other studies may be due to geographical differences in the type of environmental carcinogens to which different populations are exposed.
Can Decrease in Smoking Incidence Reduce Leukemia Mortality?
Authors: Varadarajan Ramya , Cummings Michael K , Hyland Andrew J , Wang Eunice S. , Wetzler Meir
Published: April 2020

Smoking is the leading preventable cause of death in the Western world. There is substantial evidence that smokers are approximately 1.5 times more likely to develop acute myeloid leukemia (AML) than non smokers. We were interested to know if there is a relationship between smoking and treatment outcome in AML. We searched the Centers for Disease Control and Prevention (CDC) and Surveillance Epidemiology and End Results (SEER) databases for data about smoking incidence and AML mortality. We collected AML mortality data for the United States (US) from SEER and state leukemia mortality data from CDC. CDC data are lumped for all types of leukemia. Since AML is the most common leukemia, and no significant improvement in AML treatment, as compared to chronic myeloid leukemia, occurred in the last two decades, we used the collective leukemia data. We compared smoking incidence and age-adjusted leukemia mortality between overall US and states with either a high (Alabama, Indiana, Ohio, Oklahoma, Kentucky) or a low (California, Connecticut, New York, Utah, Rhode Island) smoking incidence. SEER data revealed a statistically significant correlation (r=0.88) between smoking incidence and AML mortality for the different US regions (Figure 1). The correlation was significant whether we included a 10-year lag period (r= 0.75) for leukemia mortality or not. The correlation between smoking incidence and mortality rates for individual states was much more variable; data from two representative states, California (CA) with low smoking incidence (r=0.74) and Indiana (IN) with high smoking incidence (r=0.03) are shown (Figure 2). Possible causes for decreased mortality can include less pulmonary infections, less aggressive leukemia [reports of more frequent chromosomal aberrations involving chromosome 5, 7 and 8 in smokers] and better transplant outcome in non-smokers. To date, we did not find any data on association between leukemia incidence and smoking prevalence. These data suggest a possible association between smoking and leukemia mortality, and additional research is needed to determine if smoking cessation can be a tool to decrease leukemia mortality.

Figure 1 Figure 1. Figure 2: Figure 2:.
Antibody- and Cell-Mediated Immune Thrombocytopenia Are Differentially Sensitive to Intravenous Gammaglobulin Therapy
Authors: Chow Leola , Kim Michael , Speck Edwin R. , Aslam Rukhsana , Webster Michelle Lee , Chen Pingguo , Ni Heyu , Freedman John , Semple John W.
Published: April 2020

Immune thrombocytopenic purpura (ITP) is a bleeding disorder characterized by IgG autoantibody-opsonized platelets prematurely being destroyed in the spleen although recent evidence suggests that thrombocytopenia in perhaps as many as 40% of patients with ITP can be mediated by CD8+ T cells. Although several animal models of immune thrombocytopenia have been developed, few are induced by platelet-specific autoimmune mechanisms nor have any demonstrated cell-mediated platelet destruction. We developed a murine model of ITP by first immunizaing GPIIIa (CD61) knockout (KO) mice against wildtype (WT) CD61+ platelet transfusions and subsequently transferring their splenocytes (5×104 cells/transfer) intraperitonealy into irradiated SCID mouse recipients. The SCID mice developed significant bleeding mortality and thrombocytopenia within 2 weeks post-transfer. Lower doses (<104) of immune splenocytes transferred induced thrombocytopenia in the SCID mouse recipients with no mortality. Depletion of lymphocyte subsets in the splenocytes before transfer showed that both CD19+ B cell (antibody)- and CD8+ T cell (cell)-mediated thrombocytopenia existed and that bleeding mortality was particularly associated with antibody-mediated thrombocytopenia. Treatment of the SCID mouse recipients bi-weekly with 2g/kg intravenous gammaglobulins (IVIg) demonstrated that IVIg was beneficial in eliminating bleeding mortality and thrombocytopenia only in the recipients displaying the antibody-mediated form of ITP. Cell-mediated bleeding mortality and thombocytopenia was completely resistant to IVIg therapy. This model suggests a potential reason why some patients with ITP fail IVIg therapy and may aid in the development of new therapeutics for individuals inflicted with cell mediated thrombocytopenia.
Timed Sequential Therapy Induction and Consolidation in Newly Diagnosed AML: Achievement of Leukemia-Free Survival in Patients Using Two Cycles of Therapy Alone
Authors: Mihelic Ronald , LaPorte Justin , Carmichael Charlene , Morris Lawrence E. , Holland H. Kent , Solomon Scott R. , Bashey Asad
Published: April 2020

Long term outcomes for patients with AML are unsatisfactory following induction and consolidation chemotherapy alone except in patients with favorable–risk cytogenetics. The additional administration of the same or different agents starting 8–10 days after start of initial chemotherapy (timed sequential therapy, TST) may enable the killing of leukemic cells synchronized into cell cycling by the initial chemotherapy. However, it is unclear if patients with intermediate and unfavorable cytogenetics achieve improved outcomes using this approach. Sixty-nine unselected patients with AML (42M, 27F; median age = 53, range 16–74; cytogenetic risk group favorable =2, intermediate = 37, unfavorable = 23; 10 with an antecedent hematologic disorder) referred to a tertiary leukemia center received initial chemotherapy with a regimen of cytarabine 667mg/m2/d by 24 hour infusion on d1–3, idarubicin 12mg (age <60) or 8 mg (age >60)/m2/d on d1–3 and etoposide 100mg/m2 on d 8–10. Induction death occurred in 7 patients (10%). Complete remission was achieved following one cycle of induction therapy in 30 patients (43.5%). The corresponding complete response (CR) rates by cytogenetic subgroup were100%, 48.6% and 26% in the favorable, intermediate and unfavorable cytogenetic groups respectively. In patients who achieved CR, median time to ANC > 1000/mm3 and platelets > 100,000/mm3 were 29 d (range 21–76d) and 26d (range 17–83d). Mucositis was the most common non-hematologic toxicity. Of the 69 patients treated, 30 (43%) and 4 (6%) patients proceeded to allogeneic and autologous hematopoietic stem cell transplantation respectively. Of the patients who did not receive stem cell transplantation, eleven patients (median age 54, range 23–72; median WBC 27.1, range 1–250; cytogenetics -9 normal, 1 t(9;22); 1 11q23 abnormality) underwent consolidation with TST–consisting of a single cycle of cytarabine 667mg/m2/d (continuous infusion) on d1–3 and 10–12, and idarubicin (same dose as induction). Two year estimated probabilities of overall survival and relapse in this group were 65% and 26% respectively. In summary, TST as administered in these patients can be safe in patients with newly diagnosed AML, including those patients aged between 60 and 70. However, the regimen does not appear to improve CR rates over that seen using conventional induction regimens. Patients with intermediate risk cytogenetics who achieve CR and are not candidates for stem cell transplantation may receive consolidation with a single additional cycle of TST.
Dose Escalation of Low Molecular Weight Heparin to Manage VTE Treatment Failure in Cancer Patients
Authors: Carrier Marc , Le Gal Gregoire , Tierney Sarah , Do Kimberley , Wells Philip , Rodger Marc A.
Published: April 2020

Introduction: Cancer patients with venous thromboembolism (VTE) are at high risk of treatment failures (i.e. recurrent VTE while on therapeutic anticoagulants). Management of these treatment failures is controversial/poorly studied. Whereas some clinicians recommend inferior vena cava (IVC) filter insertion, others do not. We sought to assess the efficacy and safety of escalating the dose of low-molecular weight heparin (LMWH) in the management of treatment failure recurrent VTE in cancer patients.

Methods: Retrospective cohort study of outpatients with cancer and treatment failure recurrent VTE seen at the Ottawa Hospital Thrombosis Unit from January 2007 to June 2008. Patients were followed for three months following the treatment failure event.

Results: Thirty cancer patients had recurrent VTE despite ongoing anticoagulation. The mean age was 60.7 years. Twenty two patients (73.3%) were on LMWH treatment at the time of the recurrent event. Of these 22 patients, 4 (18.2%) were on full (100%) therapeutic doses, 15 (68.2%) on 75% of therapeutic doses and 3 (13.6%) on prophylactic doses of LMWH. All 4 patients on full therapeutic dose were treated by increasing the weight-adjusted dose of LMWH by 20% for 6 weeks. Patients on 75% of therapeutic doses were treated by increasing the weight-adjusted LMWH by 25% for 6 weeks (4/15 patients) or 3 months (11/15 patients). All three patients on prophylactic doses were treated with one month of full therapeutic doses of LMWH followed by 75% thereafter. No patients had an IVC filter inserted or a major bleeding episode. One patient had a minor bleeding episode (4.5%; 95% CI: 1.1–21.9%), 2 patients died (9.1%; 95% CI: 2.8–28.0) (no VTE-related death) and one patient (4.5%; 95% CI: 1.1–21.9%) had a second treatment failure event during the three-month follow-up period while on full therapeutic doses of LMWH.

Eight patients (26.7%) were on vitamin-K antagonist at the time of the recurrent VTE due to treatment failure. Five (62.5) patients had a therapeutic INR on the day of the recurrent VTE. All patients were treated with LMWH at full doses for a month followed by 75% thereafter. One patient (12.5%; 95%CI 2.8–48.3) had a minor bleeding episode during follow-up.

Conclusion: Escalading the dose of LMWH following a recurrent VTE due to treatment failure seems to be a safe and effective method to prevent further recurrence in cancer patients. Our data challenges the concept of using IVC filters in this setting.
Low Molecular Weight Heparin in Patients with Cancer: A New Option
Authors: Corinaldesi Giorgio , Corinaldesi Christian
Published: April 2020

The use of heparin for venous thromboembolism, upper extremity deep vein thrombosis (DVT), septic thrombophlebitis, loss of central venous device access in patients with cancer is a standard practice; a new clinical evidence suggest that low molecular weight heparin (LMWHs) may prolong survival in patients with cancer and may have anti-neoplastic effects and anti-metastatic activity.

We evaluated 74 patients with cancer (38 patients were allocated to enoxaparin 6000UI subcutaneously once a day, and 36 patients were allocated to placebo), the mean duration of follow-up was 12 months, platelet count were performed before the treatment, and once a month; in the event of thrombocytopenia < 50.000/ml or abnormal bleeding the treatment was stopped. The primary end points were overall survival, and metastasis progression.

TAB:A

Enoxaparin (n.38) Placebo (n.36) Age-years (range) 46–68 48–66 Sex (male/female) 20/18 20/16 Metastasis disease     a) before 10 12     b) end-therapy 12 18 Type of cancer     Breast cancer 8 8     Endometrial cancer 6 5     Gastric or esophageal 4/2 3/1     Colorectal cancer 6/2 8/2     Prostatic cancer 6 7     Urothelial 2 1     Lung 2 1 Death 3 8     Major bleeding 1 0     Minor bleeding 4 4     Allergic reaction 0 0     VTE 6 0 Concomitant anti-neoplastic therapy     Chemotherapy 26 26     Radiotherapy 2 1     Combined 4 3         Hormonal 6 6

These data show that LMWHs reduce or attenuate metastasis at 12 month by 11.4%, and death by 8.8%, with a significant increase of median survival.

Heparin have show to have direct antigrowth, antiangiogenesis, and antimetastatic effects, LMWHs minimize angiogenesis with the inhibition of VEGF and b-FGF, inhibit the adhesion of cancer cells to endothelium and the interaction mediated by tumor cells surface mucins and selectin, and they interfere with cancer biology; we can speculate that the binding of tumor growth to heparin have a crucial role in the modulation of activity of the high affinity receptors, it promotes receptors dimerization and activation, inhibits P and L-selectins and chemokine action (IL-8, Mip-1), blocks MMP, serin-protease and heparanase, decreases over-expression of TF and PAF, induces and increases apoptosis.
Kinetics of Human VWF Cleavage by Human ADAMTS13: Comparison of Recombinant and Plasma-Derived VWF
Authors: Rottensteiner Hanspeter , Varadi Katalin , Vejda Susanne , Schreiner Jutta , Gritsch Herbert , Turecek Peter L. , Ehrlich Hartmut J , Schwarz Hans Peter
Published: April 2020

A recombinant human CHO-expressed von Willebrand factor (rVWF) which consists of ultra-high molecular weight (UHMW) multimers resembles the VWF that is stored in Weibel-Palade bodies of endothelial cells. Once secreted into plasma, UHMW multimers are rapidly cleaved by ADAMTS13 and therefore are usually missing in VWF purified from plasma. We analyzed in vitro whether the cleavage of rVWF by ADAMTS13 is similar to the cleavage of plasma VWF by ADAMTS13, using a standard assay that depends on denaturing conditions (1.5 M urea) to expose the ADAMTS13 cleavage site of VWF. We explored the kinetics of ADAMTS13-mediated proteolysis of rVWF over time by exposing 1 VWF:Ag IU/ml of rVWF to various concentrations of recombinant and plasma-derived purified ADAMTS13, ranging from 4 mU/ml to 1 U/ml (corresponding to 0.4 to 100% of the normal human plasma concentration), and to ADAMTS13 present in normal human plasma and VWF-deficient plasma. The multimeric structure and function of VWF were analyzed by multiple assays to compare VWF before, during, and after proteolytic cleavage. In addition, the degradation kinetics of recombinant VWF were compared with those of a plasma-derived VWF product. Recombinant VWF was cleaved rapidly and with the same efficiency using recombinant or plasma-derived ADAMTS13. With 0.5 U/ml pADAMTS13 or rADAMTS13, VWF:RCo activity was below the detection limit of 0.17 IU/ml after 15 s. UHMW multimers disappeared within seconds at physiological concentrations of 0.5–1.0 U/ml ADAMTS13 (50–100% of the normal plasma concentration). Furthermore, UHMW were cleaved within 30 minutes with much lower concentrations of 10–30 mU/ml ADAMTS13 (1–3% of normal plasma concentration). The typical satellite bands appeared very early in an ADAMTS13 dose-dependent manner. Although plasma-derived VWF differs substantially from rVWF in its multimeric structure, the decrease in activity was similar for the recombinant and plasma-derived VWF. Specific cleavage of rVWF (3 IU VWF:Ag/ml) by rADAMTS13 (5 U/ml) was also demonstrated without urea under shear stress in the presence of platelets, detected by a monoclonal antibody (N10) that recognizes VWF only when cleaved by ADAMTS13. The combined data show that ADAMTS13 is able to readily cleave human rVWF even at low concentrations and that the UHMW multimeric fraction of human rVWF is removed within minutes by ADAMTS13 in vitro.
High Throughput Screening of Fibrin Clots: Transport and Mechanics Measured by Microbeads
Authors: Spero Richard Chasen , Sircar Rachel , Lord Susan T. , Wolberg Alisa S. , Superfine Richard
Published: April 2020

Correlations have been shown between cardiovascular disease and the blood clot properties measured by turbidity, permeability, elasticity, and electron or confocal microscopy. With the exception of turbidity, these techniques are low throughput and usually require large sample volumes. We are developing clinically relevant, high throughput compatible measurements of fibrin structure and mechanics. These methods use microbeads, where particles ~0.1 – 10 um are embedded in clots. We have measured the local elastic modulus of fibrin clots using a high throughput compatible technology that magnetically applies force to microbeads. In a single microplate preparation, with clots of concentrations 0.5, 1, and 3 mg/mL, we measured the stiffness G = 5.8, 12, and 42 (+/− 2, 5, and 20) Pa. Using prior technology for elasticity measurements, this experiment would have required 14 separate specimen preparations. To quantify clot structure, we have measured microbead transport due to passive diffusion. PEG-coated beads passively diffused over long distances in fibrin gels and continued diffusing for >24 hours. As expected, increasing fibrinogen concentration suppressed passive transport (from >36 um at 1 mg/mL to <18 um at 3 mg/mL over 15 minutes), and, as particle size increased from 200 nm to 1 um, transport dropped to zero. However, larger PEG-coated beads (2.8 um) transported long distances (> 100 um) through these clots when driven by applied magnetic forces. We conclude that microbead techniques show promise as high throughput alternatives to measuring permeability and elasticity in research and clinical fibrin clots.
Role of S-Phase Fraction in Differentiating Aplastic Anemia from Hypoplastic Myelodysplastic Syndrome
Authors: Tripathi Anil , Tripathi Payal , Kumar Ashutosh , Ahmad Rizwan , Balapure Anil , Vishwakerma Achchhe
Published: April 2020

Among the patients with bone marrow hypoplasia, differentiating aplastic anemia (AA) from hypoplastic myelodysplastic syndrome (HMDS) can be a difficult and challenging task because of the considerable clinical, cytological and histological similarities between these two disorders. The distinction between AA and HMDS is important because the clinical course and management of these two entities differ. There is a higher risk of progression to acute leukemia in patients with HMDS compared with AA. Various attempts have been made in the past to differentiate these entities. Different patterns of proliferation of bone marrow cells in AA and HMDS have been reported in past using proliferating cell nuclear antigens (PCNA). S-Phase Fraction (SPF) reflects the cellular proliferation and has been proven to be a useful diagnostic and prognostic marker in various hematological malignancies and solid tumors. In the present study, we examined whether flow cytometric analysis of SPF could be used as a tool to differentiate AA from HMDS.

The study group comprised of 25 consecutive patients with AA, 18 patients with HMDS diagnosed on the basis of peripheral blood and bone marrow findings along with 30 age and sex matched healthy controls. The mean age of AA patients and HMDS patients was 27.1 ± 12.7 years (range 13–65 years with median age of 23 years) and 38.8 ± 20.6 years (range 15–75 years with median age of 32.5 years) respectively. The most common clinical presentation in patients with AA and HMDS was anemia. Other manifestations were bleeding and pyrexia. No etiological association could be made in any of these cases. Peripheral blood leucocytes were stained with propidium iodide and analyzed for SPF through flow cytometry using Modfit-LT V 3.0 software.

The mean SPF value in the patients with AA and HMDS was 0.49 ± 0.33% and 0.79 ± 0.28% respectively. The mean SPF value in control subjects was 0.67 ± 0.22%. The SPF value in patients with AA was significantly lower than that of control (p=0.01) whereas there was no significant difference in SPF values in patients with HMDS and control subjects. The SPF value was statistically significant higher in HMDS patients as compared to AA (p=0.003). During follow-up, 3 patients (12%) with AA have revealed the evidence of dysplasia on repeat bone marrow examination. These patients had high SPF values as compared to the median SPF value in AA patients.

We conclude that SPF value may be an important parameter in patients with AA to predict their propensity to evolve into HMDS. SPF value may also be useful in the early diagnosis of HMDS before morphologically evidence of dysplasia is apparent.
Molecular Characterization of the T(14;18)(q32;q21) Involving the IGH Locus and the MALT1 Gene in MALT Lymphomas
Authors: Penas Eva Maria Murga , Callet-Bauchu Evelyne , Albert Nadine , Gazzo Sophie , Berger Françoise , Salles Gilles , Bokemeyer Carsten , Dierlamm Judith
Published: April 2020

The t(14;18)(q32;q21) involving the MALT1 and IGH genes is a recurrent abnormality in MALT lymphomas. So far, molecular genetic characterization of the t(14;18)/IGHMALT1 has only been performed in 2 cases and revealed a fusion of the entire coding region of MALT1 to the IGH locus.

We herein report the molecular genetic analyses of 2 new cases of MALT lymphoma harboring the t(14;18)/IGH-MALT1 using fluorescence in situ hybridization (FISH) and we determined the molecular characteristics at the IGH-MALT1 junctions using long-distance PCR (LD-PCR). The first case, a 71-year-old female, presented with an extranodal MALT lymphoma of the conjunctiva, stage IEA. The second case, a 53-year-old-male patient, was diagnosed as having a MALT lymphoma originating from the lung. FISH with PAC clones 117B5 and 59N7 revealed a translocation involving MALT1. Further FISH assays with probes hybridizing to MALT1 and IGH showed the t(14;18)(q32;q21)/IGH-MALT1. By FISH with specific probes for the P53, P16, RB1, and ATM genes no deletions of these genes were found. The IGH-MALT1 fusion was confirmed by LD-PCR on patients’ DNA with nested primers for the MALT1 and IGH genes. Cloning and sequencing of the purified PCR products revealed a fusion of sequences upstream of the coding region of MALT1 to the JH segment of the IGH locus in both cases. The breaks on chromosome 18 were located in the 5′ non-coding region of MALT1, only 13 nucleotides apart from each other. The breaks at IGH were located in the JH4 joining segment in both cases and showed features of a V(D)J-mediated recombination. Deletion and “de novo” nucleotides additions at the point of joining were observed in case 1. Furthermore, a detailed analysis of the “de novo” nucleotides additions in this case revealed the presence of DH segments of the DH gene D3-10 in the JH/MALT1 junction.

Our findings indicate that

the pathomechanism underlying the t(14;18)/IGH-MALT1 in MALT lymphomas is probably based on an illegitimate V(D)J recombination at IGH, similar to other IGH-associated translocations, such as the t(14;18)/IGH-BCL2 in follicular lymphomas and the t(11;14)/CCND1-IGH in mantle cell lymphomas and that the events leading to the t(14;18)/IGH-MALT1 might take place during an initial DH-to-JH or a later VH-to-DJH joining.
Telomere Disfunction Is Not An Early Genetic Event in Adult T-Cell Leukemia/Lymphoma
Authors: Brocardo Graciela Aparecida , Nukui Youko , Chamone Dalton , Pracchia Luis Fernando , Pereira Juliana
Published: April 2020

Adult T-cell leukemia/lymphoma (ATL) is a mature T-cell neoplasm of post-thymic lymphocytes linked to human T-cell lymphotropic virus type I (HTLV-I). ATL develops in 3–5% of HTLV-I carriers after a long period of clinical latency and presents chromosomes abnormalities resulting in aneuploidy usually seem in telomere dysfunction disease. We were interested whether the abnormalities of the telomere regulation in ATL and if its abnormalities are correlated with ATL pathogenesis. The telomere length of TCD4 and TCD8 lymphocytes in samples from HTLV-I carriers (n= 52) with median age of 49.5 years (18–71 years) and ATL patients (n= 6) with median of 39 years (18–59 years) were assessed by fluorescence in situ hybridization and flow cytometry (Flow-FISH) and compared with healthy subjects (n = 58) matched for gender and age. We did not detected significant difference the telomere length of the TCD4 and TCD8 lymphocytes between HTLV-I carriers and health subjects. However we showed an accentuated loss in telomere length of the malignant T lymphocyte in ATL disease and values closed to those ageexpected in non-malignant T lymphocyte in ATL disease. We concluded that these results do not support a major role of telomere disfunction as an early event in pathogenesis of the ATL.
Significant Survival Disparity Between Chronic Lymphocytic Leukemia (CLL) and Stage IV Small Lymphocytic Lymphoma (SLL) Patients: Analysis Using the Surveillance, Epidemiology and End Results (SEER) Database
Authors: Gundrum Jacob D , Go Ronald
Published: April 2020

Introduction: CLL and SLL are identical entities based on the World Health Organization classification of tumors due to similar tumor immunophenotype. Clinically, CLL is considered the leukemic phase of or stage IV SLL. However, population-based data comparing the natural history and outcome of these 2 diseases are lacking.

Methods: We reviewed the entire SEER database of patients with CLL (n=30,961) and stage IV SLL (n=5,151) diagnosed from 1985–2005 and compared their demographics, incidence, and survival. Age-adjusted incidence rate calculations were expressed per 100,000 persons in 5 year increments and obtained from SEER 9 database. Specific treatment data outside of surgery and radiation are not collected by SEER, so we did not include analysis according to treatment received.

Results: CLL had a slightly higher proportion of males than SLL (59.6 vs 58.2%, P =.05). The mean age at diagnosis was also higher in CLL (69.9 vs 67.6 years; P <.001). The age at diagnosis did not change over time for both diseases. Race distribution was similar in both diseases with predominance of whites (89.7%). Blacks were generally diagnosed at a younger age whether CLL (67.3 vs 70.0 yrs; P <.001) or SLL (64.3 vs 67.9 yrs; P <.001). The overall incidence rates were stable over time for CLL and SLL at 5.4 and 0.9, respectively. However, there was a decline in the incidence of CLL among blacks (4.7 in 1986–1990 vs 3.7 in 2001–2005, P <.001). The median overall survival (OS) for CLL and SLL were 77 and 63 months, respectively (P <.001). The median OS improved over time for SLL (P <.001) but not for CLL (P =.36). The incremental improvements in median OS between the 1985–1989 and 1996–2000 eras were 4 and 30 months for CLL and SLL, respectively. Multivariate analysis using separate datasets for CLL and SLL showed that increasing age at diagnosis (60–69 years, HR: 1.6, 1.7; 70–79 years, HR: 2.7, 2.8; ≥80 years, HR: 6.0, 5.1), male sex (HR: 1.3, 1.3), and black race (HR: 1.7, 1.5) were associated with worse OS (all P ≤.001). Better OS was associated with later diagnosis years (1993–1996, HR: 0.91, 0.76; 1997–2000, HR: 0.93, 0.66; 2001–2005, HR: 0.88, 0.55; all P ≤.01). Multivariate analysis of combined CLL and SLL datasets additionally showed that SLL histology was associated with a worse OS (HR: 1.3; P <.001). Similar results were obtained when we performed analyses using disease-specific survival as endpoint.

Conclusions: Contrary to current assumption, our population-based study suggests that patients with CLL have a significantly better outcome compared to stage IV SLL. This survival disparity is not due to lead time bias and is narrowing over time. Future studies should investigate whether this is due to different treatment patterns or biology.
VEGF Expression as Prognostic Factor in Early Clinical Stages of Chronic Lymphocytic Leukemia Patients
Authors: Barreto Wolney Góis , Siufi Grazziella Curado , Kimura Eliza YS , Pessoa Juliana Gilbert , Pesqueiro Joao Bosco , Vasconcelos Yuri , Silva Marcal CA , Lazar Arlete E , Yamamoto Mihoko
Published: April 2020

Introduction: Chronic Lymphocytic Leukemia (CLL) is the most frequent leukemia in adults of western countries. Its clinical course is variable with some patients presenting an indolent disease while others have an aggressive disease requiring prompt treatment. Biomarkers to identify patients with poor prognosis, especially in early clinical stages, are being studied. Increase of angiogenesis, as an apoptosis deregulator, has been associated to poor prognosis in some malignant diseases such as Multiple Myeloma and Non-Hodgkin Lymphoma. Expression of Vascular Endothelial Growth Factor (VEGF) in CLL cells seems to have an unfavorable impact on prognosis, even though only a few studies have addressed this issue.

AIMS: to analyze the expression of VEGF and its relation to Binet clinical stage, mutation status of IgVH and event free survival.

Patients and Methods: 52 CLL patients diagnosed at UNIFESP and HSPE were studied. VEGF expression was evaluated on blood samples stained with Biotinylated Human VEGF (R&D Systems) monoclonal antibody and acquired with FACScalibur® and analyzed CellQuest® software. The expression of VEGF was considered positive when its mean fluorescence intensity was >200. IgVH mutation of 25 cases status was also studied by sequencing of the amplified samples by RT-PCR using VH family specific primers. The sequences were analysed with lg Blast® software and considered mutated (M) when there was a germline homology of 98% or greater and those displaying homology <98% were classified as unmutated (UM). Fisher’s exact test was used to compare results and Kaplan Meyer analysis to evaluate progression free survival (PFS). Differences were considered significant if p<0.05.

Results: Of the 52 CLL patients (28M/24F, median age of 67 years varying between 38–78 years) 29 (56%) were Binet A, 17 (33%) Binet B and 6 (11%) Binet C. Twenty nine were VEGF+ and 23 VEGF−. Binet A patients were more frequently VEGF− than Binet B+C ones (p=0,002). In the whole population, VEGF+ patients presented shorter PFS when compared to VEGF− (p=0.004). Additionally, even early clinical stage patients (A+B), VEGF+ patients had an adverse prognosis with shorter PFS than those who were VEGF− (p=0.023). As for IgVH mutation status, of the 25 analyzed patients VEGF− were predominantly M while VEGF+ NM (p=0.043), and this difference was also seen when A+B patients were analysed (p=0.031).

Conclusion: Our study shows that VEGF expression is associated with an adverse prognosis in CLL patients, even in those in early clinical stages (A+B). FC analysis of VEGF showed to be feasible and easily executable and could be evaluated as surrogate of IgVH mutation status in additional studies with a greater series of patients. (support: FAPESP proc.no.05/57792-0).
Lumiliximab, An Apoptosis Sensitizer to Multiple CLL Therapeutic Agents
Authors: Maclaren Ann , Trauernicht Amy , Nguyen Lizbeth , McLachlan Karen
Published: April 2020

Chronic lymphocytic leukemia (CLL) is a B cell malignancy characterized by the accumulation of mature phenotype leukemic B cells in blood, spleen and lymphoid tissues. While many patients respond initially to combination chemotherapy regimens, many become chemoresistant and all will ultimately relapse. Recently the addition of novel monoclonal antibody therapies such as rituximab and alemtuzumab to these treatment regimens has provided additional therapeutic benefit to chemorefractory CLL patients and prompted interest in the evaluation of additional B cell surface antigens as targets. Lumiliximab is a primatized monoclonal antibody directed against CD23, a glycoprotein expressed on the majority of CLL cells, and is currently under investigation in patients with relapsed CLL. It was previously demonstrated that the primary mechanism of action of lumiliximab in both CD23+ lymphoma B cells and CLL patient samples is sensitization to apoptotic cell death and that lumiliximab enhances apoptosis in vivo when combined with either fludarabine or rituximab (Pathan et al., Blood, 2008). In the present study we sought to determine whether lumiliximab could enhance the apoptotic activity of a range of CLL therapies which induce cell death via distinct apoptotic pathways. Our studies demonstrate that the addition of lumiliximab in combination with the alkylating agent chlorambucil resulted in a dose-dependent and significant increase in apoptosis of CD23+ lymphoma cells. Lumiliximab also resulted in statistically significantly enhanced apoptosis when combined with alemtuzumab as compared to either single agent alone in both CD23+/CD52+ lymphoma cells and CLL patient samples. Examination of the apoptotic pathways induced by these agents revealed that lumiliximab in combination resulted in more dramatic alterations in downstream effectors of apoptosis such as caspase 3, PARP, and DNA fragmentation. Further studies are ongoing to confirm these observations in xenograft models and to delineate the mechanistic basis of the enhanced apoptotic signaling. These data suggest that the use of lumiliximab in combination with current or emerging CLL therapies could be an effective strategy to augment tumor cell killing and may result in new and more effective treatment regimens for the eradication of CLL.
Phosphotyrosine Levels by Flow Cytometric Assay for Therapeutic evaluation in Chronic Myelogenous Leukemias
Authors: Sun Xuemei , Chen Junhao , Jiang Pengjun , Zhu Xuejun
Published: April 2020

Assay of phosphotyrosine levels using flow cytometry has been used to identify patients with chronic myelogenous leukemia (CML) positive for the Bcr-Abl fusion gene. We hypothesized that clinical monitoring could identify treatment response through reductions in intra-granulocyte phosphotyrosine. Initially, we studied cell lines FDC-P1 and HL60 (Bcr-Abl–negative) and FDrv210 and K562 (Bcr-Abl–positive) with our technique. A fluorescein isothiocyanate-conjugated monoclonal antibody was used along with fluorescence-conjugated microspheres for reference (ratio of sample fluorescence: bead fluorescence=relative fluorescence unit [RFU]). Samples from 20 controls and 32 patients undergoing treatment were analyzed using the same method. Bcr-Abl status for each patient was confirmed using fluorescent in situ hybridization (FISH) or polymerase chain reaction gene amplification (PCR). Testing of cell lines consistently produced expected results. Patient values were found to be significantly higher than control values (P<0.001) and values for patients with advanced disease were significantly higher than for patients with chronic-phase disease (P< 0.05). Results of clinical monitoring were consistent with results from PCR. Two patients who received allogeneic stem cell transplantation had molecular remission confirmed by PCR and had a marked decrease in RFU value (from 62 to 5 and from 131 to 23). No such fluorescence change was observed in patients who achieved clinical remission. Flow cytometric analysis of phosphotyrosine levels is a reliable and convenient adjuvant technique for diagnosis of Bcr-Abl–positive leukemias and shows promise for serial evaluation of patients undergoing treatment.
Frequency of BCR/ABL Breakpoints in CML Venezuelan Patients : Contribution to a Possible Worldwide Distribution of BCR/ABL Transcripts Associated to Ethnicity
Authors: Carreño Fanny J. , Lopez Jose L , Mata Estluz K , Cardenas Leonor , Costa Osiris Da , Mendez Carlos , Utrera Rene
Published: April 2020

Chronic myeloid leukemia (CML) is a common clinical pathology characterized by the clone expansion of stem cells of myeloid linage. At the cytogenetic and molecular level CML is associated with one reciprocal and nonrandom translocation (t(9;22)(q34;q11)) which causes the BCR/ABL gene fusion in the 22nd chromosome (Philadelphia chromosome, pH+). This gene codifies for a chimerical protein functionally active and able to exert a transforming effect on all the cells carrying that gene. The transcripts b2a2 and b3a2 are the principal variants identified on the CML patients. Due to high frequency and variation in expression of b2a2 and b3a2 transcripts in CML patients, the researchers have tried to associate the expression of those transcripts with clinical and ethnic aspects. Nevertheless, the results have been contradictory and a direct correlation between transcripts BCR/ABL, the clinic and ethnicity has not been yet found. Although, geographic variation has been already revealed for others leukemia types, thus enhancing the accuracy of prognosis, until now a geographic distribution of CML transcripts remain unrevealed. We report here for the first time, the frequency of different BCR/ABL transcripts in 467 Venezuelan CML patients. The RT-PCR for those transcripts evidenced that 449 (96.1%) of patients had the gene fusion p210BCR/ABL, being 205 (45.6 %) b2a2, 187 (41.7%) b3a2 and 40 (8.8%) b2a2/b3a2 co-expression. The remaining 17 (3.9%) included the expression of variant P190BCR/ABL (e1a2) and its co-expressions: e1a2/b2a2, e1a2/b3a2 and e1a2/b2a2/b3a2. Most of the patients were between 21 and 60 years old and 53% were males. The analysis of automatic sequences showed the T/C polymorphism in some b2a2 transcripts, while b3a2 and co-expressions transcripts did not present it. These results were included in our study on the geographic distribution of the BCR/ABL transcripts. That study revealed that the Asian and Middle East countries (Malaysia, Thailand, Korea, India, China, Japan and Iran) showed the highest frequency of b3a2, while American countries (Brazil, Mexico and Venezuela) presented b2a2 as the highest frequency found. This geographical distribution of transcripts was found to have a pattern according to longitude: increasing the relative expression of b3a2 from west to east. As for the relative expression of b2a2 and b3a2 transcripts by ethnic groups, it showed three main groups: Asians and Middle Easterns express mainly b3a2 transcript, Europeans (Caucasians European) express both transcripts, whereas Mestizos (mulattos, Caucasians and Amerindians) express mainly b2a2 transcript. This geographical distribution pattern suggests that the relation between clinical features and CML transcripts could be masked by underlying factors such as ethnicity and geographic location.
Secondary Malignancies after Allogeneic Hematopoietic Stem Cell Transplantation
Authors: Neuburger Stefan , Hemmati Philipp , Terwey Theis , Massenkeil Gero , Dörken Bernd , Arnold Renate
Published: April 2020

Introduction: Allogeneic stem cell transplantation is a curative therapeutical option for patients (pts) with hematological diseases. As result of long term survival, late complications such as secondary malignancies are emerging.

Methods: Here we present a retrospective analysis of 589 pts (median age at transplantation 41 years, range 16–75, male 339, female 250) who underwent allogeneic stem cell transplantation in our institution between 1995 and 2007 (siblings n= 285, unrelated donors n= 304). Pts suffered from acute leukemia (n= 257), chronic myeloproliferative disorders (n= 120), myelodysplastic syndrome (n= 39), non-hodgkin-lymphomas (n= 41) and others (n= 132). Pts received conditioning with (n= 436) or without (n=152) 12 Gy total body irradiation (TBI).

Results: Up to 2007, 283 of 589 pts (48%) died of relapse or transplant related mortality (n=135 relapse, n= 84 infection, n= 36 graft-vs-host-disease (GVHD), n= 8 organ toxicity, n= 20 others or unknown). 305 out of 589 pts (52%) had survived with a median follow-up of 40 months (range 1–144 months). 21 out of 305 pts (6,9%) developed secondary malignancies at a mean of 5,1 years (range 1–10 years) after allogeneic stem cell transplantation. Localizations of secondary malignancies were skin (n= 11 basalioma, n= 2 melanoma), gut (n= 2 adenocarcinoma of the small intestine, n= 1 coloncarcinoma), oral cavity (n= 1 squamous cell cancer) and 3 lymphomas. 17/21 pts (81%) received a myeloablative conditioning with 12 Gy TBI, 4/21 pts (19%) a reduced intensity conditioning. Acute GVHD > grade 2 and chronic GVHD extensive disease appeared in 48% and 67% respectively. Thus, these pts must be treated with prolonged immunosupressive therapy. 2/21 (9,5%) died of secondary malignancies (carcinoma of small intestine and colon) and one pts of accidential infection.

Conclusion: Long term surviver of allogeneic stem cell transplantation are at increased risk of a secondary malignancies. Most of the pts received TBI-based conditioning and suffered from chronic GvHD extensive disease with consecutive immunosupressive therapy. Life-long follow-up will be needed to detect secondary malignancies in early stage of disease which might offer curative therapeutical options. Therefore, in our institution all pts undergo annual skin screening program and are sensitized for possibility of secondary malignancies late after transplantation.