bluuebunny/crossref_metadata_2025 huggingface dataset:
Higher Risk of Ischemic Stroke Associated with Factor XI Levels in Dyslipidemic Patients.
Authors: Santamaria Maria Amparo , Oliver Arturo , Mateo Jose , Belvis Roberto , Marti-Fabregas Joan , Souto Juan C. , Urrutia Teresa , Cristina Vallve , Borrell Montse , Fontcuberta Jordi
Published: October 2019

Ischemic stroke (IS) is a complex disease that involves genetic and environmental factors. The role of Factor XI in arterial thrombosis including IS is unclear. We have investigated the risk of IS related to Factor XI levels in a case-control study. We studied 445 individuals: 218 diagnosed with IS and 227 age-gender-ethnic control subjects. We measured Factor VIIIc, fibrinogen and Factor XIc levels. Factor XI<144% was taken as the reference group in the statistical analysis. Basic characteristic of patients and controls are summarized in the Table 1.

When we analyzed the OR in all population, we observed an interaction between dyslipidemia and high FXI levels. So, we analyzed the data in 2 subgroups, dyslipidemic and non-dyslipidemic. The crude OR of IS in dyslipidemic patients with high levels of FXI was 4.2 (95% CI:1.2–14.8) compared with dyslipidemic controls and low levels of FXI, but the OR in the non-dyslipidemic with high levels of FXI subgroup was 1.2 (95% CI: 0.4–3.2). The adjusted OR of IS in dyslipidemic patients with high levels of FXI was 6.4 (95%CI: 1.6–26.1) compared with dyslipidemic controls, but the OR in non-dyslipidemic subgroup with high levels of FXI was 0.6 (95%CI: 0.2–2.1). In conclusion, we found almost a six-fold higher risk of IS in patients with dyslipidemia and high levels of FXI. Further studies should elucidate the role of Factor XI in IS and therapeutical approaches should become apparent in regard to patients with dyslipidemia and high Factor XI plasma levels.

Table 1.

IS (n=218)n (% ) Controls (n=227)n (% ) Unadjusted OR (95% CI) *Difference statistically significant (p<0.059 after adjustment by sex and age Sex (F/M) 104/114 108/119 NS Age (years, mean, range) 57 (23–80) 55(21–80) NS Smoking 94(45) 75(40) 1.6(1.1–2.3)* Dyslipidemia 91(42) 40(18) 3.4(2.2–5.2)* Family History of arterial thrombosis 112(51.7) 39(19) 5.1(3.3–7.8)* Hypertension 96(43.9) 39(17.3) 3.7(2.4–5.8)* Morbid Obesity 12(4.4) 6(2.6) 2.6(0.9–7.5) Alcohol Intake 20(9.2) 11(4.8) 1.9(0.9–4.2) Diabetes Mellitus 41(19) 12(5) 4.2(2.1–8.2)* Factor VIIIc(%, mean, range) 187.3(62–516) 157.1(48–360) p<0.0001 Fibrinogen (g/l)(mean, range) 3.7(1.9–8.4) 3.5(2.1–7.8) p<0.002
The Risk of Thrombosis in Patients with Lupus Anticoagulants Is Predicted by Specific Antibody Profiles.
Authors: Huh Hee Jin , Chi Hyun Sook , Young Mi , Jang Sung Soo , Park Chan Jeoung
Published: October 2019

Introduction: Lupus anticoagulants(LA) are immunoglobulins which inhibit phospholipid dependent coagulation tests and associated with thromboembolic event. The autoantibodies that cause Lupus anticoagulant activity are heterogeneous but predominantly directed against β-2-glycoprotein(β2GPI) or prothrombin. The purpose of this study was to evaluate the prevalence of IgG, IgM anti-cardiolipin antibody(ACA), anti-β2GPI antibody and anti-prothrombin antibody in patient with lupus anticoagulant activity, and to predict the risk of thromboembolic event in patients with different immunologic profile.

Materials and methods: Lupus anticoagulant positive plasma samples from 163 patients which were sent us under the impression of antiphospholipid antibody syndrome were selected. The activity of LA was detected by mixing test and simplified DRVVT test (Gradipore Ltd, Sydney, Australia). IgG, IgM ACA (Inova Diagnostics, Sandiego, CA, USA), anti-β2GPI antibody and anti-prothrombin antibody (BL-Diagnosika, Gmbh, Mainz, Germany) were measured by commercial enzyme linked immunoassay (ELISA). The 163 patients divided into nine groups according to the results of ELISA for evaluation of correlation with thromobosis.

Results: A history of 1 or more thromboembolic events was found in 49 patients (30.1%): venous thrombosis in 29 patients (17.8%), arterial thrombosis in 29 patiensts (17.8%) and recurrent events in 14 patients (8.6%). The positivity of ELISA was follows; IgG ACA, 14 cases (8.6%); IgM ACA, 24 cases (14.7%); IgG and IgM ACA, 3 cases (3.7%); IgG anti-β2GPI antibody, 10 cases (6.1%); IgM anti-β2GPI antibody, 5 cases (3.1%); IgG and IgM anti-β2GPI antibody, 3 cases (1.8%); IgG anti- prothrombin antibody, 48 cases (29.4%); IgM anti-prothrombin antibody, 22 cases (13.5%); IgG and IgM anti-prothrombin antibody 10 cases (6.1%). Venous thrombosis prevalence was elevated in 6(25.0%) of 24 patients with IgM ACA and 1(20%) of 5 patients with IgM anti-β2GPI antibody. Arterial thrombosis prevalence was elevated in 3(30.0%) of 10 patients with IgG anti-β2GPI antibody and 5(22.7%) of 22 patients with IgM anti-prothrombin antibody. The univariate logistic analysis of risk factors for thrombosis indicated that of IgM ACA and IgM anti-β2GPI antibody were risk factors for venous thrombosis (Odds ratio, 2.3; 95% confidence interval 0.7–7.3, OR, 2.3; 95% CI 0.1–40.5) and IgG anti-β2GPI antibody were risk factors for arterial thrombosis and recurrent events (OR, 6.3; 95%CI 0.9–46.2, OR, 5.9; 95%CI 0.4–80.4).

Conclusion: The anti-prothrombin antibody is more frequently detected in patients with LA activity than anti-β2GPI antibody. However, anti-β2GPI antibody test is more helpful to identify LA positive patients at risk of thrombosis.
Evaluation of a New Assay Based on a FV-Dependent Prothrombinase Activator for the Detection of Activated Protein C Resistance Phenotype.
Authors: Wu Jogin , Quehenberger Peter , Foltyn Katherine , Dillard Patricia
Published: October 2019

Activated protein C (APC) resistance is the most frequent hereditary defect associated with deep venous thrombosis. Major cause of APC resistance phenotype is due to a point mutation of factor V (Factor V Leiden). A new clotting assay, Pefakit® APC-R Factor V Leiden (Pentapharm Ltd., Switzerland) for the detection of APC resistance phenotype was evaluated at two tertiary care hospitals, Duke University Medical Center, USA (Duke) and University of Vienna, Austria (Vienna). Samples of 242 subjects from Duke and 187 subjects from Vienna were included in the study among patients who were subjects for thormbophilia screening. The Pefakit® method is based on clotting time measurement triggered by a prothrombin activator added to a mixture of patient plasma diluted with factor V deficient plasma with and without APC. Robustness and specificity of the assay is enhanced by elimination of possible disturbing influence by factors upstream the coagulation cascade and heparin interference is precluded up to heparin level of 2 IU/ml by heparin inhibitor added to the regent. A similar, FDA approved commercial APC-R kit (COATEST of IL) was used for method comparison. Patients with elevated factor VIII (n=11), Coumadin (n=23), Lupus Anticoagulant (n-14), protein C deficient (n=7), protein S deficient (n=9), AT III (n=6) and women with pregnancy (n=9) were included in Duke study and no interference were found in phenotype. Using PCR/FRET DNA method as reference method the Pefakit® method provided 100 % sensitivity and 100 % specificity for the Vienna study and 99.0 % sensitivity and 98.6 % specificity for the Duke study and the COATEST provided 97.1 % specificity and 93.2 % sensitivity with the Duke study. Using two levels of genotype controls both studies showed similar intra and inter-assay precision (less than 6 % for the Vienna study and 9 % for the Duke study) as compared with the gold standard IL APC-R COATEST kit (less than 5 % CV). Of great interest one false positive sample from the Duke study is under investigation due to that the functional detection of the assay is supposed to detect other FV mutations leading to APC-R phenotype as well. Reasons that cause the other two false negative results for the Duke study are still unknown and under investigation. Both studies showed that the Pefakit® is simple and rebust assay. Both wild type and heterozygous groups have much higher ratio as compared with the reference method in differentiating them from homozygous phenotype.

Figure Figure
Incidence of Pulmonary Thromboembolism (PTE) and New Guidelines for PTE Prophylaxis in Japan.
Authors: Kobayashi Takao , Nakamura Mashio , Sakuma Masahito , Yamada Norikazu , Sakon Masato , Fujita Satoru , Seo Norimasa
Published: October 2019

Venous thromboembolism (VTE) has been on the rise in Japan in recent years, together with the Westernization of Japanese eating habits. According to the investigation by Editorial Committee on Guideline for Prevention of Venous Thromboembolism by Japanese Society of Anesthesiologists in 2002, 369 cases of pulmonary thromboembolism (PTE) were registered among 467 General Hospitals and University Hospitals. The rate of perioperative PTE is estimated to be 0.044% (369/837540), and the fatal rate among clinical PTE was 17.9%. 36% of the cases occurred in Orthopedics, 22% in general surgery and 10% in Obstetrics and Gynecology. 59% of the cases did not received prophylaxis, and 52% of the cases were restricted mobility. The incidence of clinical PTE after general surgery was 0.16% from 1994 to 2000 in Japan. Fatal rate among clinical PTE was 21.3%, and fatal rate among all patients was 0.04%. The incidence of clinical PTE after total hip joint replacement surgery among 46 papers between 1990 and 2001 in Japan was 1.1%, and that of fatal PTE was 0.15% among all patients. Patients of PTE were investigated between 1991 and 2000 among 68 University Hospitals and 34 General Hospitals in Japan. 76 cases of PTE occurred in Obstetrics, and 13.2% of them were fatal. The incidence of PTE was 0.003% in vaginal deliveries and 0.06% in cesarean sections. 178 cases of PTE occurred in Gynecology, and 13.5% of them were fatal. The incidence of PTE was 0.03% in benign diseases and 0.42% in malignant diseases. However, the incidence of PTE in Japan is considered to be at least one level lower compared with Western populations according to ACCP guidelines. Furthermore, low molecular weight heparin (LMWH) is not covered by health insurance and is contraindicated for pregnant women still now in Japan. Then, we established Japanese guidelines for VTE prophylaxis according to Japanese clinical evidences of PTE in 2004. We classified four risk groups according to ACCP guidelines. Recommended prophylaxis is early ambulation for low risk group, graduated compression stocking (GCS) or intermittent pneumatic compression (IPC) for moderate risk group, IPC or low dose unfractionated heparin (LDUH) for high risk group, and LDUH + IPC or LDUH + GCS for highest risk group. And, risk group should be raised one rank in cases with any additional risks, such as obesity, advanced age, pregnancy, operation time, and other complications. Recommended prophylaxis in this guideline may be minimum one, because the purpose of this guideline is to penetrate the awareness and education of VTE throughout Japan. Fortunately, the management fee for PTE prophylaxis was established and covered by health insurance in April 2004. However, after accumulation of further evidences and application of pharmacological agents, such as LMWH, we will establish the advanced guidelines in the future.
A Role for SCL in Developing Bone? the SCL +19 Core Enhancer Targets Expression to Cells of Developing Bone, Osteocytes, Chondrocytes and Bone Lining Cells.
Authors: Silberstein Lev , Pimanda John E. , Piltz Sandie , Delaney Liz , Oldham Scott , Kallianpur Asha , Dominici Massimo , Brandt Stephen , Gottgens Berthold , Green Anthony
Published: October 2019

The transcription factor SCL/TAL1 is essential for haematopoiesis and vascular development in the embryo. It is also expressed in the developing skeletal and central nervous systems, but lethality of SCL null mice has precluded detailed analysis of the role of this gene in these tissues.We have previously demonstrated that the SCL +18/19 enhancer directs reporter gene expression to haemangioblasts, endothelium and haematopoietic progenitors. Using human placental alkaline phosphatase as a reporter gene, we now report that the +19 core enhancer also directs expression to osteocytes, articular chondrocytes and bone lining cells in adult mice. In E14.5 embryos, the transgene is expressed in cells within the cartilaginous template of future bone and in the perichondrium. The pattern of expression of the transgene resembles that of endogenous SCL RNA and protein expression in age matched embryos. At E16.5, transgene-positive cells are seen within ossification centres. Activity of the enhancer during osteogenesis was observed both in bones formed through intra-membranous (e.g. cranial vault) and endochondral ossification (limbs and axial skeleton). We found that the murine pre-osteoblast cell line, MC3T3, expresses endogenous SCL. Stable transfection of these cells with luciferase reporter constructs that include the +19 core enhancer produce a 5-fold increase in luciferase activity. There is a progressive reduction in SCL RNA expression in these cells during osteogenic differentiation. This is consistent with a previous report that expression of SCL protein is down-regulated in skeletal tissues of more advanced stage embryos, and with our finding that the MLO-Y4 cell line, which phenotypically and functionally resembles mature osteocytes, does not express SCL. We addressed the issue of SCL function in bone formation using in-vitro differentiation of embryonic stem (ES) cells. Wild type and SCL−/− J1 ES cells did not differ in their ability to form bone nodules. These data demonstrate that SCL is not required for bone specification, but do not exclude a role for SCL in regulating bone formation in vivo. The SCL +19 core enhancer directs expression to haematopoietic progenitors and endothelium together with their putative precursors, haematopoietic endothelium and haemangioblasts. Our demonstration that the +19 core enhancer also targets expression to osteogenic cells is consistent with recent data suggesting that haematopoietic and osteogenic cells share a common precursor (Olmsted-Davis, EA et al PNAS 2003, Dominici M et al PNAS 2004) and that osteoblastic bone lining cells are intimately associated with haematopoietic stem cells (Calvi LM et al Nature 2003; Zhang J et al Nature 2003).
Erythropoietin Did Not Activate the JAK/STAT or the ERK1/2 Pathway in the Human Colorectal Cell Line, HT-29.
Authors: Tullai Jennifer , Chitikila Carmelata , Gechtman Ze’ev , Wang Xiwei , Jolliffe Linda , Farrell Francis
Published: October 2019

Erythropoietin (EPO) is the cytokine essential for erythropoiesis; however, the expression of EPO and EPO receptor (EPOR) is not limited to cells of erythroid lineage. Erythropoietin and EPOR expression has been localized to numerous non-hematopoietic cells and tissues including endothelial, neuronal and ovarian. Moreover, several tumor types have been shown to express both EPO and EPOR and display increased expression upon hypoxia. To shed light on the potential biological role of EPOR and tumor cells we characterized the response of human colon carcinoma HT-29 cells to EPO. Functionality of the erythropoietin receptor was assessed by radio-labeled ligand binding, cellular proliferation/signaling, and gene expression using DNA microarrays. Receptor binding experiments using [125I]-EPO did not reveal measurable EPO binding activity present on the surface of HT-29 cells under both normoxic and hypoxic conditions. Moreover, EPO failed to induce cellular proliferation or an increase in the phosphorylation state of STAT5, EPOR or ERK1/2 under normoxic or hypoxic conditions at supra-pharmacological levels (25 IU/ml). Gene expression analysis revealed no significant change in gene expression in response to EPO (5 IU/ml) under normoxic conditions. On the other hand, over 347 genes exhibited greater than a 1.5 fold change in gene expression when cells were cultured under hypoxic conditions (1 % O2). When EPO was administered to cells in the hypoxic state, 36 additional genes were observed (9 and 27 up-regulated or down-regulated, respectively). That HT-29 cells exhibit minor transcriptional changes in response to EPO raises the possibility that EPO may signal in HT-29 cells. However, the mechanism for this response is not through the previously described EPO/EPOR signal transduction pathway. This conclusion is supported by the apparent lack of EPO receptor expression on the cell surface. These results suggest that tumor microenvironment, e.g., hypoxia, exerts a greater effect than that seen by exposure to erythropoietin.
Early Results Suggest That Epoetin Alfa 60,000 U Every 2 Weeks Improves Hemoglobin in Patients with Cancer Not Receiving Chemotherapy or Radiotherapy.
Authors: Shasha Daniel , Henry David H. , Williams Denise
Published: October 2019

Epoetin alfa has been shown to increase hemoglobin (Hb), decrease transfusion requirements, and improve quality of life (QOL) in patients receiving chemotherapy (CT) and/or radiotherapy (RT). However, the efficacy of epoetin alfa in cancer patients receiving neither CT nor RT is not as well characterized, particularly at doses less frequent than 3 times weekly. The objective of this open-label, nonrandomized, multicenter pilot study was to evaluate epoetin alfa 60,000 U subcutaneously (SC) every 2 weeks (Q2W) in 50 anemic patients with cancer who were not receiving CT or RT. The primary efficacy endpoint is the proportion of patients achieving a hematopoietic response (HR; Hb increase ≥2 g/dL from baseline and/or Hb increase to ≥12 g/dL at any scheduled visit) independent of transfusion within 28 days. Patients with histologically confirmed nonmyeloid malignancy, Hb ≤11 g/dL, and who had not received CT in the previous 8 weeks or RT in the previous 4 weeks were enrolled. Patients were permitted to receive hormonal therapy, androgen deprivation therapy, and/or immunotherapy. Patients were to receive epoetin alfa 60,000 U SC Q2W, with escalation to 80,000 U Q2W after 4 weeks if Hb increased ≤1 g/dL. Dose will be titrated to maintain Hb ≤13 g/dL; all patients were to receive oral ferrous sulfate 325 mg daily. Patients will be treated for up to 12 weeks, with a 4-week follow-up after last dose of study drug. As of July 2004, 18 patients are evaluable for efficacy (modified intent-to-treat, ie, all enrolled patients who received ≥1 dose of study drug and had ≥1 postbaseline Hb or transfusion evaluation) and 18 for safety (all enrolled patients who received ≥1 dose of study drug). Mean age was 74.4 ± 8.7 yrs, mean baseline Hb was 10.0 ± 1.0 g/dL (n=18), and 7/18 were men. Of these patients, 7 completed 4 weeks, 3 completed 8 weeks, and 1 completed 12 weeks on study. The HR of these patients was assessed regardless of how many weeks of study they completed at the time of this interim analysis; HR was 44.4%. Hb increased 1.4 ± 0.7 g/dL (n=11) after 4 weeks and 1.2 ± 1.4 g/dL (n=4) after 8 weeks of treatment. Adverse events were limited to 1 patient, who experienced back pain and epistaxis. No patients died during the study, and no thrombotic vascular events were reported. Early results of this study suggest that epoetin alfa 60,000-80,000 U SC given every other week is well tolerated and appears to effectively increase Hb in anemic cancer patients not receiving CT or RT. The study is currently ongoing.
Usefulness of CD10 Study by Multi-Colour Flow Cytometry in Angioimmunoblastic T-Cell Lymphoma.
Authors: Baseggio Lucile , Berger Francoise , Carret Josiane , Thieblemont Catherine , Morel Dominique , Magaud Jean-Pierre , Felman Pascale
Published: October 2019

Angioimmunoblastic T-cell lymphoma (AITL) is a distinct clinicopathological entity among peripheral T-cell lymphoma in the WHO classification. Whereas antigen “loss” or “deletion” of one or several pan-T cell antigens is a hepful feature of neoplastic lymphocytes in many T-cell lymphomas, no specific immunophenotypic patterns were available to recognize the tumour T-cells of AITL until recently. Indeed, Attygalle et al. reported that in this disorder neoplastic T-cells can be recognized by the aberrant expression of CD10 using immunochemistry in lymph nodes as well as in the involved extranodal sites. Lee et al. has also confirmed this specific phenotypic feature in cell suspension of lymph nodes using flow cytometry (FCM) in 3 cases of AITL. Here, we evaluated the CD10 expression by T cells in patients with AITL using four-colour FCM. The present study included lymph nodes (LN, n=10), peripheral blood (PB, n=5), bone marrow (n=1) and skin (n=1) samples from 13 patients with a diagnosis of AITL and with available cytologic histologic, immunologic and molecular data. Lymph nodes of reactive hyperplasia (n=13), B-cell lymphoma (n=23), other T-cell lymphoma (n=6) and peripheral blood from healthy donors (n=18) were used as control group. According with previous immunohistochemistry results, a fraction of T-cells expressed CD10 (using a level of at least 5% of all CD5+ cells) in 9/10 AITL lymph nodes with a mean number of 18%. Interestingly, among these 9 cases, 5 could be studied in peripheral blood also and all cases showed a fraction of T-cells expressing CD10, whatever be the lymphocytosis (median 1.1 109/l range 0.82 to 11.32 109/l). In three of these cases, tumoral T-cells presented also lack of surface CD3. In two cases of AITL diagnosed in LN, the aberrant CD10 expression by T-cells was found in bone marrow and skin, respectively. In the control group, T-cells were CD10 negative using the cut-off of 5%.

In conclusion, we demonstrate that the assessment of CD10 expression by neoplastic T-cells can be achieved by multi-colour FCM in lymph nodes and involved extranodal sites. Our results are concordant with the statement of Attygalle that CD10 expression by T-cells can be used as a marker of both malignancy and AITL type. In addition, this is to our knowledge the first description of circulating CD10 neoplastic T-cells in AITL. Further study with a larger series of patients is required to confirm these data, to standardize the cut-off of positivity and to evaluate the sensibility of FCM versus immunohistochemistry.

Figure Figure
Intensified Chop (CHOP14) Plus Rituximab in the Treatment of Elderly Patients with Aggressive and High Risk Non Hodgkin’s Lymphoma (NHL).
Authors: Rigacci Luigi , Nassi Luca , Alterini Renato , Carrai Valentina , Bernardi Franco , Martini Varesco , Bernardeschi Paolo , Longo Giovanni , Bosi Alberto
Published: October 2019

The results of treatment of aggressive NHL in elderly patients is relatively poor. The use of protocol specifically devised for eldery patients can reduce hematological and extrahematological toxicity but yield worst results, particularly in high-risk IPI patients. Recentely Coiffier et al. have showed that the standard therapy for patients over 60 years with aggressive lymphoma was rituximab plus CHOP. With the aim to improve dose intensity in elderly large cell lymphoma patients and intermediate-high or high-risk IPI score we planned treatment with rituximab 375 mg/sqm on day 0 and CHOP therapy on day +2 given every 2 weeks, with G-CSF starting from day + 7 to + 11 and a profilaxis with cotrimoxazole twice weekly and itraconazole 100 mg day. With an intention to treat analysis we have included in the study, from June 2002 to June 2004, 25 patients with the following characteristics: IPI score 2 in 8 patients (32%), score 3 in 10 (40%) and score 4–5 in 7 (28%). Two patients had diagnosis of follicular grade III lymphoma and the other 23 diffuse large B-cell lymphoma. Eighteen patients (72%) had abnormal value of LDH and 18 patients had one or more extranodal sites involved. The median age was 64 years (60–76), seven patients (28%) were stage II, four (16%) were stage III and fourteen (56%) were stage IV. The aims of the present study were: 1) feasibility 2) toxicity 3) response to therapy. Twenty-two patients completed the estabilished 6 cycles and were evaluable, one patient stopped the treatment after three cycles due to infections the remaining two patients are in treatment. Six patients delayed one cycle and one patient two cycles, due to trombocytopenia or neutropenia. Only eight out 135 cycles were delayed (6%). Sixteen out 23 (70%) patients obtained complete remission (CR) and after a median follow-up of 11 months (1 – 22 months) the disease-free survival was 79%, three patients (19%) relapsed. Two of these patients died rapidly after relapse and one obtained a second CR. Three out 6 patients with a partial response obtained a CR after a salvage therapy, two died and one is still in therapy. With a median follow-up of 15 months (3–25 months) the overall survival was 78%. No remarkable extrahematological toxicity was observed, in particular, as regards cardiotoxicity, we did not observe significant variation of left ventricular ejection rate in comparison with the diagnostic ones, except one patient who, after the sixth cycle, presented a significant reduction of left ventricular ejection which rapidly recovered after he was admitted at hospital. In conclusion we observed that dose intensified CHOP with rituximab was feasible and lack of severe toxicity in elderly patients with aggressive and high risk prognosis lymphoma.
Modified Magrath IVAC Regimen as Second-Line Therapy for Relapsed and Refractory Aggressive Non-Hodgkin Lymphoma in Developing Countries: The Experience of a Single Center in Brazil.
Authors: Pracchia Luis F. , Pereira Juliana , Belesso Marcelo , Beitler Beatriz , Chamone Dalton A.
Published: October 2019

In this retrospective study we described the response and toxicity of a modified Magrath IVAC (mIVAC) regimen in 25 patients with refractory/relapsed aggressive non-Hodgkin lymphoma (NHL). The mIVAC consisted of ifosfamide 1,500mg/m2 (one-hour infusion beginning at 9:00; D1 to D5), mesna 300mg/m2 (bolus at hours 9:00, 13:00, 17:00; D1 to D5), citarabine 2,000 mg/m2 (two one-hour infusions beginning at 8:00 and 16:00; D1 and D2) and etoposide 60 mg/m2 (one-hour infusion beginning at 10:00; D1 to D5). Treatment was repeated every four weeks for a maximum of six cycles. Patients who achieved partial remission or complete remission after at least three courses were offered autologous stem cell transplantation (ASCT), if eligible. The median age was 37 years (range 18 to 59 years). Twenty-two (88%) patients had diffuse large B-cell lymphoma, fourteen (56%) had relapsed disease and 10 (40%) were considered high-intermediate and high risk by age-adjusted International Prognostic Index. The overall response rate was 68% (95% CI: 46%–90%). A total of 64 cycles were given, with a median of three courses per patient. Grade 3/4 neutropenia was observed after 85,6% of the courses, and grade 3/4 thrombocytopenia was observed after 87,5% of the courses. Grade 3/4 neutropenic fever occurred after 28% of the courses. Non-hematologic toxic effects were rare, predominantly grade 1/2. No toxic deaths were observed. Fifteen (88%) of the 17 responding patients underwent ASCT. With a median follow-up of 14 months, the median overall survival time for mIVAC sensitive patients was 16 months. This regimen may be feasible for patient with relapsed and refractory aggressive NHL in countries with inadequate numbers of hospital beds.
Treatment of Essential Thrombocythemia with Anagrelide: A Novel Antiangiogenic Agent?.
Authors: Cacciola E. , Cipolla A. , Di Francesco E. , Giustolisi R. , Cacciola R. R.
Published: October 2019

Essential thrombocythemia is a myeloproliferative disorder complicated by thrombotic phenomena as a result of the platelet-clotting hyperactivation linked to increased angiogenesis. It is reported that vascular endothelial growth factor (VEGF) generates thrombin and promotes platelet activation and that activated megakaryocytes and platelets release VEGF. Anagrelide (ANA) is a newer cytoreductive agent which decreases megakaryocyte mass and inhibits the platelet activation. Therefore, we studied platelet factor 4 (PF4), as indicator of platelet activation, VEGF and prothrombin fragment 1+2 (F1+2) and d-dimer (DD), as indicators of thrombin generation, in 22 patients (12 males and 10 females, mean age 50 years) affected by ET diagnosed according to PVSG criteria. Their mean duration of disease was 4.8 years. All patients were on either HU (6 patients) or IFN-α (4 patients) and ANA (12 patients). HU was used at doses ranging between 1 and 1.5g/day. The dosage of IFN-α was 3 MIU, 3 days/week. ANA was initially administered in dose of 0.5 mg/day, with increases of 0.5 mg/day every 7 days until the platelets decreased below 500×109/L and with a average maintenance dosage of 2.2 mg/day. All patients recieved antiplatelets either aspirin (ASA) (15 patients) or indobufen (IND) (6 patients) and dipirydamole (DYP) (1 patient). Platelets, PF4, VEGF, F1+2 and DD were measured before cytoreduction and to complete response defined as platelets≤ 500×109/L. Platelets were determined by automated analyser. PF4, VEGF and F1+2 were assayed by ELISA and DD by immunoturbimetric latex agglutination. Before treatment all patients had marked platelets (1060±356×109/L) and high PF4 and VEGFPLT (157±83 IU/ml vs 1.6±0.9 IU/ml and 1.2±1 pg/ml vs 0.3±0.2 pg/ml, respectively) (p<0.0001 and p= 0.002, respectively). F1+2 and DD were elevated 3.6±3.7nml/L and 205±83 μg/L, respectively) than controls (0.6±0.3nmol/L and 75±21 μg/L, respectively) (p<0.0001 and p<0.0001, respectively). After a median time of 4.5 months from cytoreduction all patients had platelets ≤ 500 × 109/L (430±70 × 109/L). PF4 and VEGFPLT remained high (121±72 IU/ml and 3.5±4.6 pg/ml, respectively) such as F1+2 and DD (3.5±3.8 nmol/L and 197±55 μg/L, respectively) in the HU- and IFN-α-treated patients. PF4 and VEGFPLT normalised (7.4±3 IU/ml and 0.9±0.5 pg/ml, respectively) in the ANA-treated patients such as F1+2 and DD (1.1±0.4 nmol/L and 98±62 μg/L, respectively). These measurements were repeated in another sample collected after 1 o 2 months and showed concordance for PF4, VEGFPLT, F1+2 and DD concentrations. A positive correlation we found between PF4 and F1+2 and DD (p=0.023 and p=0.019, respectively) and between VEGF and F1+2 (p=0.020, respectively). Interestingly, these data might suggest that ANA has antiangiogenic property and hence antiplatelet and anticoagulant effects.
Long Term Follow-Up of 198 IgM Monoclonal Gammopathy of Undetermined Significance (MGUS).
Authors: Annibali Ombretta , Petrucci Maria T. , Bartolozzi Francesco , Levi Anna , Del Bianco Patrizia , Gallucci Cristiano , Foa Robin , Mandelli Franco , Avvisati Giuseppe
Published: October 2019

MGUS is found in more than 1 % of people 50 years or older and in approximately 3% of those older than 70 years. Of these the great majority are of IgG or IgA type while IgM MGUS are less frequent.The aim of this study was to analyse the natural history of IgM MGUS and the risk of progression to lymphoproliferative disorders. From July 1973 to June 2004, we observed 323 monoclonal gammopathies of IgM type. At diagnosis, 198 (61%) were MGUS, 111 (34%) were Waldeström’s Macroglobulinemia (WM) of whom 11 were pretreated, 8 (2,4%) were non Hodgkin Lymphoma (NHL), 5 (1,5%) were IgM Myeloma and only 1 was a chronic lymphocytic leukaemia. Of 198 patients with IgM MGUS, 125 (63%) were men and 73 (37%) were women ( ratio 1.71).Median age at diagnosis was 65.7 (range 33–89 years). At diagnosis, all patients had an IgM concentration less than 2 gr/dl with a median of 1.7 g/dl. Median Hb, serum creatinine and albumin levels were: 13.2 gr/dl, (range 6.9–17.9), 1,04 mg/dl ( range 0.6– 2,5) and 3.9 gr/dl ( range 2.4–5). Hepatomegaly as well as splenomegaly were present in 24% and 14% of patients, respectively. The 198 patients were monitored for 8741 months/person (median 25 months, range 0–411). During The follow up a lymphoproliferative disorder developed in 17 (8.5%) patients. In particular 11 pts (5.5%) pts evolved to WM and 6 (3%) to NHL. Progression incidence to linfoproliferative disorders was 0.001 months/person. Cumulative incidence of progression to lymphoproliferative disease was 1.3 % at 1 years, 6.8 % at 5 years, 23.2% at 10 years and 45.4% at 15 years. In conclusion the patients with IgM MGUS are more likely to die of unrelated diseases than to have progression to a malignant lymphoproliferative disorder.
Chromosome Aberrations in 130 Patients with Multiple Myeloma Detected by Interphase FISH and Their Diagnostic and Prognostic Relevance.
Authors: Glasmacher Axel , Hahn Corinna , Juttner Andrea , Schubert Regine , Busert Barbara , Schwanitz Gesa , Schmidt-Wolf Ingo G.H.
Published: October 2019

Recent publications have shown that chromosomal abnormalities in patients with leukemias play an important role with respect to therapy and prognosis. In multiple myeloma (MM) the role of specific cytogenetic changes relevant for the prognosis is still to be defined. Recent data suggest that much more patients show chromosomal aberrations than previously suspected, but differentiation between main and side lines of karyotype evolution was problematic. In the present investigation, cytogenetic analysis was performed using interphase FISH in 130 patients with multiple myeloma. For hybridization, 9 repetitive (chromosomes 3, 7, 9, 11, 15, 17, 18, X, Y) and 7 single copy probes (2x5, 13, 17, 21, 2x22) were used. Aberrations were detected in 87% of the patients. Most cases showed 1–3 aberrations. There was a correlation between the number of aberrations per patient and the tumor stage. E.g. the percentage of patients with 7–12 aberrations increased from 16% in stage II to 28% in stage III. Gains and losses of chromosomes showed significant interchromosomal differences with gains being more frequent than losses. Chromosomes 3, 5, 7, 9, 21 and 22 showed predominantly gains. Losses were found in chromsomes 13, 17, X and Y. But monosomy of sex chromosomes (average age of 63.5 years) may be in part explained by the age of the patients. For chromosomes 15 and 18 a similar number of monosomies and trisomies was found which might be caused by mitotic nondisjunction. Deletions 13q14 (28%), gain of 11q13 and translocation of IgH locus 14q32 (79%) are specific aberrations detected in 39 patients analysed with specific DNA probes of the relevant loci. All three aberrations led to modified survival times of the patients. Summarizing our results in 130 patients with MM, we found that the number of numerical chromosomal aberrations as well as selected structural aberrations proved to be of diagnostic and prognostic relevance.
Association between Regimen Related Toxicity and Acute-Graft-Versus-Host Disease.
Authors: Copelan Edward A.
Published: October 2019

Tissue injury resulting from preparative therapy for transplantation is integral to the development of acute graft-versus-host disease (GVHD) according to current theory. If toxicity to normal tissues is a critical factor in the pathophysiology of GVHD, greater degrees of regimen related toxicities should be associated with a higher incidence and greater severity of GVHD. We analyzed 438 patients who underwent allogeneic transplantation from related (n=360) or unrelated (78) donors and who survived > 100 days following transplantation. Patients had received preparative regimens of BuCy (n=340) or BuCyVP16 (n=98). Median age was 36 (range 4–66). There were 263 males and 175 females. This cohort survived a median of 35 months (range 3 months to 20 years).

Sixty-eight of these patients had developed (Bearman) grade 3-4 regimen related toxicities. These patients had a 50% incidence of acute GVHD > grade II and a 26% incidence of developing GVHD ≤ grade II, compared to significantly lower incidences of 33% (P=.01) and 14% (P=.02) respectively in the group experiencing < grade 3 regimen related toxicity. Exclusion of patients whose GVHD prophylactic regimens were significantly altered because of toxicity did not significantly influence these results.

This data suggest that patients who develop severe regimen related toxicity are significantly more likely to develop severe acute GVHD, supporting a potential pathophysiologic role for tissue injury in the development of acute GVHD.
The Lymphocyte Recovery on Day +23 Correlates with Survival after Autologous Peripheral Blood Stem Cell Transplantation in Multiple Myeloma.
Authors: Kim Hawk , Kim Shin , Kim M. Wookun , Lee Jung-Shin , Suh Cheolwon
Published: October 2019

Absolute lymphocyte count (ALC) ≥1000 cells/mm3 on day +23 was an independent predictor of prolonged survival in patients with T/NK-cell lymphoma after autologous peripheral blood stem cell transplantation (APBSCT). To understand the prognostic value of lymphocyte recovery, we performed a retrospective study analyzing the result of 59 patients with multiple myeloma (MM) patients who underwent APBSCT. All patients were in complete or partial response after APBSCT. A median age at APBSCT was 51. Peripheral blood stem cells were mobilized and collected after cytoxan and G-CSF. The conditioning regimen was melphalan 200. ALC recovery day was defined as a first day of 3 consecutive days when ALC has been recovered more than 1000/mm3. A median value was used for the analysis of each noncategorical variable. A median follow-up time after APBSCT was 33.8 months and median recovery days of ALC ≥1000 cells/mm3 was 23 days. Prognostic factors at the time of APBSCT for transplant OS and PFS included beta-2 microglobulin, serum albumin, recovery days of neutrophil ≥500/mm3, infused mononuclear cell dose, infused CD+34 cell dose and recovery days of ALC ≥1000 cells/mm3. Univariate analysis revealed that significant variables at APBSCT for overall survival (OS) were beta-2 microglobulin, day of neutrophil engraftment and recovery days of ALC. Positive predictors at APBSCT for progression-free survival (PFS) were beta-2 microglobulin, day of neutrophil engraftment, serum albumin, infused mononuclear cell count, infused CD +34 cell count and recovery days of ALC. ALC ≥1000 cells/μL on day +23 was an independent predictive prognostic factors for better PFS (P = 0.003; Relative risk (RR) = 3.710; 95% Confidence interval (CI), 1.576–8.736) and showed tendency for prolonged OS (P = 0.065; RR=2.411; 95% CI, 0.946–6.142) (Table 1).In conclusion, ALC ≥1000 cells/mm3 recovery on day +23 was a good predictor for better survival in MM after APBSCT.

Table 1. Multivariate analysis for OS and PFS

Variables OS PFS RR 95% CI P RR 95% CI P ANC, absolute neutrophil count; MNC, Mononuclear cell; ALC, absolute lymphocyte count β2 microglobulin ≤ 3 vs > 3 mg/l 3.497 1.32–9.25 0.012 2.215 0.962–5.101 0.062 Serum albumin ≤ 3.7 vs > 3.7 g/dl 0.337 0.139–0.816 0.016 ANC≥ 500/mm³ recovery days≤ 11 vs > 11 2.677 1.044–6.864 0.040 1.360 0.616–3.001 0.447 Infused MNC dose≤ 3.4 vs > 3.4 ×10^8/kg 1.351 0.552–3.310 0.510 Infused CD+34 dose≤ 6 vs > 6 ×10^6/kg 0.609 0.209–1.779 0.365 ALC≥ 1000/mm³ recovery days≤ 23 vs > 23 2.411 0.946–6.142 0.065 3.710 1.576–8.736 0.003
Utilization Trends of Epoetin Alfa and Darbepoetin Alfa in Adult Patients with Cancer Receiving Chemotherapy in Community Practice Settings.
Authors: Coletti Ted , Howell Jamie B. , Todoroff Karen , Gregory Keith L. , Fastenau John M.
Published: October 2019

Background: Comparing dose utilization in actual practice in a defined patient population and setting for both epoetin alfa (EPO) and darbepoetin alfa (DARB) may improve understanding of the dose ratio at which these two agents are equally effective in those patients. The dose ratio is also important for providers and payers to gauge true comparative costs.

Objective: A cross-sectional study was conducted to understand utilization trends of EPO and DARB, estimate a dose ratio between these two agents, and compare weekly treatment costs in adult patients with non-myeloid malignancies receiving chemotherapy in community oncology practices.

Methods: Aggregated, de-identified data were obtained from a commercial drug ordering, inventory, and utilization database (OTN Lynx™ System) representing treatment patterns at the patient visit dosing level across approximately 800 community oncology practices nationwide. EPO and DARB medication records for adult patients with non-myeloid malignancies receiving chemotherapy during the period May 2003 through May 2004 were included. Monthly dosing trends for EPO and DARB were analyzed. Weekly treatment costs were estimated by applying 2004 Red Book-August Update average wholesale prices to mean weekly doses. Outcomes evaluated included: dosing frequency, mean weekly dose, dose ratio and weekly treatment costs.

Results: Data were contributed each month for an average of 6,379 EPO patients and 5,124 DARB patients. Frequency of administration for both agents remained constant. Most EPO patients received therapy weekly (QW) followed by every 2 week dosing (Q2W) while most DARB patients were dosed Q2W followed by QW dosing (EPO: QW 64%, Q2W 27%, other 9%; DARB: QW 19%, Q2W 61%, other 20%). Examination of the mean weekly doses (5/03 versus 5/04) showed an increase of 1.2% for EPO (35,735 to 36,169 Units) and 8.4% for DARB (122 to 132 mcgs) resulting in an overall decline in the EPO:DARB dose ratio (294:1 to 274:1). Weekly treatment costs showed a slight increase of $6.12 for EPO patients, but a notably greater increase of $50.76 for DARB patients.

Conclusions: The dose ratios over the 13-month study period were all less than the current ratio of 330:1 adopted by the Centers for Medicare and Medicaid Services for hospital outpatient reimbursement. Mean weekly dose and treatment costs remained relatively constant for EPO patients, but increased for DARB patients. These utilization data suggest treatment costs for EPO are consistently and markedly lower than those for DARB in community oncology patients.

Table 1

Month/Year 5/03 8/03 11/03 2/04 5/04 Mean dose per week EPO (Units) 35,735 36,034 36,738 36,143 36,169 Mean dose per week DARB (mcgs) 122 123 129 129 132 Dosing ratio EPO (Units): DARB (mcgs) 294 294 286 280 274 Weekly cost (USD) EPO $503.86 $508.08 $518.01 $509.62 $509.98 Weekly cost (USD) DARB $619.27 $624.35 $654.80 $654.80 $670.03
AMD107: Efficacy as a Selective Inhibitor of the Tyrosine Kinase Activity of BCR-ABL in Murine Leukemia Models.
Authors: Griffin James D. , Fabbro Doriano , Fendrich Gabriele , Huntly Brian , Jacob Sandra , Kung Andrew , Mestan Jurgen , Weisberg Ellen , Gilliland D. Gary , Manley Paul W.
Published: October 2019

Patient relapse due to the emergence of imatinib-resistance in advanced chronic myelogenous and Ph+ acute lymphocytic leukemias has prompted the search for improved Bcr-Abl kinase inhibitors. Up to 40% imatinib-resistant patients express mutant forms of the Bcr-Abl kinase that reduce binding of imatinib without significantly decreasing kinase activity. However, some mutants are only partially resistant, since higher concentrations of imatinib may still block kinase activity and have a beneficial clinical effect. More potent Bcr-Abl inhibitors or inhibitors with different contact points with the kinase domain are predicted to be useful for the treatment of imatinib-resistant disease. Rational drug design based upon the crystal structure of an Abl-imatinib complex, together with medicinal chemistry paradigms, resulted in the discovery of AMN107. AMN107 is a low molecular weight compound that selectively inhibits the c-Abl/Bcr-Abl, imatinib-resistant mutants of Bcr-Abl, PDGFR, and c-Kit tyrosine kinases, with IC50 values for the inibition of autophosphorylation (cell capture ELISA) of 23 nM (32D cells transfected with p210 Bcr-Abl), 83 nM (A31 cells) and 192 nM (GIST cells), respectively. Following oral administration to mice (20 mg/kg in NMP-PEG300 10:90 v/v), AMN107 was well absorbed, with a mean plasma level after 2 h in the range of 6.0-12.1 M, which corresponds to >100-fold that required to inhibit Bcr-Abl autophosphorylation in 32D.p210 cells. Following injection of 32D.p210-luciferase cells into Balb/c mice, serial imaging of the leukemic clone in live mice indicated that AMN107 could substantially reduce the accumulation of leukemic cells in the marrow, nodes, liver, and spleen, compared to a vehicle control. Further, administration of AMN107 (75 mg/kg/day p.o.) to BALB/c mice over an 18 day period, commencing 3 days after the injection of 32 D.p210 cells, resulted in the protection of 15/20 animals over 100 days observation, whereas 19/20 vehicle treated animals developed a lethal leukemic disease(all deaths occurred within 36 days of cell injection). The spleen sizes of the surviving animals in the treated group were in the normal range (0.142±0.043 g; n = 17), whereas those of the vehicle treated animals were 0.50±0.045 (n = 20). These results were confirmed in a bone marrow transplant assay, where AMN107 was found to prolong survival of mice transplanted with marrow cells infected with a p210Bcr/Abl retrovirus. AMN107 also prolonged survival of mice transplanted with a Bcr/Abl mutant (E255V) associated with imatinib resistance in patients, while imatinib treatment was unsuccessful. These in vivo studies, along with in vitro studies reported separately, indicate that AMN107 is a highly active inhibitor of Bcr/Abl that may have clinical utility in patients with Bcr/Abl+ leukemias.
VEGF Upregulates Mcl-1 Expression and Protects Multiple Myeloma Cells Against Starvation Induced-Apoptosis.
Authors: Le Gouill Steven , Podar Klaus , Amiot Martine , Hideshima Teru , Chauhan Dharminder , Ishitsuka Kenji , Kumar Shaji , Raje Noopur , Richardson Paul , Harousseau Jean-Luc , Anderson Kenneth
Published: October 2019

Vascular endothelial growth factor (VEGF) induces proliferation of MM cells and induces interleukin-6 (IL-6) secretion in a paracrine loop involving MM cells and bone marrow stromal cells. In turn, IL-6 triggers multiple myeloma (MM) cell proliferation and also protects against apoptosis by upregulating Myeloid-cell-leukemia 1 (Mcl-1), a critical survival protein in MM cells. The goal of our study was to investigate the role of Mcl-1 in VEGF induced-proliferation and protection against apoptosis. Using two murine embryonic fibroblast cell lines as a model (a Mcl-1 deleted cell line and its wild type: Mcl-1Δ/null and Mcl-1wt/wt MEFs, respectively), we here demonstrate that deletion of Mcl-1 reduces fetal bovine serum (FBS), VEGF, and IL-6 induced-proliferation. In addition, we demonstrate that the percentage of cells in S phase is lower in Mcl-1Δ/null compared to Mcl-1wt/wt MEFs (21% (+/−1) versus 30% (+/− 3), respectively). Taken together, these results demonstrate that Mcl-1 is required to mediate VEGF, Il-6 and FBS-induced-proliferation and cell cycle progression.

To highlight the key anti-apoptotic role of Mcl-1 in MM cells, humans MM1s cells were transfected with Mcl-1 siRNA. Specific inhibition of Mcl-1 was associated with decreased proliferation (42% and 61% decreases at 24 and 48 h, respectively) and induction of apoptosis (subG1 peak: 22% and 41% in Mcl-1 siRNA transfected cells versus 15% and 15 % in non-transfected cells at 24 and 48 h, respectively), confirming that Mcl-1 is critical for both proliferation and protection against apoptosis in MM cells. In 3 human MM cell lines (MM1s, U266 and MM1R) and MM patient cells we next showed that Mcl-1 protein expression, but not other bcl-2 family members, is upregulated by VEGF in a time and dose manner; and conversely that the pan-VEGF inhibitor GW654652, blocks VEGF induced-upregulation of Mcl-1. Furthermore using flow cytometry with a double staining (CD38-FITC and Apo 2.7-PE), we demonstrate that VEGF protects MM patient cells from FBS-starvation-induced-apoptosis: the percentage of apoptotic MM patient cells (CD38++ and Apo 2.7+) in non starved medium (RPMI 1640 supplemented with 10% FBS) was 15% versus 93% in starved medium (RPMI 1640 supplemented with FBS 2%), and 48% in starved medium supplemented with 25ng/ml VEGF. In conclusion, our study demonstrates that VEGF protects MM cells against apoptosis, and that VEGF-induced MM cell proliferation and survival is mediated via Mcl-1. these studies provide the preclinical framework for novel therapeutics targeting both Mcl-1 and/or VEGF to improve patient outcome in MM.