bluuebunny/crossref_metadata_2025 huggingface dataset:
Early or delayed transplantation for multiple myeloma in the era of novel therapy: does one size fit all?
Authors: Richardson Paul G. , Laubach Jacob P. , Munshi Nikhil C. , Anderson Kenneth C.
Published: October 2019

For the last 20 years, high-dose therapy with autologous stem cell transplantation (ASCT) for multiple myeloma has been considered a standard frontline treatment for younger patients with adequate organ function. With the introduction of novel agents, specifically thalidomide, bortezomib, and lenalidomide, the role of ASCT has changed in several ways. First, novel agents have been incorporated successfully as induction regimens, increasing the response rate before ASCT, and are now being used as part of both consolidation and maintenance with the goal of extending progression-free and overall survival. These approaches have shown considerable promise with significant improvements in outcome. Furthermore, the efficacy of novel therapeutics has also led to the investigation of these agents upfront without the immediate application of ASCT, and compelling preliminary results have been reported. Next-generation novel agents and the use of monoclonal antibodies have raised the possibility of not only successful salvage strategies to facilitate delayed transplantation for younger patients, but also the prospect of an nontransplantation approach achieving the same outcome. Moreover, this could be achieved without incurring acute toxicity or long-term complications that are inherent to high-dose alkylation, and melphalan exposure in particular. At present, the role of ASCT has therefore become an area of debate: should it be used upfront in all eligible patients, or should it be used as a salvage treatment at the time of progression for patients achieving a high quality of response with initial therapy? There is a clear need to derive a consensus that is useful for clinicians considering both protocol-directed and non-protocol-directed options for their patients. Participation in ongoing prospective randomized trials is considered vital. While preliminary randomized data from studies in Europe favor early ASCT with novel agents, differences in both agents and the combinations used, as well as limited information on overall survival and benefit for specific patient subsets, suggest that one size does not fit all. Specifically, the optimal approach to treatment of younger patients eligible for ASCT remains a key area for further research. A rigid approach to its use outside of a clinical study is difficult to justify and participation in prospective studies should be a priority.
Anticoagulants in children and adolescents
Authors: Young Guy
Published: October 2019

Thrombotic complications are increasing at a steady and significant rate in children, resulting in the more widespread use of anticoagulation in this population. Anticoagulant drugs in children can be divided into the older multitargeted agents (heparin, low-molecular-weight heparin, and warfarin) and the newer targeted agents (argatroban, bivalirudin, and fondaparinux). This review will compare and contrast the multitargeted and targeted anticoagulants and suggest situations in which it may be appropriate to use argatroban, bivalirudin, and fondaparinux. The various agents differ in their pharmacokinetics, requirements for therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects. The targeted anticoagulants have properties that may make them more attractive for use in specific clinical situations. Prospective clinical trial data are presented supporting the current and future use of these agents in children.
Management of prolymphocytic leukemia
Authors: Dearden Claire
Published: October 2019

B-cell (B-PLL) and T-cell (T-PLL) prolymphocytic leukemias are rare, poor-prognosis lymphoid neoplasms with similar presentation characterized by symptomatic splenomegaly and lymphocytosis. They can be distinguished from each other and from other T- and B-cell leukemias by careful evaluation of morphology, immunophenotyping, and molecular genetics. The clinical behavior is typically aggressive, although a subset of patients may have an indolent phase of variable length. First-line therapy for T-PLL is with intravenous alemtuzumab and for B-PLL is with combination purine analog-based chemo-immunotherapy. New B-cell receptor inhibitors, such as ibrutinib and idelalisib, may have a role in the management of B-PLL, especially for the patients harboring abnormalities of TP53. Allogenic stem cell transplantation should still be considered for eligible patients and may be the only current therapy capable of delivering a cure. In the past few years, many of the molecular mechanisms underlying disease pathogenesis and progression have been revealed and are likely to lead to the development of novel targeted approaches.
Germline DDX41 mutations define a significant entity within adult MDS/AML patients
Authors: Sébert Marie , Passet Marie , Raimbault Anna , Rahmé Ramy , Raffoux Emmanuel , Sicre de Fontbrune Flore , Cerrano Marco , Quentin Samuel , Vasquez Nadia , Da Costa Mélanie , Boissel Nicolas , Dombret Hervé , Peffault de Latour Régis , Socié Gérard , Itzykson Raphaël , Fenaux Pierre , Soulier Jean , Adès Lionel , Clappier Emmanuelle
Published: October 2019

This report presents the intriguing observation that cases with germline DEAD-box helicase 41 (DDX41) mutations represent a unique entity among adult myeloid neoplasms.
Extracellular RNA released due to shear stress controls natural bypass growth by mediating mechanotransduction in mice
Authors: Lasch Manuel , Kleinert Eike Christian , Meister Sarah , Kumaraswami Konda , Buchheim Judith-Irina , Grantzow Tobias , Lautz Thomas , Salpisti Sofia , Fischer Silvia , Troidl Kerstin , Fleming Ingrid , Randi Anna M. , Sperandio Markus , Preissner Klaus T. , Deindl Elisabeth
Published: October 2019

Key Points

Shear stress–induced release of RNA from endothelial cells is crucial for initiation of arteriogenesis by controlling mechanotransduction. Extracellular RNA is essential for VWF release from endothelial cells initiating the inflammatory process driving arteriogenesis.
Rapid progression of adult T-cell leukemia/lymphoma as tumor-infiltrating Tregs after PD-1 blockade
Authors: Rauch Daniel A. , Conlon Kevin C. , Janakiram Murali , Brammer Jonathan E. , Harding John C. , Ye B. Hilda , Zang Xingxing , Ren Xiaoxin , Olson Sydney , Cheng Xiaogang , Miljkovic Milos D. , Sundaramoorthi Hemalatha , Joseph Ancy , Skidmore Zachary L. , Griffith Obi , Griffith Malachi , Waldmann Thomas A. , Ratner Lee
Published: October 2019

The investigators present their analysis of primary cells from patients with human T-cell leukemia virus 1–associated adult T-cell leukemia/lymphoma treated in a phase 2 clinical trial with nivolumab to elucidate mechanisms of hyperprogression that halted the trial after just 3 patients received a single treatment.
OBSERVATIONS ON THE EFFECT OF MASSIVE DOSES OF IRON GIVEN INTRAVENOUSLY TO PATIENTS WITH HYPOCHROMIC ANEMIA
Authors: GOETSCH ANNE TOMPKINS , MOORE CARL V. , MINNICH VIRGINIA
Published: October 2019

Massive doses of iron (from 0.608 to 1.32 Gm. as colloidal terric hydroxide or colloidal ferric oxide) were given intravenously in single infusions to 8 different patients with hypochromic microcytic anemia. One patient was given a second injection after an interval of four months, so that nine administrations were made. The following observations were made:

1. The reticulocyte response was higher in each instance than would be expected in oral therapy. In 3 additional patients in whom injection had to be discontinued after 0.070, 0.180, and 0.123 Gm. of elemental iron had respectively been given, the reticulocyte rises were higher than were the average responses reported by Heath18 after optimal oral therapy. This at least suggests that "optimal" oral therapy does not provide a maximal stimulus to outpouring of reticulocytes from the bone marrow. Comparable doses of iron given to 3 control subjects with normal hemoglobin levels did not cause a reticulocytosis.

2. The average rate of hemoglobin regeneration per 100 cc. of blood per day was 0.224 Gm.; the lowest value was 0.16 Gm. and the highest 0.27 Gm. These figures were calculated for the rise that occurred from the day of iron administration to the time at which the rate of hemoglobin increase was obviously becoming slower. Since correction was not made for blood loss in 3 of the patients during the period of regeneration, the figures for the rate of hemoglobin formation are lower than they otherwise would have been. Even so they are distinctly greater than those usually obtained following oral therapy (table 2), but no greater than is found in an occasional patient given iron by mouth. The data suggest that the fastest rate of hemoglobin regeneration that can be stimulated by iron in subjects with hypochromic anemia approximates 0.3 Gm. per 100 cc. per day.

3. Calculations indicated that from 71.8 to 99.7 per cent of the injected iron was apparently used for the synthesis of hemoglobin. These figures are likewise lower than they would have been if several of the patients had not lost blood during the recovery period. The observation of other workers that parenterally administered iron is almost completely retained by the body and converted into hemoglobin was therefore confirmed.

4. Toxic reactions to the injected iron are described in detail. They were severe in all but two instances, and in 3 patients were so alarming that injection of iron had to be discontinued. There can be no doubt that the reactions to iron parenterally administered in large doses are great enough to contra-indicate use of this measure as a therapeutic procedure.
ERYTHROBLASTOSIS FETALIS IN THE FIRST-BORN
Authors: LEVINE PHILIP , WALLER R. K.
Published: October 2019

The incidence of fatal forms of erythroblastosis fetalis in the first-born can be diminished by the simple measure of transfusing all Rh negative female patients, even as infants, with Rh negative blood. Once a female patient is found to be Rh negative, all subsequent transfusions must be carried out with Rh negative blood. The indications are that sufficient human anti-Rh serums will become available for the more extensive Rh tests required for the prevention of iso-immunization by transfusion.
HEMATOLOGICAL CHANGES FOLLOWING THE ADMINISTRATION OF LARGE DOSES OF QUINACRINE HYDROCHLORIDE
Authors: MUSHETT CHARLES W. , SIEGEL HENRY
Published: October 2019

The administration of quinacrine to rats, mice, rabbits, hamsters, guinea-pigs, dogs, monkeys, chickens, and ducks results in definite hematological changes. Peculiar basophilic inclusions, usually associated with vacuoles, appear in the cytoplasm of lymphocytes of all nine species following drug therapy. Inclusions of a similar nature are seen in erythrocytes of the rat, mouse, and hamster and rarely in monocytes of the rat.

The rat shows an anemia, polynucleosis, lymphopenia, and monocytosis after quinacrine dosing. None of the other species develop a leukocytosis or monocytosis, but they sometimes show a polynucleosis and lymphopenia after quinacrine therapy. Leukopenia occurs in the monkey and occasionally in the dog following the use of this drug.
THE BLOOD GROUPS, SUBGROUPS, AND RH FACTOR OF THE MAPUCHE INDIANS OF THE PROVINCE OF CAUTÍN, CHILE
Authors: S. L. SANDOVAL , HENCKEL C. , GIVOVICH L.
Published: October 2019

The authors present a sero-anthropological study of 205 Mapuche Indians from Cautín (Chile). There were 86.8 per cent of group O, 8.3 per cent of subgroup A1, 0.5 per cent of subgroup A2, 3.4 per cent of group B, and 1.0 per cent of subgroup AB.

The 3.4 per cent group B in the series may be due to crossing with whites or to the fact that this group was always present in Mapuches even before contact with whites.

The frequency of the standard Rh factor percentage is very high (98.6 per cent) but not 100 per cent as in the data of North American investigators.
Severe Para-Aminosalicylic Acid Hypersensitivity
Authors: CANNEMEYER W. , THOMPSON J. R. , LICHTENSTEIN M. R.
Published: October 2019

A severe form of hypersensitivity to para-aminosalicylic acid in patients with tuberculosis was studied. The blood picture, lymph node biopsies, and imprints are described. The similarities between this hypersensitivity to a simple chemical and infectious mononucleosis and infectious hepatitis are discussed. The possibility is suggested that some of the findings in viral diseases are due to hypersensitivity to chemical substances derived from the virus rather than to infection per se.
Aleukemic Stem Cell Leukemia with Polyserositis
Authors: RAYNOLDS ARTHUR H. , OLIVETTI RENZO G. , EKSTRAND RICHARD W.
Published: October 2019

A case of acute leukemia is reported in which there was onset with pericardial and bilateral pleural effusions, simulating polyserositis.
Studies on Human Myoglobin
Authors: SINGER KARL , ANGELOPOULOS BASIL , RAMOT BRACHA
Published: October 2019

The problem whether patients with sickle cell anemia have not only a pathologic (type S) hemoglobin, but also an abnormal myoglobin, was investigated by means of spectroscopic and electrophoretic methods. Purified, hemoglobin-free met-myoglobin preparations, obtained from normal adults and from individuals with sickle cell anemia, were compared. No differences could be detected with either technic.

The electrophoretic studies revealed that adult met-myoglobin moves faster in an acid than in an alkaline buffer. Regardless of the buffer used, adult met-myoglobin moves always slower than either met-hemoglobin A or S. The met-compounds of hemoglobin A and S move faster than their respective oxy-compounds in an acid medium, but slower in an alkaline medium.
Immunologic Studies of Hemoglobins
Authors: RUCKNAGEL DONALD L. , CHERNOFF AMOZ I.
Published: October 2019

Changes in the concentration of fetal hemoglobin in maternal blood during pregnancy and after delivery were studied in 91 pregnant women. Significant elevations of fetal hemoglobin were detected in the blood of ten women during the second trimester of pregnancy; these values fell toward normal during the ensuing pregnancy and post partum periods. In no instance could a rise in fetal hemoglobin be detected after delivery. The significance of these observations is discussed; it is suggested that acute hormonal changes early in pregnancy may be responsible for the reactivation of a fetal erythropoietic anlage with the resultant production by the mother of erythrocytes containing fetal hemoglobin. The method used was not sensitive enough, however, to detect minute amounts of fetal blood which may have crossed the placental barrier.
An In Vitro Study of Antileukemic Serum
Authors: THOMPSON JOHN S.
Published: October 2019

1. A rabbit anti-DBA2-mouse-induced lymphogenous leukemia serum was prepared that contained antibodies to normal lymphocytic and to leukemic lymphocytic antigens, as determined by the complement fixation test of Thornton and his associates.

2. When this antiserum was incubated with normal lymphocytic antigen, all of its complement fixing activity was removed except that which reacted with the leukemic tissue. It appears that an antibody or group of antibodies was produced which was specific for this leukemia.

3. An antiserum to lymphogenous leukemia, induced in DBA2 mice, given prophylactically or therapeutically, did not significantly protect other DBA2 mice that had been inoculated with a transplantable leukemia of the same cell type.

4. The failure to induce leukemia in young, DBA2 female mice by painting them with 20-methylcholanthrene in benzene is reported.
Hemoglobin C Disease
Authors: HARTZ WILSON H. , SCHWARTZ STEVEN O.
Published: October 2019

1. The cases of four Negro patients with splenomegaly and targeting of the red cells are reported.

2. Electrophoretic analysis of the hemoglobin in these cases revealed type C hemoglobin exclusively.

3. An analysis of the genetic, clinical, and hematologic manifestations was made.

4. For convenience, the name hemoglobin C disease has been given to the mild hemolytic syndrome observed in these patients.

5. Electrophoretic recognition of hemoglobin C by filter paper and Tiselius technics is illustrated.

6. Differential diagnosis is discussed with special attention directed to the mild form of Mediterranean anemia.
Studies on Abnormal Hemoglobins
Authors: SINGER KARL , SINGER LILY , GOLDBERG SEYMOUR R.
Published: October 2019

(1) Four Negro patients with mild sickle cell-thalassemia disease (heterozygous for the genes for S hemoglobin and for thalassemia) are described. In contrast to reports in the literature, some of these patients are only mildly anemic, or not anemic at all. In three, the values for MCV and MCH are decreased, but in one, all hematologic indices are normal. All four individuals show leptocytosis and elevated reticulocyte levels.

(2) Hemoglobin analyses, consisting of a combination of electrophoresis and the alkali denaturation technic, demonstrate the S + A + F pattern in three, and the S + A pattern in the fourth. These patterns are considered pathognomonic for sickle cell-thalassemia disease. They may be sharply differentiated from the S + F pattern, encountered in classical (homozygous) sickle cell anemia, and from the A + S pattern found in the heterozygous sickle cell trait. The various types of hemoglobin are reported in the sequence of their quantitative representation in the hemolysate. Hemoglobin analysis is indispensable for the recognition of the different types of sickle cell disease.

(3) Evidence is cited that clinically almost asymptomatic sickle cell-thalassemia disease is probably not too rare in the American Negro population.

(4) The genetic aspects of the production of fetal hemoglobin are discussed. It is postulated that the production of fetal hemoglobin is also under genetic control. The genes for fetal hemoglobin are not alleles of the genes for normal adult hemoglobin and are physiologically almost completely suppressed by the latter. Pathologic genes may render this suppression incomplete.
Erythropoietic (Congenital) Porphyria: A Rare Abnormality of the Normoblasts
Authors: SCHMID RUDI , SCHWARTZ SAMUEL , SUNDBERG R. DOROTHY
Published: October 2019

1. In 5 patients with erythropoietic (congenital) porphyria, unstained bone marrow preparations were studied and photographed by fluorescence and absorption microscopy. The same marrow slides were also studied after ordinary staining.

2. Two morphologically different varieties of normoblasts were observed, which were designated as normal and abnormal cells. Normoblasts of the abnormal variety exhibited nuclear inclusion bodies containing hemoglobin.

3. Red fluorescence, indicative of porphyrin, was found only in normoblasts belonging to the abnormal cell variety. Normal normoblasts failed to exhibit red fluorescence.

4. The red fluorescence originated predominantly from the normoblastic nucleus. The fluorescence intensity of the cytoplasm was usually very low. Polychromatophilic erythrocytes also exhibited only weak fluorescence.

5. These findings indicate the coexistence of two different lines of normoblasts. The nuclei of cells belonging to the abnormal line probably form excessive amounts of porphyrins and may release them into the plasma in the course of cellular maturation. It is believed that these cells carry the abnormal trait representing the "inborn error of metabolism."

6. A critical review of all cases of porphyria, reported as "congenital," has shown that on the basis of the presented data, it was possible to establish the diagnosis of erythropoietic (congenital) porphyria beyond reasonable doubt in but 34 instances. Nineteen of the patients were female, fourteen were male. In a few families, more than one case was observed in the same generation, but in no instance was the disease recognized in subsequent generations.

7. Erythropoietic porphyria is a congenital disease, entirely distinct from hepatic photosensitive ("cutanea tarda") porphyria. No evidence has been found of a genetic mixture of these two forms of porphyria.
Splenic Aspiration Biopsy in the Dog
Authors: SWISHER SCOTT N. , DALE W. ANDREW
Published: October 2019

A method of partial marsupialization of the dog spleen which permits repeated aspiration biopsies of the spleen has been developed. Needle-core or open surgical biopsies may also be carried out on these dogs. The cytologic picture found in material from aspiration biopsies of dog spleens is described. Percutaneous splenic-portal venography or injection into the portal circulation may also be carried out by injecting directly into the marsupialized spleen.
Long-Term Tissue Culture of Human Bone Marrow
Authors: BERMAN LAWRENCE , STULBERG CYRIL S. , RUDDLE FRANK H. , CUNNINGHAM NANCY
Published: October 2019

Using methods described, long-term tissue cultures of human bone marrow pass through three typical growth phases : (1) a myeloid phase during which myeloid cells can be recognized; (2) a round-cell phase during which histioid and monocytoid cells predominate; and (3) a fibroblastic phase which can be maintained thereafter. The three phases are of variable onset and duration.

In a culture from a patient with carcinoma of the lung, isolated colonies of polygonal cells appeared on the 51st day of continuous cultivation. These were removed and subcultured. By means of trypsinization, the sheets of polygonal cells were transferred and subcultured in bulk and in a manner making it possible to obtain replicate cultures. The morphologic characteristics and growth behavior of the strain of cells (Detroit-6 strain) are similar to those observed for HeLa cells. The pattern of growth of the Detroit-6 strain is that of epithelial cells, presumably of metastatic origin from a carcinoma of the lung.

The susceptibilities of the Detroit-6 strain to infection with various viruses (poliomyelitis, Coxsackie, herpes simplex, and influenza) are similar to those observed in the HeLa strain of human malignant epithelial cells originating from a carcinoma of the cervix.

The possible values of long-term tissue culture of human bone marrow have been discussed.
Late Consolidation for Patients with Standard Risk AML up to 60 Years: Results of a Prospective Randomized Comparison of High Dose AraC and Autologous PBSCT.
Authors: Ganser Arnold , Krauter Jürgen , Hoelzer Dieter , Ottmann Oliver , Martin Hans , Lübbert Michael , Finke Jürgen , Heit Wolf , Fiedler Walter , Hossfeld Dieter , Kanz Lothar , Schlimok Günter , Kirchner Hartmut , Raghavachar Aruna , Brugger Wolfram , Heil Gerhard
Published: October 2019

421 patients (pts.) up to 60 years with de novo (n=328) or secondary (n=93) AML were treated with risk-adapted therapy. Pts. with CBF-leukemias [t(8;21) or inv(16)] or normal karyotype and good response (GR) to induction I (up to 5% blasts in day 15 BM) were considered standard risk (SR), all others as high risk (HR). Induction I consisted of standard dose araC, idarubicine and VP16 (IVA-I). Pts. with GR to IVA-I continued with IVA-II on day 21. In pts. with bad response, the second cycle consisted of either IVA-II or FlAG/Ida. Double induction was followed by early consolidation with intermediate dose araC. As late consolidation, SR patients were randomized between high dose (HD) araC (12 x 3g/m2)/daunorubicine (3 x 45mg/m2) or an autologous PBSCT with PBSC mobilized after early consolidation except SR pts. with normal karyotype and an HLA-matched sibling who were allotransplanted. 214 pts. were classified as SR and 199 as HR. 91% of the SR and 59% of the HR pts. achieved CR (overall CR rate 75%) and 1% of the SR pts. died during induction. After 55 months, overall survival was significantly better for SR (49%) than for HR pts. (25%). Within the SR group, relapse free survival at 46 months was 63% for 21 pts. with inv(16), 58% for 25 pts. with t(8;21), and 37% for 148 pts. with normal karyotype (p = 0.13). Overall survival at 48 months was significantly better (p=0.014) for pts. with inv(16) (93%) than for those with t(8;21) (60%) or normal karyotype (44%). 48 SR pts. (12 with CBF leukemia) were randomized to receive HDaraC and 53 (14 with CBF leukemia) to undergo autoPBSCT. At 55 months, the overall survival was 52% for the autotransplanted pts. and 65% for those receiving HDaraC (p=0.71, intent-to-treat analysis). Median duration of neutropenia (<500/ μl) was 8 days for autoPBSCT and 19 days for HDaraC. Eleven pts. died in the HDaraC group (4 in CR and 7 from relapse) and 12 autotransplanted pts. died (1 in CR and 11 from relaspe). In pts. with normal karyotype, overall survival at 55 months for the allotransplanted SR pts. (n = 29) was 58% with no significant difference to HDaraC (62%) or autoPBSCT (43%). Relapse free survival for SR pts. with normal karyotype was 56% after allotransplantation, and 36% after autoPBSCT and HDaraC respectively (p = n.s.). In conclusion, overall survival is similar in SR AML pts. after autoPBSCT, HDaraC or allotransplantation. In SR pts. without an HLA-identical sibling donor, the reduced treatment related toxicity recommends autoPBSCT as late consolidation. In standard risk pts. with normal karyotype, allotransplantation from an HLA-identical sibling seems to have the highest antileukemic activity.
HoxA9 Activates Transcription of the Gene Encoding Gp91phox, a Respiratory Burst Oxidase Protein, during Myeloid Differentiation.
Authors: Eklund Elizabeth A. , Bei Ling , Lu YuFeng
Published: October 2019

Transcription of the CYBB gene, which encodes the respiratory burst oxidase protein, gp91phox, is restricted to phagocytic cells, differentiated beyond the promyelocyte stage. Regulation of CYBB transcription involves several repressor cis elements in the promoter. These repressor elements are homologous to the derived consensus sequence for DNA-binding of HoxA10 as a hetero-dimer with Pbx1a. The HoxA10/Pbx1 complex recruits histone deacetylase 2 and represses CYBB transcription in undifferentiated cells. During myeloid differentiation, HoxA10 is tyrosine phosphorylated, which decreases DNA-binding affinity for the CYBB repressor element. In our previous investigations, we found this decreased binding affinity requires phosphorylation of two tyrosine residues in the DNA-binding homeodomain. These residues are highly conserved with other HoxA proteins. However, we also found decreased DNA-binding requires interaction of these homeodomain tyrosines with a non-conserved domain, amino terminal in HoxA10. In previous investigations, we determined these CYBB repressor cis elements function as positive cis elements in differentiated myeloid cells, and interact with an unidentified protein complex. In these studies, we investigate the proteins involved in transcriptional activation of the CYBB gene, via these promoter sequences. We find this cis element is activated by HoxA9 and Pbx1a, in differentiating myeloid cells. Consistent with this, we find increased binding of HoxA9 to this CYBB cis element, during myeloid differentiation, in vitro and in vivo. Consistent with our results with HoxA10, we find HoxA9 is tyrosine phosphorylated during myeloid differentiation. However, in contrast to HoxA10, we find tyrosine phosphorylation of the conserved residues in the HoxA9 DNA-binding homeodomain increases binding to the CYBB cis element. Therefore, we conclude HoxA10 and HoxA9 have opposing functions, for myeloid specific gene transcription, during differentiation. We also find these functions are regulated by post translational modification of conserved tyrosine residues in the homeodomain regions of these proteins. Additionally, our results suggest differences in the effect of phosphorylation of these residues on DNA-binding is likely due to interaction with non-conserved domains in HoxA9 and HoxA10.
Associations of DNA Repair Gene Polymorphisms in XRCC1 and ERCC2 with Clinical Outcome in ECOG Trial E9486.
Authors: Van Ness Brian , Blood Emily , Greipp Philip , Kay Neil , Rajkumar Vincent , Kyle Robert , Oken Martin , Fonseca Rafael , Zhao Fangyi
Published: October 2019

Although multiple myeloma is clinically defined as the accumulation of clonal, malignant plasma cells in the bone marrow, the disease shows significant heterogeneity with regard to morphology, progression and therapeutic response. Our hypothesis is that this heterogeneity likely is due, in part, to germline genetic polymorphisms that contribute significantly to an individual’s disease course and response. In particular, individuals deficient in the repair of DNA damage are not only at high risk for developing cancer, but also could show DNA repair dependent responses associated with DNA damaging therapeutic agents. In this study we examined the association of functional genetic polymorphisms in the DNA repair genes, XRCC1 (SNP positions 280, 399) and ERCC2 (SNP positions 312, 751), with toxicities and clinical outcomes in the ECOG, 3 arm chemotherapeutic trial, E9486 [A-VBMCP, B-VBMCP+Cylophosphamide, C- VBMCP+interferon]. DNA from 359 patients was genotyped and examined for association with response, toxicities, blood counts, bone pathology, and survival parameters. Notably, in the interferon arm of the trial significant associations were observed in progression free survival and polymorphisms of XRCC399 (AA median survival 51 months versus AG/GG median survival of 33 months; p=,008), ERCC751 (AA/AC median survival 33 months versus CC median survival of 48 months; p=.05), and ERCC312 (AA median survival 49 months versus AG/GG median survival of 34 months; p=.02). Hazard ratios ranged form 1.7 to 2.05 for survival differences associated with DNA repair genes in this arm. Interestingly, T cell counts are known to be impacted by interferon; and DNA repair polymorphisms in this arm were also associated with CD8+ T cell counts. While this represents a single arm of one clinical trial, it is intriguing to consider the impact of genetic polymorphisms on DNA repair in light of chemotherapeutic agents that may affect cells of the immune system. Previous studies from the ECOG Myeloma Committee of the E9486 trial show highly significant associations of survival and immune status in myeloma patients. Our results suggest genetic polymorphisms in DNA repair genes may influence clinical outcome in certain therapeutic regimens. Genetic polymorphisms in these DNA repair genes are currently being completed in 800 patients of the SW9321 SWOG/ECOG intergroup trial and additional association studies will be included in the presentation.
Marked Activity of Velcade Plus Thalidomide (V+T) in Advanced and Refractory Multiple Myeloma (MM).
Authors: Zangari Maurizio , Barlogie Bart , Hollmig Klaus , Fassas Athanasios , Rasmussen Erik , Thertulien Raymond , Talamo Giampaolo , Lee Choon-Kee , Tricot Guido
Published: October 2019

Based on an index patient who responded to V 1.0 mg/m2 + T 100 mg upon progression on V alone and documented prior resistance to T, a phase 1–2 trial was initiated of the V+T combination in patients with advanced and refractory MM, 79% with a history of cytogenetic abnormalities (CA) including 57% pre-V, 81% with one and 52% with 2 prior transplants (n=79). Due to concerns for synergistic neurotoxicity, V was initially given at a dose of 1.0 mg/m2 on days 1, 4, 8 and 11; with the second cycle on day 21, T was introduced at incremental doses, per cohorts of at least 10 patients, at 50, 100, 150 and 200 mg daily. In the absence of grade 3 neurotoxicity, V was then increased to 1.3 mg/m2 and the same T dose escalation scheme was applied. Accrual to the 7th cohort with V 1.3 mg/m2 + T 150 mg has been completed. Distribution of cohorts is as depicted in the attached table per V and T dose along with overall characteristics. First cycle PR to V alone was 25% including 10% achieving n-CR; maximum response was noted after completion of 2 additional cycles with combined V + T: 40% achieved PR and ~ 20% n-CR, 60% had ≥ 25% M protein reduction. Analysis of response rates by V and T cohorts (V 1.0 mg/m2, n=45; V 1.3 mg/m2, n=34) and T dose (T ≤ 100 mg, n=42; > 100 mg, n=37) revealed no significant differences in response rates: median EFS for all 79 patients is 7 mos and median OS 21 (at 12 mo 67% alive). On multivariate analysis of 17 potentially relevant prognostic markers, prior therapy > 5 yrs (36% of patients) was associated with improved survival (HR 0.4, p=.03) whereas prior T (78% of patients) was associated with inferior post-V+T survival (HR 4.1, p=.05). In addition, V 1.3 mg/m2 reduced the risk of events (HR 0.6, p=.07) and of death (HR 0.3, p=.02).
Bortezomib (VELCADE®) Plus Dexamethasone as Induction Treatment Prior to Autologous Stem Cell Transplantation in Patients with Newly Diagnosed Multiple Myeloma: Preliminary Results of an IFM Phase II Study.
Authors: Harousseau Jean-Luc , Attal Michel , Leleu Xavier , Gressin Remy , Hulin Cyrille , Fuzibet Jean-Gabriel , Troncy Jacques
Published: October 2019

When patients (pts) with newly diagnosed multiple myeloma (MM) are treated with autologous stem cell transplantation (ASCT), the standard induction therapy is a dexamethasone (Dex) based regimen. Currently, the use of VAD or Dex alone results in a complete remission (CR) rate of <10%. In an ongoing ECOG trial comparing Dex alone to the combination thalidomide plus Dex, preliminary results did not show a clear advantage of the combination (Rajkumar ASCO 2004). Since achievement of CR is a major objective in the treatment of MM, better therapeutic regimens are being investigated.

Bortezomib is currently approved in the US and in the EU for the treatment of relapsed/refractory MM. Both in vitro studies and preliminary clinical experience in relapsed/refractory pts have suggested that the combination of bortezomib and Dex could further improve the results achieved with bortezomib alone.

The IFM group initiated a Phase II open trial assessing the combination of bortezomib and Dex in pts with previously untreated MM and who are candidates for ASCT. The regimen consisted of bortezomib 1.3mg/m² iv on days 1, 4, 8, 11 and Dex 40 mg per os days 1–4, 9–12 (for the first 2 cycles, days 1–4 only for the last 2 cycles), administered on 4 consecutive 21 days cycles. Stem cell collection was performed just before cycle 4 after G-CSF priming. The primary objective of the study was CR rate after 4 cycles. As of August 1, 47 pts have been recruited and data is available for the first 18 pts. The median age is 53 years (38–63) Sixteen / 18 pts received 4 cycles: 1 patient progressed after 3 cycles and in one case the last two injections of bortezomib were not performed because of grade 3 neuropathy. The overall results were as follows: CR (negative electrophoresis) 3; very good partial remission (90% reduction of M component) 2; partial remission (50% reduction of the serum M component or 90% reduction of the urine M component) 10; failure (stable disease or progression ) 3. The overall response rate was 83% and the CR rate was 17%. Side effect were usually mild (grade 1/2); only one grade 3 neuropathy was recorded. In all cases stem cells could be adequately collected. These preliminary results appear to be very encouraging and the bortezomib / Dex combination appears effective and well tolerated in pts with newly diagnosed MM. The results will be updated at time of presentation. If updated analysis confirms currently available data, the IFM will start a large randomized phase III trial comparing VAD and bortezomib / Dex as induction treatment prior to ASCT in pts with newly diagnosed MM up to the age of 65.
Rare Concomitance of Primary Systemic Amyloidosis with Immunoglobulin M Monoclonal Gammopathy or Waldenstrom Macroglobulinemia.
Authors: Hecksel Kathleen A. , Lacy Martha Q. , Dispenzieri Angela , Gertz Morie A.
Published: October 2019

Introduction: Primary systemic amyloidosis occurs when a clonal plasma cell population secretes light chains (or light chain fragments) that deposit in tissues as amyloid and cause organ failure and ultimately patient death. Primary systemic amyloidosis generally results from non-proliferative small populations of plasma cells. While it is known that IgG, IgA and light chain producing plasma cells can secrete amyloid in association with myeloma, fewer medical professionals recognize that IgM-secreting lymphoplasmacytic cells can produce amyloid proteins. When monoclonal IgM secreting marrow lymphocytes are present, amyloidosis can result with or without overt Waldenstrom Macroglobulinemia.

Patients and Methods: All patients seen at the Mayo Clinic between January 1968 and August 2000 with both a serum IgM monoclonal protein and biopsy-proven amyloidosis were analyzed. The Mayo Clinic Dysproteinemia Database recognized 128 patients (42 female, 86 male) with a median age of 65 years.

Results: Seventy-two percent (n=92) of the patients have died with a median survival of 1.72 years following biopsy proven amyloidosis (figure 1). Median serum IgM monoclonal spike was 1.38 g/dL. In addition, serum IgM kappa to lambda light chain ratios (1:3) were found to be reversed in patients with IgM gammopathy when amyloid was present (compared to the reverse ratio (3:1) in patients with Waldenstrom macroglobulinemia in the absence of amyloidosis). Subcutaneous fat, rectum and bone marrow revealed amyloid in 72%, 69% and 70%, respectively, providing non-invasive techniques for amyloidosis diagnosis without the risks of bleeding associated with renal or hepatic percutaneous biopsy. Variables not shown to affect survival included the following: age, gender, serum M spike, urine protein, alkaline phosphatase, creatinine, light chain isotype, ejection fraction, and percent marrow plasma cells. The presence of amyloid cardiomyopathy (defined as a cardiac interventricular septal thickness greater than 12 mm.) was the only variable to adversely affect survival. Of the patients with echocardiographic evidence of cardiomyopathy, the median survival was 10.8 months. In contrast, the patients without echocardiographic evidence of cardiomyopathy at diagnosis had a median survival of 39 months (figure 2).

Conclusion: Amyloidosis is underappreciated and should be considered in the differential diagnosis of all patients presenting with IgM gammopathy. Patients found to have amyloidosis in this setting should be tested for amyloid cardiomyopathy, as its presence predicts poor outcome. Lambda light chain in serum IgM samples should increase the index of suspicion for the presence of amyloid since IgM lambda is present in only 25% of IgM MGUS or Macroglobulinemia patients but is seen in 75% of IgM amyloidosis patients.

Figure Figure
Anagrelide-Associated Cardiomyopathy in Polycythemia Vera and Essential Thrombocythemia.
Authors: Jurgens Donald J. , Moreno-Aspitia Alvaro , Tefferi Ayalew
Published: October 2019

Introduction : Anecdotal reports of “idiopathic” cardiomyopathy (ICM) in patients receiving anagrelide therapy have surfaced but not formally studied. We undertook a tertiary-center comprehensive study of ICM that was diagnosed in the setting of either polycythemia vera (PV) or essential thrombocythemia (ET).

Methods : Standard criteria were used for the diagnosis of both ET and PV. A diagnosis of ICM required echocardiogram documentation of a reduced left ventricular systolic ejection fraction (EF < 50%) as well as the absence of both coronary artery disease and other causes of cardiomyopathy. In order to avoid specific drug selection bias, we queried the entire Mayo Clinic Rochester database first for the diagnosis of ‘polycythemia’, ‘thrombocytosis’, or ‘thrombocythemia’ and subsequently cross-referenced the results with the diagnosis of either ‘cardiomyopathy’ or ‘heart failure’.

Results : Initial data inquiry yielded a total of 434 patients whose medical histories were thoroughly reviewed for the presence of an echocardiogram-documented ICM that post-dated a diagnosis of either ET or PV. Nine such patients (7 females; age range 46–78 years) were identified. Anagrelide therapy, at standard doses (median 2 mg/day), was temporally associated with ICM in 4 of the 9 patients while treatment in the remaining 5 patients consisted of either phlebotomy alone (3 patients) or other cytoreductive agents (2 patients). A similar database inquiry at Mayo Clinic Jacksonville identified 2 more patients with ICM that was temporally associated with anagrelide treatment. A normal echocardiogram was documented in 3 of the 6 patients with anagrelide-associated ICM at 2, 15, and 39 months prior to treatment (table 1).

Interval (months) Ejection fraction (%) Sex Diagnosis Diagnosis to ICM Anagrelide treatment to ICM Pre-treatment At ICM diagnosis Off-anagrelide therapy for 0.2–16 months F PV 66 60 69 30 and then 18 with continued anagrelide therapy 28 F ET 8 6 N/A 30 N/A F PV 120 36 N/A 20 66 F PV 156 13 73 35 55 F ET 108 10 N/A 35 44 F ET 108 11 58 10 34

Anagrelide therapy was immediately discontinued when ICM was diagnosed in 5 of the 6 patients and after further worsening of EF on continued anagrelide therapy in the sixth patient (first patient in table 1). All 6 patients with anagrelide-associated ICM experienced symptomatic improvement after drug discontinuation but the corresponding improvement in EF, after a period of 0.2–16 months, was often suboptimal (table 1). In contrast, ICM not associated with anagrelide therapy remained unchanged both in terms of symptoms and EF in all 5 cases.

Conclusion : Anagrelide-induced cardiomyopathy might occur in some patients with either PV or ET. Prompt recognition and drug discontinuation has the potential to adequately reverse the situation in some but not all patients.
Bone Marrow Biopsy and Aspirate Evaluation in 90 Patients with Essential Thrombocythemia Treated with PEG Interferon alpha-2b. Preliminary Results.
Authors: Gugliotta L. , Bulgarelli S. , Tieghi A. , Asioli S. , Gardini G. , Vianelli N. , Candoni A. , Latagliata R. , Rupoli S. , Martinelli V. , Zaccaria A. , De Biasi E. , Sacchi S. , Lauria F. , Miglino M. , Passamonti F. , Tabilio A. , Cacciola E. , Grossi A. , Pisapia G. , Favini P. , Baccarani M.
Published: October 2019

Ninety patients with Essential Thrombocythemia (ET) where object of a phase II prospective multicentre study designed to evaluate efficacy, safety and tolerability of a two years treatment with PEG Interferon α-2b (PEG Intron, Schering Plough). The patients, 30 M and 60 F, 18–72 years old (median 45), observed in 16 Hematological Institutions of the Gruppo Italiano Malattie Mieloproliferative Croniche (GIMMC), received the ET diagnosis according to the PVSG criteria. At PEG Intron treatment start the patients showed: previous cytoreduction 97% (IFN α 31%), platelet count >1000 x 109/L 81%, splenomegaly 22%. At the end of the first year The PEG Intron starting dose of 25 μg/week resulted increased to a mean value of 55 μg/week and the Hematological Response (HR = Plts <500x109/L) was registered in 79% of the patients still on treatment. At the end of second year 65 patient still receiving PEG Intron (mean dose 31 μg/week) showed a maintenance of the HR (66%), a Partial Response (17%) and a Minor Response (17%). By utilizing the data included in the study CRFs we preliminarily evaluated the bone marrow biopsy and aspirate both performed at baseline, after 1 and 2 years in 89 and 86, 79 and 67, 57 and 50 patients, respectively. Data concerning the bone marrow biopsies after 1 year of treatment are reported:

BONE MARROW BIOPSY BASELINE % 1 YR % 2 YRS % Cellularity increased 56 51 48 Granulopoiesis increased 51 54 39 Erytropoiesis increased 29 24 23 MK number increased 99 90 84 MK size increased 78 69 62 MK ploidy 54 51 42 MK dystrophy 52 56 59 Fibrosis mild 40 37 46 Fibrosis moderate 7 25 26

The increase of bone marrow fibrosis registered after one year (representative also of second year data) resulted not related to patient gender, age >45 years, platelet count >1000 x109/L, Hb <12 g/dL, splenomegaly, previous IFN treatment, PEG Intron dose >50 μg/week.

In conclusion, the present study shows that in ET patients a two years PEG Intron treatment, able to induce and to maintain the Hematological Response in the majority of cases, is associated to a decrease of bone marrow cellularity, granulopoiesis, erytropoiesis, MK number, size and ploidy and, moreover, with an increase of MK dystrophy and of bone marrow fibrosis. These preliminary data on bone biopsy and aspirate will be object of a planned centralized reevaluation by a Panel of Pathologists and Clinicians.
Possible Role of Rap1B in the Cross-Talk between Integrins α2β1 and αIIbβ3.
Authors: Guidetti Gianni , Bernardi Bruno , Balduini Cesare , Torti Mauro
Published: October 2019

Platelet adhesion to subendothelial collagen plays a key role in cell activation and thrombus formation. Two main receptors promote platelet binding to collagen, GPVI and integrin α2β1. It is now clear that both receptors are involved in signal transduction and platelet activation. Rap1B is a small GTPase highly expressed in platelets, and its activation is mediated by a number of agonists through multiple pathways involving PKC, Ca2+, as well as PI-3K. Although a role for Rap1B in integrin αIIbβ3 regulation has been documented, its involvement in integrin-mediated outside-in signaling and cross-talk between integrins has been poorly investigated. In this work we investigated the possible relationship between Rap1B and integrin αIIbβ3 activation mediated by platelet adhesion via integrin α2β1. Integrin α2β1-mediated adhesion has been investigated under static conditions. Monomeric collagen, decorin, and two different peptides obtained by digestion of collagen type II with CNBr (CB8 and CB11) have been used as integrin ligands. Rap1B activation in adherent cells has been evaluated by pull-down experiments using GST-RalGDS-RBD. Integrin αIIbβ3 activation in collagen adherent platelets has been monitored by measuring binding of biotinylated fibrinogen in a colorimetric assay. Integrin α2β1-mediated adhesion to monomeric collagen, decorin and collagen-derived peptides induced a rapid and sustained activation of Rap1B independently of secretion of ADP, production of thromboxane A2, or integrin αIIbβ3-dependent platelet aggregation. We further analysed the effect of several pharmacological inhibitors on Rap1B activation supported by integrin α2β1. Integrin α2β1-mediated platelet adhesion resulted in the activation of PLC, as revealed by the strong and sustained phosphorylation of pleckstrin. Inhibition of PLC by U73122 completely prevented Rap1B activation. We found that both PKC activation and intracellular calcium increase contributed to Rap1B activation in collagen adherent platelets. Platelet adhesion through integrin α2β1 also caused tyrosine phosphorylation of Src, Syk and PLCγ2. Inhibition of Src kinase by PP2 prevented tyrosine phosphorylation of PLCγ2, but had minimal effect on integrin α2β1-promoted pleckstrin phosphorylation. Moreover, inhibition of Src kinase by PP2 did not affect integrin α2β1-mediated Rap1B activation. Analysis of fibrinogen binding revealed that platelet adhesion via integrin α2β1 induces activation of integrin αIIbβ3 indicating a cross-talk between platelet integrin receptors. Binding of fibrinogen to integrin α2β1-adherent platelets was blocked by the same pharmacological inhibitors able to prevent Rap1B activation. By contrast, Src kinases did not appear to be involved in integrin α2β1-mediated integrin αIIbβ3 activation. These results demonstrated that Rap1B is activated downstream integrin α2β1-mediated platelet adhesion and suggest that it may be involved in the cross-talk between the collagen and the fibrinogen receptors.