Armando González Martín

Long‐term follow‐up in patients treated with Mini‐BEAM as salvage therapy for relapsed or refractory Hodgkin's disease

Several studies have focused on investigation of the optimal salvage regimen to induce maximum response before autologous stem cell transplantation (ASCT) in patients with relapsed or refractory Hodgkins disease (HD). However, in most of these studies, the follow‐up is relatively short. In the present study, we report on long‐term results of 55 consecutive patients with HD who received Mini‐BEAM [BCNU (carmustine), etoposide, cytarabine, melphalan] as salvage therapy before ASCT. Eleven patients were refractory to front‐line therapy, 17 were partial responders, and 27 patients had relapsed from HD. Twenty‐eight patients achieved complete response, and 18 achieved partial response with a median of two cycles of Mini‐BEAM, giving a total response rate of 84%. Significant factors predicting poor response (P < 0·05) were: initial treatment with MOPP (mechloroethamine, oncovin, procarbazine, prednisolone), ≥ two previous chemotherapy regimens and three disease characteristics at Mini‐BEAM treatment: presence of B symptoms, extranodal involvement or low serum albumin. However, only the last two factors retained independent influence on multivariate analysis. In total, 45/55 patients have been transplanted. Median follow‐up after Mini‐BEAM administration for living patients is 68 months. At the time of reporting, 31 out of 55 patients (56·4%) are still alive, 21 patients (38%) have relapsed, three (5·4%) have developed secondary neoplasias, and five have died of other complications not related to disease progression. The actuarial 7‐year overall survival (OS) was 52%, the progression‐free survival (PFS) 54% and the event‐free survival (EFS) 36%. The response to Mini‐BEAM was the most important prognostic factor for predicting the long‐term probability of surviving the disease: none of the eight patients who did not respond to Mini‐BEAM were alive at 3 years. On multivariate analysis, response to Mini‐BEAM and extranodal involvement before Mini‐BEAM had a significant influence on OS. Our results show the safety and efficacy of Mini‐BEAM before ASCT for refractory or relapsed HD patients.

Clinical significance of CD34+ cell dose in long-term engraftment following autologous peripheral blood stem cell transplantation.

The number of CD34+ cells has been described as the best parameter for predicting the quality of engraftment in peripheral blood progenitor cell (PBPC) transplantation in the early post-transplant period. In this study we have determined the optimal number of CD34+cells in order to maintain engraftment in the long term in a series of 100 patients receiving autologous PBPC transplantation. Based on our previous experience on the speed of early hematopoietic recovery, four subgroups of patients were established: patients infused less than 0.75 × 106/kg CD34+ (n = 9), 0.75 to 1.25 (n = 24), 1.25 to 2.0 (n = 37) and more than 2.0 (n = 30). These groups were designated as low, intermediate-low, intermediate-high and high CD34 groups, respectively. Transitory loss of neutrophil engraftment was observed in 67%, 30%, 16% and 6% of patients in the four mentioned CD34 groups respectively, with statistically significant differences between the different groups. Significant differences were also observed between the low CD34 group and the rest of the groups as regards platelet and red blood cell transfusion requirements, fever episodes, days of hospitalization and antibiotic requirements throughout the first year. Our results show that the dose of CD34+ cells influences engraftment also in the late post-transplant period, and correlates with transfusion and antibiotic requirements, fever episodes and days of hospitalization during the first year post-transplant.

Clinical significance of CD81 expression by clonal plasma cells in high-risk smoldering and symptomatic multiple myeloma patients

The presence of CD19 in myelomatous plasma cells (MM-PCs) correlates with adverse prognosis in multiple myeloma (MM). Although CD19 expression is upregulated by CD81, this marker has been poorly investigated and its prognostic value in MM remains unknown. We have analyzed CD81 expression by multiparameter flow cytometry in MM-PCs from 230 MM patients at diagnosis included in the Grupo Español de Mieloma (GEM)05>65years trial as well as 56 high-risk smoldering MM (SMM). CD81 expression was detected in 45% (103/230) MM patients, and the detection of CD81+ MM-PC was an independent prognostic factor for progression-free (hazard ratio=1.9; P=0.003) and overall survival (hazard ratio=2.0; P=0.02); this adverse impact was validated in an additional series of 325 transplant-candidate MM patients included in the GEM05 <65 years trial. Moreover, CD81+ SMM (n=34/56, 57%) patients had a shorter time to progression to MM (P=0.02). Overall, our results show that CD81 may have a relevant role in MM pathogenesis and represent a novel adverse prognostic marker in myeloma.

Multiparameter flow cytometry for the identification of the Waldenstrom's clone in IgM-MGUS and Waldenstrom's Macroglobulinemia: new criteria for differential diagnosis and risk stratification

Although multiparameter flow cytometry (MFC) has demonstrated clinical relevance in monoclonal gammopathy of undetermined significance (MGUS)/myeloma, immunophenotypic studies on the full spectrum of Waldenström’s Macroglobulinemia (WM) remain scanty. Herein, a comprehensive MFC analysis on bone marrow samples from 244 newly diagnosed patients with an immunoglobulin M (IgM) monoclonal protein was performed, including 67 IgM-MGUS, 77 smoldering and 100 symptomatic WM. Our results show a progressive increase on the number and light-chain-isotype-positive B-cells from IgM-MGUS to smoldering and symptomatic WM (P<.001), with only 1% of IgM-MGUS patients showing >10% B cells or 100% light-chain-isotype-positive B-cells (P<.001). Complete light-chain restriction of the B-cell compartment was an independent prognostic factor for time-to progression in smoldering WM (median 26 months; HR: 19.8, P=0.001) and overall survival in symptomatic WM (median 44 months; HR: 2.6, P=0.004). The progressive accumulation of light-chain-isotype-positive B-cells accompanied the emergence of a characteristic Waldenstrom’s phenotype (CD22+dim/CD25+/CD27+/IgM+) that differed from other B-NHL by negative expression of CD5, CD10, CD11c or CD103. In contrast to myeloma, light-chain-isotype-positive plasma cells in IgM monoclonal gammopathies show otherwise normal antigenic expression. Our results highlight the potential value of MFC immunophenotyping for the characterization of the Waldenström’s clone, as well as for the differential diagnosis, risk of progression and survival in WM.

Diagnosis of secondary myelodysplastic syndromes (MDS) following autologous transplantation should not be based only on morphological criteria used for diagnosis of de novo MDS

Secondary myelodysplastic syndromes (MDS) are increasingly being reported after autologous transplantation. Transient dysplastic changes have also been observed after this type of treatment. However, to the best of our knowledge no systematic morphological analysis has been perfomed to determine the influence of stem cell transplantation on bone marrow morphology. In 53 patients undergoing autologous transplantation, we evaluated the bone marrow, before and 6 and 12 months after the transplant, in order to analyze the appearance of dyshemopoietic changes, assessed according to a pre-established score. We also studied 25 bone marrow samples obtained at the time of diagnosis, prior to treatment, but we did not find morphological atypia. Six months after transplant, cellularity and thrombopoiesis had decreased in 38% and 49% of patients respectively, although 1 year after the process they were normal in most cases. Myelodysplasia was already present in bone marrow before transplantation and continued to be in evidence for a long time afterwards. This suggests that chemotherapy and radiotherapy used prior to transplantation are responsible for dysplastic changes. The myeloid line was the most affected with 100% of patients showing dysgranulopoiesis 1 year after autografting. Cytopenias were observed in 51% and 44% of patients 6 and 12 months after transplantation. Moreover, concomitant presence of cytopenia and myelodysplasia was observed in 37.7% of patients at 6 months after transplantation and 25% at 12 months, and therefore they could be diagnosed with MDS. These data contrast with the incidence of secondary MDS reported in earlier publications. According to these findings, the value of the French–American–British Co-operative Group criteria for the diagnosis of MDS following autologous transplantation is questionable. Moreover, since dyshemopoietic features are almost always present after autologous transplant, morphological criteria are not useful for early recognition of patients with secondary MDS after transplantation.

Multidisciplinary characterization of the long-bone cortex growth patterns through sheep’s ontogeny

Bone researches have studied extant and extinct taxa extensively trying to disclose a complete view of the complex structural and chemical transformations that model and remodel the macro and microstructure of bone during growth. However, to approach bone growth variations is not an easy task, and many aspects related with histological transformations during ontogeny remain unresolved. In the present study, we conduct a holistic approach using different techniques (polarized microscopy, Raman spectroscopy and X-ray diffraction) to examine the histomorphological and histochemical variations in the cortical bone of sheep specimens from intrauterine to adult stages, using environmentally controlled specimens from the same species. Our results suggest that during sheep bone development, the most important morphological (shape and size) and chemical transformations in the cortical bone occur during the first weeks of life; synchronized but dissimilar variations are established in the forelimb and hind limb cortical bone; and the patterns of bone tissue maturation in both extremities are differentiated in the adult stage. All of these results indicate that standardized histological models are useful not only for evaluating many aspects of normal bone growth but also to understand other important influences on the bones, such as pathologies that remain unknown.

Results of autologous transplantation in lymphoma are not improved by increasing the dose of etoposide in the BEAM regimen: a single-centre sequential-cohort study

Summary:We have undertaken a retrospective sequential-cohort analysis of 131 lymphoma patients treated with the BEAM regimen and autologous stem cell transplantation, to compare BEAM at standard doses (sBEAM; n=67 from May 1990 to April 1995) and BEAM with escalated etoposide dose from 800 to 1600 mg/m2 (eBEAM; n=64 from May 1995 to June 1999). Transplant-related mortality and incidence of secondary malignancies were similar in both groups. Disease progression was significantly lower in indolent lymphoma (IL) patients receiving eBEAM (7 vs 43%), although survival was comparable due to a higher toxic mortality in the eBEAM group. The 5-year event-free survival and overall survival were better in Hodgkins disease (HD) patients treated with eBEAM (70 and 77%, respectively) compared to sBEAM (58 and 69%, respectively), but the difference was not statistically significant. In aggressive lymphomas, no difference was detected between groups. Our results indicate that while escalation of the etoposide doses in the BEAM conditioning regimen does not appear to improve outcome, encouraging results in IL and HD may warrant further studies.

Effect of cumulative etoposide doses on the outcome of autologous peripheral-blood progenitor-cell transplantation for lymphoma

Summary:Studies evaluating the effects of previous chemotherapy on stem-cell yield and hematological recovery after autologous peripheral-blood progenitor-cell transplantation (PBPCT) have shown conflicting results. We have retrospectively analyzed 103 consecutive lymphoma patients treated with the BEAM regimen and autologous PBPCT. The impact of the different chemotherapeutic drugs (cumulative doses) on stem-cell yield and transplant-related toxicity was investigated. Highly significant differences in platelet recovery (>20 × 109/l) were observed between patients receiving less or more than 750 mg/m2 of etoposide before transplant (15 vs 29 days, P=0.001), and between patients receiving less or more than 1.2 × 106/kg CD34+ cells (27 vs 14 days, P<0.001). Differences in neutrophil engraftment between groups were not clinically significant. Pre-transplant cumulative doses of etoposide >750 mg/m2 were associated with low CD34+ cell collections on multivariate analysis. The actuarial incidence of transplant-related mortality (TRM) was 14% at 5 years. Pre-transplant cumulative doses of etoposide >350 mg/m2 and previous administration of procarbazine were found to be independent prognostic factors for TRM.

External and internal ontogenetic changes in the first rib

OBJECTIVES First ribs bear information about thorax morphology and are usually well preserved, compared to other ribs, in bone/fossil samples. Several studies have addressed ontogeny of the first rib by studying changes in bone microanatomy and rib morphology separately, but no studies have combined both approaches to study how internal and external changes covary during ontogeny. The aim of this project is to fill this gap in our knowledge. MATERIALS AND METHODS We applied 3D geometric morphometrics of sliding semilandmarks to 14 first ribs of Homo sapiens to quantify rib curvature and mid-shaft cross-section outline. Ontogenetic variation was addressed throughout a principal component analysis (PCA). Additionally, we made histological sections at the mid-shaft of the same ribs and studied tissue matrix composition and compartmentalization. Finally, we performed partial least squares (PLS) and regression analyses to study covariation between rib morphology and compartmentalization variables. RESULTS PCA shows that first ribs increase their curvature over the course of ontogeny and the rib midshaft becomes less rounded during ontogeny. In addition, the sternal end becomes more medially oriented during ontogeny and the relative head-tubercle distance becomes longer. Compartmentalization shows a decrease in the area occupied by mineralized tissues and an increase in the area occupied by non-mineralized tissues over the course of ontogeny, which covaries with mid-shaft cross-section shape. CONCLUSIONS Our results show detailed variation in rib morphology along with histological changes in bone tissue compartmentalization and, for the first time, the correlation between the two. This could be related to muscle attachments on the 1st rib and also to changes in breathing mode, from diaphragmatic in perinatals to pulmonary in adults, which could also have implications for understanding thorax evolution.

Geometric morphometrics reveals restrictions on the shape of the female os coxae

The methodology for sex determination in human skeletal remains depends on the different bone morphologies presented by men and women. Due to their direct implications in reproduction, the whole pelvis, particularly the os coxae, shows different characteristics in either sex. The sacrum and the os coxae constitute the birth canal. In this research study, the os coxae shape is analyzed using geometric morphometrics, providing information on morphology, regardless of size or any other factor beyond the geometry itself. A total of 46 adult ossa coxae from a Spanish archaeological collection were studied using geometric morphometrics. The results show that there is a restriction on the shape of female os coxae. In contrast, male os coxae presents a greater range of variation. The biological reason for this difference is the obstetrical dilemma; a concept defined as the anatomical conflict between bipedalism and the full‐term birth of a neonate whose large head requires greater dimensions in the pelvic cavity. Our experimental data reinforce the validity of the obstetrical dilemma as source of the restriction on the shape of female ossa coxae. Additionally, according to the results obtained, size itself does not represent a condition for belonging to one sex or another.