Celso Arrais Rodrigues

Evaluation of hemostasis and endothelial function in patients with paroxysmal nocturnal hemoglobinuria receiving eculizumab

Background Paroxysmal nocturnal hemoglobinuria (PNH) is associated with an increased risk of thrombosis through unknown mechanisms. Design and Methods We studied 23 patients with PNH, before and after five and 11 weeks of treatment with eculizumab. We examined markers of thrombin generation and reactional fibrinolysis (prothrombin fragment 1+2 (F1+2), D-dimers, and plasmin antiplasmin complexes (P-AP), and endothelial dysfunction tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1), soluble thrombomodulin (sTM), intercellular adhesion molecule 1 (sICAM-1), vascular cell adhesion molecule (sVCAM-1), endothelial microparticles (EMPs), and tissue factor pathway inhibitor (TFPI). Results At baseline, vWF, sVCAM-1, the EMP count, and F1+2 and D-dimer levels were significantly elevated in the patients, including those with no history of clinical thrombosis. Treatment with eculizumab was associated with significant decreases in plasma markers of coagulation activation (F1+2, P=0.012, and D-dimers, P=0.01), and reactional fibrinolysis (P-AP, P=0.0002). Eculizumab treatment also significantly reduced plasma markers of endothelial cell activation (t-PA, P=0.0005, sVCAM-1, P<0.0001, and vWF, P=0.0047) and total (P=0.0008) and free (P=0.0013) TFPI plasma levels. Conclusions Our results suggest a new understanding of the contribution of endothelial cell activation to the pathogenesis of thrombosis in PNH. The terminal complement inhibitor, eculizumab, induced a significant and sustained decrease in the activation of both the plasma hemostatic system and the vascular endothelium, likely contributing to the protective effect of eculizumab on thrombosis in this setting.

Alternative donor hematopoietic stem cell transplantation for mature lymphoid malignancies after reduced-intensity conditioning regimen: Similar outcomes with umbilical cord blood and unrelated donor peripheral blood

We have reported encouraging results of unrelated cord blood transplantation for patients with lymphoid malignancies. Whether those outcomes are comparable to matched unrelated donor transplants remains to be defined. We studied 645 adult patients with mature lymphoid malignancies who received an allogeneic unrelated donor transplant using umbilical cord blood (n=104) or mobilized peripheral blood stem cells (n=541) after a reduced-intensity conditioning regimen. Unrelated cord blood recipients had more refractory disease. Median follow-up time was 30 months. Neutrophil engraftment (81% vs. 97%, respectively; P<0.0001) and chronic graft-versus-host disease (26% vs. 52%; P=0.0005) were less frequent after unrelated cord blood than after matched unrelated donor, whereas no differences were observed in grade II–IV acute graft-versus-host disease (29% vs. 32%), non-relapse mortality (29% vs. 28%), and relapse or progression (28% vs. 35%) at 36 months. There were also no significant differences in 2-year progression-free survival (43% vs. 58%, respectively) and overall survival (36% vs. 51%) at 36 months. In a multivariate analysis, no differences were observed in the outcomes between the two stem cell sources except for a higher risk of neutrophil engraftment (hazard ratio=2.12; P<0.0001) and chronic graft-versus-host disease (hazard ratio 2.10; P=0.0002) after matched unrelated donor transplant. In conclusion, there was no difference in final outcomes after transplantation between umbilical cord blood and matched unrelated donor transplant. Umbilical cord blood is a valuable alternative for patients with lymphoid malignancies lacking an HLA-matched donor, being associated with lower risk of chronic graft-versus-host disease.

Venous thromboembolism and cancer: a systematic review

Venous thromboembolism (VTE) is a serious and potentially fatal disorder, which is often associated with a significant impact on the quality of life and on the clinical outcome of cancer patients. The pathophysiology of the association between thrombosis and cancer is complex: malignancy is associated with a baseline hypercoagulable state due to many factors including release of inflammatory cytokines, activation of the clotting system, expression of hemostatic proteins on tumor cells, inhibition of natural anticoagulants, and impaired fibrinolysis. Several risk factors, related to the patient, the disease, and the therapeutic interventions, have been identified as contributing to the occurrence of VTE. There is convincing evidence to recommend the use of heparins or fondaparinux for prevention of VTE in selected cancer patients, and, especially in some particular types of malignancies and cancer treatments. Management of VTE in patients with cancer is more challenging and bleeding complications associated with the use of anticoagulants are significantly higher in cancer patients than in those without malignancy. Important issues that need to be considered in all cases are interference with anticancer therapy, inconvenience of treatment, and impact on quality of life.

PROTHROMBIN G20210A MUTATION, AND NOT FACTOR V LEIDEN MUTATION, IS A RISK FACTOR FOR CEREBRAL VENOUS THROMBOSIS IN BRAZILIAN PATIENTS

Prothrombin G20210A mutation, factor (F)V Leiden mutation and oral contraceptive (OC) use were previously shown to be associated with an increased risk of cerebral venous thrombosis (CVT) [1–3]. We investigated the prevalences of prothrombin G20210A mutation, FV Leiden mutation and OC use in 42 consecutive patients with objectively confirmed diagnosis of CVT (median age of 28 years and 67% being women), and compared them with 134 healthy subjects, recruited from biologically unrelated acquaintances or partners of patients without history of venous thromboembolism (VTE) or known systemic diseases (median ageof34 years and 60% beingwomen). Prothrombin G20210A mutation was found in 16.7% of patients and 0.7% of the control group, yielding an odds ratio (OR) for CVT of 26.6 [95% confidence interval (CI): 3.2-223.5]. FV Leiden mutation was detected in 4.8% of patients and in 2.2% of the control group (OR: 2.2, 95% CI: 0.4–13.5). It is noteworthy that the majority of carriers of prothrombin G20210A mutation and FV Leiden mutation were Caucasian. Our prevalence of prothrombin G20210A mutation was similar to an Italian study (20%) [3], and to a previous Brazilian report with 14 CVT patients (14.3%) [4]. In accordance to previous reports [2,3], prothrombin G20210A mutation was a significant risk factor for CVT. The proportion of patients carrying FV Leiden was also similar to the previous Brazilian report (7.1%) [4], but lower as compared with the Italian series (15%) [3]. The high prevalence of the prothrombin G20210A mutation in Brazilian patients may derive from the ethnic background of the study populations. Brazilian general population has an extremely heterogeneous ethnic composition, unevenly distributed in the country with variable degrees of admixtures. Brazilian citizens of Caucasian descent originate mainly from Southern Europe (specially Portugal, Italy and Spain), where prevalence of the prothrombin G20210A mutation is twice as high as compared to Northern Europe [5]. Patients and controls had a heterogeneous ethnic distribution: among patients, 55% were Caucasians and 43% were of Caucasian and Black descent and among controls, 20% were Caucasians and 80% were of Caucasian and Black descent. It is important to point out that the high OR for the prothrombin G20210A mutation may be in part attributable to the relatively low frequency of Caucasians among controls, since carriers of prothrombin G20210A mutation were in general Caucasians. Eighty-nine percent of women had thrombosis between 20 and 50 years of age (Fig. 1). For this age group, 60% of the patients were OC users and 20% were in the puerperium when CVT was diagnosed. Among the five women with inherited thrombophilia, there were four who were also OC users. Among patients, 60% were OC users as compared to 12.5% of a historical control group of 40 consecutive women aged 20–50 that came as outpatients for reasons other than thrombosis (OR 1⁄4 10.5, 95% CI: 3.1–36.0). Our results confirmed previous findings of a higher frequency of CVT in women than in men, mostly during reproductive age when there is an excessive exposure to exogenous (OC) and endogenous (pregnancyrelated) sex hormones [1,3]. Eleven patients had acquired disorders that might be associated with CVT such as nephrotic syndrome, bacterial meningitis, antiphospholipid syndrome, Behçet’s disease, Crohn’s disease, sinusitis, homocystinuria, essential thrombocythemia and breast cancer. Both cases of CVT associated with meningitis were male patients with prothrombin G20210A mutation, and the patient with Crohn’s disease was also OC user. The prevalence of acquired disorders was higher in men (50%) than in women (14%), P 1⁄4 0.02. Overall, we found that among 42 consecutive patients with CVT, 72% had at least one acquired risk factor or predisposing condition for venous thromboembolism, six of whom were also carriers of prothrombin G20210A mutation (n 1⁄4 5) and FV Leiden mutation (n 1⁄4 1). Only 28% of patients had CVT spontaneously. Among the seven carriers of prothrombin G20210A mutation, only two subjects had no other known acquired predisposing condition for venous thromboembolism, suggesting that this mutation is usually associated with other risk factors in patients with CVT. Patients were re-evaluated 30 days after CVT diagnosis by two neurologists unaware of the genotypic results, and the functional clinical outcome was graded on the modified Rankin Scale [6]. Most patients (71%) had no activity limitations. There Correspondence: D. Lourenço, Division of Haematology and Transfusion Medicine., Universidade Federal de São Paulo., R. Botucatu, 740 3 o andar São Paulo-SP, Brazil. Tel.: +55 11 55764237; fax: +55 11 55718806; e-mail: dayse@webmail. epm.br

Acute myeloid leukemia in elderly patients: experience of a single center

Acute myeloid leukemia (AML) is a disease predominantly of older adults. Treatment of AML in the elderly is complicated not only by comorbidities but also by the high prevalence of poor prognosis markers. Thirty-one consecutive unselected patients with AML older than 60 years (representing 33% of all AML cases diagnosed at our institution during the same period) were followed over a period of 5 years (1997-2002). A high incidence of AML with multilineage dysplasia (45%) and no favorable cytogenetic abnormalities but 62% intermediate and 38% unfavorable karyotypes were found. Sixteen patients (52%) were selected for induction of intensive cytotoxic treatment and complete remission was achieved only by some of these intensively treated patients (7 of 16). Of these, 3 remained alive without disease (median: 11 months), 1 patient died shortly after complete remission, and 3 patients relapsed and died from refractory disease. Only 1 patient that was refractory to intensive cytotoxic treatment remained alive with disease under supportive care. Fifteen patients (48%) were managed with palliative/supportive care: 7 received palliative treatment and supportive care, 8 received supportive care only, and 4 patients remained alive with disease under supportive care (median: 9 months). Mortality rate was 74% and overall survival at two years was 12%. To the best of our knowledge, there is no previous report regarding elderly patients with AML in Brazilian subsets. The present data are similar to previously reported studies showing that elderly AML patients are not only older but also biologically distinct from younger AML patients, particularly in terms of the high incidence of poor prognostic karyotypes and resistance to therapy.

Hemoglobinúria paroxística noturna: da fisiopatologia ao tratamento

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder, an acquired chronic hemolytic anemia, often associated with recurrent nocturnal exacerbations, recurrent infections, neutropenia, thrombocytopenia, and episodes of venous thrombosis. Its clinical course is highly variable. It frequently arises in association with bone marrow failure, particularly aplastic anemia and myelodysplastic syndrome. It is also an acquired thrombophilia, presenting with a variety of venous thrombosis, mainly manifested with intra-abdominal thrombosis, here the major cause of mortality. The triad of hemolytic anemia, pancytopenia, and thrombosis makes a truly unique clinical syndrome of PNH, which was reclassified from a purely acquired hemolytic anemia to a hematopoietic stem cell mutation defect of the phosphatidyl inositol glycanclass-A gene. This mutation results in an early block in the synthesis of glycosylphosphatidylinositol (GPI) anchors, responsible for binding membrane functional proteins. Among these proteins are the complement inhibitors, especially CD55 and CD59, that play a key role in protecting blood cells from complement cascade attack. Therefore, in PNH occurs an increased susceptibility of red cells to complement, and consequently, hemolysis. We here review PNH physiopathology, clinical course, and treatment options, especially eculizumab, a humanized monoclonal antibody that blocks the activation of terminal complement at C5 and prevents formation of the terminal complement complex, the first effective drug therapy for PNH.

Proliferating cell nuclear antigen (PCNA), p53 and MDM2 expression in Hodgkins disease

CONTEXT AND OBJECTIVE Tumor cells in Hodgkins disease (HD) express cell proliferation markers that are evaluated according to the oncogenes involved or the expression of their proteins. Correlations between the protein expression grade and clinical data are now important for disease prognosis. DESIGN AND SETTING This was a retrospective analysis on proliferating cell nuclear antigen (PCNA), p53 and MDM2 (murine double minute-2) expression using immunohistochemistry, on formalin-fixed, paraffin-embedded tissues from diagnostic biopsies on 51 patients with HD. The study was conducted at the Division of Hematology and Transfusion Medicine, Hospital São Paulo, Universidade Federal de São Paulo. METHODS Antigen expression was evaluated as the proportions of positive Hodgkin and Reed-Sternberg (HRS) cells and reactive lymphocytes (L), which were compared using Spearman correlation coefficients. The Friedman test was used for comparisons between the markers. The Pearson test was used to investigate associations between marker expression and clinical and laboratory parameters, marrow involvement, complete remission (CR) and overall survival (OS) rates. RESULTS There was overexpression of antigen proteins in HRS, in relation to L (p < 0.001). In HRS, MDM2 was higher than p53 and PCNA (p < 0.003), while the latter two were equivalent. In L, p53 was lower than MDM2 and PCNA (p < 0.001), while the latter two were equivalent. There was no relationship between protein expression and clinical and laboratory variables or outcome. CONCLUSIONS PCNA, p53 and MDM2 are tumor markers for HD, but showed no clinical or prognostic significance in our analysis.

The Role of Transplantation in Diffuse Large B-Cell Lymphoma: The Impact of Rituximab Plus Chemotherapy in First-line and Relapsed Settings

Rituximab has improved the prognosis of patients with diffuse large B-cell lymphoma, but a high proportion of patients with advanced disease will relapse or will fail to achieve a remission with front-line treatment. Salvage chemotherapy, followed by high-dose chemotherapy or radiation therapy and autologous stem cell transplantation, remains the best treatment option for such patients, especially those who retain chemosensitivity. Allogeneic transplantation is under investigation in this setting, often as a treatment for relapse after autologous transplantation. Treatment-related mortality due to graft-versus-host disease, preparative regimen toxicity, and poor immune recovery often limits its benefits. This article reviews the role of hematopoietic stem cell transplantation in the treatment of diffuse large B-cell lymphoma, the incorporation of rituximab, and avenues of clinical investigation in this rapidly evolving field.

Amphotericin B-Induced Severe Hypertension in a Young Patient: Case Report and Review of the Literature

The description of the association between the use of amphotericin-B (amB) and the development of systemic arterial hypertension was only anecdotal so far. We describe the case of a 19-year-old female patient who had acute lymphoblastic leukemia and developed prolonged neutropenia after reinduction chemotherapy. Candida parapsilosis was isolated from blood cultures, and amB was started. Sustained severe arterial hypertension developed shortly after amB administration and continued for several hours after the infusion. Aldosterone, blood urea nitrogen, and creatinine levels were normal. After clinical improvement, amB was replaced by fluconazole, and blood pressure normalized. Severe hypertension may be an adverse event associated with AmB treatment that requires intensive treatment.

Diagnosis and treatment of chronic lymphocytic leukemia: recommendations from the Brazilian Group of Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia is characterized by clonal proliferation and progressive accumulation of B-cell lymphocytes that typically express CD19+, CD5+ and CD23+. The lymphocytes usually infiltrate the bone marrow, peripheral blood, lymph nodes, and spleen. The diagnosis is established by immunophenotyping circulating B-lymphocytes, and prognosis is defined by two staging systems (Rai and Binet) established by physical examination and blood counts, as well as by several biological and genetic markers. In this update, we present the recommendations from the Brazilian Group of Chronic Lymphocytic Leukemia for the diagnosis and treatment of chronic lymphocytic leukemia. The following recommendations are based on an extensive literature review with the aim of contributing to more uniform patient care in Brazil and possibly in other countries with a similar social–economic profile.