Disma Renda

Hepatocellular carcinoma in the thalassaemia syndromes

Hepatocellular carcinoma (HCC) frequently complicates hepatic cirrhosis secondary to viral infection or iron overload. Therefore, patients affected by thalassaemia syndromes have a theoretically high risk of developing the tumour. We collected data on patients attending Italian centres for the treatment of thalassaemia. Twenty‐two cases of HCC were identified; 15 were male. At diagnosis, the mean age was 45 ± 11 years and the mean serum ferritin was 1764 ± 1448 μg/l. Eighty‐six percent had been infected by hepatitis C virus. Nineteen of 22 cases were diagnosed after 1993, suggesting that this problem is becoming more frequent with the aging population of thalassaemia patients.

Oral supplements of vitamin E improve measures of oxidative stress in plasma and reduce oxidative damage to LDL and erythrocytes in β-thalassemia intermedia patients

Fifteen β-thalassemia intermedia patients, not requiring chronic transfusional therapy, were monitored in order to check their antioxidant status, and the lipid oxidation products in plasma, LDL, and erythrocytes before and during a 9-month oral treatment with 600 mg/day vitamin E. The low level of vitamin E, and high level of malondialdehyde in plasma clearly tended to normalize after three months (P<.001), and were quite similar to control after six months. The abnormally low level of vitamin E in LDL and the four times higher than control basal level of conjugated dienes (LDL-CD), were not modified after three months of treatment. Significant changes of LDL-VE (P<.05) and of the basal LDL-CD (P<.001) were evident after six months. LDL-VE was within the normal range after nine months, whereas LDL-CD still appeared twice as higher than control. Plasma vitamin A, ascorbate, β-carotene, and lycopene increased markedly at the end of the trial (P<.005). The level of vitamin E in red blood cells was normalized after six months of supplementation. A decrease of the baseline value of conjugated dienes was observed after nine months, although it remained 1.4-fold higher than control. The RBC count and hematocrit appeared higher at the end of the trial (P<.05 and P<.001, respectively). The hemoglobin value did not show variations. A shift to normal of the resistance of erythrocytes to osmotic lysis was observed. Our findings provide evidence that an oral treatment with vitamin E improves the antioxidant/oxidant balance in plasma, LDL particles, and red blood cells, and counteracts lipid peroxidation processes in β-thalassemia intermedia patients.

Significance of borderline hemoglobin A2 values in an Italian population with a high prevalence of β-thalassemia

This study shows that borderline hemoglobin A2 values are not a rare event in a population with a high prevalence of beta-thalassemia carriers. These cases should be investigated at a molecular level, particularly if the partner is a carrier of beta-thalassemia. We report a retrospective analysis carried out on 23,485 subjects submitted to a screening program from 2000 to 2006. Of these subjects, 3,934 had borderline HbA2 values from 3.1 to 3.9%; 410 samples, analyzed previously using PCR methods and sequencing because all of these were partners of a carrier of classical β-thalassemia, were selected for statistical analysis. Of 410 subjects, 94 (22.9%) were positive for a molecular defect in the β-, δ- or α-globin genes. The most prevalent molecular defects were β IVS1 nt 6 (HBB c.92+6T C), co-inheritance of severe β thalassemia and δ mutations, β-promoter mutations and triplication of α genes were detected; α-thalassemia and Hb-variants were also evident. Borderline HbA2 is not a rare event in a population with a high prevalence of β-thalassemia carriers. These data support the necessity to investigate these cases at a molecular level, particularly if the partner is a carrier of β-thalassemia.

The significance of the hemoglobin A2 value in screening for hemoglobinopathies

BACKGROUND AND OBJECTIVE The inherited hemoglobinopathies are a large group of disorders that include thalassemias and hemoglobin variants. Accurate determination of the carrier phenotype is essential for detecting couples at risk for producing offspring with hemoglobinopathy. Heterozygous beta-thalassemia is usually silent at the clinical level. His phenotype is characterized by microcytosis and hypochromia with increased hemoglobin A(2) (HbA(2)) value. Therefore, HbA(2) determination plays a key role in screening programs for hemoglobinopathy. The aim of this review is to address and suggest an approach for reducing or abolishing hemoglobinopathy screening mistakes. DESIGN AND METHODS Quantitative methods for HbA(2) value determination, comment on the accuracy of the test and on the interpretation of data were discussed. The most probable diagnostic conclusion based on the HbA(2) level, hemoglobin pattern, hematological parameters and iron markers was suggested in this review. RESULTS Hemoglobinopathies are the only genetic disease where it is possible to detect carriers using hematological findings rather than DNA analysis. However, hematological diagnosis is sometimes presumptive, and in these cases, DNA analysis becomes necessary. Complete screening is based on the detection of red cell indices, HbA(2), HbF and hemoglobin variant values. In particular, HbA(2) determination plays a key role in screening programs for beta-thalassemia because a small increase in this fraction is one of the most important markers of beta-thalassemia heterozygous carriers. CONCLUSION Genetic factors both related and unrelated to the beta- and alpha-globin gene clusters, iron metabolism, endocrinological disorders, and some types of anemia, together with intra- and inter-laboratory variations in HbA(2) determination, may cause difficulties in evaluating this measurement in screening programs for hemoglobinopathies. Therefore, knowledge of all these issues is important for reducing or eliminating the risk of mistakes in screening programs for hemoglobinopathies.

Hepatocellular carcinoma in patients with thalassaemia syndromes: clinical characteristics and outcome in a long term single centre experience

Hepatocellular carcinoma (HCC) is the fourth cause of cancerrelated death world-wide and the third most common tumour in men (Parkin, 2001). Hepatitis B virus (HBV) and hepatitis C virus (HCV) chronic infection cirrhosis (Bruix et al, 2001) and primary or secondary haemochromatosis (Kowdley, 2004) are the major risk factors. Usually HCC is a late complication of cirrhosis of any cause with a very poor prognosis (Bruix et al, 2001). Survival is related to early diagnosis, the extent of the underlying liver disease and the suitability for treatment. The latter aspect was generally low in the past because advanced cirrhosis was observed in the majority of cases of HCC, precluding almost all therapeutic options. Recently, the use of liver ultrasound screening and alphafetoprotein (AFP) serum level determination have increased the diagnostic rate of HCC at an early stage and in compensated cirrhosis; this, of course, improved suitability for treatment and has prolonged survival. Thalassaemia major (TM) and thalassaemia intermedia (TI) transfused patients, particularly those born before 1990, are frequently chronically infected with HCV or/and HBV, related to blood transfusion. For nearly all of them, iron overload – secondary to ongoing transfusion therapy – is a primary cause of organ damage and mortality. With improved survival of thalassaemic patients, (BorgnaPignatti et al, 2004, 2005; Cohen et al, 2004; Vento et al, 2006), achieved using iron chelating drugs for iron overload (Maggio, 2007; Maggio et al, 2009) and regular transfusions, HCC has become a more commonly reported complication and cause of mortality in thalassaemia (Borgna-Pignatti et al, 2004; Mancuso et al, 2006). This report describes, in a homogeneous cohort of thalassaemia patients, the clinical characteristics and outcome of HCC cases in a long-term single centre experience. The HCC yearly incidence in thalassaemia – 2% – is almost the same as that in nonthalassaemic patients (Mancuso et al, 2006). Three hundred and forty-six thalassaemic patients (135 TM, 211 TI; 59 transfused, 152 untransfused) with risk factors for HCC underwent semiannual ultrasound (US) evaluation by a skilled hepatologist ultrasonographer as well as AFP serum determination. The risk factors for HCC were defined as follows: increased serum ferritin (at least 2 determinations >1000 lg/l) or increased liver iron concentration (LIC) >4 mg/g dry weight in liver samples or both; HCV-RNA positivity by polymerase chain reaction and anti-HCV positivity; hepatitis B surface antigen (HBsAg) positivity; histological diagnosis of cirrhosis. Exclusion criteria were: age <18 years or a previous diagnosis of HCC. Nine cases of HCC were detected between January 2000 and October 2009, three cases in TM (two males, one female) and six cases in TI (three males, three females). All TI patients except one were regularly transfused. The mean age was 54Æ8 years (59Æ25 women, 51Æ4 men). Mean serum ferritin in the 2 years before diagnosis was 1049 ± 721 lg/l (Table I).

Desensitization to hydroxycarbamide following long-term treatment of thalassaemia intermedia as observed in vivo and in primary erythroid cultures from treated patients.

Hydroxycarbamide (HC) is a pharmacological agent capable of stimulating fetal haemoglobin (HbF) production during adult life. High levels of HbF may ameliorate the clinical course of β‐thalassaemia and sickle cell disease. The efficacy of HC for the treatment of thalassaemia major and thalassaemia intermedia is variable. Although an increase of HbF has been observed in most patients, only some patients experience significant improvement in total haemoglobin levels. This study aimed to determine the effectiveness and safety of short‐ (1 year) and long‐term (mean follow‐up 68 months) HC treatment in 24 thalassaemia intermedia patients. Additionally, we evaluated if primary erythroid progenitor cells cultured from treated patients responded to HC treatment in a manner similar to that observed in vivo. Our results confirm a good response to HC after a short‐term follow‐up in 70% of thalassaemia intermedia patients and a reduction of clinical response in patients with a long follow‐up. Erythroid cultures obtained from patients during treatment reproduced the observed in vivo response. Interestingly, haematopoietic stem cells from long‐term treated patients showed reduced ability to develop into primary erythroid cultures some months before the reduction of the ‘in vivo’ response. The mechanism of this loss of response to HC remains to be determined.

The genetic heterogeneity of β-globin gene defects in Sicily reflects the historic population migrations of the island

The aim of this study is to update the incidence and the distribution of the globin gene defects causing β-thalassemia and abnormal hemoglobins in Sicily. The data derived from a total of 8875 beta-thalassemia alleles and 1330 variant hemoglobin chromosomes studied in Sicily from 1990 during a hemoglobinopathy control program. Fifty-four beta-globin gene defects were characterized, involving 30 different beta-thalassemia mutations and 24 variant hemoglobins. Eight of 30 β-thalassemia defects accounted for 95.11% of examined alleles while other beta-globin gene defects were found at lower frequencies (<1%). A consistent number (24) of variant hemoglobins were identified of whom Hb S was the most represented (72.1%). Our data underline the heterogeneity of the beta-globin gene defects in the Sicily. The enormous progress in the technique for β-globin gene analysis permitted to characterize 99.93% of mutated alleles and it has made a first trimester prenatal diagnosis program possible in our region in all cases with a great improvement in thalassemia management. The origin of the large spectrum of mutations is discussed taking in consideration the history of the island.

CLINICAL AND HEMATOLOGICAL RESPONSES TO HYDROXYUREA IN SICILIAN PATIENTS WITH Hb S/β-THALASSEMIA

Although, several reports have detailed that hydroxyurea can ameliorate the clinical course of adult and pediatric patients with sickle cell anemia (Hb S or βS), few clinical studies have been carried out in patients with βS/β-thalassemia. In a two-year clinical study, we evaluated the efficacy of hydroxyurea in a group of 22 adult Sicilian patients with βS/β-thalassemia with severe phenotypes. Among the 20 patients evaluated during 2 years of treatment, we observed a very good clinical response with a 93% reduction of the annual number of crises (median 7 versus 0.5 crises per year; P ≤ 0.001) and of days in hospital (mean 22±21.9 versus 1.2±2.3; P < 0.001), a significant increase in Hb F (7.5±5.3% versus 25.2±5.2%; P < 0.001) and in MCV (73.1±4.8 fL versus 96.4±7.2 fL; P < 0.001), and no significant modifications in Hb (9.6±1.3 g/dL versus 10.0±1.5 g/dL; P > 0.05) and in WBC (11.4±3.9 × 109/L versus 10.2±3.9 × 109/L; P > 0.05). Twelve patients had no crises from the first month of treatment; 16 patients showed a 2–3-fold increase over baseline in Hb F. During the study no severe complications and no important side effects of hydroxyurea were observed. Our data suggest that hydroxyurea efficacy in patients with βS/β-thalassemial may be greater than that described in patients with sickle cell disease. This pattern and durability of response will need to be confirmed in a larger, randomized, clinical trial.

Treatment with hydroxycarbamide for intermedia thalassaemia: decrease of efficacy in some patients during long-term follow up

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Hepatic sickling: an unusual cause of liver allograft dysfunction.

Orthotopic liver transplantation can be performed successfully in thalassemia. In this article, we describe a case of liver transplantation in a patient with sickle cell/beta-thalassemia complicated by liver sickling. Intrahepatic sickling must be considered in case of allograft dysfunction. This condition can easily be diagnosed by biochemical investigation and liver ultrasonography.