Evarist Feliu

Bone Marrow Changes in Anorexia Nervosa Are Correlated With the Amount of Weight Loss and Not With Other Clinical Findings

The clinical history and biochemical and hematologic variables for 44 consecutive patients diagnosed with anorexia nervosa were recorded. Bone marrow aspirates and biopsy specimens were analyzed by standard morphologic procedures, and bone marrow adipocytes were studied morphometrically. The bone marrow of the 44 patients was classified as normal (5 cases [11%]), hypoplastic or aplastic (17 [39%]), with partial or focal gelatinous degeneration (13 [30%]), or with complete gelatinous degeneration of the bone marrow (GDBM; 9 [20%]). These patterns correlated with amount of weight loss (P = .005) but not other clinical findings. WBC counts were lower in patients with GDBM (P = .0189), but this and other peripheral blood variables did not always reflect the severity of bone marrow damage. Hypoplastic or aplastic bone marrow showed an increase in bone marrow fat fraction due to an increase in adipocyte diameters, while in GDBM, fat fraction and adipocyte diameters decreased. Morphologic changes in bone marrow and stereologic alterations in bone marrow adipocytes may be observed in anorexia nervosa. The extent of damage is related to the amount of weight loss, not to other factors. Peripheral blood cell counts may not reflect the extent of damage. In some patients, this process may be reversible with reestablishment of adequate nutritional intake.

Hepatosplenic T-Gammadelta Lymphoma in a Patient with Crohn's Disease Treated with Azathioprine

Hepatosplenic γ δ T-cell lymphoma (HS γ δ TCL) is an uncommon type of peripheral T-cell lymphoma, which has been associated in some cases with immunosuppression, mainly after solid organ transplants. We describe a case of HS γ δ TCL with a leukaemic course in a patient with Crohns disease who had received azathioprine during the previous 55 years. Sinusoidal infiltration by atypical lymphocytes was observed in the liver, spleen and bone marrow and the typical cytogenetic abnormalities (isochromosome 7 and trisomy 8) were found. The patient did not respond to intensive chemotherapy. This case shows the importance of ruling out HS γ δ TCL in patients with hepatosplenomegaly, B-symptoms and any immunosuppressive condition.

Outcome and prognostic factors in patients with hematologic malignancies admitted to the intensive care unit: a single-center experience.

Patients who are admitted to the intensive care unit (ICU) with hematologic malignancies have a poor prognosis, although outcomes have improved in recent years. This study analyzed ICU mortality, short- and long-term survival, and prognostic factors for 100 consecutive critically ill patients with a hematologic malignancy who were admitted to our polyvalent ICU from January 2000 to May 2006. The median age was 55 years (range, 15-75 years; male-female ratio, 60:40). The main acute life-threatening diseases precipitating ICU transfer were respiratory failure (45 patients, 45%) and septic shock (33 patients, 33%). Forty-two patients (42%) were discharged from the ICU.The ICU mortality rate from 2004 to 2006 was lower than from 2000 to 2003 (49% versus 69%,P < .047).The 1- and 2-year probabilities of survival for patients discharged from the ICU were 67% (95% confidence interval [CI], 51%-84%) and 54% (95% CI, 34%-73%), respectively. A multivariate analysis revealed hemodynamic instability (odds ratio, 2.11; 95% CI, 1.17-3.83;P = .014) and mechanical ventilation (odds ratio, 4.27; 95% CI, 1.70-10.74;P = .002) to be the main predictors of a poor survival prognosis. Almost half of patients with hematologic malignancy and life-threatening complications can be discharged from the ICU. Age and underlying disease characteristics do not influence ICU outcome, which is mainly determined by hemodynamic and ventilatory status.

Clinical significance of occult cerebrospinal fluid involvement assessed by flow cytometry in non-Hodgkin’s lymphoma patients at high risk of central nervous system disease in the rituximab era

Background and aim:  Flow cytometry (FCM) analysis of cerebrospinal fluid (CSF) is more sensitive than conventional cytology (CC) for diagnosis of lymphomatous meningeosis, but the clinical significance of occult central nervous system (CNS) disease (positive FCM with negative CC) remains unknown.

Predictive factors for poor peripheral blood stem cell mobilization and peak CD34+cell count to guide pre-emptive or immediate rescue mobilization

BACKGROUND AIMS Failure in mobilization of peripheral blood (PB) stem cells is a frequent reason for not performing hematopoietic stem cell transplantation (HSCT). Early identification of poor mobilizers could avoid repeated attempts at mobilization, with the administration of pre-emptive rescue mobilization. METHODS Data from the first mobilization schedule of 397 patients referred consecutively for autologous HSCT between 2000 and 2010 were collected. Poor mobilization was defined as the collection of < 2 × 10(6) CD34(+)cells/kg body weight (BW). RESULTS The median age was 53 years (range 4-70) and 228 (57%) were males. Diagnoses were multiple myeloma in 133 cases, non-Hodgkins lymphoma in 114, acute myeloid leukemia or myelodysplastic syndrome in 81, Hodgkins lymphoma in 42, solid tumors in 17 and acute lymphoblastic leukemia in 10. The mobilization regimen consisted of recombinant human granulocyte-colony-stimulating factor (G-CSF) in 346 patients (87%) and chemotherapy followed by G-CSF (C + G-CSF) in 51 (13%). Poor mobilization occurred in 105 patients (29%), without differences according to mobilization schedule. Diagnosis, previous therapy with purine analogs and three or more previous chemotherapy lines were predictive factors for poor mobilization. A CD34(+)cell count in PB > 13.8/μL was enough to ensure ≥ 2 × 10(6) CD34(+)cells/kg, with high sensitivity (90%) and specificity (91%). CONCLUSIONS The prevalence of poor mobilization was high, being associated with disease type, therapy with purine analogs and multiple chemotherapy regimens. The threshold of CD34(+) cell count in PB identified poor mobilizers, in whom the administration of immediate or pre-emptive plerixafor could be useful to avoid a second mobilization.

Feasibility and results of subtype-oriented protocols in older adults and fit elderly patients with acute lymphoblastic leukemia: Results of three prospective parallel trials from the PETHEMA group.

BACKGROUND AND OBJECTIVE The prognosis of acute lymphoblastic leukemia (ALL) is poor in older adults and elderly patients, and subtype-oriented prospective trials are scarce in these patients. We present the results of three prospective parallel subtype-oriented protocols in fit patients older than 55 years. PATIENTS AND METHODS In 2008, three prospective phase II trials in patients older than 55 years were activated: ALLOLD07 for Philadephia (Ph) chromosome-negative ALL, ALLOPH07 for Ph-positive ALL, and BURKIMAB08 for mature B-ALL. Early death (ED), complete remission (CR), disease-free survival (DFS), overall survival (OS) and toxicity were analyzed. RESULTS 56, 53 and 21 patients from the ALLOLD07, ALLOPH07 and BURKIMAB08 trials, respectively, were evaluable. CR was 74%, 87% and 70%, with an ED rate of 13%, 11% and 15%, respectively. The medians of DFS were 8 and 38 months for ALLOLD07 and ALLOPH07 protocols, not being achieved in the BURKIMAB08 trial (p=0.001), and the median OS was 12, 37 and 25 months, respectively (p=0.030). Neutropenia, thrombocytopenia and infections were less frequent in the ALLOPH07 trial vs. ALLOLD07 and BURKIMAB trials, and renal toxicity and mucositis were more frequent in the BURKIMAB08 trial vs. the ALLOLD07 and ALLOPH07 trials. ECOG score and WBC count had prognostic significance for OS in ALLOPH07 and BURKIMAB08 trials, whereas no prognostic factors were identified in ALLOLD07 protocol. CONCLUSION Subtype-oriented treatment had an impact in the outcome of older adults with ALL. The poorest outcome was observed in Ph-negative non-Mature B-cell ALL patients, for whom improvements in therapy are clearly needed.

Usefulness of tumor markers CA 125 and CA 15.3 at diagnosis and during follow-up in non-Hodgkin's lymphoma : study of 200 patients

CA 125 and CA 15.3 serum levels were measured at diagnosis, after treatment and at the time of recurrence in 200 consecutive patients (114 males, median age 56 years) with non-Hodgkins lymphoma (NHL) to explore its usefulness in the evaluation of response to treatment and survival in patients with NHL compared to lactate dehydrogense (LDH) and β2-microglobulin (β2-M). Their association with the clinical – biologic parameters at diagnosis, response to treatment, event-free survival (EFS) and overall survival (OS) was analysed. Eighty-six patients (43%) had elevated CA 125 levels and 35 (17.5%) had elevated CA 15.3 levels at diagnosis. CA 125 was associated with advanced stage, lung, pleural or gastrointestinal tract involvement and CA 15.3 was correlated with advanced stage, bone involvement, aggressive histology and bulky disease. LDH had the highest predictive value for failure to achieve complete remission (P = 0.001). A shorter OS was associated with increased LDH (P < 0.0001), β2-M (P = 0.013) and CA 125 (P = 0.025) whereas CA 15.3 was associated with a shorter EFS (P = 0.027). When elevated at diagnosis, CA 125 and CA 15.3 should be monitored during follow-up of patients with NHL.

Prognostic significance of copy number alterations in adolescent and adult patients with precursor B acute lymphoblastic leukemia enrolled in PETHEMA protocols

Some copy number alterations (CNAs) have independent prognostic significance for adults with acute lymphoblastic leukemia (ALL).

Low-grade, malt-type, primary B-cell lymphoma of the conjunctiva.

Although primary ocular lymphomas may be found in the conjunctiva, eye lids and lacrimal glands, the majority nevertheless occur in the orbit. Only a few cases of primary conjunctival lymphoma have been described in the literature. A 68-year-old man presented with a painless swelling of the epibulbar conjunctiva of the right eye. A diffuse lymphoid infiltrate consisting of small-sized lymphoid cells with the morphology and distribution characteristics of mucosa-associated lymphoid tissue was observed. Immunohistological study demonstrated the B lymphocyte lineage of tumor cells and Bcl-1 and bcl-2 rearrangements were negative. After clinical staging including thoracic, abdominal, brain and orbital CT scans, fiberoptic gastroscopy and bone marrow biopsy, no other foci of this lymphoma were found. Radiation therapy was given and the patient currently remains free of lymphoma 30 months after diagnosis.

El análisis modal de fallos y efectos (AMFE) ayuda a aumentar la seguridad en radioterapia

Resumen Objetivos A raiz de una incidencia de sobredosis detectada en el servicio de radioterapia, se puso en marcha un proyecto de analisis y eliminacion de riesgos para aumentar la seguridad de los pacientes. Material y metodo Se aplico el analisis modal de fallos y efectos (AMFE), un instrumento analitico aplicado en varios hospitales de Estados Unidos. Como exige la metodologia, se cuantificaron los riesgos de cada modo de fallo en una escala de 1:1.000 utilizando el indice NPR (numero de priorizacion del riesgo). En una primera fase de mejora, se definio el nivel de actuacion como NPR > 100. Se detectaron varios riesgos en los protocolos actuales y se eliminaron todos ellos mediante redefinicion de circuitos, controles y verificaciones adicionales, listas de comprobacion y auditorias internas, entre otros. Posteriormente, se introdujo un sistema de gestion de la calidad segun ISO9001, se definio una serie de indicadores y la direccion se implico realizando revisiones mensuales de los resultados. Resultados Se implantaron 100 acciones de mejora. El indice de riesgo calculado despues de haber tomado las acciones bajo significativamente y aumento la seguridad. Las mejoras realizadas aseguran el mantenimiento del grado de seguridad logrado. Conclusiones La experiencia muestra que se puede identificar objetivamente los riesgos de cada paso que damos y destinar los escasos recursos de que disponemos a los procesos o actividades donde el riesgo es mayor, mediante mejoras metodologicas de nuestros protocolos de trabajo.