Gracia Aparecida Martinez

Thalidomide treatment down-regulates SDF-1α and CXCR4 expression in multiple myeloma patients

The chemokine stromal-derived factor-1alpha (SDF-1alpha) and its receptor CXCR4 are critically involved in directional migration and homing of plasma cells in multiple myeloma. Here, we show that the expression of SDF-1alpha and CXCR4 was significantly down-regulated in patients treated with thalidomide (n=10) as compared to newly diagnosed MM patients (n=31) and MM patients treated with other drugs (n=38). SDF-1 alpha and CXCR4 expression was also significantly decreased in a RPMI 8226 cell line treated with 10 and 20micromol/L of thalidomide. Our findings indicate that thalidomide therapy induces down-regulation of CXCR4 and its ligand SDF-1alpha in multiple myeloma.

Confirmation of the utility of the International Staging System and identification of a unique pattern of disease in Brazilian patients with multiple myeloma

Multiple myeloma (MM) is one of the most frequent hematologic malignancies, and its incidence varies worldwide. Except for occasional case series or correlative biological studies, little is known about the incidence and clinical features of MM in Latin America. In Brazil, national estimates for the

CD18 deficiency evolving to megakaryocytic (M7) acute myeloid leukemia: Case report

Leukocyte adhesion deficiency type 1 (LAD 1 - CD18 deficiency) is a rare disease characterized by disturbance of phagocyte function associated with less severe cellular and humoral dysfunction. The main features are bacterial and fungal infections predominantly in the skin and mucosal surfaces, impaired wound healing and delayed umbilical cord separation. The infections are indolent, necrotic and recurrent. In contrast to the striking difficulties in defense against bacterial and fungal microorganisms, LAD 1 patients do not exhibit susceptibility to viral infections and neoplasias. The severity of clinical manifestations is directly related to the degree of CD18 deficiency. Here, a 20 year-old female presenting a partial CD18 deficiency that developed a megakaryocytic (M7) acute myeloid leukemia is described for the first time. The clinical features of the patient included relapsing oral thrush due to Candida, cutaneous infections and upper and lower respiratory tract infections, followed by a locally severe necrotic genital herpetic lesion. The patients clinical features improved for a period of approximately two years, followed by severe bacterial infections. At that time, the investigation showed a megakaryocytic acute myeloid leukemia, treated with MEC without clinical improvement. The highly aggressive evolution of the leukemia in this patient suggests that adhesion molecules could be involved in the protection against the spread of neoplastic cells.

Prognostic Factors in Adolescent and Adult Patients With Acute Lymphoblastic Leukemia With Two Protocols of Chemotherapy: A Cross-Sectional Study

BACKGROUND We evaluated the clinical, laboratory, and prognostic factors in adolescent and adult patients with acute lymphoblastic leukemia (ALL). MATERIALS AND METHODS In this observational, retrospective, cross-sectional study, we examined the medical records of all consecutive patients with ALL admitted to a public hospital in Brazil from 1990 to 2005. RESULTS Of the 102 patients included, 88 were treated with 2 protocols of chemotherapy (Berlin-Frankfurt-Münster [BFM] 86 modified [BFM-86M] and UCLA [University of California, Los Angeles] protocol). The complete remission (CR), disease-free survival, and overall survival (OS) rate was 70.6%, 27%, and 30.5%, respectively (median follow-up, 49 months). Age < 18 years and no leukemic infiltration in the central nervous system (CNS) at diagnosis were positively associated with CR (P = .03); no bleeding and hepatomegaly at diagnosis and age < 35 years were associated with better OS on multivariate analyses of the whole population (P = .01). OS at 4 years was superior with BFM-86M than with UCLA (49.5% vs. 16%; P = .004), especially in young adults without risk factors. CONCLUSION We identified age as the most important prognostic factor in patients with ALL. CNS infiltration, hepatomegaly, and bleeding were associated with lower OS but must be validated in future research with South American populations and worldwide. The BFM-86M protocol can be considered a therapeutic option for young adults (age < 35 years) without adverse prognostic factors. For other patients with ALL, we emphasize the need for different therapeutic approaches.

Is it feasible to use granulocyte-colony stimulating factor alone to mobilize progenitor cells in multiple myeloma patients induced with a cyclophosphamide, thalidomide and dexamethasone regimen?

Background Cyclophosphamide plus thalidomide as induction for multiple myeloma patients eligible for autologous stem cell transplantation may be a limiting factor for cell mobilization. The minimum acceptable mobilized peripheral blood stem cell count to prevent deleterious effects during transplantation is 2.0 × 106 CD34+ cells/kg. Combining other treatments to granulocyte-colony stimulating factor, such as cyclophosphamide, could overcome the mobilization limitation. The objective of this study was to assess the number of CD34+ cells mobilized using granulocyte-colony stimulating factor with and without cyclophosphamide after induction with cyclophosphamide, thalidomide and dexamethasone. Methods A retrospective study was performed of a cohort of multiple myeloma patients submitted to autologous stem cell transplantations at two Brazilian centers between May 2009 and July 2013. The oral cyclophosphamide and thalidomide induction doses used were 1500 mg/month and 100–200 mg/day, respectively. Mobilization doses were 10–15 mcg/kg granulocyte-colony stimulating factor with 2–4 g/m2 cyclophosphamide, or 15–20 mcg/kg granulocyte-colony stimulating factor alone for 5 days. Collection of >2.0 × 106 CD34+ cells/kg was considered sufficient. Results Eighty-eight patients were analyzed; only 18 received cyclophosphamide. The median age was 58 years old (range: 51–62) for the granulocyte-colony stimulating factor group and 56.5 years old (range: 54–60) for granulocyte-colony stimulating factor plus cyclophosphamide group. Fifty-two patients were male. Eighty cases (90.9%) were Durie-Salmon Staging System III-A/B and 38 (44.7%) and 20 cases (23.5%) were International Staging System 2 and 3, respectively. The group that received cyclophosphamide collected a higher median number of progenitor cells [3.8 (range: 3.1–4.4) vs. 3.2 (range: 2.3–3.8)] (p-value = 0.008). No correlation was observed between better responses or number of induction cycles and the number of cells collected. Conclusion The number of cells mobilized with granulocyte-colony stimulating factor plus cyclophosphamide was higher. However, in both groups, the median number of CD34+ cells was sufficient to perform a single autologous stem cell transplantation; no deleterious effects were reported during harvesting.

Differential expression of HOXB7 gene in multiple myeloma and extramedullary multiple myeloma patients.

To the Editor: Multiple myeloma (MM) is a B-cell neoplasm characterized by clonal expansion of plasma cells in the hematopoietic bone marrow (1). Events such as alterations in the expression of transcription factors might be critically involved in MM (2). The deregulation of homeobox (HOX) genes is known to play an important role in fundamental processes in hematological malignancy (3, 4). Recently, Colla et al. (3) showed the presence of HOXB7 expression in 10% of MM patients studied. In this report, we compared HOXB7 expression in three cases classified as extramedullary spread of multiple myeloma (eMM) with 30 MM patients. Multiple myeloma and eMM patients were defined clinicopathologically and radiologically. All of them had received systematic chemotherapy. The MM patients were staged according to the criteria of Durie & Salmon (5) and eMM were with age of 55–58 yr and staged as IIIA; the M components was immunoglobulin G (n = 3). Informed consent was obtained from all patients, and all protocols were approved by the Ethics Committee of the Hospital das Clinicas, University of São Paulo Medical School. Plasma cells population from bone marrow aspirates of MM and eMM patients obtained for routine diagnostic or evaluation purposes after informed consent were enriched as described previously (6). Although our results are based on a small number of eMM patients, they were obtained by absolute quantitative real-time RT-PCR (qRT-PCR) and thus should provide an accurate quantification of gene expression. qRT-PCR was performed using TaqMan Universal PCR Master Mix (Applied Biosystems, Foster City, CA, USA), TaqMan Gene Expression Assays probe and primer mix (Applied Biosystems), according to the manufacturer’s specifications. A dilution series of HOXB7 copies amplified in pTOPO-TA vector (Invitrogen, Carlsbad, CA, USA) with an insert of 123 bp fragment from exon 1-2 of HOXB7 gene (pHOXB7) was used as reference control. The volume of the purified linear dsDNA standards was adjusted to 10 copies ⁄ lL. This stock solution was serially diluted to obtain a standard series from 10 to 10 copies ⁄ lL with each step differing by 10-fold. As negative control was used a pool of mRNA from bone marrow of six healthy donors. Expression levels of HOXB7 were significantly higher (p < 0.02) in the three patients with eMM, developed 24 and 48 months after primary diagnosis, than in MM patients that showed HOXB7 expression. One patient developed eMM in pericardium 24 months and the two other developed plasmacytoma in inguinal lymph nodes 48 months after primary diagnosis. In the three eMM patients, 2.6 · 10 HOXB7copies ⁄ lL, 1.8 · 10 HOXB7 copies ⁄ lL and 3.8 · 10 HOXB7 copies ⁄ lL were found, respectively. The transcript levels of HOXB7 continued to increase during the 48-month follow-up period (median 36, range 12–60 months). Progression to eMM in the three patients demonstrated an aggressive phase of the disease and patients died because of disease progression. Within 30 MM patients tested, HOXB7 expression was found in 10 MM patients (six of them without and 4 with bone plasmacytoma). The median of HOXB7 gene expression in MM patients was 1 · 10 HOXB7 copies ⁄lL (range 10–10 copies ⁄ lL). Among the four MM patients with bone plasmacytoma, one case with 1.3 · 10 HOXB7 copies ⁄ lL and another patient with 2.4 · 10 HOXB7 copies ⁄lL showed bone tumor lesions in various sites, including vertebral column and upper and lower limbs. In the remaining two patients with 1.2 · 10 HOXB7 copies ⁄ lL and 2.8 · 10 HOXB7 copies ⁄lL, respectively, bone plasmacytoma were observed only in vertebral column. Two MM patients with bone plasmacytoma (4.6 · 10 HOXB7 copies ⁄lL) and four of the MM patients (median 10 copies ⁄ lL) without bone plasmacytoma died from the disease. Furthermore, in all patients studied, the transcript levels of HOXB7 continued to increase during the 48-month follow-up period (median 36, range 12–60 months). We also studied four patients with solitary plasmacytoma, but our results showed absence of HOXB7 expression (data no shown). In summary, the capacity of activating many angiogenic molecules makes HOXB7 an attractive target gene in MM.

Fatores prognósticos no Mieloma Múltiplo

Over the last 10 years, great changes have occurred in the treatment of multiple myeloma (MM) due to the use of new drugs. Considering the new options, it is essential to recognize clinical and biological parameters to arrive at the best therapeutic choice. More recently the new International Staging System (ISS) for multiple myeloma was validated which utilizes two straight forward laboratory parameters: the b2 microglobulin (b2M) and albumin levels. Stage I: b2M 3.5 g/dL with a median survival of 62 months; stage II: b2M 3.5 to 5.5 g/dL with a median survival of 29 months. The importance of cytogenetics and molecular features as prognostic factors is being recognized. Deletion of chromosome 13 or 13q, the t(4:14) translocation, p53 deletion and amplification of chromosome band 1q21 are all associated with poor prognosis.

Aspergillary bronchopneumonia: an unusual cause of atelectasis and asphyxia in a leukemic patient

A 22-year-old man in his first relapse of T-acute lymphoblastic leukemia developed fever and a pulmonary infiltrate after 23 days of granulocytopenia. Although having been under amphotericin B for 10 days, productive purulent cough ensued, with right lobe atelectasis and acute ventilatory failure that resolved after the elimination of a thick gelatinous bronchial plug. Sputum cultures yielded Candida Albicans and Staphylococcus epidermidis, and microscopic examination of the sputum plug disclosed Aspergillus hyphae. The patient died 9 days after, of a disseminated Aspergillus infection, confirmed by necropsy.