Krzysztof Chojnowski

Rituximab combined with cladribine or with cladribine and cyclophosphamide in heavily pretreated patients with indolent lymphoproliferative disorders and mantle cell lymphoma

In vitro studies have shown synergistic or additive interactions between rituximab and purine nucleoside analogues. The results of recent clinical trials seem to confirm these preclinical observations.

Assessment of Coagulation Disorders in Patients with Acute Leukemia Before and After Cytostatic Treatment

Coagulation disorders are often the reason for fatal bleeding in acute promyelocytic leukemia. Their occurrence as well as pathogenesis and prognostic significance in other subtypes of acute myelogenous leukemia and acute lymphoblastic leukemia is less known. Tests were carried out in 70 patients including 49 with AML and 21 with ALL. In all patients thrombin-antithrombin complexes (TAT), D-dimer (DD) and plasmin-antiplasmin complexes (PAP), antithrombin III activity, fibrinogen/fibrin degradation products, APTT and PT were determined. The tests were performed on diagnosis and after cytostatic treatment. The level of TAT, DD and PAP was elevated in 83% of the patients on diagnosis and in 90% after treatment. The highest values were observed in AML M3 patients. Among leukemic patients with normal levels of TAT, DD and PAP at diagnosis, cytostatic treatment had a negligible effect on the level of these markers. During remission the levels of these markers returned to the normal values while in patients without remission they were either elevated or returned to normal values. No correlation between the levels of activation markers and remission rate was reported. DIC was diagnosed in 13 patients including three after chemotherapy. The DIC was acute or subacute in AML and chronic in ALL patients. In the majority of acute leukemia patients there were already changes on diagnosis indicating coagulation activation. Except for AML M3, these usually had a subclinical course. The TAT, DD and PAP tests are not reliable markers of remission in acute leukemias.

Activation of blood coagulation and the activity of cancer procoagulant (EC 3.4.22.26) in breast cancer patients

The activity of cancer procoagulant (CP), prothrombin time (PT), activated partial thromboplastin time (APTT), the concentration of thrombin-antithrombin complexes (TAT) and the concentration of fibrinogen were analysed in blood of breast cancer patients scheduled for surgery. The serum level of CP activity was dependent on the stage of the disease. The CP activity was increased in 72% of patients with an early stage of cancer and in only 20% of patients with an advanced stage of the disease when compared to the baseline level for non-cancer controls. In all patients PT remained at normal levels (80-120%). There was no significant change in APTT (27-39 s) in early stage cancer patients. Only one patient with advanced cancer had APTT shortened to 23 s. Also one advanced stage patient had significantly elevated level of TAT (14.96 microg/l); in all other patients the concentration of TAT remained at normal levels (1-4.1 microg/l). Forty-four percent of early stage cancer patients and 22% of advanced cancer patients had an elevated level of fibrinogen (Fg) ( > 350 mg%). However, there was no correlation between the level of Fg and the CP activity (P > 0.05). The data suggest that: (1) serum CP activity increases at the early stage of breast cancer and decreases down to the normal level in the advanced stage of the disease; (2) there is no evidence of blood clotting activation in the early stage breast cancer patients; and (3) CP does not facilitate the activation of coagulation in the breast cancer patients or the level of such activation is below the sensitivity of assays used in the experiment.

Circulating endothelial cells in essential thrombocythemia and polycythemia vera: correlation with JAK2-V617F mutational status, angiogenic factors and coagulation activation markers

Angiogenesis plays an important role in the biology of hematological malignancies, including essential thrombocythemia (ET) and polycythemia vera (PV). Some data suggests that it has a role in the pathogenesis of thrombosis, the major clinical problem in ET and PV. The number of different subpopulations of circulating endothelial cells (CECs), plasma levels of vascular endothelial growth factor (VEGF), soluble vascular endothelial growth factor receptor 1 and 2 (sVEGFR-1,2) and placenta growth factor (PlGF) were determined in 30 patients with ET and 16 patients with PV. Correlations between angiogenesis and JAK2-V617F mutational status, risk factors for thrombosis and coagulation activation markers were also assessed. The number of CEC subpopulations, were markedly higher in ET and PV patients, irrespective of JAK2-V617F status, when compared to the control group. The median values of activated CECs were markedly higher in PV patients with WBC >8.7 (×109/l). Significantly higher VEGF plasma levels were found in ET patients and a similar trend was seen in PV patients in relation to healthy volunteers. The plasma levels of sVEGFR-1 were significantly higher, and PlGF levels markedly lower, in the ET and PV group than in controls. Our study also demonstrated markedly increased levels of D-dimer and TAT complexes in the patient groups. In conclusion, we found that angiogenesis, as measured by CEC numbers, is increased in ET and PV patients regardless of JAK2-V617F mutational status. Our results demonstrated that angiogenic cytokines interact with known thrombotic risk factors. We confirmed the coagulation activation in ET and PV patients but found no differences in levels of coagulation activation markers in relation to JAK2-V617F mutational status.

Successful treatment of refractory autoimmune thrombocytopenia with rituximab and cyclosporin A in a patient with chronic granulomatous disease.

Dear Editor, Although immunodeficiency and autoimmunity seem to be on the opposite sides of the immune response in many cases, they are associated to each other [1]. We present the first case of female with coexistence of chronic granulomatous disease (CGD) and refractory autoimmune thrombocytopenia (ITP), successfully treated with rituximab and cyclosporin A (CyA). The patient was diagnosed with CGD in 1999 at the age of 14. Thrombocytopenia with platelets (PLT) 9×10/l was first observed in June 2002, and the patient was given prednisone as the initial treatment. The response was good but thrombocytopenia (PLT<20×10/l) relapsed when the dosage of prednisone was tapered below 20 mg/day. In March 2003 the patient received high doses IVIg but during that treatment, aggravation of the haemorrhagic diathesis with epistaxis, menorrhea and secondary anaemia (Hb 8.2 g/dl) was observed. Due to severe diathesis, methylprednisolone 1,000 mg i.v. for 7 days was introduced. The platelet count increased to 340×10/l within few days, and all symptoms of bleeding retreated completely. The patient was discharged from hospital on 60 mg oral prednisone with the recommendation of reducing the dose. She was also given oral contraception. In January 2004 the patient was admitted to our Department because of epistaxis, presence of petechiae on both lips, upper palate and lower extremities. The patient’s complete blood count revealed Hb 11.2 g/dl, red blood cells 4.03×10/l, white blood cells 9.07×10/l and PLT count 3×10/l. The patient received puls of dexamethasone 40 mg i.v. for 4 days [2]. The maximum elevation of platelet count to 77×10/l was achieved, but no consent for splenectomy obtained. After 3 weeks, thrombocytopenia PLT 3×10/l relapsed, but the next dexamethasone course was not effective. The patient was then qualified for rituximab treatment whichwas administered inMay 2004 four times on aweekly basis at 375 mg/m [3, 4]. During that period, platelet and blood transfusions were required. Platelet transfusions were not effective in increasing platelet level, but there was a significant clinical response in terms of diminishing bleeding symptoms. There was also a short episode of fever with good reaction to antibiotic therapy, but neither clinical, radiological nor laboratory signs of infectionwere observed. Twoweeks after the last dose of rituximab, shewas admitted to the hospital suffering from partial blindness due to both eyes retinal haemorrhage, haematuria and profound anaemia (Hb 6.5 g/dl) caused by extensive epistaxis and menorrhea with platelet count of 2×10/l. After RBC and PLT transfusions, therapy with cyclosporinA (2.5mg/kg of bodyweight per day) was introduced [5]. The patient was discharged from the hospital after 10 days completely recovered from blindness with the platelet count of 7×10/l, but 3 days later she was presented with strong headache, nausea and general weakness. CT scan of head showed no signs of cerebral bleeding. The cyclosporin level was within therapeutic ranges, and no renal or hepatic damage was observed. Two months after the last dose of rituximab and 1.5 months after cyclosporin A was introduced, the patient required no blood transfusions and was in stabile medical state without haemorrhagic diathesis symptoms. For the next 2 months, her PLT count varied between 11 and 29×10/l with no signs of bleeding and significant clinical improvement. The dosage of CyAwas reduced to 1 mg/kg per day and continued at that level with only slight changes since it was enough to maintain a therapeutic serum level between 200 and 400 ng/ml. Renal and hepatic functions as well as blood cells counts were checked every 4 weeks. In January 2005, 7 months after CyAwas started, the platelet count was 84×10/l, while in March 2005 it reached J. Treliński . K. Chojnowski . M. Kasznicki . T. Robak (*) Department of Haematology, Medical University of Lodz and Copernicus Memorial Hospital, Lodz, Poland e-mail: robaktad@csk.umed.lodz.pl Tel.: +48-42-6895191 Fax: +48-42-6895192

Efficacy and safety of a new intravenous immunoglobulin 10% formulation (octagam® 10%) in patients with immune thrombocytopenia

Abstract Intravenous immunoglobulin (IVIg) has an established role in the treatment of immune thrombocytopenia (ITP). The safety and efficacy of a new ready-to-use IVIg 10% formulation (octagam® 10%) were investigated in a prospective phase III study in 116 adult patients with ITP (platelet count ≤20×109/l). Sixty-six patients had chronic ITP and 49 were newly diagnosed. Patients received octagam 10% 1 g/kg/day on two consecutive days; infusion rate was adjusted according to tolerability to a maximum of 0·12 ml/kg/minute. Eighty per cent of patients attained the primary efficacy endpoint of clinical response (platelet count ≥50×109/l within 6 days of dosing). The median time to response was 2 days and the median duration of response was 12 days; mean response duration was 24·1 days. octagam 10% was well tolerated and effective in this population representative of adult patients with ITP, even at the maximum infusion rate of 0·12 ml/kg/minute, without unexpected safety issues.

Efficacy and Safety of the New Intravenous Immunoglobulin IGIV 10% in Adults with Chronic Idiopathic Thrombocytopenic Purpura

Background: Intravenous immunoglobulin (IGIV) 10% is a newly developed 10% liquid immunoglobulin preparation for intravenous use where 3 dedicated virus reduction steps have been integrated into the manufacturing process. The efficacy and safety of this product were assessed in a prospective multicenter study in chronic ITP (idiopathic thrombocytopenic purpura) patients with platelet counts of =20 × 109/l. Patients and Methods: 23 adult ITP patients received the product at a total dose of 2 g/kg body weight administered over 2-5 days, and were followed for 4 weeks. Results: Of the 21 subjects included in the Per-Protocol Analysis Data Set, 15 responded successfully to treatment (71.4%). Eleven subjects in this group attained a platelet count increase to >100 × 109/l, and 8 reached a platelet count of >200 × 109/l. All 15 responders achieved a platelet count of =50 × 109/l by day 8, and 14 of them reached this level by day 5. The median duration of platelet response was 25 days, and the highest median platelet count in the responders was 182 × 109/l. A total of 81 infusions were administered to the 23 subjects in the Safety Analysis Data Set over the course of the study. There were 40 non-serious adverse events related to the use of the study drug - 35 mild, 3 moderate, and 2 severe. The most frequent related adverse events were headache and pyrexia. Conclusion: The results obtained in this study demonstrate that IGIV 10% is effective in the treatment of adult subjects with chronic ITP and indicate a good safety profile.

High activity of rituximab combined with cladribine and cyclophosphamide in a patient with pulmonary lymphomatoid granulomatosis and bone marrow involvement.

Lymphomatoid granulomatosis (LG) is a rare T-cell rich, B-cell angiodestructive non-Hodgkin’s lymphoma that involves mainly the lungs, skin, liver, kidneys and the nervous system [1]. The prognosis is generally poor and median survival is *4 years [2]. The therapeutic approach and optimal management have not been well defined. Various approaches have been reported including steroids alone or combined with cyclophosphamide and combination chemotherapy [2]. Other treatment options include interferon-a (IFN-a), cyclosporin A and bone marrow transplantation [3 – 5]. More recently, a few cases treated with anti-CD20 monoclonal antibody rituximab have been reported with good response in some of them [6 – 10]. We present a patient who developed pulmonary LG with bone marrow involvement and only partially responded to IFN-a therapy. Subsequently, she was successfully treated with rituximab combined with cladribine (2-CdA) and cyclophosphamide (RCC). The patient was a 51-year-old white female, first seen in our outpatient clinic in March 2004 because of chronic non-productive cough, fever, fatigue, over 10% body weight loss and asthenia in the last 8 months. The main finding on physical examination was splenomegaly and hepatomegaly 1 cm below the costal margin. The complete blood count revealed hemoglobin 9.5 g dl, red blood cells 4.06 10 l, hematocrite 30.7%, white blood cells 8.56 10 l and platelets 2676 10 l. The bone marrow aspirate was hypercellular. Clusters of mature and partially immature lymphoid cells with a prominent nucleolus were observed (Figure 1(a)). In the bone marrow trephine biopsy there were nodular infiltration of large B-cells which were CD20þ, and some of them CD30 positive. The erythrocyte sedimentation rate was 42 after 1 h and C reactive protein was 96.5 mg l (normal values 0 – 5 mg). The b2-microglobulin level was increased (6110 ng ml) and lactate dehydrogenase activity was also increased (341 U L). The chest X-ray showed irregular infiltrations in lower lobes of both lungs. Computed tomography of the chest also showed multiple nodules ranging from 5 – 10 mm in diameter to larger infiltrates and atelectatic changes in lower lobes of both lungs. An open lung biopsy was performed and two pieces of lung tissue were examined. Histologically, these nodules contained lymphoid tissue consisting of the mixture of small and larger lymphocytes and admixed histiocytes and neutrophiles (Figure 1(b)). Larger cells presented B-cell antigens (CD20, CD79a) and a proportion of them were also CD30positive. There were also foci of neutrophiles, mostly located close to blood vessels. The wall of blood vessels was infiltrated with B-cells but fibrinoid necrosis was not observed. Smaller cells were of T origin (CD3-positive). Polymerase chain reaction

Activity of Cladribine Combined with Etoposide in Heavily Pretreated Patients with Indolent Lymphoid Malignancies

We determined the effectiveness and toxicity of combined chemotherapy consisting of etoposide 100 mg/m2/day i.v. and cladribine (2-CdA) 0.12 mg/kg/day i.v. each for 5 days (EC regimen) in the treatment of refractory or relapsed low-grade non-Hodgkin’s lymphoma and chronic lymphocytic leukemia. The cycles were repeated every 28 days, reaching a maximum of six courses. Twenty patients entered the study. All patients had received three or more cycles of chemotherapy before the EC regimen (median 8, range 3–19). Thirteen patients received 2-CdA before the EC regimen. Seven out of 20 patients (35%) responded, including one complete response. Median overall survival time of responding patients was 22 months (range 3–30). Myelosuppression and infections were the major toxicity of the EC regimen.

Registry of inherited bleeding disorders in Poland - current status and potential role of the HemoRec database

Summary.  We present data collected in HemoRec, an Internet‐based platform implemented in 2006 in 15 haemophilia treatment centres in Poland and compare them with the national registry of inherited bleeding disorders established since 1991 at the Institute of Haematology and Blood Transfusion in Warsaw. We also analyse the current status of haemophilia treatment in Poland as well as future perspectives. Data on 1102 patients registered in HemoRec were analysed and compared with 4294 patients in the national registry (status as at 17.08.2009). The number of patients with severe haemophilia, mild/moderate haemophilia and von Willebrand in HemoRec is 530, 328 and 54 (respectively), compared with 1199, 1167 and 1128 in the national registry. The mean age of all haemophilic patients registered in HemoRec is 26.2 years, compared with 37.3 years in the general Polish male population in 2008. The number of haemophilic patients with inhibitor registered in HemoRec is 102 compared with 155 in the national registry (resulting in a prevalence of 14.9% of all severe haemophilia A and 1.6% of all severe haemophilia B patients). HemoRec includes data on a representative group of Polish haemophilic patients, mostly with haemophilia and haemophilia with inhibitor. von Willebrand’s disease is largely under‐registered in Poland. The survival of Polish haemophilic patients is shorter than that in the general population. The number of inhibitor patients in Poland is relatively large and should be decreased by wider availability of immunotolerance induction in 2010.