Margarida Brito

Visceral Leishmaniasis: A Differential Diagnosis to Remember after Bone Marrow Transplantation

Leishmania infection in immunocompromised hosts is reported in the literature, mostly concerning human immunodeficiency virus infected patients. It is not well characterized in the context of stem cell transplantation. We report a rare case clinical case of visceral leishmaniasis after allogeneic bone marrow transplantation. A 50-year-old Caucasian male was referred to allogeneic bone marrow transplantation with a high-risk acute lymphoblastic B leukemia in first complete remission. Allogeneic SCT was performed with peripheral blood stem cells from an unrelated Portuguese matched donor. In the following months, patient developed mild fluctuating cytopenias, mostly thrombocytopenia (between 60 and 80∗109/L). The only significant complaint was intermittent tiredness. The common causes for thrombocytopenia in this setting were excluded—no evidence of graft versus host disease, no signs of viral or bacterial infection, and no signs of relapsed disease/dysplastic changes. The bone marrow smear performed 12 months after transplantation revealed an unsuspected diagnosis: a massive bone marrow infiltration with amastigotes.

Abstract P1-15-03: Comparison of efficacy of primary prophylaxis with pegfilgrastim, filgrastrim and a biosimilar filgrastim in TAC regimen (docetaxel, doxorubicin and cyclophosphamide):

Background: Febrile neutropenia (FN) is a major toxicity of myelosupressive chemotherapy. Primary prophylactic use of granulocyte colony stimulating factors (G-CSF) is recommended in high risk FN regimens. The comparison of pegfilgrastim (Peg) and filgrastim (Fil) FN prophylactic effectiveness is still an issue of debate. Very recently Nivestim (Niv), a new biosimilar filgrastim, has also become commercially available. We aimed to compare the efficacy of the 3 mentioned types of G-CSF in the primary prophylaxis of FN. Methods: Single-center, retrospective study to evaluate the incidence of FN in women with breast cancer treated with adjuvant or neo-adjuvant TAC (FN risk ≥20%). Patients (Pt) were divided in 3 consecutive cohorts according to G-CSF primary prophylaxis (Fil, Peg and Niv) FN was defined as axillary temperature ≥38,3 °C and absolute neutrophil count Results: We included a total of 421 women (median age 51 y, 25–76) with Stage II (56%) and Stage III (44%) breast cancer. Age and stage distribution were similar in the 3 cohorts. A single dose of Peg was administered in all 767 cycles (cy). The standard dose of Fil and Niv was 7 daily injections, only in in 13% Fil pt and 10% Niv pt The incidence of FN per patient and per cycle is presented in Table 1. In all cohorts, approximately half of NF episodes occurred in the 1st cycle (48% Fil, 59% Peg, 42% Niv). Conclusions: No differences in terms of efficacy existed between Biosimilar Niv and original biological reference Fil. Seven daily injections of Fil and Niv seem equivalent to single dose Peg. Besides efficacy, questions like cost-effectiveness and convenience of administration should be taken into account when approaching this topic. Our data showed a predominance of events in the 1st cycle (regardless of the type of G-CSF). This has been consistently described in the literature and may support the necessity to recommend other NF preventive measures in this cycle. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-15-03.

Febrile neutropenia in FEC-D regimen for early stage breast cancer: is there a place for G-CSF primary prophylaxis?

BACKGROUND Breast cancer clinical trials prove better outcomes for anthracycline-taxane regimes albeit of a higher hematologic toxicity. Original trials may under-estimate febrile neutropenia (FN) event rates. OBJECTIVE To describe the occurrence of FN events related to FEC-D for breast cancer treatment in the real-life setting. METHODS Retrospective analysis of 189 patients with non-metastatic breast cancer consecutively treated with FEC-D (3 cycles of 5-FU, Epirubicin and Cyclophosphamide followed by 3 cycles of Docetaxel) at our Center during 33 months. FN and related dose delay and reduction, regimen change, G-CSF prophylaxis and hospitalization were analyzed. RESULTS Fifty-one patients (27%) developed at least one episode of FN during FEC-D, 21% during Docetaxel cycles. There were 61 (5.6%) FN episodes in 1100 cycles of FEC-D administered, 77% occurred during Docetaxel cycles (46% on the first D cycle). G-CSF was used in 5.8% of cycles. Hospital admission needed in 54.1% of FN events, 16.4% prompted dose reduction and 23% next cycle delay. There were no FN related deaths. CONCLUSIONS G-CSF prophylaxis is recommended for chemotherapy regimens associated with a FN rate higher than 20%. Based on our FN rates, we now recommend primary G-CSF prophylaxis during the administration of cycles 4 to 6 in FEC-D.

Enteropathy-associated T cell lymphoma as a complication of silent celiac disease

Celiac disease is an autoimmune disorder in which a genetic predisposition and the ingestion of wheat gluten triggers a deleterious immune response. This response is complex and may lead to manifestations other than enteropathyha: hepatitis, dermatitis and neuropathy. There is higher risk for neoplasia. We observed an atypical case, corresponding to a 69-year old female presenting with complicated celiac disease. The patient was referred following the histological examination of an enterectomy specimen, which unexpectedly revealed an enteropathy-associated T cell lymphoma in a background of celiac disease. Patient’s previous medical history comprised several abdominal surgical procedures, without other prior symptoms suggestive of celiac disease. Indeed, the patient was obese and no signs of malabsortion were apparent. This case draws our attention to clinically silent celiac disease, which represents a diagnostic challenge. Thus, this should be kept in mind whenever a patient presents with abdominal relapsing complications, otherwise unexplained.

Does Hypoxic Response Mediate Primary Resistance to Sunitinib in Untreated Locally Advanced Breast Cancer

BACKGROUND The antiangiogenic drug sunitinib has never been evaluated as single agent in untreated breast cancer patients. OBJECTIVE We aimed to characterize the activity of sunitinib, alone and with docetaxel, in untreated locally advanced or operable breast cancer and to uncover the mechanisms of response. METHOD Patients were treated with an upfront window of sunitinib followed by four cycles of sunitinib plus docetaxel. Response, resistance and toxicity were evaluated according to standard clinical parameters, magnetic resonance imaging, positron emission tomography, standard pathology characterization, molecular pathology and gene expression profiling. RESULTS Twelve patients were included. We detected primary resistance to sunitinib in the upfront window in untreated breast cancer, as evidenced by four non-responding patients. At surgery, five patients had viable tumor in the breast and axilla, four had viable tumor cells in the breast alone and three were taken off study and thus not evaluated, due to unacceptable toxicity. Early functional imaging was useful in predicting response. There were no clinical complete responses. Comparison of tumor gene expression profiling data between early responders and non-responders allowed us to identify the up-regulation of VEGF and angiogenic pathways in non-responders. Specifically, in tumors resistant to single-agent sunitinib we detected a transcriptional response to hypoxia characterized by over-expression of several HIF1α target genes. CONCLUSION In this report of single-agent sunitinib treatment in untreated localized breast cancer patients, we found evidence of primary resistance to sunitinib, likely mediated by up-regulation of hypoxia responsive genes.

Childhood histiocytic sarcoma - rare presentation with peripheral blood involvement.

A 2-year-old child was diagnosed with histiocytic sarcoma, a very rare and frequently aggressive disease. At diagnosis, she had localized maxillary bone involvement. After first-line chemotherapy, she relapsed with bone marrow involvement. The disease was refractory to subsequent treatments, and the photographs show progression with a rare presentation – neoplastic cells were circulating in peripheral blood (Figs 1 and 2). In the images from CellaVision Software (CellaVision DM96; Blood Differential Software, Lund, Sweden) (automated digital cell morphology, Fig. 1), the neoplastic cells in circulation were unclassifiable by the software. These cells are characterized for being large, with a basophilic cytoplasm and a closely meshed chromatin. One or two nucleoli are clearly visible. The blood smear (Fig. 2, optical microscopy, Wright Giemsa stain, 1009 magnification) confirms this characteristics: the neoplastic cells appear immature, with fine chromatin, irregular nuclear shape, and one or two nucleoli visible, as well as cytoplasm villi. The bone marrow smear (Fig. 3, Wright Giemsa stain, 1009 magnification) was showing the same large and immature cells and mitotic figures. Flow cytometry confirmed these cells had the same phenotype as the ones at the diagnosis (maxillary bone biopsy).

Rectal and anal canal neuroendocrine tumours

Neuroendocrine tumors (NETs) are rare, representing 0.5% of all newly diagnosed malignancies. Rectal and anal canal (AC) NETs account for less than 1% of all rectal and AC cancers. Review our institutional experience on NET of the rectum and AC, with emphasis on demographic, histological and treatment features and oncologic outcomes. The study group was identified from the Portuguese Regional South Oncological Registry. From 2000 to 2014, 22 patients with rectal or AC NETs were treated at our institution. Medical records were retrospectively reviewed. There were 12 males (54.5%) and 10 females (45.5%) and the median age at diagnosis was 59.5 years. The majority had rectal NET (81.8%). All 4 patients with AC NETs had neuroendocrine carcinoid (NEC) tumors. Of the patients with rectal NETs, 3 had NEC and 15 had NET, mainly G1. Different approaches to treatment were made according to histological and staging features. After an average follow-up of 39.1 months, 16 patients were alive and only one with evidence of disease. The median time to progression was 12.4 months and the liver was the most frequent site of metastasis. The European and North American Neuroendocrine Societies offer guidelines for the treatment of rectal NETs. However, for AC NETs there are only small series and not prospective studies due to their rarity, hence the importance to report institutional experience. Our practice demonstrated that primary excisional treatment, regardless the histology, provides a favorable prognosis and long survival.

Starting hormone therapy immediately after histological diagnosis of breast cancer

C modulation of tumor progression has been described in differentexperimental models. In our laboratory, we demonstrated that long term treatment of murine mammary tumors with the non-selective agonist, carbachol (CARB) promotes cell death through the activation of muscarinic (M) receptors. We studied the effect of a combination of sub threshold doses of CARB (10-12M) with paclitaxel (PX) (10-8M) acytotoxic agent used in the treatment of breast cancer, on MDA-MB231 cells derived from a human triple negative breast tumor. The combination of CARB+PX reduced cell viability by 27±3% (p <0.01 vs. control). In addition, the combination of the M2 selective agonist, arecaidine (ARE) (12.5 M) that promotes cell death in glioblastomas, with PX (10-9M) produced a similar reduction in cell viability (24±7%; p<0.05) effect that was not observed with drugs added separately. By Western blot we detected the expression of M receptors (M5> M1=M2). The silencing of M2 receptor with a specific siRNA increased cell viability to control values. ARE+PX also reduced by 98.7% mRNA levels of the drug transporter ABCG2 and by 97.8% the expression of the epidermal growth factor receptor (p<0.001 vs. control). The combination did not modify the viability of MCF-10A cells derived from human normal mammary gland that do not express M receptors. These results suggest that M receptors could be considered as therapeutic targets in breast cancer and that the combination of cholinergic agonists plus cytotoxic agents, as PX may represent a novel therapeutic tool for the treatment of this illness.

Preservation of Fertility in Breast Cancer Patients in Five Hospitals in Portugal

BACKGROUND The naturally-occurring phytochemical tannic acid (TA) has anticancer properties. We have demonstrated that estrogen receptor-positive (ER+) breast cancer cells are more sensitive to effects of TA than triple-negative breast cancer cells and normal breast epithelial cells. In the present study, cells were grown on TA-crosslinked collagen beads. Growing cells remodel collagen and release TA, which affects attached cells. MATERIALS AND METHODS The ER+ breast cancer cell line MCF7 and the normal breast epithelial cell line MCF10A were grown on TA-crosslinked collagen beads in roller bottles. Concentrations of TA in conditioned media were determined. Induced apoptosis was imaged and quantified. Caspase gene expression was calculated by real-time polymerase chain reaction (PCR). RESULTS Both cell lines attached and grew on TA-crosslinked collagen beads where they remodeled collagen and released TA into surrounding medium. Released TA induced caspase-mediated apoptosis. CONCLUSION TA induced apoptosis in a concentration-dependent manner, with ER+ MCF7 cells displaying more sensitivity to effects of TA.

Twenty Years of Autologous Stem Cell Transplantation in Diffuse Large B-Cell Lymphoma: A Single Portuguese Center Experience

INTRODUCTION Diffuse large B-cell lymphoma can be cured in 60% - 70% of patients. Autologous stem cell transplantation is the standard treatment for relapsed disease. This high-intensity treatment after first complete remission in patients with high International Prognostic Index remains controversial and was performed in our department during some years. MATERIAL AND METHODS Retrospective study, review of clinical records. RESULTS This study evaluates the outcome of 113 patients transplanted between 1992 and 2012. Considering status before transplantation patients were divided in groups: a) first complete remission after 1 line of chemotherapy (n = 64); b) first complete remission after ≥ two chemotherapy lines (n = 15); c) second complete remission (n = 15); d) more advanced diseased (n = 19). Chemotherapy used in first line therapy was mainly R-CHOP (n = 71) and CHOP (n = 28). The median follow-up of patients still alive was 34 months (1 - 221). At five years, overall survival was 73% (± 5) and disease free survival was 75% (± 5). CONCLUSION Conventional chemotherapy followed by autologous stem cell transplant is a safe and efficient option for selected patients. In our series 70% high-risk patients were free from disease with this strategy.