Maria Chiara Tisi

Anemia in diffuse large B-cell non-Hodgkin lymphoma: the role of interleukin-6, hepcidin and erythropoietin

Abstract Anemia is a frequent sign in patients with diffuse large B-cell lymphoma (DLBCL) at diagnosis. We determined erythropoietin, hepcidin and interleukin-6 (IL-6) in plasma samples of 53 patients with DLBCL. The majority of patients (40/53, 75%) showed defective endogenous erythropoietin production, in particular when anemia was present (p = 0.01). Hepcidin plasma levels were significantly higher in patients compared to controls (p = 0.006), particularly in those with characteristics associated with a more active disease, including elevated lactate dehydrogenase (LDH) (p = 0.0004), B-symptoms (p = 0.07) and an age-adjusted international prognostic index (IPI) score > 1 (p = 0.01). Hepcidin levels correlated strongly to ferritin (r = 0.77, p < 0.0001) and weakly to IL-6 concentrations (r = 0.30, p = 0.03), but not to hemoglobin values. IL-6 inversely correlated to hemoglobin values in both univariate and multivariate analysis (p = 0.04), including hepcidin and erythropoietin as variables. Our findings suggest that elevated hepcidin levels and inadequate erythropoietin response are frequent in DLBCL, but elevated IL-6 plays the major role for the development of anemia.

Interleukin-6 plasma levels are modulated by a polymorphism in the NF-κB1 gene and are associated with outcome following rituximab-combined chemotherapy in diffuse large B-cell non-Hodgkin lymphoma.

Abstract Peripheral blood cytokines are known prognostic parameters in diffuse large B-cell lymphoma (DLBCL) treated with chemotherapy, but their role after the introduction of rituximab is unknown. Seven polymorphisms in the promoter regions of IL-6, IL-10 and NF-κB1 genes were assessed in 167 patients with DLBCL and 99 controls and correlated with interleukin-6 (IL-6) and IL-10 plasma levels. Outcome was analyzed in 137 patients treated with rituximab-based chemotherapy. The NF-κB1 − 94ATTG deletion was associated with increased IL-6 and IL-10 in DLBCL. High IL-6 concentration correlated with unfavorable prognostic factors included in the international prognostic index (IPI) and predicted for inferior progression-free (p = 0.007) and overall survival (p = 0.02). IL-6 levels remained a significant outcome predictor also including IPI as a covariate (p = 0.006 for progression-free survival). Our data suggest that the NF-κB1 genetic background influences IL-6 production in DLBCL, and that high IL-6 concentration is an independent prognostic factor also in the “rituximab era.”

The host genetic background of DNA repair mechanisms is an independent predictor of survival in diffuse large B-cell lymphoma

Several drugs used for diffuse large B-cell lymphoma (DLBCL) treatment rely on DNA damage for tumor cell killing. We verified the prognostic impact of the host DNA repair genotype in 2 independent cohorts of DLBCL treated with R-CHOP21 (training cohort, 163 cases; validation cohort, 145 cases). Among 35 single nucleotide polymorphisms analyzed in the training series, MLH1 rs1799977 was the sole predicting overall survival. DLBCL carrying the MLH1 AG/GG genotype displayed an increased death risk (hazard ratio [HR] = 3.23; P < .001; q =0 .009) compared with patients carrying the AA genotype. Multivariate analysis adjusted for International Prognostic Index identified MLH1 AG/GG as an independent OS predictor (P < .001). The poor prognosis of MLH1 AG/GG was the result of an increased risk of failing both R-CHOP21 (HR = 2.02; P = .007) and platinum-based second-line (HR = 2.26; P = .044) treatment. Survival analysis in the validation series confirmed all outcomes predicted by MLH1 rs1799977. The effect on OS of MLH1, a component of the DNA mismatch repair system, is consistent with its role in regulating the genotoxic effects of doxorubicin and platinum compounds, which are a mainstay of DLBCL first- and second-line treatment.

Quantification of DAPK1 promoter methylation in bone marrow and peripheral blood as a follicular lymphoma biomarker

Hypermethylation of DAPK1 promoter gene was found to be a frequent epigenetic alteration in follicular lymphoma (FL). We evaluated whether the quantification of DAPK1 methylation in the bone marrow (BM) and peripheral blood of FL patients at diagnosis and during follow-up provides important prognostic information. DAPK1 methylation was quantitated by real-time MethyLight PCR in 107 patients at diagnosis, at end of therapy, and during follow-up. Information on BCL2-IGH rearrangement and clinical characteristics were available for all patients. Aberrant DAPK1 methylation was found in 22 of 26 (85%) lymph node biopsy samples, 62 of 107 (58%) BM specimens, and 25 of 63 (40%) peripheral blood samples at diagnosis. DAPK1 methylation was greater in patients with BM infiltration and a higher Follicular Lymphoma International Prognostic Index score. The presence of aberrant DAPK1 methylation in BM significantly reduced progression-free survival following immunochemotherapy, independent of Follicular Lymphoma International Prognostic Index score. Residual or increased methylation after treatment was associated with an increased risk for relapse. With watchful waiting, greater DAPK1 methylation at diagnosis was associated with a shorter time to antilymphoma treatment. Our study indicates that quantification of DAPK1 methylation represents a prognostically relevant FL biomarker, with promising implications for risk assessment.

Invasive fungal infections in chronic lymphoproliferative disorders: a monocentric retrospective study

Invasive fungal infections (IFIs) are serious, life-threatening complications frequently observed in hematological malignancies, in particular in patients affected by acute myeloid leukemia (AML) or in allogeneic hematopoietic stem cell transplantation (HSCT) recipients.[1][1] Epidemiological data

Whole blood EBV-DNA predicts outcome in diffuse large B-cell lymphoma

Abstract An association between Epstein–Barr Virus (EBV) infection and lymphoproliferative diseases has been reported with EBV + diffuse large B cell-lymphoma (DLBCL) of the elderly described as a distinct entity. In a cohort of 218 human immunodeficiency virus (HIV)-negative patients with diffuse large B-cell lymphomas, we detected EBV-DNA in 25% of whole blood (WB) samples at diagnosis. Presence and viral load in WB, mononuclear cells or plasma did not predict the presence of EBV in the tumor biopsy. Positive Hepatitis C virus (HCV) serology was associated with a higher frequency of EBV in WB. Patients with EBV-DNA in WB had a significantly shorter progression-free (p = 0.02) and overall survival (p = 0.05) after immunochemotherapy with R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone). We conclude that detection of EBV in WB is not a surrogate marker for EBV-association in diffuse large B-cell lymphoma, however it associates with worse outcome.

Vitamin D deficiency and supplementation in patients with aggressive B-cell lymphomas treated with immunochemotherapy

Vitamin D deficiency has been reported to be a negative prognostic factor in elderly patients with aggressive B‐cell lymphomas. In vitro data suggest that vitamin D supplementation may enhance rituximab‐mediated cytotoxicity. We prospectively assessed 25‐hydroxyvitamin D [25(OH)D] levels at diagnosis in a cohort of 155 patients with aggressive B‐cell lymphomas of whom 128 had diffuse large B‐cell lymphoma (DLBCL) not otherwise specified. 25(OH)D levels were deficient (<20 ng/mL) in 105 (67%), insufficient (20–29 ng/mL) in 32 (21%), and normal (≥30 ng/mL) in 18 (12%) patients with a seasonal variation. Patient characteristics associated with lower 25(OH)D levels were poor performance status, overweight, B‐symptoms, elevated LDH, lower albumin and hemoglobin levels. As a result of a change in practice pattern, 116 patients received vitamin D3 (cholecalciferol) supplementation that included a loading phase with daily replacement and subsequent maintenance phase with a weekly dose of 25,000 IU until end of treatment. This resulted in a significant increase in 25(OH)D levels, with normalization in 56% of patients. We analyzed the impact of 25(OH)D levels on event‐free survival in patients treated with Rituximab‐CHOP. 25(OH)D levels below 20 ng/mL at diagnosis and IPI were independently associated with inferior EFS. Moreover, patients with normalized 25(OH)D levels following supplementation showed better EFS than patients with persistently deficient/insufficient 25(OH)D levels. Our study provides the first evidence that achievement of normal 25(OH)D levels after vitamin D3 supplementation is associated with improved outcome in patients with DLBCL and deficient/insufficient 25(OH)D levels when receiving rituximab‐based treatment.

Intravascular large-B cell lymphoma: when lymphoma is suspected but routine diagnostic work-up is negative.

Intravascular large B-cell lymphoma (IVLBCL) is a rare disease recognized by the WHO classification of lymphoid neoplasms as a subtype of diffuse large B-cell lymphoma (DLBCL), which is characterized by the proliferation of neoplastic cells in the lumen of small vessels without the tendency for tumor formation [1,2]. Since its first description in 1959, more than 300 cases have been reported and in recent years increasing recognition may have contributed to a higher frequency of in vivo diagnoses. As clinical presentation is non-specific and misleading, diagnosis is often delayed, and a substantial proportion of cases is diagnosed at autopsy [2,3]. Here, we report two cases of IVLBCL diagnosed at autopsy in our institution in 2008, whose clinical presentation is paradigmatic of the behavior of IVLBCL and whose description may be helpful in future for an early diagnosis of this uncommon disease. The first patient, a 71-year-old obese woman, suffering from chronic hypoxemia, obstructive sleep apnea, and thyroid multinodular non toxic goiter, was previously admitted to the hospital with a 1-month history of continuous-remittent fever resistant to multiple antibiotic treatments. On admission, laboratory findings revealed microcytic anemia, neutrophilic leukocytosis, elevation of lactate dehydrogenase (LDH) serum levels (2195 UI/L), and D-dimer (844 ng/mL). Blood, bone marrow, urine, sputum, and pharyngeal culture resulted negative, while viral infections were ruled out by serological tests. Total-body computed tomography (CT) scan showed splenomegaly (14 cm) and bone marrow aspiration and biopsy could detect neither parasitic infection nor marrow infiltration by tumor or CD20þ lymphoma cells. Tumor markers were negative while the hormonal dosages revealed a hypothyroidism with low thyroid stimulating hormone (TSH) level. Because anemia was worsening with a positive direct antiglobulin test and a pronounced increase of LDH, a diagnosis of autoimmune hemolytic anemia was made and the patient started corticosteroid therapy with a temporary subsidence of fever. A fluorodeoxyglucose positron emission tomography (FDG-PET) revealed FDG accumulation in the middle lobe of the right lung and, following the isolation of Pseudomonas aeruginosa strain from the expectoration, a new course of antibiotic therapy was administered without benefit. As the patient’s general conditions deteriorated, a non-Hodgkin lymphoma was suspected despite negative imaging and bone marrow examinations and the patient was admitted to the Department of Hematology on Day 90 from the beginning of symptoms. Laboratory findings showed a progressive rise of LDH (upto 6135 UI/L), associated with decreased albumin levels (2.4 g/dL), progressive impairment of hepatic function, and mild pancytopenia. The patient developed generalized edema and progressive hypoxemia, and on Day 97 she was transferred to the intensive care unit where she died

Response to 5-azacytidine in a patient with relapsed Hodgkin Lymphoma and a therapy-related myelodysplastic syndrome

Treatment with hypomethylating agents, such as 5-azacytidine (Vidaza; Celgene Corporation, Summit, NJ, USA), has shown efficacy in patients with high-risk myelodysplastic syndromes (MDS) (Kantarjian et al, 2007; Fenaux et al, 2009; Voso et al, 2009) and is becoming the standard of care in this setting. 5-azacytidine has been shown to prolong the time to leukaemic transformation and improve overall survival in higher risk MDS (Fenaux et al, 2009). Chromosome 7 deletions, which are frequent in therapy-related myeloid neoplasms and are associated with poor prognosis, are associated with a favourable response to 5-azacytidine (Raj et al, 2007). To our knowledge, there are no clinical data on the role of hypomethylating drugs in Hodgkin lymphoma (HL), and there is only limited experience with other ‘epigenetic’ drugs, such as inhibitors of histone deacetylases (HDAC) (Dickinson et al, 2009). We report a patient with a therapy-related MDS and a concomitant relapse of HL who was treated with 5-azacytidine. A 46-year-old man was diagnosed in 1996 with classical nodular sclerosis HL, stage IIB with supradiaphragmatic nodal involvement, and was treated with eight cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine), achieving complete remission (CR). The first relapse occurred in 2000 and treatment consisted of the Stanford V regimen, consisting of weekly administration of cytotoxic drugs (mechlorethamine, doxorubicin, vinblastine, vincristine, bleomycin, etoposide, prednisone) for 12 weeks, followed by 36-Gy involved-field radiotherapy on cervical node residue. The second relapse occurred in 2002, and was treated with DHAP (dexamethasone, cytarabine, cisplatin)-like chemotherapy, followed by autologous stem cell transplantation using BEAM (carmustine, etoposide, cytarabine, melphalan) as conditioning regimen, obtaining CR. Two years later the patient had a new, histologicallydocumented, relapse of HL with B-symptoms, and was treated with involved-field radiotherapy (total dose 4500 cGy), and four cycles of MOPP chemotherapy (mechlorethamine, vincristine, procarbazine, prednisone), achieving CR. At this time the patient had an impaired haematological reserve, which required reduction of chemotherapy dose, packed red blood cell and platelet transfusions, antibiotics and granulocyte colony-stimulating factor administration, and had relapsing episodes of paroxysmal atrial fibrillation. In 2006, due to persistent macrocytosis, mild neutropenia and thrombocytopenia, he was diagnosed with therapy-related MDS (t-MDS), with 4% bone marrow blasts, monosomy 7 and del(12)(p11) in 14 of 20 metaphases, resulting in an Intermediate-1 score in the International Prognostic Scoring System (IPSS). The t-MDS did not show any signs of progression until 2009, when platelet and absolute neutrophil counts significantly decreased, with no evidence of lymphoma involvement at the trephine biopsy. A computerized tomography (CT) scan revealed multiple enlarged subdiaphragmatic lymph nodes, with a high [18F]-2-fluoro-2-deoxy-dglucose–positron emission tomography (F-FDG PET)/CT metabolic activity, and a maximal Standardized Uptake Value (SUV) of 16 (Fig 1A). A CT-guided biopsy of the inguinal lymph node confirmed the fourth relapse of HL. At 59 years of age, the patient had an Eastern Cooperative Oncology Group (ECOG) performance status of 1, with significant comorbidities including pulmonary emphysema, hypertension, recurrent paroxysmal atrial fibrillation, an ascending thoracic aortic aneurysm, and post-surgical

Small lymphocytic lymphoma in a patient with Fabry disease

, 2012; Early Online: 1–2© 2012 Informa UK, Ltd.ISSN: 1042-8194 print / 1029-2403 onlineDOI: 10.3109/10428194.2012.701294Cor respondence: Dr. Maria Teresa Voso, Istituto di Ematologia, Universit a Cattolica S. Cuore, L.go A. Gemelli, 100168 Rome, Italy. Tel: 0039-0630154180. Fax: 0039-0635503777. E-mail: mtvoso@rm.unicatt.it