Mariagiovanna Cefalo

Infections increase the risk of central venous catheter-related thrombosis in adult acute myeloid leukemia

INTRODUCTION Central venous catheters (CVC) related thrombosis (CRT) represents a well known complication in patients with acute myeloid leukemia (AML) receiving intensive chemotherapy but the efficacy of antithrombotic prophylaxis still remains controversial. PATIENTS AND METHODS We analyzed 71 consecutive AML patients whose CVC was inserted before each chemotherapy cycle for an overall number of 106 CVC placements. In 47/106 insertions, a prophylaxis with 100 IU/kg/day low molecular weight heparin (LMWH) was administered for 7 days after CVC insertion and additional 7 after CVC removal. This unconventional dose of LMWH, although higher than usual, appeared adequate for a short-course approach. LMWH was delivered regardless of the platelet (PLT) count once provided that it should have been maintained above 20 x 10(9)/L by transfusions. RESULTS Of 106 insertions, we observed 19 (18%) episodes of CRT, 58 (54%) of sepsis and 50 (47%) infections of CVC-exit site with no difference between LMWH and no-LMWH group. Occurrence of CRT was significantly associated with CVC-exit site infections (14/19, p=0.01) and sepsis (16/19, p=0.005) with no difference between LMWH and no-LMWH group. In multivariate analysis, both CVC-exit site infections and sepsis were confirmed to be independent risk factors for CRT development. CONCLUSION Our retrospective study, although based on a small sample size, suggests that the occurrence of CVC-exit site infections and neutropenic sepsis following chemotherapy significantly increases the risk of CRT in AML, independently from the use of LMWH prophylaxis.

Phase II Study of Bortezomib as a Single Agent in Patients with Previously Untreated or Relapsed/Refractory Acute Myeloid Leukemia Ineligible for Intensive Therapy.

We explored the safety and efficacy of bortezomib given as single agent in patients with untreated or relapsed/refractory acute myeloid leukemia (AML), unfit for conventional chemotherapy. Fourteen patients were treated with bortezomib 1.5 mg/m2 administered twice weekly for two weeks, every 3 weeks. Median age was 70 years (range 60–81) and the median number of cycles delivered was 2 (range 1–4). Of 13 evaluable patients, in 8 (61%), the administration of bortezomib resulted in an antileukemic effect as demonstrated by peripheral blood and/or bone marrow blast reduction. In 4 (50%) of these 8, a decrease by 37% of transfusion requirement was also observed (P = 0.009). Overall median survival was 4 months (range 0.25–10). Neurotoxicity was the most frequent adverse event with 7 of 13 (54%) patients experiencing grades 3-4 peripheral neuropathy. Neurotoxicity led to treatment discontinuation in 4 (57%) of 7. In conclusion, the observed anti-leukemic activity of bortezomib indicates that there is room for designing additional studies in which combination with other chemotherapeutic agents should be considered. Clinical registration no.: EUDRACT 2006-006923-38.

Clinical significance of bax/bcl-2 ratio in chronic lymphocytic leukemia

In chronic lymphocytic leukemia the balance between the pro-apoptotic and anti-apoptotic members of the bcl-2 family is involved in the pathogenesis, chemorefractoriness and clinical outcome. Moreover, the recently proposed anti-bcl-2 molecules, such as ABT-199, have emphasized the potential role of of bcl-2 family proteins in the context of target therapies. We investigated bax/bcl-2 ratio by flow cytometry in 502 patients and identified a cut off of 1.50 to correlate bax/bcl-2 ratio with well-established clinical and biological prognosticators. Bax/bcl-2 was 1.50 or over in 263 patients (52%) with chronic lymphocytic leukemia. Higher bax/bcl-2 was associated with low Rai stage, lymphocyte doubling time over 12 months, beta-2 microglobulin less than 2.2 mg/dL, soluble CD23 less than 70 U/mL and a low risk cytogenetic profile (P<0.0001). On the other hand, lower bax/bcl-2 was correlated with unmutated IGHV (P<0.0001), mutated NOTCH1 (P<0.0001) and mutated TP53 (P=0.00007). Significant shorter progression-free survival and overall survival were observed in patients with lower bax/bcl-2 (P<0.0001). Moreover, within IGHV unmutated (168 patients) and TP53 mutated (37 patients) subgroups, higher bax/bcl-2 identified cases with significant longer PFS (P=0.00002 and P=0.039). In multivariate analysis of progression-free survival and overall survival, bax/bcl-2 was an independent prognostic factor (P=0.0002 and P=0.002). In conclusion, we defined the prognostic power of bax/bcl-2 ratio, as determined by a flow cytometric approach, and highlighted a correlation with chemoresistance and outcome in chronic lymphocytic leukemia. Finally, the recently proposed new therapies employing bcl-2 inhibitors prompted the potential use of bax/bcl-2 ratio to identify patients putatively resistant to these molecules.

A cluster of Geotrichum clavatum (Saprochaete clavata) infection in haematological patients: a first Italian report and review of literature

Invasive fungal infections, usually Aspergillus and Candida, represent a major cause of morbidity and mortality in patients with malignant haematological diseases, but in the last years rare fungal infections have more frequently been reported. Here, we report the clinical history of three patients affected with haematological malignancies who developed an infection caused by Geotrichum (G.) clavatum. Two out of three patients were affected by acute myeloid leukaemia (AML), and one by mantle cell lymphoma (MCL). All patients received cytarabine‐based chemotherapeutic regimens and developed G. clavatum infection within 3 weeks from therapy initiation. In all cases, G. clavatum was isolated from central venous catheter and peripheral blood cultures. In vitro susceptibility test confirmed an intrinsic resistance to echinocandins and, in all cases, visceral localisations (spleen, liver and lung) were documented by total body computed tomography (CT) scan. A prolonged antifungal therapy with high doses liposomal amphotericin‐B was necessary to obtain fever resolution. Only the patient with MCL died while the other two AML recovered, and one of them after received an allogeneic stem cell transplantation. We consecutively reviewed all published cases of infection caused by G. clavatum. Our experience and literature review indicate that G. clavatum can cause invasive infection in haematological patients, mainly in those with acute leukaemia.

Pre-transplant persistence of minimal residual disease does not contraindicate allogeneic stem cell transplantation for adult patients with acute myeloid leukemia

Despite progress in treatment and supportive therapies, outcome of high-risk adult AML remains dismal with ~ 20% of patients becoming long-term survivors. Since the pretreatment genetics/cytogenetics of AML do not always anticipate the individual outcome, there is a strong rationale to implement laboratory techniques capable of exploring the quality of CR and allowing post-remission therapy to be optimally directed. In this view, minimal residual disease (MRD) assessment promises to be a robust approach. It captures the diversities of the underlying genetic/cytogenetic features of AML and recapitulates other patient heterogeneities regarding drug bioavailability, metabolism and resistance. Multiparametric flow cytometry (MFC) is one of the leading techniques successfully exploited to quantify MRD in AML expressing leukemia-associated immunophenotypes (LAIP). This assay applies to the vast majority of patients after chemotherapy-induced morphologic CR and has been shown to predict the clinical outcome when measured at several time points, potentially prompting prospective treatment adjustments. Recent studies have demonstrated that pretransplant MRD levels negatively affect post-transplant outcome. Years ago, we showed that MRD persistence at the end of consolidation was associated with an unfavorable outcome and that autologous stem cell transplantation (AuSCT) was not able to alter such an unfavorable course. More recently, other authors have extended this observation to either pediatric or adult patients receiving allogeneic stem cell transplantation (ASCT), showing that pretransplant MRD is a major determinant of prognosis, regardless of the occurrence of graft-versus-leukemia (GVL). Nevertheless, whether MRD positivity is an indication or a contraindication to deliver ASCT is still a matter of debate. On the basis of these premises, we analyzed a retrospective series of MRD-positive adults with AML who were submitted to ASCT. Our aim was to evaluate the impact of pretransplant MRD status on overall survival (OS) and DFS. We analyzed 230 consecutive patients achieving CR after the induction cycle of intensive EORTC/GIMEMA protocols and who harbored in their leukemic cells a LAIP suitable for MRD monitoring. The present series represents an extension of a cohort of patients already analyzed for different purposes and reported previously. Following our previous experience, MRD positivity was defined if ⩾ 3.5 × 10 4 (0.035%) residual leukemic cells (RLCs) were detected in the BM upon full hematological recovery after consolidation cycle. According to this definition, 176/230 patients (76.5%) were classified as MRD positive (MRD) and 54/230 (23.5%) as MRD negative (MRD). In the overall series, 84/230 patients (36.5%) received no transplant because of age, poor performance status or insufficient stem cell harvest, 28/230 (12.2%) relapsed before transplant delivery whereas 118/230 (51.3%) underwent ASCT (N= 50) or AuSCT (N= 68) in first CR. For the purpose of the present analysis, we focused on the 81 patients who tested MRD and who were submitted to ASCT (N= 45) or AuSCT (N= 36), respectively. The same analysis was not feasible for MRD patients due to the low numbers in the ASCT group (N= 5), preventing any statistical significance from being demonstrated. The clinico-biological characteristics of the patients are detailed in Table 1. The two groups were balanced regarding white blood cell count (WBCc), ELN risk category, FLT3 and NPM1 mutational status. Karyotypic analysis was available in 77 (95%) out of 81 patients. Intermediate risk category accounted for 78%

Recurrence of a t(8;21)-Positive Acute Myeloid Leukemia in the Form of a Granulocytic Sarcoma Involving Cranial Bones: A Diagnostic and Therapeutic Challenge

Granulocytic sarcoma (GS) is a rare extramedullary solid tumor defined as an accumulation of myeloblasts or immature myeloid cells. It can cooccur with or precede the acute myeloid leukemia (AML) as well as following treated AML. The incidence of GS in AML patients is 3–8% but it significantly rises in M2 FAB subtype AML. This variety of AML harbors t(8;21) in up to 20–25% of cases (especially in children and black ones of African origin) and, at a molecular level, it is characterized by the generation of a fusion gene known as RUNX1-RUNX1T1. Approximately 10% of M2 AML patients will develop GS, as a consequence, the t(8;21) and the relative transcript represent the most common cytogenetic and molecular abnormalities in GS. FLT3-ITD mutation was rarely described in AML patients presenting with GS. FLT3 ITD is generally strongly associated with poor prognosis in AML, and is rarely reported in patients with t(8;21). GS presentation is extremely variable depending on organs involved; in general, cranial bones and sinus are very rarely affected sites. We report a rare case of GS occurring as a recurrence of a previously treated t(8;21), FLT3-ITD positive AML, involving mastoid bones and paravertebral tissues.

Thoracic Cord Compression Caused by Epidural Extramedullary Hematopoiesis During Erythroid-Stimulating Agent Therapy in Two Patients With Myelodysplastic Syndromes

Introduction Proliferation of extramedullary hematopoiesis (EMH) is a rare event that complicates chronic anemic states. The largest series published to date included 24 cases, all of which were reported in association with hematologic disorders, in which compensatory or inappropriate increase of blood formation (eg, thalassemia, myeloproliferative disorders, sickle cell anemia, and so on) can reactivate unusual hematopoietic sites. Abnormal EMH usually occurs in sites that are involved in hematopoiesis during fetal development, such as the spleen, liver, and kidneys; however, even ectopic locations, such as the paraspinal tissue, may be frequently involved, which results in neurologic symptoms, pain, and spinal cord compression. The epidural block has been often described as midthoracic, probably because of the narrow course of the thoracic epidural space at this level. Few patients (Table 1) have been reported to have a spinal block caused by EMH in association with myelodysplastic syndromes (MDSs), but to our knowledge, none of these patients was receiving erythroidstimulating agents (ESAs) when symptoms occurred. ESAs are universally recognized as first-line treatment for patients with low-risk MDSs who are transfusion dependent. Erythropoietin alpha, erythropoietin beta, and more recently, darbepoetin, have been found to increase hemoglobin levels and ameliorate transfusion dependence in 19% to 68% of patients with MDSs. Despite concern of a detrimental effect on tumor progression in patients with solid cancers, in MDSs, several meta-analyses that have included thousands of patients showed only sporadic thromboembolic events, and no episodes of neurologic or cardiovascular complications that were directly related to the drug have been documented. We report two patients who were treated with ESAs; both patients were diagnosed as having an EMH mass that caused thoracic cord compression. In both patients, ESA withdrawal resulted in rapid relief of symptoms and mass resolution with no need of laminectomy or radiotherapy. Case Reports In March 2002, a 69-year-old woman with a diagnosis of anemia was referred to our clinic. Laboratory studies showed leucopenia (WBC count, 3.3 10/L; absolute neutrophil count, 1.8 10/L) and normochromic/normocytic anemia (hemoglobin [Hb], 8.0 mg/ dL). Bone marrow aspirate showed less than 5% blasts and karyotype was normal. The final diagnosis was refractory anemia (low risk per the International Prognostic Scoring System). Because the decreasing level of Hb required a program of regular packed red cell unit (PRCU) transfusions, in October 2002, we initiated erythropoietin alpha (10,000 UI three times per week). The therapy was administered for 30 months with good tolerance and no relevant adverse effect. In March 2005, because of an increase in the transfusion requirement from two to five PRCU transfusions per month, we incrementally increased the erythropoietin alpha dosage to 40,000 UI twice per week. A significant reduction in transfusion support was gained. In December 2007, the patient reported persistent thoracic pains spreading to the epigastric region. A total-body computed tomography (CT) scan showed an epidural mass at the D8-D9 vertebrae level, with no bone erosion. Erythropoietin alpha was stopped and the symptoms subsided within a few days. A CT-guided biopsy was performed and histologic examination revealed EMH. The patient is alive, receives erythropoietin alpha at a dose of 40,000 UI once per week, and is transfusion free. In August 2008, a 75-year-old man with a diagnosis of chronic anemia was referred to our clinic. Laboratory studies showed a WBC count of 3.4 10/L, absolute neutrophil count of 1.95 10/L, normochromic/normocyticanemia(Hb,9.5mg/dL),andmildthrombocytopenia (platelets, 95 10/L). Bone marrow aspirate showed less than 5% blasts and cytogenetic analysis demonstrated a chromosome 11 monosomy. The final diagnosis was refractory cytopenia with multilineage dysplasia (International Prognostic Scoring System risk: Intermediate-1). In November 2008, high doses of erythropoietin alpha therapy were initiated (40,000 UI twice per week) because the patient began requiring transfusion support. Erythropoietin alpha treatment was continued for 26 months with good tolerance and no relevant adverse effect. After 8 months of such therapy, the transfusion need decreased from a median number of two to 0.7 PRCU transfusions per month. In January 2011, the patient presented with complaints of persistent, intense pains that spread from the retrosternal to

Involvement of central nervous system in adult patients with acute myeloid leukemia: Incidence and impact on outcome

Incidence and effect on outcome of central nervous system (CNS) involvement in adult patients with acute myeloid leukemia (AML) is not clearly defined. To address this issue, 103 consecutive adult patients with newly diagnosed AML, regardless of neurologic symptoms, were submitted to a routine explorative lumbar puncture. Cerebrospinal fluid (CSF) samples were collected from 65 males and 38 females. All 103 CSF samples were examined by conventional cytology (CC) whereas 95 (92%) also by flow cytometry (FCM). At diagnosis, 70 patients (68%) were CNS negative (CNS-), whereas 33 (32%) were CNS positive (CNS+). In 11 of 33 (33%), CNS infiltration was documented either by CC or FCM , in 21 (67%) only by FCM. CNS positivity was significantly associated with a M4-M5 phenotype of the underlying AML (P = .0003) and with high levels of lactate dehydrogenase (P = .006). Overall, 80 of 103 (78%) achieved complete remission with no significant differences between CNS+ and CNS- patients. Five-year disease-free survival and overall survival were found to be shorter in CNS+ patients than in those CNS- (18% vs 50%, P = .006 and 19% vs 46%, P = .02, respectively). In multivariate analysis, CNS status and age were found to affect independently overall survival. In conclusion, the incidence of CNS involvement in adult patients with newly diagnosed AML is higher than expected. Regardless of neurologic symptoms, it should always be searched at diagnosis; CSF samples should routinely be investigated by FCM since a certain proportion of CNS involvements might remain undetected if examination is exclusively CC based.

Extensive toxic epidermal necrolysis following brentuximab vedotin administration.

Dear Editor, In June 2013, we observed a 22-year-old man with a diagnosis of CD30 positive, anaplastic large cell lymphoma (ALCL). Lymphoma was at stage IIIA and positive for anaplastic lymphoma kinase (ALK) molecule [1]. A total body positron emission tomography and computerized tomography (TB PET/CT) scan showed latero-cervical and mediastinal lymph nodes and abdominal bulky disease. From June to December 2013, the patient was treated with three consecutive lines of chemotherapy with no evidence of response. In January 2014, he reported symptoms of sub-ileus associated with renal failure and anuria, requiring dialysis sessions. A first dose of brentuximab vedotin (BV; 1.8 mg/kg) was administered intravenously, being uneventful. Concomitant drugs were piperacillin-tazobactam, omeprazole, morphine, granisetron, pregabalin, and amisulpride. Seven days after BV infusion, we observed a diffuse erythema of the trunk, extremities, and face, which rapidly evolved in overt blistering lesions (Fig. 1a) extending to >90 % of the body surface area. The histologic examination of a skin patch documented necrosis of epidermis, vacuolization, and sub-epidermal blistering of the basal membrane zone with rare eosinophils in the papillary dermis (Fig. 1b). The picture was consistent with a diagnosis of toxic epidermal necrolysis (TEN). The patient received topical treatments, intravenous antibiotics, steroids, and immunoglobulins. After 20 days of treatment, the signs and symptoms of TEN resolved, but eventually, the patient died due to disease progression. Although our patient was on therapy with intravenous piperacillin-tazobactam, which has been recognized as potentially responsible for TEN [2], we cannot exclude the causative role of BVin the reported clinical events. Time span between BVinfusion and onset of TENwas short [3], and at the time when TEN developed a number of concomitant drugs (including piperacillin-tazobactam) have already been given for several days and most of them were administered again. Indeed, no other episodes of TEN were seen after BV discontinuation. The mechanism by which BV might have damaged the patient’s epidermis is unclear. During development, epidermal cells of fetal skin can express CD30 antigen on membrane [4]. In the present case, immunohistochemistry analysis of skin biopsies failed to demonstrate any epidermal CD30 expression. Nevertheless, cytokines released during inflammatory processes may prompt transient expression of CD30 on epidermal cells. Actually, our patient suffered from several episodes of Staphylococcus aureus infection, which might have boosted CD30 expression in the epidermidis. Alternatively, TEN might have been triggered by a delayed-type (type IV) hypersensitivity reaction [5] taking place through the activation of antigen-specific T helper lymphocytes. Actually, type IV cutaneous hypersensitivity reactions have been associated with other monoclonal antibody-based immunotherapy including ibritumomab and rituximab [3, 5]. Finally, as described for other drugs, TEN could be related to patient genetic susceptibility to the toxic effects of BV through specific HLA class I alleles and/or polymorphisms of some metabolic enzymes [6]. To the best of our knowledge, this is the first report of an extensive BVM. I. Del Principe (*) : F. Buccisano :M. Cefalo :A. Di Veroli : G. De Santis :D. Nasso : L.Maurillo :M. Postorino :G. Del Poeta : S. Amadori :A. Venditti Istituto di Ematologia, Dipartimento di Biomedicina e Prevenzione, Universita Tor Vergata, Viale Oxford 81, 00133 Rome, Italy e-mail: del.principe@med.uniroma2.it

Rituximab single agent in age-related Epstein–Barr virus associated B cell disorder complicated by autoimmune anemia and pure red cell aplasia

Dear Editor, Although not yet formally recognized into the World Health Organization classification [1], age-related Epstein–Barr virus positive (EBV) B cell lymphoproliferative disorders (AREBVLPDs) are currently classified into four groups: (1) EBV reactive lymphoid hyperplasia; (2) EBV extranodal polymorphic lymphoproliferative disease (Poly-E); (3) EBV nodal polymorphic lymphoproliferative disease (Poly-N); and (4) EBV diffuse large B cell lymphoma [2]. EBV infection is also known to cause pure red cell aplasia (PRCA) and autoimmune hemolytic anemia (AIHA) [3]. We report on a patient affected with AR-EBVLPD associated with PRCA and AIHAwho was successfully treated with rituximab. In September 2011, we observed a 64-year-old man presenting with fever and enlarged lymph nodes. Upon admission, the hemoglobin level was normal, but in the following days, it decreased to 5.6 g/dl; a contemporary reduction of reticulocyte index and haptoglobin was also observed together with an increase of lactate dehydrogenase. Total and unconjugated bilirubin level was within normal ranges. Antiglobulin direct (DAT) and indirect (IAT) tests were positive for immunoglobulin G (IgG) and complement, and an IgG monoclonal component was identified. Antinuclear, cardiolipin, anti-dsDNA antibodies were positive. Qualitative and quantitative polymerase chain reaction for EBV tested positive with 5102 viral copies/ml being measured. A total body CT scan (TB-CTS) showed splenomegaly and enlarged mediastinal and subdiaphragmatic lymph nodes. The biopsy of a latercervical lymph node revealed a diagnosis of AR-EBVLPD Poly-N (Fig. 1). The bone marrow (BM) biopsy showed a 20 % infiltrate of T-lymphocytes which carried EBV-encoded RNA (EBER). Erythroid progenitors were undetectable as well as giant normoblasts. In BM cell culture, erythroid progenitors were nearly absent, whereas the growth of autologous erythroid progenitors was inhibited by the patient’s serum. After 1 month of intravenous methylprednisolone (1 mg/kg/day), failure to achieve any improvement made us to deliver rituximab (375 mg/m/day) once a week for a total of four doses. Following the fourth, the hemoglobin increased to 9 g/dl, and the patient was discharged. After 3 months from the end of therapy, a TB-CTS showed disappearance of splenomegaly and enlarged lymph nodes, hemoglobin was 14 g/dl, and DAT/IATwas negative, although the monoclonal component was still present. BM biopsy revealed a complete clearance of EBER T-lymphocytes associated with a resumption of normal erythropoiesis. BM cell cultures generated a normal number of erythroid colonies. Twenty-four and 22 months after diagnosis and end of therapy, respectively, the patient died in complete remission because of pneumocystis jiroveci pneumonitis. Our patient developed an AR-EBVLPD Poly-N complicated by the coexistence of AIHA and PRCA [4, 5]. AIHA and PRCA might be caused by the secretion of anti-EBVantibodies cross-reacting with erythrocyte surface antigens and by the hematopoietic suppression following EBV induced T-cell activation, respectively [3]. The peculiarity of our case relies on the successful and rapid response to rituximab alone. Although the outcome of AR-EBVLPD Poly-N is generally poor, and polychemotherapy/radiotherapy is required [6, 7], M. I. Del Principe (*) :M. Cefalo : F. Buccisano :C. Sarlo : L. Di Caprio :G. De Santis : L. Maurillo :M. Postorino : G. Del Poeta : S. Amadori :A. Venditti Cattedra di Ematologia, Dipartimento Biomedicina e Prevenzione, Università Tor Vergata, Rome, Italy e-mail: del.principe@med.uniroma2.it