Marko Lucijanic

The Degree of Anisocytosis Predicts Survival in Patients with Primary Myelofibrosis

Background: Red cell distribution width (RDW) provides a quantitative measure of anisocytosis and it is associated with the presence of subclinical systemic inflammation and a poor outcome in a variety of diseases when elevated. Anisocytosis is a feature of primary myelofibrosis (PMF) but it’s prognostic role in PMF has not yet been evaluated. Aims: To determine whether anisocytosis bears prognostic significance in patients with PMF and its relation to disease features. Methods: 33 newly-diagnosed patients with PMF were analyzed in this study. Baseline RDW values were obtained in addition to other routine blood analyses (CRP, LDH, complete blood count and iron metabolism parameters) and JAK2 V617F mutational status. Patients were staged according to IPSS prognostic scoring system, liver and spleen size were assessed by palpation. The Mann Whitney U test, the Pearson correlation and the Χ2 test/ the Fisher test were used where appropriate. Survival analyses were performed using methods of Kaplan and Meier, the log-rank test and the Cox regression analysis. All statistical tests were two-sided and P values <0.05 were considered significant. Results: Median RDW was 19.0% (15.2% - 22.5%). RDW correlated significantly with hemoglobin (p=0.005), CRP (p=0.031), spleen size (p=0.036) and IPSS score (p=0.003). Patients with more pronounced anisocytosis had an inferior overall survival (OS) – very-high RDW (≥19.0%) vs. high RDW (15.1% - 18.9%) subgroup, HR 5.37, p=0.002. RDW remained significantly associated with OS (p=0.002) in a multivariate model including IPSS score, hemoglobin level and CRP. Summary/Conclusion: PMF pathogenesis surpasses inflammation as only cause of anisocytosis. A higher degree of anisocytosis is associated with more advanced disease features and a decreased overall survival. RDW encompasses standard prognostic score and may help in the rapid detection of patients with an unfavorable prognosis.

Survival analysis, more than meets the eye

The log-rank test is a cornerstone of phase III oncology clinical trials. However, there are at least three different mathematical procedures that can be named the log-rank test and two of them are widely used by commercial statistical programs. Consequently, different P values can be obtained. In the case of a borderline statistical significance, this can mean the difference between the evidence (significant P value) and merely an observation. Since all three methods can be reported under the same name, space for possible data manipulation occurs. This should be of a particular concern in a drug regulatory context. Randomized clinical trials with borderline significant results should perhaps be required to report P values calculated by all three methods, in order to properly evaluate drug efficacy. An interactive MS Excel spreadsheet that uses all three logrank test variants is prepared as a supplementary file accompanying this article. Association of high grade of bone marrow fibrosis with poor outcome in patients with myelofibrosis is used as an example.

Canonical Wnt/β-Catenin Signaling Pathway Is Dysregulated in Patients With Primary and Secondary Myelofibrosis

INTRODUCTIONnβ-Catenin is a central effector molecule of the canonical wingless-related integration site (Wnt) signaling pathway. It is important for maintenance of stem cell homeostasis and its aberrant activation has been implicated in a wide array of malignant hematological disorders. There are few reports suggesting its dysregulation in Philadelphia chromosome-negative (Ph-)xa0myeloproliferative neoplasms (MPNs).nnnPATIENTS AND METHODSnWe analyzed β-catenin mRNA expression in bone marrow (BM) aspirates of 29 patients with primary (PMF) and 4 patients with secondary, post Ph- MPN, myelofibrosis (SMF) using quantitative real-time polymerase chain reaction (qRT PCR). The control group consisted of 16 BM aspirates from patients with limited-stage aggressive non-Hodgkin lymphoma without BM involvement. We compared relative gene expression with clinical and hematological parameters.nnnRESULTSnRelative expression of β-catenin differed significantly among groups (Pxa0= .0002), it was significantly higher in patients with PMF and SMF than in the control group, but did not differ between patients with PMF and SMF. A negative correlation was found regarding hemoglobin level in PMF (Pxa0= .017). No association according to Janus kinase 2 (JAK2) V617F mutational status or JAK2 V617F allele burden was detected.nnnCONCLUSIONnOur results show for the first time that β-catenin mRNA expression is increased in patients with PMF and SMF and its upregulation might potentiate anemia. A number of inflammatory cytokines associated with PMF are capable of mediating their effects through increased β-catenin expression. Accordingly, β-catenin can induce expression of a number of genes implicated in processes of cell cycle control, fibrosis, and angiogenesis, which are central to the PMF pathogenesis. Therefore, β-catenin might represent an interesting new therapeutic target in these diseases.

Assessing serum albumin concentration, lymphocyte count and prognostic nutritional index might improve prognostication in patients with myelofibrosis

SummaryBackgroundPrimary and secondary myelofibrosis (PMF and SMF) are malignant diseases of hematopoietic stem cell characterized by the neoplastic myeloproliferation and a strong inflammatory milieu. The prognostic nutritional index (PNI) integrates information on albumin and absolute lymphocyte count (ALC) and reflects the inflammatory, nutritional and immune status of axa0patient. The clinical and prognostic significance of albumin, ALC and PNI in patients with myelofibrosis has not been previously investigated.MethodsWe retrospectively analyzed axa0cohort of 83xa0myelofibrosis patients treated in our institution from 2006 to 2017. Albumin, ALC and PNI were assessed in addition to other disease specific markers.ResultsThe PMF and SMF patients had significantly lower ALC and PNI but similar albumin compared to controls. Lower albumin was significantly associated with older age and parameters reflecting more aggressive disease biology (e.g. anemia, lower platelet levels, higher lactate dehydrogenase (LDH), circulatory blasts, transfusion dependency, blast phase disease), inflammation (higherxa0C reactive protein (CRP), constitutional symptoms) and higher degree of bone marrow fibrosis. Lower ALC was significantly associated with lower white blood cells (WBC) and lower circulatory blasts. Low PNI was associated with lower albumin, lower ALC, anemia, lower WBCs, lower serum iron and lower transferrin saturation. There was no difference in albumin, ALC and PNI regarding the driver mutations. In multivariate analysis adjusted for age and gender, low albumin (hazard ratio [HR]u202f=u20094.61, Pu202f=u20090.001), low ALC (HRu202f=u20093.54, Pu202f=u20090.004) and Dynamic International Prognostic Scoring System (DIPSS) (HRu202f=u20092.45, Pu202f=u20090.001) were able to predict inferior survival independently of each other. Accordingly, low PNI (HRu202f=u20094.32, Pu202f<u20090.001) predicted poor survival independently of DIPSS (HRu202f=u20093.31, Pu202f<u20090.001).ConclusionAssessing albumin, ALC and PNI might improve prognostication in patients with myelofibrosis and could assist in recognition of patients under increased risk of death.

Heat shock protein 27 (HSP27/HSPB1) expression is increased in patients with primary and secondary myelofibrosis and may be affecting their survival

Marko Lucijanic , Ana Livun , Katarina Marija Tupek, Tajana Stoos-Veic, Gorana Aralica, Iva Gecek, Vlatko Pejsa and Rajko Kusec Department of Hematology, University Hospital Dubrava, Zagreb, Croatia; Clinical Institute of Laboratory Diagnosis, Division of Molecular Diagnosis and Genetics, University Hospital Dubrava, Zagreb, Croatia; Department of Clinical Cytology and Cytometry, University Hospital Dubrava, Zagreb, Croatia; School of Medicine, University of Osijek, Osijek, Croatia; Department of Pathology, University Hospital Dubrava, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia

High absolute basophil count is a powerful independent predictor of inferior overall survival in patients with primary myelofibrosis

ABSTRACT Objectives: To investigate the clinical and prognostic significance of absolute basophil count (ABC) in patients with primary myelofibrosis (PMF). Methods: We retrospectively investigated 58 patients with PMF treated in our institution in the period from 2006 to 2017. ABC was obtained in addition to other hematological and clinical parameters. Patients were separated into high and low ABC groups using the Receiver operating characteristic curve analysis. Results: ABC was higher in PMF patients than in healthy controls (Pu2009<u20090.001). Patients with high ABC had higher white blood cells (Pu2009<u20090.001), higher red cell distribution width (Pu2009=u20090.035), higher lactate dehydrogenase (Pu2009<u20090.001), more frequently had circulatory blasts (Pu2009<u20090.001), constitutional symptoms (Pu2009=u20090.030) and massive splenomegaly (Pu2009=u20090.014). ABC was also positively correlated with absolute monocyte count (AMC) (Pu2009<u20090.001) and other components of differential blood count. There was no difference in ABC regarding driver mutations or degree of bone marrow fibrosis. Univariately, high ABC was significantly associated with inferior overall survival (hazard ratio (HR) 4.79, Pu2009<u20090.001). This effect remained statistically significant (HR 4.27, Pu2009=u20090.009) in a multivariate Cox regression model adjusted for age, gender, Dynamic International Prognostic Scoring System (HR 2.6, Pu2009=u20090.001) and AMC (HR 8.45, Pu2009=u20090.002). Discussion: High ABC reflects higher disease activity and stronger proliferative potential of disease. ABC and AMC independently predict survival and therefore seem to reflect different underlying pathophysiologic processes. Hence, both have a potential for improvement of current prognostic scores. Conclusion: Basophils represent a part of malignant clone in PMF and are associated with unfavorable disease features and poor prognosis which is independent of currently established prognostic scoring system and monocytosis.

Rituximab with dose-adjusted EPOCH as first-line treatment in patients with highly aggressive diffuse large B-cell lymphoma and autologous stem cell transplantation in selected patients.

Aim To assess the benefit of rituximab with dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (R-DA-EPOCH) regimen as a first-line treatment for patients with diffuse large B-cell lymphoma (DLBCL) presenting with unfavorable or aggressive features, and autologous stem cell transplantation (ASCT) as a part of the first-line treatment for selected DLBCL patients with additional aggressive features. Methods We retrospectively analyzed 75 newly diagnosed DLBCL patients with Ki-67+≥80% or International Prognostic Index ≥2 who were treated with R-DA-EPOCH between 2005 and 2015. Of 24 DLBCL patients with additional aggressive features (Ki-67+≥90% or age-adjusted IPI≥2) who were planned to receive consolidation with ASCT, 17 patients underwent the procedure. We determined the overall response rate (ORR), complete remission (CR), partial remission (PR), 5-year overall survival (OS), and progression free survival (PFS) in all DLBCL patients and specifically those planned to receive ASCT. Results All 75 patients included in the analysis started one or more cycles of therapy. The ORR, CR, and PR rates were 80%, 55%, and 25%, respectively. The response was non-evaluable in 10 of 75 patients due to treatment discontinuation. The OS and PFS rates for all 75 patients were 70% and 61%, respectively, and 80% and 79%, respectively, for 24 planned-to-receive-ASCT patients. Age (≤65 vs >65 years) had no prognostic impact on OS and PFS (Pu2009=u20090.994 and Pu2009=u20090.827, respectively). Conclusion Our retrospective analysis of one of the largest DLBCL patient cohorts outside the US National Cancer Institute showed that R-DA-EPOCH is a very effective therapeutic option as a first-line treatment of DLBCL patients with unfavorable prognostic features irrespective of their age. ASCT provided additional benefit for DLBCL patients with additional aggressive features.

Prognostic implications of low transferrin saturation in patients with primary myelofibrosis

OBJECTIVESnTransferrin saturation (TSAT) 20% or less is considered to represent functional iron deficiency in the context of malignant disease, phenomenon mediated through inflammatory changes of iron homeostasis. We aimed to investigate clinical and prognostic significance of low TSAT in patients with primary (PMF) and secondary myelofibrosis (SMF), malignant diseases characterized by strong inflammatory milieu.nnnMETHODSnWe retrospectively analyzed 87 patients with myelofibrosis and compared TSAT with disease specific parameters.nnnRESULTSnOne-third of patients had TSAT ≤20%. Lower TSAT was significantly associated with Janus-kinase-2 (JAK2) mutation (Pu202f=u202f0.007), transfusion independency (Pu202f=u202f0.003), higher platelets (Pu202f=u202f0.004), lower mean-corpuscular-volume (Pu202f<u202f0.001), lower ferritin (Pu202f<u202f0.001), higher absolute-neutrophil-count (Pu202f=u202f0.027), lower absolute-lymphocyte-count (Pu202f=u202f0.041) and lower albumin (Pu202f=u202f0.018). PMF patients presenting with low TSAT (≤20%) experienced significantly shorter overall-survival (OS) (HRu202f=u202f2.43; Pu202f=u202f0.017), whereas TSAT did not affect OS of SMF patients (HRu202f=u202f1.48; Pu202f=u202f0.623). Low TSAT remained significantly associated with inferior OS in PMF in a series of multivariate Cox regression models comparing its properties to anemia, transfusion dependency, ferritin and Dynamic-International-Prognostic-System (DIPSS).nnnCONCLUSIONSnLow TSAT has detrimental effect on survival of PMF patients. This effect is independent of anemia and of ferritin levels that seem to be better at representing iron overload in PMF patients.

Increased mean platelet volume (MPV) is an independent predictor of inferior survival in patients with primary and secondary myelofibrosis

Neoplastic megakaryopoiesis is a dominant feature of Philadelphia-chromosome-negative myeloproliferative neoplasms (Ph− MPNs), and elevated mean-platelet-volume (MPV) is a common finding in these diseases. The clinical and prognostic significances of MPV in patients with primary (PMF) and secondary myelofibrosis (SMF) have not been reported. We retrospectively analyzed 87 patients with myelofibrosis (66 with PMF, 21 with SMF) treated at our institution. MPV was recorded in addition to other hematological and clinical parameters. MPV was elevated in both PMF and SMF patients in comparison to controls, whereas there was no statistically significant difference between PMF and SMF. Elevated MPV was associated with lower platelets (Pxa0=xa00.016), higher white blood cells (Pxa0=xa00.015), higher percentage of circulatory blasts (Pxa0=xa00.009), higher lactate dehydrogenase (Pxa0=xa00.011), larger spleen size (Pxa0=xa00.014) and higher Dynamic International Prognostic score category (Pxa0=xa00.027), while there was no statistically significant association with driver mutations or degree of bone marrow fibrosis. Higher MPV was univariately associated with inferior overall survival in the whole cohort (HRxa0=xa03.82, Pxa0=xa00.006), PMF (HRxa0=xa04.35, Pxa0=xa00.007) and SMF patients (HRxa0=xa07.22, Pxa0=xa00.034). These associations remained significant in multivariate analyses adjusted for DIPSS. Higher MPV is associated with more aggressive disease features and exhibits powerful independent prognostic properties in both PMF and SMF settings.

The role of glucagon in the possible mechanism of cardiovascular mortality reduction in type 2 diabetes patients

Type 2 diabetes (T2D) is one of the major public health issues worldwide. The main cause of mortality and morbidity among T2D patients are cardiovascular (CV) causes. Various antidiabetics are used in T2D treatment, but until recently they lacked clear evidence of the reduction in CV mortality and all‐cause mortality as independent study end‐points. The aim of this article was to present and critically evaluate potential mechanisms behind the remarkable results documented in trials with new antidiabetics for the treatment of T2D.