Nada Suvajdzic

Is there a "gold" standard treatment for patients with isolated myeloid sarcoma?

Isolated myeloid sarcoma is an extramedullary tumor of immature myeloid cells defined by the absence of leukemia history, myelodisplastic syndrome, or myeloproliferative neoplasma with a negative bone marrow biopsy. Myeloid sarcoma is a very rare condition, and few cases have been reported. We reviewed data of 12 patients with isolated myeloid sarcoma managed at a single center to determine the possible prognostic factors affecting patient survival, such as age, sex, type, localization, and treatment options. Patients were mostly men (n=8), with a median age of 39 years. Patients were initially treated with chemotherapy (n=7) or surgery (n=5). In three patients, hematopoietic stem cell transplantation was performed. During the follow-up period, nine patients died. The median overall survival was 13 months, while event-free survival was 8 months. Regarding initial treatment strategy, no significant difference in overall survival was observed. Both chemotherapy and hematopoietic stem cell transplantation independently improved event-free survival. In addition, patients who received chemotherapy combined with hematopoietic stem cell transplantation had significantly longer event-free survival than those treated with chemotherapy alone. Age<40 years together with chemotherapy/hematopoietic stem cell transplantation significant affected event-free survival. Based on our results, the treatment of myeloid sarcoma requires a systemic rather than a localized approach with surgery or radiotherapy. While prospective evaluations are needed, chemotherapy with allogenic hematopoietic stem cell transplantation should be considered as the optimal therapy for isolated myeloid sarcoma.

More than a third of non-gastric malt lymphomas are disseminated at diagnosis: a single center survey

Mucosa‐associated lymphoid tissue (MALT) lymphomas are extranodal B‐cell tumors that generally follow an indolent course. The gastrointestinal tract is the most common site of MALT lymphoma, comprising 50% of all cases. The tissue lesions are often localized, have high therapeutic response rates with late relapses with a long overall survival (OS). The patients with non‐gastric lesions may follow a different clinical course and many of them present with disseminated disease. This study reports a series of 51 patients with non‐gastric MALT lymphoma. Twenty patients (39.2%) presented with disseminated disease, seven (13.7%) patients had two MALT mucosal sites involved and eight (15.7%) had involvement of three or more mucosal sites. At presentation, 17 (33.3%) patients had the lymph node and 12 (23.5%) the bone marrow involvement. Following various combinations of treatment, complete remission was achieved in 40 (81.6%), and partial remission in three of the 49 treated patients with no difference in response rates between different disease stages. Relapse occurred in 12/43 (27.9%) patients among whom eight (18.6%) recurred in the presenting organ system. Five patients (9.8%) died because of a rapid disease progression after a median follow‐up of 56 months; two patients with primary lung lesions, 1 patient with secondary intestinal disease, and 2 patients suffered transformation to diffuse large B‐cell lymphoma. No significant difference in survival was found between localized and disseminated disease (log rank 0.05, df = 1, P = 0.81). A patient age ≥ 60 yr at diagnosis and presentation with the nodal disease were found to be statistically significant negative prognostic factors (P < 0.05). Median OS was not reached after 145 months of follow‐up, with the estimated OS being 88% at 2 yr, and 78% at 5 yr.

Thrombotic events in acute promyelocytic leukemia

INTRODUCTION Thrombotic events (TE) appear to be more common in acute promyelocytic leukemia (APL) than in other acute leukemias, with reported prevalence ranging from 2 to 10-15%. MATERIALS AND METHODS We retrospectively analyzed the data on TE appearance in 63 APL patients. RESULTS TE occured in 13 (20.6%) cases, four arterial (6.3%) and nine venous (14.3%). TE were more frequently diagnosed after initiation of weekly D-dimer monitoring (7 TE during 20 months vs 6 during 76 months, P=0.032). Patients with and without venous thrombosis were significantly different regarding female/male ratio (P=0.046), PT (P=0.022), aPTT (P=0.044), ISTH DIC score (P=0.001), bcr3 (P=0.02) and FLT3-ITD (P=0.028) mutation. The most significant risk factor for venous TE occurrence in multivariate analysis was FLT3-ITD mutation (P=0.034). PAI-1 4G/4G polymorphism was five times more frequent in patients with venous TE than without it (P=0.05). Regarding risk factors for arterial TE we failed to identify any. CONCLUSIONS We have demonstrated that APL-related TE rate is higher than previously reported and that weekly D-dimer monitoring might help to identify patients with silent thrombosis. Moreover, our study suggests a possible relationship between venous TE occurrence and several laboratory findings (PT, aPTT, ISTH DIC score, bcr3 isoform, FLT3-ITD mutation and PAI 4G/4G). Prophylactic use of heparin might be considered in patients with ISTH DIC score<5, bcr3 isoform, FLT3-ITD mutation and PAI 4G/4G.

Mycophenolate mophetil therapy for chronic immune thrombocytopenic purpura resistant to steroids, immunosuppressants, and/or splenectomy in adults

Treatment options are limited in patients with chronic immune thrombocytopenic purpura (ITP) which has been unresponsive to corticosteroids and/or splenectomy. Mycophenolate mophetil (MMF) is effective in many autoimmune disorders including severe and refractory ITP through its targeting of T-cell and B-cell lymphocytes. We report on the efficacy of MMF (1.5–2 g/day) in 16 adults with severe steroid-resistant ITP. MMF was administered for at least 12 weeks (median 37 weeks, range 14–64 weeks). Patients comprised of 10 females and six males, with median pre-treatment platelet counts of 8 × 109/L, median age of 55 years, median ITP duration of 58 months and a median of four prior treatments (range 3–8); nine had been previously splenectomized. Eleven patients (69%) responded after 12 weeks of MMF: 6 (55%) achieving complete remission (CR) and five (45%) achieved partial remission (PR). MMF therapeutic responses were better in those patients who had had fewer prior treatments (p < 0.05), and were independent of patient age, sex, disease duration, and splenectomy status (p > 0.05). Five of the 11 responders (45%; 3CR/2PR) had sustained remissions; however, six responders (55%; 3CR/3PR) relapsed after median of 14 weeks (range 9–20). Three of the six relapsing patients responded to MMF reinstitution achieving stabile PRs; three were left untreated as none had further bleeding and their platelets remained at “safe” levels (median 30 × 109/L). The MMF treatment was well tolerated; one heavily pretreated patient developed a bronchopneumonia and a second had an episode of diarrhea. MMF used as a second-line agent can produce a sustained response in severe ITP which has been unresponsive to steroid and/or splenectomy without major toxicity.

Immunohistochemical analysis of cyclin D1 and p53 in multiple myeloma: relationship to proliferative activity and prognostic significance.

Conflicting data are reported on the clinical significance of cyclin D1 deregulation in multiple myeloma. The aim of this study was to evaluate the incidence and prognostic significance of cyclin D1 expression and p53 mutations in multiple myeloma, as well as the relationship of their expression with selected clinical data, histological features, and proliferative activity of myeloma cells. We analyzed bone marrow biopsy specimens obtained from 59 patients with newly diagnosed multiple myeloma. Expression of cyclin D1 and p53 was analyzed using standard imunohistochemical method of B5-fixed and routinely processed paraffin-embedded bone marrow specimens. Cyclin D1 was overexpressed in 14/59 (27%) and p53 in 5/59 (8.5%) specimens. There was no significant correlation between cyclin D1 overexpression and age, gender, clinical stage (Durie-Salmon classification), extent of osteolytic lesions, type of monoclonal protein, hemoglobin concentration, platelet count, serum concentration of creatinine, calcium, C-reactive protein, and beta2-microglobulin. No association was observed between the expression of cyclin D1 and the extent of bone marrow infiltration, histological grade, proliferative activity index (measured with Ki-67 immunoreactivity) and response to therapy. No significant difference was observed regarding overall survival between cyclin D1 positive and cyclin D1 negative patients (29 vs 36 mo, p=0.76). Results of this study did not revealed prognostic significance of cyclin D1 overexpression in multiple myeloma. Mutations of p53 gene are rare events in myeloma, suggesting their limited role in the pathogenesis of the disease.

Haemostatic abnormalities in treatment-naïve patients with Type 1 Gaucher's disease

There is a paucity of data on the effects of enzyme replacement therapy (ERT) on the coagulation abnormalities and platelet function of patients with Gauchers disease (GDPs) and much of this data are controversial. This study investigates the haemostatic parameters in treatment-naïve GDPs and the effects of ERT. 31 Serbian treatment-naïve type 1 GDPs (M/F 17/14; median age 49 years, splenectomized 9/31) were studied. The complete blood count, prothrombin time (PT), activated partial tromboplastin time (aPTT) and coagulation factors were measured using the standard methods. Platelet aggregation was assessed with a whole-blood aggregometer. Splenic volumes were assessed using computer tomography. Twenty-one patients were treated with ERT (Imiglucerase). The haemostatic parameters were assessed after 6, 12 and 24 months (ERT6, 12, 24). Initially bleeding episodes were registered in 10/31 GDPs. Median platelet count was 108 × 109/L; 22/31 GDPs were thrombocytopenic. The PT and aPTT values were abnormal in 16/31 and 13/31 GDPs, respectively. Platelet aggregation abnormalities were recorded in 19/31GDPs. Median platelet aggregation was reduced in response to adenosine-diphosphate 5 µmol/L (ADP5 0.46) and collagen 5 µmol/L (Col5 0.47). Splenic volume inversely correlated with the platelet count and a reduced response to arachidonic acid (AA), Col5 and ADP5 (p < 0.05). The splenectomized GDPs had a significantly lower platelet aggregation to Col10 (p < 0.05). Bleeding GDPs had a significantly lower platelet count, higher chitotriosidase levels and a greater splenic volume compared to non-bleeding patients (p < 0.01). ERT: The number of bleeding GDPs had significantly decreased by ERT6 (1/10; p < 0.01). The platelet count had significantly increased by ERT6 (ERT6 180 × 109/L, p < 0.01). The PT increased significantly from ERT0 to ERT24 (PT0 65%, PT24 81%; p < 0.05). The von Willebrand factor had increased significantly by ERT6 and ERT24 (ERT0 56%, ERT6 70%, ERT12 70%, ERT24 86%; p < 0.01). The number of GDPs with abnormal platelet aggregation had decreased significantly by ERT6 (10/19; p < 0.05). Platelet aggregation on ADP10 and AA significantly increased by ERT6 (ADP10: ERT0 0.75, ERT6 0.8 p < 0.01; AA: ERT0 0.7, ERT6 0.8 p < 0.05). In conclusion, platelet dysfunction and coagulation abnormalities were found in a considerable number of our GDPs. The absence of severe bleeding episodes suggests that the haemostatic system is sufficiently balanced and therefore the exact mechanism of the etiology of these abnormalities need to be fully clarified. ERT resulted in the cessation of bleeding and marked increase in platelet count, PT, vWF and platelet aggregation.

A gene expression profile associated with relapse of cytogenetically normal acute myeloid leukemia is enriched for leukemia stem cell genes

Some 50–80% of patients with acute myeloid leukemia (AML) achieve a complete remission with contemporary chemotherapy protocols, yet the majority of them eventually relapse with resistant disease: some patients no longer respond to chemotherapy at disease recurrence; others accomplish second and even third remissions whose decreasing duration nevertheless indicates that the pool of residual leukemic cells, i.e. of cells that persisted during treatment with cytotoxic drugs, increases with every round of therapy [1]. Either of these clinical courses therefore reflects an enhanced chemotherapy resistance of leukemic cells at relapse as compared to the cell population at diagnosis. Molecular changes enabling malignant cells to survive exposure to cytotoxic drugs may already have been present in a subset of the leukemic cell population at presentation, or may emerge during treatment [2,3], but in any case are thought to be selected as a consequence of drug therapy, and to play a major role in therapy resistance at relapse. Remarkably, however, even though various types of molecular alterations may be acquired at relapse, neither specific cytogenetic alterations nor functionally relevant point mutations as identified by whole genome sequencing were associated with relapse in a recurrent manner [2,3]. Certain copy number variations and known AML associated point mutations were newly present at relapse in small proportions of patients (usually < 10%), but the latter were lost in other patients, indicating that they are unlikely to represent drivers of therapy resistance at disease recurrence [4]. These findings could either indicate that chemotherapy resistance at relapse is acquired through a large variety of different mechanisms, or that molecular changes of other types than those mentioned above are of more general relevance in this context. Indeed, an earlier study has suggested that the expression of specific genes may change in a consistent manner between diagnosis and relapse of AML [5]. However, only a limited number of genes and mostly unpaired samples were probed in this investigation. Therefore, in the present study, genes whose expression changed in a relapse-specific manner were sought in a set of paired AML samples and on a genome-wide scale. To limit the genetic heterogeneity of the study population, only samples from patients with cytogenetically normal (CN) AML were used. Clinical characteristics of 11 patients with CN AML from whom samples had been obtained at the time of diagnosis and of relapse are summarized in Supplementary Table I available online at http://informahealthcare.com/doi/abs/10.3109/10428194.2014.944523. Patients provided written informed consent prior to sample collection, and the reported studies were approved by the ethics committee of the Medical University of Vienna (EK 179/2011). Mononuclear cells were enriched through Ficoll gradient centrifugation, and RNA was extracted and hybridized to human ST1.1 microarrays (Affymetrix). Primary data analysis was performed using the Robust Multi-array Average algorithm. The levels of 4679 genes that displayed variable expression (i.e. an interquartile range of the log2 transformed data of > 0.65 across all samples) were compared between diagnosis and relapse samples using a paired moderated t-test (R-package limma), followed by multiple hypothesis correction according to Benjamini and Hochberg [6]. These analyses revealed that 536 unique genes were up- and 551 down-regulated at relapse at a false discovery rate (FDR) < 10% (Figure 1, Supplementary Table II available online at http://informahealthcare.com/doi/abs/10.3109/10428194.2014.944523). Figure 1. Genes differentially expressed between diagnosis and relapse of CN AML. Log2 fold changes compared to the mean of all samples are displayed for the 30 most up- and the 30 most down-regulated genes (i.e. significantly differentially expressed genes with ... Because relapse of AML is considered to result from the outgrowth of usually largely quiescent, chemotherapy resistant leukemic stem cells (LSCs), a possible relationship between LSC and relapse-associated gene expression signatures was investigated. Gene expression profiles of LSC enriched versus LSC depleted human AML cell populations, functionally defined based on their engraftment ability in an optimized xenotransplant assay, were recently reported [7]. Of the 163 genes up-regulated in LSC enriched cell populations at an FDR < 10%, 19 were also up-regulated at relapse (p = 6.3 × 10− 7, odds ratio 4.29; Fishers exact test). Similarly, 14 of the 41 genes down-regulated in LSCs were also down-regulated at relapse (p = 1.2 × 10− 11, odds ratio 16.36; Fishers exact test), but no genes were regulated in an opposite manner in the two conditions (Supplementary Table II available online at http://informahealthcare.com/doi/abs/10.3109/10428194.2014.944523). To further explore relations between the relapse-associated gene expression profile and gene expression patterns associated with LSCs, as well as with normal hematopoietic stem cells (HSCs) and with prognosis in AML, gene set enrichment analysis (GSEA) [8] was performed. The 4679 genes whose expression had been compared between diagnosis and relapse of CN AML were ranked according to their associated t-statistic. The following gene lists were then probed against this relapse-associated gene expression profile: (i) genes up-regulated in functionally defined LSC enriched versus LSC depleted human AML cell populations [7]; (ii) genes up- or down-regulated in LSCs versus other leukemic cells as defined by the expression of cell surface markers [9]; (iii) genes up-regulated in HSCs versus progenitor and differentiated hematopoietic cells defined by specific cell surface markers [7]; and (iv) genes whose increased or decreased expression was associated with poor outcome in AML [10,11], or in the subgroup of CN AML [12]. Of note, the LSC and HSC signatures were related to each other [7], and, even though not defined on this basis, were able to predict chemotherapy responsiveness in AML [7,9]. All gene lists were used as reported, without any modifications. Where available, the corresponding lists of down-regulated genes were also probed, but in several cases these were either not reported, or too short to be useful for GSEA. In agreement with relapse representing a chemotherapy resistant state, the functionally defined LSC signature [7] and the HSC signature [7], as well as the three gene expression signatures linked to poor outcome in AML [10–12], were significantly enriched in the relapse-associated gene expression profile (Figure 2). Conversely, the list of genes down-regulated in patients with poor response to chemotherapy [10] was significantly negatively enriched in the relapse profile (while only small numbers of genes were down-regulated in poor responders in [11,12]), as was the list of genes down-regulated in surface-marker defined LSCs [9] (Figure 2). Figure 2. Gene signatures associated with LSCs, HSCs and poor therapy response are enriched in the CN AML relapse profile. Lists of genes associated with functionally defined LSCs [7], cell surface marker-defined HSCs [7], poor response to chemotherapy [10–12 ... The data presented in this report show that, in contrast to other investigated molecular alterations, changes in the expression of specific genes are associated with relapse of CN AML in a recurrent and significant manner. Corroborating the assumption that these changes indeed reflect, and possibly contribute to, a state of increased therapy resistance, the relapse-associated gene expression profile was enriched for gene signatures connected to poor outcome. Furthermore, a significant enrichment for gene expression signatures associated with LSCs was observed, thereby supporting the concept that relapse of AML results from the outgrowth of chemotherapy resistant LSCs and is associated with increased “stemness.” At the intersection of the relapse and the LSC signatures, a number of genes with potential roles in chemotherapy resistance were uncovered. For example, the gene coding for integrin α6, ITGA6, was expressed at elevated levels at relapse and in LSCs (Supplementary Table II available online at http://informahealthcare.com/doi/abs/10.3109/10428194.2014.944523). It was also up-regulated in AML cells with high levels of EVI1, which itself is a harbinger of a poor prognosis, and contributed to their therapy resistance [13]. Similarly, targeted deletion of interferon regulatory factor 8 (IRF8), which was down-regulated both at relapse of CN AML and in LSCs (Supplementary Table II available online at http://informahealthcare.com/doi/abs/10.3109/10428194.2014.944523), increased proliferation and reduced apoptosis of myeloid cells in vitro, and promoted leukemogenesis in a mouse model [14]. In metastatic colon cancer cell lines, its methylation mediated down-regulation also contributed to apoptosis resistance [15]. Functional analyses of these and other genes at the intersections of LSCs, chemotherapy resistance, and relapse can be expected to yield novel insights into the biology of AML, and may lead to the discovery of novel targets for rationally designed therapies.

Pretreatment prognostic factors for overall survival in primary resistant acute myeloid leukemia.

AIM Primary resistant acute myeloid leukemia has a very poor prognosis. We assessed pretreatment parameters for their significance as prognostic factors in the overall survival (OS) of 53 acute myeloid leukemia (AML) patients who had failed to achieve complete remission (CR) after first-line standard-dose remission-induction therapy. RESULTS During the period January 2005-December 2009, 53 with acute myeloid leukemia received two cycles of the 3+7 protocol as a first-line standard-dose remission-induction therapy (ARA-C, days 1-7 and daunorubicin, days 1-3). The HiDAC (5 patients), MiDAC (7 patients), and FLAG-IDA protocols (3 patients) were given as salvage therapy. None of these patients achieved CR. There were 27 (51%) males and 26 (49%) females (median age, 55 years, range 28-76). The median white blood cell count was 53 (range 0.9 -350)×10(9)/L, platelets 44 (range 3-856×10(9)/l) and bone marrow blasts 67%. HCT-IC comorbidity scores were 3 in two (3.8%) patients, 2 in 11 (20.8%), 1 in 12 (22.6%) and 0 in 16 (30.2%) patients. Median OS was 3.9 months (range 1 -20 months). The hepatomegaly, white blood cell count, ECOG PS, serum level of lactate dehydrogenase, dysplastic changes, coexpression of CD64, CD15, CD11b, comorbidities and disease cytogenetics influenced survival. CONCLUSION This single-center study evaluated the significance of pretreatment factors, and found that patient age, comorbidities, ECOG performance status, leukocytosis, hepatomegaly, LDH, and the disease cytogenetics were factors which influenced the outcomes of primary resistant patients with acute myeloid leukemia. An understanding of these factors may help to predict OS in cases where CR has not been achieved and may help when making further treatment decisions.

Iliopsoas haematoma in Gaucher disease

SummaryExtrapelvis or retroperitoneal haemorrhage has long been appreciated as having many causes and considerable variability in subsequent morbidity; however, to date only two cases have been reported in patients with Gaucher disease, the most common lysosomal storage disorder. It had been our assumption that these cases were unique and a consequence of severe disease in patients who had not been treated with enzyme (or other disease-specific) therapy. Herein we present three more cases (as well as our first patient), which allow one to make some generalizations. Ultrasound was used in one centre and computed tomography in the second centre to make the definitive diagnosis. The trigger for the bleeding in all cases was muscle strain after activity. All patients were young with massive hepatosplenomegaly, anaemia, thrombocytopenia, and bone pain with skeletal involvement; the last was the most obvious commonality among these patients. Differential diagnosis is complicated by exquisite groin pain that is common to both Gaucher disease and extrapelvis haemorrhage, but not necessarily.

ALK-negative T-cell anaplastic large cell lymphoma associated with systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) appear to have an increased risk of developing malignancies, especially lymphomas. We report the development of a systemic ALK-negative T-cell anaplastic large cell lymphoma, stage IIB, in a 53-yr-old Caucasian female with a 12-yr history of stable SLE. The patient responded poorly to chemotherapy and died 2 yr after diagnosis. Lymphomas that develop in patients with SLE and other autoimmune diseases are virtually always of B-cell origin. To our knowledge this is the first report of a T-cell anaplastic large cell lymphoma in a patient with SLE. This article discusses the association of SLE and lymphoma, with an emphasis on T-lymphoproliferative states.