Pierangelo Spedini

Delayed-onset peripheral blood cytopenia after rituximab: Frequency and risk factor assessment in a consecutive series of 77 treatments

The occurrence of unexplained peripheral blood cytopenia, particularly neutropenia, has been recently reported after rituximab. Its prevalence may be underestimated since it may occur late after treatment. This study analysed all cases of unexplained delayed-onset peripheral blood cytopenia of WHO grade II – IV occurring in an unselected series of patients treated with rituximab in order to evaluate its prevalence and clinical significance. Seventy-seven courses of rituximab (corresponding to 317 rituximab infusions) given to 72 consecutive patients affected by non-Hodgkins Lymphoma and treated at a single Center with rituximab, alone (nine cases), associated with chemotherapy (50) or with chemotherapy and autologous stem cell transplantation (18) were evaluated. Twenty-three cases of cytopenia (29.8%) were observed. Neutropenia developed in 21 cases (27.3%), thrombocytopenia in eight (10.4%), anemia in four (5.2%). Multiple cytopenias were observed in nine cases. Neutropenia developed after a median of 10 weeks, anemia of 5 weeks and thrombocytopenia of 4 weeks after the last rituximab dose. Severe infections occurred in four of 21 neutropenic patients (19%), compared to two of 56 controls (3.6%) (p = 0.043). Cytopenia eventually resolved in nine of 18 evaluable cases after a median of 10 weeks (range 1 – 23). Age, sex, histology, bone marrow infiltration, hypogammaglobulinemia, previous chemotherapy, autologous stem cell transplant, rituximab schedule and timing, rituximab doses were analysed as predictors for cytopenia; by multivariate analysis only a previous treatment with chemotherapy and more than four rituximab doses were significantly associated with a higher risk of post-rituximab delayed cytopenia. Delayed-onset cytopenia, particularly neutropenia, is a clinically significant complication of rituximab treatment, which merits further investigation.

Thrombocytopenia, giant platelets, and leukocyte inclusion bodies (May-Hegglin anomaly) : Clinical and laboratory findings

PURPOSE May-Hegglin anomaly is a rare hereditary condition characterized by the triad of thrombocytopenia, giant platelets, and inclusion bodies in leukocytes. Clinical features and the pathogenesis of bleeding in this disease are poorly defined. PATIENTS AND METHODS From 1988 to 1996 we studied 15 new May-Hegglin anomaly patients from 7 unrelated Italian families. In addition to clinical examination and routine laboratory testing, we measured bleeding time, platelet aggregation and release reaction, and platelet staining for tubulin, and performed ultrastructural study of polymorphonuclear leukocytes. RESULTS Although the mean age of our patients was 33 years, May-Hegglin anomaly had not been previously recognized in any of them. Bleeding diatheses ranged from severe to absent, and platelet count from 26 to 178 x 10(9)/L. No correlation was found between bleeding tendency and platelet count. Previous therapy with corticosteroids, high-dose immunoglobulins, and splenectomy had no effect on platelet count or bleeding diathesis. Desmopressin infusion greatly shortened the bleeding time in the most severely affected patient. The in vitro function of platelets was normal except for the absence of shape change in all subjects and defective response to epinephrine in 8 of 15 patients. Platelet tubulin was distributed unevenly instead of being organized in a circumferential band at the cell periphery. CONCLUSION The diagnosis of May-Hegglin is easily missed, and its frequency is probably underestimated. A qualitative defect of platelets may be responsible for mild bleeding diathesis even in the absence of thrombocytopenia, while severe bleeding results from both qualitative and quantitative platelet defects. May-Hegglin anomaly should be suspected whenever a patient has a low platelet count or a bleeding diathesis of unknown origin.

Risk-oriented postremission strategies in adult acute lymphoblastic leukemia: prospective confirmation of anthracycline activity in standard-risk class and role of hematopoietic stem cell transplants in high-risk groups

INTRODUCTION Although definite risk classes are well known, risk-adapted modulation of first-line therapy is seldom attempted in adult ALL. So, a prospective validation of the therapeutic efficacy of a protocol (or a component thereof) in specific risk groups is uncommon. MATERIALS AND METHODS From 1996-1999 a risk-oriented program (08/96) was evaluated in 102/121 unselected patients (median age 35 years, blast count 0-450 x 10(9)/l, 100 B(lin) (lineage), 21 T(lin)) responsive to induction therapy. The standard risk (SR) class was B(lin) CD10+ Ph- with blasts < 10 x 10(9)/l (prior studies: disease-free survival (DFS) rate 52% at five years with dose-intensive anthracycline-containing programs). The SR protocol was therefore anthracycline-rich (early consolidation cycles with total idarubicin 96 mg/m2), and comprised long-term maintenance. High-risk (HR) patients were eligible to the following three options: allogeneic hematopoietic stem cell transplantation (HSCT) from related family donor; short sequence with high-dose cyclophosphamide-cytarabine-methotrexate followed by melphalan/total body irradiation with autologous HSCT; or T(lin) ALL chemotherapy regimen inclusive of high-dose cytarabine and methotrexate. RESULTS Treatment realization and three-year DFS rates according to risk class, HR subset and postremission treatment intensity were the following. SR group (n = 28): realization rate 93%, DFS 68.5%. HR group (n = 74): realization rate 80%, DFS 39% (P = 0.052 vs SR category). In HR group, three-year DFS rates by disease subtype were the following. B(lin) Ph- (n = 35) 43%; Ph+ (n = 19) 13% at 2.7 years (P = 0.006 vs other HR subtypes); T(lin) (n = 18) 59.5%. And DFS rates by treatment intensity were: allograft (n = 21) 40%; autograft (n = 28) 27%; shift to SR protocol (n = 13) 52% (P = ns vs allograft/autograft); T(lin) program (n = 10) 57%. Matched analyses of treatment protocols and disease subtypes suggested a possible therapeutic role of the autograft regimen in B(lin) Ph- ALL with a blast count < 25 x 10(9)/l, and of T(lin) protocol for T(lin) ALL. Comparisons with retrospective control cohorts were confirmatory of anthracycline activity in SR subclass. CONCLUSION The intended strategy was applicable to the majority of study patients, confirming the value of anthracyclines in SR class and, preliminarily, the usefulness a T(lin)-specific treatment. Apart from the case of Ph+ ALL, the indications for high-dose procedures with HSCT remains largely undetermined in this study.

Prospective Phase II Study on 5-Days Azacitidine for Treatment of Symptomatic and/or Erythropoietin Unresponsive Patients with Low/INT-1–Risk Myelodysplastic Syndromes

Purpose: This phase II prospective study aimed to evaluate the efficacy and safety of 5-days azacytidine (5d-AZA) in patients with low-risk myelodysplastic syndromes (MDS). Second, single-nucleotide polymorphism (SNP) genetic profile and phosphoinositide-phospholipase C (PI-PLC) β1 levels were studied to evaluate possible biologic markers able to predict the hematologic response. Experimental Design: The study tested a lower intensity schedule of azacytidine. The treatment plan consisted of 75 mg/sqm/d subcutaneous administered for 5 days every 28 days, for a total of 8 cycles. Results: Thirty-two patients were enrolled in the study. The overall response rate was 47% (15 of 32) on intention-to-treat and 58% (15 of 26) for patients completing the treatment program. In this latter group, 5 (19%) achieved complete remission (CR) and 10 (38%) had hematologic improvement, according to the International Working Group (IWG) criteria. Three patients have maintained their hematologic improvement after 37, 34, and 33 months without other treatments. Moreover, 21 and 2 of 26 cases completing 8 cycles were transfusion-dependent for red blood cells and platelets at baseline, respectively. Of these, 7 (33%) and 2 (100%) became transfusion-independent at the end of the treatment program, respectively. Grade 3–4 neutropenia occurred in 28% of patients and 4 patients died early due to infections or hemorrhage. SNP results were not significantly correlated to the clinical outcome, whereas PI-PLCβ1 level anticipated either positive or negative clinical responses. Conclusions: 5d-AZA is safe and effective in a proportion of patients with low-risk MDS. PI-PLCβ1 gene expression is a reliable and dynamic marker of response that can be useful to optimize azacytidine therapy. Clin Cancer Res; 19(12); 3297–308. ©2013 AACR.

A new variant of Bernard‐Soulier syndrome characterized by dysfunctional glycoprotein (GP) Ib and severely reduced amounts of GPIX and GPV

We describe a new variant of Bernard‐Soulier syndrome characterized by almost normal amounts of GPIb and severely reduced GPIX and GPV. Despite surface expression, GPIbα failed to support ristocetin‐induced platelet agglutination and to bind two conformation‐dependent monoclonal antibodies, suggesting a qualitative defect. Sequence analysis of the gene coding for GPIX revealed a T‐to‐C substitution at base 1811, leading to a Leu40Pro conversion, whereas no defects were found in the coding region of the GPIbα gene. Allele‐specific restriction enzyme analysis showed that the propositus and one of his sisters, both with severe bleeding diathesis, were homozygous for the GPIX mutation; the members of the family with mild bleeding diathesis and/or giant platelets in the peripheral blood were heterozygous, whereas the healthy ones were homozygous for the normal allele.

An open-label, pilot study of fludarabine, cyclophosphamide, and alemtuzumab in relapsed/refractory patients with B-cell chronic lymphocytic leukemia.

Although combination regimens have improved outcomes over monotherapy in chronic lymphocytic leukemia (CLL), patients eventually relapse. Combined fludarabine, cyclophosphamide, and monoclonal anti-CD52 antibody alemtuzumab (FCC) provided synergistic cytotoxicity with effective clearing of minimal residual disease. This phase 2 study determined FCC efficacy and safety in relapsed/refractory CD52(+) B-CLL after ≥ 1 line of treatment. From January 2005 through June 2008, up to 6 courses of oral fludarabine 40 mg/m² per day, oral cyclophosphamide 250 mg/m² per day, and subcutaneous alemtuzumab (Mab-Campath) 10 mg (increased to 20 mg after first 10-patient cohort) were administered days 1 to 3 every 28 days. The primary objective was overall response rate (ORR); secondary objectives included response duration, time to disease progression, and safety and tolerability. ORR was 67% in 43 patients; 30% achieved complete response. ORR significantly improved with 1 versus ≥ 2 prior therapies (P = .018), and without versus with previous monoclonal antibody treatment (P = .003). Median progression-free survival was 24.4 months, not reached in patients achieving complete response. Median overall survival was 33.6 months. Myelosuppression was the most common adverse event, with a low percentage of cytomegalovirus reactivations and manageable infections. However, close vigilance of opportunistic infections is warranted. FCC provides effective immunotherapy in relapsed/refractory CLL, including in patients with poor-risk prognostic factors.

Bleeding Tendency of Unknown Origin and Protein Z Levels

known origin showed low levels of protein Z, suggesting that a protein Z assay must be included in

Individual Quality Assessment of Autografting by Probability Estimation for Clinical Endpoints: A Prospective Validation Study from the European Group for Blood and Marrow Transplantation

The aim of supportive autografting is to reduce the side effects from stem cell transplantation and avoid procedure-related health disadvantages for patients at the lowest possible cost and resource expenditure. Economic evaluation of health care is becoming increasingly important. We report clinical and laboratory data collected from 397 consecutive adult patients (173 non-Hodgkin lymphoma, 30 Hodgkin lymphoma, 160 multiple myeloma, 7 autoimmune diseases, and 28 acute leukemia) who underwent their first autologous peripheral blood stem cell transplantation (PBSCT). We considered primary endpoints evaluating health economic efficacy (eg, antibiotic administration, transfusion of blood components, and time in hospital), secondary endpoints evaluating toxicity (in accordance with Common Toxicity Criteria), and tertiary endpoints evaluating safety (ie, the risk of regimen-related death or disease progression within the first year after PBSCT). A time-dependent grading of efficacy is proposed with day 21 for multiple myeloma and day 25 for the other disease categories (depending on the length of the conditioning regimen) as the acceptable maximum time in hospital, which together with antibiotics, antifungal, or transfusion therapy delineates four groups: favorable (≤7 days on antibiotics and no transfusions; ≤21 [25] days in hospital), intermediate (from 7 to 10 days on antibiotics and <3 transfusions, ≤21 to 25 days in hospital or ≥7 days on antibiotics and no transfusions; from 21 to 30 days [25 to 34] in hospital), unfavorable (>7 days on antibiotics, >3 but <6 transfusions; >30/34 days in hospital after transplantation), and very unfavorable (>10 days on antibiotics, >6 transfusions; >30 to 34 days in hospital). The multivariate analysis showed that (1) PBSC harvests of ≥4 × 10(6)/kg CD34 + cells in 1 apheresis procedure were associated with a favorable outcome in all patient categories except acute myelogenous leukemia and acute lymphoblastic leukemia (P = .001), (2) ≥5 × 10(6)/kg CD34 + cells infused predicted better transplantation outcome in all patient categories (P < .0001) except acute myelogenous leukemia and acute lymphoblastic leukemia, (3) 1 or 2 aphereses (P = .001) predicted good outcome, (4) toxicity increased with higher graft volume reinfused (>500 mL) (P = .002), and (5) patients with a central venous catheter during both collection and infusion of PBSC had a more favorable outcome post-PBSCT than peripheral access (P = .007). The type of mobilization regimen did not affect the outcome of auto-PBSCT. The present study identified predictive variables, which may be useful in future individual pretransplantation probability evaluations with the goal to improve supportive care.

Hepatic candidiasis in a patient with acute myeloid leukaemia

A 46-year-old man was hospitalized with fever, malaise and abdominal pain following a period of pancytopenia secondary to induction chemotherapy for acute myeloid leukaemia. Physical examination revealed only hepatomegaly. The full blood count showed Hb 11 g/dl, platelet count of 84 10/l and white blood cell count of 23 ́8 10/l. Fibrinogen was 7 ́30 g/l, alkaline phosphatase 1222 U/l, aspartate aminotransferase 101 U/l, alanine aminotransferase 510 U/l and g-glutamyltranspeptidase 560 U/l. He was started on empiric ceftazidime and amikacin. Because of multiple positive blood cultures for Candida albicans and persistent fever, he was also started within a few days on amphotericin B (1 mg/kg body weight/d). An ultrasound examination and a computerized tomography abdominal scan (top) showed multiple hepatic abscesses that were biopsied without result. The patient underwent an exploratory laparotomy that showed multiple white turbinate spicules on the surface of Glissons capsule (bottom). These were biopsied and fungal elements compatible with candida were seen in the histological sections. Antifungal therapy was continued for 6 months and his condition improved slowly. He is currently well and free of malignant disease and fungal infection.

Quality assessment of autologous haematopoietic blood progenitor cell grafting

Dear Editor, I read with great interest the paper by Bai L et al., focusing on factors predicting haematopoietic recovery in patients undergoing autologous transplantation: 11-year experience from a single centre [1]. This paper showed that infused CD34+ cell dose correlated to platelet but not neutrophil recovery. Interestingly, non-remission status, increasing neutrophil contamination of HPC-A and HPC-Avolumes >500ml were strongly associated with delayed engraftment post-autologous transplantation [1]. Based on these findings, authors concluded that CD34+ cell counts remain a useful and convenient marker for assessing haematopoietic stem cell content and overall engraftment capacity post-transplant. However, several variables may be implicated in the engraftment kinetics of haematopoietic stem cells post-autologous transplantation. These findings are very interesting and deserve a careful discussion. In a recent paper, we reported clinical and laboratory data collected from 397 consecutive adult patients who underwent their first autologous peripheral blood stem cell transplantation (PBSCT) [2]. We considered primary end points evaluating health economic efficacy, including antibiotic administration, transfusion of blood components and time in hospital; secondary end points evaluating toxicity, in accordance with Common Toxicity Criteria, and tertiary end points evaluating safety, i.e. the risk of regimen-related death or disease progression within the first year after PBSCT. A time-dependent grading of efficacy was proposed with day 21 for multiple myeloma (MM) and day 25 for the other disease categories (depending on the length of the conditioning regimen), as the acceptable maximum time in hospital, which together with antibiotic, antifungal or transfusion therapy, delineated four groups: favourable (≤7 days on antibiotics and no transfusions; ≤21 (25) days in hospital), intermediate (7 7 days on antibiotics, >3 but less than 6 transfusions; >30/34 days in hospital after transplantation) and very unfavourable (>10 days on antibiotics, >6 transfusions; >30–34 days in hospital). Interestingly, the multivariate analysis showed that (a) PBSC harvests of ≥4×10/kg CD34+ cells in one apheresis procedure were associated with a favourable outcome in all patient categories except AML and ALL; (b) ≥5×10/kg CD34+ cells infused predicted better transplant outcome in all patients categories except AML and ALL; (c) one or two aphereses (p=0.001) predicted good outcome; (d) toxicity increased with higher graft volume reinfused (>500 ml) and (e) patients with central venous catheter (CVC) during both collection and infusion of PBSC had a more favourable outcome post-PBSCT than peripheral access. In a further study (unpublished results), we assessed clinical and laboratory data from 35 children with haematological disorders who underwent the PBSCT, and the multivariate analysis clearly showed that engraftment post-PBSCT was quicker and toxicity lower in this patient category, in comparison with that of the adult group. F. Lanza (*) : P. Spedini : C. Vigano Hematology and BMT Unit, “Istituti Ospitalieri di Cremona” Hospital, via Concordia 1, 26100 Cremona, Italy e-mail: f.lanza@ospedale.cremona.it