An MDS-specific frailty index based on cumulative deficits adds independent prognostic information to clinical prognostic scoring.

The frailty index (FI) is based on the principle that the more deficits an individual has, the greater their risk of adverse outcomes. It is expressed as a ratio of the number of deficits present to the total number of deficits considered. We developed an MDS-specific FI using a prospective MDS registry and assessed its ability to add prognostic power to conventional prognostic scores in MDS. The 42 deficits included in this FI included measurements of physical performance, comorbidities, laboratory values, instrumental activities of daily living, quality of life and performance status. Of 644 patients, 440 were eligible for FI calculation. The median FI score was 0.25 (range 0.05-0.67), correlated with age and IPSS/IPSS-R risk scores and discriminated overall survival. With a follow-up of 20 months, survival was 27 months (95% CI 24-30.4). By multivariate analysis, age >70, FI, transfusion dependence, and IPSS were significant covariates associated with OS. The incremental discrimination improvement of the frailty index was 37%. We derived a prognostic score with five risk groups and distinct survivals ranging from 7.4 months to not yet reached. If externally validated, the MDS-FI could be used as a tool to refine the risk stratification of current clinical prognostication models.

Paroxysmal nocturnal hemoglobinuria testing in patients with myelodysplastic syndrome in clinical practice-frequency and indications.

Background: Myelodysplastic syndrome (mds) is characterized by peripheral blood cytopenias, with most patients developing significant anemia and dependence on red blood cell (rbc) transfusion. In paroxysmal nocturnal hemoglobinuria (pnh), mutations in the PIGA gene lead to lack of cell-surface glycosylphosphatidylinositol, allowing complement-mediated lysis to occur. Paroxysmal nocturnal hemoglobinuria results in direct antiglobulin test-negative hemolysis and cytopenias, and up to 50% of patients with mds test positive for pnh cells. We wanted to determine whether pnh is considered to be a contributor to anemia in mds. Methods: Patients with a diagnosis of mds confirmed by bone-marrow biopsy since 2009 were reviewed. High-resolution pnh testing by flow cytometry examined flaer (fluorescein-labeled proaerolysin) binding and expression of CD14, CD15, CD24, CD45, CD59, CD64, and CD235 on neutrophils, monocytes, and rbcs. Results: In 152 patients with mds diagnosed in 2009 or later, the mds diagnosis included subtypes associated with pnh positivity (refractory anemia, n = 7, and hypoplastic mds, n = 4). Of 11 patients who underwent pnh testing, 1 was positive (9.0%). Reasons for pnh testing were anemia (n = 3), new mds diagnosis (n = 2), hypoplastic mds (n = 2), decreased haptoglobin (n= 1), increased rbc transfusion requirement (n= 1), and unexplained iron deficiency (n= 1). Conclusions: Testing for pnh was infrequent in mds patients, and the criteria for testing were heterogeneous. Clinical indicators prompted pnh testing in 6 of 11 patients. Given that effective treatment is now available for pnh and that patients with pnh-positive mds can respond to immunosuppressive therapy, pnh testing in mds should be considered. Prospective analyses to clarify the clinical significance of pnh positivity in mds are warranted.

HIV-Associated Burkitt Lymphoma: Good Efficacy and Tolerance of Intensive Chemotherapy Including CODOX-M/IVAC with or without Rituximab in the HAART Era.

Background. The outcome of HIV-associated non-Hodgkin lymphoma (NHL) has improved substantially in the highly active antiretroviral therapy (HAART) era. However, HIV-Burkitt lymphoma (BL), which accounts for up to 20% of HIV-NHL, has poor outcome with standard chemotherapy. Patients and Methods. We retrospectively reviewed HIV-BL treated in the HAART era with the Magrath regimen (CODOX-M/IVAC±R) at four Canadian centres. Results. Fourteen patients with HIV-BL received at least one CODOX-M/IVAC±R treatment. Median age at BL diagnosis was 45.5 years, CD4 count 375 cells/mL and HIV viral load (VL) <50 copies/mL. Patients received PCP prophylaxis and G-CSF, 13 received HAART with chemotherapy and 10 rituximab. There were 63 episodes of toxicity, none fatal, including: bacterial infection, n = 20; grade 3-4 hematologic toxicity, n = 14; febrile neutropenia, n = 7; oral thrush; and ifosfamide neurological toxicity, n = 1 each. At a median followup of 11.7 months, 12 (86%) patients are alive and in remission. All 10 patients who received HAART, chemotherapy, and rituximab are alive. CD4 counts and HIV VL 6 months following BL therapy completion (n = 5 patients) were >250 cells/mL and undetectable, respectively, in 4. Conclusion. Intensive chemotherapy with CODOX-M/IVAC±R yielded acceptable toxicity and good survival rates in patients with HIV-associated Burkitt lymphoma receiving HAART.

Improved survival in HIV-associated diffuse large B-cell lymphoma with the addition of rituximab to chemotherapy in patients receiving highly active antiretroviral therapy.

PURPOSE: Recent trials suggest serious toxicity in HIV-associated non-Hodgkin's lymphoma (NHL) with rituximab (R) and chemotherapy (CT), offsetting the benefit of rituximab. METHOD: We retrospectively reviewed experience with CHOP-R vs. CT in 40 patients with HIV-associated diffuse large B-cell lymphoma (DLBCL) diagnosed between December 1992 and February 2006, all of whom were treated with curative intent. RESULTS: In a univariate analysis, International Prognostic Index (IPI) score, prior AIDS, HAART, and rituximab were significant for overall survival (OS). In a multivariate analysis, IPI 0-1 (p < .02), no prior AIDS (p < .0002), and receiving CHOP-R (p < .01) were significant for improved OS, and HAART use (p < .09) retained a trend for improved OS. The hazard ratio (HR) for patients with high IPI receiving CHOP-R was 0.3 (95% CI 0.1-0.8). Patients without prior AIDS receiving CHOP-R had an HR of 0.5 (95% CI 0.1-1.7). The OS at 30 months in patients not receiving HAART was 0%. With HAART, OS was 33% for CT and 86% for CHOP-R; HR for CHOP-R was 0.4 (95% CI 0.1-1.2). Toxic deaths were 3 (33%) for CHOP-R and 6 (25%) for CT (p = ns); all toxic deaths with CHOP-R were in patients not receiving HAART. Rituximab-treated patients had a lower death rate from lymphoma (CHOP-R, 2 [16%] vs. CT, 15 [63%]; p < .04), and overall mortality (CHOP-R, 5 [42%] vs. CT, 21 [88%]; p < .01). CONCLUSION: These retrospective data suggest that fatal toxicity of rituximab in HIV-NHL is not increased provided HAART is used, that the addition of rituximab to CT improved outcome, and that further prospective trials investigating this issue are warranted.

Intensive chemotherapy and autologous stem-cell transplantation plus rituximab is superior to conventional chemotherapy for newly diagnosed advanced stage mantle-cell lymphoma: a matched pair analysis.

BACKGROUND: The outcome of 20 patients with newly diagnosed mantle-cell lymphoma (MCL) treated on a prospective trial of autologous stem-cell transplantation (ASCT) and rituximab immunotherapy was compared with the outcome of 40 matched historical control patients treated with standard combination chemotherapy. PATIENTS AND METHODS: Control patients with MCL were identified from a lymphoma database, and pairs were matched with patients receiving ASCT-rituximab for stage of disease, gender and age (+/-5 years). Only patients treated with an anthracycline- or cyclophosphamide-fludarabine-based regimen were included. RESULTS: Seventeen of 20 patients who received ASCT-rituximab remain alive in remission at a median of 30 months from diagnosis; one patient relapsed 2 years post-ASCT, and two died at 7 and 11 months post-ASCT without evidence of lymphoma. Of 40 patients treated with conventional chemotherapy, with a median follow-up of 80 months, 33 have relapsed or progressed and 29 have died. Overall (OS) and progression-free (PFS) survival were superior in patients treated with ASCT-rituximab compared with those treated with conventional chemotherapy (PFS at 3 years, 89% versus 29%, P <0.00001; OS at 3 years, 88% versus 65%, P = 0.052). CONCLUSIONS: This matched-pair analysis suggests that patients with advanced-stage MCL treated with ASCT-rituximab had statistically significantly better PFS and a trend toward better OS than patients treated with conventional chemotherapy. Longer follow-up will determine response duration and the true impact of this treatment strategy on PFS and OS.

Limited-stage mantle-cell lymphoma.

BACKGROUND: Mantle-cell lymphoma (MCL) is known to have a poor outcome, however, most patients present with advanced-stage disease. Little information is available on limited-stage MCL. PATIENTS AND METHODS: We retrospectively reviewed clinicopathological information on all patients with limited-stage MCL seen at the British Columbia Cancer Agency since 1984. RESULTS: Twenty-six patients had low bulk (<10 cm) stage IA (12 patients) or IIA (14 patients) MCL. Initial therapy was involved-field radiation therapy (RT) with or without chemotherapy (CT), 17 patients; CT alone or observation, nine patients. Fifteen patients are alive at a median follow-up of 72 months (range 14-194). Progression-free survival (PFS) at 2 and 5 years was 65% and 46%, and overall survival (OS) 86% and 70%, respectively. Five patients surviving beyond 8 years. Only age and initial use of RT significantly affected PFS. Five-year PFS for patients <60 years of age was 83%, compared with 39% for those aged >/= 60 years, P = 0.04. Patients receiving RT with or without CT (n = 17), had a 5-year PFS of 68%, compared with 11% for those not receiving RT (n = 9, P = 0.002). Receiving RT eliminated the impact of age on PFS (with RT the 5-year PFS was 83% for those aged <60 years and 57% for those >/= 60 years, P = 0.17). Although OS for the whole group was 53% at 6 years, it was 71% for those initially treated with RT, but only 25% for those not given RT (P = 0.13). CONCLUSION: In our experience, patients with limited-stage MCL had an improved PFS when treated with regimens including RT, with a trend towards improved OS. These results suggest a potentially important role for RT in limited-stage MCL.

Necrotizing fasciitis secondary to group A streptococcus. Morbidity and mortality still high.

OBJECTIVE: To update physicians on Group A streptococcal necrotizing fasciitis, including current methods of diagnosis and treatment. QUALITY OF EVIDENCE: Current literature (1990-1998) was searched via MEDLINE using the MeSH headings necrotizing fasciitis, toxic shock syndrome, and Streptococcus. Articles were selected based on clinical relevance and design. Most were case reports, case series, or population-based surveys. There were no randomized controlled trials. MAIN MESSAGE: The hallmark of clinical diagnosis of necrotizing fasciitis is pain out of proportion to physical findings. Suspicion of underlying soft tissue infection should prompt urgent surgical examination. Therapy consists of definitive excisional surgical debridement in conjunction with high-dose intravenous penicillin G and clindamicin. Risk factors for mortality include advanced age, underlying illness, hypotension, and bacteremia. CONCLUSION: Necrotizing soft tissue infections due to Group A streptococcus might be increasing in frequency and aggression. Overall mortality remains high (20% to 34% in larger series). Clinical diagnosis requires a high level of suspicion and should prompt urgent surgical referral.

Reversal of CAMAL-mediated alterations of normal and leukemic in vitro myelopoiesis using inhibitors of proteolytic activity.

CAMAL (common antigen of myelogenous acute leukemia) is an antigenic preparation isolated in this laboratory from the bone marrow or peripheral blood leucocytes of persons with myeloid leukemias. Material from CAMAL preparations, which migrates in the range of 30 to 35 kDa by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE, P30-35 CAMAL), was shown to exert an inhibitory effect on in vitro colony formation by progenitor cells from normal healthy donors. The same preparations of P30-35 CAMAL, in contrast, exerted a stimulatory effect on in vitro colony formation by progenitor cells from patients with chronic myelogenous leukemia (CML). We now report that both the inhibitory effect on normal colony formation and the stimulatory effect on CML colony formation mediated by P30-35 CAMAL were blocked using phenyl methyl sulfonyl fluoride (PMSF), an inhibitor of the activity of serine proteases. Similarly, both the P30-35 CAMAL-mediated inhibitory effect on normal colony formation and the P30-35 CAMAL-mediated stimulatory effect on CML colony formation were blocked using the peptide ala-pro-phe-CMK, also an inhibitor of serine protease activity. These results suggest the involvement of proteolytic activity, either directly or indirectly, in the alterations of in vitro myelopoiesis exerted by P30-35 CAMAL.

Stimulation of leukemic myelopoiesis by P30-35 CAMAL, an inhibitor of normal myelopoiesis.

CAMAL (common antigen in myelogenous acute leukemia) is an antigenic preparation isolated in this laboratory from the bone marrow or peripheral blood cells of persons with myeloid leukemias and shown in an immunoperoxidase slide test to be diagnostic of these leukemias. CAMAL has been shown to be inhibitory to myelopoiesis by normal progenitor cells in vitro. This activity is associated with material which was further purified from CAMAL preparations, and which migrates at 30-35 kDa by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE). We now report that material from CAMAL preparations highly enriched for this 30-35 kDa material is stimulatory to in vitro colony formation by progenitor cells from patients with chronic myelogenous leukemia (CML). This stimulatory effect on CML colony formation was observed to be consistent. Colony formation was stimulated in a biphasic fashion; enhancement was seen at low (1 to 10 ng/ml) and high (100 to 200 ng/ml) concentrations of P30-35 CAMAL, but enhancement was reduced or absent at an intermediate concentration of P30-35 CAMAL (10 to 70 ng/ml), and was not observed at P30-35 CAMAL levels above 200 ng/ml, or below 1 ng/ml. The colony types in cultures of CML clinical specimens targetted for enhancement by P30-35 CAMAL were identified. At low concentrations of P30-35 CAMAL primitive colonies were increased, whereas at high concentrations of P30-35 CAMAL, an increase in all colony types was observed. In addition, an increase in the size of some colonies within P30-35 CAMAL-treated cultures was frequently observed. Colony formation by two cell lines derived from the leucocytes of a patient with CML was enhanced by treatment with P30-35 CAMAL in a manner similar to the stimulation observed using primary cells from CML clinical specimens.

Inhibition of murine hematopoiesis by CAMAL, an inhibitor of human hematopoiesis.

CAMAL (common antigen of myelogenous acute leukemia) is an antigenic preparation isolated in this laboratory from the bone marrow or peripheral blood leucocytes of persons with myeloid leukemias and shown using an immunoperoxidase slide test to be diagnostic of these leukemias. Material further purified from CAMAL preparations, which migrates in the range of 30-35 kilodaltons (kDa) by sodium dodecyl sulphate/polyacrylamide gel electrophoresis (SDS-PAGE), which is referred to as P30-35 CAMAL, and was previously shown to be inhibitory to colony formation by progenitor cells from normal healthy human donors in vitro. This inhibitory activity was directed toward neutrophilic granulocyte colonies (CFU-G) in particular. We now report that P30-35 CAMAL is inhibitory to colony formation by murine progenitor cells in vitro. Colonies from P30-35 CAMAL-treated cultures of murine bone marrow cells were reduced in number and in size, an effect similar to that seen in cultures of human cells. As in assays using human cells, murine CFU-G appeared to be preferentially targeted by the inhibitory activity of P30-35 CAMAL. In addition, day 10 spleen colony formation was inhibited by P30-35 CAMAL in an ex vivo assay. Hence, the effects of P30-35 CAMAL on murine progenitor cells appear to parallel the effects observed using human cells. These observations support the possibility that CAMAL might be a regulatory protein in hematopoiesis which is conserved between species.

Purification of an in vitro inhibitor of normal myelopoiesis using a monoclonal antibody directed to a common antigen of myelogenous leukemia (CAMAL).

A monoclonal antibody, CAMAL-1, has been previously shown to react specifically and at high frequencies with cells of patients with acute myelogenous leukemia (AML) and chronic granulocytic leukemia (CGL). High expression of this antigen in remission patients' bone marrow cells was shown to correlate with both relapse and lower survival times. Preliminary studies showed that material extracted from leukemic cells and eluted from CAMAL-1 immunoadsorbent columns profoundly inhibited the formation of normal colony-forming units (CFU) but had no effect on formation of such colonies from cells of patients with CGL. We have used CAMAL-1 affinity chromatography in combination with FPLC gel filtration to purify the inhibitory material from leukemic cell extracts. We have successfully isolated a 30-kd component (P30) that functions as an inhibitor of normal myelopoiesis in vitro; when P30 was added to normal progenitor cell assays it significantly inhibited the growth of normal CFU but had no inhibitory effect on the growth of CGL progenitor cells at equivalent concentrations. The inhibitory effect is preferentially directed to granulocytic progenitors. Antibodies raised to P30 reacted in Western blot analyses with affinity purified material from patients' cells as well as with a 30-kd component in the cell lysates and supernatants of the leukemic cell lines HL60 and K562; this finding suggested that the P30 inhibitory component might be produced by leukemic cells.