Correlation of progesterone levels on the day of oocyte retrieval with basal hormonal status and the outcome of ART.

This study aimed to assess whether basal hormonal levels can predict the levels of progesterone (P4) on the day of oocyte retrieval (OR) and examine the impact of P4 levels on the day of OR on the outcome of assisted reproduction. One hundred sixty-four patients that were enrolled in the assisted reproduction procedure were classified according to their P4 levels on the OR day (< 2 ng/ml vs. ≥ 2 ng/ml). Patients who had P4 levels < 2 ng/ml had significantly higher follicle stimulating hormone (FSH) levels and significantly lower anti-Mullerian hormone (AMH) levels. More than half of patients with P4 levels < 2 ng/ml on the OR day got pregnant and delivered healthy infants. There was a significant correlation between lower FSH values and higher P4 values at OR and between higher AMH values and higher P4 values on the day of OR. Regression analysis showed that high FSH levels are the most important factor that can reliably imply lower P4 levels on OR day. Our study confirmed that lower basal FSH levels can predict the levels of P4 on the OR day. Moreover, lower levels of P4 on the day of OR are associated with a positive outcome in assisted reproduction.

OC-07 - Decoding risk for thromboembolic events in lymphoma patients.

INTRODUCTION: There are few prediction tools for estimating the risk of thrombosis but they are based on studies performed on hospitalized medical patients without cancer or on hospitalized neutropenic cancer patients without special consideration to lymphoma patients. AIM: Aim of our study was to determine incidence of thromboembolic (TE) events in patients with non Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL) and chronic lymphocytic leukemia (CLL)/ small lymphocytic lymphoma (SLL) who were hospitalized to the lymphoma department in the Clinic of hematology, Clinical Center Serbia, Belgrade and Clinic of hematology, Clinical Center Kragujevac. Also, we assessed 2 predictive models (Padua and Khorana score) and create new model for the identification of lymphoma patients at risk for thromboembolism. MATERIALS AND METHODS: We reviewed all medical records of patients with with NHL, HL and CLL/SLL diagnosed and treated at two previously mentioned institution between January 2006 and December 2014. RESULTS: The study population included 1820 eligible lymphoma patients. Of all the patients included in the study, 99 (5.4%) developed at least one TE during a follow-up period of 3 months from the end of therapy. In the final multivariate analysis, the following variables were independently associated with risk of TE: previous VTE and/or arterial events, reduced mobility (ECOG 2-4), obesity (BMI >30 kg/m(2)), extranodal localization, mediastinum involvement, development of neutropenia during therapy and hemoglobin level less than 100g/L. Subsequently, we assigned points for the risk model based on the regression coefficients obtained from the final model and developed Thrombosis Lymphoma (ThroLy) score consisting of all significant variables from the multivariate analysis. The Throly score was arrived at by assigning 2 points for all parameters with an OR >5 in multivariate regression analyses (e.g., previous VTE and arterial events, mediastinum involvement, and BMI) and 1 point for rest all other significant variables. Finally, population were divided into 3 risk categories for TE based on the score from the risk model: low (score 0-1), intermediate (score 2-3) and high (score >3). High risk score had a positive predictive value (probability of TE in those designated high risk) of 65.2%. CONCLUSIONS: Significance of our investigation is development of score that help phisicians to recruit lymphoma patients at risk for development of thromboembolic complications. Also, we can say that our score is dynamic allowing us to change approach during different phase of therapy and is not limited to outpatient settings or with some complicated laboratory analysis.

Enhanced International Prognostic Index (NCCN-IPI), Charlson Comorbidity Index and absolute lymphocyte count as predictors for survival of elderly patients with diffuse large B cell lymphoma treated by immunochemotherapy.

Diffuse large B cell lymphoma (DLBCL) affects more commonly patients over 60 years. These patients have vast number of comorbidities which can modify survival as well as other clinical parameters. The aim of this study was to evaluate prognostic significance of the National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI), absolute lymphocyte count (ALC), absolute monocyte count (AMC), lymphocyte-to-monocyte ratio (LMR) and comorbidities expressed with Charlson Comorbidity Index (CCI). A total of 182 DLBCL patients 60 years old and older were included, focusing on whole group and patients older than 70. All patients were treated with immunochemotherapy.Overall treatment response was achieved in 84.6% of patients. The NCCN-IPI was of highly prognostic value in the analyzed group (p<0.0001). Survival analysis showed that ALC>1.1x109/L, AMC≤0.59x109/L, and LMR>2.8 were associated with more favorable outcome (p=0.029, p=0.019, p=0.028, respectively). The patients with CCI≥2 had poorer outcome (p=0.008) compared to the patients with CCI 0-1. Multivariate analysis showed that among ALC, AMC, LMR, NCCN-IPI and CCI, the NCCN-IPI was the critical parameter that significantly affected survival (p<0.0001). Furthermore, comorbidities were also valuable independent factors which influenced survival (p=0.031) as well as the ALC (p=0.024). In elderly DLBCL patients, NCCN-IPI and ALC proved their prognostic validity, while poorer outcome could be expected in older patients with high CCI (≥2). Furthermore, mentioned prognostic parameters retained their prognostic value in the group of patients older than 70.

Orbital and ocular adnexal Mucosa-Associated Lymphoid Tissue (MALT) lymphomas: a single-center 10-year experience.

Orbital and ocular andexal Mucosa-Associated Lymphoid Tissue Lymphoma (MALT) or ocular adnexal MALT lymphoma (OAML) is the most common of all eye non-Hodgkin lymphomas. Autoimmune inflammatory disorders and chronic infections are important etiological factors and CD5 and CD43 (sialophorin) tumor markers are significant negative prognostic factors. Disease signs and symptoms can occur a long time before diagnosis. Varieties of treatment options are available. The aim of this retrospective analysis was to compare the efficiency of different treatment options and to investigate disease outcome. Twenty OAML patients, diagnosed in the Clinic of Hematology, Clinical Centre of Serbia, between 2003 and 2013, were enrolled. In most cases, OAML developed in the eighth decade with greater incidence in the male population. Median age was 67.5 years. The median period between the appearance of local signs and symptoms and diagnosis was 7 months. The dominant sign at presentation was swelling of involved tissue (40%). The most common was orbital involvement (55%). All patients had localized disease. Observed laboratory parameters on presentation showed low disease activity. Sialophorin prognostic significance was not registered. Our patients were initially treated differently but there was no significant difference in progression-free survival (PFS) due to initial treatment option (p = 0.2957). Median PFS was 22 months (3-89), and 5-year PFS was 60%. Median overall survival (OS) was 43 months (1-105) and 5-year OS 95%. Eight patients (40%) relapsed and one patient died due to non-hematological complications. In our experience, most modern induction treatment options appear to result in the same, favorable outcome.

Predictive factors of malignancy in patients with adnexal masses.

INTRODUCTION: Good preoperative tumor triage is essential for choosing the appropriate approach. OBJECTIVE: The study aim was to identify factors from standard preoperatively collected data, which could predict the nature of adnexal masses prior surgery. MATERIAL AND METHODS: The study involved all women treated in the Clinic for Gynecology and Obstetrics Clinical Center of Serbia for adnexal tumors throughout a period of 18 months. On admission, detailed anamnestical and laboratory data were obtained and ultrasound scans were performed. Obtained data were compared with hystopathological findings of tumors. Methods of correlation and logistic regression were applied to create association models. RESULTS: Three new models for predicting tumor nature were achieved from anamnestical data, characteristics of women and tumors, and laboratory analyses. Two statistically significant (p = 0.000) equations were obtained for anamnestical data and characteristics of women and tumors, while three were made for laboratory analyses. Sensitivity of anamnestical malignancy index (AMI) was 73.33%, specificity 72.87%, positive predictive value (PPV) 39.49% and negative predictive value (NPV) 91.88%. Sensitivity of characteristic malignancy index (CMI) was 92.38%, specificity 67.36%, PPV 40.59% and NPV 97.34%. Sensitivity of laboratory malignancy index (LMI) was 56.45%, specificity 90.24%, PPV 68.63%, and NPV 84.57%. CONCLUSIONS: The best predictors of malignancy are menopausal status, body mass index (BMI), age, metastases, ascites, tumor marker CEA level, and erythrocyte sedimentation rate (ESR). Along with the risk of malignancy index (RMI), for more reliable triage and preoperative tumor evaluation the authors propose introduction of another three indexes (AMI, CMI, LMI) in clinical practice.

Conservative management of massive hematoperitoneum caused by ovulation in a patient with severe form of von Willebrand disease--a case report.

Von Willebrand disease (VWD) is the most common inherited bleeding condition that involves extended or excessive bleeding, caused by the deficiency or defect of von Willebrand factor (VWF). Hematoperitoneum as a complication of gynecologic diseases represents acute condition which is usually caused by the hemorrhagic corpus luteum or a rupture of either ectopic pregnancy or a hemorrhagic ovarian cyst. The authors present a unique case of conservatively managed massive hematoperitoneum caused by ovulation in a patient with severe form of von Willebrand disease who had right adnexectomy due to hemorrhagic corpus luteum four months prior. This conservative management by blood product and factor concentrate support could be a method of choice in selected hemodynamically stable patients. Furthermore, recurrent bleeding episodes following ovulation could be prevented by suppression of ovulation using oral contraceptive pills.

Systemic lupus Erythematosus and IgA multiple myeloma: a rare association?

The coexistence of systemic lupus Erythematosus (SLE) and multiple myeloma (MM) is uncommon and the pathogenetic mechanisms underlying this association remain unclear. We report the case of a woman who was diagnosed with SLE in 1993 aged 57, then developing IgA lambda type MM in the IIB clinical stage 7 years later. The SLE was treated successfully with methylprednisolone and chloroquine, and low dose maintenance steroid was continued with bisphosphonate protection until December 1994 when she suffered multiple vertebral fractures. She continued to receive 4 mg alternate day methylprednisolone and calcitonin until she decided to discontinue her own treatment 2 years later. In 2000, while still in stable SLE remission, she was diagnosed with MM. Protein electrophoresis revealed the IgA lambda paraprotein (40.5 g/l) and she had a Bence Jones (BJ) proteinuria of the lambda light chain type. Bone marrow trephine biopsy revealed a massive patchy infiltrate of abnormal plasmocytes (70%), while an extensive x-ray skeletal survey did not show any new fractures or osteolysis. The patient was treated according to the VMCP protocol without attaining a plateau phase. There was a similar poor clinical response to second and third line treatments (VAD, Thalidomide, Melphalan, and high dose dexamethasone). After 4 years of refractory disease the patient died from severe bilateral pneumonia. This case is discussed with reference to the literature.

Successful treatment of extranodal Hodgkin's lymphoma in a patient with longstanding hairy cell leukemia.

Purine analogs, particularly pentostatin and cladribine, are highly effective in hairy cell leukemia (HCL). Both of these drugs induce responses in approximately 80-95% of patients. However, it is not yet determined if treatment with these drugs can induce second malignancies. Hodgkin's lymphoma is very rare as a second malignancy and there are only 3 reported cases concerning the association of this lymphoma with HCL. We describe a patient with longstanding HCL in complete remission after cladribine, in whom extranodal Hodgkin's lymphoma appeared 8 years after the diagnosis of HCL. Magnetic resonance imaging revealed diffuse intra-osseal neoplastic infiltration of the corpora of the whole spinal column and extra-osseal propagation from the fifth thoracic vertebra into the spinal canal with spinal cord compression. Histological and immunohistochemical analysis of the extradural tumor, which was completely excised, disclosed nodular sclerosis Hodgkin's lymphoma with typical Reed-Sternberg cells that were positive for CD30, CD15, bcl-6, Ki67, p53, EBV LPM-1 and IgG, and negative for CD45, CD20, DBA44, kappa, lambda light chains and IgM. In addition, immunohistochemical analysis of the bone marrow in 1999 showed infiltration with positivity for IgM and negative for kappa light chains and IgG. These findings (expression of different immunoglobulins and light chains on the cells) suggest an independent origin of these 2 B-cell neoplasms. After neurosurgery the patient received 6 courses of the MP-ABVD protocol and achieved a complete remission, which has lasted 16 months thus far.

Hepatosplenic candidiasis after neutropenic phase of acute leukaemia.

Hepatosplenic candidiasis following granulocytopenic periods is a relatively recently recognised problem in immunocompromised patients, particularly in those with acute leukaemia. We present three patients in whom diagnosis of hepatosplenic candidiasis was suspected on the basis of ultrasonographic (US), computed tomographic (CT) findings and confirmed by laparoscopy and biopsy of liver lesions. All three patients were successfully treated briefly with amphotericin B, followed by a longer period of fluconazole. In one patient laparotomy and surgical evacuation of abscesses was performed. This condition could be more often recognised by careful follow-up of liver function test, C-reactive protein level, ultrasonography, CT and MRI after recovery from chemotherapy-induced neutropenia.

Inversion of chromosome 16 in accelerated phase of chronic myeloid leukaemia: report of a case and review of the literature.

A patient with a Philadelphia chromosome-positive (Ph+) chronic myeloid leukemia (CML) developed a blast crisis (FAB subtype AML-M2) without a monocytic involvement. Karyotype showed the presence of inv(16)(p13;q22) in addition to Ph, in 16/20 marrow metaphases.

Effect of all-trans-retinoic acid alone or in combination with chemotherapy in newly diagnosed acute promyelocytic leukaemia.

Between February 1992 and November 1996 we treated 30 newly diagnosed acute promyelocytic leukaemia (APL) patients either with oral all-trans-retinoic acid (ATRA) alone (45 mg m-2) or with a simultaneous combination of ATRA (45 mg m-2), daunorubicin (DNR, 50 mg/m-2 for 3 days) and cytosine arabinoside (ARA-C, 200 mg m-2 for 7 days). There were 15 patients in each group. Patients with a white blood cell count < 5 x 10(9)/l at diagnosis received only ATRA as an induction therapy. Patients with initial white blood cell count > 5 x 10(9)/l received a combination of ATRA, DNR and ARA-C as an induction therapy. Within the first 20 days of induction, there were two early deaths in the group of patients receiving only ATRA, and six early deaths in the group of patients treated with a combination of ATRA and chemotherapy. Ten out of 13 patients (76.9%) receiving ATRA only achieved complete remission (CR) whereas seven out of nine patients (77.8%) receiving ATRA with chemotherapy achieved CR. Initial median peripheral white blood cell counts were significantly lower in the group of patients treated with ATRA alone (2.3 x 10(9)/l) than in the group of patients receiving ATRA and chemotherapy (14.0 x 10(9)/l). Morphological evidence of differentiation was noted in all patients entering CR. Patients in both groups who achieved CR received one course of standard '3 + 7' chemotherapy (DNR 45 mg m-2, 1-3 days, ARA-C 200 mg m-2, 1-7 days) followed by two courses of standard '2 + 5' chemotherapy (DNR 50 mg m-2 1-2 days, ARA-C 200 mg m-2 1-5 days) as a consolidation therapy. Patients not achieving remission (three out of 13 in the ATRA group and two out of nine in ATRA+chemotherapy group) did not respond to salvage chemotherapy and all died within 3 months of diagnosis. Only one out of 10 patients (10%) in CR, treated with ATRA is in relapse after 18 months. In patients treated with ATRA alone two out of 10 (20%) survived 58 months following diagnosis whereas in the ATRA+chemotherapy group one out of seven has already survived their 58th month since diagnosis. Four out of eight patients with an early death died of retinoic acid syndrome. Other toxicities due to ATRA were minimal (cheilitis, xerosis, dermatitis, diarrhoea, liver damage or pseudotumor cerebri).