Prognostic factors in adolescent and adult patients with acute lymphoblastic leukemia with two protocols of chemotherapy: a cross-sectional study.

BACKGROUND: We evaluated the clinical, laboratory, and prognostic factors in adolescent and adult patients with acute lymphoblastic leukemia (ALL). MATERIALS AND METHODS: In this observational, retrospective, cross-sectional study, we examined the medical records of all consecutive patients with ALL admitted to a public hospital in Brazil from 1990 to 2005. RESULTS: Of the 102 patients included, 88 were treated with 2 protocols of chemotherapy (Berlin-Frankfurt-Münster [BFM] 86 modified [BFM-86M] and UCLA [University of California, Los Angeles] protocol). The complete remission (CR), disease-free survival, and overall survival (OS) rate was 70.6%, 27%, and 30.5%, respectively (median follow-up, 49 months). Age < 18 years and no leukemic infiltration in the central nervous system (CNS) at diagnosis were positively associated with CR (P = .03); no bleeding and hepatomegaly at diagnosis and age < 35 years were associated with better OS on multivariate analyses of the whole population (P = .01). OS at 4 years was superior with BFM-86M than with UCLA (49.5% vs. 16%; P = .004), especially in young adults without risk factors. CONCLUSION: We identified age as the most important prognostic factor in patients with ALL. CNS infiltration, hepatomegaly, and bleeding were associated with lower OS but must be validated in future research with South American populations and worldwide. The BFM-86M protocol can be considered a therapeutic option for young adults (age < 35 years) without adverse prognostic factors. For other patients with ALL, we emphasize the need for different therapeutic approaches.

Deep molecular responses achieved in patients with CML-CP who are switched to nilotinib after long-term imatinib.

Patients in complete cytogenetic response (CCyR) with detectable BCR-ABL1 after ≥2 years on imatinib were randomized to nilotinib (400 mg twice daily, n = 104) or continued imatinib (n = 103) in the Evaluating Nilotinib Efficacy and Safety in clinical Trials-Complete Molecular Response (ENESTcmr) trial. By 1 and 2 years, confirmed undetectable BCR-ABL1 was achieved by 12.5% vs 5.8% (P = .108) and 22.1% vs 8.7% of patients in the nilotinib and imatinib arms, respectively (P = .0087). Among patients without molecular response 4.5 (BCR-ABL1(IS) ≤0.0032%; MR(4.5)) and those without major molecular response at study start, MR(4.5) by 2 years was achieved by 42.9% vs 20.8% and 29.2% vs 3.6% of patients in the nilotinib and imatinib arms, respectively. No patient in the nilotinib arm lost CCyR, vs 3 in the imatinib arm. Adverse events were more common in the nilotinib arm, as expected with the introduction of a new drug vs remaining on a well-tolerated drug. The safety profile of nilotinib was consistent with other reported studies. In summary, switching to nilotinib enabled more patients with chronic myeloid leukemia in chronic phase (CML-CP) to sustain lower levels of disease burden vs remaining on imatinib. This trial was registered at www.clinicaltrials.gov as #NCT00760877.

Evaluation of long-term outcomes, cytogenetic and molecular responses with imatinib mesylate in early and late chronic-phase chronic myeloid leukemia: a report from a single institute.

Here we compare the management and survival outcomes of chronic myeloid leukemia (CML) patients who had early or late imatinib mesylate (IM) therapy. The cytogenetic and molecular responses of 189 CML patients were analyzed. Of this group, 121 patients were classified as the early chronic phase (ECP) group and started IM within 12 months of diagnosis. The other 68 patients were classified as the late chronic phase (LCP) group who had been treated with interferon (IFN)-alpha-2 and crossed over to IM more than 12 months after diagnosis. The overall rates of complete cytogenetic response (CCyR) and major molecular response (MMR) at last follow-up were 83.6 and 78.1% in the ECP and LCP groups, respectively. The CCyR rates were 89.3 (for ECP patients) versus 73.5% (for LCP patients; p < 0.0001). At last follow-up, 82.4% ECP and 64.2% LCP patients had achieved an MMR (p < 0.0001). No significant differences were noted between the two groups with regard to survival outcomes. Our experience reveals that IM is an effective rescue therapy in most CML LCP patients who are intolerant or in whom IFN-alpha therapy fails. Such therapeutic options should be considered in LCP patients, particularly in countries where IM may not be available.

Expanding Nilotinib Access in Clinical Trials (ENACT), an open-label multicenter study of oral nilotinib in adult patients with imatinib-resistant or -intolerant chronic myeloid leukemia in accelerated phase or blast crisis.

Nilotinib has shown favorable safety in patients with Philadelphia chromosome-positive (Ph+) chronic myeloid leukemia (CML) in chronic (CML-CP) or accelerated phase (CML-AP) who failed prior imatinib, and superior efficacy over imatinib in newly diagnosed Ph+ patients with CML-CP. Reported here are the efficacy and safety data for patients in CML-AP (n = 181) or blast crisis (CML-BC) (n = 190; myeloid BC, 133; lymphoid BC, 50; unknown, seven) enrolled in an expanded access phase IIIb study. Non-hematologic adverse events were mostly mild to moderate. Drug-related myelosuppression was generally manageable with dose reductions or interruptions and infrequently led to discontinuation of nilotinib. Drug-related grade 3/4 elevations in serum bilirubin and lipase were infrequent. While an analysis of efficacy was not the primary objective of this study, significant hematologic and cytogenetic responses were observed. These results support the safety and efficacy of nilotinib in patients with advanced CML in AP and BC.

Dasatinib overrides imatinib resistance mediated by the F359I residue mutation in two patients with chronic myeloid leukemia.

Despite the beneficial effects of imatinib mesylate, some patients may either not respond or respond suboptimally. Here, we report two chronic myelogenous leukemia patients; one had a suboptimal response according to European LeukemiaNet criteria (a major molecular response was not achieved after 18 months of standard-dose imatinib therapy) and the other had failure with a standard dose of imatinib. At the time of the suboptimal response in patient 1 and the failure in patient 2, we were able to detect the F359I mutation in the BCR-ABL tyrosine kinase domain using DNA sequencing in both patients. Therefore, it was decided to change the therapeutic regimen to dasatinib at a dose of 100 mg once daily in both patients. This change resulted in the achievement of complete cytogenetic remission in patient 1 after 4 months and a major molecular response within 2 and 3 months in both patients. Detection of the F359I mutation in our two cases likely explains the suboptimal response to imatinib in case 1 and the failure in case 2. This implies that in such cases dasatinib should be considered to effectively suppress the mutated clones.

Outpatient treatment with intravenous antimicrobial therapy and oral levofloxacin in patients with febrile neutropenia and hematological malignancies.

The purpose of this study was to evaluate outcomes such as success of the initial therapy, failure of outpatient treatment, and death in outpatient treatment during intravenous antimicrobial therapy in patients with febrile neutropenia (FN) and hematological malignancies. In addition, clinical and laboratory data and the Multinational Association for Supportive Care of Cancer index (MASCC) were compared with failure of outpatient treatment and death. In a retrospective study, we evaluated FN following chemotherapy events that were treated initially with cefepime, with or without teicoplanin and replaced by levofloxacin after 48 h of defervescence in patients with good general conditions and ANC>500/mm3. Of the 178 FN episodes occurred in 126 patients, we observed success of the initial therapy in 63.5% of the events, failure of outpatient treatment in 20.8%, and death in 6.2%. The success rate of oral levofloxacin after defervescence was 99% (95 out of 96). Using multivariate analysis, significant risks of failure of outpatient treatment were found to be smoking (odds ratio (OR) 3.14, confidence interval (CI) 1.14-8.66; p=0.027) and serum creatinine levels>1.2 mg/dL (OR 7.97, CI 2.19-28.95; p=0.002). With regard to death, the risk found was oxygen saturation by pulse oximetry<95% (OR 5.8, IC 1.50-22.56; p=0.011). Using the MASCC index, 165 events were classified as low risk and 13 as high risk. Failure of outpatient treatment was reported in seven (53.8%) high-risk and 30 (18.2%) low-risk episodes (p=0.006). In addition, death occurred in seven (4.2%) low-risk and four (30.8%) high-risk events (p=0.004). Ours results show that MASCC index was able to identify patients with high risk. In addition, non-smoking, serum creatinine levels≤1.2 mg/dL, and oxygen saturation by pulse oximetry≥95% were protection factors.

Response to dasatinib in a patient with concomitant chronic myeloid leukemia and chronic lymphocytic leukemia.

While chronic lymphocytic leukemia (CLL) and chronic myeloid leukemia (CML) are common diseases in the elderly, they rarely occur simultaneously in the same patient. Here we present the case of a 77-year-old patient diagnosed with CML in the chronic phase who showed an optimal response to 400 mg/day of imatinib. This patient progressed to Binet B-CLL with an 11q22.3 deletion and CD38 positivity in the 4th month of treatment. During the follow-up, his lymphocyte number doubled in <6 months. Based on previous reports, dasatinib was chosen instead of imatinib. After 6 months of treatment with 100 mg/day of dasatinib, the patient demonstrated a partial response, characterized by the regression of lymph node enlargement, a hemoglobin level of 10.7 g/dl, neutrophils of 1.7 × 10(9)/l, a 82% reduction in the lymphocyte number and an increase in cytotoxic CD8+ and large granular lymphocytes. This partial response has persisted to the present time. While little data have been published regarding the in vitro effect of dasatinib monotherapy for CLL, this case report provides some evidence of the clinical activity of dasatinib in CLL.

Efficacy and tolerability after unusually low doses of dasatinib in chronic myeloid leukemia patients intolerant to standard-dose dasatinib therapy.

We report our experience in 4 patients with chronic myeloid leukemia (CML) who had discontinued imatinib as a result of adverse events and had switched to dasatinib. The chronic phase (n 2) and accelerated phase (n 2) CML patients received dasatinib at starting dose of 100 and 140 mg once daily, respectively. Reappearance of hematological toxicity was observed in 3 patients and pancreatitis in one patient. Treatment was given at a lower dose and patients were followed. The median follow-up was 13 months and the median dose of dasatinib until achievement of complete cytogenetic remission (CCyR) was 60 mg daily (range = 20 to 120 mg). All four patients had achieved CCyR at a median of 4 months (range = 3 to 5 months) and among them, three had also achieved major molecular remission. We conclude that low-dose dasatinib therapy in intolerant patients appears safe and efficacious and may be tried before drug discontinuation.

Early Detection of t(8;21) Chromosomal Translocations During Treatment of PML-RARA Positive Acute Promyelocytic Leukemia: A Case Study.

Here we describe a female patient who developed acute promyelocytic leukemia (APL) characterized by t(l5;17) translocation at diagnosis. The patient began treatment with all-trans retinoic acid (ATRA) + chemotherapy. During follow up, the patient was found to be negative for the t(15;17) transcript after 3 months of therapy which remained undetectable, thereafter. However, the emergence of a small clone with a t(8;21) abnormality was observed in the bone marrow and peripheral blood (PB) cells between 3 and 18 months following treatment initiation. The abnormal translocation observed in PB cells obtained at 3 months was detected after the second cycle of consolidation therapy and reappeared at 15 months during maintenance treatment, a period without ATRA. Although based on a single case, we conclude that genetic screening of multiple translocations in AML patients should be requested to allow early identification of other emerging clones during therapy that may manifest clinically following treatment.

Impact of allogeneic 2-RBC apheresis on iron stores of Brazilian blood donors.

One limiting factor for automated two-red blood cells collections (2-RBC) is its potential iron depletion. We analyzed hematological parameters and iron balance before, two and four months after 2-RBC of 96 non-supplemented male donors. Four months after 2-RBC, ferritin level was significantly lower (P<0.01) than baseline levels and the number of donors who presented ferritin <30 ng/ml increased from 18 to 47. We concluded that four months was not sufficient for iron recuperation in the population studied. In an attempt to avoid iron depletion after 2-RBC, we recommend augmentation in the interval between blood donations and pre-donation ferritin measurement.

Anemia screening in potential female blood donors: comparison of two different quantitative methods.

BACKGROUND: Anemia screening before blood donation requires an accurate, quick, practical, and easy method with minimal discomfort for the donors. The aim of this study was to compare the accuracy of two quantitative methods of anemia screening: the HemoCue 201(+) (Aktiebolaget Leo Diagnostics) hemoglobin (Hb) and microhematocrit (micro-Hct) tests. STUDY DESIGN AND METHODS: Two blood samples of a single fingerstick were obtained from 969 unselected potential female donors to determine the Hb by HemoCue 201(+) and micro-Hct using HemataSTAT II (Separation Technology, Inc.), in alternating order. From each participant, a venous blood sample was drawn and run in an automatic hematology analyzer (ABX Pentra 60, ABX Diagnostics). Considering results of ABX Pentra 60 as true values, the sensitivity and specificity of HemoCue 201(+) and micro-Hct as screening methods were compared, using a venous Hb level of 12.0 g per dL as cutoff for anemia. RESULTS: The sensitivities of the HemoCue 201(+) and HemataSTAT II in detecting anemia were 56 percent (95% confidence interval [CI], 46.1%-65.5%) and 39.5 percent (95% CI, 30.2%-49.3%), respectively (p < 0.001). Analyzing only candidates with a venous Hb level lower than 11.0 g per dL, the deferral rate was 100 percent by HemoCue 201(+) and 77 percent by HemataSTAT II. The specificities of the methods were 93.5 and 93.2 percent, respectively. CONCLUSION: The HemoCue 201(+) showed greater discriminating power for detecting anemia in prospective blood donors than the micro-Hct method. Both presented equivalent deferral error rates of nonanemic potential donors. Compared to the micro-Hct, HemoCue 201(+) reduces the risk of anemic female donors giving blood, specially for those with lower Hb levels, without increasing the deferral of nonanemic potential donors.

The use of imatinib mesylate as a lifesaving treatment of chronic myeloid leukemia relapse after bone marrow transplantation.

We describe the response of imatinib as lifesaving treatment of chronic myeloid leukemia (CML) relapse in seven patients who underwent allogeneic bone marrow transplantation (alloBMT) at our institution over a period of 4 years. Retrospective analysis of their medical records revealed that a mean age at transplant was 45.2 years. The median time to diagnosis was 7.4 years after transplant. At relapse, four, two, and one patients were classified as having hematologic, major molecular, and cytogenetic relapse, respectively. At imatinib initiation, five had CML in a chronic phase, while one patient was diagnosed as having accelerated phase and blast crisis. All these patients could be evaluated for the therapeutic efficacy. At a mean of follow-up of 1.9 years of therapy, all evaluable patients achieved major molecular response without compromising safety. Consistent with available data, our results indicate that imatinib is safe and effective treatment option for patients with relapse after BMT.

Modified Magrath IVAC regimen as second-line therapy for relapsed or refractory aggressive non-Hodgkin's lymphoma in developing countries: the experience of a single center in Brazil.

BACKGROUND: The purpose of this retrospective study was to investigate the efficacy, toxicity and mobilization rate after modified Magrath IVAC (mIVAC) chemotherapy regimen prescribed in relapsed disease (RD) or primary refractory disease (PRD) in aggressive non-Hodgkin lymphoma (NHL). PATIENTS AND METHODS: Twenty-four patients (16 males, 8 females) aged 18-59 years (median age 37 year) were analyzed. The most frequent histopathological subgroup was diffuse large B-cell lymphoma (DLCL-B) (n=21/24), 13 (54%) were considered RD and 11 (46%) PRD. The mIVAC consisted of ifosfamide (IFM), high dose cytarabine and etoposide repeated every 28 days. RESULTS: The overall response (OR) after three cycles of mIVAC was 66. 6%. Among the patients with PRD, OR was 45.5% (5 out of 11) and with RD was 86.4%, p>0.05, however, it was observed in RD better complete response (CR) than PRD 53.8x9.1% (p<0.05). Eighty-eight percent (14 out of 16) of patients with chemosensitive disease to mIVAC underwent autologous stem cell transplantation (ASCT). The median number of collected CD34+ cells was 2.86x10(6) (range 2.17x10(6) to 4.9x10(6)). The median overall survival rate (OS) for chemosensitive to mIVAC was 16.3 months, with a median follow-up of 16 months. Grades III-IV neutropenia was observed in 85.6% per cycles and grades III-IV thrombocytopenia in 87.5%. Grades III-IV febrile neutropenia was the most common nonhematological toxicity, it occurred in 28% of the cycles and no deaths by toxicity were observed. DISCUSSION: Although a statistic comparative study was not carried out for these 24 patients, the rate of OR to mIVAC was alike the other second-line infusion regimens. The mobilization failure rate was 57.1% and it was similar to other regimens with high dose cytarabine, but it did not limit performed ASCT.

Comparison of catheter-related infection risk in two different long-term venous devices in adult hematology-oncology patients.

PURPOSE: Infection is the leading complication of long-term central venous catheters, and its incidence may vary according to catheter type. The objective of this study was to compare the frequency and probability of infection between two types of long-term intravenous devices. METHODS: Retrospective study in 96 onco-hematology patients with partially implanted catheters (n = 55) or completely implanted ones (n = 42). Demographic data and catheter care were similar in both groups. Infection incidence and infection-free survival were used for the comparison of the two devices. RESULTS: In a median follow-up time of 210 days, the catheter-related infection incidence was 0.2102/100 catheter-days for the partially implanted devices and 0.0045/100 catheter-days for the completely implanted devices; the infection incidence rate was 46.7 (CI 95% = 6.2 to 348.8). The 1-year first infection-free survival ratio was 45% versus 97%, and the 1-year removal due to infection-free survival ratio was 42% versus 97% for partially and totally implanted catheters, respectively (P <.001 for both comparisons). CONCLUSION: In the present study, the infection risk was lower in completely implanted devices than in partially implanted ones.

Comparison of catheter-related infection risk in two different long-term venous devices in adult hematology-oncology patients

OBJETIVO: Infecção é a principal complicação relacionada ao uso de cateteres venosos de longa permanência em pacientes oncológicos e sua incidência pode variar a depender do tipo de cateter utilizado. O objetivo deste estudo foi comparar a freqüência e risco de infecção entre dois tipos de dispositivos de longa permanência. MÉTODOS: Estudo retrospectivo com 96 pacientes onco-hematológicos portadores de cateteres parcialmente implantáveis (n=55) ou totalmente implantáveis (n=42). Dados demográficos e cuidados com o dispositivo foram similares entre os dois grupos. A comparação entre os dispositivos foi realizada através da avaliação da incidência de infecção e da sobrevida livre de infecção. RESULTADOS: Em uma mediana de acompanhamento de 210 dias, a incidência de infecção relacionada ao cateter foi de 0,2102/100 cateter-dias para os dispositivos parcialmente implantáveis e de 0,0045/100 cateter-dias para os totalmente implantáveis, com uma razão de incidência de 46,7 (IC 95% = 6,2 a 348,8). A taxa de sobrevida livre de primeira infecção em um ano foi de 45% versus 97% e a taxa de sobrevida livre de retirada por infecção foi de 42% versus 97%, respectivamente para cateter parcialmente ou totalmente implantável (p<0,001 para ambas comparações). Conclusão: No presente estudo, o risco de infecção foi menor nos dispositivos totalmente implantáveis do que nos parcialmente implantáveis.

First case of immune-mediated haemolytic anaemia associated to imatinib mesylate.

Imatinib mesylate is a specific inhibitor of protein tyrosine kinase activity secondary to bcr-abl, mostly indicated for the treatment of patients with Philadelphia chromosome positive chronic myeloid leukaemia (CML). Generally, the undesirable effects of imatinib administration observed in clinical trials were of mild-to-moderate degree, and no haemolysis has been associated with this drug. We report here a case of immune-mediated haemolytic anaemia associated to imatinib mesylate successfully treated with prednisone in a patient with CML. Laboratory investigation showed anaemia [haemoglobin (Hb) of 59 g/L], reticulocyte of 61 x 10(9)/L and a positive direct antiglobulin test. Anti-drug in vitro studies revealed a positive result with gel microcolumn assay by an adsorption mechanism. Seventy-four days after prednisone therapy, the patient's Hb level was of 110 g/L with negative direct antiglobulin test and drug in vitro studies. This case demonstrated that patients treated with imatinib mesylate can present immune-mediated haemolysis and adequate management of this event can be done maintaining the drug and associating corticosteroids.

Hemolytic disease of the newborn due to anti-U

Anti-U is a rare red blood cell alloantibody that has been found exclusively in blacks. It can cause hemolytic disease of the newborn and hemolytic transfusion reactions. We describe the case of a female newborn presenting a strongly positive direct antiglobulin test due to an IgG antibody in cord blood. Anti-U was recovered from cord blood using acid eluate technique. Her mother presented positive screening of antibodies with anti-U identified at delivery. It was of IgG1 and IgG3 subclasses and showed a titer of 32. Monocyte monolayer assay showed moderate interaction of Fc receptors with maternal serum with a positive result (3.1 percent). The newborn was treated only with 48 hours of phototherapy for mild hemolytic disease. She recovered well and was discharged on the 4th day of life. We conclude that whenever an antibody against a high frequency erythrocyte antigen is identified in brown and black pregnant women, anti-U must be investigated

Resolvendo um caso de ABO discrepante através da genotipagem rápida por PCR-RFLP / Solving an ABO complex discrepancy by rapid genotyping using PCR-RFLP

O uso das reaçöes de hemaglutinaçäo para identificar discrepâncias ABO pode consumir um grande tempo e dificultar sua interpretaçäo. Com o conhecimento da base molecular dos antígenos do grupo sangüíneo ABO, o PCR-RFLP foi usado para elucidar um caso complexo de discrepância ABO. Materiais e Métodos: Um bebê do sexo feminino com sete meses de idade foi admitido no hospital com o diagnóstico de mielofibrose e anemia. Os testes pré-transfusionais usando o gel-teste demonstraram ser a paciente do grupo sangüíneo A, com teste de antiglobulina direto e pesquisa de anticorpos negativos. A paciente tinha um resultado prévio de tipagem AB. Nos testes de saliva foram detectados as substâncias A e B. Como testes imuno-hematológicos se mostraram inconclusivos, o PCR-RFLP foi feito usando amostras de sangue da paciente e da mäe. Após extraçäo do DNA genômico, dois fragmentos específicos do gene ABO (exon 6 e 7) foram ampliados usando os primers mo-46/mo-57 e mo-71/mo101 e digeridos com as enzimas Kpn I e Hpa II. Os produtos digeridos foram analisados por eletroforese em gel de agarose. Resultados: Após o PCR-RFLP na amostra do bebê, foram encontrados os fragmentos 309, 252, 223, 204, 150, 137 e 119 pb, confirmando o genótipo A2B, e na amostra da mäe foram encontrados os fragmentos 309, 252, 223, 150 e 137 pb, confirmando, também, o genótipo A2B. Conclusäo: Nos casos de discrepância ABO, a determinaçäo do grupo sangüíneo ABO pode ser feita pelo PCR-RFLP