Frequency and clinical impact of CDKN2A/ARF/CDKN2B gene deletions as assessed by in-depth genetic analyses in adult T cell acute lymphoblastic leukemia.

Recurrent deletions of the CDKN2A/ARF/CDKN2B genes encoded at chromosome 9p21 have been described in both pediatric and adult acute lymphoblastic leukemia (ALL), but their prognostic value remains controversial, with limited data on adult T-ALL. Here, we investigated the presence of homozygous and heterozygous deletions of the CDKN2A/ARF and CDKN2B genes in 64 adult T-ALL patients enrolled in two consecutive trials from the Spanish PETHEMA group. Alterations in CDKN2A/ARF/CDKN2B were detected in 35/64 patients (55%). Most of them consisted of 9p21 losses involving homozygous deletions of the CDKNA/ARF gene (26/64), as confirmed by single nucleotide polymorphism (SNP) arrays and interphase fluorescence in situ hybridization (iFISH). Deletions involving the CDKN2A/ARF/CDKN2B locus correlated with a higher frequency of cortical T cell phenotype and a better clearance of minimal residual disease (MRD) after induction therapy. Moreover, the combination of an altered copy-number-value (CNV) involving the CDKN2A/ARF/CDKN2B gene locus and undetectable MRD (≤ 0.01%) values allowed the identification of a subset of T-ALL with better overall survival in the absence of hematopoietic stem cell transplantation.

Immunophenotype of acute myeloid leukemia with NPM mutations: prognostic impact of the leukemic compartment size.

NPM mutations are the most common genetic abnormalities found in non-promyelocytic AML. NPM-positive patients usually show a normal karyotype, a peculiar morphologic appearance with frequent monocytic traits and good prognosis in the absence of an associated FLT3 mutation. This report describes the immunophenotypic and genetic characteristics of a consecutive series of NPM-mutated de novo AML patients enroled in the CETLAM trial. Eighty-three patients were included in the study. Complete immunophenotype was obtained using multiparametric flow cytometry. Associated genetic lesions (FLT3, MLL, CEBPA and WT1 mutations) were studied by standardized methods. Real-time PCR was employed to assess the minimal residual status. The most common pattern was CD34-CD15+ and HLA-DR+. Small CD34 populations with immunophenotypic aberrations (CD15 and CD19 coexpression, abnormal SSC) were detected even in CD34 negative samples. Nearly all cases expressed CD33 (strong positivity), CD13 and CD117, and all were CD123+. The stem cell marker CD110 was also positive in most cases. Biologic parameters such as a high percentage of intermediate CD45+ (blast gate) (>75% nucleated cells), CD123+ and FLT3-ITD mutations were associated with a poor outcome. Quantitative PCR positivity had no prognostic impact either after induction or at the end of chemotherapy. Only PCR positivity (greater than 10 copies) detected in patients in haematological remission was associated with an increased relapse rate. Further studies are required to determine whether the degree of leukemic stem cell expansion (CD45+CD123+cells) increases the risk of acquisition of FLT3-ITD and/or provides selective advantages.

Surgical excision of retrorectal tumour using transanal endoscopic microsurgery.

Abstract Surgical excision is the best therapeutic option for tumours in the retrorectal space. Classically, surgery in this area required an abdominal or posterior approach, or a combination of the two methods. We report the use of transanal endoscopic microsurgery for the treatment of retrorectal tumours as an alternative to classical procedures.

Prognostic value of minimal residual disease (MRD) in acute myeloid leukemia (AML) with favorable cytogenetics [t(8;21) and inv(16)].

Most patients with acute myeloid leukemia (AML) and t(8;21) or inv(16) have a good prognosis with current anthracycline- and cytarabine-based protocols. Tandem analysis with flow cytometry (FC) and real-time RT-PCR (RQ-PCR) was applied to 55 patients, 28 harboring a t(8;21) and 27 an inv(16), including one case with a novel CBFbeta/MYH11 transcript. A total of 31% (n=17) of CR patients relapsed: seven with t(8;21) and 10 with inv(16). The mean amount of minimal residual disease (MRD) detected by FC in relapsed and nonrelapsed patients was markedly different: 0.3 vs 0.08% (P=0.002) at the end of treatment. The mean number of fusion transcript copies/ ABL x 10(4) also differed between relapsed and non-relapsed patients: 2385 vs 122 (P=0.001) after induction, 56 vs 7.6 after intensification (P=0.0001) and 75 vs 3.3 (P=0.0001) at the end of chemotherapy. Relapses were more common in patients with FC MRD level >0.1% at the end of treatment than in patients with < or = 0.1%: cumulative incidence of relapse (CIR) was 67 and 21% (P=0.03), respectively. Likewise, using RQ-PCR, a cutoff level of >10 copies at the end of treatment correlated with a high risk of relapse: CIR was 75% for patients with RQ-PCR >10 compared to 21% for patients with RQ-PCR levels < or = 10 (P=0.04). Combined use of FC and RQ-PCR may improve MRD detection, and provide useful clinical information on relapse kinetics in AML patients.

Adverse prognostic impact of CD36 and CD2 expression in adult de novo acute myeloid leukemia patients.

BACKGROUND AND OBJECTIVES: A consecutive series of acute myeloid leukemias (AML) patients was analyzed in conditions which reduce the inter-assay variations (the same flow cytometer, the same observers and the same panel of monoclonal antibodies) in order to investigate the prognostic information provided by flow cytometry. DESIGN AND METHODS: Two hundred and sixty-six bone marrow (BM) samples from 326 patients enrolled in the LMA-99 protocol from the CETLAM group were studied by multiparametric flow cytometry. Immunophenotyping studies were performed on erythrocyte-lysed BM samples. Antigen expression of leukemic cells was analyzed using triple stainings with fluorochrome-conjugated combinations of monoclonal antibodies. RESULTS: CD2 was positive in 21 cases (8%); an associated inv(16) was detected in eight CD2+ cases (38%). Two-year overall survival (OS) rate for CD2+/inv(16)+ patients was 75%, whereas it was 0% for CD2+/inv(16)- patients and 47% for CD2- patients (p=0.0001). CD36 was expressed in 37% of patients (n=98). Two-year leukemia-free survival (LFS) rate was 34% for CD36+ patients and 55% for CD36- patients (p=0.001). In the multivariate analysis, CD2+ (RR=8.4; p=0.0001) and adverse karyotype (RR=10.2; p=0.0001) were associated with a lower CR rate, CD36+ (RR=1.5; p=0.03), CD2+ (RR=2; p=0.04) and adverse karyotype (RR=4; p=0.0001) were associated with a lower OS and CD36+ (RR=2; p=0.002) and adverse karyotype (RR=3.5; p=0.005) predicted a lower LFS. CONCLUSIONS: CD2+ patients had a very poor OS when CD2/inv(16)+ cases were excluded. CD36 and CD2 expression at diagnosis can provide prognostically important information in adult de novo AML.

CXCR4 and SDF-1 expression in B-cell chronic lymphocytic leukemia and stage of the disease.

The pathogenesis of B-cell chronic lymphocytic leukemia (B-CLL) has been linked to an overexpression of the chemokine receptor CXCR4 and increased in vitro functional response to its natural ligand CXCL12 (SDF-1). The CXCR4/SDF-1 system appears to be important for tissue localization and increased survival of B-CLL cells. The aim of our study was to examine if CXCR4 expression and SDF-1 blood levels were correlated to clinical and pathological stage of B-CLL. Flow cytometry and enzyme-linked immunosorbent assay (ELISA) techniques were used to determine CXCR4 expression and SDF-1 plasma levels, respectively, in a cohort of 51 patients diagnosed with B-CLL to correlate these measurements with several parameters that define the clinical stage of the disease. We confirmed that CXCR4 was consistently expressed on circulating B-CLL cells with a fluorescence intensity that was five-fold greater than in cells from healthy volunteers. There was a correlation between CXCR4 expression and leukocyte count ( r: 0.55, p<0.01), and CD19(+)/CD5(+ )cells ( r: 0.63, p<0.01). Interestingly, the group of B-CLL patients showed lower SDF-1 plasma levels compared to the control group. However, there was no correlation between CXCR4 or SDF-1 expression and the clinical stage of disease or the pattern of bone marrow infiltration. The results obtained suggest that other factors, and not only alteration in the SDF-1/CXCR4 chemokine system, must account for marrow infiltration of neoplastic cells observed in B-CLL and that CXCR4 could be involved in other features that exhibit malignant B cells, such as increased survival, rather than in their homing or migration to the bone marrow.

Erythropoietin plus granulocyte colony-stimulating factor in the treatment of myelodysplastic syndromes. Identification of a subgroup of responders. The Spanish Erythropathology Group.

BACKGROUND AND OBJECTIVE: Anemia leading to transfusion is probably the most important problem in patients with myelodysplastic syndromes (MDS). Human recombinant erythropoietin (rHuEpo) and granulocyte colony-stimulating factor (G-CSF) have been used to treat patients with anemia of MDS, but fewer than 50% respond. The aim of this work was to evaluate the benefit of rHuEpo +/- G-CSF treatment and to isolate the response predictive variables in a group of selected patients with MDS. DESIGN AND METHODS: A non-randomized multicenter trial was carried out in 32 patients with MDS. The inclusion criteria were age >= 18 years, refractory anemia (RA) or refractory anemia with ringed sideroblasts, Hb <= 100 g/L or receiving transfusions and serum erythropoietin <= 250 U/L. These patients were treated with subcutaneous rHuEpo (300 U/kg) three times a week for 8 weeks. In the case of partial response (PR) or no response (NR) subcutaneosly administered G-CSF (1 microg/kg) three times a week was added to the rHuEpo for 8 more weeks. If the patient achieved complete response (CR) or PR in the second phase, he was included in a follow-up phase of 24 weeks in which the dose of growth factors was tapered down. Several variables, including the score published by the Scandinavian-American group, were used as possible predictive variables. RESULTS: An erythroid response was observed in 16 patients (50%); in 12 it was a CR and in 4 it was a PR. During the period of rHuEpo administration, 7 CR and 4 PR (34.4%) were documented. Of the 14 patients in whom G-CSF was added to rHuEpo, 7 (50%) responded (3 CR and 4 PR). No major side-effects associated with growth factors were observed. The multivariate analysis showed that of the different variables evaluated only the Scandinavian-American response score was significant with a relative probability of response of 11.8 (95% confident intervals: 2.5-53) when this score was > +1 (77% of cases responded). In contrast, when this score was <= 1 only 15 % of the cases responded. INTERPRETATION AND CONCLUSIONS: Use of the Scandinavian-American response score is to be recommended in a patient-oriented approach to treating MDS cases with the Epo and G-CSF. Treatment with rHuEpo and G-CSF is safe, its main drawback being its cost. However, a long-term study evaluating the regimen's cost-benefit ratio is warranted.

The usefulness of the serum transferrin receptor in detecting iron deficiency in the anemia of chronic disorders.

BACKGROUND AND OBJECTIVE: Recent studies have shown that the serum transferrin receptor (sTfR) is a sensitive, quantitative measurement of tissue iron deficiency. The objective of the study was to evaluate the diagnostic efficiency of some laboratory tests, including sTfR measurements, in the diagnosis of iron depletion in patients with anemia of chronic disorders. DESIGN AND METHODS: The patient population consisted of 37 anemic patients: 10 hypoferritinemic patients (serum ferritin < 25 micrograms/L), and 27 anemic in-patients with hyperferritinemia (serum ferritin > 200 micrograms/L) and clinical/analytical criteria of anemia of chronic disorders, who were submitted to a bone marrow aspirate with iron stain. The sensitivity and specificity of serum TfR was evaluated according to the results of bone marrow iron status. Statistical analysis employed Student's t-test, one way analysis of variance and a logistic regression model using the Wald test. RESULTS: Serum TfR was high in all the patients with hypoferritinemic anemia. In 12 patients with low bone marrow iron, the mean sTfR was 5.63 mg/L. In 6 of these 12 patients the sTfR was normal. On the other hand, sTfR was high in 4/15 patients with normal or increased iron stores. On multivariate analysis the most sensitive predictor of true iron deficiency was MCH (mean corpuscular hemoglobin). No other variables remained independently significant, including sTfR, after the inclusion of MCH in this model. INTERPRETATION AND CONCLUSIONS: In our opinion, the iron status of patients with anemia of chronic diseases can not be accurately assessed by sTfR, as its sensitivity and specificity are low. In these patients, the gold standard for iron stores evaluation continues to be bone marrow aspirate and Perls stain.

[Acute myelomonocytic leukemia with eosinophilia and inversion of chromosome 16. Study of 6 cases]. / Leucemia aguda mielomonocítica con eosinofilia e inversión del cromosoma 16. Estudio de 6 casos.

The purpose of this study has been to refer the main clinico-biologic characteristics, the evolution and the response to therapy in 6 patients with acute myelomonocytic leukemia with eosinophilia and inversion of chromosome 16 (AML4Eo inv[16]) belonging to a series of 92 patients with acute myeloblastic leukemia diagnosed in a single hospital between 1987 and 1995. The main clinical manifestations were anemic syndrome and hemorrhage. Anemia and thrombocytopenia were present in all cases, high white blood cell count in 4, monocytosis in 5 and eosinophilia in one. Bone marrow aspirate showed myeloid and monocytic blast infiltration (43-62%), eosinophilia (5-19%) and atypical monocytic precursors (6-18%). Induction therapy consisted in one or two cycles of daunorubicin (or idarubicin), cytosine arabinoside and etoposide, followed by two cycles of consolidation treatment, the first with mitoxanthrone and cytosine arabinoside and the second with amsacrine and cytosine arabinoside. One patient died in the induction phase, while complete remission was obtained in the remaining 5. One patient died during the consolidation therapy. Allogeneic bone marrow transplant (BMT) was performed to one patient and autologous BMT to another. The first patient remains in complete remission (CR) at 68 months from diagnosis, and the second relapsed 12 months after BMT. Another patient relapsed at 13 months from diagnosis and the remaining persists in CR 13 months from diagnosis. Actuarial probabilities of CR duration and survival were 50% at 5 years. The clinico-biologic characteristics and the response to therapy of patients with AML4Eo inv(16) are similar to those referred in other series. There is a high probability of CR attainment and, probably, the relapse rate is lower than that of other subtypes of AML.

[Acute lymphoblastic leukemia in adults. Comparative study of clinicobiologic characteristics and of response to treatment in terms of age in a group of 41 patients]. / Leucemia aguda linfoblástica del adulto. Estudio comparativo de las características clinicobiológicas y de la respuesta al tratamiento en función de la edad en un grupo de 41 pacientes.

BACKGROUND: The aim of this study was to analyze the influence of age on the clinical and biological features as well as the results of treatment in 41 adult patients with acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS: The patients diagnosed with ALL from January 1989 to October 1995 in a single center were studied. Two groups of patients were analyzed based on age. The main clinical, hematologic and biochemical parameters, morphologic subtype and immunologic phenotype and the results of the cytogenetic study were analyzed. Likewise, the attainment of complete remission (CR), its duration and overall survival (OS) were also studied. Comparison of the cited variables and the results of treatment among the two groups of patients was performed. RESULTS: Group I was made of 19 (11 males, 8 females) patients > or = 50 years of age (mean age 65 +/- 9 years). Group II included 22 patients (11 males and 11 females) with a mean age of 28 +/- 11 years. Significant differences were only observed between the two groups in regard to the proportion of peripheral blood blasts (p < 0.02), serum LDH values (p = 0.05) and the performance status at the time of diagnosis ( p < 0.00007). In the patients in group 1 cytogenetic alterations were more frequent (10/16 vs 4/20, p < 0.02), being mainly pseudodiploid. Complete remission was achieved in 7/16 patients in group I and in 17/22 in group II (p < 0.02). The median duration of CR was 34 and 18 months, respectively. The median OS was 7 months in group 1 and 15 months in group II with an estimated survival at 5 years of 0% in group I and 38% in group II (p < 0.05). CONCLUSIONS: Patients with acute lymphoblastic leukemia over the age of 50 years have a worse general status and more cytogenetic alterations (particularly structural) than younger adult patients, presenting a lower probability of achieving complete remission and a shorter survival.

[Lymphoma of the marginal zone of the spleen. A case study]. / Linfoma de la zona marginal del bazo. Estudio de un caso.

Lymphomas of the marginal spleen zone are an entity recently considered as separate by the International Lymphoma Study Group. There are B-cell non Hodgkin's lymphomas (NHL) of low grade malignancy with a characteristic phenotype that allows to differentiate from mantle lymphomas and other B-cell lymphoproliferative syndromes. The case of a 69-year-old female patient admitted for abdominal pain due to large splenomegaly is reported. Pancytopenia and the presence of atypical large-sized lymphocytes with extensive cytoplasm and a rounded nucleus with indentations, reticulated appearing chromatin and one or several nucleoli were of note in the hemogram. Microscopic examination of the bone marrow demonstrated moderate-degree lymphocytary infiltration with grade I reticulin fibrosis. Laparotomy with splenectomy was performed. White pulp invasion with multifocal infiltration of the red pulp by lymphocytes of the same characteristics as those observed in the peripheral blood and bone marrow were observed on microscopic bone marrow examination. Immunophenotypic study of these lymphocytes was positive for CD19, CD20 and CD22 while being negative for CD5, CD10, CD23, CD25, CD11c and FMC7, the phenotype belonging to the lymphocytes of marginal spleen zone. Following splenectomy the patient recovered hemoperipheral counts and did not undergo additional treatment. The patient died due to septic shock of respiratory origin 4 months later. The clinical, morphologic and immunophenotypic features of marginal spleen zone lymphomas are reported with emphasis on the differences with other B-cell non Hodgkin's lymphomas of low malignancy.

[Primary extralymphatic non-Hodgkin's lymphomas: the response to treatment and prognostic factors in 73 patients]. / Linfomas no hodgkinianos extraganglionares primarios: respuesta al tratamiento y factores pronósticos en 73 pacientes.

BACKGROUND: The aim of the present study was to determine the prognostic factors for treatment response, relapse-free survival (RFS) and overall survival (OS) in a series of 73 patients with primary extranodal lymphomas (PEL). METHODS: All the patients diagnosed with PEL in one center from January 1984 to December 1993 were studied. The Working Formulation was used for histologic classification and the stage was determined according to the Ann Arbor classification modified by Mushoff. Age, sex, localization of the lymphoma, the presence of B symptoms, the existence of bulky disease, human immunodeficiency virus (HIV) infection, the main hematological and biochemical parameters, the histologic grade of malignancy, the immunologic phenotype and stage were reported. Univariate and multivariate analyses of prognostic factors for complete response (CR), RFS and OS were carried out. RESULTS: The most frequent localization of PEL was the gastrointestinal tract (43 cases). Fourteen cases had HIV infection. CR was obtained in 37 out of the 55 patients (67%) of whom 8 (21%) had relapsed. Serum LDH level was the main prognostic factor for CR attainment (p = 0.01). The variables which negatively affected RFS were the presence of HIV infection (p = 0.02), advanced age (p = 0.018) and the existence of B symptoms (p = 0.02). OS was shorter in patients with high LDH levels (p = 0.004) and more aggressive histologic subtype (p = 0.0002). CONCLUSIONS: The prognostic factors observed in the patients with primary extranodal lymphomas are the same as those found in nodal non Hodgkin's lymphomas. The stage is not a factor of bad prognosis if chemotherapy is included in the treatment.

[Granulocytic sarcoma: a study of 5 cases]. / Sarcoma granulocítico: estudio de cinco casos.

Granulocytic sarcoma (GS) is a solid tumor of extramedullary localization constituted by immature precursors from the granulocytic series. GS may be diagnosed in different malignant blood diseases involving the granulocytic series, acute non lymphoblastic leukemia (ANLL) being the most frequent, followed by myelodysplastic syndromes (MDS) and chronic myeloproliferative syndromes, specially chronic myeloid leukemia (CML) in blastic crisis. Although the diagnosis of GS is suspected with conventional cytologic and anatomopathologic studies, histochemical staining and immunohistochemical techniques are often required for definitive diagnosis. Five cases (4 males, 1 female; age range 22-77 years) diagnosed with GS in one center over a period of nine years (1984-1993) are described. The GS were located in the lymph nodes, the jaw, paravertebral region, gallbladder and retroperitoneum, respectively. Two patients had refractory anemia with excess of blasts (RAEB). Three patients had ANLL; in one GS constituted the form of relapse, in another GS presented at the time of diagnosis and in the remaining patient GS preceded the diagnosis of ANLL. All the patients died from 2 to 8 months after diagnosis of GS with no response to treatment being observed. Immunohistochemical study of the tumor was performed in 4 patients, being positive for lysozyme and the monocytic MAC-387 monoclonal antibody. Immunocytochemical study of the tumor blasts was carried out with positivity for CD15 being observed. Although uncommon, GS should be suspected in patients with ANLL or MDS with tumors of any localization and at any time during its evolution. Immunocytochemical and immunohistochemical studies are of great value to differentiate GS from other tumors, particularly anaplastic non Hodgkin's lymphomas.