An unusual response to 5-azacitidine by a patient with chronic myelomonocytic leukemia.

Key Clinical Message: Hypomethylating agents may be useful in some but not all cases of myelodysplastic syndromes. In some versions of these conditions, this treatment may yield deleterious results. Abstract: Chronic myelomonocytic leukemia (CMML) is considered to be a heterogeneous group of hematopoietic neoplasms. Usually it shares the features of myeloproliferative neoplasms (MPN) and myelodysplastic syndromes (MDS) and is known as MDS/MPN. It occurs mostly in the elderly and has an inherent tendency to transform to acute myeloid leukemia. FDA has approved hypomethylating agents (HMAs) such as 5-azacitidine (AZA) and decitabine (DEC) for the treatment of this disorder. The extent of response rate to AZA varies considerably among patients. Our report describes a patient with CMML who not only did not respond to a conventional dose of intravenous (IV) therapy with AZA, but showed marked progression of the disease with the leucocyte count rising exponentially while undergoing the aforesaid treatment. We believe this is the first such case reported in the currently extant literature.

Higher-risk myelodysplastic syndrome in an elderly patient: Long-term partial remission with low-dose prednisone, G-CSF, and epoetin alfa.

Currently, most patients with higher-risk MDS are treated with 5-azacitidine or decitabine. These agents are toxic. The treatment described here is safe, devoid of toxicity, fosters improved quality of life, and helps reduce transfusion requirements.

Intramarrow injection needle: a new technique to treat patients with haematological and non-haematological malignancies by directly injecting therapeutic agents into the bone marrow cavity.

AIMS: The purpose of this report is to describe a new instrument designed for the injection of therapeutic agents directly into the bone marrow cavity as well as to aspirate bone marrow specimens for the diagnostic purposes. METHODS: The instrument consists of three parts: the needle, stilette and an adjustable guard. The overall length of the needle is 76 mm and has uniform external diameter except for the distal penetrating segment, which is sharp but short and safe to use on the sternum. The proximal end of the needle is fitted with a plastic T-bar handle, which is ergonomically designed for firm grip and easy manoeuvrability. RESULTS: The instrument has been designed to obtain bone marrow aspirate specimens as well as to inject therapeutic agents into the posterior ilium. CONCLUSIONS: The rationale for the intramedullary injection of therapeutic agents for the treatment of patients with leukaemia, lymphoma and other haematological and non-haematological malignant disorders is described. In an emergency when intravenous therapy becomes difficult due to collapsed veins, this instrument may be used for direct intramarrow infusion of blood and blood products.

Hypoplastic acute myeloid leukemia in an elderly patient. A long-term partial remission with low-dose prednisone and G-CSF.

Hypoplastic acute myeloid leukemia (AML) is a rare variant of AML that mainly affects the elderly and accounts for 5%-7% of de novo AML. Prognosis for this disease is poor, and there is no standard therapy. We have treated an elderly patient with hypoplastic AML with low-dose prednisone and G-CSF with good results. We propose that this treatment may be a viable alternative to supportive therapy alone, or the tenuous chemotherapeutic challenge to elderly patients with hypoplastic AML.

Diagnostic value of preparing bone marrow smears from the small amount of material left within the aspiration needle following a dry tap.

Bone marrow aspirations are used in the diagnosis of patients with hematological disorders. Cytological diagnosis becomes difficult when aspiration is a dry tap. Smears produced from the material left in the needle following a dry tap can provide valuable information either to complement or even make an accurate diagnosis.

Bone marrow solid core biopsy needle: a critical assessment of the utility, benefits and limitations of the instruments employed in current day haematology and oncology.

The optimal clinical evaluation of the bone marrow requires an examination of air-dried and well-stained films of the aspirated tissue along with a histopathological evaluation of adequately processed and properly stained core biopsy specimens. A bone marrow evaluation can be essential in establishing a diagnosis, determining the efficacy of treatment in haematological disorders and to monitor haematological status of patients following bone marrow/stem cell transplantation. It is also an essential component of the staging process for newly diagnosed malignancies. Currently available bone marrow aspiration needles are quite satisfactory and if properly used provide good-quality specimens for morphological evaluation. However, if a bone marrow core biopsy is concerned, several needles are currently in use but not all of them provide good-quality biopsy specimens for histological evaluation or are user friendly. We have compared the recently introduced Moeller Medical single use bone marrow core biopsy needle with the Jamshidi needle with marrow acquisition cradle (CareFusion), J-needle (Cardinal Health) and OnControl device (Vidacare). It is concluded that the Moeller Medical needle system has definite advantages over others and is recommended for routine use.

Induction treatment of acute myeloid leukemia in an elderly patient with intramarrow injection/administration of cytarabine. Second case report.

We show for the second time that intramarrow injection/administration of chemotherapeutic agents such as cytarabine (Ara-C) can be used safely and effectively and is associated with no toxicity, promising antileukemic activity and possible improved survival.

A case of myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) successfully treated with lenalidomide.

Lenalidomide is an immunomodulatory drug which is used to treat patients with MDS with deletion 5q chromosomal abnormality. In 2008, WHO introduced a new disease entity called MDS/MPN. No specific treatment for MDS/MPN subtype has yet been identified. We report a patient with MDS/MPN who responded well to lenalidomide therapy.

Induction treatment of acute myeloid leukemia in an elderly patient with intramarrow injection/administration of cytarabine: first report of a case.

We have used intramarrow injection/administration of cytarabine (Ara-C) instead of conventional intravenous approach to induce remission in an elderly patient with acute myelogenous leukemia. We show for the first time that the intramarrow injection of chemotherapeutic agents such as Ara-C can be used safely and effectively.

Ultrasound: a new tool for precisely locating posterior iliac crests to obtain adequate bone marrow trephine biopsy specimen.

Ultrasound imaging has evolved as a very useful tool in medical science. However, the technique of ultrasound-guided bone marrow trephine biopsy (BMTB) has not been routinely used by haematologists and oncologists to help locate the posterior iliac crest during the BMTB procedure. We have used the technique of ultrasound-guided BMTB in 20 patients diagnosed with various haematological and non-haematological malignant conditions. We found the technique simple and useful in precisely locating the posterior iliac crest. As a result, it facilitates the extraction of a satisfactory core sample or aspiration biopsy and is more surgically precise than when access to the target bone is based only on external landmarks and blind biopsy.

Bone marrow aspiration before bone marrow core biopsy using the same bone marrow biopsy needle: a good or bad practice?

A single-needle single-site technique for bone marrow aspiration and core biopsy has been compared with a two-needle technique, using 30 randomly selected patients who required these two investigations. In addition, two single-needle techniques were compared, aspirating immediately after penetrating the cortex or, alternatively, aspirating after the needle (without the stilette) had been advanced 20-25 mm. The two-needle technique was found to be superior to either of the single-needle techniques, which often resulted in a biopsy specimen that was denuded of bone marrow cells.

Treatment of viral and neoplastic diseases with double-stranded RNA derivatives and other new agents.

Many attempts have been made to inhibit viral and neoplastic diseases by targeting the RNA system. The pathophysiologic significance of the microRNA system and the therapeutic potential of its manipulation are discussed. Studies of double-stranded RNA derivatives are reviewed. The therapeutic potential of one of these compounds, polyI:MPC, is emphasized. Studies of other related antiviral and antineoplastic agents are discussed, including 2'-deoxyoligocytidilates and telomerase inhibitors.

Cytotoxic activities of ethyl acetate extract and a metabolite from a Monocillium species.

The ethyl acetate soluble fraction of a cultural broth of a Monocillium species afforded the isolation of 5-hydroxymethylfurfural. Both the extract and 5-hydroxymethylfurfural showed significant cytotoxic activities in a brine shrimp bioassay and the LC(50) values were found to be 14.96 microg/mL and 23.71 microg/mL, respectively.

A new single-use bone marrow biopsy needle.

A new needle for taking a bone marrow biopsy sample from the posterior iliac crest is described. The needle comprises a hollow tube having a front-end portion formed to a reduced diameter. The front end is tapered by means of circumferentially spaced facets, forming a cutting edge. A series of flutes/serrations are introduced at the tapering transitional portion, between the main wider portion of the hollow tube and its reduced-diameter front-end portion. This design is new and is not available in any other conventional biopsy needle. These serrations help in its penetration through the hard cortical bone. A spacer guide, which is placed between the plastic dome of the needle and the stilette cap to enhance the ergonomics, is also new. The inside of the spacer guide is funnel shaped, through which the stilette is passed, thereby ensuring an easy and accurate alignment of the distal ends of the hollow needle and the stilette. This technique facilitates removal of the biopsy sample rearwardly out of the hollow needle particularly when the mouth (distal-end opening) of the needle is covered by extraneous bony soft tissue. In this technique, the same stilette that occupies the needle during its entry into the marrow cavity is used in sample removal. Thus, the need for an additional pusher to remove the biopsy sample from within the lumen of the needle has been eliminated.

Malignancy: Case Report: Muscle Involvement in Multiple Myeloma: Report of a Patient Presenting Clinically as Polymyositis.

Although bone pain is common in multiple myeloma (MM), muscular symptoms, especially myalgias, may be rare. We describe a patient who presented with generalised myopathy and elevated creatine kinase (CK) suggestive of polymyositis. Routine blood tests showed raised viscosity and marked rouleaux formation in the peripheral blood film. A serum protein electrophoresis showed IgG Lambda paraproteinemia with immunoparesis. A sternal bone marrow aspirate and a bone marrow biopsy concurrently obtained from the right posterior iliac crest showed considerable (15-20%) marrow infiltration with plasma cells confirming a diagnosis of multiple myeloma. A review of the literature suggests that generalised myopathy and elevated CK associated with MM have not been reported in the past. We believe this is the first reported case of MM presenting as polymyositis.