Flow cytometry in the bone marrow evaluation of follicular and diffuse large B-cell lymphomas.

BACKGROUND AND OBJECTIVES: Bone marrow biopsies are routinely performed in the staging of patients with lymphoma. Despite the lack of evidence for its usefulness, many institutions include flow cytometry (FC) of bone-marrow aspirates in an attempt to increase sensitivity and specificity. The aim of this study is to evaluate the usefulness of FC for the assessment of bone-marrow involvement by lymphoma in follicular (FL) and diffuse large B-cell lymphomas (DLBCL). DESIGN AND METHODS: Seventy-nine bone marrow biopsies from 65 patients diagnosed with FL or DLBCL were examined to compare histology and FC for the assessment of bone-marrow involvement by lymphoma. RESULTS: Bone marrow histology showed involvement (BM+) in 16 cases (20.3%), lack of infiltration (BM(-)) in 52 cases (65.8%) and undetermined or undiagnosed for involvement (BMu) in 11 cases (13.9%). FC was positive for involvement in 28 cases (35.4%) and negative in 51 cases (64.6%). 65 cases (95%) showed concordance between the results of morphology and FC (BM(+)/FC(+) or BM(-)/FC(-)). No BM(+)/FC(-) cases were observed. 3 cases showed discrepant results (BM(-)/FC(+)). In these 3 cases the molecular studies (PCR) demonstrated clonal rearrangement of the heavy immunoglobulin chain (IgH) and/or bcl2-IgH in agreement with the flow results. Among the 11 cases with BMu, all but 2 were FC(+) and concordance with the PCR results was seen in 9 cases (81.9%). INTERPRETATION AND CONCLUSIONS: We conclude that FC is just as sensitive or perhaps slightly more sensitive than histology in the detection of bone marrow involvement in FL and DLBCL. FC studies may be warranted in those cases in which the morphology is not diagnosed. The clinical relevance of the small clonal B-cell population in patients without histologic bone marrow involvement (BM(-)/FC(+) cases) remains an open question.

[Thrombocytopenic thrombotic purpura. Retrospective study of 22 consecutive occurrences in 16 patients]. / Púrpura trombótica trombocitopénica. Estudio retrospectivo de 22 episodios consecutivos en 16 pacientes.

BACKGROUND: Thrombotic Thrombocytopenic Purpura (TTP) is an uncommon clinical syndrome with high mortality rate in the absence of treatment. Despite the therapeutic efficacy of plasma exchange, patients often relapse even after long periods of time in remission. Over the last few years, late relapses in previously diagnosed patients have been seen in our hospital. PATIENTS AND METHODS: We analyzed retrospectively 22 episodes of TTP in 16 patients diagnosed during a four-year period. We reviewed the clinical features at diagnosis as well as the therapeutic results. In all but one, the treatment included daily plasma exchange. Other treatments, including vincristine, were also used in addition to plasma exchange, in 18 of 21 episodes. RESULTS: A complete remission was obtained in eighty-two percent of the episodes treated by plasma exchange. The median number of plasma exchange to achieve a complete remission was 6. In 4 episodes, 20 or more plasma exchange were required before achieving a satisfactory response. A complete remission was obtained in 78% of episodes where vincristine was used, versus 84% response rate in episodes where vincristine was not used. In four patients the cause death was directly related to TTP, while a fifth patients died of progressive lymphoma without evidence of TTP. Five of the eleven surviving patients relapsed with a median time to relapse of 24.6 months. Relapsing episodes presented with a less severe clinical picture including less clear signs of microangiopathic hemolytic anemia (MAHA), when compared with the initial ones. All patients in relapse responded promptly to treatment. The variables analyzed failed to predict either the response to treatment or the probability of relapse. CONCLUSIONS: The therapeutic efficacy of plasma exchange in the treatment of TTP has been demonstrated in our series as previously observed by many other groups. We have observed some slow responders where the prolongation of treatment by plasma exchange succeeded in achieving a complete remission. The use of vincristine did not show any therapeutical advantage in our experience.

[Reversible leukoencephalopathy related to cyclosporin treatment]. / Leucoencefalopatía reversible relacionada con el tratamiento con ciclosporina.

INTRODUCTION: At the present time cyclosporin is the most commonly used immunodepressive drug for the prevention of transplant rejection. Although the mechanism by which cerebral dysfunction occurs is not well understood, it has been noted that the clinical and radiological characteristics of cyclosporin neurotoxicity, which may occur even when the blood levels of the drugs are within the therapeutic range, are very similar to those of hypertensive encephalopathy and also resolve when the blood pressure drops. CASE CLINIC: A 35 year old woman, treated with high doses of cyclosporin for a bone marrow transplant, presented with progressive headache, drowsiness, blurred vision and convulsions which coincided with a rapid rise in blood pressure. After antihypertensive treatment full recovery (of all symptoms) was seen. Neuro-radiological studies showed extensive changes in the white matter, mainly in the posterior cerebral regions that were not enhanced after contrast. The changes were compatible with oedema. A magnetic resonance study done two years later was completely normal. CONCLUSIONS: In this clinical report the aetiology and the clinical and radiological characteristics of the neurotoxicity due to cyclosporin are discussed.

[Remission of invasive sinusal and pulmonary aspergillosis with liposomal amphotericin B in a patient with chronic lymphatic leukemia following failure with conventional amphotericin]. / Resolución de una aspergilosis invasiva sinusal y pulmonar con anfotericina B liposómica en un paciente con leucemia linfática crónica tras fracaso de la anfotericina convencional.

Invasive aspergillosis is a severe complication in the immunocompromised patient. Despite antifungal treatment the mortality rate is higher than 90% if the immunity deficiency is not corrected. The use and dosage of conventional amphotericin B (deoxycholate-suspended formulation) is limited by its toxicity, especially nephrotoxicity. To reduce these untoward effects, amphotericin B has been formulated in liposomes. Better tolerance and lower nephrotoxicity in the liposomal formulations allow higher doses to be given safely, even in the presence of renal failure. Liposomal encapsulated amphotericin B (LAmB) is a safe and effective alternative to conventional formulations for antifungal therapy. We present a case of a 60-year-old man affected by chronic lymphocytic leukaemia. In the course of his disease and after chemotherapy treatment, he presented an invasive aspergillosis of the lung and paransal sinuses. The rhino-sinusal lesion had progressed despite surgical debridement and treatment with amphotericin B in a dosage of 50 mg per day. Moreover, renal impairment caused by conventional amphotericin was detected. Then, LAmB was started at a dose of 150 mg per day. Treatment with LAmB has resulted in clinical recovery and radiologic ressolution.

Myelodysplastic syndromes: a study of 101 cases according to the FAB classification.

The myelodysplastic syndromes (MDS) are a group of closely related disorders characterized by chronic cytopenias with cellular marrow, poor prognosis and refractoriness to treatment. We studied 101 consecutive cases of MDS diagnosed over a 7-year period. Peripheral blood (PB) and bone marrow (BM) samples were reviewed and classified according to the proposals of the French-American-British (FAB) cooperative group for MDS. The combined analysis of the initial laboratory features and qualitative haematological abnormalities readily allowed the distinction between the different subgroups. Thirty-two of 79 cases (40.5%) evolved towards other diseases, frequently acute leukaemia (24/79, 30%), or transformed into other MDS (7/79, 9%). In five cases, initially classified as refractory anaemia (RA) or refractory anaemia with ring sideroblasts (RAS), a transitory change to another type of MDS--two chronic myelomonocytic leukaemias (CMML), two refractory anaemias with excess of blasts (RAEB) and one refractory anaemia with excess of blasts 'in transformation' (RAEB-t)--was observed before the evolution towards acute leukaemia. This provides a new link between all these syndromes and increases the number of transitions to other MDS. Overall prognosis was very poor, with differences between subgroups. RA had the best prognosis whereas RAEB-t had the worst one. This study shows that the FAB classification is readily usable and defines well-characterized subgroups of MDS, although there are frequent transitional forms, and as the natural history of the MDS unfolds they may convert into another. The actual poor prognosis and the frequent evolution towards acute leukaemia makes necessary to investigate new methods of treatment for these disorders.