The Prevalence of MYD88 L265P and TNFAIP3 Mutations and Their Correlations with Clinico-Hematological Profile in Egyptian Patients with Diffuse Large B Cell Lymphoma.

BACKGROUND: Activated B-cell-like (ABC) subtype of diffuse large B-cell lymphoma (DLBCL) is characterized by chronic active B-cell receptor signaling and a constitutive activation of the NF-KB pathway. MYD88 L265P mutation occurs as a driving force of NF-KB overactivity in ABC-DLBCL. Nonetheless, in cases of DLBCL, the MYD88 L265P mutation has not yet been investigated in association with the tumour necrosis factor alpha induced protein3 (TNFAIP3) mutation. OBJECTIVE: To investigate the frequency of MYD88 and TNFAIP3 mutations in DLBCL and their association to the clinico-hematological profile. MATERIAL AND METHODS: We used real-time polymerase chain reaction in order to search for MYD88 L265P and TNFAIP3 mutations in 100 DLBCL patients. RESULTS: MYD88 L265P In 20% of cases, the CT heterozygous genotype was discovered.  CT heterozygous genotype was more common in ABC type, stage IV, greater IPI groups, extra-nodal infiltration, and BM infiltration. It was also linked to a shorter OS. TNFAIP3 mutation GA heterozygous genotype was detected in 18% of the patients, with ABC-DLBCL subtype accounting for 77.8%. The GA heterozygous genotype was usually related with stage IV, extranodal infiltration, and a reduced life expectancy. CONCLUSION: MYD88 L265P and to lesser extent TNFAIP3 mutations are major mutations in ABC- DLBCL and may be predictive factors for poor OS in ABC- DLBCL patients.

Prognostic significance of transforming growth factor ß receptor II in clinical stage III breast cancer patients - a pilot study.

BACKGROUND: Transforming growth factor-ß (TGFß) has a dual function in breast cancer, having a tumor suppressor activity in early carcinomas while enhancing tumor metastasis in advanced breast carcinoma. Consequently, the prognostic role of TGFß and its signaling cascade in breast cancer remain unclear. OBJECTIVE: To investigate the relationship between TßRII expression, clinic-pathological characteristics, and prognostic significance of TßRII expression in clinical stage III breast cancer. METHODS: Biopsy from the primary tumor was obtained from 30 newly diagnosed clinical stage III breast cancer patients before receiving any therapy. Expression of TßRII, ER, PR, Her2 and Ki-67 was assessed by immunohistochemistry. RESULTS: TßRII expression was positive in 66.7% of cases and was significantly associated with advanced nodal stage and distant metastases. After a median follow up of 42.3 months, TßRII was associated with poor disease-free survival and it was an independent factor for predicting the poor outcome for breast cancer patients, especially in node positive tumors, ER/PR positive and Her2-negative tumors. CONCLUSIONS: These findings suggest the usage of therapeutic drugs that target TGFß in advanced breast cancer patients may be effective. Nevertheless, blockage of the tumor promoting and sparing of the tumor suppressor effect of TGFß pathway should be taken into consideration. We suggest that these therapies might have more benefit in ER and PR positive tumors.

Evaluation of the Diagnostic and Prognostic Value of Syndecan-1 in Acute Leukemia Patients.

Syndecan-1 (also known as SDC-1 or CD138) is a transmembrane proteoglycan that is expressed in many hematological and solid tumors and affects the prognosis of those cancers. We conducted this study to investigate the prognostic role of syndecan-1 in acute leukemia. Forty cases of de novo acute leukemia patients, 24 with acute myeloid leukemia (AML) and 16 with acute lymphoblastic leukemia (ALL), presented at the Oncology Center of Mansoura University, Mansoura, Egypt, with a follow-up period of 26 months. Syndecan-1 was determined in serum and leukocytes by enzyme-linked immunosorbent assay (ELISA). The results from acute leukemia patients were compared with those of 15 healthy subjects. We observed that soluble syndecan-1 was higher in AML (median, 160.60 ng/ml) compared with ALL (median, 76.10 ng/ml) and healthy controls (median, 30.95 ng/ml). There was a significant correlation between syndecan-1 either in leukocytes or soluble form and response to treatment in patients with AML (p = 0.02 and p = 0.04, respectively), but these correlations were not statistically significant for ALL cases. Finally, there was a significant correlation between the soluble syndecan-1 level and overall survival in AML cases (p = 0.04), but the correlation was not significant for ALL cases. In conclusion, syndecan-1 is a useful biomarker for AML but not for ALL.

JAK2, CALR, and MPL Mutations in Egyptian Patients With Classic Philadelphia-negative Myeloproliferative Neoplasms.

BACKGROUND: Genetic mutations have been proven to be one of the major criteria in the diagnosis and distinction of different myeloproliferative neoplasm (MPN) subtypes. Therefore, the aim of this study was to determine the molecular profile of Egyptian patients with MPN subtypes and correlate with clinicopathological status. METHODS: A series of 200 patients with MPNs (92 polycythemia vera, 68 essential thrombocythemia, and 40 primary myelofibrosis) were included in this study. DNA from each sample was amplified using polymerase chain reaction to detect Janus kinase 2 (JAK2), calreticulin (CALR), and myeloproliferative leukemia virus oncogene (MPL) mutations. Sanger sequencing was used to determine the mutation types. RESULTS: Of the 200 samples, 44% had JAK2V617F and 10% were carrying CALR mutation with type 2 being the most frequent type in this study (55%). No MPL or JAK2 exon 12 mutations were detected. All clinical and hematological data had no differences with other populations except that our CALR-positive patients showed a decrease in the platelet count compared with JAK2V617F-positive patients. CONCLUSION: Our study on Egyptian patients shows a specific molecular profile of JAK2 mutation, and CALR mutation type 2 was higher than type 1.

MICROtransplant to refractory acute myeloid leukemia in Egyptian population.

PURPOSE OF REVIEW: The purpose of this review is to outline Egyptian experience of nonengraftment haploidentical cellular therapy [microtransplantation (MST)] for patients with refractory acute myeloid leukemia. RECENT FINDINGS: The use of granulocyte colony-stimulating factor primed halo-identical MST appears to be a biologically active therapy in patients with refractory acute myeloid leukemia (AML), especially in patients received less than four previous chemotherapy lines, fludarabine-free previous chemotherapy, response naïve and young age patients. SUMMARY: Refractory AML is still challenging. MST is promising, however the optimum conditioning, stem-cell dose, matching degree are factors should be optimized.

Prognostic value of some inflammatory markers in patients with lymphoma.

Background: Lymphoma is a group of blood cell tumors which develop from lymphocytes. The main forms of lymphoma are Hodgkin lymphoma (HL) and non-HL (NHL). Cytokines may contribute to lymphoma and they are related to risk NHL and HL. Aim: Assessment of the serum level of certain inflammatory markers as complementary indicators to confirm diagnosis of lymphoma patients that may be subjected to more invasive biopsy methods. Method: The serum levels of interleukin (IL)-1ß (IL-1ß), IL-6, IL-10, tumor necrosis factor-α (TNF-α), monocyte chemotactic protein-1 (MCP-1), granulocyte colony-stimulating factor (G-CSF), and eotaxin were assessed by Bio-Plex Pro assays in 81 lymphoma patients and 44 NHL and 37 HL patients before and after chemotherapy treatment as well as 20 healthy persons as a control group. Results: Lymphoma patients showed significantly raised marker levels before treatment and significantly reduced levels related to pre-treatment and controls of post-treatment for most of the markers. MCP-1 reported the highest diagnostic accuracy. G-CSF significantly raised pre-treatment and TNF-α. MCP-1 significantly increased in post treated HL compared with NHL. In order to distinguish HL from NHL, G-CSF reported the highest diagnostic accuracy. NHL patients reported complete remission (CR) and those who reported stable disease (SD) and progressive disease (PD) represented 25% and 38% respectively compared with 16% and 27% of HL patients, while partial remission (PR) of HL patients were 56% compared with 36% of NHL patients. Conclusion: Most of the markers were significantly increased in pre-treatment but significantly decreased post-treatment. However, it was not considerably enough to get better prognosis of the disease. Elevated serum levels of inflammatory markers correlate with disease severity and low benefit from treatment.

High Prevalence of Hepatitis C Virus among B-Cell Non Hodgkin Lymphoma Patients in Mansoura Region (Egypt), ANRS 12263 Study.

BACKGROUND: The prevalence of Hepatitis C virus in Egypt reaches 15%, which is considered the highest in the world. Genotype 4 represents 93 % of Egyptian HCV infections. Non-Hodgkin lymphoma (NHL) is the 5th most common cancer in Egypt. The association between HCV infection and occurrence of B-cell NHL is well known while data are scarce in Eastern countries. OBJECTIVES: We aimed to evaluate the prevalence of HCV infection among patients with B-cell NHL and the clinical characteristics of HCV associated B-cell NHL in the Delta region (Mansoura-Egypt). METHODS: Between March 2012 and March 2013, 110 adult patients newly diagnosed with B-cell NHL were enrolled in the current study. This study was carried out at Oncology Center, Mansoura University. Study subjects provided serum for HCV testing. RESULTS: The prevalence of HCV infection among these patients was 61% (67/110 patients). Among them, 80% (32/40 tested patients) presented with viremia. In contrast with the histological distribution previously described in Northern regions, the majority of HCV associated lymphomas were DLBCLs (72%) followed by SLL/CLL (13%), follicular lymphomas (7.5%) and marginal zone lymphomas (7.5%). CONCLUSIONS: B-cell lymphomas are highly associated with HCV infection in Egypt. Further developments are needed to give access to antiviral treatment for these patients.

A Metastatic Signet Ring Cell Carcinoma Presented as Acquired Thrombotic Thrombocytopenic Purpura: A Case Report.

Microangiopathic hemolytic anemia (MAHA) may occur as a paraneoplastic syndrome in some solid tumors, but MAHA accompanied by signet ring cell carcinoma (SRCC) of an unknown origin is very rare. We report a patient who presented with an acute onset of Coombs negative hemolytic anemia and frequent schistocytes in the peripheral blood smear which are typical for MAHA as initial presentation of metastatic SRCC. Our patients fulfilled the criteria of thrombotic thrombocytopenic purpura (TTP) and received the specific treatment for TTP without improvement.

Blastic Plasmacytoid Dendritic Cell Neoplasm: A Case Report and Clinicopathological Review.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is aggressive hematopoietic malignancy derived from the precursors of plasmacytoid dendritic cells. The present study reported a case of a 35-year-old BPDCN patient, who presented with scalp lesions without extracutaneous involvement of the lymph nodes (LNs), peripheral or bone marrow. Histopathological examination of scalp lesion revealed monomorphous diffuse infiltrate of small to medium-sized cells with irregular nuclear contours, pleomorphic nuclei, finely dispersed chromatin, inconspicuous nucleoli and scant amount of cytoplasm. Immunohistochemical staining showed diffuse positivity for CD45, CD4, CD 56, CD45 and negative for CD3, CD5, CD7, CD8, CD19, CD20, CD30, CD33, CD34, CD79a, CD99, CD117, TDT, and myeloperoxidase. Patient started treatment with acute lymphoblastic lymphoma protocol (Hyper-CVAD). Reevaluation after the second course showed marked regression of scalp lesion. The patient continued Hyper-CVAD protocol and planned for allogeneic stem cell transplant.

Inter-Observer Agreement of Whole-Body Computed Tomography in Staging and Response Assessment in Lymphoma: The Lugano Classification.

BACKGROUND: To assess inter-observer agreement of whole-body computed tomography (WBCT) in staging and response assessment in lymphoma according to the Lugano classification. MATERIAL/METHODS: Retrospective analysis was conducted of 115 consecutive patients with lymphomas (45 females, 70 males; mean age of 46 years). Patients underwent WBCT with a 64 multi-detector CT device for staging and response assessment after a complete course of chemotherapy. Image analysis was performed by 2 reviewers according to the Lugano classification for staging and response assessment. RESULTS: The overall inter-observer agreement of WBCT in staging of lymphoma was excellent (k=0.90, percent agreement=94.9%). There was an excellent inter-observer agreement for stage I (k=0.93, percent agreement=96.4%), stage II (k=0.90, percent agreement=94.8%), stage III (k=0.89, percent agreement=94.6%) and stage IV (k=0.88, percent agreement=94%). The overall inter-observer agreement in response assessment after a completer course of treatment was excellent (k=0.91, percent agreement=95.8%). There was an excellent inter-observer agreement in progressive disease (k=0.94, percent agreement=97.1%), stable disease (k=0.90, percent agreement=95%), partial response (k=0.96, percent agreement=98.1%) and complete response (k=0.87, Percent agreement=93.3%). CONCLUSIONS: We concluded that WBCT is a reliable and reproducible imaging modality for staging and treatment assessment in lymphoma according to the Lugano classification.

Computed Tomography Assessment of Hepatic Metastases of Breast Cancer with Revised Response Evaluation Criteria in Solid Tumors (RECIST) Criteria (Version 1.1): Inter-Observer Agreement.

BACKGROUND: To assess inter-observer agreement of revised RECIST criteria (version 1.1) for computed tomography assessment of hepatic metastases of breast cancer. MATERIAL/METHODS: A prospective study was conducted in 28 female patients with breast cancer and with at least one measurable metastatic lesion in the liver that was treated with 3 cycles of anthracycline-based chemotherapy. All patients underwent computed tomography of the abdomen with 64-row multi- detector CT at baseline and after 3 cycles of chemotherapy for response assessment. Image analysis was performed by 2 observers, based on the RECIST criteria (version 1.1). RESULTS: Computed tomography revealed partial response of hepatic metastases in 7 patients (25%) by one observer and in 10 patients (35.7%) by the other observer, with good inter-observer agreement (k=0.75, percent agreement of 89.29%). Stable disease was detected in 19 patients (67.8%) by one observer and in 16 patients (57.1%) by the other observer, with good agreement (k=0.774, percent agreement of 89.29%). Progressive disease was detected in 2 patients (7.2%) by both observers, with perfect agreement (k=1, percent agreement of 100%). The overall inter-observer agreement in the CT-based response assessment of hepatic metastasis between the two observers was good (k=0.793, percent agreement of 89.29%). CONCLUSIONS: We concluded that computed tomography is a reliable and reproducible imaging modality for response assessment of hepatic metastases of breast cancer according to the RECIST criteria (version 1.1).

Phase II study of low-dose fixed-rate infusion of gemcitabine combined with cisplatin and dexamethasone in resistant non-Hodgkin lymphoma and correlation with Bcl-2 and MDR expression.

This study aims to assess the efficacy of low-dose fixed-rate infusion of gemcitabine, cisplatin and dexamethasone in resistant non-Hodgkin lymphoma (NHL) patients in addition to evaluating the prognostic value of B cell lymphoma 2 (Bcl-2) and multidrug resistant (MDR) expression in this cohort of patients. Patients with relapsed/refractory NHL following at least two chemotherapy regimens were enrolled. They received gemcitabine 800 mg/m2 in fixed infusion rate of 10 mg/m2/min, cisplatin 35 mg/m2 in days 1, 15 and dexamethasone 20 mg days 1-4, 15-18 every 28 day. Response to treatment, time to disease progression (TTP) and 1-year progression-free survival (PFS) were assessed together with their association with Bcl-2, MDR expression and other prognostic variables. Overall response to treatment was 32% (14% complete response). Median TTP and 1-year PFS were 2 months and 31.3%, respectively. Predictors of response to treatment were early stage [odd ratio (OR)=4.6, 95% CI 1.3-16.4], low/low intermediate International Prognostic Index (IPI) (OR=6.2, 95% CI 1.2-31.7), negative/low Bcl-2 expression (OR=6.2, 95% CI 1.2-31.7) and negative/low MDR expression (OR=18, 95% CI 1.4-28.9). However, IPI status lost its value in multivariate analysis. TTP and 1-year PFS were significantly associated with Bcl-2 expression (p=0.04), tumor status before enrollment (relapse vs. refractory, p<0.0001) and tumor stage (p<0.000). In multivariate analysis, clinical stage was the only predictor of TTP and 1-year PFS. Fixed-rate gemcitabine infusion with cisplatin and dexamethasone had reasonable activity in resistant NHL. Clinical stage, Bcl-2 and MDR expressions were predictors of response to treatment, while only clinical stage was associated with TTP and 1-year PFS.

Prognostic implications of NPM1 mutations and FLT3 internal tandem duplications in Egyptian patients with cytogenetically normal acute myeloid leukemia.

Nucleophosmin (NPM1) and fms-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD) gene mutations represent the most frequent molecular aberrations in patients with cytogenetically normal-acute myeloid leukemia (CN-AML). We analyzed the prognostic impact of these mutations and their interactions in adults with CN-AML. NPM1 mutation (NPM1mut) and FLT3-ITD mutation (FLT3-ITD+) were analyzed by polymerase chain reaction and GeneScan assays of bone marrow samples obtained from newly diagnosed 104 CN-AML patients. FLT3-ITD+ and NPM1mut were detected in 36 (34.6%) and 30 (28.8%) out of 104 subjects, respectively, 16 cases (15.4%) had double NPM1mut/FLT3-ITD+. The incidence of FLT3-ITD+ was significantly higher in the NPM1mut group than in the NPM1 wild (NPM1wt) group (P = 0.018). Statistical analysis revealed that isolated NPM1mut group had a better clinical outcomes in terms of higher complete response (CR) rate (P = 0.01) and a trend towards favorable overall survival (OS) and disease-free survival (DFS) (P = 0.28, 0.40, respectively). In contrast, the isolated FLT3-ITD+ group had an unfavorable outcome in terms of lower CR rate (P = 0.12), shorter OS, and DFS (P < 0.0001 for both). The NPM1mut/FLT3-ITD-group had the best OS and DFS, while the NPM1wt/FLT3-ITD+ group had the worst OS and DFS than other groups (NPM1mut/FLT3-ITD+ or NPM1wt/FLT3-ITD-) (P < 0.0001 for both). Multivariate Cox regression analysis showed that age and FLT3/ITD+ were independent poor prognostic factors for OS (P = 0.006, <0.0001, respectively), while FLT3/ITD+ was independent predictor for DFS (P = 0.04). However, NPM1mut did not have a significant impact on OS and DFS. In conclusion, adult patients with CN-AML carrying isolated NPM1mut and isolated FLT3-ITD+ exhibit different clinical outcomes than those with NPM1mut/FLT3-ITD+ or NPM1wt/FLT3-ITD-. Patients with NPM1mut/FLT3-ITD- had the best prognosis in terms of higher CR, OS, and DFS, while those with NPM1mut/FLT3-ITD+ had the worst CR rate, and NPM1wt/FLT3-ITD+ had the lowest OS and DFS.

Low-dose versus standard-dose gemcitabine infusion and cisplatin for patients with advanced bladder cancer: a randomized phase II trial-an update.

Prolonged infusion of low-dose gemcitabine and cisplatin (GC) proved to be an effective treatment for patients with advanced bladder cancer. One hundred and twenty untreated patients with stage III/IV bladder cancer were randomized to receive either gemcitabine (250 mg/m(2)) 6-h infusion on days 1 and 8, and cisplatin (70 mg/m(2)) on day 2 every 21-day cycle (arm 1) or gemcitabine (1,250 mg/m(2)) 30-min infusion on days 1 and 8, with the same dose of cisplatin (arm 2). The 92 males and 28 females included in the study had a median age of 62 years (range 40-85 years). Among the 120 patient, complete response was achieved in 11.7 % (7/60 patients of arm 1) and 5 % (3/60 patients of arm 2). Eighteen patients in arm 1 (30 %) and 17 patients (28.3 %) in arm 2 had partial response on therapy. Thus, the overall response rate of patients in arm 1 and arm 2 was 41.7 % (25/60 patients) and 33.3 % (20/60 patients), respectively (p = 0.37). No significant difference in median time to disease progression (26 vs. 24 months, p = 0.4), median survival (12 vs. 16 months, p = 0.8), and 1-year survival (49.9 vs. 54.7 %, p = 0.8) was detected between arms 1 and 2, respectively. Main toxicities were similar in both arms with no statistically significant differences. Low-dose, prolonged infusion gemcitabine in combination with cisplatin is not inferior to the standard GC regimen with favorable toxicity profile and less financial costs.

High-dose chemotherapy plus non-cryopreserved autologous peripheral blood stem cell transplantation rescue for patients with refractory or relapsed Hodgkin disease.

A simplified schedule of high-dose chemotherapy consisting of cyclophosphamide (60 mg.kg(-1).d(-1) for 2 days), etoposide (15 mg.kg(-1).d(-1) for 2 days), and carboplatin (400 mg/m(2) per day for 2 days) plus autologous non-cryopreserved peripheral blood stem cells (PBSCs) was used for treatment of patients with relapsed (n = 25) and refractory (n = 3) Hodgkin disease. The use of such PBSCs mobilized by granulocyte colony-stimulating factor after high-dose myeloablative therapy resulted in a rapid, complete, and sustained hematopoietic recovery. The median time to achieve an absolute neutrophil count >0.5 x 10(9)/L was 13 days (range, 7-18 days). The median time to a self-sustained platelet count >20 x 10(9)/L was 15 days (range, 7-20 days). Twelve of the 28 patients (43%) were alive and without disease at a median follow-up of 16 months (range, 9-86 months) for all surviving patients. The estimated 2-year overall survival and disease-free survival for all patients were 45% and 42%, respectively. Thirteen patients died of relapse or progressive disease, 2 died of infection, and 1 was still surviving in relapse by the time of the analysis. The median time to relapse was 10 months (range, 3-28 months) from PBSC infusion. High-dose chemotherapy with short-duration chemotherapy and non-cryopreserved bone marrow is an effective and safe treatment modality for patients with relapsed or resistant Hodgkin lymphoma.

A study for evaluation of different diagnostic approaches in acute leukemia in Egypt.

Cytomorphology, cytochemistry, immunophenotyping, in addition to cytogenetic and molecular analyses have specific roles in the diagnosis and management of acute leukemias. This work was designed as a comparative study of different available methods for diagnosis of acute leukemia. The study comprised 47 cases with acute leukemia (21 cases with ALL and 26 cases with AML). Peripheral blood and bone marrow samples were subjected to through morphological examination of Leishman-stained smears, cytochemical analysis, immunophenotyping, conventional cytogenetic banding analysis, fluorescence in situ hybridization (FISH) for selected cases, and RT-PCR for detection of BCR-ABL rearrangement. The results of the study revealed that careful examination of Romanowsky-stained peripheral blood and BM films is fundamental in the diagnosis of acute leukemias, and when considered together with clinical and hematological features, indicates which of the more specialized techniques are most likely to be useful. The major role of cytochemistry was in the diagnosis of AML, while the major role of immunophenotyping was in the diagnosis of acute leukemia, which is not obviously myeloid. Apart from identification of chromosomal abnormalities unique to specific subtypes of leukemia, cytogenetic analysis had a salient impact on anticipating the prognosis and treatment outcome in acute leukemias. We could conclude that the techniques used in this study are considered complementary rather than alternatives and that stepwise employment of strategies is more cost effective than doing all the tests simultaneously.