Priapismo y leucemia mieloide crónica en adolescente. Debut poco frecuente. Reporte de caso / Priapism and chronic myeloid leukemia in an adolescent. Rare debut presentation. A case report

El priapismo es una erección dolorosa y persistente acompañada o no de estímulo sexual. Una causa poco frecuente de esta anormalidad es la leucemia mieloide crónica. Se han reportado pocos casos de priapismo como manifestación inicial de una leucemia de este tipo en pacientes adolescentes. A continuación, se informa el caso de un paciente de 16 años de edad que presentó priapismo como manifestación inicial de una leucemia mieloide crónica. Durante su evolución, no se realizó aspiración de los cuerpos cavernosos. Se inició tratamiento hematológico específico y, ante la persistencia del priapismo, fue necesario realizar un shunt de cuerpos cavernosos en dos ocasiones, tratamiento a pesar del cual existen altas probabilidades de secuelas.

Priapism is a painful and persistent erection, with or without sexual stimulation. A rare cause of such abnormality is chronic myeloid leukemia. Few cases of priapism as an initial manifestation of this type of leukemia have been reported in adolescent patients. Here we describe the case of a 16-year-old patient who presented with priapism as the initial manifestation of chronic myeloid leukemia. No cavernosal aspiration was performed. A specific hematological treatment was started and, given the persistence of priapism, the patient required 2 corpora cavernosa shunt procedures; despite this treatment, there is a high probability of sequelae.

Recommendations for the management of cardiovascular risk in patients with chronic myeloid leukemia on tyrosine kinase inhibitors: risk assessment, stratification, treatment and monitoring

ABSTRACT This manuscript summarizes the results of the consensus meeting composed of hematologists and cardiologists to establish recommendations for the prevention and follow-up of cardiovascular (CV) risk in patients with chronic myeloid leukemia (CML) treated with BCR-ABL tyrosine kinase inhibitors (TKIs) from the point of view of clinical practice and from the perspective of hematology consultation.In the first medical appointment, the CV risk factors should be identified to perform the baseline risk stratification, based on the Brazilian Guideline of Dyslipidemia and Atherosclerosis Prevention Update (risk levels: very high, high, intermediate and low).Once stratified, the treatment of the CV risk factors should be administered. If the patient presents risk factors, such as hypertension, diabetes, renal disease, smoking and hypercholesterolemia, the evaluation and initial treatment may be done by the hematologist, being an option the request for evaluation by a specialist. If the patient has a history of previous CV disease, we recommend referral to a specialist. As the CV risk score is dynamic and the control of risk factors can reduce the patient risk, this expert consensus recommends that the re-evaluation of the CV risk after the baseline should be performed at 3 months, 6 months and 12 months. After this period, it should be done annually and, for specific patients, at the clinician's discretion.The evaluation of the baseline CV risk and the safe administration of a TKI allow the patient to benefit from the maximum treatment, avoiding unwanted effects.

Inclusion of molecular monitoring (BCR-ABL1) in the treatment of chronic myeloid leukemia in the Brazilian Public Health System (SUS): an urgent need for treatment management

ABSTRACT Introduction: Chronic Myeloid Leukemia (CML) is a myeloproliferative disease that affects mainly adults between 50 and 55 years. In Brazil, information from the Sistema Único de Saúde (SUS) Outpatient Information System indicates that 12,531 patients had the Autorização de Procedimento Ambulatorial (APAC) approved for the CML treatment in 2017. Disease monitoring through molecular response evaluation is critical to the care of CML patients. The quantitative PCR test (real-time polymerase chain reaction) provides adequate evaluation parameters that allow the health professional to intervene at the right moments in order to reduce the chance of progression of the disease, providing the best outcome to the patient, including the possibility of treatment discontinuation for eligible patients. Although the test is included in the Clinical Protocol and Therapeutic Guidelines (PCDT) of CML, it is not possible to monitor the molecular response within SUS since there is no reimbursement for this test. Objective: Obtain expert recommendations on the importance, financing, and reimbursement of molecular monitoring in SUS. Methods: Six CML experts with different perspectives participated in the panel. The discussion was based in the main publications about the quantitative PCR test in CML monitoring. Results: Experts' recommendations: Molecular monitoring should be part of the integral treatment of patients with CML to reduce the chances of disease progression and costs to the health system; The government should put into practice what is provided in the PCDT of Chronic Myeloid Leukemia in Brazil: performing the monitoring of the molecular response via quantitative PCR; The government should create a code with adequate nomenclature and reimbursement value in SIGTAP, so that the test is carried out and covered by the public health network, as it is contained in the PCDT of the disease and the existing APAC does not cover the operational costs for its performance; Patients with chronic phase CML should perform a quantitative PCR every 3 months and, after reaching the MMR, should perform the examination every 6 months, as recommended by international guidelines; Patients should be monitored in reference laboratories that are standardized according to the international scale; The laboratories that are within the reference public centers could absorb all the test demand in Brazil, and other centers could be qualified through an ABHH accreditation; Adequate molecular monitoring may allow some patients to stop taking drugs and selffinancing the molecular test for all SUS patients Conclusion: A solution for the molecular test (BCR-ABL1) funding is urgent to ensure the monitoring of CML patients in SUS. The savings that might be generated with patients that stop taking the medication when adequately monitored may finance the test.

Guidelines for therapy of patients with chronic myeloproliferative neoplasms during the novel coronavirus SARS-CoV2 pandemic

ABSTRACT The novel coronavirus has swept across the world in 2020 and ushered a new era. In the current scenario, it is not clear how patients with myeloproliferative neoplasms (including chronic myelogenous leukemia) should be managed, considering the risk of therapy, the need for social distancing and the risk of untimely therapy discontinuation of delay. This guideline aims to give providers a sense of direction in order to better take care of patients and prioritize care.

Aspectos clínicos, laboratoriais e tratamento da leucemia mieloide crônica em cão relato de caso / Clinical aspects, hematological changes and treatments of chronic myeloid leukemia in dog: case report

O objetivo deste relato é apresentar o caso clínico de uma cadela, sem raça definida, com cinco anos de idade, diagnosticada com leucemia mieloide crônica (LMC). As leucemias são neoplasias malignas que se originam de células precursoras da medula óssea e as consequências podem ser trombocitopenia, anemia, leucocitose persistente e presença de células neoplásicas no sangue. O tratamento de escolha envolve o uso de inibidores de tirosina quinase, porém este não pode ser usado neste caso. Dessa forma a cadela recebeu diferentes protocolos quimioterápicos que incluíram inicialmente hidroxiureia, citarabina, doxorrubicina e prednisona. Devido a remissão parcial dos sinais clínicos e a resposta terapêutica pouco duradoura a essas medicações o protocolo foi alterado para quimioterapia metronômica com clorambucil. O uso desses quimioterápicos não foram eficazes em reduzir a leucocitose e controlar a anemia e trombocitopenia da paciente, devido a ocorrência do surgimento de células imaturas no sangue e resistência aos quimioterápicos. Na ausência da crise e da possibilidade do uso dos inibidores de tirosina quinase, a hidroxiureia permanece sendo o quimioterápico de eleição. O animal apresentou sobrevida de 210 dias, devido a leucocitose e anemia severas pouco responsivas ao protocolo terapêutico utilizado e o surgimento no hemograma de precursores neutrofilicos que ocorreu 46 dias

The aim of this report is to present the clinical case of a five-year-old mixed breed female dog diagnosed with chronic myeloid leukemia (CML). Leukemias are malignant neoplasms that originate from bone marrow precursor cells and the consequences can be thrombocytopenia, anemia, persistent leukocytosis and the presence of neoplastic cells in the blood. The treatment of choice involves the use of tyrosine kinase inhibitors, but it cannot be used in this case. Thus, the dog received different chemotherapy protocols that initially included hydroxyurea, cytarabine, doxorubicin and prednisone. Due to the partial remission of clinical signs and the short-term therapeutic response to these medications, the protocol was changed to metronomic chemotherapy with chlorambucil. The use of these chemotherapeutic agents was not effective in reducing leukocytosis and controlling the patient's anemia and thrombocytopenia, due to the occurrence of immature cells in the blood and resistance to chemotherapeutic agents. In the absence of the crisis and the possibility of using tyrosine kinase inhibitors, hydroxyurea remains the chemotherapy of choice. The animal had a 210-day survival, due to severe leukocytosis and anemia, which were not responsive to the therapeutic protocol used and the appearance in the blood count of neutrophilic precursors that occurred 46 days after the beginning of hydroxyurea treatment.

Síndromes MonoMAC e Emberger em paciente com mutação no gene GATA2 / MonoMAC and Emberger syndromes in a patient with GATA2 mutation

As mutações que ocorrem no gene GATA2 podem ocasionar um amplo espectro de doenças genéticas. Os pacientes podem ter anormalidades na hematopoiese, na linfangiogenesis e na resposta imunológica. Os fenótipos incluem algumas síndromes caracterizadas por monocitopenia e infecção por micobactéria (síndrome MonoMac), síndrome mielodisplásica familiar, leucemia mieloide crônica ou aguda, síndrome de Emberger (linfedema primário), e mais raramente neutropenia, anemia aplástica e deficiência isolada de células NK. A idade da apresentação clínica pode variar desde a infância até a idade adulta. A deficiência autossômica dominante de GATA2 pode permanecer clinicamente silenciosa por décadas, ou mesmo durante toda a vida. Descrevemos o caso de uma jovem brasileira que apresentou a maioria dos problemas ligados à mutação no gene GATA2, observando-se as duas síndromes: MonoMAC e Emberger.

GATA2 mutations may cause a wide spectrum of genetic disorders. Patients may have several abnormalities in hematopoiesis, lymphangiogenesis and immune response. The phenotypes include monocytopenia and mycobacterial infection (MonoMAC) syndrome, familial myelodysplastic syndrome (MDS), chronic or acute myeloid leukemia (CML or AML), Emberger syndrome and, more rarely, neutropenia, aplastic anemia and isolated NKcell deficiency. Age at clinical onset ranges from early childhood to late adulthood. Autosomal dominant GATA2 deficiency may remain clinically silent for decades or even for life. We report a case of a Brazilian young patient who had most of the problems related to GATA2 mutation as well as MonoMAC and Emberger syndromes.

Complicaciones infecciosas en pacientes con leucemia mieloide aguda / Infectious complications in acute myeloid leukemia patients

La leucemia aguda ha sido reconocida como una enfermedad compleja y rápidamente fatal desde su primera descripción hace 150 años. Librada a su historia natural, la leucemia mieloide aguda lleva a la muerte en pocos meses. Las infecciones son la principal causa de muerte, siendo la bacteriemia y la neumonía las más frecuentes.Los avances ocurridos en los últimos 50 años, como el advenimiento de quimioterapias efectivas, la mejor comprensión de la patogénesis de las complicaciones infecciosas en el paciente neutropénico, la disponibilidad de agentes anti infecciosos de amplio espectro y la mejoría en los cuidados de soporte contribuyeron a mejorar esta situación. En relación a otras enfermedades oncohematológicas, la leucemia mieloide aguda registra la mayor incidencia de eventos febriles, siendo el período de mayor riesgo el de la inducción a la remisión.La fiebre de origen desconocido, la multirresistencia bacteriana y las infecciones fúngicas invasivas constituyen un desafío para el equipo de trabajo.El uso de profilaxis antibacteriana y antifúngica no reemplaza a las medidas de prevención de carácter institucional

Acute leukemias have been recognized as complex and radiply fatal diseases since its first description 150 years ago. Delivered to its natural history, acute myeloid leukemia leads to death in a few months. Infections are the main cause of death, being bacteremia and pneumonia the most frequent. Advances in the last 50 years, such as the advent of effective chemotherapy, a best understanding of the pathogenesis of infectious complications in the neutropenic patient, the availability of broad-spectrum anti-infective agents and better supportive care helped improve this situation. Among other oncological diseases, acute myeloid leukemia has the highest incidence of febrile events, being induction to remission the period of greatest risk. Fever of unknown origin, bacterial multidrug resistance and invasive fungal infections are a challenge for the medical team. The use of antibacterial and antifungal prophylaxis does not replace institutional preventive measures

Caracterização do perfil de resistência da linhagem de leucemia mieloide crônica K-IM, resistente ao imatinibe / [Characterization of the resistance profile of the K-IM chronic myeloid leukemia strain, resistant to imatinib]

O advento da terapia alvo-específica com o imatinibe (IM) transformou o panorama da resposta ao tratamento, progressão e sobrevida dos pacientes de leucemia mieloide crônica (LMC). Apesar do sucesso e do desenvolvimento de inibidores de tirosina-quinase (TKIs) mais potentes, persiste a problemática da resistência ao tratamento. A relevância do estudo dos mecanismos de resistência aos TKIs atualmente reside na frequência das falhas terapêuticas não relacionadas à mutação em BCR-ABL, o principal alvo da terapia. Tendo por finalidade estudar os diversos mecanismos que cooperam para a aquisição de resistência, foi desenvolvida em nosso laboratório uma linhagem de LMC resistente ao IM. A linhagem resistente, denominada K-IM, foi selecionada pelo cultivo dalinhagem K562 em concentrações crescentes de IM, alcançando 1,0 μM do fármaco. Sem apresentar mutação no domínio quinase de BCR-ABL, ela se constitui um bom modelo para oestudo dos outros mecanismos de resistência ao IM. A linhagem apresentou aumento nos níveis deRNA mensageiro (RNAm) de BCR-ABL que não se traduziu em aumento da atividade de Bcr-Abl ou no impedimento da sua inibição pelo tratamento com IM. A linhagem K-IM se mostrou significativamente mais resistente do que a parental. Embora o tratamento com 1,0 μM de IM tenha promovido um acúmulo de células nas fases G0/G1 do ciclo celular, não foi acompanhado deindução à morte celular nem impediu o aumento do número de células em cultura. Foram avaliadas as proteínas transportadoras de efluxo por serem determinantes para a resistência à múltiplas drogas, porém a sua atividade não foi observada na linhagem K-IM...

The advent of target-specific therapy with imatinib (IM) has transformed the scenario of response to treatment, progression and survival of patients with chronic myeloid leukemia (CML). Despite the success and development of more potent tyrosine kinase inhibitors (TKIs), the problem of resistance to treatment remains. The relevance of the study of mechanisms of resistance to TKIs currently lies in the frequency of therapeutic failures unrelated to mutation in BCR-ABL, the main target of therapy. Aiming to study the various mechanisms that cooperate for the acquisition of resistance, a CML cell line resistant to IM was developed in our laboratory. The resistant cell line, called K-IM, was selected by culturing the K562 cell line at increasing concentrations of IM, reaching 1.0 μM of the drug. Without presenting mutation in the BCRABL kinase domain, it constitutes a good model for the study of the other mechanisms ofresistance to IM. The cell line showed an increase in BCR-ABL messenger RNA (mRNA) levels which did not result in increased Bcr-Abl activity or in the impairment of its inhibition by IMtreatment. The K-IM cell line was significantly more resistant to IM than the parental cell line. Although treatment with 1.0 μM of IM promoted cell accumulation in the G0/G1 phases of the cell cycle, it was not accompanied by induction of cell death nor prevented the increase in the number of cells in culture. The efflux transporter proteins were evaluated because they aredeterminant for multidrug resistance, but their activity was not observed in the K-IM cell line. Since the antiapoptotic proteins XIAP and survivin are studied as chemoresistance factors, their mRNA and protein levels were evaluated. K-IM showed similar levels to K562 of XIAP mRNA,but showed higher survivin levels in both instances, suggesting that this protein plays a role in its resistance...

Cutaneous myeloid sarcoma associated with chronic myeloid leukemia

Abstract: Myeloid sarcoma is an extramedullary tumor of malignant myeloid cells often associated with acute myeloid leukemia, chronic myeloproliferative disorders and myelodysplastic syndromes. The skin is one of the most commonly affected sites. We report a rare case of cutaneous myeloid sarcoma associated with chronic myeloid leukemia.

Investigação do mecanismo de ação do novo composto pterocarpanquinona LQB-118 em células de leucemia mieloide crônica / [Investigation of the mechanism of action of the new pterocarpanquinone compound LQB-118 in chronic myeloid leukemia cells]

A Leucemia Mieloide Crônica (LMC) é uma doença mieloproliferativa caracterizada pela presença da oncoproteína BCR-ABL. O tratamento da LMC é baseado no uso de inibidores de tirosina quinase (do inglês, TKI), principalmente o imatinibe. Apesar dosucesso do imatinibe na clínica, cerca de 30% dos pacientes com LMC necessitam de terapia alternativa. Neste contexto, o desenvolvimento de compostos capazes de sobrepujar a resistência aos TKIs é fundamental. A pterocarpanquinona-LQB-118 éum novo composto com efeito antitumoral cujo mecanismo de ação vem sendo investigado. Neste trabalho, demonstramos que os tratamentos com LQB-118 e imatinibe alteraram a expressão de diversos genes em duas linhagens de LMC (K562,sensível e K562-Lucena, resistente), com destaque para o gene TOB2. Alémdisso, o composto LQB-118 modulou a localização subcelular de NFB, inibiuparcialmente a atividade do proteassoma e alterou a expressão dos microRNAs -9 e -21. Ainda, o composto LQB-118 reduziu a expressão proteica de IGF-1R, AKT emTOR, inibindo também a expressão dos mir-29b e -29c. O tratamento das linhagenscom a combinação de imatinibe com LQB-118 potencializou a morte celular. Nossos dados demonstram que o composto LQB-118 modula a localização subcelular de NFκB, a expressão de membros da importante via IGF-1R/AKT/mTOR e a expressãode miR-9, -21 e –29a/b/c. Além disso, sugerimos que TOB2 pode ser importante na resposta ao tratamento do imatinibe associado ao LQB-118 e que possa estar agindo na modulação da expressão proteica observada e que a combinação de imatinibe comLQB-118 se mostrou eficiente em células de LMC

Chronic myeloid leukemia (CML), a myeloproliferative disorder characterized by the BCR-ABL oncoprotein, presents its treatment based on tyrosine kinase inhibitors(TKIs), mainly imatinib. However, despite its clinical success, almost 30% of all CML patients demand alternative therapy. In this context, the development of drugs capableof overcoming TKIs resistance is imperative. The pterocarpanquinone-LQB-118 is a novel compound with anti-tumour effect in in two CML cell lines (K562, sensitive and K562-Lucena resistant) whose mechanism of action is being elucidated. Here, we demonstrate by microarray analysis of CML cells treated with imatinib and LQB-118 several differentially expressed genes highlighting TOB2. LQB-118 modulates NFκB subcellular localization, apparently independently of the AKT and MAPK pathways,partially inhibits proteasome activity, and alters the expression of microRNAs -9 and -21. Also, IGF-1R, AKT and mTOR protein levels are decreased after LQB-118. LQB-118 alters the expression of all members of miR-29 family. Combined treatment of CML cell lines with imatinib and LQB-118 increased cell death. Taken together, we demonstrated that LQB-118 modulates NFκB subcellular localization, IGF-1R/AKT/mTOR pathway protein expressions and miR-9, -21 and –29a/b/c expressions. Furthermore, we suggest that TOB2 may be important to imatinib and LQB-118, acting as a mRNA regulator, and that combination of imatinib and LQB-118 is efficient in CML cells

Enfermedad periodontal inflamatoria asociada a la leucemia mieloide crónica. Presentación de un caso / Inflammatory periodontal illness associated to chronic myeloid leukemia. Presentation of a case

Fundamento: La enfermedad periodontal inflamatoria aguda y crónica puede estar asociada a la leucemia mieloide crónica que es una enfermedad grave Objetivo: Ilustrar como la enfermedad periodontal inflamatoria, puede estar asociada una enfermedad hematológica en este caso la leucemia mieloide crónica. Presentación del caso: Se presenta un caso de un paciente masculino de 43 años de edad con leucemia mieloide crónica que presenta absceso periodontal agudo y enfermedad periodontal crónica, se trató con los protocolos establecidos y tuvo una evolución favorable, con un pronóstico reservado. Conclusiones: La enfermedad periodontal inflamatoria aguda y crónica puede estar asociada a la leucemia mieloide crónica.

Background: The acute and chronic inflammatory periodontal illness can be associated to the chronic myeloid leukemia that is a serious illness Objective: To illustrate how the inflammatory periodontal illness, can be associated to a hematology illness in this case the chronic myeloid leukemia. Presentation of the case: A case of a 43 years-old masculine patient is presented with chronic myeloid leukemia that presents acute periodontal abscess and chronic periodontal illness, it was treated with the established protocols and he had a favorable evolution, with a reserved prognosis. Conclusions: The acute and chronic inflammatory periodontal illness can be associated to the chronic myeloid leukemia.

Patients' perceptions about diagnosis and treatment of chronic myeloid leukemia: a cross-sectional study among Brazilian patients / Percepções dos pacientes sobre diagnóstico e tratamento da leucemia mieloide crônica: estudo transversal entre pacientes brasileiros

CONTEXT AND OBJECTIVES: Chronic myeloid leukemia (CML) requires strict daily compliance with oral medication and regular blood and bone marrow control tests. The objective was to evaluate CML patients' perceptions about the disease, their access to information regarding the diagnosis, monitoring and treatment, adverse effects and associations of these variables with patients' demographics, region and healthcare access. DESIGN AND SETTING: Prospective cross-sectional study among CML patients registered with the Brazilian Lymphoma and Leukemia Association (ABRALE). METHODS: CML patients receiving treatment through the public healthcare system were interviewed by telephone. RESULTS: Among 1,102 patients interviewed, the symptoms most frequently leading them to seek medical care were weakness or fatigue. One third were diagnosed by means of routine tests. The time that elapsed between first symptoms and seeking medical care was 42.28 ± 154.21 days. Most patients had been tested at least once for Philadelphia chromosome, but 43.2% did not know the results. 64.8% had had polymerase chain reaction testing for the BCR/ABL gene every three months. 47% believed that CML could be controlled, but 33.1% believed that there was no treatment. About 24% reported occasionally stopping their medication. Imatinib was associated with nausea, cramps and muscle pain. Self-reported treatment adherence was significantly associated with normalized blood count, and positively associated with imatinib. CONCLUSIONS: There is a lack of information or understanding about disease monitoring tools among Brazilian CML patients; they are diagnosed quickly and have good access to treatment. Correct comprehension of CML control tools is impaired in Brazilian patients.

CONTEXTO E OBJETIVOS: Leucemia mieloide crônica (CML) exige estrita adesão à medicação oral e ao monitoramento do sangue e da medula. O objetivo foi avaliar percepções de pacientes com leucemia mieloide crônica (LMC) sobre a doença, seu acesso à informação sobre diagnóstico, monitoramento e tratamento, efeitos adversos e a associação destes com dados demográficos, geográficos e de acesso a tratamento. DESENHO E LOCAL: Estudo prospectivo transversal realizado com pacientes de LMC cadastrados na Associação Brasileira de Leucemia e Linfoma (Abrale). MÉTODOS: Pacientes com LMC recebendo tratamento do sistema público de saúde foram entrevistados por telefone. RESULTADOS: Entre os 1.102 pacientes entrevistados, os sintomas mais frequentemente levando à busca de consulta foram fraqueza e fadiga. Um terço foi diagnosticado por exames de rotina. O tempo entre sintoma inicial e procura por ajuda foi de 42,28 ± 154,21 dias. A maioria foi testada pelo menos uma vez para o cromossomo Filadélfia, mas 43,2% não sabiam os resultados. 64,8% fizeram exame de reação em cadeia da polimerase para o gene BCR/ABL a cada três meses. 47% acreditavam que LMC pode ser controlada, mas 33,1% acham que não há tratamento. Cerca de 24% disseram que ocasionalmente interrompem o tratamento. Imatinibe associou-se com náusea, câimbra e dor muscular. Aderência auto-reportada associou-se significativamente com hemograma normal e positivamente com uso de imatinibe. CONCLUSÕES: Falta informação ou compreensão sobre monitoramento entre pacientes com LMC; eles recebem diagnóstico rapidamente e têm bom acesso ao tratamento. A correta compreensão das ferramentas de controle em LMC está prejudicada entre eles.

Accelerated phase chronic myeloid leukemia: evaluation of clinical criteria as predictors of survival, major cytogenetic response and progression to blast phase

BACKGROUND: Published criteria defining the accelerated phase in chronic myeloid leukemia are heterogeneous and little is known about predictors of poor outcome.METHODS: This is a retrospective study of 139 subjects in the accelerated phase of chronic myeloid leukemia treated with imatinib at a single center in Brazil. The objective was to identify risk factors for survival, major cytogenetic response and progression to blast phase in this population. The factors analyzed were: blasts 10-29%, basophils ≥ 20%, platelets > 1 × 106/µL or <1 × 105/µL and white blood cells > 1 × 105/µL in the peripheral blood, as well as clonal evolution, splenomegaly, hemoglobin < 10 g/dL, time between diagnosis of chronic myeloid leukemia and imatinib treatment, and hematologic toxicity.RESULTS: Risk factors for poor survival in multivariate analysis were Grades 3-4 hematologic toxicity (p-value = 0.001), blasts 10-29% (p-value = 0.023), and hemoglobin < 10 g/dL (p-value = 0.04). Risk factors for not achieving major cytogenetic response were blasts 10-29% (p-value = 0.007), hemoglobin < 10 g/dL (p-value = 0.001), and previous use of interferon (p-value = 0.032). Risk factors for progression to the blast phase were hemoglobin < 10 g/dL (p-value = 0.005), basophils ≥ 20% (p-value = 0.023), and time from diagnosis of chronic myeloid leukemia to imatinib treatment > 12 months (p-value = 0.030).CONCLUSION: These data indicate that patients with the above risk factors have a worse prognosis. This information can guide the therapy to be used.

Clonagem molecular do oncogene EZH2 de leucemiamieloide crônica e perspectivas terapêuticas / Molecular cloning of EZH2 oncogene in chronic myeloid leukemia andtherapeutic prospects

A Leucemia Mieloide Crônica (LMC) é uma neoplasia mieloproliferativa originada, em 95% dos casos, por uma anormalidadecitogenética que se caracteriza pela translocação recíproca entre os cromossomos 9 e 22 t(9; 22) (q34; q11), resultandono cromossomo Philadelphia (Ph). Considerando que a cura da LMC só é possível com um transplante de medulaóssea bem-sucedido e que existem casos de resistência ao inibidor de tirosina quinase Mesilato de Imatinibe, fármacode primeira escolha para o tratamento, é importante que se conheça detalhadamente os genes e proteínas alterados naLMC, favorecendo a efetividade de estratégias terapêuticas, a otimização do diagnóstico e a detecção de doença residualmínima. Dentre as novas abordagens terapêuticas para a LMC está a terapia gênica, que dependendo do gene alvo, podetambém ser eficiente para o tratamento de outras neoplasias. Dentro deste contexto, os objetivos do trabalho foram:realizar a clonagem molecular de um fragmento de DNA do gene EZH2, alvo promissor da terapia gênica, que provocaalteração epigenética na LMC e em diversas neoplasias; bem como contribuir para outros trabalhos de manipulação gênicainterespécies, os quais tem grande contribuição para a área da saúde. Para isso, o gene EZH2 foi isolado a partir do DNAgenômico de sangue periférico de pacientes com LMC e posteriormente clonado em sistemas procariotos. Dessa forma,foram realizados, definidos e comprovados os procedimentos de manipulação gênica interespécies e discutido o futuro dabiotecnologia no auxílio a pesquisas e a tratamentos, com foco na LMC.

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasia, caused in 95 % of the cases by a cytogenetic abnormalitycharacterized by the reciprocal translocation between chromosomes 9 and 22 t(9; 22) (q34; q11), resulting in Philadelphiachromosome (Ph).Considering that CML cure is only possible with a successful bone marrow transplantation and that thereare resistance cases to the tyrosine kinase inhibitor Imatinib Mesylate, prescribed in first line drug treatment; it is importantto know in detail the genes and proteins that are possibly altered in CML, favoring effective therapeutic strategies, optimizeddiagnosis and minimal residual disease detection. Among the new therapeutic approaches to CML is gene therapy, which,depending on the target gene, can be efficient to other neoplasms treatment. In this context, the aims of this work were:to proceed the molecular cloning of a DNA fragment from EZH2 gene, potential target for gene therapy, that promotesepigenetic alteration in CML and in many neoplasms; as well as to contribute to studies related to interspecies gene transferthat have high contribution to health. For this reason, the EZH2 gene was isolated from peripheral blood genomic DNAfrom CML patients and cloned in prokaryotic systems. Therefore, in this study, we proceed, defined and proved the interspeciesgene transfer procedures and discussed the future of biotechnology in researches and treatments, especially in CML.

Treatment with dasatinib or nilotinib in chronic myeloid leukemia patients who failed to respond to two previously administered tyrosine kinase inhibitors - a single center experience

OBJECTIVE: To evaluate hematological, cytogenetic and molecular responses as well as the overall, progression-free and event-free survivals of chronic myeloid leukemia patients treated with a third tyrosine kinase inhibitor after failing to respond to imatinib and nilotinib/dasatinib. METHODS: Bone marrow karyotyping and real-time quantitative polymerase chain reaction were performed at baseline and at 3, 6, 12 and 18 months after the initiation of treatment with a third tyrosine kinase inhibitor. Hematologic, cytogenetic and molecular responses were defined according to the European LeukemiaNet recommendations. BCR-ABL1 mutations were analyzed by Sanger sequencing. RESULTS: We evaluated 25 chronic myeloid leukemia patients who had been previously treated with imatinib and a second tyrosine kinase inhibitor. Nine patients were switched to dasatinib, and 16 patients were switched to nilotinib as a third-line therapy. Of the chronic phase patients (n=18), 89% achieved a complete hematologic response, 13% achieved a complete cytogenetic response and 24% achieved a major molecular response. The following BCR-ABL1 mutations were detected in 6/14 (43%) chronic phase patients: E255V, Y253H, M244V, F317L (2) and F359V. M351T mutation was found in one patient in the accelerated phase of the disease. The five-year overall, progression-free and event-free survivals were 86, 54 and 22% (p<0.0001), respectively, for chronic phase patients and 66%, 66% and 0% (p<0.0001), respectively, for accelerated phase patients. All blast crisis patients died within 6 months of treatment. Fifty-six percent of the chronic phase patients lost their hematologic response within a median of 23 months. CONCLUSIONS: Although the responses achieved by the third tyrosine kinase inhibitor were not sustainable, a third tyrosine kinase inhibitor may be an option for improving patient status until a donor becomes available for transplant. Because the long-term outcome ...

Desenlaces clínicos en hematoncología: diez años de investigaciones en Pubmed / Clinical outcomes in Hemato-Oncology: Ten year Pubmed literature review

Objetivo: Determinar cuáles son los desenlaces clínicos empleados en los estudios fase III de tratamiento de neoplasias hematoncológicas y qué proporción de ellos emplean supervivencia global como desenlace primario. Método: Mediante una búsqueda en Pubmed, analizar todos los experimentos clínicos aleatorios publicados en los últimos 10 años, de tratamientos de novo, en población adulta. Resultados: La búsqueda inicial arrojó 310 referencias, entre las que se seleccionaron 90 estudios clínicos. La enfermedad más estudiada fue mieloma múltiple, con 29 estudios, seguida de linfoma no Hodgkin, con 26. Las otras fueron: leucemia mieloide aguda (12), leucemia linfocítica crónica (10), leucemia mieloide crónica (8), síndromes mielodisplásicos (3) y linfoma de Hodgkin (2). En 20 estudios (22%) se empleó la supervivencia global como desenlace primario (en solo 3 de ellos alcanzó significación estadística), en 37 más (41%) se agrupó con otros desenlaces para conformar un desenlace compuesto. En 55 estudios (61%) la supervivencia global fue un desenlace secundario. Conclusiones: Aunque la supervivencia global es el estándar de oro en terapia oncológica, los desenlaces agrupados u otros, como tiempo libre de enfermedad o indicadores paraclínicos de actividad de la enfermedad, son más empleados, quizá por ser buenos predictores y requerir muestras y seguimientos menores. Su capacidad para predecir supervivencia global (en algunos casos calidad de vida) debe ser validada. Solo en las formas más agresivas de cáncer se justifica usar de rutina la supervivencia global como el desenlace primario.

Objective: To describe the clinical outcomes used in phase III studies in Hematology-Oncology malignancies, and to determine what proportion use overall survival as the primary outcome. Methods: Using a systematic literature search in PubMed, an analysis was made of phaseIII randomized clinical trials with de novo treatments of hematology-oncological neoplasias in adult populations published in the last 10 years. Results: The initial search yielded 310 references, 90 of which were finally selected. The overall survival rate was used in 20 studies (22%) as the primary outcome (in 3 of them it reached statistical significance). Grouped intermediate outcomes were used in 37 others (41%). As a secondary outcome the overall survival rate was used in 55 studies (61%). Among the intermediate outcomes used were, response rates, disease-free or relapse-free survival rates, and progression-free survival rate. Multiple myeloma was the most studied disease, with 29 studies (32%), followed by non-Hodgkin lymphoma (28%). Conclusions: Although overall survival rate is the gold standard in cancer therapy, it is not the most often used outcome. Intermediate outcomes, such as disease-free survival or biomarkers are often good predictors, and require smaller samples and less follow-up time. Nevertheless, their predictive capacity for overall survival rate (or, in some cases, quality of life) should also be assessed. The use of the overall survival rate as the routine primary outcome is only justified in the most aggressive forms of cancer.

Análise proteômica e identificação de RNAs longos não codificantes em exossomos de plasma de pacientes com Leucemia Mielóide Crônica / [ Proteomic analysis and identification of long non-coding RNAs in plasma exosomes of patients with Chronic Myeloid Leukemia]

A Leucemia Mielóide Crônica (LMC) é uma doença mieloproliferativa ocasionada pela translocação recíproca entre o oncogene ABL 1, localizado no cromossomo 9, com o gene BCR, localizado no cromossomo 22 [t9,22], originando um novo cromossomo, denominado Philadelphia. A proteína quimérica da translocação BCR-ABL possui atividade tirosino-quinase aumentada e anormal. Apesar da contribuição indubitável da proteína BCR-ABL, alguns estudos já evidenciaram que as células-tronco leucêmicas podem ser independente de BCR-ABL para sobreviver, indicando que alguns fatores presentes no microambiente tumoral, como as microvesículas e exossomos, podem sustentar as células-tronco leucêmicas (LSCs). Os exossomos, também denominados de nanovesículas, possuem de 40 a 100nm de diâmetro, são responsáveis pela comunicação intercelular e tem ganhado atenção nos últimos anos, devido a grande quantidade de moléculas e substâncias que podem transportar de uma célula a outra, ativando importantes vias de sinalização. Sendo assim, o objetivo deste estudo foi purificar os exossomos do plasma de medula óssea de pacientes com LMC em fase crônica da doença ao diagnóstico, caracterizar o perfil imunofenotípico, realizar uma análise proteômica Label Free para identificar o perfil proteômico e identificar os RNAs longos não codificantes (lncRNAs) presente no interior destes exossomos. Foram identificadas 341 proteínas diferencialmente expressas entre pacientes com LMC e doadores, e a proteína BOC, receptor da via de Hedgehog (Hh), estava aumentada na amostra dos pacientes. O perfil imunofenotípico revelou que os exossomos foram purificados com sucesso e que, provavelmente, estavam sendo secretados pelas células mesenquimais, megacariócitos e granulócitos no microambiente da medula, uma vez que houve aumento da diferencça de média de intensidade de fluorescência (dMIF) para as tetraspaninas consideradas marcadoras destas populações celulares, respectivamente (CD105, CD61 e CD65). Em relação ao lncRNAs, ANTINOS2A, RoR, SFMBT2 e VLDLR apresentaram reprodutibilidade dos dados em amostras dos doadores, estando ausentes nos pacientes. Neste grupo somente o lncRNA HOTAIR apresentou-se diferencialmente expresso com um fold-change de 13,24. Nossos dados permitem inferir que os exossomos presentes no plasma de pacientes com LMC são capazes de carrear conteúdo molecular, de ativar a via de Hh e, assim, favorecer a leucemogênese no início da LMC.

Frecuencia de los transcriptos p190BCR-ABL y p210BCR-ABL en una población colombiana con leucemia mieloide crónica (LMC) usando RT-PCR cualitativa / Detection of p190BCR-ABL AND p210BCR-ABL fusion transcripts in patients with chronic myeloid leukemia (CML) using qualitative RT-PCR / Frequência dos transcritos p190BCR-ABL e p210BCR- ABL numa população colombiana com leucemia mielóide crônica (LMC) usando RT-PCR qualitativa

Introducción: la leucemia mieloide crónica (LMC) se caracteriza por la presencia del cromosoma Filadelfia (Ph) que resulta de la translocación recíproca balanceada t(9;22)(q34;q11); este marcador cromosómico se encuentra con menor frecuencia en pacientes con leucemia linfoide aguda (LLA). Objetivo: determinar la frecuencia de las fusiones génicas BCR-ABL, que codifican para los transcriptos p210BCR-ABL y p190 BCR-ABL en pacientes colombianos con diagnóstico de LMC, en diferentes fases de la enfermedad o de su tratamiento. Materiales y métodos: estudio descriptivo de corte transversal de 31 pacientes con LMC (15-78 años). El análisis se hizo a partir de muestras de sangre periférica con la técnica PCR anidada cualitativa para las isoformas P210 BCR-ABL (b3a2 e b2a2) y P190 BCR-ABL (e1a2). Resultados: se detectó el transcripto p210BCR-ABL en 29 de los 31 casos (93,6%). En ellos se identificaron las fusiones génicas b2a2 (16/29; 55,2%), b3a2 (10/29; 34,5%) y la coexpresión b3a2 y b2a2 (3/29; 10,3%). Conclusión: la fusión génica b2a2 fue la más frecuente en esta población con LMC.

Introduction: Chronic myelogenous leukemia (CML) is characterized by the presence of the Philadelphia chromosome (Ph), resulting from the balanced reciprocal translocation t(9;22)(q34;q11). This marker chromosome is found less frequently in patients suffering from acute lymphoblastic leukemia. Objective: To determine the frequency of BCR-ABL gene fusions encoding the p210BCR-ABL y p190 BCR-ABL transcripts in Colombian patients diagnosed with CML in different stages of the disease and/or its treatment. Materials and methods: Cross sectional, descriptive study of thirty one CML patients (aged 15-78). Analysis was carried out through qualitative nested PCR for the isoforms P210 BCR-ABL (b3a2 e b2a2) and P190 BCR-ABL (e1a2), and based on peripheral blood samples. Results: In 29 of the 31 patients (93.6%) transcript p210BCR-ABL was detected; b2a2 and b3a2 gene fusions and the coexpression b3a2 y b2a2 were identified in 55.2% (16/29), 34.5% (10/29) and 10.3% (3/29) of the cases, respectively. Conclusion: b2a2 gene fusion was the most frequent in this CML population.

Introdução: a leucemia mielóide crônica (LMC) caracteriza- se pela presença do cromossomo Filadélfia (Ph) que resulta da translocação recíproca balanceada t(9;22)(q34;q11); este marcador cromossômico se encontra com menor frequência em pacientes com leucemia linfoide aguda (LLA). Objetivo: determinar a frequência das fusões genéticas BCR-ABL, que codificam para os transcritos p210BCR-ABL e p190 BCR-ABL em pacientes colombianos com diagnóstico de LMC, em diferentes fases da doença ou de seu tratamento. Materiais e métodos: estudo descritivo de corte transversal de 31 pacientes com LMC (15-78 anos). A análise se fez a partir de mostras de sangue periférico com a técnica PCR aninhada qualitativa para as isoformas P210 BCR-ABL (b3a2 e b2a2) e P190 BCR-ABL (e1a2). Resultados: detectou-se o transcrito p210BCR-ABL em 29 dos 31 casos (93,6%). Neles se identificaram as fusões genéticas b2a2 (16/29; 55,2%), b3a2 (10/29; 34,5%) e a co-expressão b3a2 e b2a2 (3/29; 10,3%). Conclusão: a fusão genética b2a2 foi a mais frequente nesta população com LMC.