ALBERT

Description: Splenic marginal zone lymphoma (SMZL) is a newly recognized lymphoma type whose precise molecular pathogenesis is still essentially unknown. This hampers differential diagnosis with other small B-cell malignancies. With the aim of characterizing this tumor more comprehensively, and of identifying new diagnostic and prognostic markers, we performed cDNA microarray expression profiling and tissue microarray (TMA) immunohistochemical studies in a relatively large series of 44 SMZLs. The results were related to immunoglobulin heavy chain variable region (IgVH) mutational status and clinical outcome. SMZLs display a largely homogenous signature, implying the existence of a single molecular entity. Of the genes deregulated in SMZLs, special mention may be made of the genes involved in B-cell receptor (BCR) signaling, tumor necrosis factor (TNF) signaling and nuclear factor-κB (NF-κB) activation, such as SYK, BTK, BIRC3, TRAF3, and LTB. Other genes observed were SELL and LPXN, which were highly expressed in spleen, and lymphoma oncogenes, such as ARHH and TCL1. In contrast, the genes CAV1, CAV2, and GNG11 located in 7q31, a commonly deleted area, were down-regulated in the entire series. A comparison with the genes comprising the signature of other small B-cell lymphomas identified 3 genes whose expression distinguishes SMZL, namely ILF1, SENATAXIN, and CD40. Shorter survival was associated with CD38 expression, naive IgVH genes, and the expression of a set of NF-κB pathway genes, including TRAF5, REL, and PKCA. (Blood. 2005;106:1831-1838)

Description: It has been shown in non-randomized studies that tandem transplant results in an increased CR rate. A randomized trial showed that tandem transplant resulted in a significantly longer EFS and OS in patients failing to achieve CR or near-CR with a single transplant. However, other studies failed to show a survival benefit from a second transplant. The aim of our study was to investigate the feasibility and efficacy in terms of response up-grading and survival from a second transplant intensification in patients with chemosensitive disease who failed to achieve CR or near-CR with a first transplant. Patients diagnosed with MM from Oct 1999 to Dec 2003 younger than 70 years received 6 courses of VBMCP/VBAD chemotherapy and responding patients were intensified with busulphan/melphalan or MEL-200 followed by stem cell support. Patients not achieving CR or near-CR were planned to undergo a second transplant (either a second auto with CVB - cyclophosphamide, etoposide and BCNU - intensification or a dose-reduced intensity “allo” with Fludarabine/MEL-140 conditioning, depending on sibling donor availability). It is of note that 99 (55%) did not receive the second HDT procedure because patient refusal -28 pts-, lack of CD34–17 pts-, progressive disease - 16 pts-, poor PS -15 pts-, physician decision -14 pts-, others -8 pts-. Patients who did not proceed with the second transplant were significantly older (58 vs. 55 yrs, p= 0.001) and had higher serum beta2-microglobulin levels (4.7 vs. 3.5, p=0.02). Fifty nine patients received a second autologous transplant while 23 underwent a “mini-allo”. Twenty-eight percent of the patients given a second autologous transplant achieved an up-graded response (CR or near-CR: 7%, PR: 10% and MR 12%) while 61% showed “no change”, progressive disease or early death. A response up-grade was observed in 43% of patients undergoing a “mini-allo” procedure (CR: 26%, PR: 4%, MR: 3%). The CR rate was significantly higher with the allogeneic procedure (26 vs. 5%, p=0.01). However, there was a trend towards a higher TRM with the “miniallo” procedure (5% vs. 17% (p=0.09). The survival from the second high-dose procedure was not significantly different between the two transplant modalities (2nd auto vs “mini-allo”). Conclusions. in about one-half of the patients in whom a tandem transplant is planned the second high-dose procedure is not performed, a dose-reduced intensity allogeneic transplant after an autologous procedure results in a significantly higher CR rate than a tandem autologous transplant, with the current follow-up we found no significant differences in survival between the two transplant modalities.

Description: Introduction: Justification and Objectives There are little epidemiologic data about Myeloma Multiple in Spain. The heterogeneity and complexity of this pathology, and the several sociodemographic factors, justify the interest of this type of studies. On the other hand, this disease needs a high assignement of welfare and therapeutic resources, and besides new strategies have arisen for its treatment. The Spanish Leukaemia and Lymphoma Foundation (FLL)has analyzed the actual situation of Myeloma Multiple in Spain, compiling several epidemiologic and welfare parameters about the disease in a Multiple Myeloma “White Book” for Spain. Patients and Methods The period of analysis was 10 years, from 1.991 to 2.001. The information was compiled from a Hospital Based Survey about MM and the following official sources: International Agency for Research on Cancer (IARC): “Cancer incidence in Five continents” and “Incidence and Mortaliity for Cancer In Spain, Patterns and Tendences” Data Base of EUCAN and GLOBOCAN (Cancer Incidence, Mortality and Prevalence Worldwide) EUROCARE III study, (IARC Cancer Base Number 5, Lyon, IARCPress). “Natural Changes of Population and Demography. Spanish National Statistic Institute (INE) and National Spanish Center for Epidemiology (CNE.) Official Records for Mortality Rates by MM in Spain in Spanish Regions (CCAA) (death records Demograhy Records of INE). INE Hospital Case Rate Inquest. CMBD Data Base of Department of Health (Inmunoproliferative Neoplasm and Multiple Myeloma, CIE-9 Diagnosis Code: 203.0)The indicators used were: Deaths number, median of age, proportional mortality, mortality rates, mortality rates adjusted by age, gender and potential years of life lost due to multiple myeloma, (item 203 of ICD-10, OMS) during the last ten years in Spain. Results The incidence rates of MM, adjusted to the European population were: 3,54 cases by 100.000/year for men and 2,54 cases by 100.000/year for women. The global incidence rate were 4,44 cases by 100.000/year for men and 4,22 cases by 100.000/year for women. These rates were similar in all geographic regions. Performed predictions show a prevalence increase during the following five years, which means more than 2.400 cases in men and more than 2.100 in women MM cases per year. Regarding mortality, rates, myeloma is a very slightly frequent cause of death: 3.23 cases by 100.000/years of men and 2.3 cases of women. A whole an increase of mortality of 45.2 per cent was observed for the period of time between 1992 and 2001. Comments and Conclusions The MM incidence and mortality rates in Spain for this period were lower than expected in comparison with other European epidemiology studies. Nevertheless we observed that the MM mortality and prevalence rates present a continuous and uniform increment in the last years. Part of these increases can be due to the incorporation of new technologies, more sensitive for diagnosis, and to the increase of aging of the population. Furthermore certain occupational and chemical exposures and other environmental changes could explain these trends.

Description: Introduction: Thalidomide and the IMiDs are rapidly becoming mainstays in the treatment of multiple myeloma. To improve the efficacy of thalidomide (T) or Revlimid (lenalidomide) (R), we have developed the BLT-D (Biaxin® (clarithromycin) (B), low dose T, and dexamethasone (D)), and the BiRD (B, R, D) regimens. These regimens have produced remarkably high responses, including complete and near complete remissions, with almost every patient not previously exposed to thalidomide. When the BLT-D regimen was initiated, an excessive number of thrombotic episodes were noted. Subsequent to this initial observation, others have also reported an inordinate number of thrombotic events, usually when T was combined with other biological or chemotherapy agents. Given the putative antiangiogenic properties of T or R, we postulated that endothelial damage may be responsible for the enhanced thrombosis and thus, subsequently initiated low dose aspirin (ASA), 81mgs, as prophylaxis in patients (pts) undergoing treatment. We report the effect of low dose ASA as a prophylactic treatment when given to pts receiving L/T containing regimens as follows: A retrospective analysis of pts receiving BLT-D before ASA prophylaxis compared to a similar group after ASA was instituted; An examination of the incidence of thromboembolic phenomena in pts receiving either D alone, not receiving ASA, compared to combined D and low dose T, receiving ASA, as part of a prospective sequential randomized study also studying the impact of subsequent B and 3) An evaluation of thrombosis in pts receiving the BiRD regimen with mandated low dose ASA. Results: Low dose ASA significantly reduced the incidence of thrombosis in pts receiving BLT-D. Of the 60 pts studied, 5 (8%) developed grade 1–2 thrombosis, primarily thrombophlebitis (DVT), and 9 pts (15%) developed grade ≥3 thrombosis, primarily pulmonary embolism (PE) and coronary thrombosis. All episodes of thrombosis occurred prior to the institution of ASA. Slightly less thrombotic events were recorded in pts receiving low dose ASA and the T-D combination with or without B (1/12) when compared to pts not receiving ASA and D with or without B (3/11). 3) Three of 22 pts treated with the BiRD regimen have developed thromboembolic complications, all while off the prescribed ASA. Patient 1, a 44 yo male discontinued (d/c’ed) ASA due to epistaxis. Exactly 7 days after d/c’ing ASA, and while remaining on BiRD, he developed a DVT and PE. Patient 2 underwent exploratory laparotomy to investigate a renal mass. ASA and BiRD were discontinued 7 days prior to surgery. Ten days after surgery, the patient developed DVT. Patient 3 underwent closure of a colostomy; ASA and BiRD were d/c’ed 7 days prior surgery. Two days after the surgery, despite low dose heparin, he suffered a fatal massive PE. No thrombotic episodes with BiRD have not occurred with pts remaining on ASA. Conclusions: Low dose ASA appears to reduce the incidence of thrombosis in pts receiving combination T or R therapy. Endothelial damage may persist beyond the residual salutary effects of discontinued ASA.

Description: Background. There are known prognostic factors in Acute myeloid leukemia (AML) patients, being the cytogenetic analysis the strongest as single predictor of disease relapse or poor therapy response. Recently, alterations in FLT3 gene (Internal tandem duplications-ITD and D835/836 mutations) are frequently detected by PCR in 30–35% of AML patients (pts) and would be associated with aggressive disease. This study reports the molecular characterization of 82 AML pts from Argentina and Uruguay, mostly of Spanish-Italian origin, studied between 1996 to 2005. Design and Methods. This study was based on 82 pts: 71 adults, median age 36 yrs, (range 25–80) and 11 children (median age: 11 yrs, range. 3–17 yrs). Cytogenetic risk was established in 77 pts by kariotyping, PCR and FISH: 49% (n=38) with low risk, 38% (n=29) with standard risk, and 13% (n=10)with high risk. The FAB distribution (n=75) was: M0=2,7% (n=2), M1= 6,7% (n=5); M2=17,3% (n=13); M3=46,7% (n=35); M4=16% (n=12); M5=6,7% (n=5); M6=4% (n=3). Clinical endpoints and follow up were available for 45 pts and 56 pts, respectively. A total of 42 pts achieved complete remission (CR), 12 pts had relapse of disease, 10 pts underwent early death without completing induction (ED pts), and 7 pts died after treatment. Prognostic factors considered were: Age 〉 55 years, WBC average, WBC 〉 100 x 106/L, % Blasts in bone marrow, Secondary etiology (therapy related/MDS). JM and TKD domain coding sequences were amplified by PCR for characterization of ITD and D835/836 mutations, respectively. Results and Interpretation. FLT3 mutations could be demonstrated in 23% (19/82 pts): ITD =16% (13/82), D835/836 =7% (6/82). The median follow-up time was 36 months (range 1 – 96 m). A total of 48% (n=27) of pts. were still alive without relapse at the end of this study. Higher incidence of Flt3 mutations [ITD+ and D835/836+] were found in: 41,7% (n=5) of pts with no achievement of CR (n=12) Vs 7,1% (n=3) pts with CR (n=42) (p=0.01), and in 38% (n=5) of the death patients group (n=13) Vs. 7,4% (n=2) pts still alive without relapse (n=27) (p=0,027).The WBC average was significantly higher in the ITD+ group (69,38x106/L) Vs ITD(−) group (9,27x106/L) (p=0.001). ITD mutation was more frequent in pts with WBC 〉100x106/L (83,3%) Vs WBC 100.106/L. Both type of FLT3 mutations (ITD and D835/836) were associated with early death in the cohort. This colaborative study showed that FLT3 mutational status had to be considered as important tool in prognosis of AML pts, however further follow up with larger number of pts is required to fully address its association with poor clinical outcome.

Description: Results of therapy in children with VHR ALL are disappointing and he role of SCT is controversial. Few studies have compared ALLO or AUTO SCT with intensive chemotherapy in children with VHR-ALL. This multicenter randomized trial compare three options of post remission therapy in children (0–18 yr) with VHR-ALL: intensive consolidation plus maintenance chemotherapy (CHT), ALLO or AUTO SCT. Inclusion criteria: one or more of the following: age 0–1 yr., WBC〉300x109/L for B-lineage ALL (mature B-ALL excluded), or 〉100x109/L for T lineage-ALL, t(9;22) or BCR/ABL, t(4;11) or other 11q23 or MLL rearrangements, t(1;19) or slow response (〉10% blast cells in BM study at day 14 of induction therapy) or resistance to other induction therapies. Treatment schedule: Induction: 5-drug (VCR, DNR, PDN, ASP, CPM); early intensification: 3 1-week cycles including HD-MTX, HD-ARAC and HD-ASP over 3 mo. Patients with an HLA-identical familiar donor were assigned to ALLO SCT and the remaining were randomized to AUTO SCT or to delayed intensification CHT (the same three cycles given in the post-remission period) followed by maintenance CHT (MP+MTX) up to 2-yr. in complete remission (CR). Study period: 1993–2003, 119 pts, 106 evaluable (70 VHR de novo ALL, 36 with slow response to other induction therapies), 68% males, median age 8 yr. (range 3 mo-18). Early pre-B: 17 (16%), common+pre-B: 41 (39%), T: 48 (45%). Cytogenetics (81 [76%] valid cases after central review): normal: 38 (47%) t(9;22): 8 (10%), 11q23: 13 (16%), t(1;19): 2 (2%), other: 20 (25%). Response to therapy: Induction death 2 (3%), resistant disease 4 (6%) and CR 64/70 (91%) with baseline VHR features. Of 100 evaluable patients, 24 pts were assigned to ALLO SCT, 38 randomized to AUTO SCT and 38 to CHT. With a median follow-up of 6.5 yr (range 1.3-12.4), medians for DFS and OS were 2.5 yr and 3.6 yr, and 5-yr DFS and OS probabilities were 45±8% and 48±8%. Groups of ALLO, AUTO and CHT were comparable for the main clinicobiologic characteristics and the rate of response to therapy. Intention-to-treat analysis showed no differences in DFS and in OS for donor vs. no donor comparison as well as for comparison of AUTO vs. CHT in the whole series as well as wthin separate subgroups of patients (infants, patients with T-ALL, B-lineage ALL and patients with chromosomal rearrangements). The same results were observed when the analysis was performed on the basis of effectively treated pts (ALLO SCT performed in 74%, AUTO SCT in 66% and delayed intensification CHT in 74% of the pts). By multivariate analyses, slow response to induction therapy was associated with a lower CR, whereas T-cell phenotype was the only variable associated with a lower DFS and OS probabilities. This study failed to prove that, when a family donor is available, allogeneic SCT produces a better outcome than autologous SCT or chemotherapy in children with VHR-ALL. Among children with VHR ALL slow response to therapy and T-cell phenotype are the main adverse prognostic factors

Description: The aim of this study was to investigate anticardiolipin (aCL) (IgG and IgM) levels in patients with objectively confirmed venous thromboembolism (VTE). aCL IgG and IgM were measured using an in-house ELISA assay. When aCL levels were ≥10 U, a second measurement was performed using another sample at least 6 weeks after the first test. Patients tested twice with aCL levels ≥10 U were classified as having positive aCL and those with only one measurement ≥10 U had transitory aCL. aCL was evaluated in 282 outpatients with VTE, with median age of 39 years (range:15–94), 66.7% were women. We found 28 patients (9.9%) with positive aCL (IgG in 5.6%, IgM in 1.8% and IgG + IgM in 2.5%) and 29 (10.3%) with transitory aCL (IgG in 5.3%, IgM in 3.2% and IgG + IgM in 1.8%). The association of systemic disease with VTE had a significant effect on the occurrence of transitory aCL (OR= 3.6; 95%CI: 1.5–8.8), but not on positive aCL (OR= 1.7; 95%CI: 0.6–5.0). There was a significant correlation between the first and second measurements for IgG (rs= 0.58; p 〈 0.0001) and for IgM (rs= 0.49; p = 0.011). Patients with IgG 〈 30 GPLU showed a higher risk of having transitory aCL (OR= 4.9; 95%CI: 1.2–19.7; p= 0.027), and this effect was more pronounced in patients with IgM 〈 30 MPLU (OR=15; 95%CI: 1.2 – 113.6; p= 0.008). In conclusion, prevalence of transitory aCL was as high as positive aCL in patients with VTE, mainly among those with IgG or IgM 〈 30 U. Higher aCL levels were more frequently associated with repeatedly positive aCL. Transitory aCL was more frequent in the presence of systemic disease associated with VTE, which could reflect an epiphenomenon, whereas repeatedly positive aCL could play a more important role in the genesis of VTE.

Description: Background: Peripheral blood progenitor cells (PBPC) are a common source of hematopoietic stem cells for allogeneic transplantation. Information about long-term follow up and donor safety is, however, very limited. Study design and methods: A National Donor Registry was developed in Spain in 1999 directed to know the short and long-term effects of G-CSF administration on healthy donors for PBPC mobilization. A total of 1287 donors (590 M/697 F; median age, 37 years, range 1–74) have been registered. G-CSF, either filgrastim (1041 cases) or lenograstim (291 cases) was the only cytokine administered. Median (range) dose of G-CSF was 10 (5–23) mcg/kg/day, for a median of 4 days. Sixty-five donors underwent more than one mobilization procedure. A baseline investigation was performed in every donor 2–4 weeks before G-CSF administration and follow up investigations were planned at 4 weeks, and thereafter annually up to 5 years after mobilization. Results: In 588 donors at least one of the scheduled controls have been done, and 187 donors have been followed for more than two years. The peripheral white blood cell (WBC) count decreased significantly 4 weeks after leukaphereses, from 6.4 x109/L at baseline to 5.9 x109/L (P

Description: We studied the role of chemokine receptor CCR6 in acute graft-versus-host disease (GvHD), a pathology in which activated, host antigen-specific donor T cells selectively damage tissues such as skin, liver, and gut. GvHD incidence was reduced in major histocompatibility complex (MHC) class II–mismatched recipients of CD4+ T cells from CCR6-deficient donors. In MHC-matched/minor histocompatibility antigen–mismatched recipients of CD4+CD45RBhigh T cells from CCR6-deficient donors, infiltration of CD45+ and CD4+ cells to skin and gut, as well as lesion onset, were significantly delayed, and pathologic symptoms were milder. Consistent with this, in skin and gut of recipients of naive T cells from CCR6-deficient donors we observed lower levels of interferon γ (IFN-γ), interleukin 10 (IL-10), and the chemokines that control activated T-cell homing. We suggest a role for CCR6 in recruiting alloreactive CD4+ T cells to target tissues and identify CCR6 as a potential therapeutic target for GvHD.

Description: Fibrinogen Philadelphia, a hypodysfibrinogenemia described in a family with a history of bleeding, is characterized by prolonged thrombin time, abnormal fibrin polymerization, and increased catabolism of the abnormal fibrinogen. Turbidity studies of polymerization of purified fibrinogen under different ionic conditions reveal a reduced lag period and lower final turbidity, indicating more rapid initial polymerization and impaired lateral aggregation. Consistent with this, scanning and transmission electron microscopy show fibers with substantially lower average fiber diameters. DNA sequence analysis of the fibrinogen genes A, B, and G revealed a T〉C transition in exon 9 resulting in a serine-to-proline substitution near the γ chain C-terminus (S378P). The S378P mutation is associated with fibrinogen Philadelphia in this kindred and was not found in 10 controls. This region of the γ chain is involved in fibrin polymerization, supporting this as the polymerization defect causing the mutation. Thus, this abnormal fibrinogen is characterized by 2 unique features: (1) abnormal polymerization probably due to a major defect in lateral aggregation and (2) hypercatabolism of the mutant protein. The location, nature, and unusual characteristics of this mutation may add to our understanding of fibrinogen protein interactions necessary for normal catabolism and fibrin formation.