ALBERT

Description: Background CNS recurrence of aggressive lymphoma remains a distressing and usually incurable event. In an analysis of patients on protocols of the German High-Grade Non-Hodgkin’s Lymphoma Study Group (DSHNHL) between 1990 and 2000, the CNS relapse rate was 2.2% in 1693 patients treated with modern chemotherapy but without rituximab (Boehme et al., Ann. Oncol. 2007). We now analyzed the incidence and prognostic factors for CNS recurrence in the RICOVER-60 study (Pfreundschuh et al., Blood abstract 2006) where patients had been randomized to 6 or 8 courses of CHOP-14 +/- rituximab. Patients and Methods From 2000–2005, 1242 patients (pts.) between 61 and 80 years with CD20+ aggressive lymphoma were randomized to receive 6 or 8 cycles of CHOP-14 chemotherapy with or without 8 courses of rituximab. Twenty patients were excluded because of missing or retracted informed consent, leaving 1222 pts. for the intention-to-treat analysis. For patients with suspected or confirmed lymphoma manifestation in testes, bone marrow, upper cervical nodes, sinuses or other extranodal involvements in the cranial region the protocol asked for intrathecal (i.th.) prophylaxis with 15 mg methotrexate twice in the first two cycles of treatment. Results 1217 patients were evaluable, of whom 58 patients (4.8%) after a median time of 8 months (1–39) developed relapse or progression to the CNS with a median time of survival of 3 months (0.1–38). Multivariate Cox regresssion analysis identified involvement of more than one extranodal site (RR = 3.4; p〈 0.001), the presence of B-symptoms (RR = 1.9; p = 0.025) and increased LDH values (RR = 1.5; p = 0.146) as relevant predictors of CNS recurrence. Patients with these three characteristics had a CNS relapse rate of approximately 24% at 2 years, about 6-fold the incidence rate observed in all other patients. The addition of rituximab to chemotherapy reduced the risk of CNS recurrence (RR = 0.5; p = 0.025), whereas the number of treatment cycles (6 vs. 8) did have no influence on the CNS-specific outcome. 273 of 1217 patients (22%) received i.th. prophylaxis at least during one cycle and 202 of 273 prophylaxis patients (74%) were treated intrathecally in full compliance with the protocol, thus reducing the rate of CNS complications (RR = 0.3; p = 0.023). The majority of these patients had involvement of testes, bone marrow, sinuses or upper skeletal and/or nodal sites. Conclusion The incidence of CNS relapse in 1217 patients treated for aggressive lymphoma with CHOP-14 with or without rituximab was low (4.8%) but slightly higher than reported in other recent series. The prognostic factors for CNS-disease and the poor prognosis of CNS relapse remain largely unchanged although rituximab significantly reduced the incidence of CNS disease (3.6 vs. 5.9%) and the risk of CNS recurrence (RR 0.5; p = 0.025). Prophylactic i.th. therapy given to patients with distinct extranodal involvement reduces the risk of CNS disease in these individuals. Due to the low overall incidence general prophylactic strategies cannot be recommended.

Description: For patients on warfarin therapy, an international normalized ratio (INR) recall interval not exceeding 4 weeks has traditionally been recommended. Less frequent INR monitoring may be feasible in stable patients. We sought to identify patients with stable INRs (defined as having INR values exclusively within the INR range) and comparator patients (defined as at least one INR outside the INR range) in a retrospective, longitudinal cohort study. Occurrences of thromboembolism, bleeding, and death were compared between groups. Multivariate logistic regression models were used to identify independent predictors of stable INR control. There were 2504 stable and 3569 comparator patients. The combined rates of bleeding and thromboembolism were significantly lower in stable patients. Independent predictors of stable INR control were age older than 70 years and the absence of comorbid heart failure and diabetes. Stable patients were significantly less likely to have target INR of 3.0 or higher or chronic diseases. We hypothesize that many patients demonstrating stable INR control could be safely treated with INR recall intervals greater than the traditional 4 weeks.

Description: Adult patients with high risk acute leukemia have allogeneic hematopoietic transplantation as the only therapeutic option with some curative potential. Those who lack related or unrelated marrow donor are deprived of this possibility. Patients of smaller size may benefit from the transplantation of single cord blood unit, but for heavier patients two units may be required as reported by Barker et al. (Blood2005;105:1343). For very heavy patients even more units would be necessary to approximate the preferred threshold of 37 millions of cells per kilo. Moreover, cord blood units have variable size and it is always a risk that the only HLA-matched units for given patients would be small and two units would not provide adequate number of cells even for patients of moderate size. This is yet another argument to attempt transplantation of more than two units. Three patients have so far been included. Patient No 1 was 24 yrs old male (body weight 87 kg) with resistant AML transplanted with 3 units (two matched at 4/6 HLA antigens, one matched at 3/6 HLA antigens) on March 29, 2004 following conditioning with standard BuCy4 + ATG regimen. This patient died d. +42 of Gram negative sepsis without hematopoietic reconstitution. Patient No 2 is 22 yrs old male (body weight 100 kg) with Ph+ ALL in complete remission, who was transplanted on October 11, 2004 with 3 units (two matched at 4/6 HLA antigens, one matched at 3/6 antigens) following conditioning with TBI, etoposide and ATG. This patient had neutrophil recovery d. +27, and platelet recovery d. +49. He is alive and well 9 months after the transplant fully chimeric with progeny of only one of transplanted units. Patient No 3 is 31 yrs old male (body weight of 100 kg) with ALL relapsed after autologous BMT with multiple cytogenetic abnormalities. He was transplanted May 24, 2005 with 3 units (one matched at 5/6 HLA antigens, two matched at 4/6 HLA antigens) following conditioning with treosulfan, cyclophosphamide, melphalan and ATG (he earlier received TBI prior auto-BMT). Patient obtained neutrophil recovery d. +36 and as of d.+60 still has low platelets. No data on chimerism are yet available. These data confirm that transplantation of more than two cord blood units is feasible and may provide therapeutic option for patients with high risk leukemia who lack marrow donor and for whom two cord blood units do not provide sufficient number of cells. As in the case of the transplantation of two units patients seem to be reconstituted with progeny of only one “winning” unit.

Description: Introduction: Mesenteric venous thrombosis (MVT) is an uncommon but potentially life-threatening disease, accounting for 5–15% of mesenteric ischemic events. Most cases of MVT are either identified at laparotomy or at autopsy, with a mortality rate of approximately 50% in old series. Advances in imaging techniques have facilitated the early diagnosis of MVT and, thus, have contributed to a decrease in mortality in the more recent series. The treatment of MVT involves anticoagulation alone or in combination with surgery. Experts suggest that MVT can safely be managed without surgery if there is no evidence of bowel infarction. However, information on the natural history of MVT and on efficacy and safety of long term treatment with oral anticoagulant (OAT) is based on small uncontrolled series of patients with a limited follow up. Therefore, the aim of our study is to clarify the natural history of this disease in a large cohort of patients recently diagnosed with MVT. Methods: The charts of all patients with splanchnic vein thrombosis who are currently attending or who have attended four anticoagulation clinics (Denver, Albuquerque, Varese and Palermo) were reviewed. At these centres, patients are regularly followed up for the monitoring of OAT and information on clinical events is documented and registered in a computerized database. All patients with objectively diagnosed MVT, were selected. The charts of eligible patients were reviewed for baseline clinical characteristics including sex, age, prior history of cardiovascular disease and use and type of anticoagulant therapy. Information on mortality and all objectively confirmed recurrent venous thromboembolic events were noted. Results: Seventy seven patients (mean age 49.2 years; 45 males) were included. Thirteen patients had a previous thromboembolic event. Thirty two were idiopathic. Forty six patients were on long term OAT. Median follow up was 36 months (Range 2–204 months). Seven patients had a recurrent thromboembolic event (5 splancnic vein thromboses and two PEs) for an incidence rate of 23.4 events/1000 year patient. Two patients (2.6%) had a major bleeding event (one subdural haematoma and one gastroenteric bleeding). Five patients had a VTE recurrence when suspended OAT for an incidence rate of 45.9 events/1000 year patient. Seven patients (9.1%) died during follow up (4 were related to cancer). Conclusion: patients with a previous episode of MVT have a low risk of recurrent thromboembolic events while on oral anticoagulant treatment. This risk is clearly increased after treatment is stopped. In these patients, long term anticoagulant therapy appears as a safe and effective option.

Description: Dyskeratosis congenita (DC) is an inherited multisystem disorder of premature aging, typically characterized by bone marrow failure, mucosal leukoplakia, abnormal skin pigmentation, and nail dystrophy. The X-linked and autosomal dominant forms of DC are associated with mutations in genes that affect telomerase activity resulting in a decrease in telomere length. DC, like other bone marrow failure disorders, is associated with ineffective hematopoiesis and a cancer predisposition. Standard treatment of bone marrow failure or cancer requires cytotoxic therapy, and clinical observations suggest DC patients have an increased sensitivity to cytotoxic therapy. To explain this, we hypothesized that the short telomeres in somatic cells from DC patients could alter the activity and/or expression of several proteins involved in DNA repair or the response to cellular stress including p16, p53 and p21. Lymphocytes from five DC subjects and age-matched controls were stimulated to grow in vitro in the presence of various cytotoxic agents with different modes of action, including Taxol (antimitotic agent and microtubule inhibitor) and Etoposide (topoisomerase inhibitor and DNA damaging agent). In addition, we tested fibroblasts and keratinocyte extracted from skin biopsies from DC and control subjects that were serially passaged. Cellular proliferation and cell death were monitored by cell counts and flow cytometry. Western blotting was used to measure steady state and DNA damage- induced expression of tumor suppressor protein p53 and other proteins involved in DNA damage response signaling pathway, including p16 and p21 in relation to telomere length. Results of flow cytometry accompanied by direct visualization showed a decreased proliferation of DC lymphocytes compared to normal cells, and this growth disadvantage was further accentuated following cell exposure to cytotoxic agents. DC lymphocytes exposed to 10−6 M Taxol showed a decrease in cellular proliferation between 3 and 8 fold while normal control cells exposed to the same agents exhibited only a 3 to 4 fold decrease in cell growth. Similarly DC lymphocytes exposed to Etoposide were inhibited to a greater extent than control cells. Western blot analysis of whole cell lysates indicated a difference in DNA damage response proteins. Of note, lymphocytes from several DC subjects exposed to Taxol did not upregulate p53 expression, while inducible levels were noted in Taxol-treated control cells. In contrast, DC and control lymphocytes exposed to Etoposide upregulated p53 in a similar dose dependent manner. No differences were noted in DC versus control lymphocytes with regards to basal or chemotherapy induced p16 expression. Interestingly, late passage DC fibroblasts displayed enhanced basal expression of p16. These results support the clinical observation of increased “chemosensitivity” in DC subjects and suggest that diminished telomerase activity and premature telomere shortening may interfere with normal DNA damage and stress response pathways. These data are also consistent with our finding that DC fibroblasts, keratinocytes, and lymphocytes have a reduced cell proliferative lifespan. Further studies are needed to dissect the role of telomeres in the cellular response to various types of DNA damage.

Description: The optimal therapy for patients who present with markedly prolonged INR values during warfarin therapy is undefined. Evidence suggests that the risk of bleeding increases directly with the degree of prolongation of the INR. Traditional therapy for patients with excessive warfarin associated anticoagulation has included warfarin withdrawal with or without vitamin K, transfusion therapy and admission to the hospital. As part of an ongoing international study, we prospectively enrolled 32 consecutive warfarin-treated patients presenting with an INR of more than 10.0. Eligible patients had no evidence of active bleeding or need for immediate correction of their INR. All patients received 2.5 mg of oral vitamin K, were not treated with coagulation factor replacement, and were followed over 90 days for clinical events and their INR response. Seventeen of the 32 patients were women, with an average age of 65.8 (range 31 to 89). Treatment of venous thrombosis and atrial fibrillation (12 patients each) were the most common indications for warfarin. Twenty-five patients had a target INR of 2.0 to 3.0; the remainder had a target of 2.5 to 3.5. The mean INR at presentation was 12.9 (range 10.0 to 21.2). Of the 25 patients with a recorded INR value on the day following vitamin K, 19 (76%) had an INR of 6.0 or less (range 1.6 to 17.5, mean 5.0, 2 less than 2.0). On day 7 after study drug, the mean INR was 3.5 (range 1.6 to 17.5). Six (19%) patients reported bleeding over the 90 days after study drug: 1 (3%) bleed was major (retroperitoneal hemorrhage diagnosed the day after study drug) and 3 patients reported epistaxis or bruising within three days of study drug. Two patients reported late bleeding; one had a fall on day 8 at which time the INR was 10.5, and the other had bleeding associated with a surgical procedure 25 days after study drug. No patients had suspected or confirmed thrombosis, and no patients died during follow-up. This the first prospective study of vitamin K monotherapy for patients with INR values above 10, and confirms prior retrospective analyses which suggest that low dose oral vitamin K effectively lowers the INR in such patients. Our preliminary results also suggest that coagulation factor replacement may be unneeded in such patients. The true risk of bleeding, and the impact of degree of prolongation of the INR on the vitamin K response, will require additional patient recruitment.

Description: Natural killer (NK)–cell alloreactivity can be exploited in haploidentical hematopoietic stem cell transplantation (HSCT). NK cells from donors whose HLA type includes Bw4, a public epitope present on a subset of HLA-B alleles, can be alloreactive toward recipients whose cells lack Bw4. Serologically detectable epitopes related to Bw4 also exist on a subset of HLA-A alleles, but the interaction of these alleles with KIR3DL1 is controversial. We therefore undertook a systematic analysis of the ability of most common HLA-B alleles and HLA-A alleles with Bw4 serologic reactivity to protect target cells from lysis by KIR3DL1-dependent NK cells. All Bw4− HLA-B alleles failed to protect target cells from lysis. All Bw4+ HLA-B alleles with the exception of HLA-B*1301 and -B*1302 protected targets from lysis. HLA-A*2402 and HLA-A*3201 unequivocally protected target cells from lysis, whereas HLA-A*2501 and HLA-A*2301 provided only weak protection from lysis. KIR3DL1-dependent alloreactive NK clones were identified in donors with HLA-A*2402 but not in donors with HLA-B*1301 or -B*1302. These findings clarify the HLA types that donors and recipients need in haploidentical HSCT and other NK allotherapies in order to benefit from NK alloreactivity.