ALBERT

Description: Recently, Chen et al (J Biol Chem.2005;280:5361–9) showed SHP-1 (PTPN6) gene supression by FLT3/ITD in TF-1 cell lines and in primary cells from AML patients. To address the prognostic impact that both together FLT3/ITD and SHP-1 gene suppression may have in myeloid malignancies patients, we have studied 85 patients diagnosed with de novo AML and MDS. SHP-1 gene expression was quantified by real time PCR and compared with normal CD34+ cells from healthy donors. FLT3/ITD was detected by conventional agarose gel electrophoresis after PCR. FLT3/D835 was detected by melting curve methodology. FLT3 mutations were correlated with higher WBC and blasts count at diagnosis (p=0.001). FLT3/ITD had a negative impact on DFS compared with wt or D835 mutations (log-rank p=0.054). Median levels for SHP-1 were lower in leukemic blasts than in normal peripheral blood CD34+ cells (p=0.001). SHP-1 lowest expression was found in those patients where FLT3 mutations were present (p=0.001). SHP-1 lowest expression was associated with higher blasts count in BM at diagnosis (p=0.017). Having both Flt3 mutations and lowest expression for SHP-1 were strongly associated with higher WBC (〉 20 x109/L) (p=0.005). OS univariate analysis yielded a worse prognosis for patients having both lower SHP-1 expression and harboring an Flt3 mutation (p=0.021). Figure Figure In summary, SHP-1 (PTPN6) gene supression by FLT3 constitutively activating mutations confers a bad prognosis for myeloid malignancies patients and is associated with hyperleukocytosis at diagnosis.

Description: Tumour lysis syndrome (TLS) can be a life threatening complication during induction chemotherapy in patients with acute myeloid leukaemia (AML). However, its incidence, risk stratification and management strategies are based on data mainly from lymphoid malignancies. Risk-adapted prophylactic strategies for TLS are in need with the introduction agents like Rasburicase. This single-centre retrospective chart review study was conducted to identify TLS predictive factors in a large AML population undergoing first induction chemotherapy. Between January 1980 and December 2000, 614 consecutive adult patients were diagnosed of de novo AML and started therapy in our institution. Prophylaxis of TLS consisted of intravenous hydration and oral allopurinol. Laboratory TLS (LTLS) was defined as either a 25% change from baseline or level above upper laboratory normal values (ULN) (K+〉5meq/l, Uric Acid 〉7,5mg/dl, Phosphate 〉5meq/l), or below lower laboratory normal values (Ca2+1,4mg/dl and level above ULN of at least one of the previously defined parameters. These criteria must be met within 3 days before and 7 days after the initiation of chemotherapy in absence of any other recognisable cause. Clinical TLS (CTLS) was defined as the presence of LTLS and at least one of the following complications: oliguric renal failure, hemodyalysis, signs of hyperkalemia in EKG, cardiac arrhythmia, tetania, or seizures. We used the variables identified in a multivariate analysis to construct a scoring system to predict TLS. Overall, 101 patients (17%) developed TLS. Of them 72 (12%) developed LTLS and 29 (5%) developed CTLS. LTLS did not impact induction death rate (21% vs 24%, p=0.51), but CTLS was associated with higher induction death rate (83% vs 24%, p50UI/l, Creatinine 〉1.4mg/dl, Uric acid 〉7.5mg/dl, WBC〉25x109/l, and LDH 〉1xULN. In order to perform a multivariate analysis previous selected variables were stratified as follows: WBC〉25 and ≤75x109/l, 〉75x109/l; Creatinine 〉1.4mg/dl; Uric acid 〉7.5mg/dl; LDH 〉1 and ≤4xULN, 〉4xULN. According to the hazard ratio of each variable a prognostic score system for CTLS was stated, giving 3 points for: Creatinine 〉1,4mg/dl, Uric acid 〉7,5mg/dl, WBC〉75x109/l, or LDH 〉4xULN; and 1 point for: WBC〉25 and ≤75x109/l or LDH 〉1 and ≤4xULN. CTLS incidence was 1%, 9% and 25% in patients from 0–3, 4–5, and ≥6 points respectively. 80% of patients were correctly classified, with a sensitivity of 83%, when an individual score of 4 was used as cutpoint. The observed area under the ROC curve was 87%. When our predictive model was introduced in a multivariate analysis, it remained as the solely independent prognostic factor. In conclusion, this study shows that TLS is a frequent alteration found in AML during induction therapy. Nevertheless only one third of patients who met laboratory criteria developed CTLS dramatically increasing death rate in induction. Using four routinary available laboratory data, we have developed a predictive model able to identify different CTLS risk patients subsets. This model could be useful to establish risk-adapted strategies for prophylaxis against TLS.

Description: The protein-tyrosine-phosphatase (PTPase) SHP-1 is expressed almost exclusively in hematopoetic cells. Most growth factor receptors rely on the Jak/Stat pathway for intracellular transduction, to drive specific gene expression which are involved in cell proliferation and differentiation. Abnormal signaling in some of these pathways has been linked to hematopoietic malignancies, like the ALL tel-Jak2 gene fusion. In some other cases activation is mediated by kinases not normally associated with Stats, like abl. Recently several authors have linked dysregulation of PTPases, especially SHP-1, to non-Hodgkin lymphoma, familial polycythemia, chronic neutropenia and AML. There are no reports on expression of SHP-1 in myelodysplastic syndromes. Here we hypothesize that SHP-1 downregulation may play a role in the leukemic transformation of myelodysplastic syndromes and may impact survival. Retrospectively, from January 1990 to January 2004, we studied 45 patients (29 men, 16 women; median age 70 yrs) with myelodysplastic syndromes (5 RA, 3 RAS, 3 RCMD, 9 RAEB-I, 11 RAEB-II, 2 5q-, 2 Unclass, 3 AML, 6 SMDS). Bone marrow biopsies were examined from each patient. 5 μm sections were dewaxed, heated for antigen retrieval in sodium citrate buffer, and immunostained by routine methods. Antibodies against SHP-1 and Jak-2p were purchased from Santa Cruz Biotechnology (Santa Cruz, CA) and Cell Signaling (Beverly, MA) respectively. SHP-1 and Jak-2p expression were evaluated on bone marrow samples as a percentage of positive cells. A percentage between 33 and 66 was considered normal for SHP-1 expression. Jak-2p positivity was defined as normal, if less or equal to 50 % of cells stained positively. Ranges of normal values were derived from healthy controls. With a median follow-up of 65 months, 13 (28%) showed disease progression, 9 of them towards AML. Median OS and EFS were 15 and 12 months respectively. 25 patients have died, mostly of disease related complications. The U-Mann-Whitney test comparing means between patients that progressed and those that did not was only significant (p

Description: Background. AML conventional chemotherapy followed or not by autologous stem cell transplantation could be curative for high risk MDS and sAML. Aim. To evaluate outcome in 103 patients enrolled in PETHEMA’s FLAG-IDA protocol achieving complete remission (CR) followed by intensive chemotherapy and autologous transplantation compared to those with no further treatment. Patients and methods. 103 patients were recruited from 15 institutions starting December 1997 till December 2004. Eligibility criteria: de novo MDS with Spanish score 〉2 and/or International Prognostic Scoring System (IPSS) 〉1; or sAML. Induction chemotherapy was the FLAG-IDA regime (Fludarabine, cytarabine (ARA-C), idarubicin (IDA) and G-CSF). Patients achieving complete remission (CR) had consolidation chemotherapy with IDA+ARAC+G-CSF. Patients younger than 65 yrs old who mobilized enough hematopoietic progenitors proceeded to autologous stem cell transplantation. Poor mobilizers were treated further either with allogeneic transplantation, if an appropriate donor was available, or with carboplatin (CBDCA) intensification. For patients older than 65 yrs CBDCA intensification was the only therapeutic option. Results. Patients had a median age of 62 yr (range, 17–79) with a M:F ratio of 2.4:1. According to FAB classification, 2 patients had refractory anemia (RA), 1 had refractory anemia with ringed sideroblastos (RARS), 37 had refractory anemia with excess of blasts (RAEB), 23 had RAEB in transformation (RAEB-t) and 40 (39%) had sAML. Unfavorable cytogenetics according to the IPSS was found in 46 patients (45%). According to IPSS (if suitable), 9 patients were Intermediate-1, 21 Intermediate-2 and 23 were high-risk. According to the Spanish score, 3 patients had low-risk, 29 had intermediate-risk and 31 had high-risk. Sixty-six patients (64%) achieved CR and 37 patients (46%) failed (13 patients achieved partial remission; 12 had refractory disease and 12 patients died in aplasia). No variable correlated with the achievement of CR. With a median follow-up of 16 months (range, 1–80), 31 patients remained alive in continuous CR. The median event-free survival (EFS) was 11 months (range, 2–59) and the projected 3-year EFS was 29% (95% CI, 14–44). Multivariate analysis for EFS revealed poor-risk cytogenetics according to IPSS (P=0.005) as the only independent prognostic factor associated with relapse or death. Actuarial median and 3-year EFS for the 23 patients who proceeded to autologous transplantation were 10 months and 34%, not clearly different to the 10 months and 22% observed for the 35 patients treated with chemotherapy alone (P=0.67). Conclusions. CR rate after FLAG-IDA induction chemotherapy for patients with MDS is as high as that achieved with standard chemotherapy regimes in elderly patients with AML, but treatment-related toxicity remains a serious threat. Autologous stem cell transplantation did not provide any advantage in terms of EFS in comparison with chemotherapy alone in high risk MDS or sAML. These results in a homogeneous population of patients with MDS strongly disagree with those previously reported by the EBMT group.