Leukemia Research

Editorial Board

2010-02-01

Nilotinib: A second-generation tyrosine kinase inhibitor for chronic myeloid leukemia

Massimo Breccia, Giuliana Alimena — 2010-02-01

Abstract: Imatinib mesylate is currently the standard of care for chronic myeloid leukemia (CML) patients in early chronic phase. However, the emergence of resistance and intolerance has dampened the enthusiasm for this drug. To overcome this phenomenon, different strategies have been developed, including novel targeted agents. Nilotinib, formerly known as AMN107, is a second-generation tyrosine kinase inhibitor 30-fold more potent than imatinib, with high affinity and selectivity on BCR/ABL, and also active against a wide range of mutant clones, except T315I mutation. Phase II trials of nilotinib showed high activity in imatinib-resistant or intolerant CML patients, whereas front-line treatment of the disease in chronic phase demonstrated rapid and stable cytogenetic responses and increasing molecular responses. We here review the development of nilotinib and the efficacy data in phase II and front-line trials. The aim of this review is to evaluate the pharmacology, pharmacokinetic and pharmacodynamic properties of the drug and the recent results of clinical trials performed in patients with CML and Ph+ acute lymphoblastic leukemia (ALL).

The TCL1 mouse as a model for chronic lymphocytic leukemia

Terry J. Hamblin — 2010-02-01

Abstract: The TCL1 mouse has been proposed as a mouse model for chronic lymphocytic leukemia. This review details how it resembles the aggressive form of the disease rather than the more common indolent form. Although fulfilled predictions in the human disease based on investigations in the mouse model are at present lacking, there are remarkable similarities between human and mouse leukemias that have led to interesting observations on the pathophysiology of chronic lymphocytic leukemia and have identified putative therapeutic targets.

TKIs and transplant for chronic myeloid leukemia

Mark R. Litzow — 2010-02-01

The introduction of the tyrosine kinase inhibitor (TKI), imatinib mesylate, has revolutionized the treatment of chronic myeloid leukemia (CML) . Its remarkable efficacy and relative lack of toxicity have established it as the initial therapy for all patients with CML. The remarkable saga of its development from the discovery of the Philadelphia chromosome in 1961 with the subsequent identification of the BCR-ABL tyrosine kinase as the molecular event that is causative of CML has been recently chronicled . Before the imatinib era, a small minority of patients were also able to achieve major cytogenetic responses with interferon alpha. Patients who were transplant eligible and had a suitable donor were considered for allogenic blood or marrow transplant (BMT). Even after the introduction of imatinib, uncertainty about the durability of responses to it, still lead to the use of allogeneic BMT in younger patients with CML. However, our German colleagues, to their credit, recently reported a difficult-to-conduct trial where patients underwent a genetic randomization to allogeneic BMT if they had a matched related donor or to best available drug treatment, which was initially interferon alpha with or without cytarabine, and from 1999 on, imatinib. Patients with a suitable matched unrelated donor could also proceed to unrelated donor transplant. With a median observation time of nearly nine years, survival was superior for patients receiving drug treatment. Thus, even though many patients did not receive imatinib, drug treatment was still superior, and this study has helped establish imatinib as first-line therapy for CML for all patients . Long-term follow-up of patients on imatinib indicates that 89% of patients can achieve a major cytogenetic response with complete cytogenetic responses occurring in 82% of patients . Only about 5% of patients need to discontinue imatinib because of toxicity. Some patients also fail to respond or respond initially and then lose their response. Overall, it appears that, with five to seven years of follow-up, only about 60% of patients will remain on imatinib .

Epigenetic modifications in AML and MDS

Mohammad Mahmud, Justin Stebbing — 2010-02-01

DNA methylation, amongst the known epigenetic modifications, appears to play a crucial role in leukaemogenesis. Both acute myeloid leukaemia (AML) and myelodysplastic syndromes (MDS) have a high prevalence of methylation in various genes including those encoding for p15INK4B, p21CIP1/WAF1, the oestrogen receptor, CALC1, HIC-1, E-Cadherin and others. Furthermore, progression of MDS and AML is associated with an increased rate of methylation at key promoter regions, and survival in patients with AML and MDS with genomic DNA hypermethylation is significantly reduced compared to those with no abnormal DNA methylation. Since the importance of DNA methylation in disease pathogenesis of AML and MDS is becoming more accepted, promising new approaches to target and reverse DNA methylation have been routinely used in the clinic .

Insights into Familial Platelet Disorder with Propensity to Myeloid Malignancy (FPD/AML)

Carolyn Owen — 2010-02-01

Inherited predisposition to MDS and/or AML is rare but investigation of families with these conditions has provided valuable insight into the pathogenesis of leukemia. To date, only 2 gene mutations, CEBPA and RUNX1, have been causally linked to predisposition for MDS/AML . While families with germline CEBPA mutations display no warning features prior to the development of AML, individuals with germline RUNX1 mutations usually present with thrombocytopenia and/or platelet function abnormalities, leading to a clinical diagnosis of Familial Platelet Disorder with Propensity to Myeloid Malignancy (FPD/AML) that can be evident before the onset of overt malignancy. However, the clinical history is incredibly variable with many individuals displaying no platelet abnormalities prior to the onset of MDS/AML. Additionally, the incidence of malignancy among individuals with germline RUNX1 mutations is variable, with only 35% of all affected individuals developing MDS/AML with a wide age range for onset of disease. The disease presentation is also variable; some patients presenting with MDS but others with overt AML and additional cytogenetic abnormalities are common but not consistent between individuals. The cause of this significant heterogeneity remains unclear and there are no known predictors for who is at greatest risk of developing malignancy.

Second-generation tyrosine kinase inhibitors before allogeneic stem cell transplantation in patients with chronic myeloid leukemia resistant to imatinib

2010-02-01

Abstract: Philadelphia-positive chronic myeloid leukemia (Ph+ CML) patients who are resistant to imatinib are commonly treated with second-generation tyrosine kinase inhibitors (TKIs). Limited data exist on the possible effects of these drugs on subsequent allogeneic hematopoietic stem cell transplantation (allo-HSCT).The outcome of 12 imatinib-resistant CML patients treated with dasatinib or nilotinib or both before allo-HSCT, was retrospectively analyzed.Patients were treated with second-generation TKIs for 1–17 months (median, 8). At the time of transplant, 3 patients were in complete cytogenetic response (CCgR), 3 patients in partial cytogenetic response (PCgR) and 6 patients were in less than PCgR. Donors were HLA-matched related in 4 cases and unrelated in 8 cases. Stem cell source was peripheral blood, bone marrow or cord blood in 6, 5 and 1 cases, respectively. All patients engrafted successfully and all but one achieved a full donor chimerism. Three patients experienced acute and chronic graft-versus-host disease. No cases of transplant-related mortality were recorded. Best response to allo-HSCT was complete molecular response (CMR) in 9 patients, major molecular response (MMR) in 1 patient and CCgR in 2 patients. Median follow-up was 16.5 months. At the last evaluation, 9 patients were in continuous CMR and 1 patient was in MMR; 2 patients had died of disease progression.Second-generation TKIs given before allo-HSCT do not negatively affect transplant engraftment and response rate, nor increases transplant-related toxicity.

CpG methylation analysis of the MEG3 and SNRPN imprinted genes in acute myeloid leukemia and myelodysplastic syndromes

2010-02-01

Abstract: Methylation is now established as a fundamental regulator of gene transcription. To investigate this in haematologic malignancies, we evaluated the aberrant promoter methylation of two imprinted genes (MEG3 and SNRPN) in 43 MDS and 42 AML patients. MEG3 hypermethylation occurred in 15 MDS patients (34.9%), and in 20 AML patients (47.6%). SNRPN hypermethylation was observed in 15 MDS patients (34.9%), and in 21 AML patients (50%). There were no significant correlations between WHO subtype, WPSS score, karyotype, haemoglobin levels, white blood cell count, platelet count and CpG methylation of any gene. MEG3 hypermethylation was associated with significantly reduced overall survival in individuals with AML (HR=1.98, p=0.04), while SNRPN CpG methylation was not associated with survival (HR=0.94, p=0.87). In addition, no association between survival and aberrant MEG3 (HR=2.15, p=0.072) or SNRPN methylation (HR=1.08, p=0.85) was observed in patients MDS. Our findings suggest that these genes are abnormally methylated in AML and MDS patients, and methylation of MEG3 confers worse overall prognosis. The MEG3 methylation status may serve as a useful biomarker in leukemia.

Polymorphisms in genes involved in vincristine pharmacokinetics or pharmacodynamics are not related to impaired motor performance in children with leukemia

2010-02-01

Abstract: Introduction: Impaired motor performance in children who completed treatment for acute lymphoblastic leukemia (ALL) may be related to polymorphisms of the metabolising gene CYP3A5 or vincristine toxicity related genes MDR-1 and MAPT.Methods: Motor performance was measured with the Movement Assessment Battery for Children (movement-ABC). DNA, from mononuclear blood cells was genotyped for CYP3A5, MDR-1 and MAPT polymorphisms.Results: Motor performance was not significantly affected by CYP3A5 *3/*3 and CYP3A5*1*3 genotypes, MDR-1 polymorphisms or MAPT haplotype.Conclusion: Our data did not show that CYP3A5, MDR-1 or MAPT polymorphisms are linked to impaired motor performance in children after treatment for ALL.

Implementation of standardized international karyotype scoring practices is needed to provide uniform and systematic evaluation for patients with myelodysplastic syndrome using IPSS criteria: An International Working Group on MDS Cytogenetics Study

Kathy Chun, Anne Hagemeijer, Anwar Iqbal, Marilyn L. Slovak — 2010-02-01

Abstract: Karyotype status and complexity are key components of the IPSS; however, emerging data suggest the use of cytogenetics at disease presentation is not applied uniformly among MDS patients. To investigate the degree of consistency of scoring karyotypes, the International Working Group on MDS Cytogenetics (IWGMC) conducted a survey of 32 abnormal karyotype challenges carried out in two phases: (a) an initial survey without any specified karyotype counting guidelines and (b) a second survey conducted after the development of IWGMC consensus guidelines for scoring karyotype complexity. Results indicate that IWGMC guidelines were simple and clear for the cytogeneticists in scoring karyotype complexity, but not as clear for the hematologists. We propose an immediate need for standardized international karyotype counting practices and a corresponding IPSS cytogenetic risk that can be incorporated into the cytogenetics reports of all newly diagnosed MDS patients.

BCL2 gene polymorphism could predict the treatment outcomes in acute myeloid leukemia patients

2010-02-01

Abstract: The Bcl-2 protein inhibits apoptosis (programmed cell death) of hematopoietic stem cells induced by a variety of noxious stimuli, thus mediating chemoresistance and decreasing chemosensitivity. Higher Bcl-2 expression correlates to an adverse outcome following therapy for acute myeloid leukemia (AML). The current study determined whether a BCL2 gene single nucleotide polymorphism (SNP) could affect treatment outcomes in 99 AML patients excluding acute promyelocytic leukemia. Two genotypes were tested, including BCL2 −938 C>A (rs2279115) and +21 A>G (rs1801018). Neither the −938 C>A nor the +21 A>G BLC2 genotype was associated with complete remission (CR) rates following chemotherapy. The −938 A>C BCL2 genotype did not affect leukemia-free survival (LFS), event-free survival (EFS) or overall survival (OS). However, of interest, the BCL2 +21 A>G genotype correlated with LFS, EFS and OS: The group with the +21 AA genotype had a significantly longer median LFS (p<0.001) or EFS (p=0.004), and OS (p=0.04). The multivariate analyses confirmed that this BCL2 gene SNP is an independent prognostic factor for LFS (p=0.05, HR 1.83, 95% C.I. [1.02–3.45]) and EFS (p=0.02, HR 3.13 [1.34–6.43]), but not for OS (p=0.1). This data suggests the involvement of a Bcl-2-mediated mechanism in the development of chemoresistance in AML.

Circulating Ki-67 protein in plasma as a biomarker and prognostic indicator of acute lymphoblastic leukemia

2010-02-01

Abstract: Tissue-based determination of Ki-67, a marker of cellular proliferation, has shown prognostic value in solid tumors and hematological malignancies. We developed and validated an electrochemiluminescence-based method for sensitive measurement of circulating Ki-67 in plasma (cKi-67). This assay demonstrated significantly higher levels of cKi-67 in patients with newly diagnosed acute lymphoblastic leukemia (ALL) (n=27; median, 762; range, 0–4574U/100μL) than in healthy control subjects (n=114; median, 399; range, 36–2830U/100μL). Moreover, elevated plasma cKi-67 was associated with significantly shorter survival in ALL patients (P=0.05). These findings suggest that Ki-67 can be detected in circulation and has potential for use as a biomarker for predicting clinical behavior in ALL.

Flow cytometric detection of human telomerase reverse transcriptase (hTERT) expression in a subpopulation of bone marrow cells

2010-02-01

Abstract: Telomerase activity has been found in most common cancers, thus indicating that telomerase detection may be a useful marker in cancer diagnosis. The telomeric amplification protocol (TRAP) assay and RT-PCR are customarily used to detect telomerase activity and the expression of the associated genes in cells. However, these methods do not provide any information about telomerase activation at an individual cell level. To analyze cells separately, those cells have to be isolated by sometimes complicated method. The immunohistochemical detection of human telomerase reverse transcriptase (hTERT) is useful to detect telomerase positive cells in a background of non-cancerous cells.A method has been developed for the detection of intranuclear hTERT protein, in a subpopulation of hematopoietic cells, using concurrent staining of a cell surface antigen and multicolor flow cytometry.Only mouse monoclonal anti-hTERT antibody demonstrated the specific positivity in immunocytochemistry and immunofluorescent flow cytometry. Human leukemia and myeloma cell lines showed 100% positivity, whereas normal neutrophils showed 0% positivity. hTERT expression was analyzed in hematopoietic precursor cells of bone marrow samples using concurrent staining of surface CD34 antigen and intracellular hTERT protein and multi-parameter flow cytometry. CD34 positive cells demonstrated higher expression of hTERT than CD34 negative cells.A quick, easy and sensitive assay for determining the hTERT protein expression has been developed. Using this method and the multi-parameter nature of flow cytometry and its ability to identify cellular subpopulations will provide a better understanding of the mechanisms regarding the activation of telomerase.

2CdA chemotherapy and rituximab in the treatment of marginal zone lymphoma

2010-02-01

Abstract: Standard chemotherapic approach for MZL is missing. We are presenting our monocenter experience with 2CdA±rituximab.Patients received 2CdA, 5mg/m2, weekly, for 6 weeks. Patients receiving rituximab underwent to antibody administration in association with 2CdA, or after the end of chemotherapy.Global ORR was 89.3%, with 53.6% CR, with 60 months of median of TTF.2CdA and rituximab led to 96.5% ORR, with 60.3% CR, while 2CdA alone to 73.1% ORR, with 38.5% CR. TTF median was reached at 35 months with 2CdA alone; not reached yet in the combination arm.Considering subgroups of MZL, combination therapy has a more favorable outcome in SMZL and NMZL, while MALT does not differ. However, all subgroups present a delayed relapse.Considering minimal residual disease (MRD), adding of rituximab converted 65.0% to negativity versus 15.4% of 2CdA alone, with TTF in positive patients reached after 34 months; not reached yet in negatives.Concomitant use of rituximab with 2CdA allowed an ORR of 98.0%, with 68% CR and 56.3% of MRD conversion, while consequent use 100%, 54.6%, and 70.8%, respectively. TTF does not differ.2CdA therapy is effective in the treatment of MZL. Adding rituximab allows increasing ORR and CR, prolonging TTF.

Non-Hodgkin lymphoma (NHL) subtypes defined by common translocations: Utility of fluorescence in situ hybridization (FISH) in a case–control study

2010-02-01

Abstract: We used fluorescence in situ hybridization (FISH) assays to identify t(14;18) translocations in archival paraffin-embedded tumor sections from non-Hodgkin lymphoma (NHL) cases enrolled in a population-based study. t(14;18) was identified in 54% of 152 cases, including 39% of diffuse large cell lymphomas (26 of 66 cases) and 84% of follicular lymphomas (36 of 43 cases). Eighty-seven percent of t(14;18)-positive cases and 57% of t(14;18)-negative cases expressed bcl-2. FISH assays detected twice as many t(14;18)-positive follicular lymphomas as PCR assays. Overall, study findings support the use of FISH assays to detect t(14;18) in archival tumor samples for epidemiologic studies of NHL subtypes.

An open-label, Phase I study of cediranib (RECENTIN™) in patients with acute myeloid leukemia

2010-02-01

Abstract: VEGFR and c-Kit signaling pathways may contribute to the pathophysiology of acute myeloid leukemia (AML). Thirty-five patients with AML received cediranib (RECENTIN™), an oral, highly potent VEGF signaling inhibitor with c-Kit activity, at doses of ≤30mg/day. The most common adverse events were diarrhea, hypertension and fatigue. Six patients experienced an objective response (3 each at 20 and 30mg). Dose- and time-dependent reductions in sVEGFR-2 were observed, and there was a positive correlation between cediranib exposure and the change in plasma VEGF levels from baseline. Cediranib was generally well tolerated and showed preliminary evidence of activity as a monotherapy.

A novel mouse model for the aggressive variant of NK cell and T cell large granular lymphocyte leukemia

2010-02-01

Abstract: Murine models of disease are vital to the understanding of pathogenesis and the development of novel therapeutics. We have previously established interleukin (IL)-15 transgenic (tg) mice that demonstrate rapid proliferation of natural killer (NK) and T cells, followed by spontaneous transformation to lethal leukemia. Herein, we have characterized this model, which has many features in common with the aggressive variants of NK and T large granular lymphocyte leukemia (LGLL) in humans. The LGLL blasts are cytolytic and produce IFN-γ ex vivo. Cytogenetic analysis revealed trisomy of chromosome 17 and/or 15. This model should provide opportunities to develop effective standard therapies for this fatal disease.

Irradiated Blm-deficient mice are a highly tumor prone model for analysis of a broad spectrum of hematologic malignancies

2010-02-01

Abstract: Mutations in the BLM gene cause human Bloom syndrome (BS), an autosomal recessive disorder of growth retardation, immunodeficiency and cancer predisposition. Homozygous null Blmm3/m3 mice are cancer prone with a 5-fold increased risk of cancer compared with Blmm3/+ and Blm+/+ mice. Irradiation of Blmm3/m3 mice increased the risk to 28-fold. Tumors occurred mainly in the hematopoietic system and were similar to those in BS based on detailed histologic and immunohistochemical analyses. Irradiated Blm-deficient mice thus provide a novel model for understanding accelerated malignancies in BS and a new platform for investigating the molecular basis for a wide range of hematopoietic neoplasms.

Preclinical antileukemia activity of JNJ-26481585, a potent second-generation histone deacetylase inhibitor

2010-02-01

Abstract: Histone deacetylase (HDAC) inhibitors have been shown to induce cell cycle arrest, terminal differentiation, and apoptosis in a broad spectrum of human tumors and animal xenograft models. JNJ-26481585 is a hydroxamic acid derivative, second-generation pan-HDAC inhibitor that has demonstrated high potency in preclinical studies. In the current study, we demonstrated that JNJ-26481585 has antileukemia and molecular activity in leukemia cell lines and primary human leukemia cells. We also observed a synergistic effect between treatment with decitabine and JNJ-26481585. In conclusion, JNJ-26481585 is a potent second-generation pan-HDAC inhibitor with activity in human leukemia, and it is currently in clinical development.

Enhancement of arsenic trioxide cytotoxicity by dietary isothiocyanates in human leukemic cells via a reactive oxygen species-dependent mechanism

Nicole A. Doudican, Benjamin Bowling, Seth J. Orlow — 2010-02-01

Abstract: Although clearly effective in acute promyelocytic leukemia (APL), arsenic trioxide (ATO) demonstrates little clinical benefit as a single agent in the treatment of non-APL hematological malignancies. We screened a library of 2000 marketed drugs and naturally occurring compounds to identify agents that potentiate the cytotoxic effects of ATO in leukemic cells. Here, we report the identification of three isothiocyanates (sulforaphane, erysolin and erucin) found in cruciferous vegetables as enhancers of ATO cytotoxicity. Both erysolin and sulforaphane significantly enhanced ATO-mediated cytotoxicity and apoptosis in a panel of leukemic cell lines; erucin activity was variable among cell types. Cellular exposure to sulforaphane in combination with ATO resulted in a dramatic increase in levels of reactive oxygen species (ROS) compared to treatment with either agent alone. Sulforaphane, alone or with ATO, decreased intracellular glutathione (GSH) content. Furthermore, addition of the free radical scavenger N-acetyl-l-cysteine (NAC) rescued cells from ATO/isothiocyanate-mediated cytotoxicity. Our data suggest that isothiocyanates enhance the cytotoxic effects of ATO through a ROS-dependent mechanism. Combinatorial treatment with isothiocyanates and ATO might provide a promising therapeutic approach for a variety of myeloid malignancies.

Valproic acid exerts differential effects on CXCR4 expression in leukemic cells

2010-02-01

Abstract: We recently reported that the histone deacetylase inhibitor, valproic acid (VPA), increases CXCR4 receptor expression and function in cord blood hematopoietic stem/progenitor cells (HSPC) and the immature, highly CD34-positive AML cell lines KG-1a and KG-1. In this study, we investigated whether VPA influences CXCR4 in CD34-negative AML cell lines (promyelocytic HL-60 and monocytic THP-1), as well as both CD34-positive and CD34-negative primary AML cells. We found that VPA (i) diminishes CXCR4 expression and chemotaxis in HL-60 cells and in the CD34-negative subtypes of primary AML cells and (ii) increases CXCR4 expression and function in the highly CD34-positive subtypes of primary AML cells. Hence, we suggest that VPA exerts different effects on CXCR4 depending on cell maturation status, and this novel finding may have important implications for AML therapy.

Constitutive down-regulation of Osterix in osteoblasts from myeloma patients: In vitro effect of Bortezomib and Lenalidomide

2010-02-01

Abstract: Bortezomib and Lenalidomide have been shown to be effective in the control of multiple myeloma (MM) progression. We have investigated their role in the in vitro expression of Osterix by primary osteoblast cultures from MM patients and found that Osterix RNA was constitutively down-regulated in these cells. Treatment of osteoblasts with Bortezomib resulted in an increase of Osterix RNA and in enhanced activity of both BMP-2 and Runx2. Instead, Lenalidomide was unable to modify Osterix transcription. These findings provide additional evidence suggesting that, at least in vitro, Bortezomib promotes the osteoblast maturation whereas Lenalidomide is ineffective.

Cytotoxic effects of celecoxib on Raji lymphoma cells correlate with aggravated endoplasmic reticulum stress but not with inhibition of cyclooxygenase-2

2010-02-01

Abstract: Inhibition of cyclooxygenase 2 (COX-2) by the selective COX-2 inhibitor celecoxib has been suggested as potentially useful for B-cell lymphoma therapy. However, additional pharmacological activities of celecoxib have been discovered and have challenged the notion that its antitumor effects are mediated primarily via the inhibition of COX-2. To shed light on this issue, we have investigated the effects of different pharmacological agents with greatly varying COX-2 inhibitory potency in Raji lymphoma cells in vitro. We found that cytotoxic potency of these compounds did not at all correlate with their COX-2 inhibitory activity; in fact, the most potent COX-2 inhibitors lacked the ability to kill Raji cells. Instead, the cytotoxic outcome was closely aligned with these agents’ ability to trigger endoplasmic reticulum (ER) stress, which could be further enhanced by bortezomib, an agent with known ER stress-inducing potency. Together, these results indicate that celecoxib's cytotoxic effects on Raji lymphoma cells do not involve the inhibition of COX-2.

A gene expression signature of primary resistance to imatinib in chronic myeloid leukemia

2010-02-01

Abstract: Using gene expression profiling we show that the expression of 105-probe sets in mononuclear cells collected from chronic myeloid leukemia (CML) chronic phase (CP) patients with raised leukocyte counts who subsequently achieved complete cytogenetic response after 12 months on imatinib, differed substantially from that of patients who failed to achieve any degree of cytogenetic response. In the non-responder cohort, 9 of the 50 overexpressed genes were involved in DNA repair by homologous recombination, whereas 36 genes, including PTEN, were downregulated. This pattern of altered gene expression in responders and non-responders was validated in another independent dataset. These findings may prove useful for identifying at the time of diagnosis a subset of CP-CML patients who are likely to be resistant to imatinib and require an alternative treatment.

Telomerase gene mutation screening in Chinese patients with aplastic anemia

Bing Han, Bo Liu, Wei Cui, Xuan Wang, Jie lin, Yongqiang Zhao — 2010-02-01

Abstract: To study the incidence of telomerase gene mutations in Chinese patients with acquired bone marrow failure (BMF) and explore its relationship with telomere shortening. Blood samples from 66 patients with aplastic anemia (AA) in northern China were collected and TERC mutation analysis was performed. Two TERC mutations were identified. The incidence of telomerase gene mutations in Chinese people with acquired AA is similar to that of the western people.

Detection of exon 12 type A mutation of NPM1 gene in IMS-M2 cell line

2010-02-01

Abstract: Nucleophosmin 1 (NPM1), a protein that shuttles between the nucleus and cytoplasm, is mostly located in nucleoli. This is a multifunctional phosphoprotein to which both tumor-suppressor and oncogenic functions have been attributed. Here, we have found the cell line with the type A NPM1 mutation and with the other genetic alterations including ETV6-NTRC fusion. It will provide a good in vitro model for bio-molecular studies of interaction of mutated NPM1 gene and other genetic abnormalities as well as a useful tool for developing new molecularly targeted drugs.

Primary cutaneous anaplastic large-cell lymphoma presenting with hemophagocytic syndrome: A case report and review of the literature

2010-02-01

Abstract: Primary cutaneous anaplastic large-cell lymphoma (C-ALCL) is a rare entity of lymphoma. We report a case of C-ALCL presenting with hemophagocytic syndrome and skin lesion with giant ulcer. Histopathological examination of the skin biopsy specimens showed non-epidermotropic infiltrates with cohesive sheets of large tumor cells. The tumor cells showed CD4−, CD8+, CD30+, CD56−, ALK−, TIA-1+, and granzyme B+. C-ALCL is generally a disorder that progresses slowly and has a good prognosis. Manifestation of a giant ulcer and hemophagocytic syndrome, such as in the present case, is rare.

t(X;17) as the sole karyotypic anomaly in a case of M3r subtype of acute promyelocytic leukemia without RARα rearrangement

Huan-Ping Wang, Huan Xu, Zhi-Mei Chen, Xiang-Min Tong, Wen-Bin Qian, Jie Jin — 2010-02-01

Abstract: We describe here a unique chromosomal abnormality found in a patient with M3r subtype of APL. Neither t(15;17) nor rearrangement of RARα was detected by routine R-banded chromosome as well as fluorescence in situ hybridization (FISH) analysis using PML/RARα dual-color dual-fusion translocation probe and RARα dual-color break apart rearrangement probe. Instead of the typical rearrangement between chromosomes 15 and 17, all cells analyzed had a translocation between X and 17 as the sole karyotypic anomaly. The translocation was conformed by whole chromosome painting (WCP) with painting probes of chromosomes X and 17. To our knowledge, this is the first documented APL with a novel translocation involving chromosomes X and 17 without RARα gene rearrangement.

IgG secreting lymphoplasmacytoid leukemia with massive skin involvement and very aggressive clinical course: An exceptionally rare observation

2010-02-01

Lymphoplasmacytic lymphoma (LPL) is a lymphoproliferative disorder which usually has an indolent course . We recently observed a leukemic form of LPL with a very aggressive clinical course and with massive skin infiltration. A 44-year-old woman was under observation because of malaise and fatigue as result of a moderate pancytopenia. She presented with pallor and poor clinical general condition. Her past history was not contributory. Physical exam revealed no remarkable findings; in particular, no superficial lymph nodes were palpable. A whole body computed tomography (CT) scan showed multiple enlarged adenopathies but no bulky localization. The laboratory evaluation showed moderate pancytopenia and a monoclonal paraprotein (2g/dL, IgG-k isotype); serum calcium and comprehensive metabolic panel results were normal. A whole skeleton X-ray survey revealed no bone lytic lesions. Morphological evaluation of a peripheral blood (PB) smear did not show atypical lymphoid cells. A bone marrow (BM) trephine biopsy was taken and diffuse BM involvement by atypical lymphoplasmacytic cells was diagnosed (A–G). Unfortunately, cytogenetic and molecular studies were not performed, so data on important prognostic factors, such as del (17p), were not available. Moreover, the patient had no superficial adenomegaly and her clinical status did not allow surgical excision of a deep lymph node in order to permit a histological diagnosis of LPL versus other small B-cell neoplasm or a concurrent plasma cell dyscrasia. The patient was treated with a regimen including fludarabine, cyclophosphamide and rituximab (FCR) given intravenously for two cycles. Indeed, after the completion of the second FCR course, she presented a long-lasting pancytopenia and the development of prominent and diffuse dermal lesions followed by a remarkable spread in the peripheral blood (PB) of atypical lymphoid cells showing the following immunophenotype (IF): CD20+, BCL2+, CD43+, CD138+/−, CD10−, CD5−, CD23−, which was associated with cytoplasmic positivity for k light chains. A diagnosis of IgG secreting lymphoplasmacytoid leukemia was made. The BM trephine biopsy revealed a hypocellular BM with 30–40% atypical lymphoplasmacytic cells displaying the same morphologic and immunophenotypic features presented by circulating lymphoid cells and, in a lower amount, mature plasma cells (CD138 positive); both tumor populations showed the same light chain restriction. Moreover, the same IF features were expressed by tumor cells infiltrating the skin (H and I). The patient's clinical condition rapidly worsened, reaching a very poor general status for which she was unsuitable for more aggressive salvage treatments for lymphoma with or without stem cell support. Therefore, she was unsuccessfully treated with a bortezomib-based regimen; alkylating agents, such as melphalan (15mg/m2) and then intermediate doses (1000mg/m2) of cyclophosphamide were also given without any benefit. Indeed, she rapidly progressed until her death occurred from massive pneumonia and septic shock. The present case illustrates an unusually acute course of an IgG secreting LPL which was refractory to several therapeutic measures. Although an aggressive course of LPL may be observed in clinical practice, its occurrence in such a rapidly progressive and refractory form has rarely been reported; moreover, the involvement of the skin by LPL is another exceptionally rare finding , which was observed in our experience concomitantly with the highest leukemic spread and the most rapidly progressive phase of the disease. Some important findings on this issue may be drawn from a brief literature review. Indeed, although the vast majority of cases of LPL express IgM and not IgG, there are very rare and well described cases of IgG secreting lymphoplasmacytoid leukaemia . Indeed, an unusual subset of low-grade lymphoma with high-serum IgG and frequent lymphoplasmacytoid features has been reported in a study including 16 patients whose clinical history was that of a nonaggressive disease with dominant splenomegaly and long survival. In 6 out 16 patients, only IgG expression was determined whereas a coexistent serum monoclonal IgM and/or surface IgMG+ with identical light chain was identified in 10 patients. Molecular studies indicated a clonal relationship between cells expressing IgM and IgG, with one case being biclonal. Cytogenetic evaluation showed a high incidence of trisomy 12 (60%) and 13q14 deletion (40%).

Micafungin-induced hemolysis attack due to drug-dependent antibody persisting for more than 6 weeks

2010-02-01

Micafungin, which is the class of echinocandin antifungal drugs that inhibit β-(1,3)-d-glucan synthesis that is the main composition element of fungal cell walls in the peculiarity and has an excellent antimycotic activity, possesses high effectiveness against invasive aspergillosis and Candida spp., it excels also in safety, and it is used for the management of fungal infections to neutropenic patients after intensive chemotherapy or hematopoietic stem cell transplantation. Nanri et al. recently reported 2 patients developing acute hemolysis followed by acute renal failure due to micafungin administration . They revealed that red blood cells (RBCs) caused agglutination by the mixture of micafungin and the patient's plasma samples in the indirect antiglobulin test (AGT). Acute hemolysis due to a particular drug is important in managing hematologic malignancies, since it may indirectly or directly affect therapeutic strategy. We encountered an additional case of micafungin-induced hemolysis during pretreatment for hematopoietic stem cell transplantation, which hampered therapeutic further intervention.

A novel MLL-AF1p/Eps15 fusion variant in therapy-related acute lymphoblastic leukemia, lacking the EH-domains

2010-02-01

Chromosomal translocation involving the MLL gene, located at 11q23, is the most frequent abnormality in hematological malignancies and more than 50 genes have been identified as MLL fusion partners. However, unifying leukemogenic properties of partner genes remain unclear. Here, we describe a novel MLL-AF1p/Eps15 (epidermal growth factor receptor pathway substrate 15) fusion variant in previously reported therapy-related acute lymphoblastic leukemia (ALL) patient and argue for the function of AF1p as MLL fusion partner gene.

Complications of chronic lymphocytic leukemia: Analysis of 203 cases in China

Tong Wu, Zen-jun Li, Lu-gui Qiu — 2010-02-01

Chronic lymphocytic leukemia (CLL) patients are prone to various complications, such as infections, autoimmune diseases (AID), second tumors or transformations. CLL is the most frequent type of leukemia in the western world, but it is rarely seen in Asian countries . Very limited data published in Chinese patients with respect to the incidence rate, category and prognosis of CLL complications. To explore the characteristics of complications in Chinese CLL patients, 203 cases of CLL patients from the Institute of Hematology and Blood Diseases Hospital, Tianjin, China, from the year 2000 to 2007 were reviewed and followed-up retrospectively.

Motor disability in malignant hematology: An epidemiological study on Italian hospitalized patients

2010-02-01

Hematological malignancies (HM) may be progressively complicating by debilitating deteriorations of the personal status, physical deconditioning and several forms of motor disability (MD), often leading to severe limitations in performing activities of daily living (ADL) and in the loss of the individual independence. Although several forms of MD are frequent complaints of HM patients, yet information regarding its origins frequency and management is relatively scarce and most published data on this issue comes indirectly from studies focusing on solid tumours . A large variety of disabling conditions, which may be related to disease activity and/or to treatments, may be observed in this setting. In order to address this issue, we evaluated the incidence of MD in a group of consecutive and hospitalized patients with HM. In this regard, MD was assessed weekly using Barthel Index (BI) , which was used as basic ADL ability scale, and was classified as mild (BI>66%), moderate (BI, 33–66%) and severe (BI<33%). The level of 10 disability-related items (muscle, bone, joint, central nervous system, peripheral nervous system, psychological aspects, lung, heart, movement-related pain, eyes) was defined to investigate the level of impairment. There were 109 patients with median age was of 60 (20–76) years. Diagnoses were as following: acute leukemias, 37; lymphoma/chronic lymphocytic leukemia, 35; multiple myeloma, 19; myelodisplastic/myeloproliferative disorders, 18. Because of the possible modifications of disease phase or treatment over time, patients were evaluated weekly and assessed according to their disease phase. Out of 354 weeks of evaluation, 110, 53, 42, 65, 49 and 35 were the number of weeks in which the patients were evaluated in complete remission (CR), partial remission (PR), relapse, progression, new diagnosis and undefined diagnosis, respectively. Similarly, 273, 22, 24 and 35 were the weeks of active, palliative treatment, no treatment and unknown treatment respectively. Disability was present in 52/109 (48%) patients; mild in 17%, moderate in 14% and severe in 17% of patients, respectively. MD was present in 34% (122/354) of the weeks of the study evaluation. The degree of disablement was recorded as mild in 14%, moderate in 10% and severe in 10% of the weeks of the study, respectively. Statistically significant (p<0.05) lower risk of MD was noted in active vs. other treatment (41% vs. 27%) and in CR/PR vs. other disease phases (30% vs. 48%). Among the MD patients, muscle impairment (18%), movement-related pain (10%) and bone lesion (10%) were the major underlying mechanisms of MD found. The cause of disability was related to hematological disease in 32%, to disease-related complications in 7%, to therapy related effects in 46% and to other causes in 15% of patients respectively. In conclusion, although preliminary and related to a limited series of patients, our data provide new insights on a neglected issue in hematology, such as disability. Indeed, MD is a frequent feature in hematological hospitalized patients but not structured interventional programs are available in the majority of wards. Extended data analysis is required to achieve a better understanding about the disablement process and its related risk factors in this setting. Moreover, a targeted rehabilitative approach to prevent and treat disability may lead to positive effects on both patient's quality of life and caregiver work-load.

Pain and emotional distress in leukemia patients at diagnosis

2010-02-01

The few available studies on leukemia patients have so far addressed only the issue of physical pain and emotional distress in terminally ill patients The prevalence of pain during the last 3 months of life of Italian cancer patients was reported to be 83% in lymphoma and leukemia patients, according to what reported by their caregivers . This result is much higher compared with other studies reporting a prevalence of 5% in leukemia and 38% in lymphoma patients .

Refractory anaemia with ring sideroblasts associated with marked thrombocytosis (RARS-T) and JAK2V617F mutation transformed to acute myeloid leukaemia with chromosomal evolution including monosomy 7

Achille Pich, Laura Godio — 2010-02-01

Refractory anaemia with ring sideroblasts associated with marked thrombocytosis (RARS-T) is a provisional entity within the World Health Organization category myelodysplastic/myeloproliferative neoplasm, unclassifiable (MDS/MPN,U) . JAK2V617F mutation is found in virtually all patients with polycythemia vera (PV) and in approximately 50% of patients with essential thrombocythemia (ET) and primary myelofibrosis (PM) . About 50% of patients with RARS-T also display JAK2V617F mutation : this suggests that RARS-T may constitute another JAK2 mutation-associated form of MPN . Interestingly, it was shown that patients with RARS-T and JAK2V617F mutation have a more favourable prognosis than those without the mutation . However, we have recently seen a patient with JAK2V617F positive RARS-T transformed to acute myeloid leukaemia with chromosomal evolution and persistent JAK2V617F mutation, and here report the case.

Clonal relationship between precursor B-cell acute lymphoblastic leukemia and histiocytic sarcoma: A case report and discussion in the context of similar cases

Rebecca McClure, Joseph Khoury, Andrew Feldman, Rhett Ketterling — 2010-02-01

There have been several reports of patients with two hematopoietic neoplasms, one showing B-cell differentiation and the other being a histiocytic (H) or dendritic cell (DC) sarcoma (). It is intriguing that the two neoplasms have been found to be clonally related in all cases with clonality studies reported. We recently evaluated a patient who developed histiocytic sarcoma following treatment for precursor B-cell acute lymphoblastic leukemia (B-ALL) and demonstrated that the two neoplasms were clonally related.

Clarification on the categorization of comorbidities

Rong Wang, Xiaomei Ma — 2010-02-01

Comorbidities are coexisting diseases that are distinct from the primary illness for which a patient seeks health care services . Comorbidity may affect detection, prognosis, therapy, and outcome of the primary disease. We recently published a paper evaluating the role of comorbidities in the survival of patients with myelodysplastic syndromes, in which Charlson index was utilized as the measure of comorbidities .

Imatinib achieved complete cytogenetic response in a CML patient received 32-year indirubin and its derivative treatment

2010-02-01

Chronic myeloid leukemia (CML) is a clonally hematologic malignant disease arising in the stem-cell compartment. Patients with CML show considerable heterogeneity both in their presenting clinical features and in the time taken for evolution to blast crisis . Herein we report the unusual case of a patient with Ph chromosome-positive CML who achieved complete hematological response and a long survival of 32 years with indirubin and its derivative, meisoindigo, treatment. During that long period the white blood cell count was stable and no progression of the disease was noted, whereas Philadelphia chromosome was detectable. Imatinib was given resulting in a complete cytogenetic response 3 months later.

BCR-ABL transcripts are not detected in cord blood or the peripheral blood of the newborn child whose mother developed chronic myeloid leukemia while pregnant

2010-02-01

Abstract: Background and objectives: The treatment of choice for the pregnant woman with CML has not been defined. Exposure to imatinib while pregnant may cause serious fetal malformations and interferon-α is sometimes associated with side effects. Furthermore, little is known of the possibility that BCR/ABL-positive cells might be passed to the fetus and the role of the treatment given to the pregnant mother.Design and methods: Detection of BCR-ABL transcripts in the peripheral blood of the mother, the newborn and the cord blood was performed by quantitative real time PCR and FISH.Results: A patient with CML diagnosed at the beginning of pregnancy was treated with leukapheresis at 31 weeks of gestation until delivery without any untoward effects. Since no tyrosine kinase inhibitor was administered BCR-ABL transcripts contamination of the cord blood and peripheral blood of the newborn was a reasonable concern. In practice no transcripts were detected in the cord blood or in the peripheral blood of the newborn at birth, at 1 month or 3 at months of age despite the fact that throughout her pregnancy and on the day of delivery the mother had 90% BCR/ABL positive cells in her blood.Interpretation and conclusions: Leukapheresis does not eliminate the malignant clone; however the absence of BCR-ABL transcripts in the peripheral blood of the neonate and in the cord blood supports the view that transmission of CML to a fetus is improbable even if the mother's treatment during pregnancy is suboptimal.