[Role of laboratory monitoring in oral anticoagulant therapy]

The aim of oral anticoagulant therapy is to administer an amount of drug such that, without the induction of severe hemorrhagic complications, thrombi will not develop, or any existing thrombus will stop growing and resolve. For the laboratory control of oral anticoagulant therapy, the prothrombin time is used universally as the primary measurement. The expression of the prothrombin time as "percentage coagulation activity" or "ratio" is not useful as international measures of oral anticoagulant intensity because they are thromboplastin dependent. With the conversion of the "ratio" in International Normalized Ratio, at present it is possible to give a universal measure of oral anticoagulant intensity. It is important to underline that the application of the International Normalized Ratio to situations other than oral anticoagulant monitoring is not useful. Moreover there are other important factors contributing to the imprecision of the International Normalized Ratio: the imprecision of the International Sensitivity Index, the biological variation of the International Normalized Ratio. New approaches to oral anticoagulant therapy and its management are being explored. Immunologic assays have been developed with potential responsiveness to minimal warfarin-induced anticoagulant effects. Use of antibody reagents are in progress to document the clinical usefulness of the methods for monitoring oral anticoagulant therapy.

Bone marrow transplantation in adult thalassemia

Early trials of allogeneic marrow transplantation for homozygous thalassemia were disappointing in patients older than 16, with four of six patients dying early of graft-versus-host disease-related complications, one patient dying at 9 months of infection due to graft failure, and one dying at 6 years of recurrent thalassemia. Three classes of risk could be identified in analyses of results of transplantation in younger patients using the criteria of degree of hepatomegaly, the presence or absence of portal fibrosis, and a history of adequate or inadequate chelation therapy. Patients for whom all three criteria were adverse constituted a very high risk group (class 3) for marrow transplantation. On the basis of these analyses, a conditioning regimen was designed that yielded superior results for class 3 patients under 17 years of age. Most patients older than 16 years presenting for transplantation have disease characteristics that place them in class 3 and, because of the improved results with the new class 3 regimen in younger patients, a study was designed to treat patients older than 16 years using treatment regimens assigned on the basis of disease class. Twenty patients were treated using this protocol and, with a minimum follow-up of 9 months, there have been three early deaths, one patient has recurrent thalassemia, and 16 patients are alive disease-free. The actuarial probabilities of survival, disease-free survival, and rejection are 0.85, 0.80, and 0.05, respectively, with a survival plateau extending from 6 months to 3 years. Marrow transplantation is a reasonable option for adults with progressive thalassemia who have suitable donors.

Sudden cardiac tamponade after chemotherapy for marrow transplantation in thalassaemia

Published work suggests that cardiac tamponade occurs only occasionally after bone-marrow transplantation (BMT) but the worrying number of cases encountered in the transplant programme in Pesaro, Italy, has led to an analysis of this complication. Cardiac tamponade occurred in 8 (2%) of 400 consecutive thalassaemic patients during conditioning for or within a month of BMT. 6 cases were fatal; these represented 9% of all causes of death and 29% of those occurring between start of conditioning regimen and 30 days post transplant. The syndrome was characterised by sudden onset of circulatory shock and cardiac arrest. The only effective treatment was immediate fluid removal. The absence of myocardial lesions and the complete resolution of the syndrome after pericardiocentesis suggest that the pericardial membranes played the main part in the pathogenesis of the syndrome. Since irradiation was not part of the conditioning regimen and since 3 of the affected patients had bacteraemia, the triggering factor for the syndrome could have been the drugs used for conditioning, acting alone or together with bacteraemia and trauma. The frequency with which we encountered the syndrome, and the similarity among our patients in clinical picture, and in characteristics of the effusion, indicate that cardiac tamponade occurring in thalassaemic patients after start of chemotherapy as conditioning for BMT is a specific syndrome requiring rapid treatment.

With regards to the presence of iron granules in plasma cells

We report on the occasional presence of iron granules in plasma cells in two male patients respectively 64 and 71 years old, both with excessive drinking habits. One patient also had liver cirrhosis. In both patients the bone-marrow biopsy showed a macrocytic anemia without megaloblasts. We refer the morphologic data because the cases reported are not many and the presence of iron granules in plasma cells was a curious and rare aspect. The most important feature appearing from the data issued is the gap concerning both the source and mechanism that cause this phenomenon. Some investigations have suggested that the plasma cell iron is located in mitochondria, others have noted that iron granules were located between the Golgi region and the rough endoplasmic reticulum. Moreover, the morphologic data are not related to the number of plasma cells in the bone-marrow and there is no causal relation between alcoholic abuse and plasma cell iron. The first problem is common, the second is rare.

Immunohistochemistry of cutaneous graft-versus-host disease after allogeneic bone marrow transplantation

Graft-versus-host disease (GVHD) is an immunologically mediated disease occurring most frequently after allogeneic bone marrow transplantation. The aim of this study was to evaluate the contribution of immunohistochemistry in the diagnosis of cutaneous GVHD. Patients transplanted for either leukemia or beta-thalassemia were included in the study. Skin lesions of acute and chronic GVHD were examined both by direct immunofluorescence to detect immunoglobulin deposits and by an avidin-biotin-peroxidase complex technique to evaluate the inflammatory cell infiltrate. Epidermal and dermal fluorescent bodies (IgG and IgM) were frequently found in both acute and chronic GVHD. Most of the infiltrating cells were CD3+ T lymphocytes, with CD8+ cells representing the major cell population invading the epidermis both in acute GVHD and in chronic lichenoid GVHD. A small proportion of the dermal cells were CD14+ macrophages; no B cells were detected. HLA-DR, but not HLA-DQ antigens, were variably expressed by keratinocytes in all cases of acute GVHD and in chronic lichenoid GVHD. KL-1, a monoclonal antikeratin antibody specific for the 56.5 KD acidic polypeptide usually present in suprabasal keratinocytes, stained all epidermal layers, including the basal layer. Langerhans cells were dramatically reduced in number in the epidermis of both acute and chronic lichenoid GVHD. It is concluded that immunohistologic analysis may be supportive in the diagnosis of acute and early chronic lichenoid cutaneous GVHD.

Bone marrow transplantation in thalassemia

Since 1983, 350 patients aged 1 to 19 years with beta-homozygous thalassemia were given infusions of HLA-identical marrow after high doses of busulphan and cyclophosphamide. Survival and event-free survival leveled off about 1 year after bone marrow transplantation at 82% and 75%, respectively. In 172 consecutive patients who were treated with our current regimen since June 1985, a multivariate analysis demonstrated that portal fibrosis, hepatomegaly, and a history of inadequate chelation therapy were significantly associated with reduced probabilities of survival and event-free survival. The patients were divided into three classes on the basis of the presence of hepatomegaly, portal fibrosis, and inadequate chelation therapy. Class 1 had none of the factors and class 3 had all three factors; class 2 had different associations of two out of the three factors. For class 1 patients, the 3-year probabilities of survival and event-free survival were 97% and 94%, respectively. For class 2 patients, the probabilities were 86% and 83%, and for class 3 patients, 58% and 52%. Bone marrow transplantation from HLA-identical donors is followed by a high probability of event-free survival in thalassemic patients, particularly if they belong to class 1.

[Increase of beta 2-microglobulin in drug addicts with anti-HIV antibodies and high risk of AIDS]

The beta 2-Microglobulin is a polypeptide present on the surface membrane of both B and T cells and is integrated into the structure of HLA antigenes. The beta 2-Microglobulin concentration have been used as a reliable indicator of glomerular and tubular function of the kidney. Increased serum concentration of beta 2-Microglobulin are observed also in lymphoproliferative disorders with high cell proliferation rates. More recently, increased concentration of beta 2-Microglobulin was shown in patients with anti-HIV antibodies with or without symptomatic AIDS. We have determined beta 2-Microglobulin in 61 subjects: 40 between the ages of 25 and 35 and seemingly healthy, 21 patients between the ages of 22 and 32 and intravenous drug abuser with anti-HIV antibodies and at high-risk for AIDS. In all subjects we have tested: BUN, creatinine, beta 2-Microglobulin and T4/T8 ratio. In 40 subjects as normal controls, beta 2-Microglobulin average was means = 1.07 mg/L (SD = 0.39), T4/T8 ratio average: means = 1.06 (SD = 0.119). In 21 patients drug abuser with anti-HIV antibodies, the beta 2-Microglobulin average was cleanly increased: means = 4.72 mg/L (SD = 2.23), the T4/T8 ratio average cleanly decreased: means = 0.54 (SD = 0.21). We believe the beta 2-Microglobulin quantitation, even if not specific for patient with symptomatic AIDS, used in conjunction with other laboratory tests, principally T4/T8 ratio, will be a useful marker for recognizing persons with possible asymptomatic AIDS who are members of populations known to be at high-risk for AIDS.

Urothelial cell changes due to busulfan and cyclophosphamide treatment in bone marrow transplantation

Since the administration of cyclophosphamide and busulfan can cause hemorrhagic cystitis and changes in urothelial cells, an investigation was carried out to see whether patients undergoing bone marrow transplantation (BMT) who were treated with these drugs showed such urothelial changes and whether exfoliative urinary cytology can contribute to the early diagnosis and monitoring of such changes. Morphologic and morphometric analyses were performed on cytocentrifuged, Papanicolaou-stained preparations of 700 samples from 107 patients. Various degrees of urothelial cell changes were found in 30.8% of the cases. These changes consisted mainly of a considerable increase in the size of the nucleus and of a cytoplasm that was often bizarrely shaped. Even the structures of the nucleus and the cytoplasm changed. The results of this study showed that exfoliative urinary cytology permits an early diagnosis and monitoring of urothelial cell changes related to the administration of busulfan and cyclophosphamide in connection with BMT.

[Zinc-protoporphyrin determination in patients with sideropenic anemia and insufficient erythropoiesis]

We have measured erythrocyte Zinc-Protoporphyrin and serum ferritin in 125 subjects: 100 seemingly healthy controls, 17 with sideropenic anemia and 8 with erythropoietic insufficiency (sideropenia without anemia). Erythrocyte Zinc-Protoporphyrin was measured using Protofluor Z (Helena--Lab.) and serum ferritin was tested with immunoenzymatic technics. Patients with sideropenic anemia showed erythrocyte Zinc-Protoporphyrin values higher than controls, whereas serum ferritin was significantly lower than controls. Patients with erythropoietic insufficiency also showed erythrocyte Zinc-Protoporphyrin values higher than controls with statistical significance whereas the decrease of serum ferritin was not significant. Our study showed that Zinc-Protoporphyrin, in conjunction with serum ferritin, is a very useful test for evaluation of iron storage.

[Serum paraprotein in a patient with chronic lymphatic leukemia]

We report a case of chronic lymphocytic leukemia associated with paraproteinemia which proved to be a complete immunoglobulin IgM lambda. This case is reported because the process of cellular differentiation exposed to intrinsic or extrinsic stimulation may undergo morphofunctional variations which lead to the formation of plasma cells with extremely high secretionary capacities during the course of chronic lymphocytic leukemia.

Bone marrow transplantation in patients with thalassemia

We reviewed the results of transplantation of allogeneic marrow from HLA-identical donors in patients with beta-thalassemia who were less than 16 years old. Among the 222 consecutive patients who had received transplants since 1983, survival and event-free-survival curves leveled off about one year after transplantation, at 82 and 75 percent, respectively. Pretransplantation clinical characteristics were examined for their impact on survival, event-free survival, and the recurrence of thalassemia in the 116 consecutive patients who were treated with our current regimen, in use since June 1985. In a multivariate analysis, portal fibrosis and either the presence of hepatomegaly or a history of inadequate chelation therapy were significantly associated with reduced probabilities of survival and event-free survival. The patients were divided into three classes on the basis of the presence of hepatomegaly or portal fibrosis (class 1 had neither factor, class 2 had one, and class 3 had both). For class 1 patients the three-year probabilities of survival, event-free survival, and recurrence were 94, 94, and 0 percent, respectively. For class 2 patients the probabilities were 80, 77, and 9 percent, and for class 3 patients 61, 53, and 16 percent. We conclude that for patients under 16 years of age, transplantation of bone marrow from an HLA-identical donor offers a high probability of complication-free survival, particularly if they do not have hepatomegaly or portal fibrosis.

Allogeneic bone marrow transplantation for hematological malignancies following therapy with high doses of busulphan and cyclophosphamide

Thirty patients with malignant hematological disease underwent allogeneic bone marrow transplantation following Busulphan (Bu) and Cyclophosphamide (Cy). The diseases were chronic myelogenous leukemia, acute lymphoblastic and non lymphoblastic leukemia, myelofibrosis and multiple myeloma in complete remission and in relapse. A sustained disease-free survival (DFS) was achieved in 0/5 acute leukemia patients transplanted in relapse, in 5/7 acute leukemia patients transplanted in remission (600-1550 days) and in 6/9 CML patients transplanted in the chronic phase of the disease (500-950 days). A sustained DFS was also achieved in one 2nd BMT for relapsed CML. The data suggest that the Bu-Cy protocol combines high tumor ablative capability with toxicity comparable to previously described conditioning regimens for allogeneic BMT, particularly in diseases involving a great expansion of the bone marrow.

[Clinical significance of the determination of lactate dehydrogenase in acute leukemia and non-Hodgkin's lymphoma]

The serum concentration of LDH increases in various cancers and its increase can represent a prognostic marker of the disease and a good indicator of the tumoral mass's degree of growth. In patients with acute leukaemia, LDH can show a moderate increase only in some cases of acute non-lymphoblastic leukaemia with FAB M4 and M5 cytotype, whereas in acute lymphoblastic leukaemia LDH almost always increases, an event related to the number of white cells during remission or a relapse of the disease. In non-Hodgkin lymphomas, measurement of total LDH is not on its own a useful aid for monitoring the therapeutic response and the course of the disease. In such cases it is right to also evaluate LDH isoenzymes because they pinpoint the persistence of residual lymphomatous foci which do not affect the level of total LDH and have not clinical evidence.

Marrow transplantation for children with acute leukemia: experience of Pesaro

Thirty children aged 1-15 years with acute lymphoblastic leukemia and acute nonlymphoblastic leukemia were transplanted from HLA-matched donors using two different preparative regimens: 18 patients were prepared with cyclophosphamide and total body irradiation (TBI) while 12 patients received busulphan and cyclophosphamide. Fifteen patients survived 7 to 74 months after transplant. The association of busulphan and cyclophosphamide is a well-tolerated preparation for bone marrow transplant in children with eradicating and immunosuppressive efficacy comparable to that of the well-experienced TBI-cyclophosphamide association.

[Bone marrow transplant in acute leukemia in children. Experience of the Pesaro group]

Thirty children aged one to 15 years with acute lymphoblastic leukemia and acute nonlymphoblastic leukemia were transplanted from HLA matched donors using two different preparative regimens: 18 patients were prepared with cyclophosphamide and Total Body Irradiation while 12 patients received Busulphan and Cyclophosphamide. 15 patients survive 7 to 74 months after transplant. Although for the second group of patients a longer follow-up is needed in order to evaluate eradication of the disease and long-term toxicity, the combination chemotherapy alone results in improving survival (71% versus 28%) and decreasing relapse rate (30% versus 56%) compared with the group of patients who received the chemoradiotherapy regimen. Also the incidence of Interstitial Pneumonia has been lower in the group receiving chemotherapy alone. We conclude that this protocol is generally well tolerated in young patients, without increasing secondary toxicity.

[Blood platelet changes in myeloproliferative disorders]

Morphofunctional alterations to the platelets in myeloproliferative disorders (MPD), conditions featuring clonal rearrangement of the haemopoietic stem-cell, were examined. These platelet anomalies including morphological alterations, acquired storage pool disease, membrane alterations, altered arachidonic acid metabolism and structural alterations to the von Willebrand factor may cause thromboembolisms or haemorrhages that are responsible for a significant incidence of morbidity and mortality. In contrast the reduced mitogenic activity of the platelets may be of significant prognostic value since it proves the anomalous transformation of the megakaryocytic clone. The main in vivo and in vitro tests (bleeding time and the study of platelet aggregation) were investigate as indicators of platelet function. Unfortunately, these tests proved of little use for the early diagnosis of haemorrhage or thromboembolism in MPD.

A comparative trial of posttransplant immunosuppression in patients transplanted for thalassemia. Cyclosporine alone versus cyclosporine, cyclophosphamide, and methotrexate

This study compares the efficacy of 2 posttransplant immunosuppressive regimens for prevention of graft-versus-host disease (GVHD). Forty-four patients, ages 8-15 years, with homozygous beta thalassemia received marrow allografts from HLA-identical siblings following an ablative regimen of busulfan and cyclophosphamide. Twenty-two patients received cyclosporine (CsA) alone and 22 received cyclosporine, cyclophosphamide, and methotrexate for prophylaxis against GVHD. Two who received CsA alone have died (1 of graft rejection and 1 of acute GVHD) as did 4 patients who received 3 drugs (1 of rejection, 1 of acute GVHD, 1 of infection and cardiac failure before engraftment, and 1 of acute respiratory failure before engraftment). One patient in each group rejected the transplant and survives with thalassemia. The probability of developing acute GVHD was 41% for the CsA group and 15% for the 3-drug group (P = less than 0.05). Patients receiving CsA alone had a probability of event-free survival of 86% compared to 77% in the group receiving 3 drugs (P = 0.40) with a followup of 209-706 days. Although the study showed a decrease in the incidence of GVHD in recipients of the more intensive prophylactic regimen, this study was terminated since it was apparent that even if larger numbers of patients were studied it would be difficult to demonstrate a significant survival advantage with the use of this drug regimen.

[Primary non-Hodgkin's lymphoma of the breast. Description of a case]

A 65 year old female was admitted to Somma Lombardo Hospital (VA) for a growing mass in the right breast. Histology revealed a diffuse lymphocytic well-differentiated lymphoma. Malignant lymphoma primarily involving the breast is unusual, and its incidence is only 0.05% to 1.1% of all breast malignancies.

Urinary cytologic abnormalities in bone marrow transplant recipients of cyclosporin

The role of urinary cytology in the early diagnosis of cyclosporin nephrotoxicity was studied in 20 bone marrow transplant recipients. There was an evident cyclosporin cytopathy in 35% of bone marrow transplant recipients examined, consisting mainly of degenerative and necrotic abnormalities in cells of the proximal convoluted tubules seen in urinary samples. These findings regressed to normal after reduction of the cyclosporin dose. Urinary cytology proved to be a useful method for the early diagnosis of cyclosporin nephrotoxicity.

Marrow transplantation in patients with advanced thalassemia

In a study of the outcome of marrow transplantation in patients with advanced thalassemia, 40 patients with homozygous beta-thalassemia who were 8 to 15 years of age (median, 10) received HLA-identical allogeneic marrow after treatment with busulfan and cyclophosphamide. Twenty-eight of the 40 patients were alive and free of disease 260 to 939 days after transplantation, and 2 patients were alive with thalassemia 372 and 1133 days after transplantation. The actuarial probabilities of survival and of disease-free survival at two years were 75 percent and 69 percent, respectively. Ten patients (25 percent) died. Three died of cardiac failure, interstitial pneumonitis, or septicemia within 14 days of transplantation. Three died of infectious complications associated with acute graft-versus-host disease at 46 to 97 days, and two died of infectious complications of chronic graft-versus-host disease at 249 and 290 days. Two patients had transplant rejection and died with marrow aplasia 115 and 192 days after transplantation. One patient had rejection after four months and while the marrow was aplastic underwent a successful second transplantation; the patient was alive without thalassemia 624 days after the first transplantation. The actuarial probability of grade 2 or higher acute graft-versus-host disease in the 32 patients with initial sustained engraftment was 35 percent. Three patients had chronic graft-versus-host disease, which was fatal in two and still active on day 710 in the third. We conclude that bone marrow transplantation can potentially save patients with advanced thalassemia from an otherwise inexorable progression to death from the complications of blood transfusions. The ultimate outcome in this group of patients must await a longer follow-up.

Bone marrow transplantation in leukemia: experience of Pesaro

The authors report the results of 113 patients who underwent bone marrow transplant for acute nonlymphoblastic leukemia, acute lymphoblastic leukemia and chronic myeloid leukemia in complete remission and relapse after different conditioning regimens.

[Monoclonal gammopathies: classification of laboratory tests]

Monoclonal gammopathies have been examined and classified. In the field of chemico-clinical and immunological investigations, the various methods of analysing dysproteinaemia, of which the monoclonal component is a typical expression (electrophoresis, radial immunodiffusion, immunoelectrophoresis, immunofixation), and the main haematological and immunohaematological changes (lymphocyte biological markers) involved are reviewed. After describing the main histological and histo-cytochemical investigations, particularly amyloidosis, electronic microscope aspects and the most important chromosome abnormalities revealed by karyotype study are reported for their diagnostic interest.