Cytogenetic response to autografting in chronic myelogenous leukemia correlates with the amount of BCR-ABL positive cells in the graft

OBJECTIVE

An important step in successful autografting of patients with chronic myelogenous leukemia is the delivery of a leukemia-free graft. We conducted this study to determine whether the cytogenetic response after autografting was correlated with the number of BCR ABL-positive cells present within the stem cell grafts.

MATERIALS AND METHODS

By BCR-ABL mRNA quantification, we studied the serial pheresis products from 40 Philadelphia (Ph)-positive patients who received ICE/mini-ICE mobilization therapy and underwent autologous stem cell transplantation. We correlated the residual disease within the graft reinfused with the cytogenetic response following transplantation, taking into consideration those responses that lasted 12 months or more.

RESULTS

Thirty-two patients received a graft with 0-35% Ph-metaphases and 19 received a graft with BCR-ABL/ABL ratio < or =0.01. After a median of 27 months (range, 12-50) from transplant, 18 patients achieved complete or major cytogenetic response lasting at least 12 months, and 14 of them (78%) received a graft with BCR-ABL/ABL ratio < or =0.01 (range, 0.0003-0.01). Twenty-two patients experienced short-lived responses or had >35% Ph-positive cells in the marrow after transplant, but only 5 of them (23%) had a graft with BCR-ABL/ABL ratio < or =0.01 (range, 0.001-0.01). Therefore, we found a strong association between a BCR-ABL/ABL ratio less than or =0.01 and the achievement of complete or major cytogenetic remission after autografting (chi(2) test, p = 0.0001). Patients reinfused with grafts contaminated at low levels with leukemic cells also showed a longer duration of the response (log-rank test, p = 0.0009). Eleven patients were reinfused with the lowest level of contaminated stem cell collections, according to the BCR-ABL/ABL ratio. None of these patients experienced prolonged neutropenia or thrombocytopenia following stem cell reinfusion and nine of them had long-lasting complete or major cytogenetic responses after transplant.

CONCLUSION

This study demonstrates that the number of BCR-ABL positive cells present in a stem cell graft is an important predictive factor for the achievement and the duration of cytogenetic response after autografting. [corrected]

Littoral cell angioma with severe thrombocytopenia

Littoral cell angioma (LCA) is a recently described splenic vascular tumor. We present a new case in a 62-year-old woman with severe thrombocytopenia and mild bleeding diathesis, but without palpable splenomegaly. Abdominal ultrasound and magnetic resonance showed multiple nodular images, suggesting splenic hemangiomas. A platelet kinetic study revealed a very short platelet survival. As the spleen was the site of platelet destruction, splenectomy was carried out. Histopathological and immunohistochemical data allowed a final diagnosis of LCA. Following splenectomy, the patient showed a transitory normalization of the platelet counts. Thrombocytopenia then reappeared but was moderate, without hemorrhagic diathesis. A second platelet kinetic study, performed 16 months post-splenectomy, showed hepatic platelet destruction. However, there were no macroscopic hepatic lesions in a second abdominal magnetic resonance study. This case illustrates the difficulties involved in determining the etiology of many peripheral thrombocytopenias.

DNA image cytometry. An alternative method in osteoblast proliferation assays

OBJECTIVE

To assess whether DNA image cytometry can be used as an alternative method to tritiated thymidine uptake quantification in osteoblast proliferation assays. STUD DESIGN: Proliferation of normal human osteoblasts incubated with normal human serum at 0%, 2.5%, 5%, 10%, 20% and 40% was quantified by tritiated thymidine uptake quantification and DNA image cytometry.

RESULTS

Tritiated thymidine uptake quantification showed that normal human serum stimulated the proliferation of normal human osteoblasts and that the degree of stimulation was directly related to the concentration of serum in the culture medium. Similar results were obtained when the DNA image cytometry assay was used. A highly significant linear relationship between the ranks of both methods was found (Spearman's r = 1.00, P = .0253).

CONCLUSION

DNA image cytometry may be a valuable alternative when the use of radioactive material is not desired and/or subsequent morphologic or immunocytochemical characterization of cells under study is required.

Chronic myeloid leukemia with expression of ALL-type BCR/ABL transcript: a case-report and review of the literature

CML with exclusive expression of ALL-type bcr/abl has only been rarely described. In some cases, the presence of this fusion gene has been associated to a differentiated subtype of CML that share some features with CMML, while in another case this molecular hallmark has been associated to a bad prognosis of the disease with a blast phase as clinical presentation or an early transformation to blast phase. We report a case of a 30-year-old woman who was diagnosed of CML in chronic phase in May 1989. She received treatment first with busulfan, achieving hematological remission and afterwards with interferon and Hydroxiurea. In February 1998, she was admitted at our hospital for an ABSCT. Then, molecular studies were performed. Multiplex PCR revealed the presence of a 481 bp product identified as the ela2 bcr/abl transcript and confirmed by sequencing. After 9 years from diagnosis, the patient remains in hematological remission and in good clinical condition.

Squamous cell carcinoma of the vulva: study of ploidy, HPV, p53, and pRb

Seventy-one cases of invasive squamous cell carcinoma (ISCC) of the vulva were compared with 18 cases of vulvar intraepithelial neoplasia (VIN) and 21 cases of lichen sclerosus. Ploidy was studied by image analysis, HPV-DNA by PCR, and p53 and pRb by immunohistochemistry. Univariate and multivariate statistical analyses were performed. The mean age of the patients with ISCC was 70.6 years; only 8.5% were < 60 (range, 43-89) years. For the 43 patients with follow-up, FIGO surgical stages were I in 16.2%, II in 48.8%, III in 27.9%, and IV in 6.9%. The 5-year survival was 90% for the patients with curative surgery (vulvectomy and lymphadenectomy) and 32% for those with tumors in stages III to IV. Previous history of nonneoplastic epithelial alterations was recorded in 54%. Vascular invasion was detected in 4.3% and perineural invasion in 21.4%. Inguinal lymph node metastases were present in 34.9% of the cases. Fifty-one (72%) ISCCs were aneuploid, HPV-DNA-16 was detected in 7 (12.3%) cases, overexpression of p53 was found in 40 (56%), and pRb expression was negative in 15 (21.4%). Fifteen cases (80%) of VIN were aneuploid, 5 (27.7%) contained HPV-DNA, 11 (61%) were positive for p53, and all immunoreacted for pRb. All lichen sclerosus cases were diploid, did not contain HPV-DNA, failed to stain for p53, and were positive for pRb. Our study confirmed the prognostic value of conventional pathological features: stage, lymph node metastasis, histological grade, and vascular and perineural invasion; all were statistically significant for survival in the univariate analysis. Also, ploidy was significant in patients with stages I and II tumors. The only significant variable in the multivariate analysis was stage. p53 overexpression appears as a late event in vulvar carcinogenesis, but it may occur before tumor invasion. Lack of pRb expression can occur in vulvar neoplasia, but it does not seem to play any role in the initiation or prognosis of vulvar ISCC.

Quantitative competitive reverse transcriptase-polymerase chain reaction for BCR-ABL on Philadelphia-negative leukaphereses allows the selection of low-contaminated peripheral blood progenitor cells for autografting in chronic myelogenous leukemia

The Philadelphia (Ph) translocation t(9;22) results in the creation of the BCR-ABL gene, which is now regarded as central to the mechanism that underlies the chronic phase of chronic myelogenous leukemia (CML). From a clinical point of view, BCR-ABL mRNA detection has become the basis for the study of minimal residual disease in CML, particularly when a complete cytogenetic remission is achieved after interferon-alpha (IFN-alpha) therapy or allogeneic stem cell transplantation. We have recently demonstrated that it is possible to mobilize normal peripheral blood progenitor cells (PBPC) in higher rates if this procedure is performed during the early chronic phase. In an attempt to monitor the leukemic cell content of PBPC collections, we used quantitative-competitive RT-PCR (QC-RT-PCR). Thirty consecutive Philadelphia (Ph) chromosome positive patients were enrolled in this study. After chemotherapy and G-CSF, 14 patients achieved 100% Ph-negative metaphases, nine patients had < or =34% and seven patients >34% leukemic metaphases. A total of 116 collection samples were studied. For each sample, BCR-ABL transcript numbers and BCR-ABL/ABL ratio were evaluated. A highly significant correlation between Ph-positive metaphases and BCR-ABL transcript numbers (r = 0.84, P < 0.0001) or BCR-ABL/ABL ratio (r = 0.86, P < 0.0001) was found. For patients that underwent the procedure in early chronic phase, Ph-negative collections showed different levels of BCR-ABL expression. BCR-ABL transcript numbers varied from a median of 100/microg RNA in the first and second leukaphereses, to 500/microg RNA in the third and fourth leukaphereses, and 1500/microg RNA in the fifth leukapheresis (P = 0.002). BCR-ABL/ABL ratio values showed similar kinetics. We have also demonstrated that there is a correlation between low values in BCR-ABL/ABL ratio (< or =0.01) in the reinfused PBPC and the achievement of cytogenetic remission after autografting (chi2 test, P = 0.01). In conclusion, this study demonstrates that QC-RT-PCR for BCR-ABL is a reliable and helpful method for monitoring residual leukemic load in mobilized PBPC, particularly in Ph-negative collections. Moreover, QC-RT-PCR allows selection of the best available collections for reinfusion into patients after myeloablative therapy.

Autografting with philadelphia chromosome-negative mobilized hematopoietic progenitor cells in chronic myelogenous leukemia

Intensive chemotherapy given in early chronic phase of chronic myelogenous leukemia (CML) has resulted in high numbers of circulating Philadelphia (Ph) chromosome-negative hematopoietic progenitor cells (HPC). We have autografted 30 consecutive patients with CML in chronic phase with HPC collected in this way to facilitate restoration of Ph-negative hematopoiesis in bone marrow after high-dose therapy. Hematopoietic recovery to greater than 0.5 x10(9)/L neutrophils and to greater than 25 x 10(9)/L platelets occurred in all patients, a median of 13 (range, 9 to 32) days and 16 (range, 6 to 106) days postautograft, respectively. Regenerating marrow cells were Ph-negative in 16 (53%) patients and greater than 66% Ph-negative in 10 (33%) patients. Twenty-eight patients are alive 6 to 76 months (median, 24 months) after autografting. Three patients have developed blast crisis from which 2 have died. Eight patients are in complete cytogenetic remission at a median of 20 (range, 6 to 44) months with a median ratio BCR-ABL/ABL of 0.002 (range, <0.001 to 0.01). Eight patients are in major cytogenetic remission at a median of 22 (range, 6 to 48) months. No patient died as a consequence of the treatment. All patients had some degree of stomatitis that was severe in 15 (50%) patients. Gastrointestinal and hepatic toxicities were observed in about one fourth of patients. Thus, autografting with Ph-negative mobilized HPC can result in prolonged restoration of Ph-negative hematopoiesis for some patients with CML; moreover, most autograft recipients report normal or near normal activity levels, suggesting that this procedure need not to be associated either with prolonged convalescence or with chronic debility.

Autologous peripheral blood haematopoietic stem cell transplantation for chronic myelogenous leukaemia

In these last four decades there has been extraordinary progress in our understanding of the biology of, and therapeutic approach to, chronic myelogenous leukaemia (CML). During these decades new observations arising from studies of the biological behaviour of diploid and leukaemic stem cells and, recently, from clinical investigations have received the most attention. From a clinical point of view, allografting is still the only procedure which is able to cure CML. For patients without HLA-compatible donors, current therapeutic options include conventional chemotherapy (hydroxyurea), interferon-alpha (IFN-alpha) and autografting. While IFN-alpha (+/- low-dose ARA-C) must be considered the first-line therapy, autografting, according to our approach, or other procedures, raises the question of an ideal sequential strategy in the management of CML patients (diploid stem cell mobilization, autografting, IFN-alpha). Because it seems that the diploid haematopoietic reservoir declines with time, it may be desirable to mobilize and collect diploid stem cells in order to store them as soon as diagnosis is possible when the WBC count has been controlled by hydroxyurea.

Rescreening of atypical cervicovaginal smears using PAPNET

BACKGROUND

Atypical squamous cells of undetermined significance (ASCUS) is a cytopathologic term used to describe cases without specific pathologic substratum. Between 10-60% of ASCUS cases correspond to squamous intraepithelial lesions (SIL).

METHODS

The objectives of this study were: 1) to detect the pathologic significance of ASCUS in study patients, 2) to determine whether PAPNET identifies these cases, and 3) to compare the results of PAPNET with those of a second conventional screening. One hundred and sixty-three consecutive patients with the cytologic diagnosis of ASCUS and adequate follow-up were selected. Of these, 111 patients had colposcopic lesions and biopsies were performed; in the remaining 52 cases colposcopy was negative, as were 3 consecutive annual Papanicolaou smears. In a blind review, all 163 cases were rescreened using PAPNET. A second manual screening was performed for comparison.

RESULTS

One hundred and twenty-six of the 163 cases (77.3%) showed no SIL on biopsy or follow-up. Of the 37 pathologic cases, the diagnosis was koilocytosis (flat condyloma) in 13 cases (8%), cervical intraepithelial neoplasia (CIN) type I in 11 cases (6.8%) low grade SIL [LSIL] in a total of 24 cases [14.8%]), and CIN II-III or high grade SIL (HSIL) in 11 cases (6.8%). In the review using PAPNET, 57 previous ASCUS cases were classified correctly as negative, and 7 of 13 koilocytosis cases (54%), 9 of 11 CIN I cases (82%), and 7 of 11 CIN II-III cases (64%) were diagnosed correctly. In the second conventional screening, 74 cases were negative and 77 cases were ASCUS; only 3 of 13 koilocytosis cases (23%), 4 of 11 CIN I cases (36.4%) and 5 of 11 CIN II-III cases (45.5%) were reclassified correctly.

CONCLUSIONS

Among 163 patients with ASCUS, 77.3% had no precancerous squamous lesions. Concordance with definitive diagnosis was more accurate in our study using PAPNET analysis (Kappa index [K] = 0.7158) than by second conventional screening (K = 0.4537). Furthermore, we reclassified 35% of smears as negative and 15% as SIL.

K-ras gene mutations in the diagnosis of fine-needle aspirates of pancreatic masses: prospective study using two techniques with different detection limits

Detection of K-ras mutations may be useful in the evaluation of pancreatic cancer. The aim of this study was to assess, in a prospective design, the diagnostic utility of K-ras mutation analysis in 62 consecutive fine-needle aspirates of pancreatic masses, using two PCR-based techniques-standard and enriched-with detection limits of a mutant allele in the presence of 10(2) or 10(3) wild-type alleles, respectively. Cytology alone offered a diagnostic sensitivity of 75%. The enriched higher sensitivity detection technique, in combination with cytology, offered a diagnostic sensitivity of 91% without false positives. The molecular analysis would have contributed to diagnosis in an additional 14 cases of pancreatic cancer. The standard technique contributed to diagnosis in an additional 9 cases. These results strongly support the use of the enriched method of detecting K-ras mutations as a complement to cytology in the evaluation of pancreatic masses.

Evidence of cytogenetic and molecular remission by allogeneic cells after immunosuppressive therapy alone

An immunosuppressive but not myeloablative regimen followed by HLA-matched donor mobilized haemopoietic stem cell transplantation was employed in two high-risk patients. The first patient had refractory anaemia with excess blasts (RAEB) and cytogenetic evidence of translocation 1;3(p36;q21). The second patient had Philadelphia-negative but p190 BCR-ABL chimaeric gene positive chronic myelogenous leukaemia in accelerated phase (AP-CML). The conditioning regimen consisted of fludarabine (30 mg/m2/d, days 1-3) with cyclophosphamide (300 mg/m2/d, days 1-3). Cyclosporine and methotrexate were employed for acute graft-versus-host disease (aGVHD) prophylaxis. In both cases the engraftment of donor cells was demonstrated by cytogenetics and short tandem repeat polymorphisms via PCR. Both patients are alive with normal cytogenetic (RAEB) and molecular (AP-CML) remissions, 100 and 150 d after allografting, respectively. In particular, in the AP-CML patient, the BCR-ABL became undetectable and the BCR-ABL/ABL ratio was <0.0001.

Engraftment of HLA-matched sibling hematopoietic stem cells after immunosuppressive conditioning regimen in patients with hematologic neoplasias

BACKGROUND AND OBJECTIVE

The main objective of this pilot study was to assess the possibility of achieving engraftment of HLA-matched sibling donor mobilized hematopoietic stem cells after immunosuppressive non-myeloablative therapy. The second objective was to verify whether high-dose therapy with autologous stem cells rescue followed by allografting conditioned by only an immunosuppressive regimen, can be combined in order to achieve the reduction of tumor burden after autografting and the control of residual disease with immune-mediated effects after allografting.

DESIGN AND METHODS

To enter the pilot study the patients had to fulfil the following criteria: advanced resistant disease, presence of an HLA matched sibling donor, no general contraindications to stem cell transplantation. Our data refers to 9 patients: Hodgkin's disease (n = 4), non-Hodgkin's lymphoma (n = 2), advanced chronic myelogenous leukemia (n = 2) (one patient with accelerated phase Ph-negative but p190 BCR-ABL gene positive by RT-PCR and one with Ph-positive blastic phase), refractory anemia with excess of blasts t(1;3) (p36;q21) (n = 1). All patients but one received the combined approach. At a median of 40 days (range 30-96), after high-dose therapy and autologous stem cell engraftment, the patients were treated with immunosuppressive therapy consisting of fludarabine and cyclophosphamide (Flu-Cy protocol) and then HLA matched donor mobilized stem cells were infused into the patients. GvHD prophylaxis consisted of cyclosporin and methotrexate.

RESULTS

To date, with a median observation period of 4 months (range, 2-10), complete chimerism (100% donor cells) has been achieved in 6 patients. Three patients did not achieve complete chimerism: one patient died of progressive Hodgkin's disease when he reached 55% of donor cells, another patient is now in increasing phase of donor cell engraftment and the last patient (blastic phase-CML) was the only case who appears to have had autologous recovery. Two of the Hodgkin's disease patients, who were in partial remission after autografting, achieved complete remission after allografting and both are disease free 2 and 6 months after. Another Hodgkin's disease patient is alive at 10 months but she has progressive disease. One of the two patients with non-Hodgkin's lymphoma, who achieved partial remission after autografting, obtained complete remission and he is disease free 2 months after allografting. The other patient maintains partial remission obtained after autografting. The accelerated phase-CML patient obtained hematologic and molecular remission; the RAEB patient achieved hematologic and cytogenetic remission. In two patients severe aGVHD (grade II-III) was the single major complication but neither patient died of it. Mild aGVHD was seen in another patient. In only one patient did the ANC decrease to below 1 x 10(9)/L and in no case did platelets decrease below 20 x 10(9)/L. No patients required a sterile room or any red cell or platelet transfusions.

INTERPRETATION AND CONCLUSIONS

Immunosuppressive therapy with a Flu-Cy protocol allowed engraftment of HLA-matched sibling donor stem cells without procedure-related deaths; moreover, we have demonstrated that this combined procedure can be pursued in safety in a serious ill population and some of these patients achieved a complete remission. This procedure is not likely to be curative, but a fascinating step along the path to curing these diseases. Of course, the follow-up is too short to document the incidence of cGvHD.

Effective mobilization of Philadelphia-chromosome-negative cells in chronic myelogenous leukaemia patients using a less intensive regimen

To determine if reducing the intensity of the mobilizing chemotherapy protocol used would alter the number and/or quality of the progenitors mobilized in patients with chronic myelogenous leukaemia (CML), we undertook a pilot study. 36 consecutive CML patients previously treated only with hydroxyurea were given mobilization therapy within 12 months of diagnosis. 17 patients were treated by the ICE protocol and 19 patients received the mini-ICE protocol. The leukapheresis product collected from 22/36 patients (62%) was entirely Ph-negative. The cytogenetic results between ICE and mini-ICE-treated protocols were not significant, although the reduction in median days of hospitalization required for the mini-ICE versus the ICE protocol was highly significant (P < 0.0001). There was no significant difference in the yield of CD34+ cells and CFU-GM collected. No patient in the mini-ICE protocol experienced high-grade oral mucositis and GI toxicity whereas three such cases occurred with the ICE protocol. No patient died of the mobilization procedure in either group.

Clear cell tumors of the female genital tract

Clear cell adenocarcinomas of the vagina, cervix, endometrium, and ovaries show very similar histological features. Several other tumors and tumor-like lesions of the female genital tract may also contain clear cells and may occasionally be misinterpreted as clear cell adenocarcinomas. These conditions include microglandular hyperplasia, mesonephric hyperplasia, Arias-Stella change, smooth muscle tumors containing clear cells, dysgerminoma, yolk sac tumor, metastatic renal cell carcinoma, steroid cell tumors, hepatoid carcinomas, signet-ring-cell stromal tumors, and trophoblastic tumors. This review discusses the histological features of all of these lesions, emphasizing the morphological aspects that are essential to accurate differential diagnosis.

Stem-cell mobilization for autografting in chronic myeloid leukemia

In this article, the rationale for autografting in chronic myeloid leukemia is reviewed, and alternative therapeutic approaches to the use of granulocyte-colony stimulating factor and chemotherapy-mobilized peripheral blood stem cells are discussed. The data from patients treated using the original ICE (idarubicin, cytarabine, etoposide), or the shorter course mini-ICE protocols are considered, with special emphasis on those patients who received their chemotherapy regimens soon after diagnosis and prior to any treatment with interferon alpha. The appropriate design of a trial to test the value of autografting in chronic myeloid leukemia is discussed, as is the optimal timing of collections to achieve the maximal yield and purity of Ph-negative peripheral blood stem cells.

Aspiration cytology of lung metastasis of monophasic synovial sarcoma. Report of a case

BACKGROUND

Synovial sarcoma usually arises in the extremities of young adults and metastasizes in about 50% of the cases. Fine needle aspiration can reveal those metastases.

CASE

A 65-year-old female presented with a solid mass in the left lung from which a fine needle aspirate was taken. Five years earlier her left foot was amputated because of a diagnosis of synovial sarcoma. Aspiration cytology from the lung revealed numerous groups of spindle cells with scant cytoplasm and ovoid nuclei with fine, homogeneous chromatin. Only vimentin was positive. Based on the clinical, cytologic and immunocytochemical studies, a metastasis from synovial sarcoma was considered to be the most accurate cytologic diagnosis.

CONCLUSION

This case demonstrates the utility of aspiration cytology in the diagnosis of a metastatic tumor, especially in those organs in which a core or open biopsy might be too aggressive.

New insights in biology and current therapeutic options for patients with chronic myelogenous leukemia

BACKGROUND AND OBJECTIVE

From the discovery of the Ph-chromosome, there has been an extraordinary progress in our understanding of chronic myeloid leukemia (CML). During the last three decades, new findings arising from dissection of the genetic abnormalities at a molecular level have received the most attention, but there have also been important new observations arising from studies of the biologic behaviour of normal and leukemic stem cells and, more recently, from clinical investigations. In this review we first report the most important observations relevant to understanding the oncogenic potential of the BCR-ABL chimeric gene, and the behaviour and the relationships of normal and leukemic stem cells. From a clinical point of view, allogeneic stem cell transplantation is the only procedure able to cure CML. The main issues are: who can receive this procedure, and when and how it can be given. The situation is more complex in unrelated transplants. In patients without HLA compatible donors, many large trials in different countries have demonstrated that interferon alpha therapy is indicated and effective in the majority of patients. On the other hand, autologous stem cell transplantation is still an experimental procedure. These aspects will be analyzed in detail and, at the end, a therapeutic algorithm of a possible approach to the patients with untreated CML is provided.

EVIDENCE AND INFORMATION SOURCES

The method used for preparing this review was an informal consensus development. All the authors of the present review have been working in the field of chronic myeloid leukemia, and have contributed original papers in peer-reviewed journals. In addition, the material examined in the present review includes articles and abstracts published in journals covered by the Science Citation Index and Medline.

STATE OF ART AND PERSPECTIVES

The oncogenic potential of BCR-ABL has been demonstrated in a number of in vitro and in vivo model systems. Current research efforts are focused on defining the mechanism by which BCR-ABL transforms primary hematopoietic cells. The fact that BCR-ABL contains tyrosine residues, an SH2 domain, an SH3 domain, and proline-rich sequences raises the possibility of multiple protein-protein interactions. Indeed, BCR-ABL is reported to bind and/or phosphorylate more than 20 proteins. The insights into the signal transduction pathways activated by BCR-ABL will hopefully provide a new basis for the treatment of CML patients. Clinical evidence of the existence of a transplantable CML stem cell population has recently been extended to xenogeneic recipients of transplanted CML cells and by retroviral marking to autograft recipients. The potential of using immunodeficient mice as recipients of CML stem cells to create an in vivo model of chronic phase CML should be invaluable for testing novel therapies designed to eliminate residual disease in the patient. Current therapeutic options include conventional chemotherapy, IFN-a and allogeneic stem cell transplantation as established procedures, and autografting as an experimental procedure. While IFN-a as a first line therapy does not seem to jeopardize further treatments, autografting, according to the Genoa approach or other procedures, i.e. Ph-positive cells collected at diagnosis without mobilization therapy, raises the question of an ideal sequential strategy in the management of CML patients. There seems to be a general agreement that a patient less than 50 years old, with an HLA identical sibling, should receive an allogeneic stem cell transplant. This approach should be offered also to younger patients (< or = 40 years) who are able to find an unrelated matched donor. Since it seems that the normal hematopoietic reservoir declines with time, it may be desiderable to mobilize and collect peripheral stem cells in order to store Ph-negative progenitors as soon after diagnosis as possible when the WBC count has been controlled by hydroxyurea while searchin

Mobilization and transplantation of Philadelphia-negative peripheral-blood progenitor cells early in chronic myelogenous leukemia

PURPOSE

Mobilization of Philadelphia (Ph) chromosome-negative progenitors is now possible in many Ph1-positive chronic myelogenous leukemia (CML) patients who had received interferon alfa (IFN-alpha) with no cytogenetic response. In this pilot study, we used this approach in patients without prior IFN-alpha therapy to determine if the number and quality of mobilized progenitors would be increased and to evaluate the potential effect of these cells as autografts.

PATIENTS AND METHODS

Twenty-two untreated patients were mobilized within 12 months of diagnosis. The treatment regimen consisted of the mini-ICE protocol. Beginning on day +8, granulocyte colony-stimulating factor (G-CSF) was used in all patients. Leukophoresis was performed as the patients were recovering from aplasia, when WBC count exceeded 0.8 x 10(9)/L.

RESULTS

In 14 patients, (63%) the leukophoresis product was entirely Ph1-negative and in four patients the Ph1-positive cell rate was < or = 7%. Significant numbers of long-term culture-initiating cells (LTC-IC) and CD34+ Thy1+Lin- cells were found in most of the Ph1-negative collections that were tested. Twelve patients underwent autografting with their mobilized peripheral-blood progenitor cells (PBPC) (Ph1-negative collections, 10 patients; major cytogenetic response, two patients). All patients engrafted and are alive; six have Ph1-negative marrow 7 to 15 months after autografting. Posttransplant treatment was IFN-alpha combined with interleukin (IL)-2 because of the recent demonstration of synergistic activity in augmenting cytolytic activity.

CONCLUSION

Intensive chemotherapy given in early chronic phase of CML is well tolerated and results in high numbers of circulating Ph1-negative precursor cells.

Prognostic value of S-phase fraction in lymph-node-negative breast cancer by image and flow cytometric analysis

Cellular DNA content and proliferation rates have been suggested as prognostic factors in breast carcinomas. A series of 271 lymph-node negative breast carcinoma patients without adjuvant therapy was reviewed (mean follow-up, 108 mo). Tumor cells from the same paraffin-embedded block tissue (Hedley's method) were analyzed by image analysis (IA) in Feulgen-stained smears and by flow cytometric analysis (FC). Clinicopathologic features, ploidy, S-phase fraction, and percentage of tumor cells with more than 5n DNA content (in diploid tumors, by IA) were related to outcome. The results of IA and FC were compared in 115 cases. Tumor size, histologic grade, desmoplasia and S-phase fraction were significant predictors of survival in multivariate analysis (Cox proportionate regression) (P < or = 0.03). Ploidy by the two methods showed agreement in 100 carcinomas (87%). Of the 15 discordant cases, FC detected 6 multiploid and 4 aneuploid-peridiploid. In contrast, IA detected more tetraploid carcinomas. Tumor size, histologic grade, desmoplasia, and S-phase fraction were independent predictors of long-term prognosis in our patients. Ploidy and percentage of tumor cells with more than 5n DNA content were not prognostic indicators. FC detected aneuploidy more frequently than did IA.

In vivo mobilization of karyotypically normal peripheral blood progenitor cells in high-risk MDS, secondary or therapy-related acute myelogenous leukaemia

We have previously reported that mobilization of Philadelphia (Ph) chromosome-negative progenitors is possible in a significant number of Ph1-positive acute lymphoblastic leukaemia (ALL) and chronic myelogenous leukaemia (CML) patients. In this pilot study we employed the same approach for patients with RAEB-t, secondary AML (sAML) and therapy-related AML (t-AML). All patients except one had double or complex cytogenetic abnormalities in marrow cells before mobilization therapy. All patients received an idarubicin-containing regimen (mini-ICE protocol) followed by rh-G-CSF and the first leukapheresis was performed as they were recovering from aplasia. In six out of nine patients the leukapheresis product was entirely karyotypically normal, combined with a significant number of CFU-GM. CD34+ cells and LTC-IC. Recovery time from mobilization therapy was short and no patient died as a result of the procedure. To date, three patients have undergone autografting using their karyotypically normal collections, of which two (sAML) are alive with karyotypically normal marrow a few months after autografting.

Fine needle aspiration cytology in pancreatic pathology

OBJECTIVE

To assess the sensitivity and specificity of pancreatic fine needle aspiration.

STUDY DESIGN

Two hundred five fine needle aspirates were obtained from 149 patients over seven years. After excluding 40 patients lacking biopsy or follow-up, 125 aspirates from 109 patients were selected to analyze the accuracy of this method. (male:female ratio, 1.4:1; age range 43-79 years).

RESULTS

The cytologic diagnosis was true positive in 50 studies (45.9%), false positive in 0, true negative in 25 (22.9%), false negative in 19 (17.4%) and suspicious for malignancy in 17 (15.6%); 14 aspirations (12.8%) yielded material unsatisfactory for a diagnosis. Of the 17 suspicious studies, 15 were from patients in whom a malignancy was confirmed later. The other two patients had chronic pancreatitis.

CONCLUSION

The efficiency was 79.8%, sensitivity 72.5%, and specificity and predictive value of a positive result 100%. Cell blocks provided sufficient material in 96.8% of cases and smears in 90.4%. No major complications were reported after fine needle aspiration.

Diagnostic utility of K-ras mutations in fine-needle aspirates of pancreatic masses

BACKGROUND & AIMS

Mutations at codon 12 of the K-ras gene are present in 65%-100% of carcinomas of human exocrine pancreas and could be used as a potential tumor marker at the tissue level. The purpose of this study was to assess, in large series of patients, the utility of K-ras mutation analysis to evaluate fine-needle aspirates of pancreatic masses.

METHODS

One hundred fifteen fine-needle aspirates obtained from 93 patients were evaluated retrospectively. Cytological analysis was based on the review of cell blocks. Mutations were detected by using artificial restriction fragment length polymorphisms using the Hphl and BstNl approaches.

RESULTS

The sensitivity and specificity of cell block cytology was 64% and 100%, respectively, for the diagnosis of pancreatic carcinoma. K-ras mutations were detected in 41 pancreatic carcinomas (sensitivity, 59%) and in one mucinous cystic tumor; specificity of ras analysis alone was 100%. The sensitivity of cytology combined with K-ras mutations were 77.6% and 100%, respectively.

CONCLUSIONS

The detection of K-ras mutations would have suggested the diagnosis of pancreatic cancer in 14 cases otherwise not detected by cytology alone. K-ras mutation analysis should be restricted to cell blocks containing suspicious, normal-appearing duct cells, or insufficient material in the cytological examination.

Autografting Ph-negative blood precursor cells in chronic myeloid leukaemia

The study was devised to evaluate whether it was possible to collect Philadelphia-negative precursor cells in patients with chronic myeloid leukaemia. The approach was based on previous experience showing that complete remission (Ph-negative bone marrow cells) is rarely achieved after chemotherapy and is very short-lasting. We decided to explore whether it was possible to collect Ph-negative precursor cells in peripheral blood during the early phase of haemopoietic recovery. These data show that: the collection of Ph-negative precursor cells occurred in 12/16 (75%) patients mobilized within one year of diagnosis (group A) versus 12/33 (36%) in patients with a history of more than one year of disease (group B). Furthermore the numbers of Ph-negative precursor cells were significantly much higher at diagnosis. Ten patients mobilized at diagnosis were subsequently autografted with such Ph-negative precursor cells. Five of them remain Ph-negative from 4 to 12 months while the other five have percentages of Ph-positive cells in their marrow ranging from 20% to 70%. In this stage of the disease the procedure is safe and associated with a very good compliance. Occasional restoration of Ph-negative haemopoiesis could be observed up to 40 months after autograft, in patients of group B, but most of patients revert to Ph-positive haemopoiesis. in conclusion these data suggest that it is possible to restore Ph-negative haemopoiesis in 70% of patients mobilized at diagnosis. This percentage represent the highest one can obtain without allogeneic BMT, and this includes patients who never would have been cytogenetic responders to IFN-alpha. Whether and how long for Ph-negative status can be maintained is a matter for future observation and study.