Combined analysis of levels of serum B-cell activating factor and a proliferation-inducing ligand as predictor of disease progression in patients with chronic lymphocytic leukemia

B-cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL) are regulators of normal B-cell development and survival. We investigated their role in chronic lymphocyticleukemia (CLL) by relating serum protein levels and CLL cell mRNA expression with clinical factors and disease progression. In patients with CLL, BAFF serum levels were significantly lower than in controls (0.64 ng/mL vs. 0.77 ng/mL, p = 0.014), and APRIL serum levels were significantly higher (4.10 ng/mL vs. 1.84 ng/mL, p = 0.041). CLL cells expressed BAFF and APRIL mRNA at lower levels than normal B-cells. Low BAFF serum levels were significantly correlated with a high blood lymphocyte count and advanced clinical stage, whereas APRIL levels were correlated with CD38 expression. In a multivariate analysis, the combined analysis of BAFF and APRIL serum levels emerged as an independent predictor of disease progression.

Chronic lymphocytic leukemia and autoimmunity: a systematic review

Chronic lymphocytic leukemia is frequently associated with immune disturbances. The relationship between chronic lymphocytic leukemia and autoimmune cytopenias, particularly autoimmune hemolytic anemia and immune thrombocytopenia, is well established. The responsible mechanisms, particularly the role of leukemic cells in orchestrating the production of polyclonal autoantibodies, are increasingly well understood. Recent studies show that autoimmune cytopenia is not necessarily associated with poor prognosis. On the contrary, patients with anemia or thrombocytopenia due to immune mechanisms have a better outcome than those in whom these features are due to bone marrow infiltration by the disease. Moreover, fears about the risk of autoimmune hemolysis following single agent fludarabine may no longer be appropriate in the age of chemo-immunotherapy regimens. However, treatment of patients with active hemolysis may pose important problems needing an individualized and clinically sound approach. The concept that autoimmune cytopenia may precede the leukemia should be revisited in the light of recent data showing that autoimmune cytopenia may be observed in monoclonal B-cell lymphocytosis, a condition that can only be detected by using sensitive flow cytometry techniques. On the other hand, there is no evidence of an increased risk of non-hemic autoimmune disorders in chronic lymphocytic leukemia. Likewise, there is no epidemiological proof of an increased risk of chronic lymphocytic leukemia in patients with non-hemic autoimmunity. Finally, since immune disorders are an important part of chronic lymphocytic leukemia, studies aimed at revealing the mechanisms linking the neoplastic and the immune components of the disease should help our understanding of this form of leukemia.

Lestaurtinib inhibition of the Jak/STAT signaling pathway in hodgkin lymphoma inhibits proliferation and induces apoptosis

Standard cytotoxic chemotherapy for Hodgkin Lymphoma (HL) has changed little in 30 years; the treatment for patients with relapsed or refractory disease remains challenging and novel agents are under development. JAK/STAT constitutive activation plays an important role in the pathogenesis of HL. Lestaurtinib is an orally bioavailable multikinase inhibitor that has recently been shown to inhibit JAK2 in myeloproliferative disorders. The potential role of Lestaurtinib in HL therapy is unknown. We have analyzed the effect of Lestaurtinib treatment in five HL cell lines from refractory patients, L-428, L-1236, L-540, HDML-2 and HD-MY-Z. At 48 h, a dose-dependent cell growth inhibition (23%–66% at 300 nM) and apoptotic increment (10%–64% at 300 nM) were observed. Moreover, Lestaurtinib inhibited JAK2, STAT5 and STAT3 phosphorylation and reduced the mRNA expression of its downstream antiapoptotic target Bcl-xL. In addition, we have analyzed the effect of Lestaurtinib treatment in lymph nodes from four classic HL patients. We observed a decrease in cell viability at 24 hours of treatment in three patients (mean decrease of 27% at 300 nM). Our findings provide, for the first time, a molecular rationale for testing JAK2 inhibitors, specifically Lestaurtinib, in HL patients.

Mediastinal aortosympathetic paraganglioma: report of two cases

Thoracic paragangliomas or extra-adrenal pheochromocytomas are uncommon neoplasms that may arise from the extra-adrenal paraganglia. Paragangliomas arising in the anterior mediastinum are most frequent and are related to the base of the heart. Paragangliomas of the posterior mediastinum are most infrequent, and arise from aorticosympathetic paraganglia. We present two cases of posterior mediastinum paraganglioma. Complete tumor resection was done through posterolateral thoracotomy. The diagnosis of aorticosympathectic paraganglioma was established by histologic examination.

Loss of PPAR gamma in immune cells impairs the ability of abscisic acid to improve insulin sensitivity by suppressing monocyte chemoattractant protein-1 expression and macrophage infiltration into white adipose tissue

Abscisic acid (ABA) is a natural phytohormone and peroxisome proliferator-activated receptor gamma (PPARgamma) agonist that significantly improves insulin sensitivity in db/db mice. Although it has become clear that obesity is associated with macrophage infiltration into white adipose tissue (WAT), the phenotype of adipose tissue macrophages (ATMs) and the mechanisms by which insulin-sensitizing compounds modulate their infiltration remain unknown. We used a loss-of-function approach to investigate whether ABA ameliorates insulin resistance through a mechanism dependent on immune cell PPARgamma. We characterized two phenotypically distinct ATM subsets in db/db mice based on their surface expression of F4/80. F4/80(hi) ATMs were more abundant and expressed greater concentrations of chemokine receptor (CCR) 2 and CCR5 when compared to F4/80(lo) ATMs. ABA significantly decreased CCR2(+) F4/80(hi) infiltration into WAT and suppressed monocyte chemoattractant protein-1 (MCP-1) expression in WAT and plasma. Furthermore, the deficiency of PPARgamma in immune cells, including macrophages, impaired the ability of ABA to suppress the infiltration of F4/80(hi) ATMs into WAT, to repress WAT MCP-1 expression and to improve glucose tolerance. We provide molecular evidence in vivo demonstrating that ABA improves insulin sensitivity and obesity-related inflammation by inhibiting MCP-1 expression and F4/80(hi) ATM infiltration through a PPARgamma-dependent mechanism.

[Results of high bilateral endoscopic thoracic sympathectomy and sympatholysis in the treatment of primary hyperhidrosis: a study of 1016 procedures]

OBJECTIVE

Thoracic sympatholysis and sympathectomy are the current standard treatments for primary hyperhidrosis. In this study, we evaluated the incidence of peri- and postoperative complications associated with these procedures.

PATIENTS AND METHODS

From 1996 to 2004, 520 consecutive patients (364 women), with a mean age of 26.8 years, were treated for primary hyperhidrosis at our hospital. The procedure was bilateral in all but 24 cases. The 484 patients in the sympatholysis group underwent a single intervention while the 36 patients in the sympathectomy group underwent 2 separate interventions.

RESULTS

No deaths occurred. Anhidrosis of the target area was achieved in 97.6% of patients while 2.2% experienced hypohidrosis. In 0.2% of the cases, the procedure was initially unsuccessful and a second intervention was required. The mean duration of hospital stay was 72 hours for patients in the sympathectomy group and 17 hours for the sympatholysis group. Serious intraoperative complications requiring conversion to thoracotomy were recorded in 0.2% of patients. Postoperative complications--of which pneumothorax was the most common--occurred in 5.2% of the cases (in 22.5% of the sympathectomy group and 3.55% of the sympatholysis group). Compensatory hyperhidrosis occurred in 48.4% of the patients, excessive dryness of the hands and palpebral ptosis in 0.38%, and gustatory sweating in 0.9%. The degree of patient satisfaction was quite high (88.5%) and only 2.3% were very unsatisfied.

CONCLUSIONS

Given the results obtained, we can conclude that both sympatholysis and sympathectomy are appropriate treatments for hyperhidrosis. Nonetheless, because sympatholysis is both easier to perform and less aggressive, we consider it the treatment of choice for primary hyperhidrosis.

Thoracic sympathicolysis for primary hyperhidrosis: a review of 918 procedures

BACKGROUND

Bilateral upper thoracic sympathectomy or sympathicolysis, currently the standard treatment for palmar or axillary hyperhidrosis, is regarded as a safe procedure. This study evaluates the quantitative and qualitative incidence of intraoperative and postoperative complications resulting from bilateral thoracic sympathicolysis.

METHODS

From 1996 to 2004, 458 consecutive patients with primary hyperhidrosis underwent surgery. These patients comprised 143 men (31.2%) and 315 women (68.7%) with a mean age of 26 years (range, 14-52 years). In all but seven cases, the procedure was bilaterally synchronous.

RESULTS

No mortality was recorded. The anhydrosis rate was 97.4%, with a hypohidrosis rate of 2.4% and a failure rate of 0.2%. The latter was resolved with reintervention. The mean hospital stay was 17 h. The rate of major perioperative complications with conversion to thoracotomy was 0.4%. The overall rate of postoperative complications was 3.6%. The complications and rates observed were as follows: pneumothorax (2.06%), subcutaneous emphysema (1.08%), pleural bleeding (0.2%), hemothorax (0.1%), and atelectasis (0.1%). Compensatory hyperhidrosis was observed in 48.4% of the patients, but the sensation of compensatory hyperhidrosis was reported in 85.6% of the cases. Excessive dryness of the hands was reported in 0.38%, Horner's syndrome in 0.32%, and gustatory hyperhidrosis in 1.1% of the cases. The overall satisfaction rate was 88.5%.

CONCLUSIONS

The results suggest that endoscopic bilateral thoracic sympathicolysis is an effective method for managing primary hyperhidrosis, especially severe palmar hyperhidrosis, but it is necessary to inform patients fully concerning the undesirable effects.

Tracheal and cricotracheal resection for laryngotracheal stenosis: experience in 54 consecutive cases

OBJECTIVE

Partial tracheal resection (Küster operation (KO)) and cricotracheal resection (Pearson operation (PO)) are currently the standard operative techniques in the curative treatment of tracheal and cricotracheal stenosis, respectively. This study aims to analyze the outcomes of tracheal and cricotracheal resection when a specific protocol is applied.

METHODS

Between 1990 and 2004 we treated 54 patients with laryngotracheal stenosis. The mean age was 44.9 years with a sex ratio of 1:1. All patients were treated according to the random protocol "Lesions of the main airway (MA) protocol," which considers the following stenosis variables: stage of development (S), caliber (C), and length (L). We performed 38 Küster operations, 14 Pearson operations, and 2 combined Pearson-Küster-Rethi operations (ROs).

RESULTS

Overall mortality of the series was 1.85%, with a specific morbidity of 27.7%. A total of 96.2% of patients were cured (85.6% of Pearson operation and 100% of Küster operation). We performed 3.7% re-interventions (14.2% of Pearson operation and 0% of Küster operation), and the failure rate was 3.7% (14.4% of Pearson operation and 0% of Küster operation). We had 27.5% who had postoperative complications (28.5% of Pearson operation and 26.3% of Küster operation). The most frequent complications were restenosis (14.2%), granulation tissue (13.1%), edema (10.5%), anastomotic dehiscence (7.1%), and tracheoesophageal fistula (7.1%). In terms of the SCL variables, significant differences were only observed with respect to morbidity between the S4 group and the other cases without tracheoesophageal fistula in the Küster operation group; we found no differences in Pearson operation.

CONCLUSIONS

Application of the Main Airway protocol allowed development of a strategy for the surgical treatment of main airway stenosis. This, in turn, enabled a strict selection of cases and meticulous preoperative preparation that, coupled with a highly effective surgical technique, led to excellent outcomes with minimal sequel. The presence of tracheoesophageal fistula could increase the complications.

[Primary hyperhidrosis and anxiety: a prospective preoperative survey of 158 patients]

OBJECTIVE

To determine the location of hyperhidrosis, the accompanying signs and symptoms, and patient anxiety assessed on 2 scales and standardized psychometric instruments.

PATIENTS AND METHODS

A prospective study of patients with hyperhidrosis was carried out between September 1, 2001 and June 30, 2003 with a self-administered preoperative questionnaire. The variables studied included the location of hyperhidrosis, the accompanying signs and symptoms, and the self-reported degree of anxiety and perception of its effect on daily life assessed by the State-Trait Anxiety Inventory (STAI) and a questionnaire designed in our department.

RESULTS

Palmar hyperhidrosis was reported by 93.6% of patients, plantar by 70.2%, axillary by 66.4%, facial by 12.1%, groin by 8.2%, chest by 5%, and abdominal by 2%. While more than 50% of the patients reported facial blushing and palpitations as accompanying signs and symptoms, approximately 30% experienced epigastric pain, trembling, and headaches. Over half of the patients reported that their anxiety was incapacitating, and a mere 1.2% experienced none at all. STAI scores were similar to those of the general population whereas scores on our department's questionnaire reflected those of the self-reported anxiety ratings.

CONCLUSIONS

Primary hyperhidrosis is a disorder in which excessive sweating occurs mainly, but not exclusively, on the palms. The condition is accompanied by signs and symptoms typical of autonomic nervous system hyperactivity and by a degree of anxiety that has an incapacitating effect on normal life, although that anxiety is not detected by the STAI questionnaire alone.

[Compensatory sweating after upper thoracic sympathectomy. Prospective study of 123 cases]

OBJECTIVE

The most unpleasant consequence of upper thoracic sympathectomy is compensatory sweating (CS). De-pending on the series, the incidence of CS ranges from 24% to 85%. The aim of this study was to determine the relation between CS and the following factors: distribution of hyperhidrosis, procedure performed (unilateral, synchronic bilateral, or sequential bilateral), and number of sympathetic ganglia eliminated. In addition, the degree of patient satisfaction was recorded as objectively as possible.

PATIENTS AND METHODS

Prospective study of 123 patients who underwent upper thoracic sympathectomy for palmar and/or axillary hyperhidrosis between 1 January, 1996 and 1 June, 2002 at our unit. All patients completed a questionnaire on symptoms 8 weeks before and after surgery to deter-mine postoperative changes in distribution of the hyperhidrosis and the overall degree of satisfaction on a scale of 0 to 4.

RESULTS

The sensation of CS was reported by 86.1% of the patients. When asked to relate this sensation to changes in sweating intensity in specific parts of the body, 46.54% reported CS and 48.37% no change. The trunk was the only region where statistically significant increases in CS occurred; in the feet, a decrease in sweating was noted. No differences in CS were observed with respect to the type of surgery or the number of sympathetic ganglia eliminated. The overall results were considered very satisfactory or quite satisfactory by 84.55% of the patients, while 4.88% were very dissatisfied.

CONCLUSIONS

Although CS is a side effect of upper thoracic sympathectomy, not all patients are affected by it. Significant CS occurs mainly in the back, chest, and abdomen. Neither the type of intervention nor the number of ganglia eliminated has an effect on CS. This side effect notwithstanding, overall satisfaction with the treatment is very satisfactory given that the palmar hyperhidrosis is eliminated.

[Primary hyperhidrosis: prospective study in 338 patients]

BACKGROUND AND OBJECTIVE

The objective of this report is to study the clinical aspects of the patients with primary hyperhidrosis (PH) and the social and occupational distressing condition.

PATIENTS AND METHOD

From January 1998 to October 2002, 338 patients with PH completed a preoperative questionnaire to register: age, gender, profession, associated diseases, familiar hyperhidrosis history, sweating location, associated dermatological lesions and social embarrassesment. 179 patients were asked about their general symptomatology.

RESULTS

In 86% of the patients PH started during infancy, 71.5% were female (mean age 28.8 years). A few patients had others diseases and 42.5% had some associated dermatological lesions. In 47.9% of the patients there is family history of PH. 96.4% reported palmar hyperhidrosis, 80.7% plantar PH and 71.3% reported axillary PH, being less frequent in others regions of the body. The most frequent clinical founding associated is facial blushing in 60.3%, 52.3% heart palpitations, 48% muscle stress, 31.8% reported trembling of the hands and 30,8% headache. In reference to social embarrassesment, we observe that relations between friends and professional environment are the most problematic situation.

CONCLUSIONS

PH is a pathologic condition starting in infancy, family history of PH is frequent and most patients have some associated dermatological lesions. Excessive sweating is especially common in palms but no exclusively of this region as it extends to others regions with the same intensity. It can be associated with symptomatology suggestive of hyperexcitability of the sympathetic activity like facial blushing, trembling or headache, symptoms difficult to consider whether they are cause or consequence.

[Histopathological changes in sympathetic ganglia of patients treated surgically for palmar-axillary hyperhidrosis. A study of 55 biopsies]

INTRODUCTION

Primary palmar hyperhidrosis (PPH) mainly affects the sympathetic ganglia. This study aims to analyze the histopathological changes in the sympathetic ganglia of patients with PPH.

MATERIAL AND METHOD

We studied 55 tissue samples from 35 patients with PPH who underwent T2-T3 gangliectomy for definitive treatment of their disease, analyzing the presence of inflammation, chromatolysis and lipofuscin accumulation. Findings were analyzed in relation to age, compensatory sweating and type of surgery: unilateral, synchronic bilateral or sequential bilateral.

RESULTS

We found inflammation in 5.5%, chromatolysis in 61.8% and lipofuscin accumulation in 41.8% of the samples. Chromatolysis and lipofuscin were found without inflammation in 32.1%. Chromatolysis and lipofuscin accumulation were each found in 60% of the samples from synchronic bilateral sympathectomies. However, those percentages decreased between the first and second sympathectomies in sequential procedures, such that chromatolysis was found in 71.4% of first-procedure samples and 42.8% of second-procedure samples; the rates for lipofuscin accumulation changed from 64.2% to 14.2%. Although findings were unrelated to age, they did correlate with compensatory sweating, which was found in 79.7% of patients undergoing synchronic bilateral sympathectomy, 78.5% of sequential bilateral sympathectomy patients and only 56.25% of unilateral sympathectomy patients.

CONCLUSIONS

Neuronal death and lipofuscin accumulation unrelated to inflammation are evident in sympathetic ganglia from patients with PPH. Such changes are atypical for a group of patients whose mean age is 29 years, unless such lesions are the result of functional hyperstimulation. Surgery performed sequentially does not lead to overloading of contralateral T2-T3 ganglia; on the contrary, decreased injury is evident.