Development of acute leukaemia after idiopathic myelofibrosis

AIMS

To determine the characteristics of blastic transformation of idiopathic myelofibrosis.

METHODS

The clinical and haematological features, as well as the morphological characteristics of blast cells, were analysed in nine adults with blast transformation.

RESULTS

Most of the patients were male and had enlarged spleens and livers. Five of the patients had normal platelet counts, while all had pronounced anaemia and a moderate degree of leucocytosis. The duration of the acute phase was usually short: 16 (SD 8) weeks. Most myeloid cell lineages--granulocytic, monocytic, and megakaryocytic--were similarly distributed. One patient also had a hybrid (lymphoid-myeloid) phenotype. The morphological assessment of blast cells agreed with immunophenotyping in five out of the nine cases. The onset of the blastic phase was not related to previous treatment.

CONCLUSIONS

A pluripotential stem cell with preferential myeloid commitment would be the target cell of blast transformation in idiopathic myelofibrosis. Our immunophenotypic data do not support the concept of a preferential association between megakaryocytic lineage and the acute transformation of idiopathic myelofibrosis. The absence of previous treatment in some cases suggests that this kind of evolution is part of the natural history of idiopathic myelofibrosis.

[Symptomatic effect of epomediol in patients with cholestasis of pregnancy]

Epomediol is a terpenoid that prevents and reverses cholestasis induced by ethinylestradiol in the rat, apparently by improving liver cell membrane fluidity. Assuming that the pathogenesis of intrahepatic cholestasis of pregnancy (ICP) is related with increased estrogen levels, we studied the effects of epomediol in this disease. Patients hospitalized due to ICP received epomediol 900 mg/day (n = 7), or 1,200 mg/day (n = 4) orally, during 15 days. Biochemical parameters of liver dysfunction (serum bilirubin, bile salts, aminotransferase, alkaline phosphatases) were not modified during nor after epomediol administration. The severity of pruritus was significantly reduced in comparison to pretreatment status, with both doses of epomediol. A greater amelioration of pruritus was observed in patients treated with epomediol 1,200 mg/day than in patients who received 900 mg/day (to 20.7 +/- 6.2, as percent of pre-treatment severity score, versus 48.8 +/- 7.5 respectively; p < 0.05). After epomediol administration was stopped, pruritus relapsed in 6 patients; 3 of them had received the higher drug dose. After delivery, pruritus vanished and liver function tests returned to normal, in all patients. No adverse effects attributable to the drug were observed in the mothers or in their babies. The beneficial effect of epomediol on pruritus in patients with ICP appeared greater in this study than that observed recently in similar patients who received a placebo.

Enoxacin-induced photosensitivity: study of two cases

Enoxacin is a second-generation quinolone derivative recently introduced in Spain. Its activity comes through the inhibition of bacterial DNA-gyrase and it has a good antibacterial capacity against a broad spectrum of gram-positive and gram-negative bacteria. It is presumed to be less toxic than the rest of the quinolones and its use is increasing, specially to treat infections of the urogenital tract. Cases of photosensitivity to enoxacin have been very rarely reported. We describe 2 patients with photosensitivity reactions due to this drug.

Lymphoid subsets and prognostic factors in multiple myeloma. Cooperative Group for the Study of Monoclonal Gammopathies

In a uniform series of 170 untreated myeloma patients (MM) we investigated the distribution of T cell subsets in peripheral blood (PB) and their relationship with the most relevant disease characteristics, including survival. CD4 cells were significantly decreased both in percentage and absolute numbers (P less than 0.0001). On the other hand, the CD8 cells only showed a slight increase in relative numbers. Upon correlating the abnormalities in the distribution of T cells with other clinical and biological disease characteristics the most remarkable correlation was with survival. A low number of CD4 cells (less than 700 x 10(6)/l) was associated with both an advanced clinical stage and a shorter survival (20 v. 43 months, P = 0.01). Moreover, a significant correlation also exists between the decrease in CD4 cells and both high beta 2-microglobulin (beta 2M) levels and anaemia. On the other hand, no relationship was found with the type of M-component nor with the plasma cell phenotype. Finally multivariate analysis showed that the number of CD4 cells add independent prognostic information to other well-established tests for the assessment of disease outcome in patients with multiple myeloma.

[The treatment of colonic and ovarian cancer with radioactive monoclonal antibodies against the CA l9-9 and CA 125 antigens]

The age of monoclonal antibodies arose with the papers by Köhler and Milstein in 1975. By means of a fusion between a neoplastic cell with one which produced a specific antibody they obtained a hybrid or clonal cell. Five years later, Nadler et al issued the first report of a patient with lymphoma treated with monoclonal antibodies. After the first announcement, diverse research centers have reported the clinical results obtained in various neoplasias treated with radioactive monoclonal antibodies directed against antigens associated with neoplasias, as well as non-specific tumoral antigens, including lymphomas, melanomas and cancers of the colon, ovary and breast.

Cholinergic blockade with scopolamine in adult cats. Effects on the behaviors evoked by apomorphine and amphetamine

1. The aim of this work is to analyse the role that the cholinergic system could play in the production of the behaviors evoked by apomorphine and amphetamine in adult cats. These two drugs were injected s.c. in separate sessions, before and after a s.c. administration of scopolamine which blocked the muscarinic receptors. The pre and post-scopolamine results of the behaviors produced by the two catecholaminergic drugs were compared using the non-parametric Wilcoxon signed rank test. 2. In a previous step a dose-response study of the behavioral effects of scopolamine, in doses of 0.05, 0.1, 0.4 and 0.8 mg/kg was carried out in ten cats. The Kruskal-Wallis and the non-parametric multiple comparison tests were employed. A dose-dependent decrease in motility (locomotion) and a dose-dependent increase in inappetence and pupillary dilation were found. 3. In thirteen cats which were injected with 2 mg/kg of apomorphine and 2.5 mg/kg of amphetamine the findings were: 1--apomorphine after scopolamine produced a decrease in the hypermotility, compared with the results observed with the former drug previous to scopolamine; 2--with amphetamine an increase in immobility and a decrease in indifference were observed. 4. The authors conclude that the decrease in motility recorded with apomorphine and amphetamine after scopolamine, could be attributed to the proper effect of scopolamine. No explanation could be found for the decrease in indifference found by injecting amphetamine after scopolamine. 5. Considering the antagonistic effect between the dopaminergic and the cholinergic systems and that the latter one has an arousal effect, we postulate that the behavioral indifference produced by apomorphine and amphetamine could be the result of a kind of blockade of the cholinergic system when the catecholaminergic system is activated through the administration of the two cited drugs.

Comparison of capsid protein VP1 of the viruses used for the production and challenge of foot-and-mouth disease vaccines in Spain

A significant frequency of amino acid substitutions, that affect important antigenic sites on capsid protein VP1, has been found among viral preparations used for the production and for challenge, in protection assays, of foot-and-mouth disease (FMD) vaccines. The amino acid substitutions present in one of the viruses studied abolished its reactivity with two neutralizing monoclonal antibodies that recognized different epitopes on VP1. Thus, the results obtained illustrate the high potential for antigenic variation introduced by the multiple cycles of growth usually undergone by the strains used for the production and challenge of FMD vaccines.

[Oral pathology in 161 asymptomatic and symptomatic HIV-positive patients]

The aim of this study was to establish the prevalence of oral manifestations in HIV-infected patients and to correlate their frequency with the clinical stage. One hundred and sixty one HIV-positive individuals were examined, of whom 64 (40%) were in stages CDC-II and III and 97 (60%) in stage CDC-IV. The patients were examined at the AIDS out-patient clinic of the Instituto Nacional de la Nutrición Salvador Zubirán. The oral exams were performed by three examiners who were intra and inter calibrated, so that standard clinical criteria were followed. One hundred and twenty five patients (78%) showed one or more oral lesions. The proportion of patients with oral lesions increased significantly (p less than 0.05) according to the severity of the infection. Hairy leukoplakia (40%) and erythematous candidiasis (31%) were the most frequent lesions. When the prevalence of the different oral lesions was compared between the patients at early stages with the patients at the late stage no significant differences were found; only the pseudomembranous candidiasis and the exfoliative cheilitis were found with significantly higher values at stage CDC-IV than at earlier stages (p less than 0.001 and p less than 0.05 respectively). No association was found between oral candidiasis and tobacco use or xerostomia. Our study demonstrates that the prevalence and clinical features of the oral manifestations found showed similarities with those reported in other countries, but ulcero-necrotizing gingivitis was not found in our patients.

Prognostic value of S-phase white blood cell count in B-cell chronic lymphocytic leukemia

Eighty previously untreated patients with B-cell chronic lymphocytic leukemia (B-CLL) were analyzed to study the proliferation rate of their peripheral blood (PB) leukocytes to determine its relationship with the extension of the disease and its value in discriminating among patients with similar tumor cell mass. The 80 B-CLL patients were distributed into two different groups according to the absolute count of PB S-phase leukocytes: a low proliferative group (less than 1 x 10(9)/I) of 48 patients and a high proliferative group (greater than or equal to 1 x 10(9)/I) of 32 patients. The high proliferative group displayed a higher incidence of splenomegaly (p less than 0.005), hepatomegaly (p less than 0.08), anemia (p less than 0.02) and thrombocytopenia (p less than 0.03) as well as a higher lymphocytic infiltration both in PB (p less than 0.0004) and in bone marrow (BM) (p less than 0.003). These patients also showed a higher incidence of a diffuse pattern of BM involvement (p less than 0.04), advanced clinical stages [stage III/IV (p less than 0.03) and group C (p less than 0.04)] and infections (p less than 0.0008) together with significantly lower IgG (p less than 0.03) and IgM (p less than 0.03) serum levels. Regarding the immunophenotype, there was a greater percentage of either CD19+ (p less than 0.06) and CD19+ CD5+ (p less than 0.05) B-cells, together with a greater reactivity for both the CD25 (p less than 0.04) and CD9 (p less than 0.08) antigens in the high proliferative group. According to the prognostic value of the PB S-phase leukocyte count it was seen that patients with low S-phase white blood cell (WBC) numbers displayed a significantly higher survival (p less than 0.03). In addition, multivariate analysis revealed that the S-phase WBC count, although partially related to other clinical and biological prognostic factors, displayed an important independent value in predicting early deaths in patients with B-CLL.

Prevalence of antibody to hepatitis C virus in chronic HBsAg carriers

The presence of the anti-HCV antibody was investigated in sera from 102 chronic HBsAg carriers. The subjects varied as to the characteristics of the clinical states. It was found that HCV coinfection was more common in HBsAg positive intravenous drug addicts than in other parenteral risk groups. It also appears that HCV may be the causative agent of chronic liver disease in HBsAg carriers with undetectable HBV (and possibly HDV) replication.

Adverse reactions to vancomycin prophylaxis in cardiac surgery

Several adverse effects of vancomycin have been reported. The aim of this study was to assess the incidence of adverse responses to antibiotic prophylaxis with vancomycin in cardiac surgical patients. Prospectively, 116 consecutive patients (106 adults and 10 children) undergoing cardiac surgical procedures in this institution from January to June 1990 were studied. After the anesthetic induction, vancomycin, 1 g in adults and 10 mg/kg in children, was intravenously administered over 30 minutes. The infusion rate was slowed if any adverse effect was observed. As a control group, 10 similar patients were evaluated during the same period of 30 minutes after anesthetic induction but prior to vancomycin administration and surgical stimulation. Thirty-one patients (26.72%) developed an adverse effect, mainly hypotension (29 patients, 25%), which was considered severe in 15 patients (12.93%). Seven patients (6.03%) developed a maculopapular erythema that was associated with hypotension (Red-Man's syndrome) in 5 patients and with bronchospasm in 1 patient. The incidence of adverse reactions in children (20%) was similar to the overall incidence. Only 1 patient in the control group (10%) developed hypotension during the period studied. The incidence of adverse reactions was not related to age, body weight, vancomycin dose administered per kilogram body weight, type of surgical procedure, or associated disease. Mean duration of the infusion was similar in patients with and without adverse responses (34.60 +/- 12.41 minutes and 37.38 +/- 14.55 minutes, respectively). It is concluded that perioperative prophylaxis with vancomycin in cardiac surgery produces a high and unpredictable risk of significant hypotension.

Immunophenotypic, genomic and clinical characteristics of blast crisis of chronic myelogenous leukaemia

We have studied phenotypic and clinical features in a consecutive series of 45 patients with chronic myelogenous leukaemia (CML) in blast crisis (BC). In addition, in 22 of these patients we have analysed the genotypic characteristics including immunoglobulin, T-cell receptor (TCR) and major breakpoint cluster region (M-bcr) gene organization. The granulomonocytic and megakaryoblastic lineages are the most commonly involved in these BC of CML (33% and 33% of cases, respectively); only 18% of our cases displayed a lymphoid phenotype. Moreover, both morphological and immunophenotypic studies revealed the frequent coexistence of two or three cell populations, especially when the megakaryoblast component is involved. The lymphoid BC displayed the highest incidence of complete remissions although this was not associated with a longer survival. Only minor differences between the different myeloid subgroups were observed. Immunoglobulin heavy chain (IgH) gene rearrangement was found in five of the six lymphoid BC and in one myeloid BC. Only one case showed k light chain gene rearrangement. In all but one myeloid BC the TCR-beta gene was in germline configuration. The TCR-gamma gene was rearranged in all lymphoid and one myeloid BC, while TCR-delta gene rearrangement was detected in 67% and 16% of the lymphoid and myeloid BC, respectively. Most of the lymphoid BC (4/5) had the M-bcr breakpoint in subregion 3, while the myeloid BC had the breakpoint either in subregion 2 or 3. No differences between the different myeloid phenotypic subgroups were observed in relation to breakpoint.

[Clinico-hematological characteristics of acute transformation of chronic myeloproliferative syndromes]

BACKGROUND

The aim of the present study was to analyze the blastic transformation occurring during chronic myeloproliferative diseases (CMPD) and to establish the differences between them.

METHODS

The clinical and hematological characteristics of 54 patients in blastic crisis (BC) of a CMPD were analyzed: 40 chronic myelogenous leukemias (CML), 9 idiopathic myelofibroses (IMF), 4 polycythemia vera (PV), and one essential thrombocythemia (ET). The results were analyzed by the BMDP statistical program.

RESULTS

The BC of CML appeared in younger patients (p less than 0.05). Only in this group did some patients achieve complete remission. Moreover, in this BC a greater incidence of visceromegalies and leukocytoses were observed. The BC of the IMF patients led to marked anemia (p less than 0.01) and bone marrow infiltration (p less than 0.05); these leukemias were more frequent in males and began with lymphadenopathies and visceromegalies. The transformations of PV were preceded by a longer chronic phase and had a lower incidence of visceromegalies and a nearly normal hemoglobin count value. The patient with acute leukemia secondary to ET did not display visceromegalies but did have anemia, leukopenia and a normal platelet count. None of the four groups responded to therapy, and their survival was short.

CONCLUSIONS

Blast transformations of different myeloproliferative disorders have their own idiosynchratic clinical and hematological characteristics, some of these may be related to the chronic phase of disease.

Acute leukemia after a primary myelodysplastic syndrome: immunophenotypic, genotypic, and clinical characteristics

We studied the nature of blast cells in 41 patients with acute leukemia following a previous primary myelodysplastic syndrome (MDS) by a combined multiparameter analysis including morphologic, immunophenotypic, and molecular genetic (Igs, T-cell receptor (TCR)-beta, -gamma, and -delta and the major breakpoint cluster region [M-bcr]) investigations. In addition, the clinical and hematologic characteristics according to the immunophenotype of blast cells were analyzed. Our results show that, although the granulocytic and/or monocytic lineages are those most commonly involved in these acute leukemias, other cell components, including the megakaryocytic and lymphoid, may be present (12% and 15% of the cases, respectively). Moreover, both morphologic and phenotypic studies show the frequent coexistence of two or three cell populations. Interestingly, in all cases the lymphoblastic component constantly displayed an early B phenotype (CD19+, CD10-, TdT+). Upon analyzing whether the type of MDS conditioned any differences in the immunophenotype of blast cells, we observed that, although the lymphoid lineage may be involved in all MDS subgroups, some differences emerge within the myeloid leukemic transformations. Thus, the refractory anemias with excess of blasts (RAEB) and RAEB in transformation displayed a significantly higher incidence of myeloblastic and megakaryoblastic transformations, while in the RA, RA with ring sideroblasts and chronic myelomonocytic leukemia, the granulo-monocytic phenotype predominated. In addition, our results show that the clinical and hematologic characteristics of these patients may be partially related to the immunophenotype of the blast cells. Ig heavy chain gene rearrangements were found in two of 19 patients analyzed (11%), one with a hybrid leukemia (lymphoid-myeloid) and the other with a granulo-monocytic phenotype. Two other hybrid transformations analyzed were in germline configuration. Gamma and delta gene rearrangements were found in 21% and 37% of these acute transformation, respectively. The TCR-beta and M-bcr were in germline configuration in all 19 cases studied. In summary, immunophenotype and molecular studies point to a pluripotent stem cell with preferential myeloid commitment as the target cell of leukemias following a primary MDS.

Heterogeneity of T cell lymphoblastic leukaemias

Twenty eight out of 170 consecutive cases of acute lymphoblastic leukaemia (ALL) were examined. They were of T cell origin, with the following distribution: seven (28%) cases had pre-T or prothymic features; nine (36%) cases showed early thymocytic features, six (24%) had cortical features; and three (12%) had a "mature" phenotype. The remaining three cases could not be sub-classified. A striking finding was that pre-T ALL differed from intrathymic ALL not only in the absence of both E rosettes and intrathymic differentiation antigens, but also in the expression of two non-lineage specific antigens HLA-DR and CD10. Both antigens appear in the bone marrow from the very first stages of lymphoid differentiation, implying that the origin for pre-T ALL is bone marrow. A comparison of the clinical features of pre-T and thymic ALL showed that pre-T ALL disease showed a pattern more similar to non-T ALL disease: a lower incidence of mediastinal mass, absence of extrahaematopoietic disease, lower white cell counts and haemoglobin concentrations, and a higher incidence of bone pain. No obvious difference in response to treatment was apparent. The results show that T-ALL is not only a heterogeneous immunological group but also suggest that it may have different origins: bone marrow for pre-T ALL and the thymus for thymic ALL.

[Phenotypic changes in refractory and relapse acute lymphoblastic leukemias]

Out of a group of 220 acute lymphoblastic leukaemias (ALL) with phenotypic study at diagnosis, 18 were selected on which sequential studies were performed due to relapse (15 cases) or to lack of achievement of complete remission (primary resistant ALL, 3 cases). The purpose of this study was to analyse the incidence and characteristics of the possible antigenic changes with regard to the diagnosis. Along with the classic markers, a panel comprised of 20 monoclonal antibodies against lymphoid and myeloid antigens was used. Major phenotypic changes (acquisition of myeloid antigens CD13 and CD33) were found only in one case amongst the relapsing ALL (7%). Seven other patients (47%) showed minor phenotyping changes, including: 1) acquisition or loss of antigens (2 cases); 2) changes in more then 50% of any antigen's expression (4 cases); 3) both (1 case). These results might suggest that antigenic changes are rather frequent in relapsing ALL; however, none of such changes modified in our experience the phenotypic diagnosis so any change of this last should be regarded as an exceptional event. The majority of these antigenic changes consisted of the loss of maturation antigens (CD20) or acquisition of early markers (TdT, HLA-DR) or activation markers (CD38); this would mean that the relapsing blast cells show a functional status of activation and proliferation, with a phenotype more immature than that of the diagnosis, thus explaining the poorer prognosis of the patients in relapse. No phenotypic changes were found in the primary resistant ALL, which may indicate the persistence of the original cell clone without any alteration.

[Effects of ursodeoxycholic acid in patients with cholestasis of pregnancy]

In an open, pilot study, the efficacy and safety of ursodeoxycholic acid (UDCA) in the treatment of intrahepatic cholestasis of pregnancy was investigated. Four patients received 1 g/day of UDCA during 20 days and another 2 patients received 2 identical periods of treatment separated by a 14-day interval free of drug. Pruritus and serum levels of total bile salts and glutamic-pyruvic transaminase improved significantly during treatment with UDCA. Although pruritus and the laboratory alterations had a relapse in the second week after UDCA was discontinued, they improved again in the 2 patients who received a second treatment with UDCA. No adverse reactions were detected in the mothers or in their babies. All newborns are thriving normally, in a follow-up that lasted 3 to 6 months after delivery. It is concluded that UDCA appears to be safe when administered in late pregnancy; its promising efficacy in the treatment of intrahepatic cholestasis of pregnancy should now be confirmed in controlled clinical trials.

Immunophenotypic heterogeneity of multiple myeloma: influence on the biology and clinical course of the disease. Castellano-Leones (Spain) Cooperative Group for the Study of Monoclonal Gammopathies

In 112 untreated myeloma patients we have analysed the immunophenotype of plasma cells both by immunofluorescence (IF) and immunocytochemistry (APAAP). Both techniques yielded similar results pointing to an important degree of heterogeneity in antigenic expression not only between different patients but also within the same patient. The expression of CD38 and Han-PC1 antigens (Ags) was almost constant (greater than 90% positive cases), while CD9 was detected in 66% of the cases. On the other hand, less than one third of patients were positive for CD10, CD20 and HLA-DR and generally with a weak expression (less than 30% positive plasma cells). In occasional cases plasma cells were weakly positive for the myelomonocytic markers CD13 (9%), CD15 (25%) and CD14 (6%). The possibility that this heterogeneity might be the result of different stages of differentiation of the neoplastic clone is suggested both by the positive correlation in the expression of some of these antigens (CD10, CD9, CD20, HLA-DR) and by the relationship between CD10 and myeloid antigens with immature plasma cell morphology. Finally, the cALLA antigen does not seem to be of significant value in predicting survival. Moreover, none of the other markers explored showed a clear influence in the course of the disease, although the tendency towards a lower survival found for the CD20+ cases as well as the association of the expression of some antigens and advanced clinical stage, may warrant further studies in a larger series of patients.

[Antibodies against hepatitis C virus in hemophiliacs: correlation with peripheral blood lymphocyte populations]

The presence of antibodies (Abs) against hepatitis C virus (HCV) was analyzed in 26 haemophiliac patients; a prevalence of 38% was found in the total series and 56% in the treated patients. There were no cases with a positive serology among the three patients who had only received pasteurized factor. The frequency of detection of anti-HCV was higher in the patients who had a positive serology for HIV (67%) and hepatitis B virus (56%) than in the seronegative patients (24 and 29%, respectively). The patients with HCV Abs showed a decrease in the helper (CD4+) lymphocytic population, mainly due to the decrease in the helper inducer (CD4+/Leu8-) cells, such alterations being more evident in the patients who also were HIV+ who showed as well an increase in the T-cell activated lymphocytes (CD3+/la+) and a decrease in CD16+ natural killer cells. These results suggest that the lymphocytic alterations found in the patients with anti-HCV Abs are not specific and would rather be related to the presence or not of HIV infection.