Disseminated Blastoschizomyces capitatus infection in acute myeloblastic leukaemia. Report of three cases

Three new cases of Blastoschizomyces capitatus infection occurring in neutropenic patients with acute myeloblastic leukaemia are reported. B. capitatus was isolated from blood cultures in all patients. All three patients were treated with amphotericin B, but only one was cured from the infection. Our study confirms the emergence of B. capitatus as an opportunistic agent of disseminated fungal infection in leukaemic patients.

[Detection of the PML/RAR alpha rearrangement in acute promyelocytic leukemia using a reverse PCR method]

AIMS

This study describes a molecular method of reverse transcription polymerase chain reaction (RT-PCR) to detect the rearrangement PML/RAR alpha in acute promyelocytic leukaemia (APL) in order to assess its specificity and sensibility, and to evaluate its utility in the characterization of APL patients.

PATIENTS AND METHODS

Between January and June of 1995, 64 samples of bone marrow and peripheral blood stem cells (PBSC) cytapheresis were studied. There were 58 APL samples (23 patients: 10 samples obtained with disease activity, 43 samples in complete remission (CR) and 5 PBSC samples) and 6 control samples, of non-APL hematological neoplasms (3 other AML, 1 CML, 1 ALL, and 1 MDS). On the RNA obtained from the isolated mononuclear cells of each sample a conserved region of the PML/RAR alpha fusion gene was amplified by using a RT-PCR with specific primers.

RESULTS

The sensitivity assays were performed by diluting PML/RAR alpha positive RNA samples into RNA of controls. The RT-PCR assay was capable to detect the PML/RAR alpha until an 1/1000 dilution in negative control RNA. Nine out of 58 APL samples failed in the amplification of the control gene, and were considered non-evaluable. None of the 6 control samples showed PML/RAR alpha rearrangement. Nine out of 10 APL samples with disease activity were positive for the presence of PML/RAR alpha (the non-positive sample was a non-evaluable one). Six out of 43 APL samples in CR showed the rearrangement, 3 of them corresponding to 2 patients who posteriory relapsed 12 and 19 months after 1st CR. The other 3 positive samples came from other 3 APL patients (24 months in 3rd CR, 14 months in 1st CR and early CR), who remained in CR at the end of the study. No relapse could be noted in patients with negative PCR samples. PML/RAR alpha was not found in any of the 5 APL PBSC samples studied.

CONCLUSIONS

The RT-PCR method described here seems to be highly specific as it only detects this rearrangement in LPA patients. Furthermore, the presence of PML/RAR alpha in CR patients could be related to relapse. For all these reasons, this molecular method shows great usefulness and can be advocated, not only for assessing diagnosis, but for as monitoring minimal residual disease in the post remission follow up.

Immunophenotyping of AML and MDS and detection of residual disease

Immunophenotyping improves both accuracy and reproducibility of the FAB classification and is considered particularly useful for identifying poorly differentiated FAB subtypes of AML, such as AML with minimal differentiation (M0), microgranular promyelocytic leukaemia (M3V), and megakaryoblastic leukaemia (M7). Immunological studies of myeloid leukaemic blasts has become critical also in identifying biphenotypic leukaemias and AML expressing lymphoid-associated markers (Ly+ AML). At present, while the prognostic value of individual antigen expressions is still controversial, due to technical questions, the immunological detection of MRD seems to be important in monitoring AML patients in remission and, perhaps, in detecting leukaemic cell contamination into bone marrow or peripheral blood progenitor cells collected for autologous transplantation. In addition, the relationship established between genetic abnormalities and certain phenotypes within different FAB subtypes suggests that, in the future, immunophenotypical studies could be used for the screening of AML cases carrying specific genetic aberrations. Compared to acute leukaemias, little information is available concerning immunological patterns in MDS, and the role of the immunophenotype in diagnosis, subclassification, and prognosis of MDS is currently not well established.

Isocratic high-performance liquid chromatographic method for quantitative determination of lysine, histidine and tyrosine in foods

A method for the quantitative determination of lysine, histidine and tyrosine in foods based on pre-column derivatization with 5-dimethylaminonaphthalene-1-sulfonyl chloride (DnsCl) and reversed-phase liquid chromatography has been developed. Derivatization conditions, including DnsCl concentration, time, temperature, and buffer solution were studied. To establish the reliability of the proposed liquid chromatographic (LC) method, the precision and accuracy of the analyses were evaluated using samples of casein and lysozyme.

A role for 3AB protein in poliovirus genome replication

The poliovirus polypeptide 3AB, the precursor of the genome-bound VPg protein, stimulates in vitro the synthesis of poly(U) directed by the viral polymerase 3Dpol (Lama, J., Paul, A., Harris, K., and Wimmer, E. (1994) J. Biol. Chem. 269, 66-70), suggesting that 3AB could be modulating the activity of the viral polymerase in poliovirus-infected cells. To address the exact function of 3AB in the viral replication cycle, a biochemical and molecular genetic analysis of 3AB has been carried out. 3AB protein bound RNA probes in two different assays, and amino acid positions implicated in the RNA binding activity of 3AB were determined. Mutant proteins with reduced RNA binding activity were unable to stimulate 3Dpol polymerase activity. Purified protein 3A showed no RNA binding or 3Dpol stimulatory activity, but 3A and VPg mutations conferred a synergistic effect on the 3AB functions. Polioviruses encoding for these mutant 3ABs were constructed. These mutant viruses translated their RNA genomes in vitro and processed their polyproteins as wild type virus did. Cells infected with 3AB mutant viruses showed over 90% inhibition in the accumulation of plus and minus viral RNA strands and more than 100-fold reduction of virus yield at 4 h postinfection. Our results suggest that 3AB protein functions in vivo as a co-factor of the viral polymerase and that the activity of 3AB may be regulated by proteolytic processing.

[Immunohematologic study in 112 patients with myelodysplastic syndromes: 10-year analysis]

PURPOSE

To describe the immunohematological response after multiple red blood cells transfusions in 112 patients with myelodysplastic syndromes (MDS).

PATIENTS AND METHODS

From 1982 to 1992 every patient with MDS entered the study. Immunohematological studies consisted of an antibody screening test (AST) and a direct antiglobulin test (DAT) at diagnosis and after every four transfused units of red blood cell concentrates.

RESULTS

Twenty-three out of 112 patients (20.5%) presented a positive AST and/or DAT during the study period. Eleven out of the 23 patients (9.8%) developed a positive DAT, six of them with red cell alloantibodies associated. In the remaining 12 patients (10.7%) the immune response observed was the development of red cell alloantibodies without a positive DAT. No patient presented with positive AST or DAT at diagnosis and no differences were observed in the pattern of immunohematological response and the FAB subtype.

CONCLUSION

Patients with MDS have disordered immune systems with a high prevalence of autoantibodies against red cells. However, the incidence of red cell alloimmunization is similar to that observed in other multitransfused populations. Finally, despite the high immunization rate, the absence of any hemolytical reaction make the AST and DAT a safe and effective method of pretransfusion testing in this heavily transfused population.

Allogeneic peripheral blood progenitor cells mobilized by G-CSF (filgrastim) for a second transplant in a patient with acute myeloid leukemia in relapse

A 25-year-old man with AML, who relapsed 21 months after his first allogeneic bone marrow transplant (BMT), underwent a second transplant with peripheral blood progenitor cells (PBPC) obtained from his HLA-identical sibling. The donor cells were collected through four aphereses after G-CSF mobilization with 5 micrograms/kg/d for 5 days. The patient received BAVC conditioning regimen followed by non-T cell-depleted PBPC. Successful engraftment occurred with rapid hematopoietic recovery (time to reach 0.5 x 10(9)/L neutrophils and 50 x 10(9) platelets/L was 15 and 19 days, respectively). A bone marrow aspirate on day +19 showed trilineage engraftment. Erythrocyte phenotype showed that erythropoiesis was of donor origin. The patient developed grade II acute GVHD that responded to prednisone. Seven months after PBPC transplantation he remains in complete remission, alive and well, with just limited chronic GVHD. Allogeneic peripheral blood progenitor cell transplantation may be considered a suitable alternative to marrow transplant.

Rapid progression of multiple myeloma following G-CSF mobilization

A 23-year-old man diagnosed as having multiple myeloma was treated with melphalan and prednisone monthly. After six cycles, an autologous peripheral blood stem cell transplantation (ABSCT) was planned. Peripheral blood mononuclear cells were collected after G-CSF mobilization (5 micrograms/kg/day for 5 days). Ten days after the last dose of G-CSF the patient showed a striking progression of multiple myeloma. A 57% infiltration of plasma cells in bone marrow and recurrence of laboratory abnormalities were evident. The patient's clinical course strongly suggests that myeloma progression was triggered by G-CSF and supports the concept of G-CSF mediated autocrine stimulation of myeloma growth.

Semliki Forest virus 6K protein modifies membrane permeability after inducible expression in Escherichia coli cells

Semliki Forest virus encodes a small protein, known as 6K, that is associated with cellular membranes in the infected cells. This protein has been cloned and expressed in an inducible manner using pET vectors in Escherichia coli cells. Two different plasmids have been utilized; either the 6K gene is placed directly under the T7 promoter (pET3-6K) or the lac operator is located between the T7 promoter and the 6K gene (pET11-6K). In both systems, efficient synthesis of the 6K protein is achieved by induction with isopropyl-1-thio-beta-D-galactopyranoside plus rifampicin. The synthesis of the 6K protein is very toxic for E. coli causing increased membrane permeability and cell lysis as shown by alterations in permeability to either choline or hygromycin B. These results indicate that the togavirus 6K is a membrane-active protein that shows structural and functional similarities to poliovirus 3A protein. The function that the 6K protein could play during the virus replication cycle is discussed in the light of these findings.

[Leukemia and mental health: psychological disturbances, predisposing actors, precipitating conditions and psychotherapeutic approach]

PURPOSE

To determine, within a group of leukaemic patients, which data are valid parameters of predisposing factors with regard to the onset of psychological alterations, and also to establish the therapeutic approach to those factors.

PATIENTS AND METHODS

A longitudinal study was performed on 22 cases of leukaemia. A psychologic evaluation study of the mental health was carried out analysing different aspects, namely, personality, anemic status, anxiety, and stress along the last 12 months, and the grade of social support and the specific pattern of coping with stress situations were examined as well. The complete evaluation took into account the different phases of the leukaemia: diagnosis, clinical course, relapses and therapy; other circumstances such as sex, age, time from diagnosis, type of treatment, untoward therapeutic effects, type and time of isolation, were also contemplated.

RESULTS

Intersenting data were collected, it being important that 77% of the cases had psychic alterations. Adaptative and psychosomatic alterations were commonest, amounting to 82% and 59%, respectively. The findings on the predisposing factors and rushing conditions attained interesting predictive value for preventive purposes.

CONCLUSION

The cognitive-behavioural strategies of psychologic interventions included in the psychology of health and applied to the principles of medicine have proven highly efficacious in the treatment of psychopathies, but also in their prevention.

Acute myeloblastic leukemia with minimal myeloid differentiation (FAB AML-M0): a study of eleven cases

The main clinical, morphological, cytochemical, immunological features and therapy results of eleven patients diagnosed as acute myeloblastic leukemia M0 (AML-M0) are reported here. There were no clinical characteristics, abnormalities on physical examination or initial laboratory parameters that distinguished these eleven patients. Bone marrow aspirates were hypocellular in four patients. The leukemic cells were undifferentiated by light microscopy and myeloperoxidase (MPO) and/or Sudan Black B (SBB) stains were negative in all cases. Myeloid differentiation antigens were present on the leukemic cells of all eleven patients, whereas B and T cell markers were clearly negative except for CD4 and CD7 antigens. Whatever the treatment employed survival was very short. Eight of the eleven patients were treated and two achieved complete remission (CR) but only one of them is alive in continuous CR. Our results like those previously reported, suggest that AML-M0 patients have a very poor prognosis with standard induction therapies and should perhaps be considered for experimental therapeutic approaches.

Busulfan plus cyclophosphamide followed by autologous blood stem-cell transplantation for patients with acute myeloblastic leukemia in first complete remission: a report from a single institution

PURPOSE

To determine if peripheral-blood stem cells (PBSC) collected during the recovery of standard induction and consolidation chemotherapy in acute myeloblastic leukemia (AML) can be used as a safe tool for autologous transplantation, and to study aspects of the autologous blood stem-cell transplantation (ABSCT) procedure and their results in AML patients in first remission.

PATIENTS AND METHODS

Twenty-four AML patients in first remission received busulfan (BU; 16 mg/kg) and cyclophosphamide (CY; 200 mg/kg) followed by ABSCT. PBSC were collected by continuous-flow leukaphereses after induction and consolidation courses.

RESULTS

The median numbers of mononuclear cells (MNCs) and colony-forming unit granulocyte-macrophage (CFU-GM) administered were 6 x 10(8)/kg and 11 x 10(4)/kg, respectively. ABSCT induced engraftment in 22 patients and there were two graft failures. The median times to reach a polymorphonuclear (PMN) leukocyte count of 0.5 x 10(9)/L and a platelet count of 50 x 10(9)/L were 13 and 19 days, respectively. Fatal hepatic veno-occlusive disease (VOD) was observed in two cases. Other toxicities were mild and uncommon. Twelve patients relapsed between 1 and 9 months posttreatment. Actuarial disease-free survival (DFS) and actuarial risk of relapse at 30 months were 35% (95% confidence interval [CI], 25% to 45%) and 60% (95% CI, 50% to 72%), respectively.

CONCLUSION

These preliminary results show the fast hematopoietic recovery and the low infectious and hemorrhagic morbidity associated with the procedure and strongly suggest that ABSCT may be as effective as autologous bone marrow transplantation (ABMT) in AML. However, further strategies for reducing leukemic relapse must still be investigated.

[Clinical profile and course of paroxysmal nocturnal hemoglobinuria]

PURPOSE

To evaluate the clinical characteristics, laboratory findings, course, treatment and survival of a series of patients with PNH.

PATIENTS AND METHODS

The clinical records of 21 patients diagnosed of PNH in the La Fe University Hospital between 1970 and July 1991 were revised. Positivity to Ham's and sucrose tests was the major diagnostic criterion. Haemolysis was studied by means of reticulocyte count, unconjugated bilirubin, LDH levels, haptoglobin, serum iron, and haemosiderinuria. The survival analysis was performed in accordance with Kaplan and Meier.

RESULTS

The median age in the group was 38 years (range: 18-72 years) and the M/F ratio was 11/10. The commonest symptoms at onset were weakness (76%), dark urine (47%), jaundice (33%), and purpura (24%). All the patients had anaemia, six of them (28%) presenting with aplastic anaemia. The complications most frequently seen included thrombosis (documented in 7 cases, clinically suspected in 6 others), infection (6 cases) and haemorrhage (6 cases). One patient developed aplastic anaemia after 16 years of follow-up, and another one had AML. None of the patients with PNH-associated aplastic anaemia developed thrombosis. The incidence of severe cytopenia was: Hb < 80 g/L, 62%; platelet count < or = 20 x 10(9)/L, 29%, and white cell count < or = 2 x 10(9)/L, 14%. The haemolysis-related findings were as follows: unconjugated hyperbilirubinemia, 100%; haemosiderinuria, 87%; decreased haptoglobin, 80%. Transfusion support consisted of washed red cells (total amount, 1,684 units) and platelets (137 units). A female patient with anticoagulant therapy developed haemolysis after non-isogroup plasma transfusion. Five patients required no transfusions. One patient was subjected to splenectomy and other underwent a successful bone-marrow transplant. The cause of death was related to PNH in three of the five patients who had died when this study was finished (mesenteric thrombosis, subcapsular haematoma of the liver and AML). The actuarial survival at 10 years was 68%.

CONCLUSIONS

1) The incidence of PNH is very low in our experience, excessive delay in diagnosis being the rule, as in other reported series. 2) Early anti-thrombotic treatment should be carried out in PNH whenever severe thrombocytopenia is not associated. 3) Allogeneic BMT is the only curative treatment.

Alternating combination VCMP/VBAP chemotherapy versus melphalan/prednisone in the treatment of multiple myeloma: a randomized multicentric study of 487 patients

PURPOSE

To determine whether combination chemotherapy with alternating cycles of vincristine, cyclophosphamide, melphalan, and prednisone (VCMP) and vincristine, carmustine (BCNU), Adriamycin (doxorubicin; Farmitalia, Carlo-Erba Laboratories, Spain), and prednisone (VBAP) is better than the standard melphalan-prednisone (MP) regimen in multiple myeloma (MM).

PATIENTS AND METHODS

From January 1985 to December 1989, 28 institutions of the Spanish Cooperative Group for Hematological Malignancies Treatment, Spanish Society of Hematology (PETHEMA) entered 487 eligible patients with symptomatic MM into the study. Patients were randomized to receive either MP or alternating courses of VCMP and VBAP. Logistic regression and the Cox proportional hazards models were used to assess the association between patients' characteristics and response rate and survival, respectively.

RESULTS

Among 449 patients who were assessable for response, the overall response rate to MP was 51.8% (31.5% objective response plus 20.3% partial response) as compared with 62.7% (45.2% objective response plus 17.5% partial response) to VCMP/VBAP (P = .025). Also, a significantly higher proportion of objective responses was observed with combination chemotherapy (45.2% v 31.5%; P = .004). The factors associated with an unfavorable response rate in the overall series were low platelet count, treatment with MP, high creatinine level and immunoglobulin, (IgG) monoclonal (M)-component. No significant differences were found when survival rates of both groups of patients were compared. However, patients with IgA myeloma treated with VCMP/VBAP survived significantly longer than those who received MP (median, 20.2 v 38.4 months; P < .005).

CONCLUSION

These results indicate that combination chemotherapy improves response rate in MM. However, this does not result in a significantly different survival rate, except for patients with IgA myeloma, who survive significantly longer with combination chemotherapy.

Carboplatin alone or in combination in high-risk acute nonlymphoblastic leukemia

The use of newly developed antileukemic agents is one of the therapeutic options available to overcome clinical resistance in refractory or other high-risk acute leukemias. Carboplatin is a second-generation platinum compound that has demonstrated significant activity against acute leukemia, particularly when administered via continuous intravenous infusion in phase I clinical trials. Based on the preliminary reports of these trials, we designed a phase II clinical trial to evaluate the efficacy and toxicity of carboplatin via continuous infusion (300 mg/m2/d for 5 days) for remission induction in adult patients with high-risk acute leukemia. Because of the significant antileukemic activity and the scarce extrahematologic toxicity noted in this trial, in order to increase the response rate, we were encouraged to try carboplatin in combination in a similar set of patients. A phase II study of carboplatin 300 mg/m2/d for 5 days in combination with etoposide 100 mg/m2/d for 3 to 4 days was designed by our group to treat patients with high-risk acute leukemia. This combination was chosen because (1) each drug has independent activity in acute nonlymphoblastic leukemia (ANLL) and (2) carboplatin/etoposide has been extensively tested in patients with small and non-small cell lung cancer, and therefore the toxicity and maximum tolerated dose are known. The complete remission rate achieved was somewhat higher (40%) than with carboplatin alone despite the increased incidence of extrahematologic toxicities, particularly gastrointestinal bleeding. At present, carboplatin should be considered as a new effective agent for the treatment of ANLL.(ABSTRACT TRUNCATED AT 250 WORDS)

[Utility of the examination of plasma-cell morphology in the study of multiple myeloma]

PURPOSE

To assess the classification of Greipp et al in a group of multiple myeloma (MM) patients, in an attempt to correlate the morphological patterns with the clinico-biological features of the disease.

MATERIAL AND METHODS

Bone marrow aspirates from 135 patients with multiple myeloma were examined by two different observers.

RESULTS

Full accordance existed in 122 cases (90%). The four morphological MM subgroup distribution was: mature, 38%; intermediate, 30%; immature, 18%, and plasmoblastic, 14%. The analysis of the M component types with regard to morphology showed increased IgA cases within the intermediate (40%) and immature (48%) MM (p = 0.01), and Bence-Jones cases within the plasmoblastic MM (32%). On the contrary, no differences were found with regard to the clinical stage, although none of the plasmoblastic MM was in stage I. The incidence of renal insufficiency and of high bone-marrow infiltration progressively increased from mature to plasmoblastic MM, the difference between the extreme morphological groups being significant. The incidence of hypercalcaemia and lower paraprotein rates was higher in plasmoblastic myeloma, with significant difference with respect to mature myeloma (p = 0.05). The median survival was longer in intermediate (27.8 months) and mature (22.5 months) myelomas than in plasmoblastic (17.9 months) and immature (13.6 months) myelomas. After grouping the mature forms (intermediate plus mature) and the immature ones (plasmoblastic plus immature) the survival differences approached statistical significance (p = 0.07).

CONCLUSIONS

This study suggests that the morphological examination of plasma cells should be included in the prognostic criteria of multiple myeloma.

[Hyperleukocytic acute leukemia. Clinico-biological characterization, response to treatment and prognostic factors]

The white-cell count acquires an important prognostic value in acute leukaemia. Thus, very high leucocytosis conveys high risk of early death due to leucostasis. The clinico-biological features at diagnosis, response to therapy and prognostic factors of 69 cases of acute leukaemia with hyperleucocytosis (ALHL) are reported in this paper. All the patients had white-cell count over 100 x 10(9)/L and had been followed up at the Haematology Service of the Hospital La Fe between 1977 and 1989. There were 49 cases of acute nonlymphoblastic leukaemia (ANLL), 18 cases of acute lymphoblastic leukaemia (ALL) and 2 of unclassified acute leukaemia. The incidence of ALHL was 14%, and the mortality on the first week after diagnosis reached 20%, this being higher in ANLL. The actuarial median of complete remission duration was 9 months. The achievement of remission was associated with the morphological subtype, the patient's age and the presence of constitutional symptoms at onset, while the duration of remission was associated with the presence of fever and the need more than one chemotherapy course to attain remission. ALHL need new therapeutic strategies in order to diminish the rate of early death and to achieve longer survival.

Prognostic factors in myelodysplastic syndromes

The extreme variability in prognosis among patients with myelodysplastic syndromes (MDS) complicates decision-making regarding their therapy. Several studies carried out in recent years have recognized the prognostic value of some clinical and biological characteristics. The percentage of blast cells in bone marrow, cytopenias, age and chromosome abnormalities are the most relevant factors affecting outcome. More importantly, some of these studies have resulted in the development of prognostic regression formulas and scoring systems for accurately estimating the individual prognosis of patients. The major aim of this review is to offer the clinician useful tools for treating MDS patients on a risk-fitted strategy.

Disseminated Scedosporium inflatum infection in a patient with acute myeloblastic leukemia

A case of disseminated Scedosporium inflatum infection occurring in a neutropenic patient with acute myeloblastic leukemia is reported. Scedosporium inflatum was isolated from skin lesions, blood, urine and vitreous cultures. Amphotericin B treatment was ineffective in avoiding hematogenous spread. At autopsy, hyphae and ovoid conidia with truncate bases consistent with the morphology of Scedosporium inflatum were found in the lungs, kidneys, myocardium, liver, thyroid, spleen, lymph nodes, brain and the left eye. This is the first report of disseminated Scedosporium inflatum infection and the first time this organism has been isolated from a patient in Europe.

[Chronic lymphatic leukemia. II. Analysis of prognostic factors and development of survival predicting models. Study of 187 patients]

The univariate analysis of prognostic factors showed the value of clinical variables (age, symptoms, lymph node enlargement, splenomegaly, hepatomegaly, clinical stage), haematological variables (haemoglobin, platelet count, leucocyte count, lymphocyte count, bone marrow involvement and biopsy pattern, cleaved lymphocytes, prolymphocytes, LDT) and biochemical variables (BUN, creatinine, calcium, phosphorus, uric acid and albumin). The multivariate analysis chose the combination of Rai's stage, age, cervical lymph node involvement, phosphorus and BUN. Two predictive models capable of separating appropriately low, intermediate and high risk groups were developed and validated. The results were compared with others in the literature. The interest of predictive models arising from multivariate analysis is stressed.

[Chronic lymphatic leukemia. I. Clinico-biological features and survival analysis. Study of 187 patients]

A review was carried out of 187 previously untreated cases of chronic lymphocytic leukaemia diagnosed between 1969 and 1988. The median age of the patients was 65 years (range, 36-87). There were 118 males (M/F ratio, 1.7). In accordance with Rai's staging system the patients were distributed as follows: 0.29%; I, 20%; II, 25%; III, 13%; IV, 13%, and according to Binet's staging the distribution was: A, 55%; B, 21%; C, 24%. The most frequently found physical findings were lymph node enlargement (55%), splenomegaly (32%) and hepatomegaly (28%). Anaemia was present in 20% of the cases and thrombocytopenia in 13%. The mean lymphocyte count was 62 x 10(9)/L (range, 6-475 x 10(9)/L). Bone marrow infiltration of over 80% was seen in 46% of the patients. Bone marrow biopsy was performed on 97 patients, the diffuse pattern of involvement being most commonly found (44%). Increased BUN (55%), alkaline phosphatase (42%) and LDH (38%) were the most frequent biochemical alterations. Hypogammaglobulinaemia was present in 55% of the patients, IgM being the most commonly affected immunoglobulin (66%). Monoclonal gammopathy was seen in 4% of the cases. LDT, measured in 75 patients, was less than a year in 32%. No antileukaemic drugs were needed in 34% of the patients. When concluding this study, 100 patients had died. The median survival was 57 months and death was related to chronic lymphocytic leukaemia in 53% of such patients.

[Culture of cells forming granulomonocytic colonies in bone marrow (GM-CFU) in myelodysplastic syndromes and their relation to hematological findings and FAB subtype]

The results of "in vitro" culture of granulomonocytic precursor cells (CFU-GM) of the bone marrow from 44 patients were analysed in the present work. The correlation with the patient's haematological characteristics, their FAB subtypes (i.e., 6 cases of refractory anaemia (RA), 11 of acquired sideroblastic anaemia (ASA), 15 cases of refractory anaemia with excess blasts (RAEB), 5 cases of RAEB in transformation (RAEBT) and 7 cases of chronic myelomonocytic leukaemia (CMML), and the survival were examined as well. The technique used for cell culture was that of Pike and Robinson, following the classification proposed by Florensa for estimating the growth patterns. Anomalies of the myeloid clonal proliferation were found in 81% of the cases. There was direct correlation between the number of aggregates and the polymorphonuclear cell count, whereas the highest number of blast cells coincided with increased number of clusters in cultures. CNNL showed the highest aggregate counts. The B growth pattern (both colony and aggregate growth) was most frequently seen in CMML; pattern C2 (decreased colonies with increased aggregate count) appeared in RAEB, RAEBT and CMML, and pattern C3 (decrease of both colony and aggregate counts) was found only in RA and ASA. None of the culture findings appreciably associated with the survival.

[Harvesting of mononuclear cells from peripheral blood in malignant hemopathies]

After demonstrating through animal models that progenitor cells with haemopoietic regenerative capability are present in peripheral blood, such precursor cells were also found in the mononucleated cell (MNC) fraction of human peripheral blood. It was shown that such cells increase in the recuperative period following chemotherapy. A number of studies have demonstrated that autologous infusion of such MNC achieved by cytapheresis may lead to a quick restoration of haemopoiesis. The initial results of peripheral blood MNC achievement in 18 patients with different malignancies of the blood are presented in this paper. Ninety-one cytapheresis sessions were carried out, 88 with a Fenwall CS-3000 continuous-flow machine, and the remaining three with a Haemonetics V-50 discontinuous-flow cell separator. The number of sessions per patient ranged from three to six and the harvested MNC count was 19.3 x 10(9)/L, the percentage of recovery being 56.4%. Some studies are currently in course aimed to analyse the MNC subpopulations in order to measure the progenitor-cell fraction and to establish the viability of such cells for further transplants. Since only five patients have recently been transplanted, all successfully, no definite conclusions can be drawn presently in this connection.

Chronic lymphocytic leukaemia: prognostic value of lymphocyte morphological subtypes. A multivariate survival analysis in 146 patients

Among other patient and disease characteristics, different morphological lymphocyte subtypes were analysed in 146 patients with chronic lymphocytic leukaemia (CLL) to establish their clinical significance and prognostic value. The univariate analysis selected, among other well-known variables, the following lymphocyte subtypes as significant in prognosis: prolymphocytes, granulated lymphocytes, cleaved lymphocytes and small-size lymphocytes. The presence of prolymphocytes and cleaved lymphocytes was correlated with a poor prognosis, whereas granular lymphocytes and small-size lymphocytes were related to a good prognosis. A multivariate regression analysis showed that, besides clinical stages, haemoglobin level, WBC count, age, percentage of bone marrow erythroid cells, and sex, only prolymphocytes had independent prognostic significance. Prolymphocyte percentage correlated positively with characteristics expressing tumour mass such as WBC count, blood absolute lymphocyte count, serum lactate dehydrogenase level, number of enlarged lymph nodes, splenomegaly, and a high number of lymphocytes in bone marrow aspirate. Finally, a prolymphocyte threshold of 5 x 10(9)/l was found to be useful not only to separate two different groups of patients in the whole series but also in Rai's stages II and III + IV, and in Binet's stages A and C.

Pregnancy outcome in hematologic malignancies

By means of a mail questionnaire, information on a series of 56 pregnancies i in 48 women diagnosed with leukemia or lymphoma was collected from ten hospitals. Seven patients conceived while receiving treatment for their neoplasms; in 22 patients, the hematologic disease was diagnosed during pregnancy, and the remaining 27 patients became pregnant after completion of the antineoplastic treatment. When a comparison was made of the evolution of these pregnancies to that of pregnancies in a healthy population, no increase in the incidence of complications was observed: 64% of the pregnancies went to term, 9% resulted in spontaneous abortion, and 5% resulted in premature births. The observed incidence of one major malformation in 56 pregnancies did not differ from the frequency of malformations in the offspring of healthy individuals. There were no fetal losses in six pregnancies in which conception occurred during the first year after chemotherapy. In spite of the inherent limitations derived from the design of this type of study and the type of subject analyzed, the data here support the hypothesis that the cytostatic treatment of hematologic malignancies, if deemed necessary, should not be postponed because of pregnancy. Moreover, the authors agree with advice recommending that no antifolic or alkylating agents be used for prolonged periods and that radiotherapy be avoided, especially to those fields involving the pelvic area.

A phase II clinical trial of carboplatin infusion in high-risk acute nonlymphoblastic leukemia

Carboplatin (CBDCA) is a second-generation platinum drug that has been shown to be useful when used as a continuous infusion in treatment of refractory adult leukemia. We report on the effectiveness of continuous infusion CBDCA, 300 mg/m2/d x 5 days, as evaluated in nine patients with secondary acute nonlymphocytic leukemia (ANLL) (seven previous myelodysplastic syndrome and two treatment-associated ANLL), three ANLL patients in first relapse, six refractory ANLL, and nine patients with blastic phase of chronic myelogenous leukemia (BP-CML). All patients were considered assessable. The response rate was 44% (eight complete remissions [CRs], four partial remissions [PRs]). Median duration of postchemotherapy neutropenia was 36 days (range, 18 to 45). Therapy was well tolerated, and toxicity was mainly hematologic and nondose-limiting. Despite prolonged neutropenia, severe infections were rarely seen, and most patients were managed as outpatients. Twelve patients had nausea and vomiting, two had symptomatic hypomagnesemia, and one patient showed reversible ototoxicity. Because of substantial antileukemic activity and unusual extrahematologic toxicity, CBDCA appears to be an effective second-line agent in the treatment of ANLL and should be considered for upgrading to first-line treatment regimens.

[Hansenula anomala infection in acute leukemia]

Hansenula anomala infection is a clinical rarity which has only been reported in 21 cases. Although most reported cases had one or more of the risk factors of fungemia, only three developed in hematological patients. In the present study we report two cases of Hansenula anomala infection in acute leukemia, one in its teleomorphic form and another in the asexual form of this yeast, Candida pelliculosa. The sustained chemotherapy and steroid and antibiotic treatment were some of the risk factors of fungemia which were present in these patients, one of which was a carrier of a central venous catheter. As it has been suggested that Hansenula anomala has a low virulence and a high susceptibility to amphotericin B, we emphasize the potential morbidity and mortality that this organism can induce in patients with hematological disease.

Bone marrow biopsy in myelodysplastic syndromes: morphological characteristics and contribution to the study of prognostic factors

Ten characteristics of bone marrow (BM) biopsies in paraffin sections, obtained at diagnosis from patients with myelodysplastic syndromes (MDS) classified according to the FAB criteria, were analysed to identify both the most relevant morphologic data and any possible influence on survival. Agreement between two observers was obtained for 94% of the data. BM cellularity was increased in 63% of the cases and was higher in refractory anaemia with excess of blasts (RAEB). RAEB in transformation (RAEB-t) and chronic myelomonocytic leukaemia (CMML) (P = 0.001). Dysmegakaryopoiesis and dyserythropoiesis were present respectively in 83% and 72% of the cases, with slight differences among the FAB subtypes. Abnormal localization of immature precursors (ALIP) was found in more than half of the cases and somewhat more frequently seen in the RAEB + RAEB-t + CMML group (P = 0.07). Eosinophilia, plasmacytosis and reticulin fibrosis were evident in 26%, 18% and 47% of the cases respectively. Cellularity (P = 0.006), eosinophilia (P = 0.009) and, to some extent, dysmegakaryopoiesis (P = 0.07) bore a certain relationship with survival on univariate analysis. The presence of ALIP was not seen to affect the outcome. Multivariate analysis showed that the cellularity and presence of dysmegakaryopoiesis, in BM biopsy, added significant independent prognostic information to that achieved with age, platelet count and proportion of blast cells in BM aspirate, three variables with proven prognostic value in MDS patients. Using a regression model including these five characteristics we have stratified the patients into low, intermediate and high-risk groups with different survivals (P = 0.00001). The present findings show that BM biopsy is able to provide both morphological characteristics and information about the prognosis of survival, and should thus be included in the initial evaluation of MDS.

Two regression models and a scoring system for predicting survival and planning treatment in myelodysplastic syndromes: a multivariate analysis of prognostic factors in 370 patients

Therapy planning in patients with myelodysplastic syndromes (MDSs) is complicated by its high prognostic heterogeneity. Forty-one patient and disease characteristics at onset of 370 patients with MDS were analyzed to identify significant prognostic factors for survival and transformation to acute myeloblastic leukemia (AML), and to develop and validate a regression model for predicting survival. Multivariate regression analysis showed that the total bone marrow percentage of blast cells, age, platelet count, WBC count, and hemoglobin level were the characteristics more significantly associated with survival in the overall series. The bone marrow percentage of type I blast cells was the most important factor predicting transformation into AML. Proportional hazards regression analysis in a randomly selected training sample of 240 patients demonstrated that the combination of total bone marrow percentage of blast cells, platelet count, and age had the strongest predictive relation to survival length. The resulting regression models, continuous and categorized, were validated in the remaining test sample of 130 patients by demonstrating its capability of segregating patients into low-, intermediate-, and high-risk groups, with distinctively different survival curves (P less than .0001). A scoring system derived from the categorized model also had a great prognostic value (P less than .0001). These regression models and the simpler scoring system may be accurately used for decision-making regarding therapy in MDS patients.

Chronic myelomonocytic leukemia--clinicobiological characteristics: a multivariate analysis in a series of 70 cases

In a series of 70 patients diagnosed according to the FAB criteria, 42 clinical and biological disease characteristics were analyzed in order to identify significant prognostic factors by means of univariate and multivariate analysis. The univariate analysis identified ten parameters associated with poor prognosis: Symptoms of anemia, WBC over 10 x 10(9)/l, presence of blast cells, myeloid precursors or erythroblasts in peripheral blood (PB), high bone marrow (BM) cellularity, severe dysthrombopoiesis, percent of blast cells in BM and high serum levels of bilirubin and LDH. The Cox proportional hazards regression method revealed that the combination of high leukocyte counts and BM percentage of blast cells had the strongest predictive relation to survival length (p = 0.002 and p = 0.060 respectively). A new multivariate analysis treating the presence of myeloid and erythroid precursors in PB as a single variable selected only this as the most significant prognostic factor (p = 0.001). Both regression models allowed us to discriminate two significantly different risk groups of patients.

[Recurrent thrombotic thrombocytopenic purpura and pregnancy]

Two women are presented who were diagnosed of thrombotic thrombocytopenic purpura (TTP) during their first pregnancies, leading in both cases to spontaneous abortion. Both patients improved after plasma exchange or fresh plasma infusion. Two new pregnancies on each patient, closely watched on gynaecological and haematological grounds, led to TTP reactivation. Obstetrical and haematological management was similar for the two women (fresh-frozen plasma administration) but it yielded different results, since, although the risks for the mothers were controlled, one of the patients gave birth successfully on two occasions while the other developed stillborns on two occasions as well. These observations suggest the inter-relationship between TTP and pregnancy, and point to some pathophysiological aspects of the foetal deth repeteadly presented by one of the patients. A review of the literature is presented on the basis of these cases of PTT associated to pregnancy.

[Prediction of survival in myelodysplastic syndrome. Analysis of 2 scoring systems with prognostic value]

The wide prognostic variability of myelodysplastic syndromes (MDS) complicates decision-making regarding the choice and evaluation of alternative treatments to transfusional and antiinfectious supportive measures. Due to its simplicity the Bournemouth scoring system seems to have achieved wide acceptance for establishing the prognosis in MDS patients. The aims of this study were to examine the Bournemouth system in a series of 370 patients with MDS and to evaluate the capability of the prognostic index recently proposed by our group to better define the outcome predicted by the former. The Bournemouth scoring system identified 3 risk groups, A (0-1 points), B (2-3 points) and C (4 points), in the whole series (p less than 0.0001) and it allowed us to stratify refractory anemia (RA), RA with excess of blasts (RAEB) and RAEB in transformation (RAEB-t) patients into two distinct prognostic groups (p = 0.03 and p = 0.01, respectively). This scoring system did not show a significant value in RA with ringed sideroblasts (RARS) and chronic myelomonocytic leukemia (CMML) patients (p greater than 0.05). Our prognostic index clearly segregated patients in the whole series into low- (0-1 points), intermediate- (2-3 points) and high-risk (4-5 points) groups (p less than 0.00001) as well as stratifying ARSA (p = 0.0005), CMML (p less than 0.0001) and RAEB and RAEB-t patients (p less than 0.00001) into different prognostic subset, although it failed to demonstrate a significant predictive value in RA patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors in chronic myelodysplastic syndromes: a multivariate analysis in 107 cases

A retrospective multivariate analysis of 37 clinical, biochemical, and hematological data was performed in 107 cases of primary myelodysplastic syndromes (MDS) in order to recognize their prognostic significance. The most important individual variables, isolated in a previous univariate analysis, were placed in a multiple regression modeling procedure to identify major significant prognostic factors. Multivariate analysis tends to identify prognostic variables containing significant independent predictive information. Characteristics were examined on both continuous and binary bases. The FAB classification was the first parameter entered in regression equations on both models, followed by platelet count, hemoglobin level, and circulating erythroblasts in the binary model, and by hemoglobin level, systemic symptoms, platelet count, age, and dyserythropoiesis in the continuous model. Our analysis confirms FAB classification as the main prognostic factor in MDS, supports the previously noted predictive value of platelet count, hemoglobin level, and age, and recognises the importance of circulating erythroblasts, systemic symptoms, and dyserythropoiesis as prognostic characteristics in MDS.