Preoccupation with death as predictor of psychological distress in patients with haematologic malignancies

The purpose of the present study was to identify preoccupation with death in relation to levels of psychological distress in patients with haematologic malignancies. One hundred and two inpatients with haematologic malignancies, treated with curative intent, and thirty-three control inpatients with benign dysfunction participated in the present study. Psychological distress was measured with the Hospital Anxiety and Depression Scale and the Freiburg Questionnaire of Coping with Illness. Preoccupation with death was assessed with the Subjective Estimation of Sickness and Death Scale. Patients with haematologic malignancies had significantly more preoccupation with death than the control group. In patients with haematologic malignancies preoccupation with death was related to depressive coping style as well as symptoms of depression and anxiety; regression analyses reveal that the diagnosis of haematologic malignancy leads to stronger subjective feelings of being close to death, which in turn leads to more psychological distress. To the best of our knowledge this is the first study that quantitatively shows the existence of preoccupation with death in patients with haematologic malignancies and its association with psychological distress. Our findings indicate that patients who are treated with a curative regime need psychological intervention focusing on death-related fear in order to prevent severe emotional distress.

[Current tumor pathology. Clinical expectations of pathological diagnosis]

Modern histochemical, immunological, genetic and molecular biological techniques now make precise tumour diagnosis and identification of biological subgroups possible. By detecting molecular and genetic aberrations, subgroups with varying clinical courses can be distinguished and treated in a targeted manner with the use of antibodies or tyrosine kinase inhibitors. This development will lead to even more accurate diagnosis and affect therapeutic decisions.

[Severe microcytic anemia with megaloblastic changes in the bone marrow. A hematological paradoxon?]

We discuss the case of a 32 year-old male with severe microcytic anemia (hemoglobin 2,9 g/dl) and megaloblastic changes in the bone marrow. The patient reported of substantial dietary weight loss. The family history was positive for beta-thalassemia. Previous blood work showed iron deficiency with mild anemia. Further work-up verified beta-thalassemia minor and revealed severely decreased vitamin B12 levels with positive anti intrinsic-factor antibodies, pathognomonic for autoimmune pernicious anemia. The paradoxon therefore dissolved as a pernicious anemia with megaloblastic changes with microcytic erythrocytes due to beta-thalassemia.

[Modern leukemia diagnosis in adults]

Identification of numerous criteria important in the pathogenesis, biology, prognosis and treatment of the different types of leukemia necessitates a broad spectrum of diagnostic methods for the initial diagnosis and in the further course of the disease. In addition to cytomorphology with cytochemistry, which is been path-breaking for the application of further diagnostic methods, cytogenetics has become an obligatory diagnostic tool. Immunophenotyping and, even more relevant, molecular genetics plays an important role. Other diagnostic techniques are widely developed. The diagnostic procedures are described, with a focus on their mode of operation as well as their clinical significance. Because of their high clinical relevance and growing complexity, the diagnosis of leukemias should be performed in specialized laboratories.

Ifosfamide, carboplatin, and etoposide (ICE) in combination with regional hyperthermia (RHT) in chemotherapy-pretreated nonresponders with locally advanced high-risk soft tissue sarcoma (HR-STS)

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Background: Regional hyperthermia (RHT) improves outcome in combination with neoadjuvant chemotherapy as first-line therapy in locally advanced HR-STS (Issels et al., Abstract 10009, ASCO 2007). Efficacy of ICE combined with RHT as second-line treatment strategy in pts with locally advanced HR-STS pretreated with anthracycline-based chemotherapy ± RHT was evaluated. Methods: Between 9/97 and 6/08, 49 pts were treated with ICE + RHT (median age: 51 years, range: 21–74 years), with high-grade (G2 24 pts; G3 25 pts) STS histology (20 Lipo-Sa; 6 Leiomyo-Sa, 6 MPNST, 5 NOS, 2 DSRCT, 10 others). As first-line therapy 35 pts had received chemotherapy combined with RHT and 14 pts without RHT. Second-line ICE consisted of 1.5 g/m2 ifosfamide, 100 mg/m2 carboplatin, and 150 mg/m2 etoposide on days 1–4 combined with RHT on two days and was repeated on day 28 (4–6 cycles). Besides toxicity, primary and secondary endpoints were objective response (OR) (RECIST), progression free rate (PFR) at 3 and 6 months, and overall survival (OS). Results: Pts received a median of 4 ICE cycles (range 1–8) in combination with RHT. Hematological toxicity grade III (11 pts)/ IV (23 pts) occurred in 34 pts (69 %), 3 pts (6 %) suffered from therapy-related deaths due to infection during cytopenia (2 pts) or postsurgery-related complications (1 pt). In 35 of 49 pts evaluable for OR, 26% achieved objective remission (1 CR + 8 PR), 51% showed stable disease (18 SD) and 23% progressive disease (8 PD). OR rates after initial chemotherapy with or without RHT were 17 % (4 PR of 24 pts) and 45% (1 CR + 4 PR of 11 pts), respectively (p=0.13). Irrespective of pretreatment, for all pts the PFR after 3 and 6 months was 87% (CI95=96%-77%) and 76% (CI95=88%-63%) and median OS was 22 months (CI95=29–16 months). Conclusions: Second-line ICE combined with RHT is feasible and effective in pts with locally advanced HR-STS non-responding to first-line anthracycline-based chemotherapy with or without RHT. (Supported by Deutsche Krebshilfe and HelmholtzZentrum münchen - German Research Center for Environmental Health)

No significant financial relationships to disclose.

Plesiomonas shigelloides pneumonia

Plesiomonas shigelloides is known to cause mild to cholera-like diarrhea in most infected persons. In immunocompromised patients extra-intestinal manifestations have been described. We report the first case of pneumonia caused by P. shigelloides in a 76-year-old woman who had undergone a curative gastrectomy and esophageal-jejunostomy due to a low differentiated adenocarcinoma of the stomach (pT2, pN1 pMx, G3, R0, Lauren: intestinal type). The patient was admitted in hospital with clinical signs of pulmonary infection. CT-scan revealed a cavernous lesion in the right upper pulmonary lobe. Bronchial lavage showed a granulocytic inflammation 105CFU/ml P. shigelloides. Although antibiotic treatment led to a decrease of inflammation parameters and decrease of the pulmonary infiltrate the patient died due to development of torsades de pointes tachycardia leading to ventricular fibrillation and hypoxic brain damage.

The addition of rituximab to front-line therapy with CHOP (R-CHOP) results in a higher response rate and longer time to treatment failure in patients with lymphoplasmacytic lymphoma: results of a randomized trial of the German Low-Grade Lymphoma Study Group (GLSG)

Lymphoplasmacytic lymphoma (LPL) is an indolent lymphoma with moderate sensitivity to conventional chemotherapy. This study investigated whether the addition of rituximab to standard chemotherapy improves treatment outcome in LPL and the subgroup of LPL patients fulfilling the criteria of Waldenstroem's macroglobulinemia (WM). A total of 69 patients with previously untreated LPL were enrolled into the trial; 64 patients were evaluable for treatment outcome. In all, 48 of the 64 LPL patients fulfilled the criteria of WM. Patients were randomly assigned to R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone, n=34) or CHOP (n=30). R-CHOP resulted in significantly higher overall response (OR) rate (94 vs 67%, P=0.0085) in the LPL patients and in the WM subgroup (91 vs 60%, P=0.0188). With a median observation time of 42 months, R-CHOP induced a significantly longer time to treatment failure (TTF) with a median of 63 months for R-CHOP vs 22 months in the CHOP arm in the LPL patients (P=0.0033) and in the WM subgroup (P=0.0241). There was no major difference of treatment-associated toxicity between both treatment groups. These data indicate that the addition of rituximab to front-line chemotherapy improves treatment outcome in patients with LPL or WM.

Proteomic identification of the MYST domain histone acetyltransferase TIP60 (HTATIP) as a co-activator of the myeloid transcription factor C/EBPalpha

The transcription factor C/EBPalpha (CEBPA) is a key player in granulopoiesis and leukemogenesis. We have previously reported the interaction of C/EBPalpha with other proteins (utilizing mass spectrometry) in transcriptional regulation. In the present study, we characterized the association of the MYST domain histone acetyltransferase Tat-interactive protein (TIP) 60 (HTATIP) with C/EBPalpha. We show in pull-down and co-precipitation experiments that C/EBPalpha and HTATIP interact. A chromatin immunoprecipitation (ChIP) and a confirmatory Re-ChIP assay revealed in vivo occupancy of the C/EBPalpha and GCSF-R promoter by HTATIP. Reporter gene assays showed that HTATIP is a co-activator of C/EBPalpha. The co-activator function of HTATIP is dependent on its intact histone acetyltransferase (HAT) domain and on the C/EBPalpha DNA-binding domain. The resulting balance between histone acetylation and deacetylation at the C/EBPalpha promoter might represent an important mechanism of C/EBPalpha action. We observed a lower expression of HTATIP mRNA in undifferentiated U937 cells compared to retinoic acid-induced differentiated U937 cells, and correlated expression of CEBPA and HTATIP mRNA levels were observed in leukemia samples. These findings point to a functional synergism between C/EBPalpha and HTATIP in myeloid differentiation and suggest that HTATIP might be an important player in leukemogenesis.

[The older patient with malignant diseases]

Most malignancies show a steep increase of incidence with growing age. Because of this age specific incidence and the general aging of the population in western industrial countries the number of elderly cancer patients continuously and rapidly increases. Despite this development elderly cancer patients are currently underrepresented in clinical trials. This is caused in part by the lack of a common definition of the elderly patient and by the fact that a part of the elderly patients suffers from co-morbidities, not allowing a more dose intense treatment in these patients. It is one of the key current challenges to compensate this deficit and to develop therapeutic concepts specifically for the elderly patients, taking the individual somatic, but also social situation and finally the quality and perspective of life of the elderly patient into account.