Trisomy 11 in myelodysplastic syndromes defines a unique group of disease with aggressive clinicopathologic features

Trisomy 11 in myelodysplastic syndromes (MDS) is rare, with undefined clinical significance and is currently assigned to the International Prognostic Scoring System (IPSS) intermediate-risk group. Over a 15-year period, we identified 17 MDS patients with trisomy 11 either as a sole abnormality (n=10) or associated with one or two additional alterations (n=7), comprising 0.3% of all MDS cases reviewed. Of 16 patients with Bone Marrow material available for review, 14 (88%) patients presented with excess blasts, 69% patients evolved to acute myeloid leukemia (AML) in a 5-month median interval and the median survival was 14 months. For comparison, we studied 19 AML patients with trisomy 11 in a noncomplex karyotype, of which, a substantial subset of patients had morphologic dysplasia, and/or preexisting cytopenia(s)/MDS. Genomic DNA PCR showed MLL partial tandem duplication in 5 of 10 MDS and 7 of 11 AML patients. A review of literature identified 17 additional cases of MDS with trisomy 11, showing similar clinicopathologic features to our patients. Compared with our historical data comprising 1165 MDS patients, MDS patients with trisomy 11 had a significantly inferior survival to patients in the IPSS intermediate-risk cytogenetic group (P=0.0002), but comparable to the poor-risk group (P=0.97). We conclude that trisomy 11 in MDS correlates with clinical aggressiveness, may suggest an early/evolving AML with myelodysplasia-related changes and is best considered a high-risk cytogenetic abnormality in MDS prognostication.

Remicade as TNF Suppressor in Patients with Myelodysplastic Syndromes

Remicade, a chimeric human-murine monoclonal antibody capable of neutralizing tumor necrosis factor alpha was given to 37 low-risk myelodysplastic syndromes (MDS) patients in two cohorts; 5 and 10 mg/kg intravenously every 4 weeks for 4 cycles. Median age was 68 years, 33 had primary MDS, 14 had refractory anemia (RA), 14 RA with ringed sideroblasts, 9 RA with excess blasts. Nine patients stopped therapy prior to completing 4 cycles, 3 from cohort 1 and 6 from cohort 2 and response was evaluated using the International Working Group criteria in 28 patients who completed the 4 cycles. Six patients showed disease progression, 14 had stable disease and 8 showed hematologic responses, 3/15 (20%) in cohort 1 and 5/13 (38%) in cohort 2. Two patients had multi-lineage responses, 2 had > 100% increase in absolute neutrophils, 1 had > 1 gm/dl increase in hemoglobin, 1 had reduction in blasts from 7% to 1%, and 2 had minor cytogenetic responses (> 50% reduction in + 8 and 20q-metaphases respectively). We conclude that Remicade may have a variety of activities in low risk MDS patients, is well tolerated with a high patient compliance, and may be considered for combination therapy in the future.

Haemangiopericytoma presenting as acute subdural haematoma

Haemangiopericytomas are vascular neoplasms that arise from capillary pericytes. They rarely present with haemorrhage. We report a patient whose meningeal tumour was revealed by acute subdural and intratumoural haemorrhage.

A safety and schedule seeking trial of Bcl-2 inhibitor obatoclax in previously untreated older patients with acute myeloid leukemia (AML)

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Background: Obatoclax (Ob) is a small-molecule inhibitor of all Bcl-2 prosurvival proteins. In a previous study a 70 year old patient with untreated AML had a cytogenetic CR 8 days after receiving 20 mg/m2 of Ob over 24 hrs. This study evaluated the single-agent response rate in older patients with previously untreated AML. Methods: A Safety phase to evaluate escalating doses of Ob given by 3-hr infusion was performed. Based on previous results, the dose of 60 mg over 24 hrs was used for the 24-hr infusion arm of the Schedule Seeking phase, in which Ob was administered as either a 3-hr or 24-hr infusion for 3 consecutive days every 2 wks. The endpoint of the Schedule Seeking phase was CR after C2 in 16 randomized patients. Eligibility criteria included age ≥ 70, untreated AML (1 prior Rx allowed in Safety phase), ECOG PS ≤2, adequate renal and hepatic function. PK samples were collected during C1. Results: 18 patients (8 male; median age 82) were enrolled. 2/3 patients enrolled into the 1st cohort (30 mg x 3 days) of the Safety phase had DLT events (ataxia and somnolence). 3 patients enrolled into a 20 mg x 3 days cohort had no DLTs; this dose was used for Schedule Seeking patients receiving 3-hr infusions. In the Schedule Seeking phase, 7 patients were randomized to receive 20 mg by 3-hr infusion and 5 were randomized to receive 60 mg by 24-hr infusion. The most common (>25%) AEs were euphoric mood (50%), ataxia (38%), & somnolence (38%). Efficacy data after C2 show that 3 patients in the 20 mg 3-hr infusion cohort in the Safety phase and 1 at the same dose & schedule in the Schedule Seeking phase had ≥50% decrease in BM blasts after C2, which was not seen in the 60 mg 24-hr infusion cohort. There were no CRs. There was a single death by D28 (24-hr infusion). There were significant differences in PK by infusion schedule. Conclusions: MTD for Ob as a 3-hr infusion administered in older patients with AML on 3 consecutive days is 20 mg/day, and both this regimen and 60 mg as a 24-hr infusion x 3 days were well tolerated. Evidence of biological activity was seen with the 3-hr infusion schedule but not with the 24-hr infusion schedule, suggesting that efficacy may be improved with the 3-hr infusion schedule and may be related to PK differences.

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Prevalence of paroxysmal nocturnal hemoglobinuria (PNH) cells in patients with myelodysplastic syndromes (MDS), aplastic anemia (AA), or other bone marrow failure (BMF) syndromes: Interim results from the EXPLORE trial

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Background: In patients with PNH, lack of the glycophosphatidylinositol (GPI)-anchored terminal complement inhibitor CD59 on hematopoietic stem cells results in chronic intravascular hemolysis, kidney and pulmonary disorders, thrombosis, and shortened life span. Presence of even minor populations of PNH cells in AA or MDS patients is medically important as it may indicate a higher likelihood of response to immunosuppressive therapy. We conducted the first large multicenter, point-prevalence study (EXamination of PNH, by Level Of CD59 on REd and white blood cells [EXPLORE]) of PNH cells in patients with AA, MDS, or other BMF syndromes. Here we report an interim analysis. Methods: A central laboratory conducted high-sensitivity flow cytometry utilizing a combination of GPI-linked antibodies (CD59, CD24, and CD14) and fluorescent aerolysin (FLAER) to identify GPI anchor-deficient PNH cells in RBC and WBC resulting in 0.01% sensitivity. The primary endpoint was percentage of patients who had a PNH WBC clone ≥1%. Results: Among 5,212 patients screened, 4,500 (86.3%) were MDS patients, 413 (7.9%) were AA patients, and 356 (6.8%) had other BMF syndromes. Approximately 1/4 (24.5%) of patients with AA, 1.2% with MDS, and 4.6% with other BMF were newly found to have a significant PNH clone ≥ 1%. Many of the newly identified clones were of clinical significance as the median PNH clone size was 11.1% in AA patients, 16.3% in MDS patients, and 32.6% in patients with other BMF. Presence of PNH cells (≥ 0.01%) was common in all examined BMF types: 70% of AA patients, 55% of MDS patients and 55% of patients with other BMF. PNH cells were identified in all MDS subtypes represented in the trial. Conclusions: Interim analysis from this first large multicenter study demonstrates that PNH cells are present in a majority of patients with AA, MDS, and other BMF. A spectrum of PNH clone sizes was noted in patients with each form of BMF. Screening patients with BMF with high-sensitivity flow cytometry for PNH cells may guide treatment options for the underlying BMF and/or PNH. The EXPLORE trial continues to enroll patients with AA. (EXPLORE Clinical Study Abstract 1/6/2009)

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Multicentre randomised controlled trials in obstetrics and gynaecology: an analysis of trends over three decades

To assess the trend in multicentre randomised controlled trials (RCTs), a database of 670 RCTs was assembled from four generic obstetric and gynaecological journals (Acta Obstetricia et Gynecologica Scandinavica, British Journal of Obstetrics & Gynaecology, Obstetrics & Gynecology and American Journal of Obstetrics & Gynecology) for 1975, 1980, 1985, 1990, 1995, 2000 and 2005. During this period, there was an inflationary trend with the proportion of published multicentre RCTs (from 12.9% in 1975 of all RCTs to 23.8% in 2005; P = 0.008). Multicentre RCTs had multiauthored publications (OR = 2.90; 95% CI 1.99-4.22) and more often received external funding (OR = 2.41; 95% CI 1.70-3.48) than single centre RCTs. The inflationary trend in multicentre RCTs requiring funding and collaboration represents the increasing complexity of medical research necessary to underpin evidence-based practice.

Unexplained Cardiac Arrest During Closure of Craniotomy: Case report and review of literature

Hypotension and bradycardia after application of suction to a subgaleal drain, or stimulus inside or outside the skull, have been reported in the medical literature. The commonly reported occurrence is stimulation of the Trigeminal nerve along its distribution and is the main factor that sets off the whole reflex arc through the Vagus nerve ending in a series of serious hemodynamic changes that institute severe bradycardia, asystole and severe hypotension. Another less common but possible patho logy caused by a suction drain is Pseudo-Hypoxic Brain Swelling (PHBS). We report a case of transient cardiac arrest after the application of theatre suction to a subgaleal drain at the closure of an uneventful craniotomy and discuss the possibilities as well as review the literature.

Usage of venous grafts in aorto-iliac reconstructive surgery

The authors present their clinical experience utilizing venous grafts (greater saphenous vein and superficial femoral vein) in the aorto-femoral position.

MATERIALS AND METHODS

Span of study is five years. The situations when these techniques were implemented are as follows:-(A). Infected synthetic prosthesis and (B). aorto-iliac occlusive disease in younger patients. A. In synthetic prosthetic infections there are 2 situations: (1) IMMEDIATE INFECTION. Observed in 10 cases, from which 2 cases where of severe infection and 8 cases of superficial infection--localized in the postoperative wound--Scarpa triangle region (7 cases) and left para-rectal (1 case). Superficial infections were treated successfully by daily dressings, excision of necrotic debris, antibiotic-therapy according to local antibiogram (only cases involving local invasion), and of course secondary wound closure at a later on date. The 2 cases of severe graft infection required harvesting of the superficial femoral vein and its usage in the aorto-femoral position. (2) LATE INFECTIONS. 3 patients were diagnosed with late infection of the synthetic prosthesis. In 2 cases, the infection was localized in the Scarpa triangle region, and the third in the abdomen (at the level of the aortic anastomosis). B. Aorto-iliac occlusive disease in younger patients--2 cases benefited from an aorto-bifemoral bypass reconstruction using the superficial femoral vein, and 5 cases where the greater saphenous vein was used in the iliac position.

RESULTS

Only 1 patient with severe prosthetic infection died due to multiple organ dysfunctions after the operation; the rest survived without any major amputation.

CONCLUSIONS

the harvesting and usage of these venous grafts is sometimes the final solution for patients with synthetic prosthesis infection.

Prognostic value of low platelets in MDS patients with del(5q)

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The most common (10–15%) chromosomal abnormality found in myelodysplastic syndromes (MDS) is an interstitial deletion of the long arm of chromosome 5 (del(5q)). The recent finding that lenalidomide is efficacious for MDS patients with del(5q) as either the sole abnormality or as part of a complex karyotype has focused renewed interest in the prognostic characteristics of these patients. We analyzed 189 patients with del(5q), 70 having isolated and 119 having additional chromosomal abnormalities. The median survival for the isolated del(5q) patient was 2.45 years and for those with complex abnormalities was 0.63 years (p=0.001). Each of these groups was then divided by IPSS category; median survival for Low/Int1 (n=56) was 2.46 years and 0.49 years for Int2/High (n=10, p=0.019).Thus our median survival times match previously published results and we have a representative dataset. Since 5q- syndrome patients with normal to high platelets have the best survival, platelet count may be of prognostic significance. We determined the median platelet count for our dataset to be 115,000 and analyzed median survival for patients with greater (n=89) or less (n=88) than the median value. Survival for those with higher platelet counts was 2.6 years, but dropped to 0.54 years with lower counts (p=0.0001). We then analyzed each of these two groups independently for survival based on IPSS, blast % and karyotype. Median survival for patients with >115,000 platelets and either Low/Int1-risk (n=62), <5% blasts (n=46) or an isolated del(5q) (n=46) was 2.95–3.0 years. The survival of these patients dramatically decreased (0.63 years) if they had Int2/High IPSS (n=19) or >10% blasts (=11). The presence of additional chromosomal abnormalities decreased survival to 1.85 years (n=28). A different range of survival times occurred with patients that had <115,000 platelets. Their median survival based on Low/Int1 IPSS (n=20), <5% blasts (n=18) or isolated del(5q)(n=20) was only 0.68–0.84 years. Int2/High IPSS (n=64), >5% blasts (n=50) or additional chromosomal abnormalities (n=68) lowered survival to 0.44–0.49 years. Thus lower platelet counts in del(5q) MDS patients with favorable IPSS (median survival 0.84 years), <5% blasts (median survival 0.68 years) or isolated del(5q) (median survival 0.74 years) appear to have poor prognosis.

No significant financial relationships to disclose.

Validation of IPSS criteria in more than 1,600 MDS patients

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Myelodysplastic syndromes (MDS) are a diverse group of clonal stem cell disorders characterized by bone marrow failure, dysmyelopoiesis and peripheral cytopenias and affecting predominantly an elderly population. The International Prognostic Scoring System (IPSS) incorporates the number of peripheral cytopenias, percentage of bone marrow blasts and chromosomal abnormalities and assigns a score to predict survival and risk of disease progression to AML. Using the extensive MDS database at the University of Massachusetts we analyzed survival time in relation to IPSS scoring and also its various individual components, i.e. blast percentage, number of cell lines involved and the number of karyotype abnormalities in 1,200+ patients. The overall median survival time in 1,424 MDS patients as a group was 2.9 years. IPSS low group had the longest median survival time of 7.5 years with IPSS Int-1 3.6 years. There was minimal difference in the median survival time between IPSS Int-2 and IPSS high risk group 1.2 and 1.1 years respectively. These results were significant for a P value of <0.0001. The median survival time for blasts <5% was 5.3 years and blast 5–10% was 1.7 years. Interestingly, there was minimal survival difference between median survival time for blasts 11–20% and blasts >20% showing 1.2 years and 1.3 years respectively. Again, these results were significant for a P value of <0.0001. The median survival time for the number of cytopenias involved was also calculated with 0, 1, 2 and 3 numbers of cytopenias showing 6.4 years, 4.4 years, 2.6 years and 1.8 years respectively, with P value of <0.0001. The median survival time for normal karyotype versus one or two karyotype abnormality was 4.9 years, 2.6 years and 2.4 years respectively. Three or more karyotype abnormalities showed a median survival time of 0.8 years. The P value was again significant (<0.0001). Our results not only validate the prognostic value of IPSS scoring system as a whole but also its various individual prognostic indicators.

No significant financial relationships to disclose.

Multivariate dimensions of hemotologic chaos indices for responders versus non-responders of patients with myelodysplastic syndromes (MDS) after treatment with ptx/cipro/decadron: A qualitative study

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Background: In our clinical study of 35 MDS patients who were treated with PTX/Cipro/Decadron, there was an 80% response rate in terms of achieving improved hematopoiesis (responders) during a 4-week period. The primary question of interest was, “What were the hematologic dynamic patterns that transpired between patients who responded versus those who did not?” The purpose of this study was an attempt to answer this question by applying chaos theory to peruse the underlying patterns that may have prognosis utility. Methods: Responders and non-responders were identified and were matched by age, sex, and FAB type. Only those patients who have sufficient and complete hematologic evaluations after treatment with at least 6 months follow-up to derive stable chaotic indices were included. The resulted sample was 3 patients from the non-responded group and 4 patients from the responded group. The three selected hematoloic parametes were white blood count, hemoglobin and platelets. The selected chaos index to indicate its magnitude of across time was the fractal dimension that has three components, namely capacity, information and correlational. Results: The mean ages for the non-responders and responders were 68 and 65, respectively. The median number of weeks evaluated was 38 for the non-responders and 35 weeks for the responders. The three hematologic parameters were analyzed simultaneously in the form of 3-dimensional space. Table indicates the chaos fractal indices for the two groups. Conclusion: Across the three indices, non-responders have an average of 7.4 % larger than responders, suggesting the former exhibited a relatively higher degree of “chaos” than the latter. For prognosis purpose, this result also suggests that patients who exhibit lower magnitude of the chaotic phenomena, will have a higher probability of responding to therapy. This work was done while the authors were at Rush-Presbyterian-St.Luke’s Medical Center.

[Table: see text]

No significant financial relationships to disclose.

Complete blood count may provide risk stratification for survival and AML transformation in CMML

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We performed a retrospective analysis of 120 patients with CMML (98 de novo CMML and 22 evolving from MDS) to examine clinical features that may influence survival and AML transformation. Univariate analysis showed low hemoglobin level; WBC > 13,000, platelet count < 50,000 and abnormal cytogenetics as poor prognostic features. Univariate analysis also determined that BM blasts >5% and Int2/High IPSS were associated with higher rates of AML but IPSS could not be used for survival assessment. Multivariate analysis showed hemoglobin < 12 g/dL, older age, abnormal cytogenetics as risk factors for shorter survival; older age, male sex, low platelet count, BM blasts > 5%, lymphocyte and monocyte counts were independent risk factors for AML transformation. Previous attempts to devise prognostic scoring systems for CMML have incorporated both peripheral blood and bone marrow features. We have used hemoglobin, lymphocyte count and platelet count to generate 3 prognostic scoring systems, which differed by severity of thrombocytopenia. Score 1 (>100, 50–100, <50) identified 3 different risk groups (low, intermediate, and high) with median OS: not reached (n/a), 18, and 9 months for all CMML patients (p<0.0001) as well as for the de novo CMML patients (p<0.0001). Score 2 (>50, <50) divided patients into 3 risk groups (low, intermediate, and high) with median OS: n/a, 19 and 10 months for all CMML (p=0.0002) versus n/a, 28 and 11 months for de novo CMML patients (p=0.0011). Score 3 (<100, >100) separated all CMML (p=0.0073) and de novo CMML patients (p=0.0054) into 2 risk groups (high, low) with median time to AML 53 months and n/a. In conclusion we suggest three new scoring systems for CMML patients that can be easily calculated after an initial CBC. Scores 1 and 2 help to assess survival while score 3 indicates risk for AML transformation. *Acknowledgements: This work has been partially supported by the AMA Foundation Seed Grant Research Program 2006.

No significant financial relationships to disclose.

Phase I evaluation of tipifarnib in combination with low-dose Ara-C (LDAC) in high-risk myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML): Interim results

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Background: Tipifarnib (T) is a farnesyltransferase inhibitor with clinical activity in MDS and AML. LDAC has utility in the elderly with MDS/AML; hence its use in combination with the investigational agent T to improve outcomes is warranted. Methods: The primary objective of this ongoing phase I, dose finding, multicenter, open-label study was to determine the maximum tolerated dose (MTD) based on dose limiting toxicities (DLT) of T+LDAC observed during the first 28 day cycle. MDS (IPSS Int 1, 2 or High) and untreated AML pts (age =75y or =65y with preceding MDS) or relapsed/refractory AML (age >18y) were included. Planned sample size was up to 57 pts with a traditional 3+3 dose escalation and a minimum of 3 pts enrolled per cohort. T (Dose Level 0) was administered initially at 200mg PO BID x 21 days in combination with LDAC 10mg SC BID x 10 days; both repeated every 28 days. Efficacy will be assessed by bone marrow and peripheral blood count studies. Results: 15 pts have been enrolled to date: 2 MDS (Int 1 n=1, High n=1) and 13 AML (7/13 pts with no previous therapy); all 15 pts were evaluable. Mean baseline characteristics for the entire cohort were: age 76.2y, 67% men, Hb 9.4 ± 0.9 g/dL, WBC 8.7 ± 11.3 x 103/μL, platelets 96.8 ± 96.6 x 103/μL. The observed DLT for T+LDAC was generalized rash seen at Dose Level 3. The MTD was therefore determined to be T 300mg and LDAC 15mg. The most common grade 3/4 adverse events were neutropenia, thrombocytopenia, anemia, and rash. Conclusions: These interim findings show the combination of T at 300mg PO BID x 21 days and LDAC at 15mg SC BID x 10 days to be the MTD in this study. Assessment for efficacy is ongoing.

[Table: see text]

No significant financial relationships to disclose.