The Complexities of Diagnosis with Co-Existing Gaucher Disease and Hemato-Oncology-A Case Report and Review of the Literature

Hematological abnormalities are the most common early symptoms of Gaucher disease (GD), with an increased risk of hematopoietic system malignancies reported in patients with GD. GD may be associated with monoclonal and polyclonal gammopathies; however, the mechanism of association of GD with multiple myeloma (MM) remains uncertain. Enzyme replacement therapy (ERT) has been shown to improve patients' cytopenia and it seems to facilitate anti-myeloma therapy in patients with co-occurring GD and MM. Although it is necessary to demonstrate the deficiency of enzymatic activity, as well as using genetic tests to finally diagnose GD, due to changes in the blood count image, bone marrow biopsy is still a frequent element of the GD diagnosis procedure. The diagnosis of GD is often delayed, mainly due to the heterogeneity of the histopathological picture of bone marrow biopsy or overlapping hematological abnormalities. Unrecognized and untreated GD worsens the response of a patient with an oncological disease to targeted treatment. We present a literature review, inspired by the case of a Caucasian patient initially diagnosed with MM and later confirmed with comorbid GD type 1 (GD1). We would like to point out the problem of underdiagnosis and delay in patients with GD.

Multiplex real-time PCR to identify a possible reinfection with different strains of human cytomegalovirus in allogeneic hematopoietic stem cell transplant recipients

Human cytomegalovirus (HCMV) infection remains the leading cause of serious contagious complications after allogeneic hematopoietic stem cell transplantation. These infections in HCMV-seropositive recipients can be due to reactivation or reinfection. Different HCMV strains were identified by determining the genotypes isolated from repeatedly tested patients. The UL55 sequences encoding viral glycoprotein B (gB) have been chosen as the target gene. The region, in which the gB precursor protein is cleaved into two fragments by a cellular endoprotease, is characterized by genetic variability, and based on that HCMV is classified into four major genotypes: gB1, gB2, gB3 and gB4. Multiplex real-time PCR assay enabled both, HCMV gB genotyping, as well as simultaneous quantitative assessment of the detected genotypes. This study was carried out in 30 transplant recipients, from whom 105 isolates of HCMV DNA were genotyped. In 40% of recipients, a mixed infection with two or three genotypes was detected. Genotype gB1 dominated in general, and characteristically for mixed infections, the genotype gB3 or gB4 was always present. Although there were no significant differences in the load for each genotype, in case of multiple infections, the number of copies of gB1 genotype was significantly higher when compared to a single gB1 infection. In patients with mixed genotypes, chronic HCMV infections and graft versus host disease were observed more often, as well as antiviral treatment was less effective. It was assumed that these adverse effects can be related to the presence of gB3 and gB4 genotypes.

Mild chronic graft-versus-host disease may alleviate poor prognosis associated with FLT3 internal tandem duplication for adult acute myeloid leukemia following allogeneic stem cell transplantation with myeloablative conditioning in first complete remission: a retrospective study

Internal tandem duplication (ITD) of the FLT3 gene (Fms-like tyrosine kinase 3) is the most commonly found mutation in acute myeloid leukemia (AML). The significance of FLT3-ITD at diagnosis was retrospectively estimated for allo-HSCT (allogeneic hematopoietic stem cell transplantation) outcomes in 140 patients, median age of 38, undergoing allo-HSCT after myeloablative conditioning in first complete remission of AML. FLT3-ITD was detected at AML diagnosis in 42/140 (30%) of included into this study patients. At 3 years, relapse incidence (RI) following allo-HSCT in AML patients with intermediate or normal karyotype was significantly higher in those FLT3-ITD positive than FLT3-ITD negative [52.9 vs. 20.4%, P = 0.002]. Additionally, patients with mild chronic graft-versus-host disease (cGvHD) had significantly lower RI compared to patients with moderate or severe grade cGvHD or those not experiencing cGvHD, respectively, 4.8 vs. 36.0 vs. 27.8%, P = 0.032. FLT3-ITD was harboring a poor prognosis in AML with intermediate or normal karyotype and significantly increased risk of relapse following allo-HSCT. It appears that allo-HSCT does not cure patients with FLT3-ITD, unless they develop symptoms of mild cGvHD and graft versus leukemia, which may decrease RI.

Autologous stem cell transplantation as consolidation therapy for patients with peripheral T cell lymphoma in first remission: long-term outcome and risk factors analysis

This report is a retrospective analysis of 65 patients with peripheral T cell lymphoma (PTCL), who underwent high-dose therapy and autologous hematopoietic stem cell transplantation (autoHCT) as a consolidation of first response achieved with either induction or salvage chemotherapy. We intended to determine the prognostic factors that influenced outcome after autoHCT and to define the predictive value of the scoring systems most often applied for transplant outcomes. Nineteen patients in either complete or partial remission underwent autoHCT after induction chemotherapy. Forty-six patients received second-line chemotherapy as a consolidation of partial response after induction chemotherapy (n = 34) or as a salvage therapy after primary induction failure (n = 12), and thereafter proceeded to autoHCT. Finally, the 36 patients were in complete remission, and 29 in partial remission at autoHCT. The median follow-up of survivors was 53 months (range 7–157 months). The 5-year overall survival and progression-free survival for all patients were 61.5 % (95 % CI 47.0–74.2 %) and 59.4 % (95 % CI 46.1–71.5 %), respectively. In multivariate analysis, bone marrow involvement at diagnosis and less than partial remission after induction chemotherapy were factors independently predictive for overall survival and progression-free survival. The prognostic index for PTCL could reliably stratify the prognosis of PTCL in this analysis.

[Health of patients after bone marrow transplantation and coping with stress -- psychological and medical perspective]

A study on the relationship between level of subjective and objective health by patients after bone marrow transplantation (BMT) and their coping with stress is presented. The theoretical basis of researches is Helena Wrona-Polanska's Functional Model of Health (2003), in which health is a function of creative coping with stress.141 patients after BMT -- 80 males and 61 females -- at the Hematology Clinic of University Hospital were studied clinically. Objective health was examined doctor on the scales. Examined methods were -- the questionnaires examining stress, coping strategies, and grading scales of health and anxiety. There is a clear difference between subjective and objective level of health. Subjective health depend on coping strategies with stress and objective health depend on patient's collaboration with terapeutic team. The basis of health promotion by persons after BMT is development effective strategies of coping with stress and increase patent's activity.

Cladribine, But Not Fludarabine, Added to Daunorubicin and Cytarabine During Induction Prolongs Survival of Patients With Acute Myeloid Leukemia: A Multicenter, Randomized Phase III Study

Purpose

The goal of this study was to evaluate whether the addition of a purine analog, cladribine or fludarabine, to the standard induction regimen affects the outcome of adult patients with acute myeloid leukemia (AML).

Patients and Methods

A cohort of 652 untreated AML patients with median age 47 years (range, 17 to 60 years) were randomly assigned to receive one of three induction regimens: DA (daunorubicin plus cytarabine), DAC (DA plus cladribine), or DAF (DA plus fludarabine). Postremission treatment was the same for all arms.

Results

Complete remission rate in the DAC arm was higher compared with the DA arm (67.5% v 56%; P = .01) as a consequence of reduced incidence of resistant disease (21% v 34%; P = .004). There was no significant difference in early outcome between the DAF and DA arms. The probability of overall survival was improved for the DAC arm (45% ± 4% at 3 years) compared with the DA arm (33% ± 4%; P = .02), and leukemia-free survival was comparable. Long-term outcome did not differ significantly for the comparison of the DAF and DA arms. A survival advantage of the DAC arm over the DA arm was observed among patients age 50 years or older (P = .005), those with initial leukocyte count above 50 × 109/L (P = .03), and those with unfavorable karyotype (P = .03). DAF revealed a significant advantage over DA in patients with adverse karyotype (P = .02).

Conclusion

The addition of cladribine to the standard induction regimen is associated with increased rate of complete remission and improved survival of adult patients with AML.

Association between P-glycoprotein and lymphoid antigen expression on myeloblasts versus therapy response and survival in de novo acute myeloid leukemia: long-term follow-up results

P-glycoprotein (PGP) over-expression on malignant cells is associated with poor prognosis and treatment outcome due to the development of a multidrug resistance phenotype. In this study, we analyzed the correlation between expression of PGP and lymphoid antigens (Ly) on leukemic myeloblasts versus response to therapy and survival in acute myeloid leukemia (AML). Fifty-one consecutive patients, aged 16-75 (median age 44.6 years), diagnosed with de novo AML between 1997 and 2000, and who received at least one induction chemotherapy course, were enrolled in the study. Expression of PGP on ≥ 10% of the myeloblasts (PGP(+)AML) at the time of diagnosis was observed in 21 patients (41%). The complete remission rate did not differ between PGP(+) (13/21) and PGP(-) (20/30) patients (62 vs. 67%). Twelve of the 51 patients (24%) were still alive after a median follow-up time of 11.5 years (range 10.7-13.1). The Ly(+)AML patients showed significantly better overall survival compared with Ly(-)AML patients (8/18 vs. 4/33 patients alive at the last follow-up, P = 0.003). The subgroup of patients with co-expression of PGP and Ly also showed better overall survival compared with PGP(+)AML patients without Ly expression (4/8 vs. 0/13 patients alive at the last follow-up; P = 0.04). Our results suggest that expression of lymphoid antigens on PGP(+) myeloblasts in AML can positively affect survival in AML patients, mainly due to a decreased relapse risk and better survival. Although the small number of patient may be perceived as a limitation of the study, the long follow-up period strengthens its value. Further prospective trials are needed to obtain more information concerning the association between PGP and lymphoid antigens in AML, which would put our results in their ultimate proper context.

Lymphotropic herpesvirus DNA detection in patients with active CMV infection - a possible role in the course of CMV infection after hematopoietic stem cell transplantation

BACKGROUND

The natural history of cytomegalovirus (CMV) infection and disease in transplant recipients prompts researchers to look for other factors contributing to this infection. The ubiquity of lymphotropic herpesviruses (EBV, HHV-6, and HHV-7) and the possibility of their activation during immunosuppression may suggest their participation in progression of CMV infection in patients after hematopoietic stem cell transplantation (HSCT).

MATERIAL/METHODS

The presence of CMV, EBV, HHV-6 and HHV-7 was confirmed through detection of viral DNA isolated from leukocytes. Allo-HSCT recipients (n=55) were examined repeatedly within the average period of 14±7.3 months post-transplant.

RESULTS

CMV DNA was detected in 24% of samples, while EBV, HHV-6 and HHV-7 were detected in 20%, 15% and 14% of samples, respectively. Based on the presence of CMV infection at particular time-points (months) after transplantation, the recipients were divided into 3 groups: Group I (N=15) with persistent infection, Group II (N=20) with transient infection, and Group III (N=20) without CMV infection. In Group I, the mean CMV load was significantly higher than in Group II, and the clinical condition of Group I patients was poorer. All these patients manifested clinical symptoms, and all had episodes of GvHD. All Group I patients developed multiple infections; EBV in 80%, HHV-6 in 47% and HHV-7 in 87% of patients. In the remaining groups, with the exception of HHV-6 in group II, the frequency of infected patients was lower. In addition, CMV presence was often preceded by another herpesvirus.

CONCLUSIONS

The results suggest that other herpesviruses, mainly HHV-7, could predispose CMV to cause chronic infection.

The early reduction of leukemic blasts in bone marrow on day 6 of induction treatment is predictive for complete remission rate and survival in adult acute myeloid leukemia; the results of multicenter, prospective Polish Adult Leukemia Group study

The aim of this study was to prospectively evaluate the impact of early bone marrow response on complete remission (CR) rate and long-term outcome in adults with acute myeloid leukemia. Bone marrow cytology was assessed on day 6 of induction treatment in 164 patients, revealing the presence of ≥5% blasts in 61 cases. In this subgroup the CR rate was significantly lower compared to the remaining patients (P < 0.00001) resulting in decrease of the overall survival (P = 0.002). Persistence of ≥5% blasts in bone marrow on day 6 of induction is an easily available surrogate marker to be used for treatment decisions.

[Long-term survival results according to cytogenetic risk in patients with acute myeloid leukemia--singl center experience]

Cytogenetic analysis of leukemic blasts has become a part of the standard diagnosis approach of acute myeloid leukemia patients. Chromosomal aberrations findings separate AML patients into three broad prognostic categories: favorable, intermediate and high risk. We analyzed retrospectively 179 adults with de novo acute myeloid leukemia (AML), younger than 60 years admitted to our Department between January 1999 and April 2009 to evaluate the prognostic impact of cytogenetic abnormalities on complete remission (CR) rate, disease free survival (DFS), and overall survival (OS). All patients received similar induction therapy. Median follow-up of 3.8 years for favorable cytogenetic group CR rate was 85%, 3-year DFS was 70% and 3-year OS was 65%, for intermediate group CR rate, 3-year DFS and 3-year OS were respectively: 64%, 43%, and 38%. Among high risk patient CR rate was 40%, 3-year DFS was 24%, 3-year OS was 17%. We conclude that cytogenetics is among the most useful factors in predicting attainment of CR, DFS, and long-term overall survival in adult de novo AML patients younger than 60 years.

[High-dose chemotherapy and autologous stem cell transplantation in multiple myeloma patients--single center experience]

Multiple myeloma (MM) is one of the hematologic malignancies in which the impact of dose intensity has been demonstrated. In 2005 it was the most common disease for which autologous stem cell transplantation (ASCT) was performed. However, ASCT is not curative, and most patients relapse within a median of 3 years, the introduction of high-dose therapy resulted in prolonged survival. Novel agents such as thalidomide, bortezomib, or lenalidomide have been introduced to improve high-dose therapy outcome. From April 1998 to December 2008, 65 patients with MM underwent in our Department high-dose chemotherapy supported by autologous transplantation of peripheral blood stem cells (APBSCT). Transplantation of progenitor cells was conducted as consolidation of first line treatment in the majority of patients. Double transplantation was performed in 20 patients (31%). Conditioning regimen consisted of high-dose melphalan (200 mg/m2), in the second procedure the dose of melphalan was reduced to 140 mg/m2. Transplant related mortality was not observed. The duration of hematological recovery after first and second transplantation did not differ significantly. At the time of the analysis (June 2009) 51/65 (78.5%) patients are alive, 14/65 (21.5%) died due to disease progression. Median overall survival (OS) and progression free survival ( PFS) obtained were 86 (range 24-128) and 33 (range 4-110) months respectively. This retrospective analysis confirms the efficacy and safety of APBST in multiple myeloma patients.

[Evaluation of hematopoietic chimerism after allogeneic bone marrow transplantation by modern molecular techniques (STR-PCR and RQ-PCR)--single center]

Allogeneic hematopoietic stem cell transplantation (alloSCT) is a curative treatment for many patients suffering from malignant and non-malignant hematological disorders. Successful transplantation is a process that requires the engraftment of transplanted pluripotent hematopoietic stem cells which re-establish normal hematological and immunological systems. Distinguishing between host and donor origin of bone marrow and blood cells is vitally important for monitoring of the engraftment process. One of the most useful tools for engraftment monitoring is the assessment of hematopoietic chimerism. Which occurs after alloHSCT and describes the percentage of donor hematopoietic and lymphoid cells in a transplant recipient. 38 adult patients, after alloSCT performed in Katedra i Klinika Hematologii Collegium Medicum UJ entered the study and the total number of transplantations was 43. The evaluation of hematopoietic chimerism was based on PCR amplification of polymorphic non-coding DNA sequences--short tandem repeats (STR-PCR). The main tool was a semiquantitative method--fragment length analysis. The product of amplification was analyzed using the sequencer. The second method was based on a quantitative Real Time PCR technique (RQ-PCR) based on SYBRgreen chemistry. There were performed amplification of biallelic non-coding DNA sequences with short insertions or deletions. Hematopoietic chimerism evaluations were performed on +30, +60, +90, +120, +150, +180, +270 and +360 day and then every 6 months post alloSCT on peripheral blood or bone marrow samples. STR-PCR and RQ-PCR chimerism assays were compared and results evidenced the greater sensitivity of RQ-PCR method. There were not crucial differences in the results of chimerism evaluation obtained by means of these two methods. The analysis of chimerism kinetics after allogeneic stem cell transplantation allowed to modify the post-transplantation-treatment in 3 patients after alloNMSCT leading to increase of donor-origin hematopoiesis in transplant recipients (in 2 pts decision of DLI, 1 of them withdrawal of immunosuppression, 1 pt giving G-CSF). The results of chimerism monitoring confirmed that the failure of achieving a CC or lost of CC can predict the relapse of the disease.

Neopterin and other inflammatory markers in the early period following allogeneic bone marrow transplantation: series of 3 cases

The 3 case reports presented here constitute a pilot study assessing the profile of changes in concentrations of selected inflammatory markers, including C-reactive protein, serum amyloid A, neopterin, and interleukin 18, in an early period after allogeneic stem cell transplantation.

Status of minimal residual disease determines outcome of autologous hematopoietic SCT in adult ALL

The role of autologous hematopoietic SCT (autoHSCT) in the treatment of high-risk (HR) adult ALL is controversial. In this study, we retrospectively analyzed the results of autoHSCT according to the status of minimal residual disease (MRD) at transplantation, as a joint analysis of the European Study Group for Adult ALL (EWALL). Data on 123 recipients of autoHSCT, aged 31 (16-59) years, with B-lineage (n=77) or T-lineage (n=46) ALL were included. In a cohort of Ph-negative ALL, the probability of leukemia-free survival at 5 years was higher for patients with MRD <0.1% compared with those with MRD > or = 0.1% (57 vs 17%, P=0.0002). The difference was significant for T-lineage ALL (62 vs 8%, P=0.001), and a tendency was observed for B-lineage ALL (54 vs 26%, P=0.17). In a multivariate analysis, adjusted for other potential prognostic factors, high MRD level remained the only independent factor associated with increased risk of failure (risk ratio, 2.8; P=0.0005). We conclude that MRD determines the outcome of autoHSCT in HR adult ALL. Our results suggest the need to reevaluate the role of this treatment option in prospective trials.

Infectious complications in patients with acute myeloid leukemia treated according to the protocol with daunorubicin and cytarabine with or without addition of cladribine. A multicenter study by the Polish Adult Leukemia Group (PALG)

OBJECTIVES

The addition of cladribine to the standard regimen consisting of daunorubicin and cytarabine has been reported to increase the efficacy of induction therapy in acute myeloid leukemia (AML). The goal of this study was to determine the effect of this modification on the incidence and spectrum of infectious complications.

METHODS

Case report forms of 309 patients with newly diagnosed AML who had been enrolled in the prospective, randomized 'DAC-7 vs. DA-7' trial were reviewed. The frequency, etiology, localization, severity, and outcome of infections were compared for patients receiving only daunorubicin and cytarabine (DA-7) and those additionally treated with cladribine (DAC-7).

RESULTS

A total of 443 febrile episodes were reported with no significant difference between the treatment groups. A trend towards a higher frequency of bacteremias was observed among DA-7 patients compared to those in the DAC-7 group (31% vs. 21%; p=0.08). The treatment arms did not differ in terms of the distribution of the isolated Gram-positive, Gram-negative, fungal, and viral organisms. However, when bacteremias were considered, Gram-positive blood cultures tended to be more frequent in the DA-7 compared to the DAC-7 group (16% vs. 8.5%; p=0.07). This difference reached statistical significance when major blood bacteremias were analyzed separately (13% vs. 5%; p=0.02). Complete recovery from infections was observed in the majority of patients across both treatment arms and no significant difference was noted regarding infection-related mortality.

CONCLUSIONS

The addition of cladribine to standard induction chemotherapy has no impact on the incidence and spectrum of infectious complications in newly diagnosed AML patients.

Detection of specific lytic and latent transcripts can help to predict the status of Epstein-Barr virus infection in transplant recipients with high virus load

Epstein-Barr virus (EBV), a member of the family Herpesviridae, is widely spread in the human population and has the ability to establish lifelong latent infection. In immunocompetent individuals the virus reactivation is usually harmless and unnoticeable. In immunocompromised patients productive infection or type III latency may lead to EBV-associated post-transplant lymphoproliferative disorder (PTLD). The aim of our research was to investigate the utility of PCR-based methods in the diagnosis and monitoring of EBV infections in bone marrow transplant recipients. Thirty-eight peripheral blood leukocyte samples obtained from 16 patients were analysed, in which EBV DNA was confirmed by PCR. We used semi-quantitative PCR to estimate the viral load and reverse-transcription PCR (RT-PCR) to differentiate between latent and productive EBV infection. In 14 patients we confirmed productive viral infection. We observed a correlation between higher number of EBV genome copies and the presence of transcripts specific for type III latency as well as clinical symptoms.

Detection of specific lytic and latent transcripts can help to predict the status of Epstein-Barr virus infection in transplant recipients with high virus load

Epstein-Barr virus (EBV), a member of the family Herpesviridae, is widely spread in the human population and has the ability to establish lifelong latent infection. In immunocompetent individuals the virus reactivation is usually harmless and unnoticeable. In immunocompromised patients productive infection or type III latency may lead to EBV-associated post-transplant lymphoproliferative disorder (PTLD). The aim of our research was to investigate the utility of PCR-based methods in the diagnosis and monitoring of EBV infections in bone marrow transplant recipients. Thirty-eight peripheral blood leukocyte samples obtained from 16 patients were analysed, in which EBV DNA was confirmed by PCR. We used semi-quantitative PCR to estimate the viral load and reverse-transcription PCR (RT-PCR) to differentiate between latent and productive EBV infection. In 14 patients we confirmed productive viral infection. We observed a correlation between higher number of EBV genome copies and the presence of transcripts specific for type III latency as well as clinical symptoms.

Use of L-asparaginase in acute lymphoblastic leukemia: recommendations of the Polish Adult Leukemia Group

L-asparaginase is a hydrolase that catalyzes the conversion of L-asparagine--an endogenous amino acid necessary for the function of some neoplastic cells, such as lymphoblasts. In most human cells deficiency of L-asparagine can be compensated by alternative synthesis pathway through which L-asparagine is produced from aspartic acid and glutamine by asparagine synthethase. Depletion of L-asparagine from plasma by L-asparaginase results in inhibition of RNA and DNA synthesis with the subsequent blastic cell apoptosis. Owing to the unique anti-cancer mechanism of action, L-asparaginase has been introduced to the multi drug chemotherapy in children and adults with acute lymphoblastic leukemia, which has contributed to significant improvement of therapy outcomes and to achieve complete remission in about 90% of patients. Notwithstanding its high therapeutic efficacy, L-asparaginase can increase the risk of thrombosis. Inhibition of protein synthesis causes most complications observed during treatment with a native and pegylated form of L-asparaginase, including impaired functions of liver, kidneys or central nervous system. Thrombotic events occur as a result of inhibited synthesis of anticoagulant proteins (mainly antithrombin). Coagulopathy has been observed in 1.1-4% of patients treated with the pegylated L-asparaginase and in 2.1-15% of those receiving its native form. In this paper approaches to optimize the therapy with L-asparaginase have been discussed.

Prophylaxis and therapy of central nervous system involvement in adult acute lymphoblastic leukemia: recommendations of the Polish Adult Leukemia Group

The central nervous system (CNS) is one of the most frequent extramedullary locations of adult acute lymphoblastic leukemia (ALL), affecting approximately 5% of patients at diagnosis. T-lineage ALL, high initial leukocyte counts and mediastinal involvement are the predisposing factors. In case of relapse, if no prophylaxis was administered, the rate of CNS involvement reaches 30-50%. As the prognosis of patients with isolated or mixed CNS relapse is particularly poor, adequate prophylaxis seems critical. The treatment comprises intrathecal cytostatics, cranial and spinal cord irradiation, as well as systemic chemotherapy including agents penetrating to the CNS. This strategy allows a reduction in CNS relapses to less than 5% of cases. Compliance to the prophylactic protocols should be one of the principles in the treatment of adult ALL.

Clinical presentation of extraintestinal infections caused by non-typhoid Salmonella serotypes among patients at the University Hospital in Cracow during an 7-year period

The most characteristic finding in non-typhoid salmonella (NTS) infection is acute food related outbreaks of gastroenteritis, which is usually benign and self-limiting. However, more serious extraintestinal findings, such as bacteraemia and focal infections localized to any organ may appear. The objective of this paper is to describe the most important characteristic of the extraintestinal infections due to NTS serotypes observed in University Hospital, in Cracow between January 2000 and December 2006. To do so, we reviewed the clinical presentations, risk groups, complications and outcomes of in-patients, in which extraintestinal non-typhoid Salmonella serotypes were isolated, applying a clinomicrobiological protocol. Out of 30 patients with either bacteraemias (n = 22) or focal salmonella infections (n = 8), 12 had malignancies, 17 had immune dysfunction state, 9 had gastrointestinal disorders and 8 had chronic heart, pulmonary or kidney disease. Four of these patients (13%) who had hematological malignancies (2), renal transplantation (1) and pulmonary disease (1) died. Regarding the clinical picture, primary bacteraemia and focal infections occurred with similar frequency (33.3% and 26.7%, respectively); the remaining were bacteraemias secondary to gastroenteritis. The incidence rate (mean 0.30/1000 hospital admission/year) increased steadily from 0.19/1000 to 0.32/1000 hospital admission during the study period. From 30 Salmonella isolates from extraintestinal samples collected, only four isolates were resistant to ampicillin, ciprofloxacin or trimethoprim-sulfamethoxazole. This finding indicate that multidrug resistance does not represent a serious problem among NTS serotypes collected from the our medical center as monitored over a period of 7 years. Given this presentation, clinicians need to have a high index of suspicion and to consider preemptive therapy, especially in elderly patients who are likely to develop severe immunosuppression following interventions.

[Herpesviruses mixed infections in allogeneic steam cell recipients (allo-HSCT)]

AIM

Assessment of frequency and clinical course of infections with herpesviruses: CMV, EBV, HHV-6 and HHV-7 in patients that underwent non-manipulated allo-HSCT from matched-related donors.

METHODS

35 recipients of age 31 +/- 8 years. Serological status of donor and recipient against CMV and EBV assessed before transplantation. After transplantation, herpesviruses infection was confirmed based on the presence of viral DNA isolated from peripheral leukocytes, using nested PCR method. Patients were examined repeatedly, during 11.7 +/- 7 months of observation.

RESULTS AND CONCLUSIONS

mixed infections appeared in 80% of allo-HSCT recipients. Infections with two or three viruses dominated, especially CMV and EBV (65%). We observed specific tendency of appearance of particular herpesviruses in each episode--in the first and the second episodes CMV dominated, EBV or HHV-6 infections were rare, whereas in the successive episodes EBV and HHV-7 were the leading viruses. In correlation with clinical symptoms mixed CMV and EBV infections were characterised by the most severe course. Superinfections with HHV-6 or HHV-7 had no significant influence on the progression of illness. Our observations may suggest that the serious CMV infections in allo-HSCT recipients are the result of not only the pathogenic properties of CMV but of the additive effect of replication of other herpesviruses.

Cladribine combined with high doses of arabinoside cytosine, mitoxantrone, and G-CSF (CLAG-M) is a highly effective salvage regimen in patients with refractory and relapsed acute myeloid leukemia of the poor risk: a final report of the Polish Adult Leukemia Group

OBJECTIVES

Patients with primary refractory AML and with early relapses have unfavorable prognoses and require innovative therapeutic approaches. Purine analogs fludarabine (FA) and cladribine (2-CdA) increase cytotoxic effect of Ara-C in leukemic blasts and inhibit DNA repair mechanisms; therefore its association with Ara-C and mitoxantrone (MIT) results in a synergistic effect. In the current report, we present the final results of multi-center phase II study evaluating the efficacy and toxicity of CLAG-M salvage regimen in poor risk refractory/relapsed AML patients.

METHODS

The induction chemotherapy consisted of 2-CdA 5 mg/m2, Ara-C 2 g/m2, MIT 10 mg/m2, and granulocyte-colony stimulating factor. In the case of PR, a second CLAG-M was administered. Patients in CR received consolidation courses based on high doses of Ara-C and MIT with or without 2-CdA.

RESULTS

One hundred and eighteen patients from 11 centers were registered; 78 primary resistant and 40 relapsed. Sixty-six patients (58%) achieved CR after one or two courses of CLAG-M, 49 (35%) were refractory, and 8 (7%) died early. WBC >10 g/L and age >34 yr were factors associated with increased risk of treatment failure. Hematological toxicity was the most prominent toxicity of this regimen. The probability of OS at 4 yr was 14% (95% CI 4-23%). OS was influenced by age, WBC >10 g/L and poor karyotype in both univariate and multivariate analyses. The probability of 4 yr DFS was 30% for all 66 patients in CR (95% CI 11-49%). Poor karyotype was the only factor associated with decreased probability of DFS.

CONCLUSIONS

We conclude that CLAG-M is a well-tolerated and highly effective salvage regimen in poor risk refractory/relapsed AML.

The influence of palifermin (Kepivance) on oral mucositis and acute graft versus host disease in patients with hematological diseases undergoing hematopoietic stem cell transplant

In this multicenter study, we assessed the use of palifermin (recombinant human-keratinocyte growth factor 1) in the prevention of oral mucositis (OM) and acute GvHD (aGvHD) induced by a hematopoietic stem cell transplant (HSCT). Fifty-three patients with hematological diseases received three doses of palifermin (60 mug/kg once daily i.v.) pre- and post-conditioning regimens (total six doses). A retrospective control group of 53 transplant patients received no palifermin. There was a significant reduction in the incidence of OM of WHO (World Health Organization) grades 1-4 (58 vs 94%, P<0.001), 3-4 (13 vs 43%, P<0.001) and the median duration of OM (4 vs 9 days, P<0.001) in the palifermin group compared to the control group. The incidence of analgesics (32 vs 75.5%, P<0.001), opioid analgesics (24 vs 64%, P<0.001) and total parenteral nutrition (11 vs 45%, P<0.001) was also significantly reduced. The analysis of distribution of affected organs revealed that aGvHD was less prevalent in the palifermin group (P=0.036). There was no significant difference in the onset of any OM after HSCT, time to engraftment and length of hospitalization between groups. The drug was generally well tolerated and safe. Our results suggest that the use of palifermin reduces OM and probably aGvHD after HSCT, but a randomized trial is needed.

Addition of cladribine to induction/consolidation regimen does not impair peripheral blood stem cell mobilization and bone marrow harvest for autotransplantation in acute myeloid leukemia patients

BACKGROUND

The previous study by the Polish Adult Leukemia Group has demonstrated that addition of cladribine to standard DNR+AraC induction potentiates the antileukemic activity. The goal of this study was to compare the efficacy of bone marrow or peripheral blood hematopoietic cell collection in patients who obtained remission after daunorubicine plus cytarabine induction with cladribine (DAC-7) or without addition of cladribine (DA-7) in preparation for autotransplantation.

PATIENTS AND METHODS

Sixty-six patients aged 41 years (range, 17-58 years) were included in this study: 33 cases in the DAC-7 and 33 in the DA-7 arm. Hematopoietic cells were collected from the bone marrow (ABMT, n = 29) or from the peripheral blood (ABCT, n = 37) using cytopheresis after administration of AraC (2 x 2 g/m2) on days 1, 3, 5 and subsequent G-CSF (10 microg/kg) from day 7 as mobilization therapy.

RESULTS

The numbers of harvested CD34+ cells were similar in the DAC-7 and DA-7 pretreated patients both after harvesting from peripheral blood (2.55 x 10(6)/kg vs 2.5 x 10(6)/kg) and from bone marrow (1.62 x 10(6)/kg vs 1.55 x 10(6)/kg), respectively. The proportion of patients with sufficient material for autologous bone marrow transplantation was higher in the DAC-7 compared with the DA-7 arm. All patients engrafted; hematopoietic recovery was similar in both subgroups.

CONCLUSION

Addition of cladribine to a standard DA induction does not impair the harvesting of hematopoietic cells and their engraftment after autotransplantation.

[Epstein-Barr virus (EBV) infections in patients treated with allogenic hematopoietic cells transplantation (allo-HCT)]

OBJECTIVE

Assessment of frequency and clinical course of EBV infection in patients that underwent non-manipulated allo-HCT from matched-related donors.

METHODS

Active EBV infection was confirmed based on the presence of anti-EA antibodies (ELISA) and/or viral DNA (nPCR) isolated from peripheral leukocytes. For positive DNA-isolations semi-quantitative analysis were done. Patients were examined repeatedly, the time of monitoring was approximately 6 +/- 5 months.

RESULTS

Active EBV infection was confirmed in 27 among 56 examined allo-HCT recipients. Primary infection was detected in 5 patients, in the remaining patients it was probably the result of virus reactivation. In most cases EBV-load was approximately 200 copies per 1 million of leukocytes, 1 patient with lymphoproliferative disorder (PTLD) had 2 million copies. EBV infection was asymptomatic in most cases (17), in 7 cases aminotransferase levels were insignificantly increased, in 2--diarrhea was observed and in 4 patients GvHD was intensified.

CONCLUSIONS

In recipients without risk of PTLD, permanent monitoring of the EBV-load has no clinical justification.

Acute lymphoblastic leukemia in elderly: the Polish Adult Leukemia Group (PALG) experience

This is a retrospective, multicenter study to evaluate biological features and outcome of elderly patients diagnosed with acute lymphoblastic leukemia (ALL) during the last 10 years in ten hematological centers in Poland. Eighty-seven patients aged 60 years or older were studied. To our knowledge, this is one of the largest group of elderly patients with ALL evaluated. We have not observed differences in immunological subtypes and Ph chromosome incidence as compared with younger adult ALL presented in the literature. Induction chemotherapy was administered in 75 patients. We observed complete remission (CR) in 34 (45%, 95% CI: 33-56%) patients. Induction death occurred in 11 (15%) patients. Thirty patients (40%) showed primary resistance to chemotherapy. Median overall survival (OS) of all patients was 150 days. Median disease-free survival (DFS) of responding patients was 180 days. We observed four long-term survivors (DFS longer than 3 years) in our group of patients. Factors influencing OS were CR achievement, female gender, and WBC below 30 x 10(9)/l. Male gender was the only prognostic factor negatively affecting probability to achieve CR. We have not observed any differences in either biology or outcome between patients aged 60-69 years and those aged more than 70 years. ALL of the elderly is a rare disease with poor prognosis. Further clinical trials evaluating the disease features, outcome, and new therapeutic approaches are warranted.

[Hypopituitarism and hematological abnormalities mimicking myelodysplastic syndrome. Report of four cases]

Insufficiency of the pituitary gland and hematological abnormalities may coexist in the context of two syndromes. In the course of some hematopoietic neoplasms, particularly acute leukemias, the pituitary insufficiency may be caused by destruction of the gland either by direct neoplastic infiltration or occlusion of vessels. Alternatively, thy pituitary dysfunction may be associated with but not caused by hematological abnormalities, usually mild peripheral cytopenias. We present four cases of the latter type (1. M/33, pituitary tumor, hypogonadism, hyperprolactinemia, anemia, mild leukopenia with leukocytosis, 2. F/54, pituitary tumor, hyperprolactinemia, thyreotropic and corticotropic insufficiency, anemia, thrombocytopenia, mild neutropenia, 3. F/27, pituitary tumor, diabetes insipidus, hypogonadism, sideropenic anemia, leukopenia, thrombocytopenia, 4. M/24, primary multihormonal insufficiency of the anterior portion of the pituitary gland, neutropenia, microcytosis). Trephine and aspiration bone marrow biopsies revealed topographic and cytological abnormalities partially resembling these found in myelodysplastic syndromes (MDS). Bone marrow cellularity varied markedly between and within the cases, and in three patients abnormal aplastic areas were found. The percentage of hematopoietic stem cells (CD34+) was low in three cases and normal in one case. Pituitary dysfunction may be associated with hematological abnormalities simulating MDS, but showing different, less aggressive clinical course. The proliferative potential of hematopoietic cells is low, the peripheral blood abnormalities are stable, and no patient developed acute leukemia. Detailed bone marrow examination, including the trephine bone marrow biopsy, is useful in differentiation with true MDS, which was also reported in the literature in the patients with pituitary insufficiency.

[Mucositis--a major non-hematologic complication of high-dose chemotherapy and radiotherapy--pathogenesis, prevention and treatment]

High-dose chemotherapy and radiotherapy--induced oral mucositis (OM) represents a major non-hematologic complication of stem cell transplantation in cancer patients. This side effect causes significant treatment-related morbidity and is an important clinical problem because of the pain, odynodysphagia, the requirement for parenteral nutrition, narcotics and the risk of local infections which are exacerbated by the severe neutropenia and can become systemic. The pathogenesis of OM can be attributed to the direct mucosal toxicity of high-dose chemotherapy and ionizing radiation and to indirect mucosal damage caused by a concomitant local bacterial, viral and mycotic infections. This review describes pathophysiology as well as prophylactic and therapeutic armamentarium for the treatment of oral mucositis in patients receiving high dose chemotherapy and/or radiotherapy.

[Epstein-Barr virus infection in patients after bone marrow and heart transplantation]

Epstein-Barr virus (EBV) infections in immunosuppressed patients cause the severe clinical problems. Posttransplant lymphoproliferative disease (PTLD) might occur as a result of the latent EBV activation.

OBJECTIVE

Occurrence of active EBV infection in heart and bone marrow transplant patients.

METHODS

68 serum samples obtained from 13 allogenic bone marrow and 20 heart transplant patients were tested by IF and ELISA methods. Antibodies against VCA, EA and EBNA antigens were measured.

RESULTS

All patients showed the presence of anti-VCA IgG antibodies, thus all were seropositive. Three patients (9%) showed primary EBV infection while in 12 (36%) patients virus reactivation or reinfection was confirmed.

CONCLUSIONS

1. EBV infection in immunosuppressed patients is mainly caused by latent virus reactivation. 2. Type of EBV infection can be confirmed serologically only by the detection of specific anti-VCA, EA and EBNA antibodies. 3. The risk of PTLD in transplant patients creates the need for frequent monitoring.

Fatal post-transplant lymphoproliferative disorder following allogeneic bone marrow transplantation for aplastic anemia

Post-transplant lymphoproliferative disorder (PTLD) constitutes a serious complication of allogeneic bone marrow transplantation. We describe a case of PTLD in a twenty-six year-old male treated with bone marrow transplantation for aplastic anemia of unknown cause. The patient received unmanipulated marrow graft from his HLA-matched brother. Fifty-one days post transplant he developed progressive enlargement of cervical lymph nodes, followed by hepatosplenomegaly and generalized lymphadenopathy. Polymorphic PTLD was diagnosed basing on the lymph node histopathology, positive EBV detection, flow cytometry and IgH rearrangement studies proving monoclonality (capillary electrophoresis with ABI PRISM 310 Genetic Analyzer). There was no response to anti-CD20 antibody, cessation of immunosuppression, donor lymphocyte infusion and cytostatic therapy. The patient died on the 65th day of multiple organ failure. We discuss the diagnostics and management of PTLD in the setting of bone marrow transplantation.

[Severe depression with psychotic symptoms, diagnosed in the final stage of treatment of acute bi-phenotype leukemia]

The psychologic characteristics of a patient treated of acute leukemia in the ward of bone-marrow transplantation at the Haematology Clinic of CM UJ in Cracow, have been presented. During chemotherapy, proceeding the bone marrow transplant, the patient developed an acute depressive episode with psychotic symptoms. Following the transplantation and discharge from the Haematology Clinic, due to the insufficiency of out-patient treatment and a marked increase of psychotic depression symptoms, the patient was hospitalised at the Depression-Treatment Ward of the Psychiatric Clinic of CM UJ in Cracow. Changes of intensity and character of the psychiatric disorder in the following stages of haematologic and psychiatric intervention are presented. Adaptive strategies considering the important theoretical models according to the authors in connection to the general problem of depressive disorders accompanying neoplasmatic disorders have been described.

[Hemorrhagic cystitis related to the high-dose conditioning therapy in a bone marrow recipient]

Hemorrhagic cystitis (HC) is the syndrome of hematuria combined with symptoms of lower urinary tract irritation in the absence of bacterial infection or generalized hemorrhagic diathesis. HC often occurs as a difficult complication after autologous as well as allogeneic hematopoietic cell transplantation (HCT). It may be secondary to pretransplant preparative regimen (chemotherapy and/or radiation therapy) or viral infection by adenovirus, JC and BK viruses. The most effective treatment for HC has not been established yet. We report a case of a 17-year-old male with common acute lymphoblastic leukemia (cALL) in second CR, who was treated with high-dose chemotherapy (BuCy conditioning regimen) followed by autologous bone marrow transplantation (ABMT), complicated by hemorrhagic cystitis on day 0 (several hours after infusion of transplant material). The immediate use of increased dose of 2-mercaptoethane sulfonate sodium (mesna), bladder irrigation and intensive hydration with forced diuresis resulted in resolution of macroscopic hematuria on day +3 after the transplant and urinary tract recovery with normalization of urine analysis parameters on day +7.

[The role of autologous hematopoietic cell transplantation in adult acute myelogenous leukemia]

High dose chemotherapy with autologous hemopoietic cell transplantation (AHCT) is a common method of treatment of acute myelogenous leukemia (AML). AHCT is a treatment of choice for patients who have no matched family donor. AHCT is particularly recommended for older patients, excluded from allogeneic transplantation procedures. Prospective randomised trials have shown better efficacy of AHCT comparing with conventional chemotherapy in postremission treatment of AML. Both in vitro and in vivo bone marrow purging allow to achieve better transplantation results. Since two years peripheral blood instead of bone marrow is increasingly used as a source of transplant material. It allows more rapid hemopoiesis regrowth. Various methods of immunotherapy such as interleukin-2, Linomid and mixed hemopoietic cell transplantation (delayed donor lymphocytes transfusion) are used to evoke an autologous graft versus leukemia (GvL) phenomenon and to reduce AML relapse rate. Analysis of prognostic factors allows to identify a group of AML patients for whom AHCT is strongly recommended.

[Autologous transplantation in acute lymphoblastic leukemia in adults]

Over the past ten years considerable experience has been gained in autologous bone marrow transplantation (ABMT) for acute myelogenous leukemia and it is becoming possible to identify patients who may benefit from this approach. In acute lymphoblastic leukemia (ALL)the precise role of autologous transplantation particularly in first remission is much less clear than in AML. Formerly, most adult ALL patients who underwent ABMT did so in relapse or in second or subsequent remission. The fact that some of these patients could become long term survivors has encouraged the use of ABMT in first remission. In most studies 40-50% of first remission patients attained long term disease free survival (DFS). Relapse rates are considerably higher in patients receiving ABMT when compared to those receiving an allogeneic transplant, but the latter group of patients experience significant morbidity and mortality (15-30%) due to graft-versus-host disease and opportunistic infections. ABMT clearly has the potential to effect cures in ALL patients and its role and timing are now the subject of major clinical studies. As the mortality of ABMT for ALL rapidly decreases to approximately 5%, more widespread use of such a procedure may replace the protracted maintenance chemotherapy usually given in this disease.

[Supportive therapy in patients with autologous hemopoietic stem cell transplantation]

Infectious complications remain one of the most serious diagnostic and therapeutic problems in modern hematology and are the major cause of morbidity and mortality following stem cell transplantation. Myeloablative therapy supported by haemopoietic stem cell transplantation remains standard policy in the treatment of certain haematological malignancies and solid tumors. Proper preventive strategies for patients in deep immunosuppression including prompt diagnosis and treatment of infections correlate with favourable prognosis and survival. Prophylaxis and therapy of bacterial, fungal and viral infections in neutropenic patients following myeloablative chemotherapy have been submitted in this article. Our guidelines are based on European Group for Bone and Marrow Transplantation recommendations and some European transplantological centres protocols. These standards were adapted to Polish conditions and now are used at Bone Marrow Transplantation Ward at Haematology Department at the Jagiellonian University.