Malignancies in beta-thalassemia patients: a single-center experience and a concise review of the literature

Thalassemia represents the world's most common monogenic disease, characterized by absence of or decreased globin chain production. The lifespan of thalassemia patients has been extended as a result of current supportive treatment. We report three cases of cancer (non-Hodgkin lymphoma, Hodgkin disease, and seminoma) in thalassemic patients. Factors that may contribute to the pathogenesis of cancer seem to be infections and iron overload through mechanisms of oxidative damage; immunomodulation or coexistence of the two diseases may only be coincidental.

Recombinant human erythropoietin for the treatment of anaemia in patients with chronic idiopathic myelofibrosis

BACKGROUND

Patients with chronic idiopathic myelofibrosis (CIMF) usually present with anaemia. Treatment is often palliative and the majority of patients receive regular red blood cell (RBC) transfusions. Although recombinant human erythropoietin (rhu-EPO) has been proved effective for the treatment of anaemia in several chronic diseases, including haematological malignancies, its role in the treatment of the anaemia in CIMF is not well established. We report the beneficial effect of rhu-EPO administration in 20 patients with CIMF and discuss the parameters predicting favourable response.

PATIENTS

Twenty patients with CIMF (9 women and 11 men) regularly treated with supportive RBC transfusions were included in the study. The median age was 70 years (range 45-81 years). Rhu-EPO, 10,000 U, was given subcutaneously 3 times a week. The median duration of therapy was 83 months, ranging from 13 to 87 months.

RESULTS

Treatment was considered effective if haemoglobin levels increased over 2 g/dl within 12 weeks after enrolment or the RBC transfusion requirements were reduced by 50% within the same interval. Twelve patients (60%) responded to therapy. Responders were mainly female, had smaller spleen size (p = 0.024), low RBC transfusion requirements (< or = 1-2 units per month), and significantly lower endogenous serum erythropoietin (EPO) and beta2-microglobulin (beta2-M) levels when compared with non-responders (p < 0.0001 and 0.00001, respectively). Treatment was well tolerated and none of the patients was withdrawn from the treatment protocol because of side effects.

CONCLUSIONS

Rhu-EPO administration is an effective, safe and well-tolerated treatment for patients with CIMF and anaemia leading to a significant reduction in RBC transfusion requirements. Factors predicting favourable response are low endogenous EPO and beta2-M serum levels and slight to moderate splenomegaly.

Spontaneous splenic haematoma in a multiple myeloma patient receiving pegfilgrastim support

Growth factors are a significant advance in the supportive care of patients with cancer with a wide range of indications. Frequent side effects of G-CSF include bone pain, headache, fatigue and nausea. We report a case of subcapsular splenic haematoma following pegfilgrastim administration in a 65-year old patient with multiple myeloma. Proposed mechanisms accounting for splenic enlargement include extramedullary haemopoiesis, intrasplenic infiltration by mature and immature myeloid cells and intrasplenic stem cell homing and proliferation. The risk of spontaneous splenic rupture is difficult to quantify. Physicians should be aware of this life-threatening condition and early diagnosis can be difficult since anemia and splenomegaly are common findings in haematologic patients.

Clinical correlation of bone marrow microvessel density in essential thrombocythemia

The aim of this study was to investigate the prognostic relevance of angiogenesis expressed as bone marrow microvessel density (MVD) in 40 patients with essential thrombocythemia (ET). Bone marrow MVD was visualized in paraffin tissue sections using immunohistochemical staining for CD34 protein. Increased MVD of bone marrow specimens was not significantly correlated with clinical (sex, age, microvascular disturbances, liver and spleen size, complications, treatment or no before biopsy), laboratory (peripheral blood count), bone marrow histopathological parameters (cellularity, megakaryocyte clumping and reticulin fibrosis) and overall survival. These preliminary findings suggest that angiogenesis has no prognostic value in patients with ET.

Beneficial Effect of Rituximab in Combination with Oral Cyclophosphamide in Primary Chronic Cold Agglutinin Disease

Cold agglutinin disease (CAD) is an uncommon autoimmune hemolytic anemia characterized by B-cell proliferation. Conventional therapies for primary CAD such as corticosteroids, oral alkylating agents, splenectomy, interferon alpha, and plasma exchange are often ineffective at controlling the disease. The anti-CD20 monoclonal antibody rituximab (MabThera) depletes B-lymphocytes and thereby interferes with the production of cold agglutinin. We describe an elderly patient with primary (idiopathic) chronic CAD refractory to steroids who was successfully treated with 4 weekly infusions (375 mg/m2) of rituximab and 6 months of oral cyclophosphamide at a dosage of 60 mg/m2 per day. The increase in hemoglobin level and the decline in the plasma cold agglutinin titer were rapid (from the second rituximab infusion). The hematologic remission persisted for at least 8 months after treatment start, with no adverse effects. Rituximab and cyclophosphamide may be supplementary therapeutic modalities whose combination warrants further clinical investigation.

A single-center, retrospective study of management and outcome of 45 elderly AML patients, diagnosed in 2001

Acute myeloid leukemia (AML) predominantly affects older adults, a population with a poor prognosis, due to age, comorbidities and forms of disease. We present a retrospective study of 45 patients older than 60 years of age, with AML, who were diagnosed and/or treated in our clinic in the year 2001. Our study refers to 32 men, 63-80 years of age and 13 women, 62-85 years of age. Fourteen of them were diagnosed as de novo leukemia while 31 developed secondary leukemia, due to myelodysplasia, chronic myeloid leukemia and essential thrombocytemia. A therapeutic protocol that included 2 courses of induction chemotherapy with idarubicin 8mg/m2 for 3 days, aracytin 100 mg/m2 for 5 days and etoposide 75 mg/m2 for 5 days, followed by 2 courses of consolidation chemotherapy with aracytin 800 mg/m2/d for 4 days, was administered. In patients with acute promyelocytic leukemia we additionally administered all trans retinoic acid. Those with erythroleukemia also received erythropoietin, 10,000 IU 3 times a week. All patients received supportive therapy with blood products and G-CSF during blood marrow aplasia. Four patients refused therapy and three patients received only blood product support because of poor performance status. Nine out of the 38 patients who received chemotherapy (23.7%) achieved a complete remission after treatment, while, 13 out of 38 (34.2%) only a partial one (overall remission rate: 57.9 %). Ten patients relapsed in <6 months and 12 patients relapsed in >6 months. Patients who received only supportive treatment died 2-5 months after initial diagnosis. During therapy, 16 patients (42.1%) died due to: infection, cerebrovascular or gastrointestinal bleeding and acute myocardial infarction. In conclusion, it appears that a high percentage of the elderly patients with AML, despite the unfavourable prognosis, responded to chemotherapy (57.9%) and achieved longer survival durations compared to patients who refused therapy or received supportive treatment alone. Unfortunately, a large number of them exhibited serious complications during treatment, with a mortal outcome. Close follow-up and supportive care highly contributed to an improvement of treatment outcome in elderly patients with acute myeloid leukemia.

Treatment of MDS patients with recombinant human erythropoietin and the role of GSTs

Glutathione S-transferases (GSTs) are a group of enzymes involved in the detoxification process of carcinogens and other substances. The genes encoding isoenzymes M1 and T1 have "null" alleles, which are polymorphic in humans. Our purpose was to examine whether the GSTM1 and GSTT1 homozygous null genotypes have an impact on the response to recombinant human erythropoietin (rhuEpo) treatment in MDS patients. We analyzed lymphocyte DNA samples from 27 patients with all types of myelodysplastic syndromes (MDS) at the time of diagnosis. All patients were scheduled to receive rHuEpo in doses of 150 u/Kg/day for a period of 12 weeks in order to obtain and maintain stable responses. A multiplex polymerase chain reaction (PCR) was used to genotype both GSTM1 and GSTT1 simultaneously, in responders and non-responders to rhuEpo with respect to various pretreatment parameters: haemoglobin, white blood cell count, platelets, serum erythropoietin, transfusion requirements and bone marrow blasts. The data obtained were evaluated by chi2 test and odds ratio were extracted. Twelve out of 27 evaluated patients demonstrated an erythroid response (44%). Nine out of the 12 patients (75%) responding after 12 weeks of treatment had GSTM1 null genotype (OR=3.4). In contrast, only 1 responder (8.3%) was homozygotes of GSTT1 null genotype. Furthermore, no statistically significant difference in the response rate of the different MDS subgroups was observed. Our results suggest that a treatment with rHuEpo may be effective in achieving a stable erythroid response in MDS patients who carry an homozygous deletion of the GSTM1 gene.

Treatment of resistant/relapsing chronic lymphocytic leukemia with a combination regimen containing deoxycoformycin and rituximab

BACKGROUND

Patients with chronic lymphocytic leukemia (CLL) are sometimes resistant to treatment or relapse soon after the administration of the currently available frontline therapy including chlorambucil-prednisolone CHOP and fludarabine. We report the beneficial effect of an alternative chemotherapeutic regimen containing 2'-deoxycoformycin (pentostatin) and the monoclonal antibody anti-CD20 (rituximab) in 5 patients with resistant/relapsing CLL.

PATIENTS

Five patients (4 men and 1 woman) with CLL at stage C, according to Binet's classification, were included in the therapeutic protocol. The median age of the patients was 76 years (range 57-84 years). Previous treatment consisted of chlorambucil-prednisolone, fludarabine, and CHOP. The current regimen comprised six 2-week cycles of pentostatin, 4 mg/m(2) i.v., combined with four cycles of rituximab, in a dose of 375 mg/m(2), every other week.

RESULTS

Three patients responded to therapy, 2 achieved complete remission and 1 a partial response. Two patients did not respond to treatment. Toxicity was mild and well tolerated. The median survival duration of the responders was 19 months. These promising results suggest that salvage therapy with a combination regimen including pentostatin and rituximab may have a beneficial effect in patients with resistant/relapsing CLL.

T-cell receptor gammadelta-large granular lymphocytic leukemia associated with an aberrant phenotype and TCR-Vbeta20 clonality

Large granular lymphocytic (LGL) leukemia is a rare heterogenous disorder of mature lymphocytes with a characteristic morphology, multiple autoimmune disorders and indolent clinical course. Most cases exhibit a T-cell phenotype of CD3, CD8 and CD57 positivity, while the minority exhibit a CD2, CD56, and CD16 positive NK-cell phenotype. We report a case of a 71-year-old female suffering from a TCRgammadelta positive T-cell leukemia with a morphology compatible to LGL leukemia. She referred to the hospital for investigation of mild anemia, lymphocytosis, neutropenia and hyperglobulinemia. Peripheral blood and bone marrow were occupied by mature large granular lymphocytes with abundant azurophilic granules. The immunophenotype was CD3+, CD2+, CD5+, CD7+, CD4-, CD8-, CD16-, CD56-, CD57- and the Vbeta repertoire analysis showed clonal reactivity with Vbeta20 mAb. The patient was diagnosed as having T-LGL and was treated with G-CSF. So far, she experiences an indolent clinical course. To our knowledge, this is a rare case of TCRgammadelta positive T-LGL leukemia with the aberrant immunophenotype of CD3+, CD4-, CD8-, CD16-, CD56-, CD57-.

Successful treatment of refractory anemia with a combination regimen containing recombinant human erythropoietin, low-dose methylprednisolone and nandrolone

Myelodysplastic syndromes (MDS) are a heterogenous group of hematological clonal malignancies. Patients belonging to the refractory anemia (RA) subtype are usually treated with recombinant human erythropoietin (EPO). Not all patients respond to EPO administration and they are strictly dependent on supportive therapy with red cell blood (RBC) transfusions. The aim of this study was to investigate the efficacy of an alternative combination regimen containing EPO, low-dose methylprednisolone and nandrolone decanoate, in patients with RA unresponsive to EPO administration alone. Ten patients, 4 women and 6 men, median age: 70 years (range: 55-78 years) with refractory anemia unresponsive to EPO administration and RBC transfusion-dependent were included in the study. Median hematological data at baseline were Hb: 8.7 g/dl, (range 6.2-9.8), WBC: 3.35x10(9)/l (range 2.1-4), PLT: 82.5x10(9)/l (range 59-110). EPO 150 U/Kg three times/week subcutaneously, low-dose methylprednisolone 8 mg/day orally and nandrolone decanoate (Decadurabolin) 50 mg two-times/week intramuscularly were administered. As complete response (CR) to treatment was considered the normalization of the peripheral blood and bone marrow smears and biopsy. As partial response (PR) was considered increase in Hb level > or = 2 g/dl, or up to 10 g/dl and discontinuation of RBC transfusions. The response to therapy was evaluated on the 4th week after the initiation of the combination treatment. Bone marrow smear evaluation was carried out at baseline and every six months afterwards. After a 4-week treatment all patients achieved PR and discontinued RBC transfusions. Median and range hematological values on the 4th week after treatment initiation were Hb: 11.2 g/dl, (range: 9.8-12.8), WBC: 4.4x10(9)/l (3.5-6.6), PLT: 130x10(9)/l (95-160). The increase observed in hematological values was significant (p = 0.0001, 0.0004 and < 0.0001, respectively, for Hb, WBC and PLT counts). Treatment was well tolerated. Furthermore, two women, on treatment with the combination regimen, achieved CR one after six months and the second after 12 months. They are alive after 5 years from initiation of the combination treatment. After a median period of 18 months (range 12 to 20 months) in PR three men developed acute leukemia; they received intensive antileukemic chemotherapy without any response and died during the phase of pancytopenia. Three other men achieved CR, one after 6 and two after 12 months of therapy and they are on regular follow-up. Two women after 10 and 14 months in PR developed acute leukemia and died. In conclusion, combination therapy with EPO, nandrolone decanoate and low-dose methylprednisolone may be effective as an alternative treatment for RBC transfusion-dependent patients with RA unresponsive to EPO administration alone.

Antierythropoietin antibodies in thalassemia patients

We evaluated sera from 58 thalassemic patients for the presence of antierythropoietin antibodies to investigate whether these autoantibodies may relate with modest response to treatment with recombinant human erythropoietin (rhEpo). Thirty-seven patients had beta-thalassemia major, 9 patients had beta-thalassemia intermedia, and 12 patients had sickle/beta(+)-thalassemia. Of 58 patients, 24 were on rhEpo treatment in order to increase the intervals between transfusions or the hemoglobin (Hb) values. The study population was divided into three groups according to rhEpo treatment. Group A consisted of 15 patients who were on rhEpo treatment (400-600 IU/kg three times per week, subcutaneously) showing an increase of Hb values or reduction of transfusion requirements. Group B included 9 patients who did not respond to rhEpo and group C consisted of 34 patients who did not receive rhEpo. Laboratory studies included a complete blood count, measurement of serum erythropoietin, immunological evaluation, and determination of antierythropoietin antibodies using enzyme-linked immunosorbent assay (ELISA). There were no significant differences among groups A, B, and C concerning age, Hb, and endogenous erythropoietin values. Fifteen patients had positive antinuclear antibodies and three patients had positive rheumatoid factor. Antierythropoietin antibodies were detected in the sera of seven patients (five men and two women) who received rhEpo. The male patients and one female patient had no response to rhEpo while the other female patient showed response when the dose increased. Other autoantibodies seem to have no clinical significance. In the present study, we detected for the first time in thalassemia patients the presence of antierythropoietin antibodies, which may contribute to rhEpo resistance. Thalassemia patients with low response rates to rhEpo should be evaluated for the presence of antierythropoietin antibodies.

Distribution and frequency of beta-thalassemia mutations in northwestern and central Greece

OBJECTIVES

Beta-Thalassemia is a common autosomal recessive disorder resulting from over 200 different mutations of the beta-globin genes. The spectrum of beta-thalassemia mutations in Greece has been previously described in the population of the capital city of Athens, or in beta-thalassemia patients having transfusion therapy. The aim of the present study was to identify the distribution of the most common beta-thalassemia mutations in the population of northwestern and central Greece.

METHODS

The data for this study were derived from a total of 1,130 unrelated subjects including 46 beta-thalassemia major, three beta -thalassemia intermedia and 1,081 carriers identified in our antenatal screening program. beta-Thalassemia mutations were identified by ARMS, DGGE and Reverse Dot Blot.

RESULTS

The most common mutation, IVS-I-110, is followed, in order of frequency, by the mutations Cd-39, IVS-I-1, IVS-II-1, Cd-6, IVS-I-6, IVS-I-5, IVS-II-745, Cd-5 and 44 bp del. IVS-I-110 and Cd-39 frequencies are similar with those found in other Balkan countries. Significant differences in regional distribution were observed. The results showed a clear drift of the distribution of the most frequent IVS-I-110 mutation in the south-north (29.4, 40.0, 44.6 and 61.7%) and the east-west axis (31.8 and 44.6%).

CONCLUSIONS

Population screening and prenatal diagnosis are significantly facilitated by these data. Furthermore, the detailed distribution tables of beta-thalassemia mutations are essential for counseling and extraction of genetic diversity estimates for population genetic studies in other inherited disorders.

Solitary bone plasmacytoma in a young patient

Plasma cell disorder, a disease of the elderly, is extremely rare in those below 30 years of age. A young 18 year old patient with solitary plasmacytoma is described in this case report.

Interleukin-3 and interleukin-4 in childhood brucellosis

BACKGROUND

The Th1/Th2 cytokine balance seems to be involved in the susceptibility or resistance to Brucella infection, however the precise role of interleukins in human brucellosis has not been thoroughly explored.

PATIENTS AND METHODS

The serum levels of interleukin-3 (IL-3) and interleukin-4 (IL-4) were measured by enzyme-linked immunosorbent assay (Quantikines, R&D Systems) in five children hospitalized for brucellosis and in a control group comprising ten children who were residents of the same area.

RESULT

IL-4 levels were significantly increased during both the acute phase (p = 0.0036) and convalescence (p = 0.026) as compared to controls. IL-3 levels were mildly increased during the acute phase (p = 0.026) without any significant difference noted during convalescence (p = 0.271) as compared to controls. Both IL-3 and IL-4 levels were neither related to hemoglobin values, nor to red and white blood cell, neutrophil, lymphocyte and platelet counts.

CONCLUSION

Serum IL-4 levels are increased in hospitalized children with symptomatic brucellosis, a finding suggestive of a Th2 response leading to severe infection.

Rheumatoid arthritis and B-cell chronic lymphocytic leukemia

The association between lymphoproliferate malignancies, especially lymphoma, and rheumatoid arthritis (RA) has been confirmed by several studies. However; there are few reports of RA patients who developed B-cell chronic lymphocytic leukemia (B-CLL) and vice versa. We report a patient with B-CLL who developed RA and another with RA who presented with B-CLL during follow-up. We discuss the incidence of B-CLL among the RA population and the possible interaction of the pathogenetic mechanisms of these two entities.

Skin and gingival lesions in a young woman with B-prolymphocytic leukemia (B-PLL)

B-PLL has not been often associated with diffuse skin involvement or oral lesions. We present a 32 year-old woman in whom skin and gingival manifestations were the prominent clinical signs of disease relapse.

Recombinant human erythropoietin therapy in a transfusion-dependent beta-thalassemia major patient

We report on a 28-year-old patient with transfusion-dependent beta-thalassemia major, who was treated effectively with recombinant human erythropoietin (rHuEpo). rHuEpo promotes the differentiation and proliferation of erythroid cells, induces the production of fetal hemoglobin (HbF), and could be useful in the treatment of some selected transfusion-dependent thalassemia patients. Prior to rHuEpo treatment, the patient was on a regular blood transfusion regimen. Splenectomy did not decrease the transfusion requirements. Additionally, red cell alloimmunization had developed; therefore, we decided to start rHuEpo treatment (Eprex, Jansen Cilag, Greece) in an attempt to improve his anemia and the quality of life. Our patient responded well to rHuEpo treatment and was able to extend the intervals between transfusions from 10-14 to 55-65 days and to sustain a pretransfusion hemoglobin level above 7 g/dl. HbF levels were slightly increased from 55% to 60-65%. Indicators of vascular endothelial activation [serum endothelin-3, intracellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and E-selectin] were decreased during treatment. rHuEpo was well tolerated without complications. rHuEpo treatment seemed to have had a beneficial effect and to have improved the quality of life in beta-thalassemia major, although it did have a slight effect on HbF levels, suggesting other possible mechanisms of rHuEpo action.

Treatment of plasma cell leukemia with vincristine, liposomal doxorubicin and dexamethasone

Primary plasma cell (PCL) leukemia is a rare lymphoproliferative disorder characterized by a malignant proliferation of plasma cells in the bone marrow and peripheral blood. Survival with standard therapy using melphalan is very poor. Doxorubicin encapsulated with liposomes has less cardiotoxicity, is at least as efficient and has fewer side effects than conventional doxorubicin. Two female patients (69 and 54 yr old) with primary PCL are described in this study. They both received a modified form of VAD (vincristine, doxorubicin and dexamethasone), a regimen which includes liposomal doxorubicin (40 mg/m2 for 1 d), vincristine (2 mg for 1 d) and dexamethasone 40 mg per os on days 1-4, 9-12 and 17-20. A disease evaluation of the first patient after six courses of the modified \VAD regimen showed no plasma cells in the peripheral blood, a decrease in the serum M protein level and a plasma cell infiltration in the bone marrow of less than 5%. The patient died from a cardiac episode 24 months post-diagnosis, while she was in complete hematological remission. The second patient also exhibited good tolerance to liposomal doxorubicin with no side effects, achieved complete haematological remission and remains in good condition 7 months after the last VAD administration. These results suggest that this modified form of VAD regimen also seems to work in PCL and is well tolerated with no side effects.

Lack of HLA-DR expression in a patient with B-chronic lymphocytic leukemia

We describe a rare case of a patient with chronic lymphocytic leukemia (CLL) whose immunophenotype analysis revealed lack of HLA-DR in B-cells.

Increased prevalence of GSTM(1) null genotype in patients with myelodysplastic syndrome: a case-control study

BACKGROUND AND OBJECTIVE

Myelodysplastic syndromes (MDS) are clonal disorders of bone marrow stem cells characterized by ineffective hematopoiesis leading to blood cytopenia; they often progress to acute myeloid leukemia (AML). The glutathione S-transferases (GST) detoxify various agents, including those implicated in MDS. Both GSTM(1) and GSTT(1) genes have "null" alleles and are polymorphic. We studied the impact of GTM(1) and GSTT(1) null genotypes on the MDS susceptibility, disease severity and laboratory indices with prognostic value for the syndrome.

MATERIAL AND METHODS

In a hospital-based case-control study we analyzed lymphocyte DNA samples from 54 patients with MDS and 60 cancer-free controls matched for age, sex, smoking habits and origin. A multiplex polymerase chain reaction was used to genotype both GSTM(1) and GSTT(1) simultaneously. The chi(2) test was used for statistical evaluation of the data and the odds ratios and attributable risk and population attributable risk were also calculated.

RESULTS

A significantly increased frequency of GSTM(1) null genotype was found among MDS patients (57.4%) compared to controls (33.3%) (p < 0.01), while the frequency of GSTT(1) null genotype was not significantly higher in MDS patients (11.1% vs. 6.66%). Neither GSTM(1) and GSTT(1) null genotype was associated with a particular category of the French-American-British (FAB) classification in the patients studied. Additionally, GSTM(1) null genotype was associated with a significant decrease in the absolute number of neutrophils among the MDS patients.

CONCLUSIONS

Individuals with GSTM(1) null genotype may have increased susceptibility to MDS. Null genotypes do not seem to have be associated with FAB classification while they may be associated with putative prognostic factors.

Alpha-2-macroglobulin and interleukin-6 levels in steady-state sickle cell disease patients

Endothelial activation and subclinical microvascular occlusions are an ongoing process during steady-state sickle cell disease, leading to interleukin production and an acute-phase response. Alpha-2-macroglobulin (alpha2M) is an acute-phase protein mainly regulated by interleukin-6 (IL-6). On the other hand, alpha2M acts as a carrier protein for IL-6 during inflammatory stress. The purpose of this study is to further assess the interactions between IL-6 and alpha2M as potent modulators of inflammatory reactions during the steady state of sickle cell disease. We measured alpha2M and IL-6 levels in 21 patients (12 male, 9 female; age range 12-44 years) in the steady state of sickle cell disease. Four patients had homozygous sickle cell anaemia and 17 had double heterozygous sickle cell/beta-thalassaemia. Diagnostic quantification of alpha2M was performed by rate nephelometry. Commercial enzyme immunoassay test kits were used for the quantitative measurement of IL-6. The alpha2M and IL-6 levels were compared to the values obtained from healthy volunteers. Mean values (+/- SD) of alpha2M and IL-6 were found to be significantly increased (p < 0.0005) in the patients (alpha2M: 337.2 +/- 104 mg/dl; IL-6: 4 +/- 2.1 pg/ml) compared to the healthy controls (alpha2M: 204.2 +/- 45.8 mg/dl; IL-6: 1.15 +/- 2.5 pg/ml). IL-6 values were positively correlated with alpha2M levels (r = 0.61, p < 0.01). We observed increased alpha2M and IL-6 levels in steady-state sickle cell disease and a positive correlation between these two inflammatory mediators. We suggest that alpha2M is a potent modulator of the inflammatory reaction and tissue repair mechanism during steady-state microvascular occlusions. Elucidating the role of alpha2M in sickle cell disease could lead to the development of novel strategies and therapies for preventing the harmful systemic or local effects of excess cytokine production.

Preliminary results of amifostine administration in combination with recombinant human erythropoietin in patients with myelodysplastic syndromes

Amifostine is a cytoprotective agent mainly used in cancer therapies, in order to ameliorate the toxic effects of anticancer chemotherapy and radiotherapy. In the past years an intriguing number of applications of amifostine have been identified; one of these is bone marrow cells protection and stimulation. Amifostine was administered in seven patients with myelodysplastic syndromes, four males and 3 females aged between 67 and 78 years old, in order to estimate its efficacy in reducing the need for red blood cells transfusions. Two patients had RAEB, four RA and one RARS. The drug was administered in an outpatient basis in a dose of 300 mgr/m2, three times weekly for at least four weeks. We administered at the same time erythropoietin 10.000 U subcutaneously. All patients received daily supplementation of oral ferrum sulfate and folic acid. Three patients, a woman with RA and two men, one with RA and another with RAEB improved the levels of Hb beyond 12,0 gr/dl and did not receive blood transfusions after the second week of treatment. The drug was well tollerated without any side effects in all of the patients.

Investigation for the presence of anti-erythropoietin antibodies in patients with myelodysplastic syndromes

OBJECTIVES

Recombinant human erythropoietin (rHuEpo) improves anemia in 25% of patients with myelodysplastic syndromes (MDS). The variable and sometimes low response rate to rHuEpo treatment raises the question whether the existence of autoantibodies against erythropoietin (epo) is partially responsible. In the present study we investigated the presence of anti-epo autoantibodies in MDS patients.

METHODS

Forty-three patients with MDS were studied. Sixteen patients had refractory anemia (RA), 13 had RA with ringed sideroblasts, 3 had RA with excess of blasts (RAEB), 9 had RAEB in transformation and 2 patients had chronic myelomonocytic leukemia. They were divided in 3 groups according to rHuEpo treatment. Group A consisted of 10 patients who did not receive rHuEpo treatment. Group B included 13 patients who were on rHuEpo treatment (150 IU/kg subcutaneously, 3 times weekly) showing an increase of hemoglobin (Hb) values or reduction of transfusion requirements and Group C consisted of 20 patients who did not respond or stopped responding to rHuEpo treatment. Laboratory studies consisted of a complete blood cell count, measurement of serum epo and determination of anti-epo antibodies using ELISA.

RESULTS

There were no significant differences with regard to age and sex among the three groups. No autoantibodies against epo were found in the examined sera, apart from a female patient from group A who showed a low positive titer.

CONCLUSION

We suggest that anti-epo autoantibodies do not contribute to the development of MDS-related anemia and are not responsible for the modest response to rHuEpo treatment. Further investigation is needed to identify possible reasons for the low response rate to rHuEpo treatment.

Serum levels of IL-6 and its soluble receptor (sIL-6R) in Waldenström's macroglobulinemia

BACKGROUND

Interleukin-6 (IL-6) is a multifunctional cytokine that plays roles in the immune response, inflammation and hematopoiesis. Serum IL-6 levels have reported to reflect disease severity and high tumor burden in multiple myeloma (MM) patients and to correlate with several other laboratory parameters. Serum-soluble IL-6 receptor (sIL-6R) plays an agonist role in IL-6 signaling, enhancing its biological activity tenfold. PURPOSE-METHODS: We measured IL-6 and sIL-6R levels in 11 patients (7 male, 4 female, mean age 66.9 yr) with Waldenström's macrobulinemia (WM) using a commercially available enzyme-linked immunoassay in order to investigate their biological role and to find any possible relationship with disease severity, tumor burden or response to treatment.

RESULTS

Serum IL-6 and sIL-6R concentrations at diagnosis were significantly higher than in healthy controls (Mann Whitney U-test, p < 0.001 and p < 0.01, respectively). Patients who were effectively treated had a significant reduction in IL-6 levels (p = 0.017). With regard to sIL-6R levels, no specific tendency was observed. In some of the responsive patients the levels increased whereas in others they decreased. No correlation was found between IL-6 and sIL-6R levels at diagnosis (p = 0.9, r = 0.036) or after treatment (p = 0.083, r = 0.3).

CONCLUSIONS

Our results suggest that IL-6 may be a marker reflecting tumor burden, disease severity and response to treatment in WM. With regard to sIL-6R, we believe that it does not seem to be of much value, and its role remains to be clarified. However, future studies are needed to confirm and further extend the present results.

A patient with essential thrombocytosis and multiple sclerosis

We report on a patient with a 5-year history of essential thrombocytosis (ET) who developed multiple sclerosis (MS) during the last 5 months. The patient was treated for MS with interferon-beta (IFN-beta), which also had a beneficial effect on the ET. We describe the patient's history and the beneficial effect of IFN-beta administration in reducing the number of platelets. We also discuss the possible link between the pathogenesis of ET and MS.

Two siblings with chronic myelogenous leukemia

In the present study we report the occurrence of Chronic Myelogenous Leukemia in two siblings (brother and sister) 47 and 62 years old respectively. These two cases raised the question of a possible genetic prodiathesis or a possible trasmission (environmental factor) cause.

Pleural effusion in chronic myelomonocytic leukemia

Pleural effusion in 4 patients with chronic myelomonocytic leukemia (CMML) is described in this report. According to the literature, pleural effusion in CMML is a poorly understood and rare occurrence. Two of our patients presented with pleural effusion as an initial symptom while the other 2 developed it during the course of the disease. In only 1 patient was the pleural effusion due to leukemic infiltration while in the other 3 it was a reactive phenomenon. Peripheral lymphadenopathy was observed only in the former patient who died of acute leukemia. After prednisolone therapy the pleural effusions resolved in the other 3 patients.

The role of cytokines in sickle cell disease

Sickle cell disease (SCD) is characterized by chronic hemolysis, frequent infections, and recurrent occlusions of microcirculation, which cause painful crises and result in chronic organ damage and failure. Occlusions of the microcirculation and infections are important factors that stimulate the production of cytokines and acute-phase proteins. Cytokines seem to be involved with several possible mechanisms in the pathogenesis of vasoocclusive phenomena in SCD: vascular endothelial activation, induction of red-cell adhesiveness to vascular endothelium, induction of neutrophil adhesiveness to endothelium, development of vascular intimal hyperplasia, platelet activation, endothelin-1 production, and dysregulation of endothelial apoptosis. Cytokines are also thought to be involved in the regulation of hemopoiesis, the inhibition of immune functions, and the development of growth deficits. Investigation of cytokines in SCD patients will elucidate the pathogenesis of the disease and its complications and may help in assessing disease severity and prognosis.

Administration of a modified chemotherapeutic regimen containing vincristine, liposomal doxorubicin and dexamethasone to multiple myeloma patients: preliminary data

For elderly patients with multiple myeloma (MM), conventional melphalan and prednisone (MP) therapy has been the treatment of choice; the vincristine, doxorubicin and dexamethasone (VAD) regimen is preferred for younger patients who also receive high-dose melphalan in combination with autologous or allogeneic bone marrow transplantation (BMT). Although survival time is similar in both the MP and VAD regimens, the continuous infusion of doxorubicin which the latter treatment entails constitutes a disadvantage along with the 4-day hospitalization required. Doxorubicin also induces cardiotoxicity, particularly in the elderly. A modified form of VAD therapy includes liposomal doxorubicin (Caelyx) (40 mg/m2 for 1 d) [corrected], oncovin (2 mg for 1 d) and dexamethasone 40 mg for 4 d per os. Doxorubicin encapsulated with liposomes has less cardiotoxicity, is more efficient and has fewer side effects than conventional doxorubicin, and it can be administered on an outpatient basis: dexamethasone can be given orally and vincristine in bolus infusion. In order to estimate its efficacy and tolerability, we administered this regimen to 12 patients (first-line treatment in 6 patients, salvage therapy in 6 patients). All patients exhibited good tolerance to liposomal doxorubicin with no severe side effects. Eight patients achieved complete hematological remission and three partial response. One patient died before completing the treatment. In conclusion, compared to other therapies, this modified VAD regimen containing liposomal doxorubicin can be more easily administered to MM patients, without severe side effects and with increased full remission rates, almost similar to those with the conventional VAD treatment.

Skin lesion's treatment with alfa interferon in a patient with B-CLL

Treatment with recombinant alfa-2b-interferon in a patient with advanced B-CLL resulting in complete remission of skin lesions after one month therapy is reported in this paper. Interferon was administered subcutaneously three times weekly. Six months later while the treatment continued, the disease remained stable.

Coexistence of myelodysplastic syndrome and multiple myeloma

We describe the simultaneous presentation of myelodysplastic syndrome (MDS) and multiple myeloma (MM). Our patient had MDS (RAEB type) and bone marrow infiltration (40% plasma cells), as well as biclonal paraprotein. Patients with MM, MDS have been reported after chemotherapy but few cases documenting the coexistence of MDS and MM at diagnosis have been reported in the literature.

Rituximab (anti-CD20 monoclonal antibody) administration in a young patient with resistant B-prolymphocytic leukemia

Following the administration of the human anti-CD20 monoclonal antibody IDEC-C2B8 (rituximab), a 31-year-old woman with B-prolymphocytic leukemia, who had been resistant to CHOP, fludarabine, pentostatin and 2-CdA, achieved complete remission. Rituximab was administered intravenously once a week for 4 weeks. The patient only had mild but tolerable side effects during the first cycle of therapy. She remains in complete remission 8 months following the discontinuation of treatment.

Influence of growth factors erythropoietin and granulocyte macrophage colony stimulating factor on mechanical strength and healing of colonic anastomoses in rats

OBJECTIVE

To find out what influence erythropoietin and granulocyte macrophage colony stimulating factor (GM-CSF) had on the healing of left colonic anastomoses in rats.

DESIGN

Experimental study.

SETTING

University hospital of Ioannina, Greece.

ANIMALS

40 rats.

INTERVENTIONS

An end to end anastomosis was created in the left colon. The rats in the experimental groups were treated with erythropoietin, or GM-CSF, or the two in combination.

MAIN OUTCOME MEASURES

Tensile breaking strength of the anastomosis, histological characteristics of the anastomosed segment, changes in body weight, and packed cell volume (PCV) during the experiment.

RESULTS

The tensile breaking strength of the anastomosis on the seventh postoperative day was significantly greater in the erythropoietin group (mean 2.8N, 95% confidence interval (CI) 0.12N, p 0.0004) than in the control group (mean 1.60N, 95% CI 0.12N). It did not differ from the GM-CSF groups (mean 1.67N, 95% CI 0.21N, p 0.68) or erythropoietin GM-CSF (mean 1.67N, 95% CI 0.11N, p 0.44). The PCV was significantly higher in the two groups given erythropoietin (p < 0.001) but not in the GM-CSF group (p 0.8) while that in the control group was significantly lower (p < 0.001). The body weight followed the same pattern, being significantly more in the two groups given erythropoietin (p = 0.03 and 0.003) but not in controls (p = 0.09) or the GM-CSF group (p = 0.2).

CONCLUSIONS

Erythropoietin enhances the healing of anastomosis in rat colon by increasing the number of fibroblasts and accelerating the maturation of new vessels.

A patient with multiple myeloma, amyloidosis and light-chain deposition disease in kidneys with a long survival

We report a case of a 39-year-old man with lambda-light-chain multiple myeloma, nephrotic syndrome due to lambda-light-chain deposition disease in kidneys and amyloidosis in other tissues. The patient was treated with melphalan and prednisone for 1 year. After that, he was administered interferon-alpha2b (IFN-alpha2b; 3 MU, 3 times a week) as maintenance therapy for 2 years. At present, 5 years and 6 months after the initial diagnosis, the patient receives IFN-alpha2b (3 MU, twice a week) and remains in complete haematological remission.

Serum beta-2-microglobulin, TNF-alpha and interleukins in myeloproliferative disorders

Whereas beta-2-microglobulin (beta2M) has mainly been used as a prognostic factor in patients with lymphoproliferative disorders, some studies have reported the value of beta2M in myeloproliferative disorders (MPD). In order to investigate a potential role in the pathogenesis of MPD and to find a possible value as indicators in monitoring the course of the disease, we measured beta2M, TNF-alpha, IL-1alpha, IL-1beta, IL-2, sIL-2R, IL-6 and IL-10 in 55 patients with MPD, at diagnosis and during the course of the disease. In progressive disease and particularly when transformation to acute leukemia occurred, high levels of beta2M, IL-2 and sIL-2R were found in all patients; the elevation was progressive, which suggests a potential prognostic usefulness in the individual patient.

Interleukins, TNF-alpha and beta-2M in patients with B cell chronic lymphocytic leukemia

In order to investigate the possible existence of a prognostic factor for B cell chronic lymphocytic leukemia (B-CLL), we determined the serum levels of TNF-alpha, IL-1a, IL-1b, IL-2, sIL-2R, IL-6, IL-10 and beta-2M in 20 patients. We observed significant changes in sIL-2R and beta-2M levels, whereas in all stages of disease, TNF-alpha and other interleukins exhibited only mild changes. An excellent correlation between sIL-2R and beta-2M levels and disease activity wes reported. Patients with aggressive disease (Rai stages III and IV and Richter's syndrome) had increased levels. Patients who responded to therapy and with improved clinical status had decreased sIL-2R and beta-2M levels. However, patients with progressive disease and no response to therapy were associated with increased levels of sIL-2R and beta-2M. In conclusions, as serum levels of sIL-2R and beta-2M are increased in the aggressive stages of B-CLL, they may be used as reliable markers for monitoring B-CLL activity, showing response to treatment and early relapse and/or disease progression.

Recombinant human erythropoietin treatment of postpartum anemia. Preliminary results

OBJECTIVES

The aim of this study was to investigate the efficacy of recombinant human erythropoietin (rHuEpo) in postpartum anemia.

STUDY DESIGN

At the University Hospital of Ioannina, rHuEpo was administrated subcutaneously to twenty anemic women (hemoglobin [Hb]<10 g/dl), for 15 days following delivery; all were given iron and folic acid per os. Twenty other women (the control group) with postpartum anemia (Hb<10 g/dl), received only iron and folic acid. The Mann-Whitney U-test was used for the comparison of hematological indices between the two groups, on days 1, 3, 5, 10, 15 and 40 postdelivery.

RESULTS

On day 3, reticulocyte counts were significantly higher in the women who received rHuEpo, as compared to the controls (P<0.05). The mean Hb value increased to >2 g/dl in the group undergoing rHuEpo therapy as compared to 0.7 g/dl in the control group on day 5 (P<0.05). Furthermore, two women in the control group required blood transfusions, while no transfusions were required by the rHuEpo group.

CONCLUSIONS

rHuEpo administration is useful for a more rapid amelioration of hematological indices in women with postpartum anemia. Further, the dose given in this study was not associated with significant side-effects.

Acute phase proteins and interleukins in steady state sickle cell disease

To identify a possible acute phase response during the steady state of sickle cell disease, we estimated the serum alterations of acute phase proteins, beta2-microglobulin (beta2M), kappa and lambda light chains, interleukins (ILs) and tumor necrosis factor-alpha (TNFalpha) in 21 patients. Increased concentrations of C-reactive protein (CRP) were found in 5 patients, alpha-1-acid-glycoprotein (AGP) in 3, alpha-1-antitrypsin (AAT) in 8, ceruloplasmin (CER) in 2, alpha-2-macroglobulin (AMG) in 14 and decreased haptoglobin (HPT) and transferrin (TFR) in 11 and 9, respectively. Increased beta2M was found in 10 patients and kappa and lambda light chains in 11. IL-1beta, IL-2, IL-4, IL-10 and TNFalpha were not detected in any of the patients. However, significantly increased values of IL-6 and sIL-2r were found. This study has demonstrated increased serum levels of some of the acute phase proteins in patients during the steady state of sickle cell disease. This may be a result of a subclinical vaso-occlusion which in turn leads to a covert inflammatory response. Cytokines, and in particular IL-6, produced after this response, seem to be responsible for the high levels of acute phase proteins in the steady state of this disease.

Patients with multiple myeloma and solid tumors: six case reports

Six patients with multiple myeloma (MM) and a second non-hematological neoplasm (solid tumor) are documented in this study. Two patients had a previous history of adenocarcinoma of the colon prior to MM diagnosis; in three patients a second neoplasm (lung cancer, adenocarcinoma of the urinary bladder and adenocarcinoma of the colon) appeared at the time of MM diagnosis; one patient, a woman with a six-year history of MM, developed hepatoma. The two patients who had had a neoplasm of the colon ten years before and the patient with bladder carcinoma, responded to MM therapy. The patient with lung cancer and the patient with adenocarcinoma of the colon died; the last patient, with MM and liver cancer, is alive but with aggressive disease. In conclusion we have found that in MM patients a second neoplasm may develop or co-exist, in greater frequency than that of the general population.

Chronic myelogenous leukemia terminating in acute megakaryoblastic leukemia. Case report

A case of chronic myelogenous leukemia (CML) terminating in acute megakaryoblastic leukemia (AMKL) is here presented. Megakaryoblasts were identified by the presence of platelet peroxidase in the bone marrow as well as in pleural effusion and ascites. The clinical course, morphology and immunologic studies of the blast cells are described in this report.

Renal abnormalities in patients with sickle cell-beta thalassemia

We examined renal abnormalities in Greek patients with sickle-cell beta thalassemia (S-beta thal). A total of 17 patients aged 16-59 years suffering from S-beta thal and 17 age- and sex-matched healthy controls were studied. In all individuals we carried out a detailed study of renal function including electrolytes in serum and urine, concentrating or diluting ability, urine acidification ability, glomerular filtration rate (GFR), and hormones [such as plasma renin activity (PRA), serum aldosterone, and erythropoietin (EPO)]. Though the GFR did not differ significantly in patients and controls, half the patients had either supranormal or subnormal values. Serum potassium and uric acid were significantly higher in patients than controls. Serum phosphorus was similar in both groups, though patients with S-beta thal had significantly lower phosphate excretion indices. All patients were unable to maximally concentrate the urine, and seven also had limited ability to maximally dilute it. Five patients had incomplete distal renal tubular acidosis. Four had mild proteinuria, and six had microalbuminuria. Serum EPO and aldosterone were higher in S-beta thal patients than controls, but there was no difference in PRA between the two groups. There was a strong correlation between hemoglobin concentration and EPO levels, which was strongest in patients with GFR < 50 ml/min. We conclude that patients with S-beta thal, like sickle-cell anemia patients, present multiple abnormalities of renal function.