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Vassilakopoulos TP, Arapaki M, Diamantopoulos PT, Liaskas A, Panitsas F, Siakantaris MP, Dimou M, Kokoris SI, Sachanas S, Belia M, Chatzidimitriou C, Konstantinou EA, Asimakopoulos JV, Petevi K, Boutsikas G, Kanellopoulos A, Piperidou A, Lefaki ME, Georgopoulou A, Kopsaftopoulou A, Zerzi K, Drandakis I, Dimopoulou MN, Kyrtsonis MC, Tsaftaridis P, Plata E, Variamis E, Tsourouflis G, Kontopidou FN, Konstantopoulos K, Pangalis GA, Panayiotidis P, Angelopoulou MK. Prognostic Impact of Serum β 2-Microglobulin Levels in Hodgkin Lymphoma Treated with ABVD or Equivalent Regimens: A Comprehensive Analysis of 915 Patients. Cancers (Basel) 2024; 16:238. [PMID: 38254729 PMCID: PMC10813286 DOI: 10.3390/cancers16020238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
The significance of serum beta-2 microglobulin (sβ2m) in Hodgkin lymphoma (HL) is controversial. We analyzed 915 patients with HL, who were treated with ABVD or equivalent regimens with or without radiotherapy. Sβ2m levels were measured by a radioimmunoassay (upper normal limit 2.4 mg/L). Sequential cutoffs (1.8-3.0 by 0.1 mg/L increments, 3.5 and 4.0 mg/L) were tested along with ROC analysis. The median sβ2m levels were 2.20 mg/L and were elevated (>2.4 mg/L) in 383/915 patients (41.9%). Higher sβ2m was associated with inferior freedom from progression (FFP) at all tested cutoffs. The best cutoff was 2.0 mg/L (10-year FFP 83% vs. 70%, p = 0.001), which performed better than the 2.4 mg/L cutoff ("normal versus high"). In multivariate analysis, sβ2m > 2.0 mg/L was an independent adverse prognostic factor in the whole patient population. In multivariate overall survival analysis, sβ2m levels were predictive at 2.0 mg/L cutoff in the whole patient population and in advanced stages. Similarly, sβ2m > 2.0 mg/L independently predicted inferior HL-specific survival in the whole patient population. Our data suggest that higher sβ2m is an independent predictor of outcome in HL but the optimal cutoff lies within the normal limits (i.e., at 2.0 mg/L) in this predominantly young patient population, performing much better than a "normal versus high" cutoff set at 2.4 mg/L.
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Affiliation(s)
- Theodoros P. Vassilakopoulos
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Maria Arapaki
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Panagiotis T. Diamantopoulos
- First Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (P.T.D.)
| | - Athanasios Liaskas
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Fotios Panitsas
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Marina P. Siakantaris
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Maria Dimou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Styliani I. Kokoris
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Sotirios Sachanas
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Marina Belia
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Chrysovalantou Chatzidimitriou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Elianna A. Konstantinou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - John V. Asimakopoulos
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Kyriaki Petevi
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - George Boutsikas
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Alexandros Kanellopoulos
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Alexia Piperidou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Maria-Ekaterini Lefaki
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Angeliki Georgopoulou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Anastasia Kopsaftopoulou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Kalliopi Zerzi
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Ioannis Drandakis
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Maria N. Dimopoulou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Marie-Christine Kyrtsonis
- First Department of Internal Medicine Propedeutic, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece
| | - Panayiotis Tsaftaridis
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Eleni Plata
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Eleni Variamis
- First Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (P.T.D.)
| | - Gerassimos Tsourouflis
- Second Department of Surgery Propedeutic, National and Kapodistrian University of Athens, Laikon General Hospital, 11527Athens, Greece
| | - Flora N. Kontopidou
- Second Department of Internal Medicine, National and Kapodistrian University of Athens, Ippokration General Hospital, 11527 Athens, Greece;
| | - Kostas Konstantopoulos
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Gerassimos A. Pangalis
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Panayiotis Panayiotidis
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
| | - Maria K. Angelopoulou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 17 Ag. Thoma Str., 11527 Athens, Greece; (M.A.); (M.D.); (M.B.); (C.C.); (E.A.K.); (J.V.A.); (A.K.); (P.T.); (M.K.A.)
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Vassilakopoulos TP, Kravvariti E, Panitsas F, Angelopoulou MK, Liaskas A, Kontopidou FN, Yiakoumis X, Variami E, Dimopoulou MN, Siakantaris MP, Asimakopoulos JV, Arapaki M, Dimou M, Diamantopoulos P, Sachanas S, Chatzidimitriou C, Belia M, Konstantinou E, Boutsikas G, Petevi K, Kanellopoulos A, Kokoris S, Kyrtsonis MC, Viniou NA, Lakiotaki E, Tsourouflis G, Korkolopoulou P, Konstantopoulos K, Panayiotidis P, Pangalis GA. Very late relapses in Hodgkin lymphoma treated with chemotherapy with or without radiotherapy: linear pattern and distinct prognostic factors. Blood Cancer J 2022; 12:102. [PMID: 35790712 PMCID: PMC9256621 DOI: 10.1038/s41408-022-00674-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/11/2022] [Accepted: 04/25/2022] [Indexed: 11/09/2022] Open
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Karakatsanis SJ, Bouzani M, Symeonidis A, Angelopoulou MK, Papageorgiou SG, Michail M, Gainaru G, Kourti G, Sachanas S, Kalpadakis C, Katodritou E, Leonidopoulou T, Kotsianidis I, Hatzimichael E, Kotsopoulou M, Dimou M, Variamis E, Boutsis D, Kanellias N, Dimopoulou MN, Michali E, Karianakis G, Tsirkinidis P, Vadikolia C, Poziopoulos C, Pigaditou A, Vrakidou E, Economopoulos T, Kyriazopoulou L, Siakantaris MP, Kyrtsonis MC, Anargyrou K, Papaioannou M, Hatjiharissi E, Vervessou E, Tsirogianni M, Palassopoulou M, Stefanoudaki E, Zikos P, Tsirigotis P, Tsourouflis G, Assimakopoulou T, Verrou E, Papadaki H, Lampropoulou P, Dimopoulos MA, Pappa V, Konstantopoulos K, Karmiris T, Roussou P, Panayiotidis P, Pangalis GA, Vassilakopoulos TP. Real-life Experience With Rituximab-CHOP Every 21 or 14 Days in Primary Mediastinal Large B-cell Lymphoma. In Vivo 2022; 36:1302-1315. [PMID: 35478115 DOI: 10.21873/invivo.12831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Primary mediastinal large B-cell lymphoma (PMLBCL) is an aggressive B-cell non-Hodgkin lymphoma (NHL), whose prognosis has greatly improved since the incorporation of the anti-CD20 monoclonal antibody rituximab into current therapeutic regimens. Evidence, however, on the optimal time interval between consecutive chemoimmunotherapy (CIT) cycles is still scarce. This study aimed to evaluate the efficacy outcomes of the more commonly administered 3-weekly regimens to the biweekly ones in a PMLBCL patients' population, who were mostly treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone every 21 days (R-CHOP-21) or R-CHOP-14. PATIENTS AND METHODS We retrospectively studied our cohort of consecutively treated PMLBCL patients, focusing on their treatment density, in order to determine possible differences in treatment outcomes. RESULTS CIT, in the form of both R-CHOP-21 as well as R-CHOP-14 (or similar regimens), is highly active in PMLBCL, with low rates of early treatment failure. In our cohort of patients, R-CHOP-14 did not result in a meaningful improvement of freedom from progression (FFP) or overall survival (OS). CONCLUSION Both R-CHOP-14 and R-CHOP-21 are probably equally effective in PMLBCL, yet further, prospective, randomized studies are warranted to clarify whether dose-dense regimens can be associated with better disease control and long-term results.
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Affiliation(s)
- Stamatis J Karakatsanis
- Third Department of Internal Medicine and Laboratory, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - Maria Bouzani
- Department of Hematology and Lymphoma, Evangelismos General Hospital, Athens, Greece
| | - Argyris Symeonidis
- Hematology Division, Department of Internal Medicine, University of Patras, Patras, Greece
| | - Maria K Angelopoulou
- Department of Haematology and Bone Marrow Transplantation,Laikon General Hospital, Athens, Greece
| | - Sotirios G Papageorgiou
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Chaidari, Greece
| | - Michail Michail
- Department of Hematology, Nicosia General Hospital, Nicosia, Cyprus
| | | | - Georgia Kourti
- Third Department of Internal Medicine and Laboratory, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece.,Department of Hematology and Lymphoma, Evangelismos General Hospital, Athens, Greece
| | | | | | - Eirini Katodritou
- Department of Hematology, Theagenion Anticancer General Hospital, Thessaloniki, Greece
| | | | - Ioannis Kotsianidis
- Department of Hematology, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Maria Kotsopoulou
- Department of Hematology, Metaxa Anticancer Hospital, Piraeus, Greece
| | - Maria Dimou
- Department of Haematology and Bone Marrow Transplantation,Laikon General Hospital, Athens, Greece
| | - Eleni Variamis
- First Department of Internal Medicine,Laikon General Hospital, Athens, Greece
| | | | - Nick Kanellias
- Department of Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Maria N Dimopoulou
- Department of Haematology and Bone Marrow Transplantation,Laikon General Hospital, Athens, Greece
| | - Evridiki Michali
- Department of Clinical Hematology, G.Gennimatas Athens General Hospital, Athens, Greece
| | | | | | | | | | - Anna Pigaditou
- Department of Hematology, Athens Medical Center, Marousi, Greece
| | | | | | - Lydia Kyriazopoulou
- Department of Hematology, University of Ioannina, Medical School, Ioannina, Greece
| | - Marina P Siakantaris
- Department of Haematology and Bone Marrow Transplantation,Laikon General Hospital, Athens, Greece
| | | | | | - Maria Papaioannou
- Hematology Unit, 1 Department of Internal Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evdoxia Hatjiharissi
- Department of Hematology, Theagenion Anticancer General Hospital, Thessaloniki, Greece.,Hematology Unit, 1 Department of Internal Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Maria Tsirogianni
- Department of Hematology, Aghios Savvas Anticancer Hospital, Athens, Greece
| | | | | | | | - Panayiotis Tsirigotis
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Chaidari, Greece
| | | | | | - Evgenia Verrou
- Department of Hematology, Theagenion Anticancer General Hospital, Thessaloniki, Greece
| | - Helen Papadaki
- Department of Hematology,University Hospital of Heraklion, Heraklion, Greece
| | | | | | - Vassiliki Pappa
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Chaidari, Greece
| | - Kostas Konstantopoulos
- Department of Haematology and Bone Marrow Transplantation,Laikon General Hospital, Athens, Greece
| | - Themis Karmiris
- Department of Hematology and Lymphoma, Evangelismos General Hospital, Athens, Greece
| | - Paraskevi Roussou
- Third Department of Internal Medicine and Laboratory, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - Panayiotis Panayiotidis
- Department of Haematology and Bone Marrow Transplantation,Laikon General Hospital, Athens, Greece
| | - Gerassimos A Pangalis
- Department of Haematology and Bone Marrow Transplantation,Laikon General Hospital, Athens, Greece.,Department of Hematology, Athens Medical Center, Psychikon, Greece
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Karakatsanis S, Panitsas F, Arapaki M, Galopoulos D, Asimakopoulos JV, Liaskas A, Chatzidimitriou C, Belia M, Konstantinou E, Vassilopoulos I, Papadatos SS, Sachanas S, Efstathopoulou M, Yiakoumis X, Pardalis V, Iliakis T, Giannakopoulou N, Dimou M, Chatzidavid S, Boutsikas G, Petevi K, Kanellopoulos A, Gainaru G, Variamis E, Siakantaris MP, Kyrtsonis MC, Plata E, Tsaftaridis P, Dimopoulou MN, Viniou NA, Syrigos KN, Pangalis GA, Panayiotidis P, Konstantopoulos K, Angelopoulou MK, Vassilakopoulos TP. Serum ferritin levels in previously untreated classical Hodgkin lymphoma: correlations and prognostic significance. Leuk Lymphoma 2022; 63:799-812. [DOI: 10.1080/10428194.2021.2010054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Stamatios Karakatsanis
- Third Department of Internal Medicine and Laboratory, National and Kapoditrian University of Athens, School of Medicine, “Sotiria” General Hospital, Athens, Greece
| | - Fotios Panitsas
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Arapaki
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios Galopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - John V. Asimakopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Athanassios Liaskas
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Chrysovalantou Chatzidimitriou
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Marina Belia
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Elianna Konstantinou
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Vassilopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Stamatis S. Papadatos
- Third Department of Internal Medicine and Laboratory, National and Kapoditrian University of Athens, School of Medicine, “Sotiria” General Hospital, Athens, Greece
| | - Sotirios Sachanas
- Department of Hematology, Athens Medical Center, Psychikon Branch, Athens, Greece
| | - Maria Efstathopoulou
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
- Department of Hematology, Athens Medical Center, Psychikon Branch, Athens, Greece
| | - Xanthoula Yiakoumis
- Department of Hematology, Athens Medical Center, Psychikon Branch, Athens, Greece
| | - Vassilios Pardalis
- First Department of Internal Medicine, Propaedeutic, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
| | - Theodoros Iliakis
- First Department of Internal Medicine, Propaedeutic, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
| | - Nefeli Giannakopoulou
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Dimou
- First Department of Internal Medicine, Propaedeutic, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
| | - Sevastianos Chatzidavid
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Boutsikas
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Kyriaki Petevi
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Alexandros Kanellopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Gabriella Gainaru
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eleni Variamis
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina P. Siakantaris
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Marie-Christine Kyrtsonis
- First Department of Internal Medicine, Propaedeutic, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
| | - Eleni Plata
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis Tsaftaridis
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria N. Dimopoulou
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Nora-Athina Viniou
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos N. Syrigos
- Third Department of Internal Medicine and Laboratory, National and Kapoditrian University of Athens, School of Medicine, “Sotiria” General Hospital, Athens, Greece
| | | | - Panayiotis Panayiotidis
- First Department of Internal Medicine, Propaedeutic, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
| | - Kostas Konstantopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria K. Angelopoulou
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Theodoros P. Vassilakopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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5
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Vassilakopoulos TP, Michail M, Papageorgiou S, Kourti G, Angelopoulou MK, Panitsas F, Sachanas S, Kalpadakis C, Katodritou E, Leonidopoulou T, Kotsianidis I, Hatzimichael E, Kotsopoulou M, Dimou M, Variamis E, Boutsis D, Terpos E, Dimopoulou MN, Karakatsanis S, Michalis E, Karianakis G, Tsirkinidis P, Vadikolia C, Poziopoulos C, Pigaditou A, Vrakidou E, Economopoulos T, Kyriazopoulou L, Siakantaris MP, Kyrtsonis MC, Symeonidis A, Anargyrou K, Papaioannou M, Hatjiharissi E, Vervessou E, Tsirogianni M, Palassopoulou M, Gainaru G, Stefanoudaki E, Zikos P, Tsirigotis P, Tsourouflis G, Assimakopoulou T, Konstantinidou P, A Papadaki H, Megalakaki K, Dimopoulos MA, Pappa V, Karmiris T, Roussou P, Panayiotidis P, Konstantopoulos K, Pangalis GA. Identification of Very Low-Risk Subgroups of Patients with Primary Mediastinal Large B-Cell Lymphoma Treated with R-CHOP. Oncologist 2021; 26:597-609. [PMID: 33870594 DOI: 10.1002/onco.13789] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 04/02/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND R-CHOP can cure approximately 75% of patients with primary mediastinal large B-cell lymphoma (PMLBCL), but prognostic factors have not been sufficiently evaluated yet. R-da- EPOCH is potentially more effective but also more toxic than R-CHOP. Reliable prognostic classification is needed to guide treatment decisions. MATERIALS AND METHODS We analyzed the impact of clinical prognostic factors on the outcome of 332 PMLBCL patients ≤65 years treated with R-CHOP ± radiotherapy in a multicenter setting in Greece and Cyprus. RESULTS With a median follow-up of 69 months, 5-year freedom from progression (FFP) was 78% and 5-year lymphoma specific survival (LSS) was 89%. On multivariate analysis, extranodal involvement (E/IV) and lactate dehydrogenase (LDH) ≥2 times upper limit of normal (model A) were significantly associated with FFP; E/IV and bulky disease (model B) were associated with LSS. Both models performed better than the International Prognostic Index (IPI) and the age-adjusted IPI by Harrel's C rank parameter and Akaike information criterion. Both models A and B defined high-risk subgroups (13%-27% of patients [pts]) with approximately 19%-23% lymphoma-related mortality. They also defined subgroups composing approximately one-fourth or one-half of the patients, with 11% risk of failure and only 1% or 4% 5-year lymphoma-related mortality. CONCLUSION The combination of E/IV with either bulky disease or LDH ≥2 times upper limit of normal defined high-risk but not very-high-risk subgroups. More importantly, their absence defined subgroups comprising approximately one-fourth or one-half of the pts, with 11% risk of failure and minimal lymphoma-related mortality, who may not need more intensive treatment such as R-da-EPOCH. IMPLICATIONS FOR PRACTICE By analyzing the impact of baseline clinical characteristics on outcomes of a large cohort of patients with primary mediastinal large B-cell lymphoma homogeneously treated with R-CHOP with or without radiotherapy, we developed novel prognostic indices which can aid in deciding which patients can be adequately treated with R-CHOP and do not need more intensive regimens such as R-da-EPOCH. The new indices consist of objectively determined characteristics (extranodal disease or stage IV, bulky disease, and markedly elevated serum lactate dehydrogenase), which are readily available from standard initial staging procedures and offer better discrimination compared with established risk scores (International Prognostic Index [IPI] and age-adjusted IPI).
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Affiliation(s)
- Theodoros P Vassilakopoulos
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Michail Michail
- Department of Hematology, Nicosia General Hospital, Nicosia, Cyprus
| | - Sotirios Papageorgiou
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Georgia Kourti
- Third Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens, Greece.,Department of Hematology and Lymphoma, Evangelismos General Hospital, Athens, Greece
| | - Maria K Angelopoulou
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Fotios Panitsas
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Sotirios Sachanas
- Department of Hematology, Athens Medical Center, Psychikon Branch, Athens, Greece
| | | | - Eirini Katodritou
- Department of Hematology, Theagenion Anticancer General Hospital, Thessaloniki, Greece
| | | | - Ioannis Kotsianidis
- Department of Hematology, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Maria Kotsopoulou
- Department of Hematology, Metaxa Anticancer Hospital, Piraeus, Greece
| | - Maria Dimou
- First Propedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Eleni Variamis
- First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | | | - Evangelos Terpos
- Department of Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Maria N Dimopoulou
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Stamatios Karakatsanis
- Third Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens, Greece
| | - Eurydiki Michalis
- Department of Clinical Hematology, "G.Gennimatas" Athens General Hospital, Athens, Greece
| | | | | | | | | | - Anna Pigaditou
- Department of Hematology, Athens Medical Center, Amaroussion Branch, Athens, Greece
| | | | | | | | - Marina P Siakantaris
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Marie-Christine Kyrtsonis
- First Propedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Argyris Symeonidis
- Hematology Division, Dept of Internal Medicine, University of Patras, Patras, Greece
| | | | - Maria Papaioannou
- Hematology Unit, 1st Dept of Internal Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evdoxia Hatjiharissi
- Department of Hematology, Theagenion Anticancer General Hospital, Thessaloniki, Greece.,Hematology Unit, 1st Dept of Internal Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Maria Tsirogianni
- Department of Hematology, Aghios Savvas Anticancer Hospital, Athens, Greece
| | | | | | | | | | - Panayiotis Tsirigotis
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Gerasimos Tsourouflis
- Second Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | | | | | - Helen A Papadaki
- Department of Hematology, University of Crete, Iraklion, Crete, Greece
| | | | | | - Vassiliki Pappa
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Themis Karmiris
- Department of Hematology and Lymphoma, Evangelismos General Hospital, Athens, Greece
| | - Paraskevi Roussou
- Third Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens, Greece
| | - Panayiotis Panayiotidis
- First Propedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Kostas Konstantopoulos
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Gerassimos A Pangalis
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece.,Department of Hematology, Athens Medical Center, Psychikon Branch, Athens, Greece
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6
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Vassilakopoulos TP, Dimopoulou MN, Angelopoulou MK, Petevi K, Pangalis GA, Moschogiannis M, Dimou M, Boutsikas G, Kanellopoulos A, Gainaru G, Plata E, Flevari P, Koutsi K, Papageorgiou L, Telonis V, Tsaftaridis P, Sachanas S, Yiakoumis X, Tsirkinidis P, Viniou NA, Siakantaris MP, Variami E, Kyrtsonis MC, Meletis J, Panayiotidis P, Konstantopoulos K. Prognostic Implication of the Absolute Lymphocyte to Absolute Monocyte Count Ratio in Patients With Classical Hodgkin Lymphoma Treated With Doxorubicin, Bleomycin, Vinblastine, and Dacarbazine or Equivalent Regimens. Oncologist 2016; 21:343-53. [PMID: 26921291 DOI: 10.1634/theoncologist.2015-0251] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/24/2015] [Indexed: 01/02/2023] Open
Abstract
Low absolute lymphocyte count (ALC) to absolute monocyte count (AMC) ratio (ALC/AMC) is an independent prognostic factor in Hodgkin lymphoma (HL), but different cutoffs (1.1, 1.5, and 2.9) have been applied. We aimed to validate the prognostic significance of ALC/AMC in 537 homogenously treated (doxorubicin, bleomycin, vinblastine, and dacarbazine or equivalents ± radiotherapy) classical HL patients at various cutoffs. The median ALC/AMC was 2.24 (0.44-20.50). The median AMC was 0.653 × 10(9)/L (0.050-2.070). Lower ALC/AMC was associated with established markers of adverse prognosis. In total, 477 (89%), 418 (78%), and 189 (35%) patients had an ALC/AMC ratio of ≥1.1, ≥1.5, and ≥2.9; respectively; 20% had monocytosis (≥0.9 × 10(9)/L). Ten-year time to progression (TTP) was 77% versus 55% for patients with ALC/AMC ≥1.1 and <1.1 (p = .0002), 76% versus 68% for ALC/AMC ≥1.5 and <1.5 (p = .049), 77% versus 73% for ALC/AMC ≥2.9 and <2.9 (p = .35), and 79% versus 70% for ALC/AMC ≥2.24 and <2.24 (p = .08), respectively. In stages ΙΑ/ΙΙΑ and in patients ≥60 years old, ALC/AMC had no significant effect on TTP. In advanced stages, ALC/AMC was significant only at the cutoff of 1.1 (10-year TTP 67% vs. 48%; p = .016). In younger, advanced-stage patients, the differences were more pronounced. In multivariate analysis of TTP, ALC/AMC < 1.1 (p = .007) and stage IV (p < .001) were independent prognostic factors; ALC/AMC was independent of International Prognostic Score in another model. ALC/AMC was more predictive of overall survival than TTP. At the cutoff of 1.1, ALC/AMC had independent prognostic value in multivariate analysis. However, the prognostically inferior group comprised only 11% of patients. Further research is needed prior to the widespread use of this promising marker.
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Affiliation(s)
- Theodoros P Vassilakopoulos
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria N Dimopoulou
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria K Angelopoulou
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kyriaki Petevi
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Maria Dimou
- First Propedeutic Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Boutsikas
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Kanellopoulos
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gabriella Gainaru
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Plata
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Pagona Flevari
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina Koutsi
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Loula Papageorgiou
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vassilios Telonis
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panayiotis Tsaftaridis
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | - Nora-Athina Viniou
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina P Siakantaris
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Variami
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marie-Christine Kyrtsonis
- First Propedeutic Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John Meletis
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panayiotis Panayiotidis
- First Propedeutic Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kostas Konstantopoulos
- Department of Haematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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7
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Kalpadakis C, Pangalis GA, Angelopoulou MK, Sachanas S, Kontopidou FN, Yiakoumis X, Kokoris SI, Dimitriadou EM, Dimopoulou MN, Moschogiannis M, Korkolopoulou P, Kyrtsonis MC, Siakantaris MP, Papadaki T, Tsaftaridis P, Plata E, Papadaki HE, Vassilakopoulos TP. Treatment of splenic marginal zone lymphoma with rituximab monotherapy: progress report and comparison with splenectomy. Oncologist 2013; 18:190-7. [PMID: 23345547 DOI: 10.1634/theoncologist.2012-0251] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Treatment of splenic marginal zone lymphoma (SMZL) patients is not standardized. Recent data suggest that rituximab is highly effective and could be considered as initial therapy. AIM To assess the efficacy of rituximab monotherapy in a large series of patients with SMZL and compare these results with splenectomy results. METHODS The studied population included 85 patients. Fifty-eight received rituximab at a dose of 375 mg/m2 per week for 6 weeks as induction followed by maintenance at the same dose every 2 months for 1-2 years, whereas 27 patients were treated using splenectomy only. RESULTS The overall response rate to rituximab 2 months after the end of induction was 95% (complete response [CR], 45%; unconfirmed CR, 26%; partial response, 24%). The median times to hematologic and clinical response were 2 weeks and 3 weeks, respectively. Forty-three of 55 patients already completed the maintenance phase: 28 sustained their initial response, 14 improved their response, and one progressed. Eighty-five percent of splenectomized patients responded, and two were treated with rituximab as consolidation after splenectomy and achieved a CR. The 5-year overall and progression-free survival (PFS) rates for rituximab-treated and splenectomized patients were 92% and 77% (p = .09) and 73% and 58% (p = .06), respectively. Furthermore, maintenance therapy with rituximab resulted in a longer duration of response (at 5 years, PFS was 84% for patients receiving maintenance and 36% for patients without maintenance, p <.0001). CONCLUSIONS Rituximab is a very effective and well-tolerated therapy and may be substituted for splenectomy as the first-line treatment of choice for patients with SMZL.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Murine-Derived/adverse effects
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Disease-Free Survival
- Female
- Humans
- Lymphoma, B-Cell, Marginal Zone/drug therapy
- Lymphoma, B-Cell, Marginal Zone/pathology
- Lymphoma, B-Cell, Marginal Zone/surgery
- Male
- Middle Aged
- Retrospective Studies
- Rituximab
- Splenectomy/adverse effects
- Splenectomy/methods
- Splenic Neoplasms/drug therapy
- Splenic Neoplasms/pathology
- Splenic Neoplasms/surgery
- Treatment Outcome
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Affiliation(s)
- Christina Kalpadakis
- Department of Haematology, University Hospital of Heraklion, P.O. Box 1352, Heraklion, Crete, Greece.
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8
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Vassilakopoulos TP, Pangalis GA, Katsigiannis A, Papageorgiou SG, Constantinou N, Terpos E, Zorbala A, Vrakidou E, Repoussis P, Poziopoulos C, Galani Z, Dimopoulou MN, Kokoris SI, Sachanas S, Kalpadakis C, Dimitriadou EM, Siakantaris MP, Kyrtsonis MC, Dervenoulas J, Dimopoulos MA, Meletis J, Roussou P, Panayiotidis P, Beris P, Angelopoulou MK. Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone with or without radiotherapy in primary mediastinal large B-cell lymphoma: the emerging standard of care. Oncologist 2012; 17:239-49. [PMID: 22282906 PMCID: PMC3286173 DOI: 10.1634/theoncologist.2011-0275] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Accepted: 11/02/2011] [Indexed: 11/17/2022] Open
Abstract
UNLABELLED More aggressive treatment approaches (methotrexate, cytarabine, cyclophosphamide, vincristine, prednisone, and bleomycin [the MACOP-B regimen] or consolidation with high-dose therapy and autologous stem cell transplantation) have been considered to be superior to cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) in patients with primary mediastinal large B-cell lymphoma (PMLBCL). Rituximab-CHOP (R-CHOP) is the standard of care for diffuse large B-cell lymphoma, whereas efficacy in PMLBCL has not been adequately confirmed. PATIENT AND METHODS Seventy-six consecutive PMLBCL patients who received R-CHOP with or without radiotherapy (RT) were compared with 45 consecutive historical controls treated with CHOP with or without RT. Baseline characteristics of the two groups were balanced. RESULTS The rate of early treatment failure was much lower with R-CHOP with or without RT (9% versus 30%; p = .004). The 5-year freedom from progression rate after R-CHOP with or without RT was 81%, versus 48% for CHOP with or without RT (p < .0001). The 5-year event-free survival rates were 80% and 47% (p < .0001) and the 5-year overall and lymphoma-specific survival rates were 89% and 69% (p = .003) and 91% and 69% (p = .001), respectively, with only seven of 76 lymphoma-related deaths. Among R-CHOP responders, 52 of 68 received RT. CONCLUSIONS Based on these results, most patients with PMLBCL appear to be cured by R-CHOP in 21-day cycles with or without RT, which could be the current standard of care. Therefore, the need for more aggressive treatment strategies is questionable unless high-risk patients are adequately defined. Further studies are required to establish the precise role of RT.
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Affiliation(s)
- Theodoros P Vassilakopoulos
- Department of Haematology, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens 11527, Greece.
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Spiropoulos A, Theodosaki M, Stefanaki K, Paterakis G, Tzetis M, Giannikou K, Petrakou E, Dimopoulou MN, Papassotiriou I, Roma ES, Kanavakis E, Graphakos S, Goussetis E. Rapid clinical-scale propagation of mesenchymal stem cells using cultures initiated with immunoselected bone marrow CD105+ cells. J Cell Mol Med 2012; 15:1983-8. [PMID: 20731745 PMCID: PMC3918053 DOI: 10.1111/j.1582-4934.2010.01157.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Current clinical protocols used for isolation and purification of mesenchymal stem cells (MSC) are based on long-term cultures starting with bone marrow (BM) mononuclear cells. Using a commercially available immunoselection kit for enrichment of MSC, we investigated whether culture of enriched BM-CD105+ cells could provide an adequate number of pure MSC in a short time for clinical use in the context of graft versus host disease and graft failure/rejection. We isolated a mean of 5.4 × 105 ± 0.9 × 105 CD105+ cells from 10 small volume (10–25 ml) BM samples achieving an enrichment >100-fold in MSC. Seeding 2 × 103 immunoselected cells/cm2 we were able to produce 2.5 × 108 ± 0.7 × 108 MSC from cultures with autologous serum enriched medium within 3 weeks. Neither haematopoietic nor endothelial cells were detectable even in the primary culture cell product. Expanded cells fulfilled both phenotypic and functional current criteria for MSC; they were CD29+, CD90+, CD73+, CD105+, CD45−; they suppressed allogeneic T-cell reaction in mixed lymphocyte cultures and retained in vitro differentiation potential. Moreover, comparative genomic hybridization analysis revealed chromosomal stability of the cultured MSC. Our data indicate that adequate numbers of pure MSC suitable for clinical applications can be generated within a short time using enriched BM-CD105+ cells.
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Affiliation(s)
- Antonia Spiropoulos
- Stem Cell Transplant Unit, 'Aghia Sophia' Children's Hospital, Athens, Greece
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Goussetis E, Peristeri I, Kitra V, Vessalas G, Paisiou A, Theodosaki M, Petrakou E, Dimopoulou MN, Graphakos S. HLA-matched sibling stem cell transplantation in children with β-thalassemia with anti-thymocyte globulin as part of the preparative regimen: the Greek experience. Bone Marrow Transplant 2011; 47:1061-6. [DOI: 10.1038/bmt.2011.219] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Goussetis E, Paisiou A, Kitra V, Peristeri I, Vessalas G, Stefanaki K, Panayotou I, Giamaiou K, Kontou E, Kitzoni M, Dimopoulou MN, Karkelis S, Kafritsa Y, Rapsomaniki E, Papassotiriou I, Tsirigotis P, Roma E, Graphakos S. Acute Gastrointestinal Graft-versus-Host Disease in Pediatric Patients: Serum Albumin on Day 5 from Initiation of Therapy Correlates with Nonrelapse Mortality and Overall Survival. Biol Blood Marrow Transplant 2011; 17:1058-66. [DOI: 10.1016/j.bbmt.2010.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 11/03/2010] [Indexed: 11/26/2022]
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Dimopoulou MN, Gandhi S, Ghevaert C, Chakraverty R, Fielding A, Webster D, Mackinnon S, Kottaridis PD. Successful treatment of autoimmune lymphoproliferative syndrome and refractory autoimmune thrombocytopenic purpura with a reduced intensity conditioning stem cell transplantation followed by donor lymphocyte infusion. Bone Marrow Transplant 2007; 40:605-6. [PMID: 17618315 DOI: 10.1038/sj.bmt.1705775] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kyrtsonis MC, Vassilakopoulos TP, Kafasi N, Sachanas S, Tzenou T, Papadogiannis A, Galanis Z, Kalpadakis C, Dimou M, Kyriakou E, Angelopoulou MK, Dimopoulou MN, Siakantaris MP, Dimitriadou EM, Kokoris SI, Panayiotidis P, Pangalis GA. Prognostic value of serum free light chain ratio at diagnosis in multiple myeloma. Br J Haematol 2007; 137:240-3. [PMID: 17408464 DOI: 10.1111/j.1365-2141.2007.06561.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The prognostic value of baseline serum free light chain ratio (sFLCR) was investigated in 94 multiple myeloma (MM) patients. sFLCR was calculated as kappa/lambda or lambda/kappa, depending on the patients' dominating monoclonal light chain. Median baseline sFLCR was 3.57 in kappa-MM patients, 45.09 in lambda-MM. 'High' sFLCR (> or = the observed median value for kappa- and lambda-MM respectively) correlated with elevated serum creatinine and lactate dehydrogenase, extensive marrow infiltration and light chain type MM. The 5-year disease-specific survival was 82% and 30% in patients with sFLCR lower than and equal or greater than the median, respectively (P = 0.0001). sFLCR was an independent prognostic factor.
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Affiliation(s)
- Marie-Christine Kyrtsonis
- Department of Haematology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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14
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Galani Z, Viniou N, Kyrtsonis MC, Sachanas S, Antoniou T, Dimopoulou MN, Vassilakopoulos TP, Korkolopoulou P, Nakopoulou L, Patsouris E, Pangalis GA. Hepatic and renal plasma cell lesions in a patient with multiple myeloma in hematological remission. Anticancer Res 2007; 27:571-4. [PMID: 17348443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Plasma cell myeloma is characterized by plasma cell infiltrations, the presence of paraprotein and mostly skeletal destruction with osteolytic lesions. Liver or kidney infiltration has been described in patients with end stage multiple myeloma (MM), while the features of this malignant dissemination is not clearly understood. An atypical form of MM relapse is presented in a patient being in bone marrow remission, with simultaneous lesions in liver, kidney and suspicion of brain involvement. This case is an interesting model of refractory MM extraosseous involvement, that a clinician should be aware of when carrying out differential diagnosis.
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Affiliation(s)
- Zacharoula Galani
- First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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15
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Kalpadakis C, Pangalis GA, Dimopoulou MN, Vassilakopoulos TP, Kyrtsonis MC, Korkolopoulou P, Kontopidou FN, Siakantaris MP, Dimitriadou EM, Kokoris SI, Tsaftaridis P, Plata E, Angelopoulou MK. Rituximab monotherapy is highly effective in splenic marginal zone lymphoma. Hematol Oncol 2007; 25:127-31. [PMID: 17514771 DOI: 10.1002/hon.820] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Splenectomy has traditionally been considered as a standard first line treatment for splenic marginal zone lymphoma (SMZL) conferring a survival advantage over chemotherapy. However it carries significant complications, especially in elderly patients. The purpose of this retrospective study was to report our experience on the efficacy of Rituximab as first line treatment in 16 consecutive SMZL patients, diagnosed in our department. The diagnosis was established using standard criteria. Patients' median age was 57 years (range, 48-78). Prior to treatment initiation all patients had splenomegaly, nine had anemia, five lymphocytosis, five neutropenia and six thrombocytopenia. Rituximab was administered at a dose of 375 mg/m2/week for 6 consecutive weeks. The overall response rate was 100%. After treatment, all patients had a complete resolution of splenomegaly along with restoration of their blood counts. Eleven patients (69%) achieved a CR, three (19%) unconfirmed CR and two (12%) a PR. Among the complete responders seven patients had also a molecular remission. The median time to clinical response was 3 weeks (range, 2-6). Rituximab maintenance was given to 12 patients. Eleven of them had no evidence of disease progression after a median follow-up time of 28.5 months (range, 14-36), while two out of four patients who did not receive maintenance, relapsed 7 and 24 months after the completion of induction treatment. Median follow-up time for the entire series was 29.5 months (range, 15-81). No deaths were recorded during the follow-up period. Therapy was well tolerated. The present study demonstrates that rituximab is an effective treatment for SMZL and could be considered as a substitute or alternative to splenectomy.
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Affiliation(s)
- C Kalpadakis
- First Department of Internal Medicine, National Kapodistrian University of Athens, Laikon University Hospital, Athens, Greece
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16
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Kyrtsonis MC, Siakantaris MP, Kalpadakis C, Dimopoulou MN, Vassilakopoulos TP, Kontopidou FN, Antoniou C, Korkolopoulou P, Panayiotidis P, Pangalis GA. Favorable outcome of primary cutaneous marginal zone lymphoma treated with intralesional rituximab. Eur J Haematol 2006; 77:300-3. [PMID: 16856917 DOI: 10.1111/j.1600-0609.2006.00720.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Primary cutaneous marginal zone lymphoma (PCMZL) is an indolent disease. Treatment options include excision, local irradiation, interferon-alpha or chemotherapy. We present two patients with PCMZL and multiple skin lesions successfully treated with intralesional administration of the anti-CD20 monoclonal antibody rituximab. The first presented with four red skin lesions and the second with two. Biopsy of the largest lesion revealed marginal zone B-cell lymphoma in both patients. There was no evidence of systemic involvement in either patient. Both patients were treated with intralesional rituximab for 18 consecutive weeks. Skin lesions gradually regressed. Apart from mild local pain during the injection, no other adverse effects were observed. In conclusion, rituximab can be safely administered intralesionally in patients with PCMZL and can produce disease remission.
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Affiliation(s)
- Maria-Christina Kyrtsonis
- First Department of Internal Medicine and Department of Haematology, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
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17
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Pangalis GA, Kyrtsonis MC, Vassilakopoulos TP, Dimopoulou MN, Siakantaris MP, Emmanouilides C, Doufexis D, Sahanas S, Kontopidou FN, Kalpadakis C, Angelopoulou MK, Dimitriadou EM, Kokoris SI, Panayiotidis P. Immunotherapeutic and Immunoregulatory Drugs in Haematologic Malignancies. Curr Top Med Chem 2006; 6:1657-86. [PMID: 17017950 DOI: 10.2174/156802606778194235] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A better understanding of the biology and pathogenesis of hematological malignancies has led to the development of immunotherapeutic and immunoregulatory drugs. Many of these agents have revolutionized the current treatment modalities, while others are under investigation. Rituximab (anti-CD20 antibody) has been established as the gold standard of treatment for aggressive B-cell lymphomas in combination with CHOP and has shown significant activity as monotherapy in the treatment of indolent B-cell lymphomas. In follicular lymphomas the combination of Rituximab with chemotherapy improves the outcome compared to chemotherapy alone. CD 20-based radioimmunotherapy, with the advantage of the bystander effect, represents an additional therapeutic alternative in B-cell lymphomas and may produce tumor regression in Rituximab resistant patients. The anti-CD52 monoclonal antibody, alemtuzumab, further expands the armamentarium against lymphoid malignancies producing high response rates in these entities. Antibody-targeted chemotherapy such as gemtuzumab ozogamicin, consisting of an anti-CD33 antibody combined to calicheamicin, has shown efficacy in the treatment of refractory acute myeloid leukemia; exact indications, timing and dosing schedule for optimized efficacy remain to be determined. Interferons have proven significant activity in cutaneous lymphomas, hairy cell leukemia and chronic myelogenous leukemia by mechanisms that are not fully elucidated. Thalidomide, by acting as an immunomodulatory and antiangiogenic agent can modulate neoplastic cells microenvironment and lead to disease control in multiple myeloma as well as in numerous other hematological malignancies. Bortezomib, a proteasome inhibitor, displays significant anti-tumor activity, especially in multiple myeloma and lymphoproliferative disorders. The addition of these agents in therapeutic regimens has improved considerably the treatment of hematological malignancies.
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Affiliation(s)
- Gerassimos A Pangalis
- First Department of Internal Medicine, First Department of Propedeutic Internal Medicine & Department of Hematology, National and Kapodistrian University of Athens Medical School, Laikon General Hospital, Athens, Greece.
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18
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Lilakos K, Viniou NA, Mavrogianni D, Vassilakopoulos TP, Dimopoulou MN, Plata E, Angelopoulou MK, Variami E, Stavrogianni N, Liapi D, Xilouri I, Galanopoulos A, Ageloudi M, Panayiotidis P, Voulgarelis M, Rombos J, Meletis J, Yataganas X, Pangalis GA. FLT3 overexpression in acute promyelocytic leukemia patients without detectable FLT3-ITD or codon 835-836 mutations: a pilot study. Anticancer Res 2006; 26:1201-7. [PMID: 16619525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND Activating mutations of the FLT3 receptor tyrosine kinase are common in acute promyelocytic leukemia (APL) but have uncertain prognostic significance. Information regarding FLT3 expression levels in APL without FLT3 mutations is lacking. MATERIALS AND METHODS Using RT-PCR, mutation analysis of the FLT3 gene, regarding internal tandem duplications (ITDs) and codon 835-836 point mutations, was performed and real-time PCR was carried out to determine the level of FLT3 expression in 11 APL patients at diagnosis and 5 in haematological remission with molecularly detectable disease. RESULTS High levels of FLT3 transcript, at least a 10-fold increase compared to the normal controls, were found at diagnosis in all 3 mutated cases and in 2 patients without detectable FLT3 mutations. CONCLUSION FLT3 overexpression can be documented in patients without FLT3 mutations. These patients might benefit from treatment using specific FLT3 tyrosine kinase inhibitors. Larger studies are needed to evaluate the clinical and biological significance of FLT3 overexpression in the absence of FLT3 mutations.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bone Marrow/metabolism
- Codon
- Humans
- Leukemia, Promyelocytic, Acute/drug therapy
- Leukemia, Promyelocytic, Acute/genetics
- Leukemia, Promyelocytic, Acute/metabolism
- Neoplasm Proteins/biosynthesis
- Neoplasm Proteins/genetics
- Oncogene Proteins, Fusion/biosynthesis
- Oncogene Proteins, Fusion/genetics
- Pilot Projects
- Point Mutation
- RNA, Messenger/biosynthesis
- RNA, Messenger/genetics
- Tandem Repeat Sequences
- fms-Like Tyrosine Kinase 3/biosynthesis
- fms-Like Tyrosine Kinase 3/genetics
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Affiliation(s)
- K Lilakos
- First Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, The Greek AML Study Group, Athens, Greece
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19
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Vassilakopoulos TP, Angelopoulou MK, Siakantaris MP, Konstantinou N, Symeonidis A, Karmiris T, Repoussis P, Roussou P, Dimopoulos AM, Kokoris SI, Dimitriadou EM, Kyrtsonis MC, Dimopoulou MN, Tsatalas C, Kokkinis G, Vrakidou E, Grigoraki V, Poziopoulos C, Stamatellou M, Liapis D, Georgiou G, Panayiotidis P, Pangalis GA. Pure infradiaphragmatic Hodgkin's lymphoma. Clinical features, prognostic factor and comparison with supradiaphragmatic disease. Haematologica 2006; 91:32-9. [PMID: 16434368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pure infradiaphragmatic Hodgkin's lymphoma (HL) is a rare disease. The prognostic impact of a purely infradiaphragmatic localization of this lymphoma is controversial. We aimed to evaluate the baseline clinicopathologic features, prognostic factors and outcome of a large series of consecutive patients with pure infradiaphragmatic HL. DESIGN AND METHODS We analyzed 131 patients with clinical stage I/II infradiaphragmatic HL treated with ABVD or equivalent regimens with or without radiotherapy, and compared 54 of them with 444 patients with pure supradiaphragmatic disease, who were treated at the same center. RESULTS Older age, clinical stage II (borderline), involvement of > or =3 sites, lymphocyte predominant histology, elevated serum beta2-microglobulin and higher International Prognostic Score were more frequent in patients with infradiaphragmatic disease than in those with supradiaphragmatic disease, while nodular sclerosis was less frequent. The complete remission rate was 100%, 97% and 82% for stages I, IIA and IIB, respectively. Only B-symptoms independently predicted for inferior failure-free survival, while inferior overall survival was independently associated with the involvement of > or =3 sites. At 10 years failure-free survival was 82+/-6% (vs. 85+/-2% for patients with supradiaphragmatic disease, p=0.45), overall survival was 74+/-8% (vs. 91+/-2%, p=0.0006), and disease-specific survival 87+/-5% (vs. 94+/-1%, p=0.04). In multivariate analysis the differences between infradiaphragmatic and supradiaphragmatic disease were obscured by older age and B-symptoms. INTERPRETATION AND CONCLUSIONS Pure infradiaphragmatic HL presents with distinct clinicopathologic characteristics. The previously reported poorer outcome may be explained by the unfavorable profile of the patients rather than the infradiaphragmatic presentation per se. Patients with stage IIB disease should probably be classified as having advanced HL because of the unacceptable rate of primary refractory disease.
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Affiliation(s)
- Theodoros P Vassilakopoulos
- First Dept. of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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20
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Vassilakopoulos TP, Kyrtsonis MC, Papadogiannis A, Nadali G, Angelopoulou MK, Tzenou T, Dimopoulou MN, Siakantaris MP, Kontopidou FN, Kalpadakis C, Kokoris SI, Dimitriadou EM, Tsaftaridis P, Pizzolo G, Pangalis GA. Serum levels of soluble syndecan-1 in Hodgkin's lymphoma. Anticancer Res 2005; 25:4743-6. [PMID: 16334170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Syndecan-1 (CD138) is expressed by the Hodgkin-Reed-Sternberg (HRS) cells of classic Hodgkin's lymphoma (cHL), but not in nodular lymphocyte-predominant HL. Syndecan-1 may be involved in the interaction between HRS cells and the cellular and stromal microenvironment typical of nodular sclerosing HL. PATIENTS AND METHODS Serum levels of soluble syndecan-1 were determined by ELISA in 66 patients with HL and 14 age- and sex-matched healthy individuals. RESULTS The levels of syndecan-1 were higher in HL patients than controls (100.2 +/- 35.9 ng/ml vs. 67.9 +/- 24.5 ng/ml, p < 0.001). They marginally correlated with advanced age (p = 0.06), male gender (p = 0.07) and consequently high IPS (p = 0.01), but did not correlate with markers of tumor burden and prognosis, including serum interleukin-10 and soluble CD30. At 6 years, failure-free survival was 70 +/- 9% vs. 50 +/- 11% (p = 0.32) for patients with serum soluble syndecan-1 levels above or below the observed median value of 91 ng/ml. CONCLUSION The serum levels of syndecan-1 were elevated in patients with HL, but were not strongly correlated with other potential prognostic factors. Their effect on prognosis deserves further evaluation.
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Affiliation(s)
- Theodoros P Vassilakopoulos
- First Department of Internal Medicine and Department of Haematology, National and Kapodistrian University of Athens, Laikon University Hospital, Athens, Greece
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21
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Vassilakopoulos TP, Angelopoulou MK, Constantinou N, Karmiris T, Repoussis P, Roussou P, Siakantaris MP, Korkolopoulou P, Kyrtsonis MC, Kokoris SI, Dimopoulou MN, Variamis E, Viniou NA, Konstantopoulos K, Dimitriadou EM, Androulaki A, Patsouris E, Doussis-Anagnostopoulou IA, Panayiotidis P, Boussiotis VA, Kittas C, Pangalis GA. Development and validation of a clinical prediction rule for bone marrow involvement in patients with Hodgkin lymphoma. Blood 2005; 105:1875-80. [PMID: 15536150 DOI: 10.1182/blood-2004-01-0379] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We developed a clinical prediction rule for bone marrow involvement (BMI) in Hodgkin lymphoma based on 826 patients and validated it in 654 additional patients. Independent prognostic factors for BMI were x1, B symptoms; x2, stage III/IV prior to bone marrow biopsy; x3, anemia; x4, leukocytes fewer than 6 x 10(9)/L; x5, age 35 years or older; and x6, iliac/inguinal involvement. Each factor was graded as x(i)=1, if present, or x(i)=0, if absent. A simplified score Zs=8x1+6x2+5x3+5x4+3x5+3x6-8 was assigned to each patient. The sensitivity, specificity, and positive and negative predictive value of this prediction rule was 97.8%, 51.5%, 10.6%, and 99.8%, respectively. In the validation group, they were 98.1%, 40.3%, 12.7%, and 99.6%. According to Zs value, 3 risk groups for BMI were defined: low risk (Zs<0, 44% of patients, 0.3% risk), standard risk (Zs, 0-9; 37% of patients; 4.2% risk), and high risk (Zs>or=10, 20% of patients, 25.5% risk). Patients with low risk (stage IA/IIA without anemia and leukopenia; stage IA/IIA, younger than 35 years, with either anemia or leukopenia but no inguinal/iliac involvement; and stage IIIA/IVA without any of these 4 risk factors) do not need bone marrow (BM) biopsy. Patients with standard risk should be staged with unilateral biopsy, but patients with high risk may benefit from bilateral biopsy.
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Affiliation(s)
- Theodoros P Vassilakopoulos
- Haematology Section, First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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22
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Pangalis GA, Kyrtsonis MC, Kontopidou FN, Siakantaris MP, Dimopoulou MN, Vassilakopoulos TP, Tzenou T, Kokoris S, Dimitriadou E, Kalpadakis C, Tsalimalma K, Tsaftaridis P, Panayiotidis P, Angelopoulou MK. Differential Diagnosis of Waldenström's Macroglobulinemia and Other B-Cell Disorders. ACTA ACUST UNITED AC 2005; 5:235-40. [PMID: 15794855 DOI: 10.3816/clm.2005.n.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Waldenstrom's macroglobulinemia (WM) is characterized by lymphoplasmacytic infiltration of bone marrow and/or other tissues and by the presence of serum monoclonal immunoglobulin M ([IgM], without cutoff limit). Differential diagnosis from other B-cell disorders (BCDs) is usually easy based on clinical, morphologic, histopathologic, immunophenotypic, and genetic features. However, all BCDs potentially produce monoclonal IgM. In this study we reviewed the medical files of 130 patients with IgM-secreting BCDs. Eighty-four patients were diagnosed with WM, 5 with IgM-monoclonal gammopathy of undetermined significance (MGUS), and 41 with other BCDs (9 with B-cell chronic lymphocytic leukemia, 5 with small lymphocytic lymphoma, 14 with marginal zone lymphoma, 5 with mantle-cell lymphoma, 2 with follicular lymphoma, 2 with diffuse large B-cell lymphoma, 2 with cryoglobulinemia, and 2 with low-grade lymphoma not otherwise specified). Median IgM levels were 3215 mg/dL in WM, 840 mg/dL in IgM-MGUS, and 285 mg/dL in other BCDs (5 had IgM levels > 1500 mg/dL). In 10% of non-WM BCDs, monoclonal IgM was found only when more sensitive immunofixation methods were used. Forty-four percent of patients with BCDs (splenic marginal zone lymphoma or small lymphocytic lymphoma) had diagnoses that corresponded to that of WM. Careful diagnosis requires the concomitant evaluation of all parameters of BCDs together. Marginal zone lymphoma is the most frequently overlapping entity. Special attention should be given to mantle cell lymphoma in its atypical forms. Research in this field should continue to further clarify the disease entities that overlap with WM. New technology such as gene-expression profile techniques may contribute to this purpose.
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Affiliation(s)
- Gerassimos A Pangalis
- First Department of Internal Medicine and Department of Hematology, National and Kapodistrian University of Athens, Laikon General Hospital, 16 Sevastoupoleos Street, Athens 11526, Greece.
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23
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Vassilakopoulos TP, Nadali G, Angelopoulou MK, Dimopoulou MN, Siakantaris MP, Kontopidou FN, Karkantaris C, Kokoris SI, Dimitriadou EM, Calpadaki C, Sarantopoulos A, Galani Z, Sachanas S, Kyrtsonis MC, Tsaftaridis P, Variamis E, Panayotidis P, Pizzolo G, Sarris AH, Pangalis GA. beta(2)-microglobulin in Hodgkin's lymphoma: prognostic significance in patients treated with ABVD or equivalent regimens. J BUON 2005; 10:59-69. [PMID: 17335133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
PURPOSE Serum beta-2 microglobulin (sbeta(2)m) is an established prognostic factor for several lymphoproliferative disorders. Because its significance in Hodgkin's lymphoma (HL) is controversial, we determined sbeta(2)m levels in pretreatment serum samples of patients with HL in order to elucidate its prognostic value in this condition. PATIENTS AND METHODS Pretreatment sbeta(2)m levels were determined in 379 HL patients who were treated with ABVD or equivalent regimens with or without radiotherapy (RT), using a radioimmunoassay (upper normal limit 2.4 mg/l). Sbeta(2)m levels were correlated with several clinical and laboratory parameters. RESULTS Elevated sbeta(2)m levels were detected in 138/379 (36%) patients and correlated with all clinical and laboratory baseline features except gender, lung involvement and mediastinal bulk. They also correlated with serum soluble CD30 and interleukin-10 levels. The 8-year failure-free survival (FFS) was 78 -/+ 4% for patients with normal versus 65 -/+ 7% for patients with elevated sbeta(2)m levels (p=0.003). The corresponding rates among early-stage patients were 83 -/+ 53% versus 71 -/+ 9% (p=0.003), while for advanced stages they were 70 -/+ 6% versus 64 -/+ 8% (p=0.54). In multivariate analysis of the whole patient population elevation of sbeta(2)m levels was not predictive of FFS, but it was strongly predictive among early-stage patients. The 8-year overall survival (OS) rates were 91 -/+ 3% for patients with normal versus 59 -/+ 11% (p <0,0001) for patients with elevated sbeta(2)m levels, while unrelated mortality at 8 years was 1 -/+ 1% versus 27 -/+ 12% (p<0.0001). CONCLUSION Our data suggest that sbeta(2)m levels may be a potent prognostic factor for FFS in patients with early stage HL treated with ABVD and equivalent regimens. Their effect on OS is confounded by the higher unrelated mortality in patients with elevated baseline sbeta(2)m levels, probably due to the strong association between sbeta(2)m and older age.
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Affiliation(s)
- T P Vassilakopoulos
- Hematology Section, First Department of Internal Medicine, National and Kapodistrian University of Athens, "Laikon" General Hospital, Athens, Greece
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24
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Vassilakopoulos TP, Angelopoulou MK, Siakantaris MP, Kontopidou FN, Dimopoulou MN, Kokoris SI, Kyrtsonis MC, Tsaftaridis P, Karkantaris C, Anargyrou K, Boutsis DE, Variamis E, Michalopoulos T, Boussiotis VA, Panayiotidis P, Papavassiliou C, Pangalis GA. Combination chemotherapy plus low-dose involved-field radiotherapy for early clinical stage Hodgkin's lymphoma. Int J Radiat Oncol Biol Phys 2004; 59:765-81. [PMID: 15183480 DOI: 10.1016/j.ijrobp.2003.11.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2003] [Revised: 09/24/2003] [Accepted: 11/12/2003] [Indexed: 10/26/2022]
Abstract
PURPOSE To present our long-term experience regarding the use of chemotherapy plus low-dose involved-field radiotherapy (IFRT) for clinical Stage I-IIA Hodgkin's lymphoma. METHODS AND MATERIALS We analyzed the data of 368 patients. Of these, 66 received mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) and 302 received doxorubicin (or epirubicin), bleomycin, vinblastine, and dacarbazine [A(E)BVD]. Patients with complete remission or very good partial remission were scheduled for low-dose IFRT (< or =3200 cGy). RESULTS The 10-year failure-free survival (FFS) and overall survival (OS) rate was 85% and 86%, respectively. A(E)BVD-treated patients had superior 10-year FFS and OS rates compared with MOPP-treated patients (87% vs. 75%, p = 0.009; and 93% vs. 71%, p = 0.0004, respectively). Only 10 of 41 relapses had any infield (irradiated) component. Of the complete responders/very good partial responders treated with low-dose IFRT, those who received <2800 cGy had inferior FFS but similar OS as those who received 2800-3200 cGy. Adverse prognostic factors for FFS included age > or =45 years, leukocytosis > or =10 x 10(9)/L, and extranodal extension. Secondary acute leukemia developed after MOPP with or without salvage therapy (n = 6) or after ABVD plus salvage therapy (n = 2). None of the nine secondary solid tumors developed within the RT fields. CONCLUSION IFRT at a dose of 2800-3000 cGy is highly effective in clinical Stage I-IIA HL patients who achieved a complete response or very good partial response with A(E)BVD. The long-term toxicity with respect to secondary malignancies appears to be acceptable.
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Affiliation(s)
- Theodoros P Vassilakopoulos
- Haematology Section, First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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25
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Kyrtsonis MC, Vassilakopoulos TP, Siakantaris MP, Kokoris SI, Gribabis DA, Dimopoulou MN, Angelopoulou MK, Pangalis GA. Serum syndecan-1, basic fibroblast growth factor and osteoprotegerin in myeloma patients at diagnosis and during the course of the disease. Eur J Haematol 2004; 72:252-8. [PMID: 15089762 DOI: 10.1046/j.0902-4441.2003.00205.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Neovascularisation and bone resorption are related to myeloma disease activity. OBJECTIVES To investigate the possible prognostic importance of serum syndecan-1, basic fibroblast growth factor (bFGF) and osteoprotegerin (OPG) levels, the relationship between them, with parameters of disease activity and the effect of treatment on their levels. PATIENTS AND METHODS Twenty-seven patients were studied from diagnosis and an additional five from remission, for a median follow-up of 40 months. Twenty-three patients received chemotherapy plus bisphosphonates and nine only bisphosphonates. Sera from 11 healthy individuals (HI) were used as controls. Cytokines were determined by commercially available enzyme-linked immunosorbent assays (ELISA) kits. RESULTS In HI, median syndecan-1 was 40 ng/mL (28-75), bFGF 8 pg/mL (7-30), OPG 35 pg/mL (4-100). Pretreatment median serum syndecan-1 was 177.5 ng/mL (34-3500), bFGF 11.5 pg/mL (8-65) and OPG 100 pg/mL (4-1000). Pretreatment syndecan-1, bFGF and OPG serum levels were increased in patients compared with HI (P = 0.001, 0.03 and 0.01, respectively). Syndecan-1 and bFGF levels were correlated with stage (P = 0.004 and 0.03, respectively). Both syndecan-1 and OPG levels were correlated with beta2M (P = 0.04 and 0.01, respectively). Patients with elevated syndecan-1 and bFGF serum levels had shorter survival than patients with normal levels (P = 0.01 and 0.05, respectively). After chemotherapy syndecan-1 and OPG levels were found to be decreased in responders and syndecan-1 level was reduced in patients receiving bisphosphonates alone. CONCLUSIONS Pretreatment syndecan-1, bFGF and OPG levels were found to be increased at diagnosis. Syndecan-1 and OPG fluctuated according to MM activity. Elevated serum syndecan-1 and bFGF levels predicted short survival.
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Affiliation(s)
- Maria-Christina Kyrtsonis
- Hematology Section and Research Laboratory, First Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
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Pangalis GA, Kyrtsonis MC, Kontopidou FN, Vassilakopoulos TP, Siakantaris MP, Dimopoulou MN, Kittas C, Angelopoulou MK. Differential diagnosis of Waldenstrom's macroglobulinemia from other low-grade B-cell lymphoproliferative disorders. Semin Oncol 2003; 30:201-5. [PMID: 12720136 DOI: 10.1053/sonc.2003.50046] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Waldenstrom's macroglobulinemia (WM) is a rare lymphoproliferative disorder (LPD) characterized by lymphoplasmacytic infiltration of the bone marrow (BM) and/or occasionally other tissues and by the presence of a serum monoclonal IgM. The disease belongs to the lymphoplasmacytic lymphoma (LPL) subtype. Whether WM is indeed a separate entity or is merely an IgM-secreting subtype of low-grade B-cell lymphoma is still controversial. In our series of 67 patients, WM has a long median overall survival of 110 months, and the male/female ratio is 1.2/1. Clinical features include a wide spectrum of manifestations, many of which may be common to other LPDs. Differential diagnosis is based on: (1) clinical and laboratory features (anemia, organomegaly, lymphadenopathy, IgM paraproteinemia), (2) cell morphology (lymphocytes, lymphoplasmacytes, few plasma cells), (3) histopathology of bone marrow or lymph node, (4) immunophenotype (CD5 expression and the intensity of CD5, CD20, and CD79b antigens may help in discrimination from other LPDs and atypical CLL), and (5) characteristic genetic features (present in other LPDs). Based on the former, diagnosis is usually easy. It may be harder in LPL cases not secreting IgM. We consider that WM should be, for the time being, handled as a separate entity. Further studies are necessary.
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Affiliation(s)
- Gerassimos A Pangalis
- Haematology Section, First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Pangalis GA, Vassilakopoulos TP, Dimopoulou MN, Siakantaris MP, Kontopidou FN, Angelopoulou MK. B-chronic lymphocytic leukemia: practical aspects. Hematol Oncol 2002; 20:103-46. [PMID: 12203655 DOI: 10.1002/hon.696] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
B-CLL is the most common adult leukemia in the Western world. It is a neoplasia of mature looking B-monoclonal lymphocytes co-expressing the CD5 antigen (involving the blood, the bone marrow, the lymph nodes and related organs). Much new information about the nature of the neoplastic cells, including chromosomal and molecular changes as well as mechanisms participating in the survival of the leukemic clone have been published recently, in an attempt to elucidate the biology of the disease and identify prognostic subgroups. For the time being, clinical stage based on Rai and Binet staging systems remains the strongest predictor of prognosis and patients' survival, and therefore it affects treatment decisions. In the early stages treatment may be delayed until progression. When treatment is necessary according to well-established criteria, there are nowadays many different options. Chlorambucil has been the standard regimen for many years. During the last decade novel modalities have been tried with the emphasis on fludarabine and 2-chlorodeoxyadenosine and their combinations with other drugs. Such an approach offers greater probability of a durable complete remission but no effect on overall survival has been clearly proven so far. Other modalities, included in the therapeutic armamentarium, are monoclonal antibodies, stem cell transplantation (autologous or allogeneic) and new experimental drugs. Supportive care is an important part of patient management and it involves restoring hypogammaglobulinemia and disease-related anemia by polyvalent immunoglobulin administration and erythropoietin respectively.
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Affiliation(s)
- Gerassimos A Pangalis
- Hematology Section, 1st Department of Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece.
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Vassilakopoulos TP, Nadali G, Angelopoulou MK, Siakantaris MP, Dimopoulou MN, Kontopidou FN, Karkantaris C, Kokoris SI, Kyrtsonis MC, Tsaftaridis P, Pizzolo G, Pangalis GA. The prognostic significance of beta(2)-microglobulin in patients with Hodgkin's lymphoma. Haematologica 2002; 87:701-8; discussion 708. [PMID: 12091120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Serum beta(2)-microglobulin (s beta(2)m) is an established prognostic factor for multiple myeloma and non-Hodgkin's lymphoma, but only limited data suggest an adverse prognostic significance for Hodgkin's lymphoma (HL). This study was undertaken to examine the impact of s beta(2)m on the prognosis of patients with HL. DESIGN AND METHODS s beta(2)m was measured by a radioimmunoassay (upper normal limit 2.4 mg/L), in pretreatment serum samples of 232 patients with HL, who were then treated with ABVD or equivalent regimens with or without radiotherapy. Multivariate survival analysis was based on Cox's proportional hazards model. RESULTS Main patients' characteristics: median age 30.5 years (14-78); 58% males; 68% nodular sclerosis, 20% mixed cellularity and 12% lymphocyte predominance; 34% B-symptoms; 24% Ann Arbor stage I, 49% II, 18% III and 9% IV. Elevated s beta(2)m levels were detected in 65/232 patients (28%) and correlated with older age (p<0.001), mixed cellularity (p=0.03), B-symptoms (p=0.002), advanced stage (p=0.02), > or = 5 involved sites (p=0.02), inguinal/iliac involvement (p=0.009), lymphocytopenia (p=0.002) and elevated lactate dehydrogenase (p=0.01). The 7-year failure free survival (FFS) was 75% vs. 72% for patients with normal vs. elevated s beta(2)m (p=0.15). The corresponding 7-year overall survival (OS) rates were 86% vs. 52% (p=0.003). In multivariate analysis, elevated s beta(2)m was not predictive of FFS, but was independently associated with inferior OS (p=0.01), along with the number of involved sites (p<0.001). INTERPRETATION AND CONCLUSIONS s beta(2)m is not a potent prognostic factor for FFS in optimally treated patients with HL. However s beta(2)m may be predictive of OS, probably due to its effect on the timing of treatment failure.
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Affiliation(s)
- Theodoros P Vassilakopoulos
- Hematology Section, First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Pangalis GA, Siakantaris MP, Angelopoulou MK, Vassilakopoulos TP, Dimopoulou MN, Kyrtsonis MC, Konstantopoulos K, Tsaftaridis P, Vaiopoulos GA, Kontopidou FN. Downstaging Rai stage III B-chronic lymphocytic leukemia patients with the administration of recombinant human erythropoietin. Haematologica 2002; 87:500-6. [PMID: 12010663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the effectiveness of recombinant human erythropoietin (r-HuEPO) on disease-related anemia in patients with B-chronic lymphocytic leukemia (B-CLL) and to explore whether improvement of anemia could delay the initiation of cytotoxic therapy. DESIGN AND METHODS Twenty five B-CLL patients (12 males and 13 females; median age 70 years) with disease-related anemia were treated with r-HuEPO. Patients were either on no treatment or on a standard regimen, and had at least Rai stage III disease, with a hematocrit (Hct) <32%. Eleven were newly diagnosed, whereas 14 developed anemia during follow-up. Treatment induction lasted for a maximum of 3 months, during which patients were receiving 150 IU/kg of r-HuEPO s.c. t.i.w. with an escalation to 300 IU/kg t.i.w. if response was slow after one month. Responding patients were placed on maintenance r-HuEPO with 150 IU/kg s.c. once weekly, continuously. Complete response (CR) was defined as an increase of Hct to 38% or more and partial response (PR) as an increase of >6% from pretreatment level. RESULTS CR was observed in 18/25 (72%) and PR in 2/25 (8%) of the patients. Six patients were downstaged to stage Rai 0, 9 to Rai I and 4 to Rai II. Response was sustained with maintenance therapy. At a median follow-up of 32 months only 4 of the responders required antileukemic treatment. The median survival of responders has not been reached, and 3-year survival is 84%. INTERPRETATION AND CONCLUSIONS r-HuEPO was efficient in downstaging Rai stage III B-CLL patients, and delayed the initiation of antileukemic therapy. Whether this effect can be translated into better survival rates remains to be clarified in randomized trials.
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MESH Headings
- Aged
- Aged, 80 and over
- Anemia/drug therapy
- Anemia/etiology
- Erythropoietin/administration & dosage
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Neoplasm Staging
- Recombinant Proteins
- Remission Induction
- Treatment Outcome
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Affiliation(s)
- Gerassimos A Pangalis
- National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 16 Sevastoupoleos St., P.O. Box 14044, Athens 11510, Greece.
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Vassilakopoulos TP, Angelopoulou MK, Siakantaris MP, Kontopidou FN, Dimopoulou MN, Boutsis DE, Anargyrou K, Kokoris SI, Giannakakis A, Karkantaris C, Kyrtsonis MC, Tsaftaridis P, Rombos J, Variamis E, Korkolopoulou P, Kittas C, Pangalis GA. Hodgkin's lymphoma in first relapse following chemotherapy or combined modality therapy: analysis of outcome and prognostic factors after conventional salvage therapy. Eur J Haematol 2002; 68:289-98. [PMID: 12144535 DOI: 10.1034/j.1600-0609.2002.01721.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To investigate the prognosis of patients with Hodgkin's lymphoma (HL) who relapse following a complete remission (CR) achieved by chemotherapy with or without radiotherapy (CT+/-RT), and to identify prognostic factors for freedom from second progression (FF2P). METHODS We analyzed the prognostic significance of the initial CT regimen (4 vs. 7-8 drugs), treatment-free interval (TFI), and demographic, clinical, and laboratory factors at the time of relapse and diagnosis, in 113 patients with HL, who relapsed after a CR achieved by CT+/-RT. RESULTS Conventional salvage CT+/-RT was administered in 107 patients, while six received RT only. The 5-yr FF2P was 24%, while the 10-yr survival after relapse (O2S) was 39% and was not afffected by the initial CT regimen. Multivariate analysis revealed that extranodal disease at relapse (P<0.001), TFI<6 month (P<0.001), > or =5 involved sites at diagnosis (P=0.04) and anemia at relapse (P=0.03) were independent predictors of FF2P. 55% of patients had 0 or 1 of these adverse prognostic factors. The 5-yr FF2P of patients with 0, 1 or 2 adverse factors was 58%, 34% and 5% (P<0.0001). The corresponding rates for 10-yr O2S were 68%, 51% and 25%, respectively (P=0.002). CONCLUSIONS Our data confirmed the significance of TFI and extranodal relapse and demonstrated a potential role for anemia at relapse and number of involved sites at diagnosis, for the prognosis of patients with HL relapsing after CT+/-RT. The combination of these prognostic factors defines a sizeable subgroup of patients with favorable outcome following conventional salvage therapy.
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Affiliation(s)
- Theodoros P Vassilakopoulos
- Hematology Section, First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, 16 Sevastoupoleos Street, Athens, Greece
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Pangalis GA, Dimopoulou MN, Angelopoulou MK, Tsekouras C, Vassilakopoulos TP, Vaiopoulos G, Siakantaris MP. Campath-1H (anti-CD52) monoclonal antibody therapy in lymphoproliferative disorders. Med Oncol 2002; 18:99-107. [PMID: 11778765 DOI: 10.1385/mo:18:2:99] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2000] [Accepted: 10/16/2000] [Indexed: 11/11/2022]
Abstract
Campath-1H is a humanized monoclonal antibody targeted against the CDw52 membrane antigen of lymphocytes, which causes complement and antibody-dependent cell-mediated cytotoxicity. Campath-1H has been used in B-chronic lymphocytic leukemia (B-CLL), T-prolymphocytic leukemia (T-PLL), and low-grade non-Hodgkin's lymphoma (LGNHL). Campath-1H is administered intravenously thrice weekly for up to 12 wk, at an initial dose of 3 mg, escalated to 10 and 30 mg. The responses (complete [CR] and partial [PR]) obtained in untreated B-CLL patients are of the order of 90%. In previously treated B-CLL patients, responses are of the order of approximately 40%, with 2-4% CRs. Responses are more prominent in the blood and bone marrow compared to the lymph nodes. The median duration of response is 9-12 mo. Because of the antibody's higher activity on circulating lymphocytes, it has been used for in vivo purging of residual disease in B-CLL, followed by autologous stem-cell transplantation. In heavily pretreated advanced stage LGNHL, response is achieved only in 14% of cases with B-phenotype; a 50% response rate is noted in mycosis fungoides. In T-PLL, the CR rate is approximately 60%. Promising results have been reported in a small number of patients with refractory autoimmune thrombocytopenia of lymphoproliferative disorders. The main complications of Campath-1H treatment are caused by tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 release, usually during the first intravenous infusion, and include fever, rigor, nausea, vomiting, and hypotension responsive to steroids. These side effects are usually less severe with subsequent infusions and can be prevented by paracetamol and antihistamines. Immunosupression resulting from normal B- and T-lymphocyte depletion is frequent, resulting in an increased risk for opportunistic infections. More clinical trials in a larger number of patients are necessary to determine the exact role and indications of Campath-1H in lymphoproliferative disorders.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/adverse effects
- Antibodies, Neoplasm/pharmacology
- Antibodies, Neoplasm/therapeutic use
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Dose-Response Relationship, Drug
- Humans
- Immunosuppression Therapy
- Infections
- Infusions, Intravenous
- Interleukin-6/adverse effects
- Interleukin-6/metabolism
- Leukemia, B-Cell/drug therapy
- Leukemia, Prolymphocytic/drug therapy
- Lymphoma, Non-Hodgkin/drug therapy
- Phenotype
- Risk Factors
- Treatment Outcome
- Tumor Necrosis Factor-alpha/adverse effects
- Tumor Necrosis Factor-alpha/metabolism
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Affiliation(s)
- G A Pangalis
- 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Greece.
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Angelopoulou MK, Siakantariz MP, Vassilakopoulos TP, Kontopidou FN, Rassidakis GZ, Dimopoulou MN, Kittas C, Pangalis GA. The splenic form of mantle cell lymphoma. Eur J Haematol 2002; 68:12-21. [PMID: 11952817 DOI: 10.1034/j.1600-0609.2002.00551.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe the clinical, immunophenotypic and molecular features, as well as the clinical course of patients with unusual presentation of mantle cell lymphoma (MCL) purely located to the spleen. PATIENTS AND METHODS We describe seven patients presented with splenomegaly and a leukemic picture without lymphadenopathy, fulfilling the diagnostic criteria of MCL. In addition to clinical and pathologic features, patients were studied with respect to surface immunophenotype, including adhesion molecule profile, immunohistochemical expression of cyclin-D1 and bcl-1 rearrangement by polymerase chain reaction. RESULTS Four patients were male and three female. The median palpable spleen size was 15 cm. A preliminary diagnosis of MCL was made, based on blood cell morphology and immunophenotype. All patients underwent splenectomy for therapeutic purposes. Studies done in blood and splenic lymphocytes revealed the following: 7/7 patients were CD19/CD5, CD20 and CD38 positive; CD10 negative and 6/7 CD23 negative. The adhesion molecule expression pattern was consistent in all patients: L-Selectin and CD11c were negative, CD11alpha and CD18 weakly positive and CD54 strongly positive. The median spleen weight was 1775 g. Histology disclosed a cytologic and architectural pattern consistent with MCL. Cyclin-D1 was positive in 6/6 studied patients. Bcl-1 rearrangement was found in 5/7 patients. Splenectomy was applied as the sole treatment and was beneficial in all patients, with median blood values as following: prior to splenectomy, Ht 29.5%, platelets 110 x 10(9)/l, lymphoma cells 5.0 x 10(9)/L, and at 6 months post-splenectomy, Ht 43%, platelets 311 x 10(9)/l and lymphoma cells 3.0 x 10(9)/L. Of the seven patients, two developed progressive disease 11 and 26 months post-splenectomy. The remaining five are in improving clinical and hematological condition without chemotherapy at a median follow up of 20 months. CONCLUSIONS We conclude that this presentation represents a separate form of MCL which requires splenectomy. It remains to be seen whether it carries a better prognosis than classical MCL.
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MESH Headings
- Aged
- Aged, 80 and over
- Antigens, CD/analysis
- Antigens, Neoplasm/analysis
- Biomarkers, Tumor/analysis
- Blood Cell Count
- Bone Marrow/pathology
- Cell Adhesion Molecules/analysis
- Cyclin D1/analysis
- Disease Progression
- Female
- Follow-Up Studies
- Genes, bcl-1
- Humans
- Immunophenotyping
- Lymphocytes/chemistry
- Lymphocytes/pathology
- Lymphoma, Mantle-Cell/chemistry
- Lymphoma, Mantle-Cell/diagnosis
- Lymphoma, Mantle-Cell/genetics
- Lymphoma, Mantle-Cell/pathology
- Lymphoma, Mantle-Cell/surgery
- Male
- Middle Aged
- Neoplasm Proteins/analysis
- Neoplastic Stem Cells/chemistry
- Neoplastic Stem Cells/pathology
- Splenectomy
- Splenic Neoplasms/chemistry
- Splenic Neoplasms/diagnosis
- Splenic Neoplasms/genetics
- Splenic Neoplasms/pathology
- Splenic Neoplasms/surgery
- Splenomegaly/etiology
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Affiliation(s)
- Maria K Angelopoulou
- Hematology Section, First Department of Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, 16 Sevastoupoleos Street, 11510 Athens, Greece
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Kyrtsonis MC, Vassilakopoulos TP, Angelopoulou MK, Siakantaris P, Kontopidou FN, Dimopoulou MN, Boussiotis V, Gribabis A, Konstantopoulos K, Vaiopoulos GA, Fessas P, Kittas C, Pangalis GA. Waldenström's macroglobulinemia: clinical course and prognostic factors in 60 patients. Experience from a single hematology unit. Ann Hematol 2001; 80:722-7. [PMID: 11797112 DOI: 10.1007/s00277-001-0385-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2001] [Accepted: 09/09/2001] [Indexed: 11/25/2022]
Abstract
Waldenström's macroglobulinemia (WM) is a lymphoplasmacytic lymphoma characterized by the presence in patients' serum of an IgM monoclonal component. We report on our experience with 60 WM patients, focusing on their clinical findings, response to treatment, and the possible identification of prognostic factors. Of these patients, 70% presented with fatigue, and lymphadenopathy was observed in 22%, splenomegaly in 18%, hepatomegaly in 13%, and extranodal site of involvement in 6%. Bleeding tendency was seen in 17%, infections in 17%, hyperviscosity syndrome in 12%, and cardiac failure in 25% of the patients. The median of IgM levels was 30 g/l with hypoalbuminemia in 20% of cases, hypogammaglobulinemia in 27%, polyclonal hypergammaglobulinemia in 15%, kappa light-chain restriction in 78%, and Bence-Jones proteinuria in 54%. Anemia was frequent (85%), followed by leukocytosis (18%), lymphocytosis (12%), leukopenia (10%), and thrombocytopenia (10%). Cryoglobulinemia and autoimmune hemolytic anemia were encountered in 5%. In all cases but two, bone marrow was involved. Of 50 patients initially treated with intermittent oral chlorambucil, 46 (92%) responded. Median overall survival was 108 months. Factors associated with adverse prognosis were age > or =65 years (p=0.06), presence of lymphadenopathy (p=0.06), bone marrow infiltration > or =50% (p=0.007), international prognostic index (IPI) > or =3 (p=0.0001), and Morel's scoring system (p=0.04). Concluding, we found in this series of WM patients that chlorambucil is an effective treatment and that the parameters of age, lymphadenopathy, percentage of bone marrow infiltration, IPI, and Morel's scoring system carry prognostic significance.
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Affiliation(s)
- M C Kyrtsonis
- Hematology Section, First Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, 16 Sevastoupoleos St., Athens 11526, Greece
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Vassilakopoulos TP, Angelopoulou MK, Siakantaris MP, Kontopidou FN, Dimopoulou MN, Barbounis A, Grigorakis V, Karkantaris C, Anargyrou K, Chatziioannou M, Rombos J, Boussiotis VA, Vaiopoulos G, Kittas C, Pangalis GA. Prognostic factors in advanced stage Hodgkin's lymphoma: the significance of the number of involved anatomic sites. Eur J Haematol 2001; 67:279-88. [PMID: 11872075 DOI: 10.1034/j.1600-0609.2001.00561.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Advanced Hodgkin's lymphoma (HL) is curable by conventional chemotherapy in 60--70% of patients. The pretreatment identification of a sizeable subgroup of patients with sufficiently low failure-free survival (FFS) to be eligible for investigational treatment is necessary. OBJECTIVES To determine the prognostic significance of the number of involved sites (NIS) in patients with advanced HL and its relationship to the International Prognostic Score (IPS). METHODS A retrospective review of patients with advanced HL, defined as Ann Arbor stage (AAS) IB, IIB, III or IV, treated with anthracycline-based regimens. The end-point was FFS. RESULTS We identified 277 patients with a median age of 32 yr (14--78), 57% of whom were males. AAS was I in 4% of patients, II in 29%, III in 38% and IV in 29%. B-symptoms were recorded in 81%. Most patients had nodular sclerosis (64%) and mixed cellularity (26%) histology. IPS was greater-than-or-equals 3 in 44% of 242 evaluable patients. The NIS was greater-than-or-equals 5 in 32% of the patients and 20% of all patients had both greater-than-or-equals 5 involved sites and IPS greater-than-or-equals 3. The 10-yr FFS was 67%, being 76% vs. 50% for patients with less-than-or-equals 4 vs. greater-than-or-equals 5 involved sites (P < 0.0001). The NIS (greater-than-or-equal 5), AAS IV and anemia were independent predictors of FFS in multivariate analysis. The NIS remained significant along with IPS, when the latter was included in the analysis. Patients with greater-than-or-equals 5 involved sites and IPS greater-than-or-equals 3 had 10-yr FFS overall, and relapse-free survival of 41%, 45% and 49%, respectively. CONCLUSIONS The NIS was associated with FFS in advanced HL, was independent of IPS, and led to the identification of a sizeable subgroup of patients with 10-yr FFS of approximately 40%. This factor should be evaluated during the development of prognostic systems.
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Affiliation(s)
- T P Vassilakopoulos
- Hematology Section, First Department of Internal Medicine, National and Kapodistrian University, School of Medicine, Laikon General Hospital, Athens, Greece
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Kyrtsonis MC, Angelopoulou MK, Kontopidou FN, Siakantaris MP, Dimopoulou MN, Mitropoulos F, Kalovidouris A, Vaiopoulos GA, Pangalis GA. Primary lung involvement in Waldenström's macroglobulinaemia: report of two cases and review of the literature. Acta Haematol 2001; 105:92-6. [PMID: 11408711 DOI: 10.1159/000046541] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pulmonary involvement in Waldenström's macroglobulinaemia (WM) occurs in 3-5% of cases, but lung involvement without bone marrow infiltration is extremely rare. We report 2 patients who presented with bilateral consolidations on chest X-ray and non-specific symptoms and were treated for a long period of time for pulmonary infections until the diagnosis was made by open lung biopsy. Both patients presented high monoclonal IgM in the serum and one also had blood lymphoplasmacytosis. Trephine bone biopsy and bone marrow smears were normal and there was no other site of involvement. Along with the presentation of our patients, we review the literature, discuss some of the possible underlying mechanisms and raise the attention of clinicians to this rare manifestation of the disease.
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Affiliation(s)
- M C Kyrtsonis
- Hematology Section, First Department of Internal Medicine, National and Kapodistrian University, School of Medicine, Laikon General Hospital, Athens, Greece
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Vassilakopoulos TP, Nadali G, Angelopoulou MK, Siakantaris MP, Dimopoulou MN, Kontopidou FN, Rassidakis GZ, Doussis-Anagnostopoulou IA, Hatzioannou M, Vaiopoulos G, Kittas C, Sarris AH, Pizzolo G, Pangalis GA. Serum interleukin-10 levels are an independent prognostic factor for patients with Hodgkin's lymphoma. Haematologica 2001; 86:274-81. [PMID: 11255274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Interleukin-10 (IL-10) is a pleiotropic cytokine which increases bcl-2 levels and protects cells from steroid or doxorubicin-induced apoptosis. Hodgkin and Reed-Sternberg (HRS) cells bear functional IL-10 receptors. Thus serum IL-10 (sIL-10) might inhibit apoptosis in HRS cells, which could occur as a result of either chemotherapy or the crippled immunoglobulin genes. DESIGN AND METHODS We determined sIL-10 levels in 122 patients with Hodgkin's lymphoma (HL), treated with ABVD or equivalent regimens with or without radiotherapy, and correlated them with presenting clinical and laboratory features, as well as failure-free survival (FFS) and overall survival. RESULTS Elevated sIL-10 levels ( > or = 10 pg/mL) were detected in 55 patients (45%), and were correlated with advanced stage and elevated serum b2-microglobulin levels. At 7 years FFS was 85% vs. 63% for patients with normal vs. elevated sIL-10 levels, respectively (p=0.01); overall survival was 97% vs. 73% (p=0.005). Multivariate analysis with Cox's proportional hazards model demonstrated that elevated sIL-10 levels were the strongest independent predictor of FFS, and were also associated with inferior overall survival. INTERPRETATION AND CONCLUSIONS We conclude that sIL-10 levels are elevated in 45% of patients with HL, and are associated with inferior FFS and overall survival, independently of other established prognostic factors.
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Affiliation(s)
- T P Vassilakopoulos
- Hematology Section, First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Siakantaris MP, Angelopoulou MK, Vassilakopoulos TP, Dimopoulou MN, Kontopidou FN, Pangalis GA. Correction of disease related anaemia of B-chronic lymphoproliferative disorders by recombinant human erythropoietin: maintenance is necessary to sustain response. Leuk Lymphoma 2000; 40:141-7. [PMID: 11426615 DOI: 10.3109/10428190009054891] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Thirty three B-chronic lymphoproliferative disorder (B-CLD) patients [22 with B-chronic lymphocytic leukemia (B-CLL), 5 with small lymphocytic lymphoma (SLL) and 6 with lymphoplasmacytic lymphoma (LPL)] with anaemia (Ht <32%) of no other cause but their disease, received recombinant human erythropoietin (r-HuEPO). The treatment protocol provided r-HuEPO in a dose of 150 U/kg s.c. thrice weekly for 3 mo. After 1.5 mo of r-HuEPO administration, if response was not satisfactory, r-HuEPO dose escalation was utilised by giving incremental doses of 50 U/kg more than the previous dose up to a maximum dose of 300 U/kg tiw. After maximal response, half of the responding patients discontinued therapy, while the other half received maintenance therapy at a dose of 150 U/kg s.c./w. Oral iron was given throughout the study. Pretreatment EPO levels were determined in all patients. A complete response (CR) was defined when Ht was >38% and a partial response (PR) when there was an increase of the Ht >6% from the initial value was achieved. Sixteen of the 22 B-CLL patients had Rai stage III disease and 6 stage IV, with a median duration of anaemia 27 months (6-38); twelve of them were receiving chlorambucil while the rest were on no treatment. Of the SLL and LPL group, 4 patients had Ann Arbor stage III disease and 7 stage IV with a median duration of anaemia 24 months (5-36); 8 patients were on chlorambucil. Complete response was achieved in 50% of the B-CLL group and 54% of the SLL and LPL group, with an overall response rate of 77% and 81% respectively. All patients on maintenance therapy had a continuous response, while all patients, in whom rHuEPO was discontinued, relapsed. No correlation was found between patients: with low or high pretreatment serum EPO levels; those receiving concomitant therapy or not; those with B-symptoms or not; those with a non-diffuse or diffuse bone marrow infiltration pattern; and with splenomegaly or not. Life quality was significantly improved and no major side effects were encountered. We conclude from our study that r-HuEPO is very effective in correcting disease-related anaemia in B-CLD, resulting in down-staging of Rai stage III patients and that maintenance therapy is necessary. Whether the correction of anaemia improves patients' overall survival, still remains to be seen.
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Affiliation(s)
- M P Siakantaris
- First Department of Internal Medicine, National and Kapodistrian University, School of Medicine, Laikon General Hospital, Athens, Greece
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Pangalis GA, Dimopoulou MN, Angelopoulou MK, Tsekouras CH, Siakantaris MP. Campath-1H in B-chronic lymphocytic leukemia: report on a patient treated thrice in a 3 year period. Med Oncol 2000; 17:70-3. [PMID: 10713664 DOI: 10.1007/bf02826220] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Monoclonal antibody (mAb) therapy is a novel alternative treatment for lymphoid malignancies. In this report we present a 55-year-old patient with B-chronic lymphocytic leukemia, who was initially treated with chlorambucil p.o. and subsequently with cyclophosphamide iv with poor response. Then Campath-1H mAb was administered. He received three cycles of Campath-1H, over a 3 yr period, lasting 12 weeks each, at a final dose of 30 mg weekly, on an outpatient basis. After each cycle of Campath-1H administration there was a significant decrease of the size of the palpable lymph nodes, spleen and liver. Restoration of the blood lymphocyte count to normal and a significant decrease of the bone marrow lymphocytic infiltration was observed at the end of each cycle. Therefore, a major clinical response was obtained after all cycles. Campath-1H administration was well tolerated without causing any serious toxicity.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/immunology
- Antibodies, Neoplasm/therapeutic use
- Antineoplastic Agents/immunology
- Antineoplastic Agents/therapeutic use
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Lymphocyte Count
- Male
- Middle Aged
- Time Factors
- Treatment Outcome
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Affiliation(s)
- G A Pangalis
- Hematology Section, 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece.
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