Experience of Daratumumab in Relapsed/Refractory Multiple Myeloma: A Multicenter Study from Türkiye

Objective

This study aimed to evaluate patients with relapsed/refractory multiple myeloma (RRMM) who underwent daratumumab (DARA) therapy.

Materials and Methods

This multicenter retrospective study included 134 patients who underwent at least two courses of DARA from February 1, 2018, to April 15, 2022. Epidemiological, disease, and treatment characteristics of patients and treatment-related side effects were evaluated. Survival analysis was performed.

Results

The median age at the start of DARA was 60 (range: 35-88), with 56 patients (41.8%) being female and 48 (58.2%) being male. The median time to initiation of DARA and the median follow-up time were 41.2 (5.1-223) and 5.7 (2.1-24.1) months, respectively. The overall response rate after DARA therapy was 75 (55.9%), and very good partial response or better was observed in 48 (35.8%) patients. Overall survival (OS) and progression-free survival (PFS) for all patients were 11.6 (7.8-15.5) and 8.0 (5.1-10.9) months, respectively. OS was higher for patients undergoing treatment with DARA and bortezomib-dexamethasone (DARA-Vd) compared to those undergoing treatment with DARA and lenalidomide-dexamethasone (DARA-Rd) (16.9 vs. 8.3 months; p=0.014). Among patients undergoing DARA-Rd, PFS was higher in those without extramedullary disease compared to those with extramedullary disease (not achieved vs. 3.7 months; odds ratio: 3.4; p<0.001). The median number of prior therapies was 3 (1-8). Initiation of DARA therapy in the early period provided an advantage for OS and PFS, although it was statistically insignificant. Infusion-related reactions were observed in 18 (13.4%) patients. All reactions occurred during the first infusion and most reactions were of grade 1 or 2 (94.5%). The frequency of neutropenia and thrombocytopenia was higher in the DARA-Rd group (61.9% vs. 24.7%, p<0.001 and 42.9% vs. 15.7%, p<0.001).

Conclusion

Our study provides real-life data in terms of DARA therapy for patients with RRMM and supports the early initiation of DARA therapy.

Clinical Characteristics and Outcomes of Cancer Cases Among Syrian Refugees From Southern Turkey

Importance

Cancer was a common noncommunicable disease in Syria before the present conflict and is now a major disease burden among 3.6 million Syrian refugees in Turkey. Data to inform health care practice are needed.

Objective

To explore sociodemographic characteristics, clinical characteristics, and treatment outcomes of Syrian patients with cancer residing in the southern border provinces of Turkey hosting more than 50% of refugees.

Design, Setting, and Participants

This was a retrospective hospital-based cross-sectional study. The study sample consisted of all adult and children Syrian refugees diagnosed and/or treated for cancer between January 1, 2011, and December 31, 2020, in hematology-oncology departments of 8 university hospitals in the Southern province of Turkey. Data were analyzed from May 1, 2022, to September 30, 2022.

Main Outcomes and Measures

Demographic characteristics (date of birth, sex, and residence), date of first cancer-related symptom, date and place of diagnosis, disease status at first presentation, treatment modalities, date and status at last hospital visit, and date of death. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision and International Classification of Childhood Cancers, Third Edition, were used for the classification of cancer. The Surveillance, Epidemiology, and End Results system was applied for staging. The diagnostic interval was defined as the number of days from first symptoms until the diagnosis. Treatment abandonment was documented if the patient did not attend the clinic within 4 weeks of a prescribed appointment throughout the treatment.

Results

A total of 1114 Syrian adult and 421 Syrian children with cancer were included. The median age at diagnosis was 48.2 (IQR, 34.2-59.4) years for adults and 5.7 (IQR, 3.1-10.7) years for children. The median diagnostic interval was 66 (IQR, 26.5-114.3) days for adults and 28 (IQR, 14.0-69.0) days for children. Breast cancer (154 [13.8%]), leukemia and multiple myeloma (147 [13.2%]), and lymphoma (141 [12.7%]) were common among adults, and leukemias (180 [42.8%]), lymphomas (66 [15.7%]), and central nervous system neoplasms (40 [9.5%]) were common among children. The median follow-up time was 37.5 (IQR, 32.6-42.3) months for adults and 25.4 (IQR, 20.9-29.9) months for children. The 5-year survival rate was 17.5% in adults and 29.7% in children.

Conclusions and Relevance

Despite universal health coverage and investment in the health care system, low survival rates were reported in this study for both adults and children with cancer. These findings suggest that cancer care in refugees requires novel planning within national cancer control programs with global cooperation.

The Turkish perspective on apheresis activity: The Turkish apheresis registry report

Therapeutic apheresis is an extracorporeal treatment that selectively removes abnormal cells or harmful substances in the blood that are associated with or cause certain diseases. During the last decades the application of therapeutic apheresis has expanded to a broad spectrum of hematological and non-hematological diseases due to various studies on the clinical efficacy of this procedure. In this context there are more than 30 centers performing therapeutic apheresis and registered in the apheresis database in Turkey. Herein, we, The Turkish Apheresis Registry, aimed to analyze some key articles published so far from Turkey regarding the use of apheresis for various indications.

Acquired Hemophilia A In Adults: A Multicenter Study from Turkey

Acquired hemophilia A (AHA) is a rare disease caused by autoantibodies inhibiting factor VIII (FVIII) activity. Although the conditionis usually idiopathic, there may be other underlying diseases. Treatment consists of two steps: treatment of acute bleeding and immunosuppression. In this multicenter study, we aimed to demonstrate the clinical characteristics, management details, and survival of AHA patients in Turkey. Data was collected from eleven centers in Turkey. aPTT, FVIII, FVIII inhibitor, and hemoglobin (HB) levels, mixing test results, and demographics at diagnosis, treatment information, adverse events, bleeding episodes during follow-up, relapses, and outcome were analyzed. Twenty-nine patients were analyzed (58.6% female). No underlying disorder could be detected in 14 patients. The most prevalent etiologies were pregnancy, malignancy and infections. The median FVIII activity and FVIII inhibitor titer at diagnosis were 0.7% (0.0-29.4%) and 32.6 BU (0.6-135.6 BU) respectively. Bleeding was severe in 44.8% of patients. The HB value was significantly lower in patients with severe bleeding. Most of the patients (n = 25, 86.2%) had only one bleeding episode without relapse, three patients (10.3%) had two bleeding episodes, and one patient had more than three bleedings. 21 (75%) patients received hemostatic therapy. The use of recombinant FVIIa was slightly higher than activated prothrombin complex concentrate (15 versus 10 patients). Immunosuppressive treatment was initiated in 26 (93%) patients. Regimens containing steroid, cyclophosphamide, and rituximab in different combinations were the most preferred. The median follow-up period was 13 months (2-156 months). Median overall survival was 154.97 months. Four and six-year survival were 90.9 ± 0.8% and 77.9 ± 14.1% respectively. This is a unique study that investigated the demographic characteristics, treatment approaches, and patient survival of AHA in Turkey.

Castleman Disease: A Multicenter Case Series from Turkey

Objective:

Castleman disease (CD) is a rare disease also known as angiofollicular lymph node hyperplasia. The two main histological subtypes are the hyaline vascular and plasma cell variants. It is further classified as unicentric CD (UCD) or multicentric CD (MCD) according to the anatomical distribution of the disease and the number of lymph nodes involved. The aim of this multicenter study was to evaluate all cases of CD identified to date in Turkey to set up a national registry to improve the early recognition, treatment, and follow-up of CD.

Materials and Methods:

Both adult (n=130) and pediatric (n=10) patients with lymph node or involved field biopsy results reported as CD were included in the study. Patients’ demographic information, clinical and laboratory characteristics, imaging study results, treatment strategies, and clinical outcomes were evaluated retrospectively.

Results:

A total of 140 patients (69 male and 71 female) with a diagnosis of UCD (n=73) or MCD (n=67) were included. The mean age was 39 years in the UCD group and 47 years in the MCD group. Female patients were more common in the UCD group. The most common histological subtype was hyaline vascular for both UCD and MCD patients. Asymptomatic patients were more common in the UCD group. Anemia, elevations of acute phase reactants, and hypoalbuminemia were more common in the MCD group. The most commonly used treatment strategies for UCD were surgical excision, rituximab, and radiotherapy, respectively. All UCD patients were alive at a median of 19.5 months of follow-up. The most commonly used treatment strategies for MCD were methyl prednisolone, R-CHOP, R-CVP, and rituximab. Thirteen MCD patients had died at a median of 34 months of follow-up.

Conclusion:

This study is important in presenting the patient characteristics and treatment strategies for CD from Turkey, with the potential of increasing awareness about CD. Treatment data may help in making decisions, particularly in countries that do not have access to siltuximab. However, larger prospective studies are needed to make definitive conclusions.

Ruxolitinib Reduces Oxidative Stress in Patients With Primary Myelofibrosis: A Multicenter Study

Introduction

Primary myelofibrosis (PM) has a lower overall survival rate than other myeloproliferative neoplasms, and leukemic transformation is the most common cause of death. Increased oxidative stress has an important role in leukemic transformation in these patients. In this study, we aimed to find an answer to the question, "Could Ruxolitinib, which has been widely used in patients with myelofibrosis in recent years, have a role in reducing oxidative stress in these patients?".

Methods

A total of 106 patients with PM and 111 healthy volunteers were included in this study. We collected the serum samples of healthy volunteers and patients with myelofibrosis at the time of diagnosis and one month after the initiation of Ruxolitinib treatment. Ischemia modified albumin (IMA), native thiol, total thiol, and disulfide levels were studied. The disulfide/native thiol, disulfide/total thiol, and native thiol/total thiol ratios were calculated.

Results

IMA, native thiol, total thiol, disulfide levels, disulfide/native thiol, and disulfide/total thiol ratios at the time of diagnosis were significantly different in patients with myelofibrosis compared to the control group (p=0.001). Ruxolitinib significantly reduced oxidative stress when the measurements in the first month after Ruxolitinib were compared with those at the time of diagnosis (p=0.001). In patients with ASXL1 mutation, intermediate-2 risk, and high-risk according to the Dipps-plus score, the decrease in oxidative stress in the first month of treatment was more significant than at the time of diagnosis.

Conclusion

Ruxolitinib may be an effective treatment for reducing oxidative stress in patients with PM. The reduction in oxidative stress parameters with treatment in patients with ASXL1 mutation, intermediate-2, and high-risk patients was observed to be higher.

Results of multicenter registry for patients with inherited factor VII deficiency in Turkey

INTRODUCTION

Inherited factor VII (FVII) deficiency (FVIID) is the most common of inherited rare bleeding disorders. Other determinants of clinical severity apart from FVII level (FVIIL) include genetic and environmental factors. We aimed to identify the cut-off FVIILs for general and severe bleedings in patients with FVIID by using an online national registry system including clinical, laboratory, and demographic characteristics of patients.

METHODS

Demographic, clinical, and laboratory data of patients with FVIID extracted from the national database, constituted by the Turkish Society of Hematology, were examined. Bleeding phenotypes, general characteristics, and laboratory features were assessed in terms of FVIILs. Bleeding rates and prophylaxis during special procedures/interventions were also recorded.

RESULTS

Data from 197 patients showed that 46.2% of patients had FVIIL< 10%. Most bleeds were of mucosal origin (67.7%), and severe bleeds tended to occur in younger patients (median age: 15 (IQR:6-29)). Cut-off FVIILs for all and severe bleeds were 16.5% and 7.5%, respectively. The major reason for long-term prophylaxis was observed as central nervous system bleeding (80%).

CONCLUSION

Our data are consistent with most of the published literature in terms of cut-off FVIIL for bleeding, as well as reasons for prophylaxis, showing both an increased severity of bleeding and younger age at diagnosis with decreasing FVIIL. However, in order to offer a classification similar to that in Hemophilia A or B, data of a larger cohort with information about environmental and genetic factors are required.

Thiol/Disulfide Balance in Older Patients with BCR-ABL Negative Myeloproliferative Neoplasms

BACKGROUND

The trio Essential Thrombocytosis (ET), Polycythemia Vera (PV), and Primary Myelofibrosis (PM) are BCR-ABL negative myeloproliferative neoplasms. All three diseases have the risk of transforming into acute leukemia. Oxidative stress and some genetic mutations increase the risk of leukemic transformation. The median age in patients with ET, PV, and MF is around 64 years, and it is expected to exceed 65 in the coming years. Since oxidative stress increases with age, we aimed to evaluate the oxidative stress parameters in older patients with myeloproliferative neoplasms.

METHODS

The study included a total of 160 patients (57 patients with Essential Thrombocytosis, 52 patients with Primary Myelofibrosis, and 51 patients with Polycythemia Vera) and 56 healthy controls, aged 65 and over. Ischemia Modified Albumin (IMA) and thiol parameters (native thiol, total thiol, and disulfide) were studied from serum samples taken at the time of diagnosis.

RESULTS

The median age of the patients was 69 (65 - 85) years. Patients had higher levels of IMA and lower levels of thiol compared to the control group (p < 0.001). When evaluated according to disease subgroups, it was observed that the highest IMA levels and the lowest thiol levels were in patients with PM (p < 0.001). Higher IMA levels and lower native thiol levels were found in patients with the ASXL1 mutation (p < 0.001).

CONCLUSIONS

Serum IMA and thiol levels are also significantly changed in older patients with BCR-ABL negative myeloproliferative neoplasia. Changes in these markers are independent of age. Disease-associated mutations such as ASXL1 can also affect the serum levels of these markers.

Real world results of venetoclax combined with hypomethylating agents in relapsed/refractory AML

OBJECTIVE

Relapsed/refractory AML cases are much more resistant to chemotherapy. Venetoclax is a highly sensitive BCL-2 inhibitor. It was aimed to evaluate the effects of venetoclax therapy on real-world R/R AML survival outcomes, the effects of the cytogenetic characteristics of the patients and previous clinical applications on treatment response, and venetoclax treatment toxicity.

PATIENTS AND METHODS

The study included patients who only received a venetoclax-based salvage on R/R AML patients from Turkey. The study included a total of 62 patients from 6 different centers in Turkey. Response to 2 cycles of venetoclax treatment was assessed by bone marrow blast rate. The demographic data, cytogenetic characteristics, AML type, MDS type, response rates and overall survival of the patients after venetoclax combination treatment were assessed. Median age of the patients was 65 (19-85). Mean number of prior treatments was 2.67 ±1.75.

RESULTS

13 patients (21%) had a history of allogenic stem cell transplantation. 58 (93.5%) had received HMA therapy before venetoclax. 36 patients (58.1%) had de-novo AML, and 25 (40.3%) previously had MDS. Treatment response was evaluated as complete remission (n = 21, 33.9%), partial response (n = 17, 27.4%), and treatment failure (n = 24, 38.7%). Patients in the TF group were significantly more likely to have poor cytogenetic and to have received allogeneic transplants. The mean estimated overall survival after the venetoclax treatment was 9.13 ± 0.75 months.

CONCLUSIONS

The study population consisted of a group of patients who had relapsed or primary refractory disease with poor prognosis, despite numerous rounds of chemotherapy. It is our belief that the high response rates obtained with the combination of venetoclax/HMA, and having obtained positive results with poor risk patients, indicated a promising perspective for R/R AML patients.

Integration of low muscle mass into the IPS system and its prognostic significance in patients with Hodgkin's lymphoma

Aim: The aim of this study is to determine whether a novel prognostic score can be obtained by including low muscle mass in the international prognostic score (IPS) system. Materials & Methods: Psoas muscle areas were determined in the PET/CT scans of the patients taken for staging at the time of diagnosis and after two cycles of ABVD. After evaluating the effect of low muscle mass on overall survival, receiver operating characteristic (ROC) analyzes were performed by including it in IPS systems. Results: Overall survival was significantly lower in patients with low muscle mass. Adding low muscle mass to IPS scores increased AUC, sensitivity and specificity. Conclusion: The integration of low muscle mass into the IPS scoring systems increased the success of these systems in predicting a prognosis.

Efficacy and Safety of Ibrutinib Therapy in Patients with Chronic Lymphocytic Leukemia: Retrospective Analysis of Real-Life Data

Objective:

This study aimed to retrospectively evaluate the efficacy, safety, and survival outcome of single-agent ibrutinib therapy in chronic lymphocytic leukemia patients.

Materials and Methods:

A total of 136 patients (mean age ± standard deviation: 64.6±10.3 years, 66.9% males) who had received at least one dose of ibrutinib were included in this retrospective multicenter, noninterventional hospital-registry study conducted at 33 centers across Turkey. Data on patient demographics, baseline characteristics, laboratory findings, and leukemia-cell cytogenetics were retrieved. Treatment response, survival outcome including overall survival (OS) and progression-free survival (PFS), and safety data were analyzed.

Results:

Overall, 36.7% of patients were categorized as Eastern Cooperative Oncology Group (ECOG) class 2-3, while 44.9% were in Rai stage 4. Fluorescence in situ hybridization revealed the presence of del(17p) in 39.8% of the patients. Patients received a median of 2.0 (range: 0-7) lines of pre-ibrutinib therapy. Median duration of therapy was 8.8 months (range: 0.4-58.0 months). The 1-year PFS and OS rates were 82.2% and 84.6%, respectively, while median PFS time was 30.0 (standard error, 95% confidence interval: 5.1, 20.0-40.0) months and median OS time was 37.9 (3.2, 31.5-44.2) months. Treatment response (complete or partial response), PFS time, and OS time were better with 0-2 lines versus 3-7 lines of prior therapy (p<0.001, p=0.001, and p<0.001, respectively), with ECOG class 0-1 versus class 2-3 (p=0.006, p=0.011, and p=0.001, respectively), and with Rai stage 0-2 versus 3-4 (p=0.002, p=0.001, and p=0.002, respectively). No significant difference was noted in treatment response rates or survival outcome with respect to the presence of comorbidity, bulky disease, or del(17p). While 176 adverse events (AEs) were reported in 74 (54.4%) patients, 46 of those 176 AEs were grade 3-4, including pneumonia (n=12), neutropenia (n=11), anemia (n=5), thrombocytopenia (n=5), and fever (n=5).

Conclusion:

This real-life analysis confirms the favorable efficacy and safety profile of long-term ibrutinib treatment while emphasizing the potential adverse impacts of poorer ECOG performance status, heavy treatment prior to ibrutinib, and advanced Rai stage on patient compliance, treatment response, and survival outcomes.

The Usefulness of Platelet Distribution Width and Platelet Distribution Width to Lymphocyte Ratio in Predicting Severity and Outcomes in Patients with Snakebite

INTRODUCTION

Tissue damage, inflammatory response, and hematologic abnormalities may occur in snakebite envenomation. This study aimed to evaluate the predictive ability of platelet distribution width (PDW) and platelet distribution width to lymphocyte ratio (PDWLR) in the severity and outcome of envenomation in patients with snakebites in the emergency department (ED).

METHODS

All adult patients admitted to the ED after a snakebite were retrospectively evaluated. Patients were classified according to the severity of envenomation. The relationship between the PDW and PDWLR and envenomation severity and patient outcomes was analyzed. Multivariate logistic regression analysis was performed to determine the predictors of severe envenomation. Results were presented as 95% CIs with odds ratios. Statistical significance was accepted at P<0.05.

RESULTS

Envenomation was classified as none/minimal in 42 patients and moderate/severe in 29. PDW and PDWLR were significantly higher in the moderate/severe group (P=0.016 and P<0.001, respectively). Cut-off values of 16.5 for PDW and 6.15 for PDWLR were related to more severe envenomation (area under the curve 0.67, 95% CI 0.55-0.78 and area under the curve 0.85, 95% CI: 0.74-0.92, respectively). Blood product replacement, thrombocytopenia, hematologic abnormality, advanced local findings, compartment syndrome/fasciotomy, antivenom dosing, and moderate/severe envenomation were associated with PDWLR >6.15 (P<0.05). In multivariate analysis, PDWLR (odds ratio 1.19 [95% CI 1-1.4]; P=0.04) was an independent predictor of severe envenomation.

CONCLUSIONS

Higher PDW and PDWLR were associated with severe envenomation in patients with snakebites in the ED. PDWLR may be used as a predictor of severe envenomation and adverse outcomes.

Cardiac Chamber Quantification by Echocardiography in Adults With Sickle Cell Disease: Need Attention to Eccentric Hypertrophy

Introduction and aim

Sickle cell anemia (SCA) is the most common hemoglobinopathy worldwide, and cardiovascular diseases are the most common causes of death. In these patients, cardiac remodeling begins from childhood and leads to sickle cell cardiomyopathy in the following years. Concentric hypertrophy and eccentric hypertrophy are known to predict early cardiac events. This study aims to reveal the relationship between cardiac remodeling types and survival in patients with SCA and investigate the factors that may affect left ventricular mass.

Materials and methods

A total of 146 patients with SCA were included in the study, and the left ventricular mass index (LVMI) and relative wall thickness (RWT) of the patients were calculated according to echocardiographic measurements, and the patients were categorized into normal, concentric remodeling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH) groups.

Results

The median age of the patients is 32 (18-72). In logistic regression analysis, hemoglobin S (HbS) and ferritin levels were independent predictors for LVMI (p = 0.01 and p < 0.001, respectively). It was observed that 56 (38.4%) of the patients had normal left ventricles, 24 (16.4%) had CR, 21 (14.4%) had CH, and 45 (30.8%) had EH. 31 (21.2%) of the patients died. When we look at the survival curves, there was a statistically significant difference between the four groups (log-rank p < 0.001). It was observed that patients with EH were the group with the lowest probability of survival.

Conclusion

Cardiac death is one of the most common causes of death in patients with SCA. Early detection of cardiac disorders and starting treatment may be important in reducing mortality in these patients.

Lymphoblastic Involvement of the Bone Marrow as a Cause of Superscan Appearance in 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography

The ¹⁸F-fluorodeoxylucose (FDG) positron emission tomography (PET) is the gold standard imaging modality in the staging of lymphoma. The superscan appearance in the FDG PET/computerized tomography (CT) imaging might be because of benign diseases or malignant infiltrations. This case report presents lymphomatous blastic infiltration as a cause of superscan appearance in ¹⁸F-FDG PET/CT.

P3622Demographic and clinical characteristics of atrial fibrillation patients suffering from an ACS without prior revascularization history

Background

The incidence of atrial fibrillation in acute coronary syndromes (ACS) ranges from 3% to 25%. The purpose of the current study was to investigate the demographic and baseline clinical characteristics, cardiovascular risk factors and comorbid conditions between patients (pts) with concomitant atrial fibrillation (AF) to those without AF in patients suffering from ACS without previous coronary artery bypass graft (CABG) and/or percutaneous coronary intervention.

Methods

The MINOCA-TR study has a cross-sectional, multicenter, observational design and was conducted with 32 interventional cardiology centers in our country. Heart rhythm at emergency admission, demographical, clinical and angiographic data was recorded for each patient. Patients with stable coronary artery disease, unstable angina pectoris and with type 4/5 myocardial infarction were excluded from study population.

Results

A total of 1626 patients (male: 70.7%, mean age: 61.4±12.5 years) were classified according to the presence of AF. The rate of AF was 3.1% in study population. This group was older (73.4 vs. 61.0 years, p<0.001) and AF was more common among females (43.1% vs. 28.7%, p=0.027). The frequency of AF was slightly higher (7.8%) in MINOCA group (p=ns).

STEMI presentation was more common in patients without AF (31.3% vs. 46.9%, p=0.028). LVEF was significantly lower in ACS patients with AF (44.1% vs. 49.4%, p=0.039). The frequency of AF was significantly higher (3.7%) in MINOCA group.

AF vs. non-AF ACS pts w/o prior revasc Parameter ACS with AF ACS without AF p value Age (years) 73.4 (±9.4) 61.0 (±12.4) <0.001 Female (%) 43.1 28.7 0.027 cTnT levels (pg/dL) median (IQR) 15.2 (96) 15.3 (428) 0.421 STEMI (%) 31.3 46.9 0.028 LVEF (%) 44.1 (±12.2) 49.4 (±10.4) 0.039 MINOCA (%) 7.8 6.6 0.743 STEMI: ST-segment elevation MI; NSTEMI: Non-ST-segment elevation myocardial infarction; LVEF: left ventricular ejection fraction; MINOCA: Myocardial Infarction with Non-Obstructive Coronary Arteries.

Conclusions

The frequency of AF was relatively lower in patients suffering from an ACS without prior revascularization history. They were older than patients without AF and were common in females. Non-ST-segment elevation myocardial infarction was significantly higher in the AF. The presence of MINOCA was similar between 2 groups.

A National Registry of Thalassemia in Turkey: Demographic and Disease Characteristics of Patients, Achievements, and Challenges in Prevention

Objective:

The Turkish Society of Pediatric Hematology set up a National Hemoglobinopathy Registry to demonstrate the demographic and disease characteristics of patients and assess the efficacy of a hemoglobinopathy control program (HCP) over 10 years in Turkey.

Materials and Methods:

A total of 2046 patients from 27 thalassemia centers were registered, of which 1988 were eligible for analysis. This cohort mainly comprised patients with β-thalassemia major (n=1658, 83.4%) and intermedia (n=215, 10.8%).

Results:

The majority of patients were from the coastal areas of Turkey. The high number of patients in Southeastern Anatolia was due to that area having the highest rates of consanguineous marriage and fertility. The most common 11 mutations represented 90% of all β-thalassemia alleles and 47% of those were IVS1-110(G->A) mutations. The probability of undergoing splenectomy within the first 10 years of life was 20%, a rate unchanged since the 1980s. Iron chelators were administered as monotherapy regimens in 95% of patients and deferasirox was prescribed in 81.3% of those cases. Deferasirox administration was the highest (93.6%) in patients aged <10 years. Of the thalassemia major patients, 5.8% had match-related hemopoietic stem cell transplantation with a success rate of 77%. Cardiac disease was detected as a major cause of death and did not show a decreasing trend in 5-year cohorts since 1999.

Conclusion:

While the HCP has been implemented since 2003, the affected births have shown a consistent decrease only after 2009, being at lowest 34 cases per year. This program failure resulted from a lack of premarital screening in the majority of cases. Additional problems were unawareness of the risk and misinformation of the at-risk couples. In addition, prenatal diagnosis was either not offered to or was not accepted by the at-risk families. This study indicated that a continuous effort is needed for optimizing the management of thalassemia and the development of strategies is essential for further achievements in the HCP in Turkey.

The Role of Azacitidine in the Treatment of Elderly Patients with Acute Myeloid Leukemia: Results of a Retrospective Multicenter Study

Objective:

In this study, we aimed to investigate the efficacy and safety of azacitidine (AZA) in elderly patients with acute myeloid leukemia (AML), including patients with >30% bone marrow (BM) blasts.

Materials and Methods:

In this retrospective multicenter study, 130 patients of ≥60 years o ld who were ineligible for intensive chemotherapy or had progressed despite conventional treatment were included.

Results:

The median age was 73 years and 61.5% of patients had >30% BM blasts. Patients received AZA for a median of four cycles (range: 1-21). Initial overall response [including complete remission (CR)/CR with incomplete recovery/partial remission] was 36.2%. Hematologic improvement (HI) of any kind was documented in 37.7% of all patients. HI was also documented in 27.1% of patients who were unresponsive to treatment. Median overall survival (OS) was 18 months for responders and 12 months for nonresponders (p=0.005). In the unresponsive patient group, any HI improved OS compared to patients without any HI (median OS was 14 months versus 10 months, p=0.068). Eastern Cooperative Oncology Group performance status of <2, increasing number of AZA cycles (≥5 courses), and any HI predicted better OS. Age, AML type, and BM blast percentage had no impact.

Conclusion:

We conclude that AZA is effective and well tolerated in elderly comorbid AML patients, irrespective of BM blast count, and HI should be considered a sufficient response to continue treatment with AZA.

Quality of life, clinical effectiveness, and satisfaction in patients with beta thalassemia major and sickle cell anemia receiving deferasirox chelation therapy

Objectives:

There is a need to remove excess iron with iron chelation therapy (ICT) to avoid the serious clinical sequelae associated with iron overload in patients with beta thalassemia major (BTM) and sickle cell anemia (SCA). Due to the effects of the diseases and their treatments, ICT is still a major reason for unsatisfactory compliance. The aim of this single-center observational study was to evaluate the quality of life, clinical effectiveness, and satisfaction in pediatric and adult patients with BTM and SCA receiving deferasirox (DFX) chelation therapy.

Methods:

In this study, 37 pediatric and 35 adult patients with BTM or SCA receiving DFX for at least 6 months participated. Upon receipt of Informed Consent Form, Case Report Form, Demographic Data Collection Form, Child Health Questionnaire-Parent Form, Life Quality Survey Short Form-36, and ICT Satisfaction Survey were used to obtain data for the effectiveness of ICT and parameters that may affect compliance to treatment and life quality of the participants.

Results:

As a main index for the effectiveness of DFX chelation therapy, serum ferritin levels were higher than the normal values in the patients receiving DFX. The increased ferritin levels were also associated with hematological and biochemical abnormalities. Our findings regarding quality of life and satisfaction with DFX chelation therapy indicated that the patients with BTM or SCA had lower scores. Overall, problems with treatment regimen and side effects appeared to be common causes of poor compliance to DFX chelation therapy.

Conclusions:

Our findings suggest that health care providers should be aware of the importance of monitoring iron load with timely initiation of DFX chelation therapy and ongoing adjustments to chelation regimens and/or transfusion methods to decrease hospitalizations and improve compliance to ICT of the patients with BTM and SCA.

MicroRNA Expression Analysis in Patients with Primary Myelofibrosis, Polycythemia vera and Essential Thrombocythemia

MicroRNAs (miRNA) are small non-coding RNA molecules that play critical roles in cell differentiation, proliferation and apoptosis and thus regulate haematopoietic stem cells and committed progenitor cells. We analyzed expressions of miRNAs associated with hematopoietic transformation of myeloid, erythroid and megakaryocytic progenitor cells during haematopoiesis (mir155, mir181a, mir221, mir222, mir223, mir451), in patients with primary myelofibrosis (PMF) (n = 22), polycythemia vera (PV) (n = 33), essential thrombocythemia (ET) (n = 49) and in healthy controls (n = 40) by quantitate/real time polymerase chain reaction. RT-PCR testing was negative for BCR-ABL1 fusion gene in all the patients. Mir155 was expressed in higher levels in all 3 disorders (p < 0.05). Mir221 was higher especially in ET and PMF group (p < 0.05). Mir222 expression was lower in PV patients (p < 0.05) and higher in ET and PMF patients compared to control group. Mir223 expression was higher in ET and PMF group than control group (p > 0.05). Mir451 levels were lower in all three groups compared to control group (p < 0.05). There was no difference in expression levels of mir181a between groups. JAK2V617F positivity, co-morbidities, drugs, and gender did not affect miRNA expressions. This study holds promise for the future application of these molecules for differential diagnosis and as therapeutic targets in Philadelphia chromosome negative myeloproliferative neoplasms.

Clinical and pathological characteristics of triple-negative breast cancer patients: A single-center experience

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Background: Triple negative breast cancer in which estrogen, progesterone receptors and c-erbB2 overexpression are negative, seems to have different clinical course and recurrence pattern. Methods: We evaluated retrospectively clinical demographic and pathological characteristics of triple negative breast cancers and investigated the association of these characteristics with OS and PFS. Results: 59 early stage patients with triple negative breast cancer patients followed in Baskent University Hospital between 1997-2009 were enrolled into the study. The median age of patients was 49. Median follow-up duration was 27 months (0.27-132 months). Two patients died during the follow-up. Invasive ductal carcinoma pathology was reported in 38 patients, invasive lobular in 3 patients, medullary in 5 patients.Almost half of the patients had LVI. 79% of patients had a T2 disease. 30% of patients’ tumor histological grade was III. Cancer history in the family was present in 95% of patients. Almost half of the patients had stage II disease. Adjuvant chemotherapy was given to 43 patients. Relapses were observed in 15 patients.The most common metastatic site was lung. Patients having high grade tumor, >3 (+) lymph nodes, younger age have higher chance of relapse during follow-up. Conclusions: In accordance with the literature, our triple negative breast cancer patients showed more aggressive characteristics. Although median follow-up is short, one-fourth of the patients having recurrence support natue of the triple negative breast cancer patients. In our study, triple negative patients had younger age at diagnosis, high grade tumors and more tendency to metastasize to visceral organs.

Proteolysis of insulin-like growth factor-binding protein-3 is increased in urine from patients with diabetic nephropathy

The insulin-like growth factor (IGF) system has been implicated in the development of experimental diabetic nephropathy. IGF-binding protein-3 (IGFBP-3) modulates IGF actions, and proteolysis decreases its binding affinity for IGFs. The aim of this study was to explore the possibility that proteolysis of IGFBP-3 may be altered in diabetic nephropathy and may therefore modify the intrarenal effects of IGFs. IGFBP-3 proteolysis in urine from diabetic patients with normo- [albumin excretion rate (AER), <20 microg/min], micro- (AER, 20-200 microg/min), and macroalbuminuria (AER, >200 microg/min) was studied in 34 patients with noninsulin-dependent diabetes mellitus (NIDDM), 14 patients with insulin-dependent diabetes mellitus, and 9 controls. Urine samples were analyzed by Western ligand blotting and IGFBP-3 immunoblotting. Protease activity was quantitated using [125I]IGFBP-3 as a substrate. WLB showed three main bands (40-46, 35, and 26 kDa) in control urine and a fainter 18-kDa band. All but the 35-kDa band were immunoreactive with the IGFBP-3 antiserum. The same pattern of IGFBPs was seen in urine from normoalbuminuric diabetic patients. However, the urine of diabetic patients with micro- and macroalbuminuria contained little or no intact 40- to 46-kDa IGFBP-3. In patients with noninsulin-dependent diabetes mellitus, urinary IGFBP-3 protease activity in micro- (n = 13) and macroalbuminuric patients (n = 12; mean +/- SD[SCAP], 75 +/- 25% and 84 +/- 24%) was significantly higher than that in normoalbuminuric patients (29 +/- 9%; P = 0.0001). Similar results were observed in patients with insulin-dependent diabetes mellitus. Proteolytic activity in diabetic urine was due to a serine protease. In conclusion, diabetic nephropathy was associated with IGFBP-3 proteolysis in urine. As similar changes were not observed in patients' sera, this is likely to reflect changes in the kidney or urinary tract, resulting in increased local IGF bioavailability, and therefore may contribute to the structural changes of diabetic nephropathy.

The results of surgical treatment and percutaneous drainage of hepatic hydatid disease

BACKGROUND

Hydatid disease of the liver remains an important and challenging problem in rural areas. Although, surgery is considered the treatment of choice for hydatid disease of the liver, percutaneous drainage is an alternative treatment method for selected cases. The purpose of this study was to evaluate the results of percutaneous drainage and surgery.

METHODS

A total of 66 patients underwent surgery; 36 cases had percutaneous drainage and were evaluated preoperatively for treatment choice according to localization, multiplicity, echographic type and size of the cysts in the liver. The patients were also evaluated postoperatively for systemic complications, e.g. fistula formation, infection of residual cyst, recurrence and hospitalization period for each group.

RESULTS

Two groups, those with multiple cysts and cysts bigger than 5 cm, were treated by surgery. At the end of two treatment modalities, systemic complications, biliary fistulizations, recurrence and infection of cyst's cavity were seen more frequently in the surgery group and caused a longer hospital stay.

CONCLUSIONS

Percutaneous drainage plus medical treatment can be successfully done for type I, type II and some selected type III hydatid cysts of the liver giving less complications, lower recurrence and shorter hospitalization periods. But, surgery is the primary treatment for big, multiple, complicated and recurrent hydatid cysts of the liver.

Detection of microalbuminuria in diabetic patients by urinary dipstick

The present study was undertaken to determine the usefulness of a new, sensitive urinary dipstick, Micral-Test II (Boehringer-Mannheim, Mannheim, Germany) for the detection of microalbuminuria (urinary albumin concentration: 20-200 mg/l) in diabetic patients. four hundred and eleven consecutive outpatients with diabetes were screened for microalbuminuria. The diagnostic accuracy of Micral-Test II for the detection of urinary albumin excretion > 20 mg/l was assessed by comparing the urinary albumin concentration determined by Micral-Test II with radioimmunoassay (RIA). In comparison with radioimmunoassay, Micral-Test II had an overall sensitivity of 93%, specificity of 93% and positive predictive value of 89%. False negative results were found in 7% and false positives were obtained in 7% of specimens. These findings suggest that Micral-Test II may be a useful method for the screening of microalbuminuria. However, it should not be regarded as a diagnostic test and a positive result should be followed by measuring AER by a laboratory based method.

Effects of liver transplantation and resection on lipid parameters: a longitudinal study

BACKGROUND

The liver plays a vital role in the production and clearance of a large number of lipoproteins and is an important determinant of the plasma levels of various lipids including cholesterol, as well as apoproteins such as apoprotein (a).

METHODS

To explore the role of the liver in the regulation of lipids and apoprotein concentrations, a serial prospective study measuring lipid parameters and apoprotein (a) levels over 6 months was performed in individuals undergoing hepatic resection for isolated hepatic metastases, transplantation for end-stage liver disease and in individuals undergoing colorectal surgery for malignancy.

RESULTS

In the group with hepatic resection, there was a rapid decrease in total, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol in the immediate postoperative period. However, these changes could be explained by fasting and surgical intervention as a similar phenomenon was observed in the control subjects. In patients undergoing liver transplantation, total cholesterol decreased over the the immediate postoperative period but had fully recovered by day 40. Apoprotein (a) was low pre-operatively, remained low over the first week but had risen by day 10. Apoprotein (a) at day 40 correlated with the apoprotein (a) level of the donor (r = 0.80, P < 0.01) but not of the recipient's pre-operative level and this correlation persisted 6 months after hepatic transplantation.

CONCLUSIONS

The liver has a large reserve and is able to maintain lipoprotein production and removal despite greater than 50% removal. The major cause of reduced plasma lipid concentrations in the postoperative period relates to other factors such as fasting and handling of the gut during surgery. In liver transplantation, apoprotein (a) levels resemble those of the donor within 2 weeks of organ donation, consistent with the liver being the major site of production of this apoprotein.

Relationship of progressively increasing albuminuria to apoprotein(a) and blood pressure in type 2 (non-insulin-dependent) and type 1 (insulin-dependent) diabetic patients

This study has explored the temporal relationship between apoprotein(a), blood pressure and albuminuria over a mean interval of 11 years in a cohort of 107 diabetic patients of whom 26 (14 Type 2 (non-insulin-dependent), 12 Type 1 (insulin-dependent) had progressively increasing albuminuria ('progressors'). In Type 2 diabetic patients, no significant differences were noted for HbA1, blood pressure, creatinine clearance or serum lipids between progressors and non-progressors. In Type 1 diabetic patients, final systolic and diastolic blood pressures were higher in progressors compared with non-progressors and progressors showed impairment of renal function in association with a rise in blood pressure at the macroalbuminuric stage. Initial apoprotein(a) levels were similar in progressors and non-progressors of either diabetes type. Apoprotein(a) levels increased exponentially with time in 12 of 14 Type 2 progressors but only in 5 of 12 Type 1 progressors (p < 0.01). In Type 2 diabetic patients, the annual increase in apoprotein(a) levels was 9.1 +/- 2.4%, which was significantly greater than in non-progressors, 2.0 +/- 1.2% (p < 0.01) and also exceeded the rates of increase of apoprotein(a) in progressors with Type 1 diabetes, 4.0 +/- 1.4%, (p < 0.05). Apoprotein(a) levels correlated significantly with albuminuria in 8 of 14 Type 2 progressors but only in 3 of 12 Type 1 progressors (p < 0.05). The rate of increase of apoprotein(a) levels was not related to mean HbA1, creatinine or creatinine clearance levels, or to albuminuria.(ABSTRACT TRUNCATED AT 250 WORDS)

Semi-quantitative determination of microalbuminuria by urinary dipstick

Microalbuminuria predicts subsequent clinical nephropathy and mortality in diabetic patients. This study was undertaken to determine the usefulness of a new immunochemical urinary dipstick test (Micral-Test, Boehringer Mannheim, GmbH Mannheim, Germany) in identifying urinary albumin concentrations within the microalbuminuric range (urinary albumin concentration 20-200 mg/L). Twenty-four hour urine specimens were collected from 298 consecutive diabetic outpatients. Micral-Test was performed by two laboratory scientists blinded to each other's results and those of radioimmunoassay (RIA) and immunoturbidimetry on the same specimen. When compared with RIA, Micral-Test had an overall sensitivity of 92.2%, specificity of 92.3% and positive predictive value of 86.4%. However, at the threshold value of 20 mg/1 Micral-Test showed false positive results in 37.8% of samples when compared with RIA. Similar results were obtained when Micral-Test was compared with immunoturbidimetry. We conclude that Micral-Test is a useful screening method for the detection of microalbuminuria. We suggest that positive tests be confirmed by a timed urine collection using established methodology and that patients whose Micral-Test is negative be subjected to annual retesting.