The Role of "Critical" Ultrasound Reassessment in the Decision-Making of Bethesda III Thyroid Nodules

Background and Objectives: Bethesda III (BIII) thyroid nodules have an expected malignancy rate of 5-15%. Our purpose was to assess which US criteria are most associated with cancer risk, and the value of critical ultrasound (US) reassessment. Methods: From 2018 to 2022, 298 BIII nodules were enrolled for thyroidectomy (79 malignancies). We evaluated ultrasonographic data: hechogenicity, intralesional vascularization, spiculated margins, micro-calcifications, "taller than wide" shape, extra-thyroidal growth, size increase, as well as their association with histology. We also evaluated if the ultrasound reassessment modified the strategy. Results: Spiculated margins and microcalcification were significantly correlated with malignancy risk. Spiculated margins showed a specificity of 0.95 IC95% (0.93-0.98); sensitivity 0.70 IC95% (0.59-0.80). Microcalcifications showed a sensitivity of 0.87 CI95% (0.80-0.94); specificity 0.75 CI95% (0.72-0.83). The presence of these signs readdressed the strategy in 76/79 cases Then, the indication for surgery was appropriate in 75% of cases. Conclusions: Microcalcifications and spiculated margins should be routinely sought during a final ultrasound reassessment in BIII nodules. These signs allowed for a modification of the strategy in favor of surgery in 96% of the cases that were not otherwise referred to surgery. The importance of integrating ultrasound and cytology in the evaluation of BIII thyroid nodules is confirmed. Reassessment with ultrasound of BIII nodules allowed for a redirection of the surgical choice.

Influence of Operational Strategies for the Recovery of Magnesium Hydroxide from Brines at a Pilot Scale

The continuous depletion of minerals caused by land mining and the increase in their demand have pushed the development of novel sustainable technological processes for mineral recovery from unconventional sources. In this context, magnesium (Mg) has gained considerable attention for its peculiar properties and high relevance of its compounds, such as magnesium hydroxide, Mg(OH)₂. In the present work, the influence of several operating conditions on the Mg(OH)₂ precipitation process was thoroughly investigated by adopting a novel multiple feed-plug flow reactor. The influence of (i) initial Mg²⁺ concentrations in the feed stream; (ii) brine and alkaline flow rates; and (iii) the product recycling strategy (seeded crystallization) was considered. The results marked the possibility of improving sedimentation and filterability properties of Mg(OH)₂ suspensions by adopting the recycling strategy to overcome industrial issues associated with the production of Mg(OH)₂ suspensions using NaOH solutions.

Incidence of AIDS-defining cancers and virus-related and non-virus-related non-AIDS-defining cancers among HIV-infected patients compared with the general population in a large health district of Northern Italy, 1999-2009

OBJECTIVES

The aim of the study was to investigate the incidence of AIDS-defining cancers (ADCs) and virus-related and non-virus-related non-AIDS-defining cancers (NADCs) in HIV-infected patients compared with the general population, and to assess the risk factors associated with these malignancies.

METHODS

We performed a retrospective cohort study for the period from 1999 to 2009 of HIV-infected patients residing in the Local Health Authority of Brescia (northern Italy). Observed cancers in patients with HIV infection were compared with expected cancers in the population living in the same area using standardized incidence ratios (SIRs). Risk factors were assessed using Poisson regression analysis.

RESULTS

A total of 5090 HIV-infected patients were included in the study, with 32 390 person-years of follow-up. We recorded 416 tumours in 390 HIV-infected patients. Two hundred of these (48.1%) were ADCs, 138 (33.2%) were non-virus-related NADCs and 78 (18.7%) were virus-related NADCs. An increased risk (SIR = 4.2) of cancers overall was found in HIV-infected patients. A large excess of ADCs (SIR = 31.0) and virus-related NADCs (SIR = 12.3) was observed in HIV-infected patients, while the excess risk for non-virus-related NADCs was small (SIR = 1.6). The highest SIRs were observed for Kaposi sarcoma among ADCs and for Hodgkin lymphoma among virus-related NADCs. Conversely, among non-virus-related NADCs, SIRs for a broad range of malignancies were close to unity. In multivariate analysis, increasing age and CD4 cell count < 50 cells/μL were the only factors independently associated with all cancers.

CONCLUSIONS

Among HIV-infected people there was an excess of ADCs and also of NADCs, particularly those related to viral infections. Ageing and severe immunodeficiency were the strongest predictors.

Factors predicting response and graft-versus-host disease after donor lymphocyte infusions: a study on 593 infusions

In the present study, we analyze factors predicting graft-versus-host disease (GvHD) and response after donor lymphocyte infusions (DLI). A total of 100 patients received 593 DLI between June 1990 and December 2000 in a bulk dose (n=14) or in escalating dose infusions (n=86). Patients were analyzed after stratification for type of relapse: (1). molecular relapse (n=6), (2). cytogenetic relapse (n=20), (3). chronic phase of chronic myeloid leukemia (CML) or complete remission of other disease post chemotherapy (n=24), (4). CML in accelerated/blastic phase (n=14), (5). resistant disease not responding to chemotherapy (n=36). The proportion of responders to DLI in these five groups was 100, 90, 75, 36 and 0% (P<0.0001). Factors predicting response by multivariate analysis were type of relapse (P<0.0001), post-DLI GvHD (P=0.005), pancytopenia (P=0.008), and a diagnosis of CML (P=0.04). Acute GvHD (grades II-IV) occurred in 21 patients (21%), and correlated in multivariate analysis with pancytopenia and less than four DLI. Other predictors of GvHD were the number of CD3+cells/infusion and serum levels of gamma-glutamyl transferase (gammaGT). The actuarial probability of treatment-related mortality was 9% for HLA identical siblings and 44% for alternative donor transplants (P=0.006). Response to DLI is predicted by tumor burden and is associated with GvHD and pancytopenia.

Interferon-alpha protects Philadelphia-negative progenitors from exhaustion in chronic myeloid leukemia patients with cytogenetic response

INTRODUCTION

Normal immature hematopoietic progenitors are relatively well preserved in most patients newly diagnosed with chronic myeloid leukemia, but tend to decline rapidly with time. Such exhaustion could reflect a suppressive effect of the Philadelphia positive clone expansion and/or be induced by Interferon-alpha treatment.

MATERIALS AND METHODS

A total of 51 CML patients were classified into three groups. Newly diagnosed untreated patients were group A (n=30). Of the 21 treated individuals with Interferon-alpha, for at least 12 months, 15 showed no cytogenetic response (group B) while six showed persisting major/complete response (group C). Patients belonging to groups A and B were mobilized with chemotherapy plus G-CSF while patients of group C received a short course of G-CSF only.

RESULTS

Patients responding to IFN-alpha (group C) showed comparable numbers of bone marrow Ph- long-term culture initiating cells to those of newly diagnosed individuals (group A): 8.5 (<1-65)/10(6) MNC vs 10.5 (<1-30), while non-responders had markedly lower numbers: <1 (<1-5). The amount of Ph- LTC-IC collected was significantly lower in patients of group B 1.8 (0-325)x10(2)/kg than in patients of either group A 31.3 (0-952)x10(2)/kg (P<0.002) or group C 109 (8-259)x10(2)/kg (P<0.01). Interestingly, five patients of group B who had 100% Ph+ metaphases, but Ph- progenitors in their bone marrow, mobilized normal amounts of Ph(-) progenitors.

CONCLUSION

These findings suggest that the decline of normal hematopoietic progenitors, currently observed in the majority of CML patients, is not induced by IFN-alpha treatment, but it is likely due to the expanding leukemic clone. They also indicate that normal hematopoietic reservoir is consistently preserved in patients given IFN-alpha early after diagnosis and achieving a stable cytogenetic response.

Symptoms, bothersomeness and quality of life in patients with LUTS suggestive of BPH

The QUIBUS study is the largest investigation ever performed in Italy with an extensive use of the ICS-BPH questionnaire. The internal consistency of each of its three domains was high for ICS-Male (Cronbach's alpha = 0.83 and 0.89 for symptoms and bother, respectively) and lower for ICS-Sex (Cronbach's alpha = 0.63 and 0.75, see a following paper of this issue) and ICS-QoL (Cronbach's alpha = 0.53), as previously reported in the validation study of this tool. Voiding symptoms were more frequently reported, with reduced urinary stream, terminal dribble and incomplete bladder emptying as the most frequently represented. The first storage symptom in the ranking by frequency was 'rush to toilet' (70% of the population), in 7th position; however, the relevant bother was among the highest reported. Items related to urinary incontinence appeared, when present, highly bothersome (87-92% of patients), even though exhibited by a minority of the population (5-34%). The mean (+/-SD) IPSS, calculated on 970 patients, was 15 (+/-7). Two major discrepancies were found in the comparison between IPSS and ICS-Male. First, terminal dribble, which is not considered in the IPSS, is often reported in the ICS-Male. Second, some storage symptoms (nocturia and day-time frequency) are less frequently reported in the ICS-Male than in the IPSS, while being, in general, highly bothersome. As regards QoL, 95% of subjects declared that they would not be completely happy to spend the rest of their life with their actual symptoms (ICS-QoL item 33) and 79% that BPH influences their life from 'a little' to 'a lot' (ICS-QoL item 30). The mean (+/-SD) IPSS-QoL single question score was 3.0 +/- 1.4 (n = 970), and the frequency distribution of scores was equivalent to the one detected by the corresponding question of ICS-QoL (item 33). SF-36, a disease-independent questionnaire about QoL, after a 1-year follow-up is expected to clarify which among the IPSS and ICS-BPH items better describe the impact of BPH on QoL.

[Ultrasound-guided transrectal biopsy of the prostate]

The author proposes his personal experience through this metodology matured as person in charge of "Modulo di ecografia uro-andrologica ed ecointerventistica", besides a case histories of about 1,000 biopsy exams practiced.

Cytogenetic response to autografting in chronic myelogenous leukemia correlates with the amount of BCR-ABL positive cells in the graft

OBJECTIVE

An important step in successful autografting of patients with chronic myelogenous leukemia is the delivery of a leukemia-free graft. We conducted this study to determine whether the cytogenetic response after autografting was correlated with the number of BCR ABL-positive cells present within the stem cell grafts.

MATERIALS AND METHODS

By BCR-ABL mRNA quantification, we studied the serial pheresis products from 40 Philadelphia (Ph)-positive patients who received ICE/mini-ICE mobilization therapy and underwent autologous stem cell transplantation. We correlated the residual disease within the graft reinfused with the cytogenetic response following transplantation, taking into consideration those responses that lasted 12 months or more.

RESULTS

Thirty-two patients received a graft with 0-35% Ph-metaphases and 19 received a graft with BCR-ABL/ABL ratio < or =0.01. After a median of 27 months (range, 12-50) from transplant, 18 patients achieved complete or major cytogenetic response lasting at least 12 months, and 14 of them (78%) received a graft with BCR-ABL/ABL ratio < or =0.01 (range, 0.0003-0.01). Twenty-two patients experienced short-lived responses or had >35% Ph-positive cells in the marrow after transplant, but only 5 of them (23%) had a graft with BCR-ABL/ABL ratio < or =0.01 (range, 0.001-0.01). Therefore, we found a strong association between a BCR-ABL/ABL ratio less than or =0.01 and the achievement of complete or major cytogenetic remission after autografting (chi(2) test, p = 0.0001). Patients reinfused with grafts contaminated at low levels with leukemic cells also showed a longer duration of the response (log-rank test, p = 0.0009). Eleven patients were reinfused with the lowest level of contaminated stem cell collections, according to the BCR-ABL/ABL ratio. None of these patients experienced prolonged neutropenia or thrombocytopenia following stem cell reinfusion and nine of them had long-lasting complete or major cytogenetic responses after transplant.

CONCLUSION

This study demonstrates that the number of BCR-ABL positive cells present in a stem cell graft is an important predictive factor for the achievement and the duration of cytogenetic response after autografting. [corrected]

Quantitative competitive reverse transcriptase-polymerase chain reaction for BCR-ABL on Philadelphia-negative leukaphereses allows the selection of low-contaminated peripheral blood progenitor cells for autografting in chronic myelogenous leukemia

The Philadelphia (Ph) translocation t(9;22) results in the creation of the BCR-ABL gene, which is now regarded as central to the mechanism that underlies the chronic phase of chronic myelogenous leukemia (CML). From a clinical point of view, BCR-ABL mRNA detection has become the basis for the study of minimal residual disease in CML, particularly when a complete cytogenetic remission is achieved after interferon-alpha (IFN-alpha) therapy or allogeneic stem cell transplantation. We have recently demonstrated that it is possible to mobilize normal peripheral blood progenitor cells (PBPC) in higher rates if this procedure is performed during the early chronic phase. In an attempt to monitor the leukemic cell content of PBPC collections, we used quantitative-competitive RT-PCR (QC-RT-PCR). Thirty consecutive Philadelphia (Ph) chromosome positive patients were enrolled in this study. After chemotherapy and G-CSF, 14 patients achieved 100% Ph-negative metaphases, nine patients had < or =34% and seven patients >34% leukemic metaphases. A total of 116 collection samples were studied. For each sample, BCR-ABL transcript numbers and BCR-ABL/ABL ratio were evaluated. A highly significant correlation between Ph-positive metaphases and BCR-ABL transcript numbers (r = 0.84, P < 0.0001) or BCR-ABL/ABL ratio (r = 0.86, P < 0.0001) was found. For patients that underwent the procedure in early chronic phase, Ph-negative collections showed different levels of BCR-ABL expression. BCR-ABL transcript numbers varied from a median of 100/microg RNA in the first and second leukaphereses, to 500/microg RNA in the third and fourth leukaphereses, and 1500/microg RNA in the fifth leukapheresis (P = 0.002). BCR-ABL/ABL ratio values showed similar kinetics. We have also demonstrated that there is a correlation between low values in BCR-ABL/ABL ratio (< or =0.01) in the reinfused PBPC and the achievement of cytogenetic remission after autografting (chi2 test, P = 0.01). In conclusion, this study demonstrates that QC-RT-PCR for BCR-ABL is a reliable and helpful method for monitoring residual leukemic load in mobilized PBPC, particularly in Ph-negative collections. Moreover, QC-RT-PCR allows selection of the best available collections for reinfusion into patients after myeloablative therapy.

High-dose cyclophosphamide followed by autografting can improve the outcome of relapsed or resistant non-Hodgkin's lymphomas with involved or hypoplastic bone marrow

We report our experience of high-dose cyclophosphamide (HDCY) followed by high-dose therapy (HDT) and peripheral blood progenitor cell (PBPC) autografting in patients with diffuse, intermediate and high-grade non-Hodgkin's lymphomas who have failed conventional treatment. From 1991 to 1996, 54 consecutive patients pre-treated with a median of two chemotherapy lines entered the study. Eighteen patients (33%) were still responders to conventional chemotherapy (sensitive relapse), and 20 patients (37%) were in partial response (PR) after chemotherapy (CT). Sixteen patients (30%) were resistant to conventional CT either at presentation (non responder) or in relapse (resistant relapse). Thirty-nine patients had bone marrow involved by disease and fifteen had an hypoplastic marrow following conventional treatment. Patients received HDCY (7gr/m2) and G-CSF or GM-CSF in order to collect PBPC. Median collected CD34+ cells was 12.3 x 10(6)/Kg (range 0.7-197). After HDT (BEAM or Melphalan + TBI) 50 patients underwent PBPC autografting. According to intention to treat, 44 (81%) of 54 patients achieved complete remission (CR) (50% after HDCY and 31% after HDT). Procedure related death occurred in 6 patients (11%), one after HDCY and 5 after autografting. Twenty-nine (66%) of 44 patients are still in CR, 7 to 63 months (median 27 months) after the procedure. Three-year probability of survival, disease-free survival and progression-free survival are 63%, 64% and 52% respectively. In conclusion, HDCY is an effective procedure not only in mobilizing PBPC, but also in reducing tumour burden. HDT with PBPC support may further improve the outcome in this category of high-risk non-Hodgkin's lymphomas.

Autografting with philadelphia chromosome-negative mobilized hematopoietic progenitor cells in chronic myelogenous leukemia

Intensive chemotherapy given in early chronic phase of chronic myelogenous leukemia (CML) has resulted in high numbers of circulating Philadelphia (Ph) chromosome-negative hematopoietic progenitor cells (HPC). We have autografted 30 consecutive patients with CML in chronic phase with HPC collected in this way to facilitate restoration of Ph-negative hematopoiesis in bone marrow after high-dose therapy. Hematopoietic recovery to greater than 0.5 x10(9)/L neutrophils and to greater than 25 x 10(9)/L platelets occurred in all patients, a median of 13 (range, 9 to 32) days and 16 (range, 6 to 106) days postautograft, respectively. Regenerating marrow cells were Ph-negative in 16 (53%) patients and greater than 66% Ph-negative in 10 (33%) patients. Twenty-eight patients are alive 6 to 76 months (median, 24 months) after autografting. Three patients have developed blast crisis from which 2 have died. Eight patients are in complete cytogenetic remission at a median of 20 (range, 6 to 44) months with a median ratio BCR-ABL/ABL of 0.002 (range, <0.001 to 0.01). Eight patients are in major cytogenetic remission at a median of 22 (range, 6 to 48) months. No patient died as a consequence of the treatment. All patients had some degree of stomatitis that was severe in 15 (50%) patients. Gastrointestinal and hepatic toxicities were observed in about one fourth of patients. Thus, autografting with Ph-negative mobilized HPC can result in prolonged restoration of Ph-negative hematopoiesis for some patients with CML; moreover, most autograft recipients report normal or near normal activity levels, suggesting that this procedure need not to be associated either with prolonged convalescence or with chronic debility.

Normal primitive haemopoietic progenitors are more frequent than their leukaemic counterpart in newly diagnosed patients with chronic myeloid leukaemia but rapidly decline with time

We carried out studies to quantify Ph-negative progenitors both in steady state and during regeneration after chemotherapy and G-CSF in 23 newly diagnosed chronic myeloid leukaemia (CML) patients (group A) and in 14 individuals more than a year from diagnosis (nine in chronic and five in accelerated phase, group B). In steady-state bone marrow, Ph-negative long-term culture initiating cells (LTC-IC) and Ph-negative colony-forming-cells (CFC) were detected in 18/23 and 14/23 patients of group A versus 3/14 and 3/14 patients of group B (P<0.001 and P<0.02, respectively). The absolute number of mobilized Ph-negative progenitors was markedly higher in group A versus group B (P<0.02 for LTC-IC, P<0.003 for CFC). 12/16 newly diagnosed patients mobilized Ph-negative LTC-IC only and the yield was in the range of normal allogeneic donors. Overall the frequency of Ph-negative LTC-IC in the bone marrow predicted the yield of Ph-negative LTC-IC mobilized into peripheral blood (P<0.001). The bone marrow frequency of Ph-positive LTC-IC was considerably lower than the normal counterpart. Taken together, these findings suggest that normal progenitors are relatively well preserved in newly diagnosed CML patients, but tend to rapidly decline with time. This observation helps in the understanding of the pathogenesis of CML and has potential implications for autografting. The optimal time for a successful collection of Ph-negative circulating progenitors would appear to be soon after diagnosis.

Mobilization/transplantation of peripheral blood progenitor cells for aggressive non-Hodgkin's lymphoma with marrow involvement

Thirty-five aggressive non-Hodgkin's lymphomas (NHL) with marrow involvement received high-dose cyclophosphamide (7 g/m2) and G-CSF in order to collect peripheral blood progenitor cells (PBPC). Fourteen patients were in partial remission, 16 patients were in relapse ("sensitive", 12; "resistant", 4) and 5 patients were in refractory to conventional treatment. A good yield of PBPC was obtained in 30 patients, while a low number of CD34+ cells and of CFU-GM was seen in two cases. Two patients entered progression and one patient died. Thirty patients underwent PBPC autografting. Twenty-nine out of 35 (83%) patients entered complete remission (CR). Two patients died in CR of infection following marrow aplasia 3 and 6 months after autografting. At 3 years the probability of survival and disease-free survival (DFS) are of 62% and 51% respectively.

Transplantation of HLA-mismatched CD34+ selected cells in patients with advanced malignancies: severe immunodeficiency and related complications

This trial was designed to test the use of CD34+ selected haemopoietic stem cells (HSC) in HLA-mismatched donor-recipient pairs, following intensive conditioning with thiotepa, antilymphocyte globulin (ALG), cyclophosphamide and single-dose total-body irradiation (sTBI). 10 patients aged 16-50 with advanced malignancies and a two- or three-antigen mismatched family donor entered this study. Donor marrow and G-CSF primed peripheral blood cells were processed separately on CD34 columns (Ceprate). The median number of infused CD34+ cells were 5.66 x 10(6)/ kg, with 0.55 x 10(6)/kg CD3+ cells. Nine patients received cyclosporin for graft-versus-host disease (GvHD) prophylaxis. Median neutrophil counts on day 21 were 2 x 10(9)/l with a median platelet count of 60 x 10(9)/l, but CD4 counts remained extremely depressed throughout the study. Acute GvHD was scored as grade 0-I in two patients, as grade II in seven, and grade III in one. Eight patients died at a median interval of 72 d from HSCT (range 20-144) due to cytomegalovirus (CMV) associated interstitial pneumonitis (IP) (n = 5), renal failure (n = 1). GvHD (n = 1) and Aspergillus meningitis (n = 1). Two patients are alive 365-495 d post transplant, one in remission and one in relapse. This study suggests that large numbers of positively selected mismatched HSC can rapidly engraft after intensive conditioning regimen: however, profound post-transplant immunodeficiency leads to a high risk of lethal infectious complications.

Donor lymphocyte infusions (DLI) in patients with chronic myeloid leukemia following allogeneic bone marrow transplantation

Donor lymphocyte infusions (DLI) were given between June 1990 and March 1996 to 18 patients with chronic myeloid leukemia (CML) for the treatment of cytogenetic (n = 6) or hematologic relapse (n = 12) following an allogeneic bone marrow transplant (BMT). Patients were divided in two groups: patients in group A (n = 8) received a large dose of donor lymphocytes (> or = 1 x 10(8)/kg), whereas patients in group B (n = 10) received escalating numbers of cells (2 x 10(5) up to 2 x 10(8)/kg). The median number of DLI in group A was 2 (range 1-3); the median number of infusions in group B was 7 (range 3-9). Acute GVHD occurred in 12 patients (grades I-III) and was a major cause of death in two. The risk of developing GVHD correlated with the number of cells infused: 37%, 14%, 5% and 0% for DLI with cells > or = 1 x 10(8), 2 x 10(7)/kg, 2 x 10(6)/kg, and 2 x 10(5)/kg, respectively (P = 0.01). Median transaminase levels were found to be significantly increased in patients with, as compared to patients without, acute GVHD (GPT 412 vs 28 IU/l; P = 0.03). Severe aplasia occurred in four and was a contributing cause of death in two patients. Overall, four patients died as a consequence of DLI and all received > 1 x 10(8)/kg cells: the actuarial risk was 38% in group A and 14% in group B (P = 0.1). There were 10 complete and three partial cytogenetic responses: the actuarial probability at 5 years of being Ph negative was 69%: it was 46% for group A and 85% for group B (P = 0.1). The longest patient is now 6 years post-DLI, Ph negative, BCR-ABL negative. The actuarial 3 year survival is 38% in group A and 86% in group B (P = 0.06). The study confirms that DLI post-BMT is not innocuous and that there is a definite long-lasting antileukemic effect in patients with CML. It also suggests that: (1) the risk of developing GVHD correlates with the number of infused cells; (2) that significant elevations of serum GPT levels are associated with GVHD; and (3) that the use of escalating doses of cells may allow the identification of side-effects and discontinuation of infusions before life-threatening GVHD has developed.

Mobilization and transplantation of Philadelphia-negative peripheral-blood progenitor cells early in chronic myelogenous leukemia

PURPOSE

Mobilization of Philadelphia (Ph) chromosome-negative progenitors is now possible in many Ph1-positive chronic myelogenous leukemia (CML) patients who had received interferon alfa (IFN-alpha) with no cytogenetic response. In this pilot study, we used this approach in patients without prior IFN-alpha therapy to determine if the number and quality of mobilized progenitors would be increased and to evaluate the potential effect of these cells as autografts.

PATIENTS AND METHODS

Twenty-two untreated patients were mobilized within 12 months of diagnosis. The treatment regimen consisted of the mini-ICE protocol. Beginning on day +8, granulocyte colony-stimulating factor (G-CSF) was used in all patients. Leukophoresis was performed as the patients were recovering from aplasia, when WBC count exceeded 0.8 x 10(9)/L.

RESULTS

In 14 patients, (63%) the leukophoresis product was entirely Ph1-negative and in four patients the Ph1-positive cell rate was < or = 7%. Significant numbers of long-term culture-initiating cells (LTC-IC) and CD34+ Thy1+Lin- cells were found in most of the Ph1-negative collections that were tested. Twelve patients underwent autografting with their mobilized peripheral-blood progenitor cells (PBPC) (Ph1-negative collections, 10 patients; major cytogenetic response, two patients). All patients engrafted and are alive; six have Ph1-negative marrow 7 to 15 months after autografting. Posttransplant treatment was IFN-alpha combined with interleukin (IL)-2 because of the recent demonstration of synergistic activity in augmenting cytolytic activity.

CONCLUSION

Intensive chemotherapy given in early chronic phase of CML is well tolerated and results in high numbers of circulating Ph1-negative precursor cells.

Spontaneous exodus of high numbers of normal early progenitor cells (Ph-negative LTC-IC) in the peripheral blood of patients with chronic myeloid leukaemia at the beginning of the disease

Elevated white blood cell counts are frequently found in patients with chronic myeloid leukaemia (CML). Although some studies have disclosed that bone marrow of CML patients may contain some normal Philadelphia-negative early progenitor cells, it has been assumed that the dramatic increase of white blood cells was entirely related to the leukaemic cell expansion. In this study we attempted to quantify the number of normal and leukaemic progenitor cells in the bone marrow and peripheral blood of newly diagnosed CML patients. Bone marrow and peripheral blood cells of eight newly diagnosed CML patients were analysed for clonogenic colony-forming cells (CFC) and very early progenitor cells, i.e. long-term culture initiating cells (LTC-IC). The leukaemic (Ph-positive) or normal (Ph-negative) origin of progenitor cells was revealed by cytogenetic analysis performed on single colonies arising from in-vitro assays. In 6/8 patients the marrow CFC frequency ranged from 400 to 9300/10(6) mononuclear cells (MNC), 0-50% being Philadelphia chromosome negative; the LTC-IC frequency ranged from 0 to 11/10(6) MNC, and were 80-100% Ph-negative. The corresponding absolute values into peripheral blood were: CFC = 1-35.5 x 10(3)/ml, 0-50% Ph-negative, and LTC-IC = 0-2.5 x 10(3)/ml, 0-100% Ph-negative. In one patient, no LTC-IC were detected in either the marrow or the peripheral blood. In conclusion, in the peripheral blood of some CML patients, the number of normal LTC-IC is more than 3 times the number of leukaemic progenitor cells, and is much higher (50 times) than the corresponding value found in normal subjects in steady state (2.5/ml v 124/ml). These data support the concept that leukaemic 'stem cells', with respect to normal ones, may be considerably fewer than previously thought. In addition it is shown that at the beginning of CML high numbers of normal LTC-IC are spontaneously mobilized into the blood. Finally, the presence of Ph-negative early progenitors into the blood may represent a potential source of normal stem cells available for autografting providing they can be separated from leukaemic cells.

Early hemopoietic progenitors in the peripheral blood of patients with severe aplastic anemia (SAA) after treatment with antilymphocyte globulin (ALG), cyclosporin-A and G-CSF

BACKGROUND AND OBJECTIVE

We previously reported that patients with acquired severe aplastic anemia (SAA) treated with antilymphocyte globulin (ALG), 6-methylprednisolone, cyclosporin A (CyA) and granulocyte colony-stimulating factor (G-CSF) can mobilize peripheral blood hemopoietic progenitors (PBHP). The aim of the present study was to assess phenotypic and functional properties of these PBHP.

METHODS

We studied seven patients who underwent 43 leukophereses (median 5) between day +30 and +80 following ALG, while in treatment with CyA and G-CSF. Mobilized peripheral blood hemopoietic progenitors were analyzed using surface markers, conventional assays for clonogenic cells (CFU-GM, BFU-E, CFU-GEMM) as well as the recently developed assay for long-term culture initiating cells (LTC-ICs).

RESULTS

The proportion of CD34+ cells ranged between 0% and 5.4% (median 0.3%), CD34+DR between 0% and 3.5% (median 0.1%) and CD8+ cells between 3.3% and 56% (median 31%). When light density mononuclear cells (MNC) were plated in vitro, we could grow colony-forming units-granulo-macrophage (CFU-GM) (range 0-45/10(5) MNC; normal controls 21-200/10(5) MNC), burst-forming units-erythroid (BFU-E) (range 0-5/10(5) MNC; normal controls 0-6/10(5) MNC), multipotent colonies (CFU-GEMM) (range 0-3/10(5) MNC; normal controls 0-6/10(5) MNC) and high proliferative potential colony-forming cells (HPP-CFC) (range 0-3.4/10(5) MNC). We studied long-term culture-initiating cells (LTC-ICs) in 18 leukophereses from 4 patients; in 7/18 samples LTC-ICs were grown at low frequency (range 0.4-2/10(6) MNC) (normal controls 5-130/10(6) MNC), and in one patient in the absence of CFU-GM growth. The total yield of LTC-ICs in two patients was 7.64 and 10.5 x 10(2)/kg of body weight.

INTERPRETATION AND CONCLUSIONS

This study suggests that cells with the phenotype and in vitro function of early hemopoietic progenitors are found, though in small numbers, in the peripheral blood of patients with SAA after treatment with immunosuppressants and prolonged G-CSF administration. Whether G-CSF-mobilized progenitors contribute to hemopoietic recovery in these patients remains to be determined.

Mobilization/transplantation of peripheral blood progenitor cells for aggressive non-Hodgkin's lymphoma with marrow involvement

Thirty-five aggressive non-Hodgkin's lymphomas (NHL) with marrow involvement received high-dose cyclophosphamide (7 g/m2) and G-CSF in order to collect peripheral blood progenitor cells (PBPC). Fourteen patients were in partial remission, 16 patients were in relapse ('sensitive', 12; 'resistant', 4) and five patients were refractory to conventional treatment. A good yield of PBPC was obtained in 30 patients, while a low number of CD34+ cells and of CFU-GM was seen in two cases. Two patients entered progression and one patient died. Thirty patients underwent PBPC autografting. Twenty-nine out of 35 (83%) patients entered complete remission (CR). Two patients died in CR of infection following marrow aplasia 3 and 6 months after autografting. At 3 years the probability of survival and disease-free survival (DFS) are 62 and 51%, respectively.

Autografting Ph-negative blood precursor cells in chronic myeloid leukaemia

The study was devised to evaluate whether it was possible to collect Philadelphia-negative precursor cells in patients with chronic myeloid leukaemia. The approach was based on previous experience showing that complete remission (Ph-negative bone marrow cells) is rarely achieved after chemotherapy and is very short-lasting. We decided to explore whether it was possible to collect Ph-negative precursor cells in peripheral blood during the early phase of haemopoietic recovery. These data show that: the collection of Ph-negative precursor cells occurred in 12/16 (75%) patients mobilized within one year of diagnosis (group A) versus 12/33 (36%) in patients with a history of more than one year of disease (group B). Furthermore the numbers of Ph-negative precursor cells were significantly much higher at diagnosis. Ten patients mobilized at diagnosis were subsequently autografted with such Ph-negative precursor cells. Five of them remain Ph-negative from 4 to 12 months while the other five have percentages of Ph-positive cells in their marrow ranging from 20% to 70%. In this stage of the disease the procedure is safe and associated with a very good compliance. Occasional restoration of Ph-negative haemopoiesis could be observed up to 40 months after autograft, in patients of group B, but most of patients revert to Ph-positive haemopoiesis. in conclusion these data suggest that it is possible to restore Ph-negative haemopoiesis in 70% of patients mobilized at diagnosis. This percentage represent the highest one can obtain without allogeneic BMT, and this includes patients who never would have been cytogenetic responders to IFN-alpha. Whether and how long for Ph-negative status can be maintained is a matter for future observation and study.

High-dose chemo-radiotherapy followed by autologous Philadelphia chromosome-negative blood progenitor cell transplantation in patients with chronic myelogenous leukemia

Twenty-three patients with chronic myelogenous leukemia in early chronic phase (ECP) and not previously treated with alpha-interferon (IFN-alpha) (10 patients), in ECP but pretreated with IFN-alpha (<12 months) (seven patients) and in late chronic phase (LCP) pretreated with IFN-alpha (>12 months) (six patients) underwent autografting with Philadelphia (Ph) chromosome-negative blood progenitor cells (BPCs) (20 patients), or partially/totally Ph-positive BPCs (three patients), previously mobilized during the early phase of recovery after aplasia induced by intensive chemotherapy. The conditioning regimen consisted of high-dose chemotherapy alone or followed by total body irradiation (TBI). Recombinant G-CSF was given after BPCs infusion on day +8. All patients in ECP not pretreated with IFN-alpha are alive and five of them are Ph-negative in the marrow after autografting. Six of seven patients autografted with Ph-negative BPCs in the group of ECP pretreated with IFN-alpha (<12 months) are alive and two of them are still Ph-negative in the marrow. In the same group, the only patient transplanted with partially Ph-positive BPCs, died of blastic transformation 2 months after reinfusion. Three patients (two patients autografted with Ph-negative BPCs and one patient with Ph-positive BPC) in the group of LCP pretreated with IFN-alpha >12 months are alive but Ph-positive after autografting. The other three patients of the same group died of procedure-related toxicity (two patients) and blastic transformation (one patient). Seventeen patients (10/10 ECP not pretreated with IFN-alpha; 5/7 ECP pretreated with IFN-alpha and 2/6 LCP pretreated with IFN-alpha) of 23 autografted patients were treated with IFN-alpha +/- IL-2. Toxicities after autografting were mostly related to myelosuppression, particularly thrombocytopenia. All patients of the two groups pretreated with IFN-alpha developed febrile episodes during the aplastic phase following BPCs reinfusion. No patient autografted in ECP and those not pretreated with IFN-alpha developed febrile episodes. This is also probably due to the use of i.v. antibiotic and antimicotic prophylaxis when neutrophils were < or = 1 x 10(9)/l after autografting. Greater toxicity was observed in patients pretreated with IFN-alpha, being lethal in two cases in LCF. In conclusion, the "in vivo' manipulation approach employed in our institution is a safe procedure and it results in a high collection of Ph-negative cells in the blood if the cells are harvested: (1) in early chronic phase; (2) in early phase of recovery after chemotherapy-inducing aplasia; (3) in patients not extensively pretreated with IFN-alpha. The data presented here have shown encouraging trends in chronic phase of CML and offer new perspective for patients without an HLA-identical donor or for patients who do not respond to IFN-alpha.

Very primitive hemopoietic cells (LTC-IC) are present in Philadelphia negative cytaphereses collected during early recovery after chemotherapy for chronic myeloid leukemia (CML)

We have previously demonstrated that Philadelphia negative (Ph-ve) hemopoietic cells can be collected by leukaphereses after an acute leukemia-like chemotherapy during the early hemopoietic recovery in patients with chronic myeloid leukemia (CML). In this study we have evaluated whether these collections contain very primitive hemopoietic cells defined as 'long-term culture initiating cells' (LTC-IC) and whether these cells belong to the Ph-positive or Ph-negative population. Twenty-eight out of 76 cytaphereses collected in 15 patients with CML proved to contain Ph-ve cells only (six patients), 21 showed only Ph+ve cells (five patients), and 27 a mixture of Ph+ve and Ph-ve cells (four patients). In cytaphereses containing Ph-ve cells only, we found variable numbers of LTC-ICs, more consistently when we mobilized patients in the first 3 months from diagnosis. In three cases cytogenetic analysis on LTC-ICs and CFU-GM confirmed results obtained on fresh samples. Ph-positive collections were devoid of LTC-ICs except for 2/21 samples. However, their cytogenetic analysis revealed a small number of Ph-negative progenitors. LTC-ICs were randomly detected in mixed (Ph+ve and Ph-ve) collections. In conclusion these data indicate that, in a consistent proportion of chronic myeloid leukemia patients, intensive chemotherapy is able to recruit Ph-ve LTC-ICs in to the peripheral blood. Moreover these data provide the biological basis for developing autografting programs with Ph-negative cells.

[Role of echography in neoplastic priapism]

The author, observing one case of neoplastic priapism, poiting on the role of ultrasonography in this disease. Its easy and quick execution, the possibility to repeat it, its low cost, its diagnostic sensibility in evaluating the infiltration of the cancer, permit us to consider it a screening technique of primary importance.

Oxidative metabolism of human peripheral blood eosinophils and neutrophils: H2O2 production after stimulation with phorbol myristate acetate and immune complexes

Eosinophils like neutrophils possess an oxidative metabolism which is activated by phagocytosis and cell membrane activation. Since eosinophils may take part in inflammatory reactions by releasing oxygen species and have membrane receptors for immunoglobulins, immune complexes may activate their respiratory burst. We compared the ability of phorbol myristate acetate (PMA) and immunoglobulin G (IgG) and immunoglobulin E (IgE) immune complexes to stimulate hydrogen peroxide (H2O2) release from circulating eosinophils and neutrophils. PMA was able to stimulate a significant respiratory burst in both cell types, PMA-induced H2O2 production being higher in eosinophils than in neutrophils (p less than 0.05). Similar results were obtained when the cells were stimulated by IgG (p less than 0.05). In contrast, aggregated human myeloma IgE induced a detectable H2O2 release only from peripheral blood eosinophils. We conclude that H2O2 release from eosinophils may play a role in parenchymal injury associated with hypereosinophilic disorders and the presence of immune complexes at sites of disease activity.

Bronchoalveolar lavage during fiberoptic bronchoscopy: what has it brought to pulmonary medicine?

In the last 13 years, bronchoalveolar lavage has been widely used to study the mechanisms involved in the defense of the lower respiratory tract and in the pathogenesis of a variety of lung disorders. This technique, which is a relatively safe and simple extension of fiberoptic bronchoscopy, has been proved to be a powerful investigative tool with enormous potential since it has enhanced our knowledge on a variety of disorders, including interstitial lung diseases, lung destruction associated to cigarette smoking and, recently, bronchial asthma. In addition, bronchoalveolar lavage has also been utilized as an interesting test to help in the diagnostic procedures and in the management of patients with a variety of pulmonary diseases. Its actual importance in clinical respiratory medicine, however, is still under debate and the value of some suggested applications remains to be established.

Changes in pulmonary surfactant composition following MACC chemotherapy for lung carcinoma

Many antineoplastic drugs can derange lung structures, cause necrosis of type I pneumocytes, abnormal proliferation of type II alveolar epithelial cells, and, occasionally, accumulation of inflammatory and immune effector cells. Since type II cells secrete lung surfactant, treatment may alter surfactant composition. In 8 patients with nonresectable lung cancer, we performed bronchoalveolar lavage before and after MACC polychemotherapy (methotrexate, doxorubicin HCl, cyclophosphamide and lomustine). Before treatment, cellular composition and the phospholipid and fatty acid constituents of lavage surfactant were similar to those found in control subjects. After MACC polychemotherapy there was, in all patients, a mild decrease in the number of immune effector cells, without changes in the relative proportion of cell types. In addition, MACC therapy resulted in a significant decrease of phosphatidylcholine levels, and increased levels of phosphatidylglycerol, whereas the levels of palmitic lavage surfactant were decreased. These MACC treatment abnormalities of the phospholipid and fatty acid composition of lung surfactant may reflect preclinical pulmonary toxicity. The decrease in the numbers of bronchoalveolar cells suggests that the changes in surfactant composition may be chemically induced rather than immune mediated.

Two further examples of IgG thimerosal-dependent antibodies and their serological characteristics

Two further examples of IgG thimerosal-dependent antibodies have been found by routine immunohematological tests carried out in our laboratory. Both antibodies fixed the complement and had no apparent blood group specificity. Their reactivity was inhibited by adding thimerosal to the serum prior to the addition of red blood cells. If cross matching is performed accordingly, thimerosal-dependent antibodies should not any longer represent a blood bank problem.

Histochemical and contractile properties of soleus muscle trained during development

The effects of endurance training on the histochemical and contractile properties of developing rat soleus was studied. Five 18 day old Long Evans rats were trained twice a day for 28 days (E group); workloads were increased to 30 m/min (15% grade) for 40 min/bout. Contraction time (Tc), twitch tension (Pt), half relaxation time (t1/2R), tetanic tension (Po), maximal rate of rise in tension (t50% Po) and fatigue index (FI, % decline in force after 15 s tetanic stimulation) were measured and compared to a control (C) group. The contralateral soleus was excised, rapidly frozen and histochemical (myosin ATPase pH 9.4 and 4.3) and histological sections prepared for analysis of fibre type, number and area. Similar fibre types (mean = 70 and 71% ST), fibre numbers (mean = 2115 and 2242) and areas of ST (mean = 2000 and 2320 micron 2) and FT fibres (mean = 1476 and 1628 micron 2) were found in C and E groups respectively. Po (p less than 0.05) was greater and t50% Po (p less than 0.01) was significantly faster in E. Pathological changes were found in about 1% of fibres in each trained muscle, but not in controls. Histochemical differentiation of fibre types was unaffected and contractile properties only minimally by training during early development.