A novel germline hyperactivating JAK2 mutation L604F

Somatic JAK2 mutations are the main molecular cause of the vast majority of polycythemia vera (PV) cases. According to a recent structural model, the prevalent acquired V617F mutation improves the stability of the JAK2 dimer, thereby enhancing the constitutive JAK2 kinase activity. Germline JAK2 mutations usually do not largely alter JAK2 signaling, although they may modulate the impact of V617F. We found an unusual germline JAK2 mutation L604F in homozygous form in a young PV patient, along with a low allele burden JAK2 V617F mutation, and in her apparently healthy sister. Their father with a PV-like disease had L604F in a heterozygous state, without V617F. The functional consequences of JAK2 L604Fmutation were compared with those induced by V617F in two different in vitro model systems: (i) HEK293T cells were transfected with plasmids for exogenous JAK2-GFP expression, and (ii) endogenous JAK2 modifications were introduced into HeLa cells using CRISPR/Cas9. Both mutations significantly increased JAK2 constitutive activity in transfected HEK293T cells. In the second model, JAK2 modification resulted in reduced total JAK2 protein levels. An important difference was also detected: as described previously, the effect of V617F on JAK2 kinase activity was abrogated in the absence of the aromatic residue F595. In contrast, JAK2 hyperactivation by L604F was only partially inhibited by the F595 change to alanine. We propose that the L604F mutation increases the probability of spontaneous JAK2 dimer formation, which is physiologically mediated by F595. In addition, L604F may contribute to dimer stabilization similarly to V617F.

NPM1 and DNMT3A mutations are associated with distinct blast immunophenotype in acute myeloid leukemia

The immune system is important for elimination of residual leukemic cells during acute myeloid leukemia (AML) therapy. Anti-leukemia immune response can be inhibited by various mechanisms leading to immune evasion and disease relapse. Selected markers of immune escape were analyzed on AML cells from leukapheresis at diagnosis (N = 53). Hierarchical clustering of AML immunophenotypes yielded distinct genetic clusters. In the absence of DNMT3A mutation, NPM1 mutation was associated with decreased HLA expression and low levels of other markers (CLIP, PD-L1, TIM-3). Analysis of an independent cohort confirmed decreased levels of HLA transcripts in patients with NPM1 mutation. Samples with combined NPM1 and DNMT3A mutations had high CLIP surface amount suggesting reduced antigen presentation. TIM-3 transcript correlated not only with TIM-3 surface protein but also with CLIP and PD-L1. In our cohort, high levels of TIM-3/PD-L1/CLIP were associated with lower survival. Our results suggest that AML genotype is related to blast immunophenotype, and that high TIM-3 transcript levels in AML blasts could be a marker of immune escape. Cellular pathways regulating resistance to the immune system might contribute to the predicted response to standard therapy of patients in specific AML subgroups and should be targeted to improve AML treatment.

Integrin expression and adhesivity to fibronectin in primary acute myeloid leukemia cells: Impact of NPM1 and FLT3 mutations

OBJECTIVES

Interaction of leukemia cells with the bone marrow extracellular matrix promotes cell survival and resistance to chemotherapy. In this work, we analyzed integrin expression and adhesivity to fibronectin in primary cells from patients with acute myeloid leukemia.

METHODS

Surface expression of integrins β1 and αVβ3 on primary leukemia cells (N = 46) was correlated with the stem cell marker CD34, as well as with cell adhesivity to fibronectin. The results were analyzed with regard to the mutational status of NPM1 and FLT3 genes.

RESULTS

The integrin β1 was omnipresent, whereas αVβ3 was often more expressed on CD34-positive cells. In particular, higher αVβ3 expression on CD34+ cells was associated with NPM1 mutation (P = .0018). Monocytic leukemias had significantly higher αVβ3 expression compared to less maturated cases (P = .0008). Cells from patients with internal tandem duplications in FLT3 (FLT3-ITD) had lower adhesivity to fibronectin compared to cells with wild-type FLT3 (P = .031), specifically in less differentiated myeloblasts. Inhibition of a putative FLT3-ITD target, EZH2, increased cell adhesivity in MV4-11 cell line (P = .024).

CONCLUSIONS

The integrin αVβ3 is expressed in particular on CD34+ cells with NPM1 mutation and might have a prognostic value in patients with mutated NPM1. FLT3-ITD is associated with lower cell adhesivity, especially in patients with less differentiated leukemias.

Functionalized aromatic esters of the Amaryllidaceae alkaloid haemanthamine and their in vitro and in silico biological activity connected to Alzheimer's disease

A novel series of aromatic esters (1a-1m) related to the Amaryllidaceae alkaloid (AA) haemanthamine were designed, synthesized and tested in vitro with particular emphasis on the treatment of neurodegenerative diseases. Some of the synthesized compounds revealed promising acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) inhibitory profile. Significant human AChE (hAChE) inhibition was demonstrated by 11-O-(3-nitrobenzoyl)haemanthamine (1j) with IC₅₀value of 4.0 ± 0.3 µM. The strongest human BuChE (hBuChE) inhibition generated 1-O-(2-methoxybenzoyl)haemanthamine (1g) with IC₅₀ value 3.3 ± 0.4 µM. Moreover, 11-O-(2-chlorbenzoyl)haemanthamine (1m) was able to inhibit both enzymes in dose-dependent manner. The mode of hAChE and hBuChE inhibition was minutely inspected using enzyme kinetic analysis in tandem with in silico experiments, the latter elucidating crucial interaction in 1j-, 1m-hAChE and 1g-, 1m-hBuChE complexes. The blood-brain barrier (BBB) permeability was investigated applying the parallel artificial membrane permeation assay (PAMPA) to predict the CNS availability of the compounds.

Treatment of Relapsed/Refractory Hodgkin Lymphoma: Real-World Data from the Czech Republic and Slovakia

Introduction: Clinical trials have demonstrated the effectiveness of the CD30-targeted antibody-drug conjugate brentuximab vedotin (BV) for the treatment of relapsed/refractory Hodgkin lymphoma (R/R HL). In this study, we report on outcomes with BV in a real-world setting using data collected in clinics in the Czech Republic and Slovakia. Patients and Methods: Clinical and epidemiological data for patients with R/R HL who received treatment with BV at eight centers across the Czech Republic and Slovakia were examined. Data were amalgamated and analyzed retrospectively. Results: Clinical data for 58 patients (median age: 30.5 years) with R/R HL who received BV during the course of their treatment were collected and analyzed. Patients had received a median of 3 prior treatment regimens and most (91%) were treated with BV after relapse following autologous stem cell transplantation. Therapeutic responses after BV included 19 (33%) complete responses (CRs) and 8 (14%) partial responses. CRs occurred more frequently in patients who had received fewer prior treatment regimens. The 1-, 2-, and 3-year overall survival (OS) rates from initiation of BV were 78%, 62%, and 41%, respectively. Conclusion: Response rates and OS in this analysis of BV in real-world settings in the Czech Republic and Slovakia were consistent with those reported for pivotal clinical trials and from previous studies outside the clinical trial setting. The results support the efficacy of BV for treatment of R/R HL in real-life clinical practice.

[Treatment of Relapsed and Refractory Hodgkin Lymphoma - Recommendations of the Czech Hodgkin Lymphoma Study Group]

High-dose chemotherapy with autologous stem cell transplantation remains the current standard of treatment for young patients with Hodgkin lymphoma in first relapse or in those who are refractory to first-line treatment. The most important prognostic factors in relapses are clinical stage IV, poor performance status, bulky mass, and less than partial remission after salvage chemotherapy. Standard salvage chemotherapy in relapse before autologous transplantation has not been defined; however, DHAP and ICE are most frequently used in this setting. A standard conditioning regimen before autologous transplantation is BEAM. Tandem autologous transplantation has been investigated in high-risk patients. Brentuximab vedotin is recommended as a consolidation treatment in patients with a high risk of relapse after autologous transplantation. Brentuximab vedotin is the standard of treatment for relapse after autologous transplantation, and subsequent allogeneic stem cell transplantation should be considered in young patients. Bretuximab vedotin in combination with bendamustine, nivolumab, and pembrolizumab, and combinations thereof with other drugs, were investigated in clinical trials in relapsed or refractory patients with Hodgkin lymphoma.Key words: Hodgkin lymphoma - autologous stem cell transplantation - brentuximab vedotin - nivolumabThis work was supported by grant awarded by AZV 16-29857, Ministry of Health in Czech Republic, Research project P 27/2012 awarded by Charles University in Prague, 3rd Faculty of Medicine, Prague.The authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 7. 6. 2016Accepted: 24. 8. 2016.

Sentence comprehension in Slovak-speaking patients with Alzheimer's disease

BACKGROUND

According to some studies, sentence comprehension is diminished in Alzheimer's disease (AD) patients, but they differ on what underlies the sentence comprehension impairment. Sentence comprehension in AD patients has been studied mainly in the English language. It is less clear how patients with AD speaking a morphologically rich language with grammatical morphemes indicating case and through it even thematic roles process reversible sentences.

AIMS

To compare the comprehension of various syntactic constructions in Slovak-speaking AD patients and cognitively intact elderly people. We were concerned with the influence of the following aspects on sentence comprehension: its length, the order of thematic roles and the presence of a morphological cue placed on the first noun (or at the beginning of a sentence).

METHODS & PROCEDURES

We used our own Slovak test of sentence comprehension based on matching pictures to spoken sentences. These sentences contain transitive verbs and two nouns (person/animal), one functioning as a subject and the other as an object, which both can perform the action expressed by the verb. We assessed 62 healthy elderly people and two groups of AD patients. The first group consisted of 34 participants with a mild degree of AD and the other group of 43 participants with a moderate degree of AD.

OUTCOME & RESULTS

Statistical comparisons showed that the elderly controls were significantly better in the comprehension of simple active OVS (object-verb-subject word order) sentences and complex EO sentences (a centre-embedded relative clause with a relative pronoun substituting for an object) than patients with a mild degree of AD. In patients with a moderate degree of AD, comprehension of all tested sentence types was worse than in healthy elderly people. The results also indicated that even mild AD patients have more serious problems with processing sentences with non-canonical order of thematic roles regardless of a morphological cue at the beginning of a sentence.

CONCLUSION & IMPLICATIONS

The results point to diminished sentence comprehension in patients with AD. In the group of mild AD patients, the order of thematic roles played a significant role in their sentence comprehension. Even though the grammatical morphemes clearly code the functions of words in the Slovak language, mild AD patients do not process them in sentences with a non-canonical order of thematic roles at the same level as the healthy controls. Patients with moderate AD have significant problems even with the comprehension of sentences with a canonical order of thematic roles. These difficulties seem to be a consequence of insufficient resources for language processing.

[Chemotherapy-related Cognitive Impairment in Patients with Hodgkin Lymphoma - Pathophysiology and Risk Factors]

BACKGROUND

Cognitive impairment (impairment of memory, attention, or concentration) is documented in 17-75% of patients with various malignancies treated with chemotherapeutic agents that worsen quality of life. CRCI affects patients of all ages. The impairment of cognitive function in connection with chemotherapy is usually mild, but an event. relationship with dementia remains to be confirmed. Chemotherapy in combination with radiotherapy in Hodgkin lymphoma can cure 80-90% of patients.

AIM

This review summarizes the most frequently observed changes in cognitive function in patients suffering from CRCI. The article further describes the possible pathophysiological mechanisms behind these changes and the risk factors that can increase the likelihood of cognitive functional impairment after chemotherapy of malignant tumors. Special attention is given to how this relates to Hodgkins lymphoma. We also discuss the neuroprotective factors involved in chemotherapy-related cognitive impairment and its treatment options.

CONCLUSION

Changes occur mainly in the ability to learn and remember, in the speed of reactions, and in attention and executive functions. Although CRCI pathophysiological mechanisms are complex and not yet fully understood, the involvement of neurotoxicity, such as that induced by treatment, anemia, higher levels of oxidative stress and inflammatory responses, genetic factors, and reduced brain connectivity is discussed. CRCI is further modified by comorbidities and patient age. Pharmacological and nonpharmacological treatment options for CRCI are outlined.Key words: Hodgkin lymphoma - chemotherapy - cognitive impairment - risk factors The project was supported by the grant of the Agency for the Czech Republic Health Research of the Ministry of Health of the Czech Republic 16-29857A and by the project Sustainability for the National Institute of Mental Health No. LO1611 with a financial support of the Ministry of Education, Youth and Sports of the Czech Republic in the frame of the National Sustainability Programme I. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 29. 9. 2016Accepted: 12. 2. 2017.

[The role of radiotherapy in the treatment of malignant lymphomas - recommendations of the Czech Lymphoma Study Group]

BACKGROUND

Indication of radiotherapy in lymphoma treatment is an important strategic decision requiring comprehensive expertise. It also calls for a better definition of the position of radiotherapy in clinical practice.

DESIGN

This position paper represents a consensus between hematooncologists and radiation oncologists on the role of RT in treatment of different histological types and stages of malignant lymphomas. The discussion was underway within professional societies of both specializations (Czech Lymphoma Study Group for the hematooncologists and the Society of Radiation Oncology, Biology and Physics for the radiation oncologists).

RESULTS

The consensus presented here was reached in early 2012 and draws on evidence-based medicine and clinical practice. Besides defining the role of radiotherapy in lymphoma treatment, this paper also gives specific recommendations on total doses of radiotherapy in lymphoma treatment.

CONCLUSION

These recommendations will supplement 7th edition of "Diagnostic and treatment guidelines in patients with malignant lymphoma" scheduled for publication in 2013.

Prognostic impact of DNMT3A mutations in patients with intermediate cytogenetic risk profile acute myeloid leukemia

OBJECTIVES

Recently, mutations in DNMT3A gene have been described in about 25% acute myeloid leukemia (AML) cases, preferentially in monocytic AML. They were found to predict worse overall survival (OS) of mutated patients.

PATIENTS AND METHODS

RT-PCR followed by direct sequencing was used to test the presence of DNMT3A mutations in 226 AML patients with an intermediate-risk (IR) cytogenetics.

RESULTS

Sixty-seven patients of 226 (29.6%) carried a mutation in the DNMT3A gene. Occurrence of DNMT3A mutations was associated with female sex (P = 0.027) and with the presence of FLT3/ITD (P = 0.003), but not with particular FAB subtypes. Patients with DNMT3A mutation had higher initial WBC counts than those without it (P = 0.064) only because of higher incidence of FLT3/ITD within these cases. There was no difference between mutated and wild-type groups in reaching complete remission (CR) (P = 0.380). OS was not affected by DNMT3A mutation (P = 0.251), but OS of patients who reached CR was longer in DNMT3A negative cases (P = 0.025). Patients with DNMT3A mutation had a higher relapse rate (P = 0.007). Patients carrying both the DNMT3A mutation and FLT3/ITD relapsed more often than either patients with single DNMT3A mutation (P = 0.044) or patients with FLT3/ITD only (P = 0.058). DNMT3A mutations were associated with higher relapse rate even within the FLT3/ITD-negative group (P = 0.072). After reaching CR, these two genetic factors were independent predictors of relapse at multivariate analysis (P < 0.001). Only three of 30 'double-mutated' (FLT3/ITD+, DNMT3A+) patients are still alive, all of them having undergone hematopoietic stem cell transplant.

CONCLUSIONS

We have confirmed the high incidence of DNMT3A mutations in patients with AML with IR cytogenetics. Patients with DNMT3A mutations relapse more often and have inferior OS when only patients achieving CR are analyzed. 'Double-mutated' patients have a very poor prognosis.

Estimation of molecular upper remission limit for monitoring minimal residual disease in peripheral blood of acute myeloid leukemia patients by WT1 expression

To date, approximately one half of acute myeloid leukaemia (AML) patients do not have a suitable specific molecular marker for monitoring minimal residual disease (MRD). The Wilm's tumour gene (WT1) has been suggested as a possible molecular marker of MRD in AML. The expression of WT1 in peripheral blood (PB) was measured using quantitative real-time reverse transcription-polymerase chain reaction in peripheral leukocytes from 151 patients with AML at diagnosis. WT1 expression was significantly elevated, i.e. up to 3 orders of magnitude in the majority (80%) of AML patients at diagnosis compared to the PB of healthy donors. Sequence samples of the long-term followed-up AML patients treated with chemotherapy and/or allogeneic bone marrow transplantation were analysed for WT1 expression. The results revealed that the hematological relapses were preceded (median, 1.8 months) by an increase in WT1 gene expression. For the practical utility of this gene as a molecular marker of relapse, it was necessary to determine an upper remission limit, crossing which would signal hematological relapse. The upper remission limit was determined in our set of patients to be 0.02 WT1/ABL. The AML patients who consequently relapsed crossed this upper remission limit; however, those in permanent remission did not. Therefore, this upper remission limit could be taken as the border of molecular relapse of AML patients. Moreover, insufficient decline of WT1 expression under the upper remission limit following induction and/or consolidation therapy was associated with markedly high risk of relapse. The results show that our upper remission limit can be taken as the border of molecular relapse of AML patients and WT1 levels following initial therapy as a beneficial prognostic marker.

Monitoring of minimal residual disease in patients with core binding factor acute myeloid leukemia and the impact of C-KIT, FLT3, and JAK2 mutations on clinical outcome

Mutational analysis of C-KIT, fms-like tyrosine kinase 3 (FLT3), and JAK2 genes was performed in 60 patients with core binding factor acute myeloid leukemia (CBF-AML). Patients reaching molecular remission had lower incidence of relapse and better overall survival (OS) than those not achieving molecular remission (p = 0.008 and 0.044, respectively). The overall incidence of C-KIT mutations was 33.3%, FLT3/internal tandem duplication (ITD) 6.6%, FLT3(D835) 10.0% and JAK2(V617F) mutations 3.3%. C-KIT mutations did not predict for clinical/molecular relapse (p = 0.33). OS of patients with C-KIT mutations was identical to patients without them when all patients with CBF-AML were analyzed together (p = 0.58). When AML1/ETO-positive patients were evaluated separately, OS in C-KIT-mutated patients was slightly inferior to unmutated ones (p = 0.14). Patients with CBF-AML with a mutated C-KIT gene were also more prone to extramedullary disease (p = 0.08). Of six patients harboring various FLT3(D835) mutations, four (66.7%) relapsed, whereas among 43 cases without these mutations, 16 relapses (37%) were observed (p = 0.08). Our results on minimal residual disease, C-KIT, and FLT3/ITDs are in line with previous studies. Surprisingly, a possible role for FLT3(D835) mutations was noted in addition. These results need validation in even larger patient cohorts than ours. For routine clinical practice, it may be meaningful to screen for C-KIT mutations in AML1/ETO-positive patients, as well as for FLT3(D835) mutations in CBF-AML.

Unusually long survival of a 67-year-old patient with near-tetraploid acute myeloid leukemia m0 without erythroblastic and megakaryocytic dysplasia

Patients with near-tetraploid acute myeloid leukemia (NT-AML) typically have poor survival. We present the case of a 67-year-old Caucasian male with NT-AML M0 who had an unusually long first complete remission of 51 months and an overall survival of 80 months. The only characteristic distinguishing him from other previously described patients with NT-AML was the absence of erythroblastic and/or megakaryocytic dysplasia (EMD) at diagnosis. Molecular-genetic testing for AML fusion transcripts associated with a favorable prognosis (PML/RARα,AML1/ETO, and CBFβ/MYH11) were negative, as were other prognostic markers like MLL-PTD,FLT3-ITD, or mutations of FLT3-D835,NPM1, or CEBPA. Expression studies of ERG,MN1, and EVI1 revealed overexpression of ERG only. The absence of EMD may be a useful prognostic/diagnostic feature of this new rare subtype of NT-AML.

[Treatment of patients with relapsed/refractory Hodgkin lymphoma]

BACKGROUNDS

This retrospective study evaluated treatment outcomes in patients undergoing autologous stem cell transplantation (ASCT) for relapsed/refractory Hodgkin lymphoma (HL).

PATIENTS AND METHODS

Overall, 194 HL patients treated with ASCT between 2000 and 2009 were analyzed. Survival was calculated using Kaplan-Meier method and differences in survival between subgroups with log-rank test.

RESULTS

Best responses observed after ASCT: 124 complete and 35 partial remissions, 2 patients with stable disease and 33 relapses/progressions. During a median follow-up of 44 months, seventy patients after ASCT progressed/relapsed. Thirty-seven patients received salvage chemotherapy only with or without radiotherapy, 25 underwent allogeneic stem cell transplantation (SCT), 4 the second ASCT and 4 refused treatment. 5-year overall survival after ASCT was 71% and progression-free survival 54%. Median survival of the 70 patients relapsing after ASCT was 16.9 months. Median survival in patients after allogeneic SCT was 31.8 months and 12.4 months in patients treated with other modalities (p = 0.21). Overall mortality was 26.3% (51/194 patients): 13.4% progressions/relapses of HL and 12.9% non-relapse mortality.

CONCLUSION

Efficacy of ASCT was confirmed in 54% progression-free survivors. Median survival after ASCT failure is relatively short. There is a slightly longer overall survival after allogeneic SCT, although not statistically significant when compared to other approaches.

[Urgent states in hematology: acute promyelocytic leukemia--principles of diagnosis]

A review of diagnosis of acute promyelocytic leukemia (APL) is presented. There are still many patients with progressive disease with leukocytosis at presentation. These are at greater risk of early death due to bleeding (often intracranial), or, less frequently, due to thrombotic complications. In Czechia, we have, in some instances, noted an unacceptably long time from the first symptoms to diagnosis and to administration of the highly specific differentiation therapy with tretinoin (ATRA) along with anthracycline chemotherapy. This combination is highly efficient--cures are seen in some 70% of patients. Therefore, we present a diagnostic minimum for each and every internist, and even better for every general practician, to get acquainted with. All cases of pancytopenia and consumption coagulopathy should be suspected of APL and referred to a specialized hematologist without any delay. In the following more detailed review of diagnostic measures, much attention is given to APL morphology, which is the first clue leading to diagnosis. The finding of the typical hypergranular FAB M3 morphology and of cells with bundles of Auer rods ("faggot cells"), along with the HLA-DR, CD33+ immunophenotype, is highly (but not absolutely) specific for APL. In cases of the micro-/hypo-granular variant FAB M3v Form, and whenever APL cannot be ruled out with certainty, a test to prove the presence of the PML/RARalpha fusion gene is indicated, using either RT-PCR or, eventually, immunological demonstration of the specific distribution of the PML protein in the cell nucleus. Given that morphology of APL cases, as defined according to WHO criteria (95% of which carry the PML/RARalpha fusion gene), admits extremely divergent morphological pictures ofthe variant forms, we recommend these investigations to be performed in every case of de novo acute myeloid leukemia. A review of the less frequent morphological, as well as genetic variants is given, and the principles of immunophenotypic, cytogenetic and molecular diagnostics are also reviewed.

[Therapy of acute promyelocytic leukemia in Czechia: results and analysis of prognostic factors]

We have retrospectively evaluated a cohort of 144 patients (including 17 pediatric ones) with de novo acute promyelocytic leukemia registered in databases of institutions cooperating within the CELL group (The Czech Leukemia Study Group for Life). The patients were diagnosed according to WHO criteria from 1989 until 2006. The aim was to check how well fared the patients, the majority of whom was not included into clinical trials, in real life. Of 140 evaluable patients, 97 (69.3%) attained complete remission (CR). The projected overall survival (OS) 4 years after diagnosis was 58.9%, and 55.3% at 6 years. In 8 patients (6.0%), no antileukemic therapy at all was given (either they died shortly after admission to the ward or therapy was not feasible due to their clinical status). Of 125 patients with documented commencement of some kind of therapy, 96 (76.8%) achieved CR. Of 102 patients with induction treatment with a combination of anthracycline and tretinoin (ATRA), 84 individuals (82.4%) attained CR (typically, this cohort might have been subjected to clinical trials). This result was better than that of patients treated by chemotherapy only (n = 15; CR 46.7%; P = 0.003) or by ATRA monotherapy (n = 13; CR 62.5%; P = 0.17). Another parameter with a significant impact on attaining CR was the leukocyte (WBC) count at diagnosis: its median values in patients achieving and not achieving CR were 2.1 and 24.0 x 10(9)/l, respectively (P < 0.0001). The WBC counts affected OS as well (P = 0.0001). However, when only patients after attaining CR were evaluated, the initial WBC counts no longer affected OS (P = 0.18). Achieving CR was also influenced by the performance status (PS) 0-1 (P = 0.005), which was in turn closely correlated to WBC counts (P = 0.0006). Additional factors (most likely connected with leukocytosis) influenced attaining CR with borderline statistical significance: e.g. FAB M3v morphology, LDH serum level, fibrinogen level, presence of internal tandem duplication (ITD) of the FLT3 gene (which was strongly associated with leukocytosis and also with the short PML/RARalpha transcript resulting from the bcr3 break in the PML gene). It may be speculated that FLT3-ITD is just one of the possible factors that lead to leukocytosis. The platelet counts at diagnosis had no impact on entering CR. Thus, we have not validated the current PETHEMA risk stratification in distinguishing intertermediate and low risk patients. Our study points to a significant difference of the results obtained in real life and of the results that could be achieved in patients who were fit to enter clinical trials. Among the prognostic factors, the most important one was the WBC count, the PS (which is highly affected by the WBC count), and feasibility of administration of the most potent induction therapy with anthracyclines and ATRA.

Semiquantitative RT-PCR evaluation of the MDR1 gene expression in patients with acute myeloid leukemia

Resistance to chemotherapy is one of the major obstacles to effective treatment in acute myeloid leukemia (AML). The most extensively studied protein involved in multidrug resistance (MDR) is the transmembrane glycoprotein P (P-gp), the product of the multidrug resistance gene 1 (MDR1). MDR1/P-gp overexpression is frequently observed in hematological malignancies, especially in acute leukemia, and has been reported to correlate with poor prognosis in acute myeloid leukemia (AML). The aim of this study was to evaluate the level of MDR1 gene expression in bone marrow and/or peripheral blood samples in 92 AML patients in relation to their prognosis. The analyzed group was stratified according to presence or absence of prognostically favorable aberrations (PFAs), such as t(15;17) with PML/RARalpha fusion gene, t(8;21) with AML1/ETO fusion gene or inv(16)/ t(16;16) with CBFbeta/MYH11 fusion gene. These prognostically favorable aberrations were detected by RT-PCR and/or standard cytogenetic techniques. MDR1 expression was detected by semiquantitative comparative RT-PCR using software-based evaluation. The levels of MDR1 expression in the bone marrow predicted induction of complete remission in the whole group of analyzed patients (P = 0.032). They were significantly lower in PFA negative patients who achieved complete remission compared to those who failed to achieve complete remission (P = 0.008). In PFA negative patients, MDR1 expression was higher when compared to PFA positive patients (P = 0.055). No such difference was found when analyzing peripheral blood samples. Our experiments showed no impact of MDR1 expression in bone marrow or peripheral blood cells on overall survival (P = 1.000 and P = 0.903 respectively). In summary, the present study shows the prognostic impact of MDR1 expression on induction of complete remission in AML patients. We confirmed that MDR1 overexpression is an unfavorable prognostic factor in AML, which may help to stratify the risk rate of PFA negative patients. In future studies, quantitative detection of MDR1 expression might be a valuable tool to predict prognosis in this patient subset.

Prognostic relevance of the FAB morphological criteria in chronic lymphocytic leukemia: correlations with IgVH gene mutational status and other prognostic markers

Morphological examination is the routine first step in the diagnosis of hematological malignancies, including chronic lymphocytic leukemia (CLL). Atypical cell morphology according to the FAB criteria is known to herald disease progression. Several years ago, it was proposed that FAB morphology at diagnosis had a considerable prognostic impact. However, this proposal has not been widely adopted in practice. Thus we questioned the prognostic value of the morphological examination, which was performed retrospectively in 88 patients out of our 110 institutional registry patients (70 males and 40 females, median age 57 yrs) with CLL at diagnosis. We related the results to the more modern prognostic markers. Atypical FAB morphology was shown to correlate with IgVH gene mutation status, trisomy of chromosome 12 and deletion of 17p detected either by conventional G-banding or by fluorescence in situ hybridization (FISH) analysis. The correlation of FAB morphology with CD38 antigen expression or with the histopathological pattern of bone marrow infiltration was not significant. Overall survival (OS) data were available for 84 morphologically examined patients. The patients with atypical morphology (64 patients) had a significantly shorter OS (103 months) than the 20 patients presenting with typical CLL morphology (237 months; p=0.03). Only the mutation status of IgVH genes correlated more closely with OS (p=0.002). Of note, there was no leukemia-related death within "unmutated" cases who had typical FAB morphology (p=0.14), and vice versa, the mutation status had a significant prognostic impact within the morphologically atypical cases (p=0.01). Thus FAB morphology and the mutation status may yield complementary prognostic information. OS was affected both by the presence of cytogenetic aberrations (p=0.03) - most adversely by deletions of 17p and 11q, and by CD38 expression (p=0.003). We conclude that careful examination of peripheral blood smears according to FAB is a simple, cheap and valuable tool in the first-line assessment of prognosis of CLL patients and should not be overlooked even in 3rd millennium when more sophisticated prognostic markers are at hand. This ought to be confirmed in larger prospective studies with multivariate analysis of data.

[The use of quantitative assessment of Wilms tumour gene 1 for monitoring of residual disease in acute myeloid leukemia patients]

BACKGROUND

Despite a considerable effort, the majority of acute myeloid leukaemia (AML) patients do not have a suitable specific molecular marker for monitoring minimal residual disease (MRD). The results of some studies suggest the Wilms tumour gene (WT1) as a possible molecular marker of MRD.

METHODS AND RESULTS

We measured the expression of WT1 at diagnosis and during treatment of the acute myeloid leukaemia (AML) patients. The expression of WT1 was measured by the quantitative real-time RT-PCR in peripheral leukocytes from 56 AML at diagnosis and 7 patients with AML transformed from myelodysplastic syndromes (MDS). The WT1 expression was significantly elevated (up to 3 orders of magnitude) in peripheral blood samples (PB) of AML patients at diagnosis compared to PB samples of healthy donors (P < 0.0001). The level of WT1 expression depends particularly on FAB AML subtype, with the highest being found in AML patients with subtypes M4, M1, M3 and AML transformed from MDS. Conversely, AML patients with M2 and with the presence of AML1/ET0 at presentation showed a significantly lower expression of the WT1 gene compared to the remaining AML patients at presentation (P = 0,005). Further, sequence samples of 12 AML patients under long-term surveillance were tested for the WT1 expression in parallel with the expression of specific MRD markers--fusion genes: AMLI/ETO, PML/RARalpha and CBFB/MYH11. The levels of WT1 gene expression and the above specific fusion genes significantly correlated. Moreover, 14 patients without the specific MRD marker were tested for the WT1 expression. The results show that haematological relapses were associated with the rise of expression of the specific fusion genes and with the WT1 gene expression. The rise of WT1 expression above the level seen in leucocytes from peripheral blood and/or bone marrow of healthy donors--in four patients under long-term surveillance the "molecular relapse" predicted ongoing haematological relapses as early as 2 months in advance.

CONCLUSIONS

Our results, in accordance with some of the previously published ones, show that WT1 expression seems to be a suitable marker of minimal residual disease in AML patients.

Touch-Down Reverse Transcriptase-PCR Detection of IgVH Rearrangement and Sybr-Green-Based Real-Time RT-PCR Quantitation of Minimal Residual Disease in Patients with Chronic Lymphocytic Leukemia

BACKGROUND

Patients with chronic lymphocytic leukemia (CLL) can relapse even after aggressive therapy and autografts. It is commonly assumed that to prevent relapse the level of minimal residual disease (MRD) should be as low as possible. To evaluate MRD, highly sensitive quantitative assays are needed.

AIM

The aim of the study was to develop a robust and sensitive method for detection of the clonal immunoglobulin heavy-chain variable (IgV(H)) rearrangement in CLL and to introduce a highly sensitive and specific methodology for MRD monitoring in patients with CLL who undergo intensive treatment.

METHODS

As a prerequisite for MRD detection, touch-down reverse transcriptase (RT)-PCR using degenerate primers were used for the diagnostic identification of (H) gene rearrangement(s). For quantitative MRD detection in 18 patients, we employed a real-time RT-PCR assay (RQ-PCR) making use of patient-specific primers and the cost-saving Sybr-Green reporter dye (SG). For precise calibration of RQ-PCR, patient-specific IgV(H) sequences were cloned.

RESULTS

Touch-down RT-PCR with degenerate primers allowed the successful detection of IgV(H) clonal rearrangement(s) in 252 of 257 (98.1%) diagnostic samples. Biallelic rearrangements were found in 27 of 252 (10.7%) cases. Degenerate primers used for the identification of clonal expansion at diagnosis were not sensitive enough for MRD detection. In contrast, our RQ-PCR assay using patient-specific primers and SG reached the sensitivity of 10(-)(6). We demonstrated MRD in each patient tested, including four of four patients in complete remission following autologous hematopoietic stem cell transplantation (HSCT) and three of three following allogeneic 'mini'-HSCT. Increments in MRD might herald relapse; aggressive chemotherapy could induce molecular remission.

CONCLUSIONS

Our touch-down RT-PCR has higher efficiency to detect clonal IgV(H) rearrangements including the biallelic ones. MRD quantitation of IgV(H) expression using SG-based RQ-PCR represents a highly specific, sensitive, and economic alternative to the current quantitative methods.

[Skeletal involvement in Hodgkin's lymphoma--personal experience]

PURPOSE

To assess the incidence and prognostic significance of osseous Hodgkin's lymphoma.

METHODS AND MATERIALS

The authors retrospectively analyzed 85 patients treated at their institutions between 1995-2001. They assessed the incidence of bone involvement, involved localities and basic characteristics of the subgroup (age, gender, stage, histology). All patients were treated according to the protocols of the German Hodgkin Study Group (GHSG). Treatment response, disease free- and overall survival were evaluated with special attention to predictive and prognostic significance of bone involvement.

RESULTS

From the total of 85 eligible patients 10 cases of bone involvement were recorded of who seven were diagnosed primarily and three at relapse. Most frequently involved were lumbar vertebrae. Diagnosis was based on CT and bone scan, biopsy was performed only in one case. In the evaluated subgroup, there was apparently higher incidence of advanced stage disease, other parameters did not differ from the control group. Of the 10 patients, six achieved complete remission, two uncertain complete remission and two progressed primarily. At present, eight patients are alive in complete remission, one is being treated with salvage chemotherapy and high dose therapy with autologous stem cell transplantation. One patient expired due to progressive disease. Median overall survival is 12 months.

CONCLUSION

Bone involvement is not an adverse predictive factor for treatment response in Hodgkin's lymphoma. Because of short follow-up period seems preliminary to evaluate its prognostic power for disease free- and overall survival.

[Comparison between conventional imaging methods and positron emission tomography in the treatment of Hodgkin's lymphoma]

BACKGROUND

Positron emission tomography with fluorodeoxyglucose offers the possibility to differentiate between lymphoma and nonmalignant tissue. The aim of this retrospective study was a comparison between PET and conventional imaging methods before and after therapy--during the follow-up of Hodgkin's lymphoma.

METHODS AND RESULTS

The group of 94 patients with HL underwent 180 PET examinations. PET was performed in 53 patients during initial staging of lymphoma. 119 PET studies were undertaken after therapy during the follow-up. Eight patients underwent PET examination for suspected relapse or progression of HL. Findings were verified by a follow-up in all patients and by histology in selected cases. PET and conventional imaging methods were positive in 42 of 53 (79%) patients in initial stages. The stage of the disease was changed in 7 patients (13.2%) according to PET. False negative findings were recorded in three cases and false positive in one case. Sensitivity of PET was higher compared to conventional imaging methods (92% vs 87%) in initial staging. PET and conventional imaging methods were identical in 94.9% of cases during the follow-up (77.3% negative and 17.6% positive findings). Sensitivity of PET during the follow-up after therapy was higher compared to conventional imaging methods (99.1% vs 95.7%). PET was positive in all eight cases in relapse/progression of HL and conventional imaging methods were positive in only seven of eight cases.

CONCLUSIONS

PET is a more sensitive method in initial staging, during follow-up and in suspected progression/relapse of HL than conventional imaging methods and it should be included into routine examination methods of HL.

Echocardiographic evaluation of acute cardiotoxicity in the treatment of Hodgkin disease according to the German Hodgkin's Lymphoma Study Group

Echocardiography is a sensitive method for detecting wall motion abnormalities, as well as for monitoring cardiotoxicity during treatment with anthracyclines. Using echocardiography, this study investigated possible acute cardiotoxicty associated with primary treatment of Hodgkin's disease according to German Hodgkin's Lymphoma Study Group (GHSG) clinical trial protocols for adults. A group of 88 patients (48 men) was registered in the prospective, randomized clinical trial involving the treatment of Hodgkin's disease using third and fourth generation GHSG protocols. These patients were monitored by echocardiography. The average age was 34 years (range, 18-65; median, 32). The average anthracycline dose was 174 mg/m2 (median 200 mg/m2), and the average mediastinum irradiation dose was 21 Gy (median 30 Gy). Left ventricle end-systolic diameter (ESD) and left ventricle end-diastolic diameter (EDD), as well as fractional shortening (FS) and ejection fraction (EF) (M-mode calculation) were evaluated, as was the presence of pericardial effusion and wall motion abnormalities. The examinations were conducted before and at the end of therapy (up to 2 months). Results show that all evaluated parameters changed from one follow-up examination to the other, but these changes did not reach statistical significance. ESD increased from 30 +/- 4 to 31 +/- 4 mm. EDD increased from 49 +/- 4 to 49 +/- 5 mm. Ejection fraction changed from 69 +/- 7 to 66 +/- 7% and fractional shortening was unchanged (from 38 +/- 7 to 38 +/- 7%). In seven patients (8%), we observed new wall motion abnormalities characterized by hypokinesis without decrease of left ventricular function. Significant changes in the amount of pericardial effusion were not observed. In four patients (5%), there was progression of Hodgkin's disease. In conclusion, treatment according to third and fourth generation clinical trial protocols of the GHSG leads only to minimal wall motion changes, without concomitant reduction of left ventricular function, thus not meeting the criteria, acute cardiotoxicity.

[Late recurrence of Hodgkin's disease 20 years after initial diagnosis. Personal observation of two cases and a literature review]

Most patients with Hodgkin's disease (especially early stage disease) are successfully treated using modern treatment modalities. Disease relapse usually occurs within the first three years after initial therapy. Late relapses of Hodgkin's disease, occurring after 10 years or even later, are rare (0.6% of cases only). Their biological behaviour is different from that of early relapses, resembling primary disease. The question whether very late relapses represent a second primary disease in patients with a genetic predisposition to Hodgkin's disease rather than a relapse of the original disease remains the subject of much discussion. We report here two cases of very late relapses of Hodgkin's disease, occurring twenty years after initial treatment. Both patients were now treated by intensified chemotherapy, escalated BEACOPP. In one case, this was followed by radiotherapy of the residual tumor (40 Gy). Both patients are in complete remission.

[Personal experience with intra-arterial locoregional chemotherapy of liver metastases from colorectal carcinoma]

Locoregional chemotherapy is one of the possible ways of treatment of inoperable metastatic affection of the liver by colorectal carcinoma. The advantage of regional administration of the cytostatic is the possibility to achieve a higher local concentration of the cytostatic associated with a higher percentage of therapeutic responses. In our department we preferred combined locoregional intraarterial chemotherapy (5-fluorouracil/Mitmycin C/Doxorubicin) combined with systemic intravenous chemotherapy (5-fluorouracil/leukovirin). Locoregional cghemotherapy was administered in the majority as chemotherapy of series 2 or 3 with a very good tolerance. In 2/19 patients we observed marked diminution of liver metastases and subsequent operability and with a duration of complete response for 13 and 18 months. In 7/19 patients a partial therapeutic response was achieved. The total therapeutic response (complete and partial) was 47%. Locoregional chemotherapy attains a higher therapeutic response as compared with systemic chemotherapy and is associated with an acceptable toxicity.

[Treatment of Hodgkin's disease using the German Study Group protocol. Personal experience and results]

The article present an evaluation (02/1999) of the study of primary treatment of Hodgkin's disease (HD) according to the third generation of the German Hodgkin's Disease Study Group (GHSG), and our experience with this treatment strategy. HD7 study of early stages HD showed better results (fewer relapses) for combined chemo and radiotherapy than for radiotherapy alone (2x ABVD + extended field radiotherapy compared to extended field radiotherapy alone). HD8 study of intermediate stage HD did not show any difference between chemotherapy 2x (COPP + ABVD) combined with radiotherapy extended field, or involved field. Due to the long-term consequences (especially secondary neoplasm), in the current (fourth) generation protocol extended field radiotherapy in early and intermediate stage HD has been replaced by a combination of lesser toxic chemotherapy and involved field radiotherapy. HD9 study of advanced HD. The standard treatment at present of COPP/ABVD (A) was compared with the new chemotherapeutic regimen, BEACOPP baseline (B) and escalated (C). The first evaluation of this study (1996) showed better results in the case of BEACOPP. The latest evaluation showed significantly better results for the escalated version. This is best illustrated by the low percentage of disease progression (C 2%, B 8%, A 12%, p < 0.05). Therefore, DHSG is considered to be the new standard for treatment of advanced stage HD.

OUR RESULTS

Between 1995-1998, 54 patients with primary HD were treated at the FN Královaké Vinohrady, Prague according to the third generation GHSG protocol. Of these, 5 patients (9%) according to HD7, 14 (26%) according to HD8 and 35 patients (65%) according to HD9. Our results correspond to those of the whole GHSG, but they can not be statistically evaluated because of the small number of patients involved.

Primary manifestation of Hodgkin's disease in the central nervous system

A 62-year-old woman presented with loss of memory and a mild hemiparesis. Neuroradiology demonstrated a left frontoparietal tumour. Biopsy specimens of this lesion revealed intracerebral Hodgkin's lymphoma, a diagnosis supported by immunohistochemical reactions of the tumour cells for the CD30 antigen. Additional cell cycle studies revealed a high proliferative activity of the tumour cells in association with absence of apoptosis. There was no evidence that overexpression of bcl-2 or Epstein-Barr virus infection was involved in the pathogenesis of this neoplasm. Lymphomas in the lung were detected 3 months later. Following neurosurgical excision, radiotherapy, and chemotherapy, the patient had no evidence of Hodgkin's disease after 13 months of follow-up.

[Safety of emergency surgical procedures in patients with pathological values in Quick's test]

In clinical practice doctors are frequently faced with the necessity of rapidly influencing a prolonged prothrombin time (Quick's test) in a patient who will have a surgical operation or invasive examination. After establishment of the cause of the prolonged prothrombin time the doctor has the following possibilities: if a planned operation is involved, anticoagulation treatment can be discontinued or vitamin K administered by the oral route, in urgent conditions virus-inactivated vitamin K concentrate dependent coagulation factors can be administered. Every transfusion is associated with the risk of transmissions of disease (hepatitis, HIV and others). Therefore it is better to use these concentrates rather than fresh frozen plasma-FFP.

[Anomalies of the basilar and vertebral arteries that are of practical importance]

Anomalies of vertebrobasilar vessels arise as early embryonal developmental deteriorations. The majority of them concerns the position, origin and shape of the vertebral and/or basilar arteries. In three patients, reported here, the aberrations were found occasionally and contributed in no way to the clinical symptomatology. In the first patient, a fenestration of A. basilaris was found with a fork-like division on its periphery. In the second patient we noted a doubled proximal origin of the vertebral artery. One artery arose from A. subclavia sinistra, the second one from the aortic arch. Both joined thereafter the common vertebral stem at the level of C4. In the third patient, A. vertebralis originated from the aortal arch, and, at the level of the thyroid, A. thyreoidea inferior originated from it. Attention is drawn to the practical importance of such variations as a possible source of diagnostic errors during cerebral arteriography.

Terguride in parkinsonism. A multicenter trial

Terguride is an ergoline derivative with mixed agonistic/antagonistic dopaminergic activity. This led to a paradoxical suggestion that it is effective in the treatment of both schizophrenia and parkinsonism. A total of 65 in- or outpatients with parkinsonism mostly of vascular or idiopathic etiology were included in a 4-week, open, multicenter trial. Terguride was administered under an increasing dose schedule which was leveled off according to the clinical response. Mostly because of nausea, vomiting, and lack of improvement 25% of inpatients and 61% of outpatients were removed from the study. The average daily dose at the end of the trial was 4.2 mg, ranging from 1.0 to 5.5 mg. The average Simpson and Angus scale total score and performance in the Spiral Drawing Task improved significantly during the trial by 20% and 38% respectively. The following adverse effects were noted most frequently throughout the study (including those who withdrew): constipation (occurred in 42% of all ratings performed during the trial) drowsiness and nausea (16% each). Adverse circulatory effects were negligible. Psychotic symptoms, including depression, confusion, hallucinations, and paranoid syndrome, each occurred in 1 patient, i.e., at a lower rate than with other dopaminergic drugs. Scotopic electroretinograms in a subsample of 7 patients showed a significant transitory decrease in the B-wave amplitude at the end of the 1st week and a subsequent return to pretreatment values.