Optimization of the indications for allogeneic stem cell transplantation in Acute Myeloid Leukemia based on interactive diagnostic strategies

The indications for allogeneic stem cell transplantation (SCT) in Acute Myeloid Leukemia (AML) represent a real challenge due to the clinical and genetic heterogeneity of the disorder. Therefore, an optimized indication for SCT in AML first requires the determination of the individual relapse risk based on diverse chromosomal and molecular prognosis-defining aberrations. A broad panel of diagnostic methods is needed to allow such subclassification and prognostic stratification: cytomorphology, cytogenetics, molecular genetics, and immunophenotyping by multiparameter flow cytometry. These methods should not be seen as isolated techniques but as parts of an integral network with hierarchies and interactions. Examples for a poor risk constellation as a clear indication for allogeneic SCT are provided by anomalies of chromosome 7, complex aberrations, or FLT3-length mutations. In contrast, the favorable reciprocal translocations such as the t(15;17)/PML-RARA or t(8;21)/AML1-ETO are not indications for SCT in first remission due to the rather good prognosis after standard therapy. Further, the indication for SCT should include the results of minimal residual disease (MRD) diagnostics by polymerase chain reaction (PCR) or flow cytometry. New aspects for a safe and fast risk stratification as basis for an optimized indication for SCT in AML might be provided by novel technologies such as microarray-based gene expression profiling. Keywords: Acute Myeloid Leukemia (AML), Allogeneic Stem Cell Transplantation (SCT), Indication, Cytogenetics, Polymerase Chain Reaction (PCR

The PML-RAR alpha transcript in long-term follow-up of acute promyelocytic leukemia patients

Background and Objectives. Detection of PML-RAR alpha transcripts by RT-PCR is now established as a rapid and sensitive method for diagnosis of acute promyelocytic leukemia (APL), Although the majority of patients in longterm clinical remission are negative by consecutive reverse transcription polymerase chain reaction (RT-PCR) assays, negative tests are still observed in patients who ultimately relapse. Conversion from negative to positive PCR has been observed after consolidation and found to be a much stronger predictor of relapse. This study reports on 47 APL patients to determine the correlation between minimal residual disease (MRD) status and clinical outcome in our cohort of patients. Design and Methods. The presence of PML-RAR alpha t transcripts was investigated in 47 APL patients (37 adults and 10 children) using a semi-nested reverse transcriptase-polymerase chain reaction to evaluate the prognostic value of RT-PCR tests. Results. All patients achieved complete clinical remission (CCR) following induction treatment with all-trans retinoic acid (ATRA) and chemotherapy (CHT) or ATRA alone. Patients were followed up between 2 and 117.6 months (median: 37 months). Relapses occurred in 11 patients (9 adults and 2 children) between 11.4 and 19 months after diagnosis (median: 15.1 months) while 36 patients (28 adults and 8 children) remained in CCR, Seventy-five percent of patients carried the PML-RARa long isoform (bcr 1/2) which also predominated among the relapsed cases (9 of 11) but did not associate with any adverse outcome (p = 0.37), For the purpose of this analysis, minimal residual disease tests were clustered into four time-intervals: 0-2 months, 3-5 months, 5-9 months and 10-24 months. Interpretation and Conclusions. Children showed persisting disease for longer than adults during the first 2 months of treatment, At 2 months, 10 (50%) of 20 patients who remained in CCR and 4 (80%) of 5 patients who subsequently relapsed were positive. Patients who remained in CCR had repeatedly negative results beyond 5.5 months from diagnosis. A positive MRD test preceded relapse in 3 of 4 tested patients. The ability of a negative test to predict CCR (predictive negative value, PNV) was greater after 6 months (> 83%), while the ability of a positive test to predict relapse (predictive positive value, PPV) was most valuable only beyond 10 months (100%). This study (i) highlights the prognostic value of RT-PCR monitoring after treatment of APL patients but only from the end of treatment, (ii) shows an association between conversion to a positive test and relapse and (iii) suggests that PCR assessments should be carried out at 3-month intervals to provide a more accurate prediction of hematologic relapses but only after the end of treatment, (C) 2001, Ferrata Storti Foundatio

Splanchnic vein thrombosis in myeloproliferative neoplasms: Pathophysiology and molecular mechanisms of disease

Myeloproliferative neoplasms (MPNs) are the most common underlying prothrombotic disorder found in patients with splanchnic vein thrombosis (SVT). Clinical risk factors for MPN-associated SVTs include younger age, female sex, concomitant hypercoagulable disorders, and the JAK2 V617F mutation. These risk factors are distinct from those associated with arterial or deep venous thrombosis (DVT) in MPN patients, suggesting disparate disease mechanisms. The pathophysiology of SVT is thought to derive from local interactions between activated blood cells and the unique splanchnic endothelial environment. Other mutations commonly found in MPNs, including CALR and MPL, are rare in MPN-associated SVT. The purpose of this article is to review the clinical and molecular risk factors for MPN-associated SVT, with particular focus on the possible mechanisms of SVT formation in MPN patients

Cytogenetic analysis and FISH of terminal deletion of the long arm of chromosome 9 in a patient with acute promyelocytic leukemia.

Deletions of the long arm of chromosome 9, del(9)(q22), are rare aberrations specifically found in acute myeloid leukemia (AML). Yamamoto et al, 1999, reported the first case of acute promyelocytic leukemia (APL) with a terminal 9q deletion as a sole abnormality. Here we describe the second case with the same aberration, the patient, an eleven-years-old girl with APL. Chromosomal analysis by the Giemsa R-banding technique and FISH using BCR/ABL and PML/RARA probe on short-term cell cultures from bone marrow was performed. A deletion of a 9 chromosome, del(9)(q22) was detected. Deletions of 9q have been described in about 3% to 4% of the AML patients, especially in M1 and M2 myeloid leukemia. Sole 9q terminal deletions, are less common than interstitial ones and involve q21~q22 band predominantly. A recent study suggests that 9q deletion, even in the absence of t(15;17), shows a relatively good prognosis. However, our patient died during the treatment

Visszatérő szomatikus mutáció hajas sejtes leukémiában

A hajas sejtes leukémia olyan érett B-sejtes non-Hodgkin-lymphoma, amelyet egyedi klinikai, morfológiai és immunfenotípusbeli sajátosságok jellemeznek. A betegséget splenomegalia, progresszív pancytopenia és relatív indolens lefolyás kíséri. A diagnózis megszületése után a klinikai stádiumtól függ, hogy a „watchful waiting” stratégiát választjuk, avagy azonnali kezelés szükséges. Az első vonalban javasolt purin-nukleozid analógokkal (cladribin, pentostatin) akár több évtizedig tartó komplett remisszió is elérhető. A hajas sejtes leukémia néha igen komoly differenciáldiagnosztikai kérdéseket felvető betegség. A pontos diagnózis igen nagy horderejű, hiszen a rokon kórképek prognózisa és kezelése nagymértékben különbözik a hajas sejtes leukémiáétól. Ezért volt kiemelkedő fontosságú az a felismerés, hogy létezik olyan genetikai elváltozás, amely e betegségek elkülönítő diagnózisában döntő értékű. A BRAF gén V600E szomatikus mutációja hajas sejtes leukémiában szenvedő betegek csontvelői mintáiból izolált DNS-ben minden esetben jelen van, míg a rokon kórképekre ezen mutáció hiánya a jellemző. A szerzők a mutáció felismerésének és a mutációvizsgálat alkalmazásának jelentőségét foglalják össze. Orv. Hetil., 2013, 154, 123–127. | Hairy cell leukemia is a mature B-cell non-Hogkin lymphoma characterized by unique clinical, morphological and immunhistochemical features. Patients with hairy cell leukemia usually present with splenomegaly, progressive pancytopenia and a relative indolent clinical course. The diagnosis does not always indicate immediate treatment, as treatment depends on the clinical stage of the leukemia. Asymptomatic disease without progression requires a watchful waiting policy, while other categories usually need treatment. The treatment of choice is purin nucleosid analogues (pentostatin, cladribine) which can achieve complete remission even for decades. Interferon and monoclonal CD20 antibodies can also significantly prolong tevent free survival. Unfortunately, only the latter two therapies are easily available in Hungary. Splenectomy, which was suggested as first line treatment before the era of purin nucleosid analogues, is only recommended as ultimum refugium. Although hairy cell leukemia is a well-defined lymphoproliferative disease, sometimes it is difficult to differentiate it from other similar entities such as hairy cell leukema variant, splenic marginal zone lymphoma, small lymphocytic lymphoma etc. Making the correct diagnosis is of utmost importance because of the great difference in treatment modalities. Recently, a somatic mutation was found in all analysed hairy cell leukemia samples, but not in other splenic B-cell lymphomas. This article reviews the significance of this observation and presents the different types of methods for the detection of this mutation. Orv. Hetil., 2013, 154, 123–127

The Use of Imatinib Mesylate as a Lifesaving Treatment of Chronic Myeloid Leukemia Relapse after Bone Marrow Transplantation

We describe the response of imatinib as lifesaving treatment of chronic myeloid leukemia (CML) relapse in seven patients who underwent allogeneic bone marrow transplantation (alloBMT) at our institution over a period of 4 years. Retrospective analysis of their medical records revealed that a mean age at transplant was 45.2 years. The median time to diagnosis was 7.4 years after transplant. At relapse, four, two, and one patients were classified as having hematologic, major molecular, and cytogenetic relapse, respectively. At imatinib initiation, five had CML in a chronic phase, while one patient was diagnosed as having accelerated phase and blast crisis. All these patients could be evaluated for the therapeutic efficacy. At a mean of follow-up of 1.9 years of therapy, all evaluable patients achieved major molecular response without compromising safety. Consistent with available data, our results indicate that imatinib is safe and effective treatment option for patients with relapse after BMT

بررسی جهش‌های اگزون‌های 8 و 17 ژن C-KIT در مبتلايان به لوسمی ميلوئيدی حاد در ايران

زمينه و هدف: جهش در ژن C-KIT منجر به تکثير بدون کنترل سلولهای لوسميک شده و يک پيش‌آگهی بد را به همراه دارد. وجود حذف و اضافه شدن( deletion and insertion ) اگزون 8 که پنجمين دومن ايمونوگلوبولينی C-KIT را کد می‌کند و همچنين جهش نقطه‌ای( Point mutation ) در اگزون 17 که ناحيه تيروزين کينازی C-KIT را کد می‌کند، در لوسمی حاد ميلوئيدی مورد اهميت قرار دارند. هدف از اين مطالعه، اجرائی کردن آزمايشات مولکولار برای تشخيص و غربالگری اين جهش‌ها در بيماران مبتلا به لوسمی ميلوئيدی حاد بود. روش بررسی: 212 بيمار مبتلا به لوسمی ميلوئيدی حاد از نظر جهش در ژن C-KIT مورد مطالعه مشاهده‌ای توصيفی قرار گرفتند و درصد بروز جهش گزارش شد. جهش اگزون 8 در ژن C-KIT با انجام PCR ( polymerase chain reaction ) و با استفاده از پرايمرهای طراحی شده انجام شد و بعد از حرکت باند حاصل از PCR روی ژل CSGE ، وجود جهش بر روی اين ژن بررسی گرديد. در مورد جهش نقطه‌ای در اگزون 17، ژن C-KIT ، بعد از PCR روی DNA ژنوميک اين بيماران، محصولات بيماران PCR شده با استفاده از آنزيم محدودالاثر ArtII و تکنيک RFLP مورد مطالعه قرار گرفتند. يافته‌ها: جهش اگزون 8 در 4/1% مبتلايان به لوسمی ميلوئيدی حاد مورد مطالعه، مشاهده گرديد که برای زير گروه‌های مختلف، اين نتايج متفاوت بود. همچنين 7/4% از بيماران مورد مطالعه هم، جهش نقطه‌ای D816 در اگزون 17 را داشتند که توزيع آنها در زير گروه‌های لوسمی ميلوئيدی حاد يکسان نبود. نتيجه‌گيری: اين مطالعه نشان داد که جهش‌های ژن C-KIT ، درصد قابل توجهی از بيماران مبتلا به لوسمی ميلوئيدی حاد(زير گروه‌های M2 ، M4 ) در ايران را شامل می‌شود که می‌توان با تشخيص مولکولی اين جهش‌ها، در مورد پروتکل درمانی صحيح تصميم گرفت

Significance of cytogenetic abnormalities in acute myeloid leukaemia

Objective: To evaluate the role of karyotype in acute myeloid leukaemia (AML) as a predictor of response to induction chemotherapy. Methods: A cross-sectional study was carried out at the department of Pathology and Oncology, Aga Khan University Karachi from January 2003 to January 2005. Newly diagnosed patients with denovo AML admitted to the hospital were included in the study. Diagnosis of AML was based on FAB criteria, immunophenotyping and cytogenetic studies. They were treated according to standard protocols (combination of anthracycline and cytarabine -3+7) and those who had acute promyelocytic leukaemia additionally received all- trans retinoic acid (ATRA). Results: A total of 56 patients were enrolled, 4 were excluded due to inadequate cytogenetic analysis and the remaining patients entered the study protocol. There were 32 males and 20 females with mean age of 31.3 years (range 9 months to 73 years). Thirty-five (67.3%) patients had normal karyotype while 17 (32.7%) were found to have cytogenetic abnormalities. Eleven patients did not receive treatment at our hospital. Half of the (51.2%) patients out of remaining 41 achieved complete remission on bone marrow examination after receiving induction chemotherapy. In favourable risk group 3/3 (100%) achieved complete remission (CR) while 15/32 (46.9%) in intermediate risk group and 3/6 (50%) in unfavourable risk group. There was low CR rate in patients with high white cell counts. Conclusion: The frequency of cytogenetic abnormalities in AML and response to induction chemotherapy was low when compared with international data possibly due to the small sample size. However, there was a clear difference in CR rates between favourable and unfavourable risk group

Preventing hereditary cancers caused by opportunistic carcinogens

Objectives
Previous studies reported inherited BRCA1/2 deficits appear to cause cancer by impairing normal protective responses to some carcinogens. Opportunistic carcinogens can exploit these deficits by causing chronic inflammation, constant cell death and replacement in a mutagenic environment, DNA crosslinking or double strand breaks. Some of the resulting cancers may be prevented if BRCA1/2 specific carcinogens are identified.
Methods
The literature was systematically searched for carcinogens capable of exploiting deficits in BRCA1/2 pathways. Search criteria were common exposure, available information, required BRCA1/2 pathway repairs, increased risks for any cancer, and effects on stem cells.
Results
Formaldehyde and acetaldehyde are closely related carcinogens and common pollutants that are everywhere. Alcohol metabolism also produces acetaldehyde. High levels of either carcinogen overwhelm normal detoxification systems, cause inflammation, inhibit DNA repair and produce DNA cross links as critical carcinogenic lesions. Searching model system studies revealed both carcinogens activate stem cells, BRCA1/2 pathways and connected BRCA1/2 pathways to myeloid leukemia. For example, the BRCA1-BARD1 complex is required for proper nucleophosmin functions. Nucleophosmin prevents a major subset of acute myeloid leukemia (AML). Next, these concepts were independently tested against risks for myeloid leukemia. Epidemiologic results showed that BRCA2 gene defects inherited on both chromosomes increased risks so dramatically that AML occurs in most children. Using data from 14 studies, known/potential heterozygous BRCA1/BRCA2 mutations increased risks for myeloid leukemias by at least 3 fold in 7 studies and by at least 50% in 12.
Acetaldehyde occurs in breast milk. In model studies, excessive acetaldehyde/alcohol exposure affects estrogen metabolism and stimulates alternate alcohol detoxification pathways.
These pathways can cause DNA cross linking by releasing oxygen species and activating procarcinogens. Acetaldehyde in rats’ drinking water increased incidence of leukemias, lymphomas,pancreatic cancers and fibroadenomas. Human epidemiologic studies showed increased premenopausal breast cancer risks associated with persistent/high acetaldehyde levels related to alcohol metabolism genotype.
Conclusions
Although it is difficult to prove direct causation, BRCA1/2 mutation carriers may reduce cancer risks by avoiding excessive formaldehyde and acetaldehyd