Molecular Monitoring in Acute Myeloid Leukemia Patients Undergoing Matched Unrelated Donor: Hematopoietic Stem Cell Transplantation

Minimal residual disease (MRD) in acute myeloid leukemia (AML) is a complex, multi-modality assessment and much as its clinical implications at different points are extensively studied, it remains even now a challenging area. It is the disease biology that governs the modality of MRD assessment; in patients harboring specific molecular targets, high sensitivity techniques can be applied. In AML patients undergoing allogenic hematopoietic stem cell transplantation (alloHSCT), relapse in considered as leading cause for treatment failure. In post-transplant setting, regular MRD status assessment enables to identify patients at risk of impending relapse when early therapeutic intervention may be beneficent. We analyzed data of AML patients who underwent matched unrelated donor (MUD) HSCT since the introduction of this procedure in the Republic of North Macedonia. Chimeric fusion transcripts were identified in three patients; two of them positive for RUNX-RUNX1T1 transcript and one for CBFB-MYH11. One patient harbored mutation in the transcription factor CCAAT/enhancer binding protein α (CEBPA). Post-transplant MRD kinetics was measured by quantitative polymerase chain or multiplex fluorescent-PCR every three months after the transplantation during the first two years after the transplant. MRD negativity was achieved in three patients by the sixth month of HSCT, who were pre-transplant MRD positive. They sustained hematological and molecular remission for 19, 9 and 7 months, respectively. The forth patient died due to transplant-related complication. Our experience suggests, when molecularly-defined AML patients undergo HSCT, regular MRD monitoring helps predict impending relapse and direct future treatment strategies

Clinical Significance of Minimal Residual Disease at the End of Remission Induction Therapy in Childhood Acute Lymphoblastic Leukemia

BACKGROUND: Detection of minimal residual disease (MRD) in the early phase of therapy is the most powerful predictor of relapse risk in children with acute lymphoblastic leukaemia (ALL). AIM: We aimed to determine the significance of MRD at the end of remission induction therapy in the prediction of treatment outcome in children with ALL. METHODS: Sixty-four consecutive patients aged 1-14 years with newly diagnosed ALL were enrolled in this study from January 2010 to October 2017. All patients were treated according to the ALL IC BFM 2002 protocol. MRD was detected at the end of remission induction therapy (day 33) by multiparameter 6-colour flow cytometry performed on bone marrow specimens with a sensitivity of 0.01%. RESULTS: Overall, 42.2% of patients had detectable MRD on day 33 of therapy. MRD measurements were not significantly related to presenting characteristics but were associated with a poorer blast clearance on day 8 and 15 of remission induction therapy. Patients with negative MRD status on day 33 had a 5-year event-free survival of 94.6% compared with 76.1% for those with positive MRD status (P = 0.044). CONCLUSION: MRD levels at the end of remission induction therapy measured by multiparameter flow cytometry have clinical significance in childhood ALL. High levels of MRD are strongly related to poor treatment outcome

Use of chronic lymphocytic leukemia-international prognostic index in patient risk stratification-single center experience

Background: Several prognostic factors have been identified to predict the outcome of patients with chronic lymphocytic leukemia (CLL). To predict the time to first treatment (TFT) we integrated the data of clinical and biological markers in CLL-International prognostic index (CLL-IPI). Aim of the study was the determination of the impact of CLL-IPI in prediction of TFS in CLL patents.Methods: The study was set up retrospectively and included 90 patients with CLL diagnosed and treated at the university clinic of hematology for a period of time from January 2012 to January 2020. We incorporated the data of Binet staging system, most adverse cytogenetic marker and mutational status of immunoglobulin heavy chain in CLL-IPI.Results: The statistical data of the 90 patients showed that the median TFS for low CLL-IPI (N=24), intermediate CLL-IPI (N=40), high risk CLL-IPI (N=17) and very high risk group (N=9) according to the CLL-IPI scoring system was 20.1, 17.6, 7.1 and 5.8 months, respectively. Multivariate analysis indicated that del 17p (p<0.008) was independent prognostic factors of TFS.Conclusions: CLL-IPI is a powerful risk stratification tool for CLL patients and this system has also provided treatment recommendations for different patient risk subgroups.

Interplay between lymphocyte subpopulation, inflammatory cytokines and their correlation with oxidative stress parameters in COVID-19

Our objective was to investigate the inflammatory and oxidative stress markers in patients with moderate and severe form of COVID-19. In addition, we show the correlation between changes in lymphocyte subsets and markers of oxidative stress as a tool for patient classification. IL-6 and VEGF were analysed by utilizing a High Sensitivity Evidence Investigator™ Biochip Array technology. The total antioxidant capacity (PAT) and the free radical concentrations (d-ROM) were measured in serum utilizing analytical photometric system FRAS5. Peripheral blood was used to determine CD45 + mononuclear, B, T, and NK cells using a multi-parameter flow cytometric immunophenotypic test. Statistically significant differences in IL-6 and VEGF levels were observed between the two patient groups. Decreased values of the absolute number of lymphocytes and their CD4 + and CD8 + positive T cells, NK cells, and CD8 were obtained. In the moderate group, good correlations were found between IL-6 and VEGF and NK cells (r = 0.6973, p <0.05; for IL6 and r = 0.6498, p <0, for VEGF. 05). Cytokines were correlated with CD45+ (r = 0.5610, p <0.05; for IL-6 and r = 0.5462, p <0.05 for VEGF). The oxidative stress index can be used as a cheaper alternative and as a triage tool between severe and moderate illnesses, after showing good correlation with more expensive patient classification analysis

Immunoblastic morphology as a possible prognostic indicator for the outcome of the patients with diffuse large B cell lymphoma in era of the rituximab based treatment: single centre experience

Recently the results from one large prospective study indicated that immunoblastic morphology and not immunohistohemical features predict the outcome of the Diffuse large B lymphoma (DLBL). In order to investigate the prediction value of the immunoblastic morphology (IB) as a possible prognostic indicator for the outcome of our DLBL patient treated with the Rituximab (R)-CHOP regimen we conducted a retrospective study. Our study enrolled 192 DLBL patients diagnosed and treated at the University Clinic of Hematology in the period between February 2002 and December 2007. They were all treated with R-CHOP regimen and the median follow-up of the patient was 36 months. We analyzed the biopsy samples immunohistochemically for markers of germinal center (BCL6), post-germinal center (MUM1) and apoptosis (BCL2).The patients were categorized as DLBL(132; 68.7%), IB(60; 31.2). The median overall survival time (OS) were 59.3 months in DLBL group and 42.2 months in IB group, and time to treatment (TT) were 56.8 and 30.6 months respectively for the IB group. The DLBL and IB groups were comparable regarding the age, gender distributions and all others already established prognostic parameters as performance status, advanced IPI, albumin level except for the low IPI 0-2 which was statistically associated with the DLBL group (p=.024). Our results did not show any statistical survival advantage and better outcome for the patient classified as DLBL when treated with R-CHOP and indicate that immunohistohemical markers do not really reflect the molecular diversity of the tumor.  Our work shows that IB morphology is a major risk factor in DLBL patients treated with R-CHOP. Therefore this morphology appears to capture some adverse molecular events that a currently hard to detect with routine diagnostic procedures.

Безбедност на пациентите во клиничка пракса - програма за контролиран пристап до лекот леналидомид

Леналидомид е лек кој поседува антинеопластично, антиангиогено, проеритропоетско и имуномодулаторно дејство, но притоа поседува и изразено тератогено дејство. Клиничкиот фармацевт при ЈЗУ Универзитетска клиника за хематологија - Скопје е одговорен за спроведување на процесот на фармаковигиланца. Затоа, со цел подобрување на безбедноста на пациентите, на клиниката се спроведе контролирана дистрибуција на лекот таблети леналидомид од 5 mg. Kако мерка за минимализација на ризикот (ММР) за пациентите кои го примаат овој лек се спроведе програмата за контролиран пристап (CAP), според која пропишувањето на лекот го вршат исклучиво лекари кои се евидентирани во Регистарот на едуцирани лекари за спроведување на програмата за превенција на бременост (PPP). Со тоа се водеше грижа пациентот да го прими лекот само доколку се исполнети барањата од PPP. Бидејќи лекот се излачува и во спермата, во програмата покрај жени мораше да бидат вклучени и пациенти од машка популација. За лекот таблети леналидомид 5 mg, PPP е спроведена кај 36 пациенти (23 мажи и 13 жени), во тек на 18 месеци, започнувајќи од октомври 2021 година. Вo овој период лекот е издаден на 14 пациенти со мултипен миелом кои претходно примиле барем една линија на терапија (во комбинација со дексаметазон), 22 пациенти со терапија на одржување на новодијагностициран мултипен миелом кај кои е спроведена трансплантација на автологни матични клетки и 1 пациент со дијагноза Не-Хочкинов фоликуларен лимфом. Со едуцирање на пациентите и преземање на сите пропишани мерки од PPP, потенцијалниот ризик од тератогеното дејство на лекот беше сведен на минимум

Determination of non-adherence in patients receiving Eltrombopag

Eltrombopag, an orally administered thrombopoietin receptor agonist, selectively binds to the transmembrane domain of the thrombopoietin receptor on the surface of platelets, megakaryocytes and megakaryocyte precursor cells (1). The aim of our research is to determine patient non-adherence and its impact on the effectiveness and safety of prescribed therapy, as well as the possibility of treatment failure. The observational, longitudinal, and retrospective study was conducted in the PHO University Clinic of Hematology in Skopje, R.N.Macedonia. 17 patients (9 men and 8 women) were followed from January to August 2023. Five of them were with diagnose aplastic anemia and 12 with immune thrombocytopenia. All of them treated with Eltrombopag. We have systematically reviewed medical records from the Department of Hospital pharmacy, collected anamnestic data and determine non-adherence to therapy, followed by dose frequency, double taking therapy, omitted doses, drug-drug interactions and food/supplement-drug interactions. Thirteen types of non-adherence were identified, of which 3(23,08%) were related to dose frequency, 1(7,69 %) was related to double taking therapy, 5(38,46%) were related to the possibility of drug-drug interactions, 2(15,38%) with possibility for food/supplement-drug interactions and 2(15,38 %) were related with omitted doses. Failure to adherence is a serious problem which not only affects the patient but also the health care system. The clinical pharmacist intervention can improve patient adherencе, because the most important determinants effectiveness and safety are adherence to the prescribed therapy, multiple drug and food/supplement interactions which can vary on dose-response relationship, and risk of insufficient effectiveness of therapy (2)

A Rare Case of Soft Tissue Erdheim Chester Disease: Diagnostic Dilemma and Management

BACKGROUND: Erdheim Chester disease (ECD) is a rare form of non-Langerhans histiocytosis that still presents a diagnostic and clinical dilemma. CASE PRESENTATION: We present a rare case of ECD, young 31 male with atypical localisation and soft tissue presentation and no bone involvement. He started clinical investigations due to subcutaneous tumour mass in the lumbar spine that caused severe back pain. Skin biopsy revealed ECD with Immunohistochemistry CD68+, CD10+, CD11c+, vimentin+, S100A4+. Activating BRAFV600E mutation was positive from the tumour tissue. The patient was referred to the haematology department. PET CT was performed for initial disease staging. Treatment was started with corticosteroids (methylprednisolone 0.5 mg/kg per day), and after 7 days, a significant clinical improvement was noticed in terms of pain disappearance with no need for pain killers. After two weeks, treatment with interferon Alfa (IFN-α) was started in a dose of 3 million units 3 times per week. After 4 months of interim treatment PET, CT revealed a significant reduction of the tumour mass. Therapy with IFN-α was continued, and the patient is still clinically in good condition. CONCLUSION: It can be concluded that shortening the time of diagnosis of ECD is essential in treatment outcome of this disease. Still, large studies have to confirm the best treatment of this rare condition

Arterial blood gas alterations in retroperitoneal and transperitoneal laparoscopy

Background: Due to its numerous benefits laparoscopic surgery become very popular among physicians, hospitals and patients nowadays. In the urologic pathology laparoscopy can be performed with retroperitoneal or transperitoneal approach. Insufflation of CO2 for achieving visibility in both of the approaches can be absorbed in the vessels and can lead to alterations in arterial blood gasses. Material and Method: Study population was elective urologic patients scheduled for laparoscopic surgery. Investigated arterial blood gas variables were determined in three time points: T0 before induction – basal, T1 after one hour of CO2 insufflation, and T2 at the end of the surgery. Results: Alterations in arterial blood gasses were seen in T1 and T2 for PaO2 in retroperitoneal vs transperitoneal group 173.3 ± 19 vs 196.6 ± 29 (p < 0.003) and 95.5 ± 5.4 vs 101.1 ± 8.2 (p < 0.001). The PaCO2 was also statistically significant in second observed time point T1 in retroperitoneal vs transperitoneal group 45.9 ± 4.1 vs 38.2 ± 0.3 (p < 0.002). Conclusion: The findings that we have presented can suggest that both approaches are safe although hypercarbia is observed in retroperitoneal group. Key Words: arterial blood gasses, retroperitoneal laparoscopy, transperitoneal laparoscopy, urologic laparoscopy. Corresponding author: Aleksandra Gavrilovska-Brzanov, University Clinic for Anesthesia, Reanimation and Intensive Care, Skopje, Republic of North Macedoni