PROGNOSTIC ROLE OF NF-κB EXPRESSION IN DIFFUSE LARGE B-CELL LYMPHOMA SUBGROUPS

Difuzni B-velikostanični limfom (DLBCL) s fenotipom germinalnog centra B stanica (GCB) ima bolju prognozu nego limfom aktiviranih zrelih B-stanica (ABC) fenotip ili tip 3 podskupina. Prethodne studije su navodile da nuklearni faktor-κB (NF- κB) ima značajnu ulogu kod ABC i tip 3 fenotipa, dok GCB fenotip karakteriziraju česte REL amplifi kacije. Upotrebom imunohistokemijske metode analizirali smo kod 99 bolesnika kojima je postavljena dijagnoza DLBCL prisutnost DC10, BCL6 i MUM1, da bismo mogli bolesnike podijeliti u GCB, ABC i tip 3 podskupine, te smo zatim analizirali prisutnu ekspresiju NF- κB u jezgri i u citoplazmi. Kod 22 (22 %) slučajeva prisutna je ekspresija NF-κB u jezgri kod svih podskupina DLBCL. NF-κB ekspresija u citoplazmi prisutna je u svim podskupinama DLBCL i nalazi se kod 77 (77%) bolesnika, i rezultat je značajan. Analizirali smo prisutnost CD10, Bcl6 i MUM1 i prisutnost NF-κB u jezgri i rezultati nisu značajni. Analiza nuklearne akumulacije NF-κB nije povezana ni s jednim kliničkim parametrom uključujući dob, spol, stadij bolesti, primijenjenu terapiju i MPI. Bolesnici s prisutnim NF κB u citoplazmi bez obzira na podskupine prema Hansu i sur. imaju značajno lošije preživljenje nego bolesnici koji nemaju prisutan NF-κB i rezultati su značajni. Bolesnici s GCB fenotipom i negativnom ekspresijom NF-κB u jezgri imaju bolje preživljenje nego bolesnici s GCB fenotipom i pozitivnom ekspresijom NF-κB u jezgri i rezultati su značajni. Bolesnici koji su primali kemoterapiju po shemi R-CHOP i imaju pozitivan NF-κB u jezgri imaju bolje preživljenje, ali rezultati nisu značajni. Ovi rezultati ukazuju na to da NF-κB ekspresija u jezgri i citoplazmi može biti prognostički čimbenik kod DLBCL i to može pojasniti slojevitost rizika kod bolesnika u kombinaciji s GCB / ne-GCB fenotipom. Naša analiza pokazuje da je NF-κB aktivnost kod svih podskupina DLBCL ključna i na taj način može predstavljati obećavajući molekularni cilj za buduće terapije.Objective: Diffuse large B-cell lymphoma (DLBCL) with germinal center B-cell (GCB) phenotype has better prognosis than activated mature B-cell (ABC) phenotype or type 3 subgroup. Previous studies have reported on a major role of the nuclear factor-κB (NF-κB) in ABC and type 3 phenotypes, whereas GCB phenotype is characterized by frequent REL amplifi cations. Methods: In 99 patients diagnosed with DLBCL, the presence of CD10, BCL6 and MUM1 was analyzed by immunohistochemical method to divide them into the GCB, ABC and type 3 subgroups. Then, NF-κB expression was analyzed in the nucleus and cytoplasm. Nuclear NF-κB expression was detected in 22 (22%) cases from all DLBCL subgroups. NF-κB expression in the cytoplasm was recorded in 77 (77%) cases from all DLBCL subgroups and this fi nding was signifi cant. Results: Results on the presence of CD10, BCL6 and MUM1 and the presence of NF-κB in the nucleus were not signifi cant. Analysis of nuclear NF-κB accumulation is not associated with any of the clinical parameters including age, sex, stage of disease, therapy administered and IPP. According to Hans et al., patients with NF-κB expressed in the cytoplasm have signifi cantly poorer survival irrespective of the subgroup than patients without cytoplasmic NF-κB, and these results are signifi cant. Patients with GCB phenotype and negative nuclear NF-κB expression have better survival than those with GCB phenotype and positive nuclear NF-κB expression, and these results are also signifi cant. Patients having received chemotherapy according to the R-CHOP schedule and with positive nuclear NF-κB expression have better survival; however, these results are not signifi cant. Discussion and Conclusion: These data suggest that nuclear and cytoplasmic NF-κB expression may be a prognostic factor in DLBCL, thus explaining the stratifi ed risk observed in patients in combination with GCB/non-GCB phenotype. Our study showed the NF-κB activity to be crucial in all DLBCL subgroups, thus potentially representing a promising molecular target for future therapies

Treatment of severe acquired haemophilia A with an immunosuppressive agent

Acquired haemophilia A (AHA) is a rare hemorrhagic disease caused by an autoantibody against coagulation factor VIII. Nonhaemophiliac patients develop autoantibodies (inhibitors) directed against the factor VIII circulating coagulation protein. Disease is associated with an increased morbidity and mortality. Inhibitors against FVIII induce acute and life-threatening hemorrhagic diathesis because of abnormal blood clotting. FVIII inhibitors demonstrate bleeding disorders and prolonged activated partial thromboplastin time and a normal prothrombin time. AHA should be considered in the differential diagnosis particularly in postpartum women and in the elderly patients with bleeding tendency. Treatment of acute hemorrhage is focused in the control of the acute bleeding episode and the long term suppression of the autoantibody. In congenital hemophilia A with inhibitors, in which using repetitive infusions of high dose FVIII concentrates is effective for inhibitor eradication. This report presents one patient treated with immunosuppressive regimens. The most effective first-line treatment for the eradication of factor VIII autoantibodies is the combination of steroides and cyclophosphamide

Resveratrol kao antioksidans u kardijalnoj kirurgiji – ima li potencijala u kliničkoj primjeni?

Cardiopulmonary bypass (CPB) is an essential technique in cardiac surgery but is also associated with adverse effects, including the systemic inflammatory response syndrome that manifests itself as ischaemia-reperfusion injury and multi-organ dysfunction. The aim of this mini review is to take a look at the current knowledge of resveratrol, a stilbenoid and natural antioxidant believed to have many cardioprotective effects including vasodilation, lowering of blood pressure and reactive oxygen species levels, suppression of low-density lipoprotein peroxidation, and mitigation of ischaemia/-reperfusion injury. We mostly focus on its cardioprotective potential in patients undergoing cardiac surgery supported by CPB. Current findings, however, are still inconclusive and call for further research, including clinical trialsKardijalna kirurgija je kirurška struka koja se vrlo brzo razvija, a u kojoj se pri radu koristi uređaj za izvantjelesni krvotok. Njegovo korištenje dovodi do sustavnog upalnog odgovora koji se prezentira kao ishemijsko-reperfuzijska ozljeda i multiorganska disfunkcija. Resveratrol, stilbenoid iz skupine fenola, prirodni je antioksidans koji se nalazi u grožđu, borovnicama, malinama, murvi i kikirikiju, a smatra se da ima neuroprotektivna, antidijabetička, antikarcinogena i kardioprotektivna svojstva. Prema dosadašnjim znanstvenim istraživanjima, resveratrol je moguće glavni čimbenik kardioprotektivnoga djelovanja vina, koje se očituje vazodilatacijom, smanjenjem količine reaktivnih radikala kisika i arterijskoga krvnog tlaka, zatim smanjenjem peroksidacije lipoproteina male gustoće i ublažavanjem ishemijsko-reperfuzijske ozljede. Cilj je ovoga pregleda sažeti trenutačno znanje o potencijalnim kardioprotektivnim svojstvima resveratrola u bolesnika koji se podvrgavaju kardiokirurškom zahvatu pri kojem se koristi uređaj za izvantjelesni krvotok. Resveratrol ima razne učinke na ljudsku kardiovaskularnu fiziologiju, od kojih mnogi još moraju biti istraženi

WOUNDS IN HEMATOLOGY PATIENTS

Kod hematološkog bolesnika rane mogu biti dio kliničke slike u trenutku postavljanja dijagnoze, posljedica infekcije, nuspojave terapije ili napredovanja tumorske bolesti s kožnim infiltratima. liječenje rana kod hematoloških bolesnika zahtijeva multidisciplinaran pristup hematologa, kirurga, dermatologa, mikrobiologa i ostalog medicinskog osoblja koje je uključeno u svakodnevnu brigu o bolesniku. Kako se radi o onkološkim imunosuprimiranim bolesnicima, iznimno je važno pridržavati se mjera asepse te spriječiti infekcije rana zbog kojih bi se zakomplicirao ionako dugotrajan oporavak i zaliječenje. Važno je na vrijeme prepoznati ranu s malignom infiltracijom jer je pravodobna kemoterapija u takvom slučaju kurativna mjera.Hematology patients can have wounds as part of the initial presentation of the disease, as a result of infection or therapy. Wound therapy is very important and requires multidisciplinary approach of the hematologist, surgeon, dermatologist, and all other medical staff involved in the patient’s care. It is very important to provide aseptic care and prevent infections that could complicate the patient’s recovery and cure. It is very important to recognize the wound with malignant infiltration because an appropriate chemotherapy can be curative

CLINICAL FEATURES IN DLBCL AND TRANSLOCATION BCL2/c-MYC “DOUBLE HIT” LYMPHOMA

Difuzni B velikostanični limfom (DLBCL) je klasificiran kao limfom različitog entiteta i pomoću genske ekspresije proteina klasificiran je u tri podskupine. Cilj ovog rada je da pojasni kliničke, biološke, imunofenotipske i citogenetske značajke DLBCL s translokacijom t(14;18) i 8q24/c-MYC. Jedanaest bolesnika s DLBCL s dvostrukom translokacijom praćeno je u razdoblju od 2000. do 2009. god. Obilježja tih bolesnika uključuju morfološke, imunohistokemijske i citogenetske analize. Svi bolesnici imaju agresivna obilježja, prisutnost B simptoma (64 %), opće stanje bolesnika prema ECOG ljestvici ≥2 (55 %), povišenu aktivnost serumske laktat dehidrogenaze (73 %), klinički stadij III i IV (82 %), ekstranodalnu zahvaćenost bolesti (73 %), IPI ≥2 (73 %). Parcijalna remisija je postignuta kod 73 %, svi su bolesnici (73 %) umrli u kratkom roku. Bolesnici su liječeni CHOP i sličnim protokolima (COP, CVP, CNOP) uz dodatak Mabthere. Učinjena je imunofenotipizacija te određena ekspresija biljega CD20, CD3, CD10, Bcl6 i MUM1. u svih je učinjena citogenetska analiza ⌠fluorescentna hibridizacija in situ - FISH)⌡i nađene su kompleksne kariotipske promjene. Tako smo analizirali prisutnost gena BCL2, BCL6 i c-MYC, osam bolesnika je imalo translokacije gena BCL2 i c-MYC, dok je troje imalo translokaciju gena BCL6 i c-MYC. Usprkos provedenoj adekvatnoj terapiji, prognoza bolesnika je loša. Medijan preživljenja tih bolesnika je 1,85 godina. Zaključujemo da je DLBCL s BCL2 i c-MYC preuređenjem podskupina limfoma s vrlo lošim preživljenjem. Prisutnost tih dviju translokacija ima agresivan klinički tijek.Diffuse large B-cell lymphoma (DLBCL) is classified as lymphoma and various entities using the gene expression of proteins are classified into three groups. The aim of this study was to clarify the clinical, biological, immunophenotypic and cytogenetic features of DLBCL with translocation t (14; 18) and 8q24/c-MYC. Eleven DLBCL patients with dual translation were monitored during the 2000-2009 period. The characteristics of these patients included morphological, immunohistochemical and cytogenetic analysis. Study results showed that all patients had aggressive characteristics, presence of B symptoms (64%), general patient condition according to ECOG scale ≥2 (55%), elevated serum lactate dehydrogenase activity (73%), clinical stage III and IV (82%), extranodal involvement of the disease (73%), and IPI ≥2 (73%). Partial remission was achieved in 73% of all patients and all patients (73%) died within a short time. Patients were treated with CHOP and similar protocols (COP, CVP, CNOP), with the addition of MabThera. Immunophenotyping was performed and determined expression of the CD20, CD3, CD10, BCL6 and MUM1 markers. The cytogenetic analysis/fluorescence in situ hybridization revealed complex karyotype changes. Thus, we analyzed the presence of BCL2, BCL6 and c-MYC genes and found eight patients to have BCL2 and c-MYC translocation genes, while three had translocation of the BCL6 and c-MYC genes. Despite appropriate therapy, the patient prognosis is poor. The median survival in these patients was 1.85 years. DLBCL with BCL2 and c-MYC rearrangement of the subgroups of lymphoma is associated with very poor survival. The presence of these two translocations has an aggressive clinical course

Serum Immunoglobulins in non-Hodgkin’s Lymphoma Patients

Serum proteins and immunoglobulin (Ig) findings in 119 non-Hodgkin’s lymphoma (NHL) patients were analysed. Out of them 96 (81%) patients had B non-Hodgkin lymphoma (B-NHL), and 23 (19%) T-NHL. Indolent type of NHL was more frequent (77 patients, 65%), then aggressive type of NHL (42 patients, 35%). Most patients had normal serum protein concentration, the increased protein concentration was seen in 17% of patients while decreased concentration was noticed in 7% of patients. Hypoalbuminaemia was more frequent (43%) then hyperalbuminaemia (1%). In contrast to albumin, low levels of other protein fractions (alpha1-, alpha2-, and beta-globulin) were rather rare (0.6%, 4%, and 3% of patients, respectively) and high levels were frequent (23%, 37%, and 8%, respectively). Polyclonal hyperimmunoglobulinaemia was more frequent finding than hypoimmunoglobulinaemia. In 29% patients higher IgG level and in 25% patients higher IgA level were found. IgM hypoimmunoglobulinaemia (22%) was more frequent than IgG (11%) and IgA (8%) hypoimmunoglobulinaemia. M-spike in serum protein electrophoresis was found in 11 (7%) patients. The statistically significant association was not found between serum Ig concentration and lymphoma malignancy grade as well as between serum Ig concentration and immunologic origin of lymphoma. T-NHL patients have more often IgA concentration level above or under normal values than B-NHL patients (p<0.05)

CLINICAL FEATURES IN DLBCL AND TRANSLOCATION BCL2/c-MYC “DOUBLE HIT” LYMPHOMA

Difuzni B velikostanični limfom (DLBCL) je klasificiran kao limfom različitog entiteta i pomoću genske ekspresije proteina klasificiran je u tri podskupine. Cilj ovog rada je da pojasni kliničke, biološke, imunofenotipske i citogenetske značajke DLBCL s translokacijom t(14;18) i 8q24/c-MYC. Jedanaest bolesnika s DLBCL s dvostrukom translokacijom praćeno je u razdoblju od 2000. do 2009. god. Obilježja tih bolesnika uključuju morfološke, imunohistokemijske i citogenetske analize. Svi bolesnici imaju agresivna obilježja, prisutnost B simptoma (64 %), opće stanje bolesnika prema ECOG ljestvici ≥2 (55 %), povišenu aktivnost serumske laktat dehidrogenaze (73 %), klinički stadij III i IV (82 %), ekstranodalnu zahvaćenost bolesti (73 %), IPI ≥2 (73 %). Parcijalna remisija je postignuta kod 73 %, svi su bolesnici (73 %) umrli u kratkom roku. Bolesnici su liječeni CHOP i sličnim protokolima (COP, CVP, CNOP) uz dodatak Mabthere. Učinjena je imunofenotipizacija te određena ekspresija biljega CD20, CD3, CD10, Bcl6 i MUM1. u svih je učinjena citogenetska analiza ⌠fluorescentna hibridizacija in situ - FISH)⌡i nađene su kompleksne kariotipske promjene. Tako smo analizirali prisutnost gena BCL2, BCL6 i c-MYC, osam bolesnika je imalo translokacije gena BCL2 i c-MYC, dok je troje imalo translokaciju gena BCL6 i c-MYC. Usprkos provedenoj adekvatnoj terapiji, prognoza bolesnika je loša. Medijan preživljenja tih bolesnika je 1,85 godina. Zaključujemo da je DLBCL s BCL2 i c-MYC preuređenjem podskupina limfoma s vrlo lošim preživljenjem. Prisutnost tih dviju translokacija ima agresivan klinički tijek.Diffuse large B-cell lymphoma (DLBCL) is classified as lymphoma and various entities using the gene expression of proteins are classified into three groups. The aim of this study was to clarify the clinical, biological, immunophenotypic and cytogenetic features of DLBCL with translocation t (14; 18) and 8q24/c-MYC. Eleven DLBCL patients with dual translation were monitored during the 2000-2009 period. The characteristics of these patients included morphological, immunohistochemical and cytogenetic analysis. Study results showed that all patients had aggressive characteristics, presence of B symptoms (64%), general patient condition according to ECOG scale ≥2 (55%), elevated serum lactate dehydrogenase activity (73%), clinical stage III and IV (82%), extranodal involvement of the disease (73%), and IPI ≥2 (73%). Partial remission was achieved in 73% of all patients and all patients (73%) died within a short time. Patients were treated with CHOP and similar protocols (COP, CVP, CNOP), with the addition of MabThera. Immunophenotyping was performed and determined expression of the CD20, CD3, CD10, BCL6 and MUM1 markers. The cytogenetic analysis/fluorescence in situ hybridization revealed complex karyotype changes. Thus, we analyzed the presence of BCL2, BCL6 and c-MYC genes and found eight patients to have BCL2 and c-MYC translocation genes, while three had translocation of the BCL6 and c-MYC genes. Despite appropriate therapy, the patient prognosis is poor. The median survival in these patients was 1.85 years. DLBCL with BCL2 and c-MYC rearrangement of the subgroups of lymphoma is associated with very poor survival. The presence of these two translocations has an aggressive clinical course

Primary Gastrointestinal non-Hodgkin Lymphoma in Adults: Clinicopathologic and Survival Characteristics

Primary non-Hodgkin lymphomas of gastrointestinal tract (PGI-NHL) are the most common extranodal lymphomas with an increasing incidence. The incidence, clinicopathologic characteristics, treatment and survival were assessed in 39 successive, newly diagnosed PGI-NHL patients (23 male and 16 female) treated at »Merkur« University Hospital. The aim of the study was to precisely evaluate their characteristics and compare them with the results reported from other similar studies. The most common site of PGI-NHL was stomach (n=29, 74%), followed by small intestine (n=5, 13%), and colon and rectosigmoid (n=5, 13%). According to the Ann Arbor classification, 34 (87%) patients had stage IE and IIE, and five patients (12%) stage IIIE and IVE. According to World Health Organization (WHO) classification, 29 (87%) patients had diffuse large B-cell lymphoma (DLCBL), two had mantle cell lymphoma, and seven (18%) had marginal zone B-cell lymphoma-mucosa associated tissue (MALT). Twenty-six (66%) patients underwent surgical resection followed by chemotherapy, ten (26%) were treated with chemotherapy alone, and three (8%) were treated surgically. Complete remission was achieved in 28 (72%) and partial remission in seven (18%) patients. Four (10%) patients had progressive disease. In our patients, the major prognostic factor for outcome was the stage of disease. Patients with localized lymphoma (stage IE and IIE) had a significantly longer overall survival: 85% at five years and 65% at ten years. Patients with extended disease (stage IIIE and IVE) had overall survival less than 33%. The prognostic power of erythrocyte sedimentation rate (ESR), total protein, serum albumin, LDH concentration and activity was analyzed. Of these parameters, only LDH had a statistically significant effect on overall survival. In conclusion, our patient group was comparable to other literature reports on PGI-NHL patients according to clinicopathologic characteristics. Disease stage and LDH were the only parameters that had a statistically significant effect patient survival

Primary Gastrointestinal non-Hodgkin Lymphoma in Adults: Clinicopathologic and Survival Characteristics

Primary non-Hodgkin lymphomas of gastrointestinal tract (PGI-NHL) are the most common extranodal lymphomas with an increasing incidence. The incidence, clinicopathologic characteristics, treatment and survival were assessed in 39 successive, newly diagnosed PGI-NHL patients (23 male and 16 female) treated at »Merkur« University Hospital. The aim of the study was to precisely evaluate their characteristics and compare them with the results reported from other similar studies. The most common site of PGI-NHL was stomach (n=29, 74%), followed by small intestine (n=5, 13%), and colon and rectosigmoid (n=5, 13%). According to the Ann Arbor classification, 34 (87%) patients had stage IE and IIE, and five patients (12%) stage IIIE and IVE. According to World Health Organization (WHO) classification, 29 (87%) patients had diffuse large B-cell lymphoma (DLCBL), two had mantle cell lymphoma, and seven (18%) had marginal zone B-cell lymphoma-mucosa associated tissue (MALT). Twenty-six (66%) patients underwent surgical resection followed by chemotherapy, ten (26%) were treated with chemotherapy alone, and three (8%) were treated surgically. Complete remission was achieved in 28 (72%) and partial remission in seven (18%) patients. Four (10%) patients had progressive disease. In our patients, the major prognostic factor for outcome was the stage of disease. Patients with localized lymphoma (stage IE and IIE) had a significantly longer overall survival: 85% at five years and 65% at ten years. Patients with extended disease (stage IIIE and IVE) had overall survival less than 33%. The prognostic power of erythrocyte sedimentation rate (ESR), total protein, serum albumin, LDH concentration and activity was analyzed. Of these parameters, only LDH had a statistically significant effect on overall survival. In conclusion, our patient group was comparable to other literature reports on PGI-NHL patients according to clinicopathologic characteristics. Disease stage and LDH were the only parameters that had a statistically significant effect patient survival

T Lymphoblastic Leukaemia with an Unusual Burkitt Lymphoma Morphology – A Case Report

Precursor T-cell acute lymphoblastic leukaemia (T-ALL)/lymphoma (T-LBL) is a neoplasm with cytological features that include blast cells of medium size, high nuclear cytoplasmic ratio and inconspicuous nucleoli, which are usually TdT (Terminal Deoxynucleotidyl Transferase) positive and variably express T-cell markers. We report a case of T-ALL with atypical cytological presentation which showed lymphoblasts with homogenous nuclear pattern, larger amounts of cytoplasm with vacuoles and prominent nucleoli. A 56-year-old male was hospitalized due to high fever and kidney infection. Further examination confirmed anemia, thrombocytopenia, normal level of white blood cells and high level of lactat-dehidrogenase (LDH). Bone marrow aspiration revealed 87% and peripheral blood 41% of lymphoblasts with cytoplasmic vacuoles which suggested Burkitt lymphoma (BL) morphology. Patient’s karyotype showed no chromosomal aberations. Identification of immunophenotype discovered cells which were CD2 and CD3 positive and CD20 negative with focal acid phosphatase activity in 67% of blasts. This excluded Burkitt lymphoma and led to diagnosis of T-ALL. The patient was submitted to two cycles of chemotherapy, autologous stem cell transplantation, and intrathecal chemotherapy, but he died after 10 months because of disease complications (lung aspergillosis and pleural effusion). Our case report showed how morphology alone can be misleading and sometimes is not enough in diagnosing ALL. Beside morphologic criteria, setting correct diagnosis depends on identification of immunophenotype by flow cytometry and cytogenetic-molecular abnormalities. Further improvements in the molecular definition of ALL subtypes, development of new and targeted drugs will improve patient’s outcome and prognosis