Treatment of venous thromboembolism

Deep vein thrombosis (DVT) is defined as an episode of thrombosis involving deep veins, usually of the lower limbs. DVT is frequently accompanied by pulmonary embolism (PE). Venous thromboembolism (VTE) is the generic term commonly used to refer to both clinical conditions indistinctly. In this paper, we present a brief review of current concepts in the treatment of VTE. Use of unfractionated and low molecular weight heparin is approached, and special attention is given to its transition to long term use of oral anticoagulants. In addition, specific therapeutic measures in special clinical conditions and in the supportive management of patients with VTE are also discussed.A trombose venosa profunda (TVP) é definida como um episódio de trombose, envolvendo as veias profundas dos membros inferiores. A TVP é freqüentemente acompanhada por embolia pulmonar (EP). Tromboembolismo venoso (TEV) é o termo empregado para designar ambas as eventualidades indistintamente. No presente artigo, oferecemos uma breve revis ão dos conceitos atualmente preconizados para o tratamento do TEV. São abordados aspectos relativos à utilização da heparina não fracionada, aos novos esquemas terapêuticos com as heparinas de baixo peso molecular e à transição para o tratamento clássico com anticoagulantes orais a longo prazo. Adicionalmente, são discutidas condutas em situações clínicas especiais, além de medidas terapêuticas que se mostraram eficazes no tratamento de pacientes com TEV

Diagnostic investigation of bleeding disorders

Na presente revisão, discutimos as ferramentas clínicas e laboratoriais, utilizadas na investigação de distúrbios hemorrágicos.In this review we discuss the importance of several clinical and laboratory tools currently used in the investigation of bleeding disorders

FOXP3 and CTLA4 overexpression in multiple myeloma bone marrow as a sign of accumulation of CD4(+) T regulatory cells

Multiple myeloma (MM) development involves a series of genetic abnormalities and changes in the bone marrow (BM) microenvironment, favoring the growth of the tumor and failure of local immune control. T regulatory (Treg) cells play an important role in dampening anti-tumor immune responses while T-helper-17 (Th17) cells seem to be critical for the eradication of malignant cells. the aim of our study was to characterize the expression of Treg- and Th17-related genes in total myeloma BM samples to assess their role as biomarkers, prognostic factors, and possible therapeutic targets in this incurable disease.Expression of markers for Treg (FOXP3, CTLA4) and Th17 cells (ROR gamma t) was determined by quantitative real-time PCR in BM aspirates of 46 MM patients, four patients with monoclonal gammopathy of undetermined significance, five solitary plasmacytomas, and five healthy BM donors. Gene expression was evaluated regarding an influence on the patients' overall survival (OS).FOXP3 and CTLA4 presented a sixfold (p = 0.02) and 30-fold higher expression (p = 0.03), respectively, in MM patients than in controls. ROR gamma t expression was similar in MM patients and controls. Median OS of MM patients was 16.8 (range 4.5-29.1) months, and international staging system was the only independent prognostic factor for patients survival.Overexpression of FOXP3 and CTLA4 in total BM samples suggests a local accumulation of immunosuppressive Tregs, the MM tumor environment, possibly dampening anti-tumor host immune responses. Therapeutic approaches targeting Treg cells and restoring local anti-tumor immunity may provide new treatment strategies for this incurable malignancy.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Universidade Federal de São Paulo UNIFESP, BR-04037003 São Paulo, BrazilFleury Med & Saude, São Paulo, BrazilInsper Inst Educ & Res, São Paulo, BrazilUniv Med Ctr Hamburg Eppendorf, Hamburg, GermanyUniversidade Federal de São Paulo UNIFESP, BR-04037003 São Paulo, BrazilFAPESP: 2010/17668-6Web of Scienc

"Gene expression profiling of mantle cell lymhoma in leukemic phase with oligonucleotide microarrays"

O linfoma de células do manto é associado à translocação t(11;14)(q13;q32) e à hiperexpressão da ciclina D1. Os pacientes com linfoma de células do manto apresentam-se com doença avançada ao diagnóstico e a fase leucêmica da doença é observada em cerca de um terço dos casos. Os linfócitos B virgens pré-centro germinativo, que ocupam a zona do manto dos folículos linfóides secundários, constituem a origem celular do linfoma de células do manto. A hiperexpressão da ciclina D1, por si só, não é suficiente para a patogênese da neoplasia, e a elucidação das alterações moleculares adicionais poderá fundamentar novas estratégias terapêuticas. Nesse contexto, os métodos de estudo do perfil de expressão gênica em larga escala têm potencial para auxiliar na descoberta dessas alterações moleculares adicionais. Todavia, nos estudos que empregaram esses métodos até o momento, o material genético foi obtido de amostras de gânglios acometidos pelo tumor, que contêm uma proporção variável de células normais do estroma do tecido linfóide. Por isso, ainda não se sabe quais dos genes identificados como alterados no linfoma de células do manto são específicos das células linfomatosas, e quais são dependentes das células normais que perfazem o estroma do gânglio. Com o objetivo de elucidar as alterações moleculares do linfoma de células do manto em nível celular, realizamos um estudo comparativo entre o perfil de expressão gênica de células linfomatosas purificadas e de linfócitos B virgens, utilizando microarrays de oligonucleotídeos. Células linfomatosas e linfócitos B virgens (IgD+CD38±CD27-) foram purificados em colunas magnéticas a partir do sangue periférico de pacientes com linfoma de células do manto em fase leucêmica e de amígdalas de indivíduos normais, respectivamente (pureza > 95%). Três indivíduos foram selecionados em cada grupo e os experimentos foram realizados em duplicatas usando microarrays comerciais modelo CodeLink Human UniSet I, com 10.000 genes. Foram identificados 106 genes com variação de expressão maior do que três vezes, 63 deles induzidos e 43 reprimidos no linfoma de células do manto em relação aos linfócitos B virgens. Dez genes (seis induzidos e quatro reprimidos) foram selecionados para quantificação, por RT-PCR em tempo real, em amostras de sangue periférico de 21 pacientes com linfoma de células do manto em fase leucêmica, além de 14 pacientes com outras doenças linfoproliferativas crônicas e de sete indivíduos sem doenças neoplásicas. Os resultados dos experimentos com microarrays foram confirmados pela quantificação por RT-PCR em tempo real em todos os 10 genes selecionados e os valores de expressão do gene TLR1 obtidos por esse método demonstraram correlação significativa com a sobrevida dos pacientes com linfoma de células do manto. Além de identificar vários genes modulados no linfoma de células do manto em nível celular, este estudo também revelou a expressão aberrante de diversos genes relacionados à apoptose e às vias de sinalização PI3K/AKT, WNT e TGFβ. Esses resultados adicionam informações originais à patogênese molecular do linfoma de células do manto e apontam para vias específicas de sinalização molecular como potenciais alvos para novas abordagens terapêuticas.Mantle cell lymphoma is associated with the translocation t(11;14)(q13;32) and overexpression of cyclin D1. Mantle cell lymphoma is predominantly disseminated at diagnosis and a frank leukemic phase is detected in one third of patients. The pre-germinal-center naive B-cells, which populate the mantle zone of the secondary lymphoid follicles, are the cells of origin of mantle cell lymphoma. Overexpression of cyclin D1 is not sufficient by itself to cause lymphoma, and a better understanding of the additional molecular lesions may provide insights toward new therapeutic approaches. In this context, large scale gene expression studies may be useful in the investigation of such additional molecular lesions. However, the great majority of mantle cell lymphoma cases studied by these methods to date had the genetic material harvested from lymph nodes, which have a variable proportion of normal cells from the lymphoid stroma. It is therefore not known how many genes identified as differentially expressed in mantle cell lymphoma by tumor versus normal experiments are cell-autonomous rather than dependent on the tumor microenvironment. To address this issue, we compared the gene expression profile of mantle cell lymphoma cells and normal naive B-cells using oligonucleotide microarrays. Lymphoma cells and naive B-cells (IgD+CD38±CD27-) were highly purified, by magnetic activated cell sorting, from the peripheral blood of patients with mantle cell lymphoma in the leukemic phase and from tonsils of normal individuals, respectively (purity > 95% in all samples). Three individuals were selected for each group and experiments were performed in replicates using the Amersham CodeLink Human UniSet I Bioarrays, with 10,000 genes. We identified 106 genes differentially expressed with a fold change of at least three-fold, 63 induced and 43 repressed in mantle cell lymphoma in comparison with naive B-cells. Ten genes were selected (six induced and four repressed in lymphoma cells) for quantification by real-time RT-PCR in non-purified peripheral blood samples from 21 patients with mantle cell lymphoma in the leukemic phase, as well as in 14 patients with other chronic lymphoproliferative diseases and seven normal individuals. Microarray results were confirmed by real-time RT-PCR for all selected genes and expression values of the TLR1 gene as quantified by this method showed significant correlation with patient survival in mantle cell lymphoma. In addition to the identification of several modulated genes in mantle cell lymphoma at cellular level, this study revealed that some genes functionally connected through apoptosis or the PI3K/AKT, WNT and TGFβ signaling pathways are aberrantly expressed in mantle cell lymphoma. These results add original data to the molecular pathogenesis of mantle cell lymphoma and point to specific molecular signaling pathways related to inhibition of apoptosis as potential targets for new therapeutic approaches

Diagnosis and treatment of mast cell disorders: practical recommendations

CONTEXT AND OBJECTIVE The term mastocytosis covers a group of rare disorders characterized by neoplastic proliferation and accumulation of clonal mast cells in one or more organs. The aim of this study was to assess the principal elements for diagnosing and treating these disorders. DESIGN AND SETTING Narrative review of the literature conducted at Grupo Fleury, São Paulo, Brazil. METHODS This study reviewed the scientific papers published in the PubMed, Embase (Excerpta Medica Database), Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde) and Cochrane Library databases that were identified using the search term “mastocytosis.” RESULTS The clinical presentation of mastocytosis is remarkably heterogeneous and ranges from skin lesions that may regress spontaneously to aggressive forms associated with organ failure and short survival. Currently, seven subtypes of mastocytosis are recognized through the World Health Organization classification system for hematopoietic tumors. These disorders are diagnosed based on clinical manifestations and on identification of neoplastic mast cells using morphological, immunophenotypic, genetic and molecular methods. Abnormal mast cells display atypical and frequently spindle-shaped morphology, and aberrant expression of the CD25 and CD2 antigens. Elevation of serum tryptase is a common finding in some subtypes, and more than 90% of the patients present the D816V KIT mutation in mast cells. CONCLUSION Here, we described the most common signs and symptoms among patients with mastocytosis and suggested a practical approach for the diagnosis, classification and initial clinical treatment of mastocytosis

Understanding myeloma cancer stem cells

Universidade Federal de São Paulo, UNIFESP EPM, São Paulo, BrazilGrp Fleury, BR-04344903 São Paulo, BrazilUniversidade Federal de São Paulo, UNIFESP EPM, São Paulo, BrazilWeb of Scienc