Could Immunophenotype Guide Molecular Analysis in Patients with Myeloid Malignancies?

Objective: Immunophenotype has been correlated with molecular aberrations in several studies. The aim of this study was the discovery of immunophenotypic features related to mutations in AML and MDS patients connected to prognostic factors. Moreover, an effort to evaluate a method for the detection of the most common NPM1 mutations of exon12 and Internal Tandem Duplications (ITD) mutations of FLT3 gene by flow cytometry was performed. Method: Patients with de novo myeloid neoplasms [ AML and MDS (AML-M3 patients were excluded)] were included. FLT3/ITD/TKD and NPM1 mutations were detected by PCR and fragment analysis. The immunophenotypic analysis was performed by multi-dimensional flow cytometry (FC) with a standardized panel of monoclonal antibodies on peripheral blood or bone marrow samples. Nucleophosmin Antibody and CD135 were used for the mutations immunophenotypic detection. Results: NPM1 and/or FLT3 mutations correlated with low or no expression of more immature cells markers such as CD34, CD117, HLADR, as well as higher expression of more mature markers such as CD11b. The higher expression of CD33 should be mentioned as well. The presence of NPM1mut and FLT3/ITD does not seem to be detectable by FC at least using these two monoclonal antibodies. The presence of CD7 aberrant lymphoid marker’s expression was associated with FLT3mut, NPM1wt genotype. CD56 or CD2 positivity was found only in patients’ samples negative for NPM1 and/or FLT3 mutations. Conclusions: Certain immunophenotype findings including the presence of aberrant lymphoid markers may be indicative of the presence of mutations in NPM1 and FLT3 linked to prognosis

Thromboembolic Disease in Patients With Cancer and COVID-19: Risk Factors, Prevention and Practical Thromboprophylaxis Recommendations–State-of-the-Art.

Cancer and COVID-19 are both well-established risk factors predisposing to thrombosis. Both disease entities are correlated with increased incidence of venous thrombotic events through multifaceted pathogenic mechanisms involving the interaction of cancer cells or SARS-CoV2 on the one hand and the coagulation system and endothelial cells on the other hand. Thromboprophylaxis is recommended for hospitalized patients with active cancer and high-risk outpatients with cancer receiving anticancer treatment. Universal thromboprophylaxis with a high prophylactic dose of low molecular weight heparins (LMWH) or therapeutic dose in select patients, is currentlyindicated for hospitalized patients with COVID-19. Also, prophylactic anticoagulation is recommended for outpatients with COVID-19 at high risk for thrombosis or disease worsening. However, whether there is an additive risk of thrombosis when a patient with cancer is infected with SARS-CoV2 remains unclear In the current review, we summarize and critically discuss the literature regarding the epidemiology of thrombotic events in patients with cancer and concomitant COVID-19, the thrombotic risk assessment, and the recommendations on thromboprophylaxis for this subgroup of patients. Current data do not support an additive thrombotic risk for patients with cancer and COVID-19. Of note, patients with cancer have less access to intensive care unit care, a setting associated with high thrombotic risk. Based on current evidence, patients with cancer and COVID-19 should be assessed with well-established risk assessment models for medically ill patients and receive thromboprophylaxis, preferentially with LMWH, according to existing recommendations. Prospective trials on well-characterized populations do not exist

Η κλινική σημασία των ανοσοϋποδοχέων PD σε ασθενείς με διάχυτα λεμφώματα από μεγάλα Β κύτταρα: συσχέτιση με κλινικά και παθολογοανατομικά ευρήματα των ασθενών.

Το διάχυτο λέμφωμα από μεγάλα Β κύτταρα (Diffuse Large B-Cell Lymphoma, DLBCL) αποτελεί το συνηθέστερο non-Hodgkin λέμφωμα και ανήκει στα υψηλής κακοήθειας λεμφώματα. Σε κυτταρικό και μοριακό επίπεδο, η κλινική πορεία και πρόγνωση των ασθενών με αυτή την κακοήθεια φαίνεται πως εξαρτώνται σε σημαντικό βαθμό από την διαφυγή των λεμφωματικών κυττάρων από τους αμυντικούς μηχανισμούς του ανοσοποιητικού συστήματος και συγκεκριμένα από τα Τ λεμφοκύτταρα. Ανασταλτικό ρόλο στον πολλαπλασιασμό και στην ενεργοποίηση των T λεμφοκυττάρων και επομένως στην ανοσοεπιτήρηση και καταστροφή των νεοπλασματικών κυττάρων διαδραματίζει ο ανοσοκατασταλτικός υποδοχέας των λεμφοκυττάρων programmed cell death-1 (PD-1) μέσω της σύνδεσής του με 2 μόρια-συνδέτες, τα PD-L1 (CD274 ή B7-H1) και PD-L2 (CD273 ή B7-DC). Η σηματοδότηση μέσω του PD-1 φυσιολογικά αμβλύνει την διέγερση των Τ λεμφοκυττάρων και προστατεύει τους γειτονικούς ιστούς από την επέκταση της φλεγμονής, παρέχοντας μία ισορροπία μεταξύ αποτελεσματικής ανοσιακής απάντησης και ανοσοεπαγόμενης ιστικής καταστροφής, αλλά στην περίπτωση κακοηθειών διαδραματίζει αρνητικό ρόλο αφού συμβάλλει στην ανοσοδιαφυγή των νεοπλασματικών κυττάρων. Ο PD-L1 έχει ανιχνευθεί σε βιοψίες κυρίως από ασθενείς με πρωτοπαθές λέμφωμα μεσοθωρακίου (Primary Mediastinal Large B-cell Lymphoma, PMLBCL) αλλά και σε ασθενείς με DLBCL του ιστολογικού υπότυπου του μη προερχόμενου από το βλαστικό κέντρο (non-Germinal Center B-cell like, non-GCB). Επίσης, σε ασθενείς με DLBCL, ο PD-1 υποδοχέας έχει ανιχνευθεί τόσο στα λεμφωματικά κύτταρα όσο και στα λεμφοκύτταρα που ανευρίσκονται μεταξύ των νεοπλασματικών κυττάρων (Tumor Infiltrating Lymphocytes, TILs). Η παρούσα εργασία στόχευε στην διερεύνηση πιθανών παθογενετικών οδών και μοριακών μηχανισμών χημειοανθεκτικότητας στα DLBCL και συγκεκριμένα στα DLBCL, not otherwise specified (NOS), τα οποία και συνιστούν τουλάχιστον το 25-30% των DLBCL. Στην μελέτη που πραγματοποιήσαμε φάνηκε ότι η έκφραση του PD-L1 δεν αποτελεί ανεξάρτητο προγνωστικό παράγοντα για την συνολική επιβίωση των ασθενών με DLBCL, NOS, φαίνεται ωστόσο ότι η ανοσοϊστοχημική ανίχνευση των ανοσοϋποδοχέων και των συνδετών τους στα DLBCL, NOS απέχει ακόμα από το να θεωρηθεί αντικειμενική ή αξιόπιστη. Ένα άλλο εύρημα της μελέτης μας είναι ότι τα PD-L1 θετικά DLBCL, NOS συσχετίζονται κατά κύριο λόγο με τον non-GCB ιστολογικό υπότυπο, όπως περιγράφεται και σε άλλες μελέτες. Συνοψίζοντας, από την μελέτη μας φαίνεται ότι η έκφραση του PD-L1 στον νεοπλασματικό ιστό ασθενών με DLBCL, NOS θα μπορούσε να οδηγήσει σε επιθετικότερες βιολογικές συμπεριφορές και η αναστολή της PD-1/PD-L1 οδού με μονοκλωνικά αντισώματα μπορεί να έχει θέση σε αυτούς τους ασθενείς. Ωστόσο, θα πρέπει να προσδιοριστούν με σαφήνεια οι ασθενείς εκείνοι που θα ωφεληθούν περισσότερο από τις στοχευμένες ανοσοτροποποιητικές θεραπείες (όπως και εκείνοι που είναι πιο πιθανό να εμφανίσουν σοβαρού βαθμού παρενέργειες), ο πλέον κατάλληλος χρόνος και τρόπος χορήγησής τους και η διάρκειά τους, αλλά και δείκτες ανταπόκρισης στη θεραπεία. Ιδιαίτερο ενδιαφέρον παρουσιάζει και ο πιθανός συνδυασμός κυτταροτοξικών θεραπειών με αναστολείς των ανοσοϋποδοχέων. Η μεγαλύτερη ωστόσο πρόκληση στο εγγύς μέλλον θα είναι η εύρεση του βέλτιστου δυνατού συνδυασμού θεραπειών που στοχεύουν στους διάφορους μηχανισμούς ανοσοδιαφυγής των λεμφωματικών κυττάρων. Αυτή η ανακάλυψη θα ανοίξει τον δρόμο για εντελώς εξατομικευμένες θεραπείες για τον ασθενή που έχει υποτροπιάζον / ανθεκτικό στην θεραπεία λέμφωμα ή ακόμα και σε θεραπείες 1ης γραμμής.Diffuse Large B-Cell Lymphoma (DLBCL) is the most common non-Hodgkin lymphoma and belongs to the aggressive subtypes. At cellular and molecular level its clinical course and the prognosis of patients with this malignancy appear to depend to a large extent on the escape of lymphoma cells from the immune system and specifically from T lymphocytes. The immunosuppressive receptor of lymphocytes, programmed cell death-1 (PD-1), plays an inhibitory role in the proliferation and activation of T lymphocytes and, therefore, in the immune surveillance and destruction of neoplastic cells through its binding to 2 ligands, PD-L1 (CD274 or B7-H1) and PD-L2 (CD273 or B7-DC). PD-1 signaling physiologically attenuates T cell activation and protects adjacent tissues from the spread of inflammation, providing a balance between an effective immune response and immune-induced tissue damage, but in the case of malignant cells PD-1 plays a negative role as it contributes to the immune escape of neoplastic cells. PD-L1 has been detected in biopsies mainly of patients with Primary Mediastinal Large B-cell Lymphoma (PMLBCL) but also in patients with DLBCL of the non-germinal center histological subtype (non-GCB). Moreover, in patients with DLBCL, the PD-1 receptor has been detected in both lymphoma cells and tumor infiltrating lymphocytes (TILs). The present study aimed to investigate possible pathogenetic pathways and molecular mechanisms of refractoriness to chemotherapy of DLBCL cells, specifically among DLBCL, not otherwise specified (NOS) patients, who constitute at least 25-30% of all DLBCL cases. Our study showed that PD-L1 expression is not an independent prognostic factor for the overall survival in patients with DLBCL, NOS, it appears however that immunohistochemical detection of immunoreceptors and their ligands in DLBCL, NOS is still far from being objective or trustworthy. Another finding of our study is that PD-L1 positive DLBCL, NOS is primarily associated with the non-GCB histological subtype, as described in other studies as well. In summary, our study suggests that PD-L1 expression in patients with DLBCL, NOS could lead to more aggressive biological behaviors and inhibition of the PD-1 / PD-L1 pathway with monoclonal antibodies may be of value in these patients. However, the patients who will benefit the most from targeted immunomodulatory therapies (as well as those who are most likely to experience severe side effects), the most appropriate time and route of administration, and their duration are still unknown and should be clearly identified, as well as predictors of response to treatment. Of great interest is the possible combination of cytotoxic therapies with immunoreceptor inhibitors. However, the biggest challenge in the near future will be to find the optimal possible combination of therapies that target the various mechanisms by which lymphoma cells evade immune system mechanisms. This discovery will pave the way for completely personalized treatments for patients with recurrent or refractory lymphoma, or even under 1st line treatment

Clinical significance of PD immunoreceptors among diffuse large B-cell lymphoma patients: correlation with clinical and pathological findings

Diffuse Large B-Cell Lymphoma (DLBCL) is the most common non-Hodgkin lymphoma and belongs to the aggressive subtypes. At cellular and molecular level its clinical course and the prognosis of patients with this malignancy appear to depend to a large extent on the escape of lymphoma cells from the immune system and specifically from T lymphocytes. The immunosuppressive receptor of lymphocytes, programmed cell death-1 (PD-1), plays an inhibitory role in the proliferation and activation of T lymphocytes and, therefore, in the immune surveillance and destruction of neoplastic cells through its binding to 2 ligands, PD-L1 (CD274 or B7-H1) and PD-L2 (CD273 or B7-DC). PD-1 signaling physiologically attenuates T cell activation and protects adjacent tissues from the spread of inflammation, providing a balance between an effective immune response and immune-induced tissue damage, but in the case of malignant cells PD-1 plays a negative role as it contributes to the immune escape of neoplastic cells.PD-L1 has been detected in biopsies mainly of patients with Primary Mediastinal Large B-cell Lymphoma (PMLBCL) but also in patients with DLBCL of the non-germinal center histological subtype (non-GCB). Moreover, in patients with DLBCL, the PD-1 receptor has been detected in both lymphoma cells and tumor infiltrating lymphocytes (TILs).The present study aimed to investigate possible pathogenetic pathways and molecular mechanisms of refractoriness to chemotherapy of DLBCL cells, specifically among DLBCL, not otherwise specified (NOS) patients, who constitute at least 25-30% of all DLBCL cases. Our study showed that PD-L1 expression is not an independent prognostic factor for the overall survival in patients with DLBCL, NOS, it appearshowever that immunohistochemical detection of immunoreceptors and their ligands in DLBCL, NOS is still far from being objective or trustworthy. Another finding of our study is that PD-L1 positive DLBCL, NOS is primarily associated with the non-GCB histological subtype, as described in other studies as well. In summary, our study suggests that PD-L1 expression in patients with DLBCL, NOS could lead to more aggressive biological behaviors and inhibition of the PD-1 / PD-L1 pathway with monoclonal antibodies may be of value in these patients. However, the patients who will benefit the most from targeted immunomodulatory therapies (as well as those who are most likely to experience severe side effects), the most appropriate time and route of administration, and their duration are still unknown and should be clearly identified, as well as predictors of response to treatment.Of great interest is the possible combination of cytotoxic therapies with immunoreceptor inhibitors. However, the biggest challenge in the near future will be to find the optimal possible combination of therapies that target the various mechanisms by which lymphoma cells evade immune system mechanisms. This discovery will pave the way for completely personalized treatments for patients with recurrent or refractory lymphoma, or even under 1st line treatment.Το διάχυτο λέμφωμα από μεγάλα Β κύτταρα (Diffuse Large B-Cell Lymphoma, DLBCL) αποτελεί το συνηθέστερο non-Hodgkin λέμφωμα και ανήκει στα υψηλής κακοήθειας λεμφώματα. Σε κυτταρικό και μοριακό επίπεδο, η κλινική πορεία και πρόγνωση των ασθενών με αυτή την κακοήθεια φαίνεται πως εξαρτώνται σε σημαντικό βαθμό από την διαφυγή των λεμφωματικών κυττάρων από τους αμυντικούς μηχανισμούς του ανοσοποιητικού συστήματος και συγκεκριμένα από τα Τ λεμφοκύτταρα. Ανασταλτικό ρόλο στον πολλαπλασιασμό και στην ενεργοποίηση των T λεμφοκυττάρων και επομένως στην ανοσοεπιτήρηση και καταστροφή των νεοπλασματικών κυττάρων διαδραματίζει ο ανοσοκατασταλτικός υποδοχέας των λεμφοκυττάρων programmed cell death-1 (PD-1) μέσω της σύνδεσής του με 2 μόρια-συνδέτες, τα PD-L1 (CD274 ή B7-H1) και PD-L2 (CD273 ή B7-DC). Η σηματοδότηση μέσω του PD-1 φυσιολογικά αμβλύνει την διέγερση των Τ λεμφοκυττάρων και προστατεύει τους γειτονικούς ιστούς από την επέκταση της φλεγμονής, παρέχοντας μία ισορροπία μεταξύ αποτελεσματικής ανοσιακής απάντησης και ανοσοεπαγόμενης ιστικής καταστροφής, αλλά στην περίπτωση κακοηθειών διαδραματίζει αρνητικό ρόλο αφού συμβάλλει στην ανοσοδιαφυγή των νεοπλασματικών κυττάρων.Ο PD-L1 έχει ανιχνευθεί σε βιοψίες κυρίως από ασθενείς με πρωτοπαθές λέμφωμα μεσοθωρακίου (Primary Mediastinal Large B-cell Lymphoma, PMLBCL) αλλά και σε ασθενείς με DLBCL του ιστολογικού υπότυπου του μη προερχόμενου από το βλαστικό κέντρο (non-Germinal Center B-cell like, non-GCB). Επίσης, σε ασθενείς με DLBCL, ο PD-1 υποδοχέας έχει ανιχνευθεί τόσο στα λεμφωματικά κύτταρα όσο και στα λεμφοκύτταρα που ανευρίσκονται μεταξύ των νεοπλασματικών κυττάρων (Tumor Infiltrating Lymphocytes, TILs).Η παρούσα εργασία στόχευε στην διερεύνηση πιθανών παθογενετικών οδών και μοριακών μηχανισμών χημειοανθεκτικότητας στα DLBCL και συγκεκριμένα στα DLBCL, not otherwise specified (NOS), τα οποία και συνιστούν τουλάχιστον το 25-30% των DLBCL. Στην μελέτη που πραγματοποιήσαμε φάνηκε ότι η έκφραση του PD-L1 δεν αποτελεί ανεξάρτητο προγνωστικό παράγοντα για την συνολική επιβίωση των ασθενών με DLBCL, NOS, φαίνεται ωστόσο ότι η ανοσοϊστοχημική ανίχνευση των ανοσοϋποδοχέων και των συνδετών τους στα DLBCL, NOS απέχει ακόμα από το να θεωρηθεί αντικειμενική ή αξιόπιστη. Ένα άλλο εύρημα της μελέτης μας είναι ότι τα PD-L1 θετικά DLBCL, NOS συσχετίζονται κατά κύριο λόγο με τον non-GCB ιστολογικό υπότυπο, όπως περιγράφεται και σε άλλες μελέτες. Συνοψίζοντας, από την μελέτη μας φαίνεται ότι η έκφραση του PD-L1 στον νεοπλασματικό ιστό ασθενών με DLBCL, NOS θα μπορούσε να οδηγήσει σε επιθετικότερες βιολογικές συμπεριφορές και η αναστολή της PD-1/PD-L1 οδού με μονοκλωνικά αντισώματα μπορεί να έχει θέση σε αυτούς τους ασθενείς. Ωστόσο, θα πρέπει να προσδιοριστούν με σαφήνεια οι ασθενείς εκείνοι που θα ωφεληθούν περισσότερο από τις στοχευμένες ανοσοτροποποιητικές θεραπείες (όπως και εκείνοι που είναι πιο πιθανό να εμφανίσουν σοβαρού βαθμού παρενέργειες), ο πλέον κατάλληλος χρόνος και τρόπος χορήγησής τους και η διάρκειά τους, αλλά και δείκτες ανταπόκρισης στη θεραπεία.Ιδιαίτερο ενδιαφέρον παρουσιάζει και ο πιθανός συνδυασμός κυτταροτοξικών θεραπειών με αναστολείς των ανοσοϋποδοχέων. Η μεγαλύτερη ωστόσο πρόκληση στο εγγύς μέλλον θα είναι η εύρεση του βέλτιστου δυνατού συνδυασμού θεραπειών που στοχεύουν στους διάφορους μηχανισμούς ανοσοδιαφυγής των λεμφωματικών κυττάρων. Αυτή η ανακάλυψη θα ανοίξει τον δρόμο για εντελώς εξατομικευμένες θεραπείες για τον ασθενή που έχει υποτροπιάζον / ανθεκτικό στην θεραπεία λέμφωμα ή ακόμα και σε θεραπείες 1ης γραμμής

Chest pain with increased troponin level; not always a cardiology issue

Thrombotic Thrombocytopenic Purpura (TTP) is a thrombotic microangiopathy syndrome resulting from decrease or absence of “a disintegrin and metalloproteinase with a thrombospondin type 1 motif member 13” (ADAMTS13). TTP has been characterized by the classical pentad of thrombocytopenia, hemolysis, fever, renal injury and neurological deficits, yet the patient may present with any atypical symptom related to microthrombi formation in the microcirculation. Here we present a rare case of a young patient with retrosternal chest pain and myocardial injury as the first manifestation of TTP

The use of novel oral anticoagulants in cancer patients with venous thromboembolism

Venous thromboembolism (VTE) is not uncommon among patients with cancer and is one of the major causes of mortality and morbidity. Treatment with low-molecular-weight heparin (LMWH) is effective, yet accompanied by the need for daily administration of injections for a prolonged time and (even rarely) thrombocytopenia. The discovery of novel oral anticoagulants (NOACs) was based on an effort to improve the pharmacodynamic and pharmacokinetic properties of previous generation anticoagulants while maintaining efficacy without the need for daily subcutaneous administration and frequent laboratory monitoring. The MEDLINE database was searched using PubMed in order to find relevant studies on the use of NOACs in patients with active malignancy and VTE. Furthermore, critical reading of references in recently published studies and reviews was performed. NOACs appear to be at least equivalent to coumarin anticoagulants in terms of efficacy and safety and their administration is easier, but data specifically concerning patients with active malignancy or comparing them to LMWH in this specific clinical setting are not yet available. Furthermore, patients with active cancer present several unique characteristics and drawing conclusions from studies involving other patient groups may not be appropriate. Specific studies in cancer patients are still pending that will help decide if NOACs will be the drugs of choice in this group of patients in need of efficient and simple to administer treatments. (C) 2016 Elsevier Inc. All rights reserved

A Prospective Multicenter Cohort Surveillance Study of Invasive Aspergillosis in Patients with Hematologic Malignancies in Greece: Impact of the Revised EORTC/MSGERC 2020 Criteria

Data concerning the incidence of invasive aspergillosis (IA) in high-risk patients in Greece are scarce, while the impact of the revised 2020 EORTC/MSGERC consensus criteria definitions on the reported incidence rate of IA remains unknown. A total of 93 adult hematology patients were screened for IA for six months in four tertiary care Greek hospitals. Serial serum specimens (n = 240) the sample was considered negative by PCR were collected twice-weekly and tested for galactomannan (GM) and Aspergillus DNA (PCR) detection. IA was defined according to both the 2008 EORTC/MSG and the 2020 EORTC/MSGERC consensus criteria. Based on the 2008 EORTC/MSG criteria, the incidence rates of probable and possible IA was 9/93 (10%) and 24/93 (26%), respectively, while no proven IA was documented. Acute myeloid leukemia was the most (67%) common underlying disease with most (82%) patients being on antifungal prophylaxis/treatment. Based on the new 2020 EORTC/MSGERC criteria, 2/9 (22%) of probable and 1/24 (4%) of possible cases should be reclassified as possible and probable, respectively. The episodes of probable IA were reduced by 33% when GM alone and 11% when GM + PCR were used as mycological criterion. The incidence rate of IA in hematology patients was 10%. Application of the 2020 EORTC/MSGERC updated criteria results in a reduction in the classification of probable IA particularly when PCR is not available

Performance, Correlation and Kinetic Profile of Circulating Serum Fungal Biomarkers of Invasive Aspergillosis in High-Risk Patients with Hematologic Malignancies

As conventional microbiological documentation of invasive aspergillosis (IA) is difficult to obtain, serum fungal biomarkers are important adjunctive diagnostic tools. Positivity rates and the kinetic profiles of galactomannan (GM), 1,3-β-D-glucan (BDG) and Aspergillus DNA (PCR) were studied in high-risk patients with hematologic malignancies. GM, BDG and PCR data from serial serum specimens (n = 240) from 93 adult hematology patients with probable (n = 8), possible (n = 25) and no (n = 60) IA were retrospectively analyzed. Positivity rates and sensitivity/specificity/positive/negative predictive values (NPV) of each fungal biomarker alone and in combination were estimated. The three markers were compared head-to-head and correlated with various biochemical, demographic and patient characteristics. The positivity rates for patients with probable/possible/no IA were 88%/8%/0% for GM (X2 = 55, p < 0.001), 62%/46%/35% for BDG (X2 = 2.5, p = 0.29), 62%/33%/27% for PCR (X2 = 3.9, p = 0.15), 50%/4%/0% for GM + BDG and GM + PCR (X2 = 31, p < 0.001), 50%/8%/22% for BDG + PCR (X2 = 6.5, p = 0.038) and 38%/4%/0% for GM + BDG + PCR (X2 = 21, p < 0.001). Higher agreement (76%) and negative correlation (rs = −0.47, p = 0.0017) was found between GM index and PCR Ct values. The sensitivity and NPV was 45–55% and 90–92% when biomarkers assessed alone and increased to 75–90% and 93–97%, respectively when combined. Weak significant correlations were found between GM, PCR and BDG results with renal/liver function markers (r = 0.11–0.57) with most GM+ and PCR+ samples found in the first and second week of clinical assessment, respectively and BDG later on. Different positivity rates, time profiles and performances were found for the three biomarkers advocating the combination of GM with PCR for the early diagnosis of IA, whereas the high NPV of combined biomarkerscould help excluding IA

Performance, Correlation and Kinetic Profile of Circulating Serum Fungal Biomarkers of Invasive Aspergillosis in High-Risk Patients with Hematologic Malignancies

As conventional microbiological documentation of invasive aspergillosis (IA) is difficult to obtain, serum fungal biomarkers are important adjunctive diagnostic tools. Positivity rates and the kinetic profiles of galactomannan (GM), 1,3-beta-D-glucan (BDG) and Aspergillus DNA (PCR) were studied in high-risk patients with hematologic malignancies. GM, BDG and PCR data from serial serum specimens (n = 240) from 93 adult hematology patients with probable (n = 8), possible (n = 25) and no (n = 60) IA were retrospectively analyzed. Positivity rates and sensitivity/specificity/positive/negative predictive values (NPV) of each fungal biomarker alone and in combination were estimated. The three markers were compared head-to-head and correlated with various biochemical, demographic and patient characteristics. The positivity rates for patients with probable/possible/no IA were 88%/8%/0% for GM (X-2 = 55, p < 0.001), 62%/46%/35% for BDG (X-2 = 2.5, p = 0.29), 62%/33%/27% for PCR (X-2 = 3.9, p = 0.15), 50%/4%/0% for GM + BDG and GM + PCR (X-2 = 31, p < 0.001), 50%/8%/22% for BDG + PCR (X-2 = 6.5, p = 0.038) and 38%/4%/0% for GM + BDG + PCR (X-2 = 21, p < 0.001). Higher agreement (76%) and negative correlation (r(s) = -0.47, p = 0.0017) was found between GM index and PCR Ct values. The sensitivity and NPV was 45-55% and 90-92% when biomarkers assessed alone and increased to 75-90% and 93-97%, respectively when combined. Weak significant correlations were found between GM, PCR and BDG results with renal/liver function markers (r = 0.11-0.57) with most GM+ and PCR+ samples found in the first and second week of clinical assessment, respectively and BDG later on. Different positivity rates, time profiles and performances were found for the three biomarkers advocating the combination of GM with PCR for the early diagnosis of IA, whereas the high NPV of combined biomarkerscould help excluding IA