Salvage treatment for refractory or relapsed acute myeloid leukemia: a 10-year single-center experience

OBJECTIVES: The outcomes of refractory and relapsed acute myeloid leukemia (AML) patients in developing countries are underreported, even though the similar classic regimens are widely used. METHODS: We conducted a retrospective comparison of "MEC" (mitoxantrone, etoposide, and cytarabine) and "FLAG-IDA" (fludarabine, cytarabine, idarubicin, and filgrastim) in adults with first relapse or refractory AML. RESULTS: In total, 60 patients were included, of which 28 patients received MEC and 32 received FLAG-IDA. A complete response (CR) rate of 48.3% was observed. Of the included patients, 16 (27%) died before undergoing bone marrow assessment. No statiscally significant difference in CR rate was found between the two protocols (p=0.447). The median survival in the total cohort was 4 months, with a 3-year overall survival (OS) rate of 9.7%. In a multivariable model including age, fms-like tyrosine kinase 3 (FLT3) status, and stem-cell transplantation (SCT), only the last two indicators remained significant: FLT3-ITD mutation (hazard ratio [HR]=4.6, p<0.001) and SCT (HR=0.43, p=0.01). CONCLUSION: In our analysis, there were no significant differences between the chosen regimens. High rates of early toxicity were found, emphasizing the role of supportive care and judicious selection of patients who are eligible for intensive salvage therapy in this setting. The FLT3-ITD mutation and SCT remained significant factors for survival in our study, in line with the results of previous studies.

Secondary myeloid neoplasms: bone marrow cytogenetic and histological features may be relevant to prognosis

Abstract Background: Secondary myeloid neoplasms comprise a group of diseases arising after chemotherapy, radiation, immunosuppressive therapy or from aplastic anemia. Few studies have addressed prognostic factors in these neoplasms. Method: Forty-two patients diagnosed from 1987 to 2008 with secondary myeloid neoplasms were retrospectively evaluated concerning clinical, biochemical, peripheral blood, bone marrow aspirate, biopsy, and immunohistochemistry and cytogenetic features at diagnosis as prognostic factors. The International Prognostic Scoring System was applied. Statistical analysis employed the Kaplan–Meier method, log-rank and Fisher's exact test. Results: Twenty-three patients (54.8%) were male and the median age was 53.5 years (range: 4–88 years) at diagnosis of secondary myeloid neoplasms. Previous diseases included hematologic malignancies, solid tumors, aplastic anemia, autoimmune diseases and conditions requiring solid organ transplantations. One third of patients (33%) were submitted to chemotherapy alone, 2% to radiotherapy, 26% to both modalities and 28% to immunosuppressive agents. Five patients (11.9%) had undergone autologous hematopoietic stem cell transplantation. The median latency between the primary disease and secondary myeloid neoplasms was 85 months (range: 23–221 months). Eight patients were submitted to allogeneic hematopoietic stem cell transplantation to treat secondary myeloid neoplasms. Important changes in bone marrow were detected mainly by biopsy, immunohistochemistry and cytogenetics. The presence of clusters of CD117+ cells and p53+ cells were associated with low survival. p53 was associated to a higher risk according to the International Prognostic Scoring System. High prevalence of clonal abnormalities (84.3%) and thrombocytopenia (78.6%) were independent factors for poor survival. Conclusion: This study demonstrated that cytogenetics, bone marrow biopsy and immunohistochemistry are very important prognostic tools in secondary myeloid neoplasms.

Validation of interphase fluorescence in situ hybridization (iFISH) for multiple myeloma using CD138 positive cells

BACKGROUND: Multiple myeloma is a plasma cell neoplasm with acquired genetic abnormalities of clinical and prognostic importance. Multiple myeloma differs from other hematologic malignancies due to a high fraction of low proliferating malignant plasma cells and the paucity of plasma cells in bone marrow aspiration samples, making cytogenetic analysis a challenge. An abnormal karyotype is found in only one-third of patients with multiple myeloma and interphase fluorescence in situ hybridization is the most useful test for studying the chromosomal abnormalities present in almost 90% of cases. However, it is necessary to study the genetic abnormalities in plasma cells after their identification or selection by morphology, immunophenotyping or sorting. Other challenges are the selection of the most informative FISH panel and determining cut-off levels for FISH probes. This study reports the validation of interphase fluorescence in situ hybridization using CD138 positive cells, according to proposed guidelines published by the European Myeloma Network (EMN) in 2012. METHOD: Bone marrow samples from patients with multiple myeloma were used to standardize a panel of five probes [1q amplification, 13q14 deletion, 17p deletion, t(4;14), and t(14;16)] in CD138+ cells purified by magnetic cell sorting. RESULTS: This test was validated with a low turnaround time and good reproducibility. Five of six samples showed genetic abnormalities. Monosomy/deletion 13 plus t(4;14) were found in two cases. CONCLUSION: This technique together with magnetic cell sorting is effective and can be used in the routine laboratory practice. In addition, magnetic cell sorting provides a pure plasma cell population that allows other molecular and genomic studies.

Detecção de mutações no gene KIT em leucemia mieloide aguda / The detection of KIT mutations in acute myeloid leukemia

OBJETIVO: Descrever a metodologia para detecção de mutações nos éxons 8 e 17 do gene KIT em pacientes portadores de leucemia mieloide aguda, para implementação desse teste no laboratório clínico do Hospital Israelita Albert Einstein. MÉTODOS: Extração do DNA genômico de 54 amostras de sangue periférico ou medula óssea de pacientes com leucemia mieloide aguda para amplificação, por reação em cadeia da polimerase, sequenciamento e análise de fragmentos. RESULTADOS: Dentre as amostras analisadas, quatro apresentaram mutação no éxon 8, duas no éxon 17 e uma amostra apresentou mutação nos dois éxons. CONCLUSÃO: A pesquisa de mutação nos éxons 8 e 17 do gene KIT foi padronizada com sucesso e o teste está em processo de inclusão no menu de exames do laboratório clínico do Hospital Israelita Albert Einstein.

OBJECTIVE: This study describes a new method used in the clinical laboratory at Hospital Israelita Albert Einstein to detect mutations in exons 8 and 17 of the KIT gene in patients with acute myeloid leukemia. METHODS: Genomic DNA extraction was performed on 54 samples of peripheral blood or bone marrow from patients with acute myeloid leukemia. The extracted DNA was amplified by polymerase chain reaction and sequenced, and the fragments were analyzed. RESULTS: Within the analyzed samples, we detected four mutations in exon 8, two mutations in exon 17, and mutations or a double mutation in one sample. CONCLUSION: The tests detecting mutations in exon 8 and 17 on the KIT gene were successfully standardized. The test is now included among the routine diagnostics employed for patients at Hospital Israelita Albert Einstein clinical laboratory.

Classificação dos tumores hematopoéticos e linfoides de acordo com a OMS: padronização da nomenclatura em língua portuguesa, 4ª edição / Classification of haematopoietic and lymphoid tumors: WHO, standardization of nomenclature in Portuguese, 4th edition

INTRODUÇÃO: A classificação da Organização Mundial da Saúde (OMS) para os tumores do tecido hematopoético e linfoide (4ª edição, 2008) representa uma revisão atualização da 3ª edição publicada em 2001. A tradução da nomenclatura utilizada para identificar as entidades descritas deve ser clara, precisa e uniforme no sentido de reproduzir de forma correta as diversas entidades clinicopatológicas para clínicos, patologistas e pesquisadores envolvidos na área da onco-hematopatologia. OBJETIVO: Os autores apresentam uma proposta de atualização e padronização terminológica em língua portuguesa, com base na OMS/2008.

INTRODUCTION: The World Health Organization (WHO) classification of hematopoietic and lymphoid tissue (4th edition, 2008) tumors constitutes an updated review of the 3rd edition published in 2001. The translation of the nomenclature used to describe the entities should be clear, precise and uniform so that clinicians, pathologists and researchers involved in the onco-hematopathological area may identify them accurately. OBJECTIVE: With this purpose, the authors present an updated proposal and a terminological standardization in Portuguese based on WHO/2008.

Karyotypic and fluorescent in-situ hybridization study of the centromere of chromosome 7 in secondary myeloid neoplasms

BACKGROUND: Secondary myeloid neoplasms comprise a group of secondary diseases following exposure to myelotoxic agents or due to congenital diseases. The improvement of anticancer agents and immunosuppressive drugs seem to be associated with an increased incidence of secondary myeloid neoplasms. Karyotyping of bone marrow is essential for diagnosis and prognosis. Previous use of alkylating agents and radiation are associated with clonal abnormalities such as recurrent unbalanced -5/5q-, -7/7q- and complex karyotypes, whereas topoisomerase-II inhibitors lead to changes such as the balanced 11q23 rearrangement, t(8;21), t(15;17) and inv(16). OBJECTIVE: To study the clinical and cytogenetic data of patients with secondary myeloid neoplasms who took antineoplastic and/or immunosuppressive drugs or progressed from aplastic anemia. METHODS: The clinical and cytogenetic characteristics of 42 patients diagnosed with secondary myeloid neoplasms in one institution were retrospectively evaluated. Of these, 25, 11 and 6 patients had had oncological diseases, aplastic anemia and other diseases, respectively. Conventional cytogenetic and FISH analyses were performed for monosomy 7. RESULTS: The cytogenetic study was conclusive in 32 cases with 84.4 percent of clonal abnormalities. Monosomy 7 and complex karyotypes were present in 44.4 percent and 37 percent, respectively. A high prevalence of unbalanced abnormalities (96.3 percent) was observed. Monosomy 7 was more prevalent in patients with myelodysplastic syndromes/myeloid neoplasms after aplastic anemia (66.6 percent). The median survival after diagnosis of myeloid neoplasms was only 5.7 months. Normal cytogenetics was associated to better survival (p-value = 0.03). There was a slightly worse trend of survival for patients with complex karyotypes (p-value = 0.057). Abnormal karyotype was an independent risk factor for poor survival (p-value = 0.012). CONCLUSION: This study enhances the importance ...

Correlação entre citometria de fluxo e anatomia patológica: experiência de dez anos na investigação de doenças linfoproliferativas / Correlation between flow cytometry and histologic findings: ten year experience in the investigation of lymphoproliferative diseases

Objetivo: Evidenciar as vantagens da correlação entre imunofenotipagem por citometria de fluxo e exame anatomopatológico/imunoistoquímico de adenomegalias e/ou nódulos no diagnóstico de doenças linfoproliferativas. Métodos: Estudo retrospectivo no qual foram avaliadas 157 amostras de biópsias ou punções aspirativas de gânglios ou nódulos de 142 pacientes, durante o período de 1999 a 2009. As amostras tinham sido encaminhadas simultaneamente para os Serviços de Citometria de Fluxo e Anatomia Patológica do Hospital Israelita Albert Einstein, em São Paulo. Para a análise na anatomia patológica, as amostras foram preparadas em lâminas e coradas com hematoxilina-eosina, Giemsa, ou marcadas com anticorpos monoclonais para detecção de antígenos específicos. Para a análise por imunofenotipagem por citometria de fluxo, as amostras foram hemolisadas e marcadas com diferentes painéis de anticorpos monoclonais para detecção dos diferentes antígenos. Resultados: Foram concordantes os diagnósticos entre a anatomopatológico e imunofenotipagem por citometria de fluxo em 115 (81%) pacientes, o que correspondeu a 127 amostras distribuídas da seguinte forma, conforme o diagnóstico anatomopatológico: 63 pacientes com linfoma não Hodgkin de células B; 26 pacientes com hiperplasia linfoide reacional; 5 pacientes com linfoma não Hodgkin de células T; 4 pacientes com proliferação linfoide atípica; 5 pacientes com processo inflamatório crônico granulomatoso; 5 pacientes com diagnósticos não hematológicos; 2 pacientes com sarcoma granulocítico; 2 pacientes com timoma; 1 paciente com leucemia bifenotípica; 1 paciente com plasmocitoma Kappa; e 1 paciente com linfoma de Hodgkin. A correlação entre os resultados das duas técnicas permitiu a classificação dos subtipos de linfomas da seguinte forma: 19 pacientes com linfoma folicular; 15 pacientes com linfoma difuso de grandes células B; 7 pacientes com linfoma linfocítico de pequenas células B/leucemia linfocítica crônica; 3 pacientes com linfoma de células do manto; 1 paciente com linfoma de Burkitt; 1 paciente com linfoma do tipo MALT (tecido linfoide associado à mucosa); 1 paciente com doença linfoproliferativa pós-transplante; 2 pacientes com linfoma não Hodgkin de células B de alto grau; 1 paciente com linfoma não Hodgkin de células B de baixo grau; 1 paciente linfoma de Hodgkin; e 12 pacientes com linfoma não Hodgkin de células B, sem outra especificação. Conclusão: A imunofenotipagem por citometria de fluxo complementa os achados do estudo anatomopatológico/imunoistoquímico, permitindo um diagnóstico hematopatológico rápido e preciso das doenças linfoproliferativas.

Alterações citogenéticas e moleculares em leucemia mieloide aguda: revisão e descrição de casos / Molecular and cytogenetic abnormalities in acute myeloid leukemia: review and case studies

Objective: To study the frequency of mutations that may lead to a good or bad prognosis, as well as their relation with the karyotype and immunophenotype in patients with acute myeloid leukemia. Methods: Thirty samples of patients with acute myeloid leukemia were studied, in which FLT3-ITD, FLT3-TKD and NPM1 mutations were investigated. All samples were submitted to immunophenotyping and 25 to karyotyping. Results: An occurrence of 33.3% NPM1 mutation and an equal number of FLT3-ITD mutation were observed. When only the cases with normal karyotype were studied, this figures increased to 50 and 40%, respectively. Eight percent of cases with normal karyotype and genotype NPM1+/FLT3- were included in the group of acute myeloid leukemia with good prognosis. The typical phenotype of acute myeloid leukemia with normal karyotype and mutated PM1 (HLA-DR and CD34 negative) was not observed in this small series. Conclusion: Good prognosis cases were identified in this series, emphasizing the need to include new genetic markers in the diagnostic routine for the correct classification of acute myeloid leukemia, to more properly estimate prognosis and determine treatment.

Objetivo: Estudar a frequência de mutações, que podem configurar bom ou mau prognóstico, bem como sua relação com estudo de cariótipo e imunofenotípico, em portadores de leucemias mieloides agudas. Métodos: Foram estudadas 30 amostras de portadores de leucemias mieloides agudas, que foram submetidas à pesquisa das mutações FLT3-ITD, FLT3-TKD e NPM1. Todas as amostras foram submetidas a estudo munofenotípico e 25 delas foram submetidas a estudo cariotípico. Resultados: Pudemos observar frequência de 33,3% de mutação NPM1 e igual número em FLT3-ITD, frequênciaque se elevou para 50 e 40% quando se estudaram apenas os casos com cariótipo normal. Dos casos com cariótipo normal, 8% apresentaram o genótipo NPM1+/FLT3-, migrando para o grupo de leucemia mieloide aguda de bom prognóstico. Não observamos o fenótipo típico das leucemias mieloides agudas com cariótipo normal e NPM1 mutado (HLA-DR e CD34 negativos) nesta pequena casuística. Conclusão: O presente estudo foi capaz de identificar casos de bom prognóstico, enfatizando que há necessidade de se incorporarem à rotina diagnóstica novos marcadores genéticos, para a correta estratificação prognóstica e orientação terapêutica da leucemia mieloide aguda.

Classificação da Organização Mundial da Saúde para os tumores dos tecidos hematopoético e linfoide, 4ª edição, 2008: principais modificações introduzidas em relação à 3ª edição, 2001 / World Health Organization classification of tumors of hematopoietic and lymphoid tissues, 4th edition, 2008: major changes from the 3rd edition, 2001

A Classificação da Organização Mundial da Saúde (OMS) para os tumores do tecido hematopoético e linfoide (4ª edição, 2008)¹ representa uma atualização da 3ª edição, 2001². Apresentamos a seguir um resumo dessas alterações nos grupos das doenças mieloproliferativas, mileodisplásicas, leucemias mieloides agudas, neoplasias de células precursoras B e T, e neoplasias de células B, T e NK maduras. O entendimento das alterações genético-moleculares e os resultados alcançados com propostas terapêuticas inovadoras nesses grupos de doenças demandam constante reavaliação de sua classificação, justificando as alterações importantes aqui discutidas1,3-5.

The World Health Organization (WHO) Classification of tumors of hematopoietic and lymphoid tissues (4th edition, 2008)¹ presents an updated version of the 3rd edition published in 2001². A summary of these changes relates to the groups of chronic myeloproliferative disorders, myelodisplasia, acute myeloid leukemias, neoplasms of precursor B and T cells and neoplasms derived of mature B, T and NK cells. A better understanding of molecular genetic changes and results achieved with innovative therapeutic approaches in these groups of diseases requires constant reassessment of the classifications, supporting the major changes discussed here, including interesting comments from literature1, 3-5.

Aspergillary bronchopneumonia: an unusual cause of atelectasis and asphyxia in a leukemic patient

Aspergilose pulmonar: causa infrequente de atelectasia e asfixia em paciente leucêmico. Paciente de 22 anos em primeira recidiva de leucemia linfóide aguda de tipo T desenvolveu febre e infiltrado pulmonar após 23 dias de granulocitopenia. Apesar do uso de Anfotericina B, houve progressäo da doença pulmonar com aparecimento de expectoraçäo purulenta, atelectasia do pulmäo direito e insuficiência ventilatória. Esta foi resolvida após eliminaçäo de rolha brônquica espessa. Culturas de escarro revelaram Candida Albicans e Staphylococcus epidermidis; a microscopia óptica da rolha revelou a presença de hifas de aspergilos. O paciente foi a óbito 9 dias após, por infecçäo disseminada por aspeergilos, confirmada por necrópsia