Bone marrow transplantation in adult thalassemic patients.

One hundred seven adult patients with thalassemia aged from 17 through 35 years and transplanted from HLA-identical siblings between November 1988 and September 1996 were evaluated on December 31, 1997. The outcome experience of 20 consecutive patients transplanted between November 13, 1988 and January 10, 1991 and reported in September 1992 is updated after 5 additional years. The experience on 87 patients transplanted between May 1991 and September 1996 is described and evaluated as of the end of December 1997. Of 107 patients, 69 survive between 1.5 and 9 years after transplantation. Sixty-six of these patients do not have thalassemia and are identified as ex-thalassemic after bone marrow transplantation. The youngest survivor is 20 years old, 6 are older than 30 years, and the oldest is 37 years of age. Patients with chronic active hepatitis at the time of transplant were significantly more likely to die than patients without (P =.05; relative risk, 2.05). Marrow transplantation is a valid treatment option for older patients with thalassemia who have suitable donors and show deterioration with conventional therapy.

[Plasma and urinary fibrin fibrinogen degradation products in a case of renal thromboembolism]. / Prodotti di degradazione della fibrina-fibrinogeno plasmatici ed urinari in un caso di tromboembolia renale.

The authors examined the trend of plasma (FDPp) and urine (FDPu) fibrin-fibrinogen degradation products in a case of renal thromboembolism during atrial fibrillation. No alterations of FDP are reported in the literature for this renal pathology. This raises the question of whether this laboratory parameter is of diagnostic value during the course of renal embolism. The case concerned a patient who was admitted to the emergency ward with painful symptoms in his right flank. He was initially hospitalised with a diagnosis of right renal colic. A few days later multiple thromboembolism of the right kidney was diagnosed using CAT with i.v. infusion of contrast medium and renal scintigraphy with 99Tc DTPA. From day 6 to day 17 after the start of painful symptoms, a number of assays were made of FDPp and FDPu using the rapid latex test for FDP which uses specific anti-fragment D and E antiserum (Thrombo-Wellcotester). Alterations of plasma and urine FDP were found which also showed an opposite trend: an inversion of the changes was noted on day 8 with normalisation of FDPp and a persistent increase in FDPu by day 17. Earlier tests may confirm the trend of FDP and their value in diagnostic screening for cases of renal thromboembolism.

[Treatment with human tetanus immunoglobulins in the Emergency Department. Effects of informed consent]. / Trattamento con immunoglobuline umane antitetaniche in Pronto Soccorso. Effetti del consenso informato.

BACKGROUND: The impact of informed consent to tetanus prophylaxis with human immunoglobulins on patients treated in the Emergency Department has been evaluated. METHODS: Tetanus vaccination history was investigated in 1435 patients in 1995 and in 1300 patients in 1996 with post-traumatic skin lesions. RESULTS: The study has shown that in 1995, 55% and in 1996 49.5% of the total patients studied had not received vaccine for tetanus or boosters for over 10 years. These patients had been proposed the treatment with human tetanus immunoglobulins (TIG). The research was performed comparing the consent obtained before (from 17/5 to 15/7/1995) and after (from 17/5 to 15/7/1996) the introduction of the informed consent. The survey was divided into 15-day periods. In 1995 prophylaxis with human immunoglobulins was refused by 42 patients out of 831 (5%) while, in the following year, by 284 out of 641 (44.3%). Every period examined has shown highly significant differences (p < 0.000). CONCLUSIONS: Informing the patients that tetanus prophylaxis with human immunoglobulins can expose them to the risk, at present remote, of transmission of viral infections, has caused a heavy rise of denials to the suggestion of treatment with human immunoglobulins. The amount of the treated patients and the time that was devoted to informed consent would make Emergency Department one of the main places for effective and widespread tetanus prophylaxis. However a greater activity of outer structures would also be hoped for.

Effectiveness of fludarabine in advanced B-cell chronic lymphocytic leukemia.

AIMS: The study was carried out to investigate the efficacy and toxicity of fludarabine phosphate in the treatment of B-cell chronic lymphocytic leukemia (B-CLL) in previously treated patients. METHODS: Sixteen patients, 11 males and 5 females, 9 in stage B and 7 in stage C, according to the Binet Staging System, were treated with a maximum of 6 cycles of fludarabine (25 mg/m2) for 5 days, every 4 weeks. All patients had been pretreated, 10 were refractory to standard regimens, 5 were in relapse, and 1 patient was in partial remission. RESULTS: Thirteen patients were judged suitable for evaluation. Overall 9 patients were responsive to treatment; 4 complete and 5 partial responses were observed. Of the 4 patients in complete remission, 3 were alive at 6, 10 and 13 months, respectively, from the beginning of treatment. One patient died after 11 months for acute graft-versus-host disease after allogenic bone marrow transplantation by an HLA sibling donor. Two of the 5 patients in partial remission were alive at 7 and 17 months, respectively, and the other 3 died (2 of disease reexpansion after 14 and 16 months and 1 of septic shock following pneumonia). Four patients were not responsive to treatment: 1 died from disease progression after 8 months from the beginning of therapy, 1 from cardiac failure after 9 months, 1 from septic shock following meningitis, and 1 was alive after 7 months of follow-up. Treatment was well tolerated, with nausea and vomiting in only one patient. We observed two episodes of pneumonitis, without any evidence of the responsible agent, a tumor lysis syndrome with acute renal failure, a recurrence of autoimmune thrombocytopenia, and a Coombs-positive hemolytic anemia. CONCLUSIONS: Fludarabine phosphate is effective in the treatment of patients with advanced B-CLL, even in those refractory to multiple chemotherapy regimens.

Polyclonal hemopoiesis in leukemia patients following molecularly documented remission.

We performed clonality studies of hemopoietic reconstitution in 24 female patients (pts) with leukemias characterized by specific tumor markers. Thirteen pts had Acute Promyelocytic Leukemia (APL) with rearrangements of the RAR-a and PML genes, 8 BCR rearranged (BCR+)/Ph+ Chronic Myeloid Leukemia (CML) and 3 BCR+/Ph+ Acute Lymphoid Leukemia (ALL). Bone marrow (BM) DNA samples were obtained at diagnosis and at remission after Southern blot documented suppression of specific markers. The clonal or non-clonal nature of hemopoietic reconstitution was assessed by hybridizing the same DNAs with the M27 beta probe, in order to detect methylation differences at the X-linked DXS255 locus. Twenty four pts showed a polyclonal methylation pattern at remission, whereas in 3 cases an apparently clonal pattern was observed despite no evidence of specific gene rearrangement. In 2 of these 3 cases, however, DNAs derived from non-affected tissues (T lymphocytes, skin and BM fibroblasts) revealed the presence of the same DXS255 unmethylated allele detected at diagnosis, while in the third case we found the same apparently clonal pattern in blood mononuclear cells obtained from her healthy female BM donor. These data indicate that polyclonal hematopoiesis occur in APL and CML pts after therapy induced suppression of specific tumor markers, and that unbalanced or aberrant X chromosome methylation patterns are observed in some cases, most likely reflecting constitutional features.

Polyclonal hematopoietic reconstitution in leukemia patients at remission after suppression of specific gene rearrangements.

Clonality studies of hematopoietic reconstitution after remission were performed in 24 female patients (pts) with leukemias characterized by specific molecular markers. At diagnosis, 13 pts had promyelocytic leukemia (PML) retinoic acid receptor-alpha (RAR-alpha)-rearranged acute promyelocytic leukemia (APL), 8 Philadelphia positive (Ph'+) break-point cluster region (BCR+) chronic myeloid leukemia (CML), and 3 Ph'+ (BCR+) acute lymphoblastic leukemia (ALL). All pts were analyzed at presentation and after Southern blot suppression of specific rearrangements after various treatments, including conventional chemotherapy, autologous or allogeneic bone marrow transplant (BMT), all-trans retinoic acid, and alpha-2b interferon. DNA from BM samples collected at diagnosis and, during remission phases, were subjected to Southern blot analysis with the M27 beta probe to detect X chromosome methylation differences, and with BCR, in CML and ALL cases, or PML/RAR-a probes for gene rearrangements, in APL cases. Twenty-one of the 24 pts had polyclonal methylation patterns at remission, together with disappearance of the specific rearrangement, whereas 3 pts retained the same single unmethylated DXS255 allele detected at diagnosis despite no evidence of gene rearrangement. Concerning these 3 pts, such an apparently clonal pattern was also observed in one case in T lymphocytes and skin-derived DNA; in a second case in BM fibroblasts and T lymphocytes; and, in the third case, in blood mononuclear cells obtained from her healthy female BM donor. All these 3 pts are in unmaintained clinical and cytogenetic remission after more than 20 months off therapy. These data suggest that (1) polyclonal and presumably normal hematopoiesis occurs in APL, CML, and Ph'+ ALL pts once the major burden of leukemic cells carrying a specific rearrangement is suppressed by treatment; and (2) unbalanced X chromosome methylation patterns, or aberrant methylation of X chromosome regions may be observed in some cases, most likely reflecting constitutional features simulating a clonal picture.

Identification of DNA rearrangements at the retinoic acid receptor-alpha (RAR-alpha) locus in all patients with acute promyelocytic leukemia (APL) and mapping of APL breakpoints within the RAR-alpha second intron. Italian Cooperative Study Group "GIMEMA".

Seventy patients with acute promyelocytic leukemia (APL) were characterized at the DNA level using genomic retinoic acid receptor-alpha (RAR-alpha) probes on Southern blot experiments. Sixty-two cases were defined as M3 according to the French-American-British (FAB) criteria, and eight had a diagnosis of microgranular or variant (M3v) APL. The use of two restriction enzymes and three probes exploring the second intron of the RAR-alpha gene allowed us to detect specific abnormal DNA fragments in every case, with clustering of rearrangements within the 20-kb intronic region between RAR-alpha exons II and III. A more detailed mapping of APL breakpoints was performed in 52 cases in which three EcoRI subregions of the RAR-alpha second intron were analyzed with corresponding probes. Comparison of clinical and hematological features in the three subgroups of patients with distinct RAR-alpha breakpoints did not show significant differences regarding age, peripheral blood (PB) counts, presence of coagulopathy, or FAB classification (M3 v M3v). Interestingly, a significant difference was observed in the M/F ratio of the three subgroups, with a higher incidence of rearrangements at the 5' end of the RAR-alpha second intron in female patients, and more frequent 3' breakpoints in males. The results of this study indicate that a unique genomic alteration consistently occurs on the 17q- derivative of the APL specific t(15;17) aberration. Moreover, the clinical relevance of RAR-alpha gene analysis both at diagnosis and in follow-up studies is further emphasized.

PML/RAR-alpha rearrangement in acute promyelocytic leukaemias apparently lacking the t(15;17) translocation.

Recent investigations have clarified some of the molecular mechanisms underlying the t(15;17) translocation specific for acute promyelocytic leukaemia (APL). Together with providing new insights into the pathogenesis of the disease, the identification of breakpoints within the RAR-alpha and PML loci on chromosomes 17 and 15 has allowed a new relevant diagnostic tool for the recognition of this leukaemic form. We report the molecular characterization of 6 cases of acute myelogenous leukaemia (AML) in which a diagnosis of typical M3 by conventional morphocytochemistry (FAB criteria) was not accompanied by cytogenetic evidence of the specific t(15;17) aberration. DNA rearrangements were documented in all cases at the PML and RAR-alpha loci. Moreover, in 4 cases also analysed by Northern blot hybridization, we could detect aberrant RAR-alpha transcripts. These findings highlight the specificity of PML/RAR-alpha rearrangements in APL, whereas the lack of t(15;17) may be attributed to sub-microscopic translocations as well as to the presence of non-neoplastic cells undergoing mitosis in the samples examined for karyotype.