Blood stream infections after allogeneic stem cell transplantation: a single-center experience with the use of levofloxacin prophylaxis.

Blood stream infections (BSIs) remain one of the major causes of morbidity and mortality for patients receiving an allogeneic hematopoietic stem cell transplantation (HSCT). In the present study, we evaluated the incidence and characteristics of BSI within 1 year after allogeneic HSCT in 269 consecutive adult patients who received antibacterial prophylaxis with levofloxacin. Cumulative incidence of BSI was 12% (95% confidence interval, 8-16%). Bacteria were responsible for 30 out of the 32 BSI, while fungi were responsible for 2 episodes of BSI. The median onset of BSI was day 8 (range 1-328 days) post transplant, and 66% of BSI occurred before neutrophil recovery. Gram-positive organisms accounted for 60% (n=18) of bacteremia, and gram-negative isolates for 40% (n=12) of the cases. Coagulase-negative staphylococci were the most commonly isolated gram-positive pathogens (53% of the cases), while Escherichia coli was the most commonly isolated gram-negative bacteria (58% of the cases). Candida albicans and Candida guillermondii were isolated from patients with candidemia. Resistance to fluoroquinolones (FQ) was common with 13% of gram-positive isolates being susceptible to FQ, while 50% of the gram-negative rods were susceptible to FQ. Crude mortality and mortality attributable to BSI were both 3% (1 of 32). In conclusion, our data suggest that despite the emergence of antibiotic resistance, FQ prophylaxis may be considered an appealing approach in allogeneic HSCT recipients and is also worth evaluating in randomized studies.

JAK2V617F activating mutation is associated with the myeloproliferative type of chronic myelomonocytic leukaemia.

BACKGROUND: Chronic myelomonocytic leukaemia (CMML) is a haematopoietic malignancy with heterogeneous clinical and morphological features. It is classified in the World Health Organization myeloproliferative-myelodysplastic overlap category. JAK2(V617F) mutation can be found in a large percentage of patients with myeloproliferative neoplasms. AIMS: To investigate the association between JAK2(V617F) mutation and clinical, haematological and bone marrow histological features in CMML and to verify whether the mutation is associated with the myeloproliferative type of the disease. METHODS: 78 consecutive patients with newly diagnosed CMML from 2004 to 2008 were included in the study. JAK2(V617F) mutation was assessed using direct sequencing of exon 14 or by allele-specific PCR from total peripheral blood or bone marrow samples. RESULTS: JAK2(V617F) mutation was identified in eight cases (10.2%). All patients with the mutation presented with splenomegaly and had a significantly higher haemoglobin level and neutrophil count than patients without the mutation. All bone marrow biopsies of JAK2(V617F)-mutated CMML showed increased erythropoiesis, a marked myeloid and megakaryocytic hyperplasia with occasionally clustered megakaryocytes, and a mild or moderate (grade 1 or 2) fibrosis; six cases showed an increased number of dilated sinusoids and reactive lymphoid nodules. CONCLUSIONS: The results indicate that JAK2(V617F) mutation is associated with clinical and morphological features of the myeloproliferative type of CMML. Therefore, JAK2 mutation analysis together with bone marrow morphology could help in a more appropriate classification of the disease.

Assessment of minimal residual disease (MRD) in CBFbeta/MYH11-positive acute myeloid leukemias by qualitative and quantitative RT-PCR amplification of fusion transcripts.

The inv(16)(p13q22) chromosomal rearrangement associated with FAB M4Eo acute myeloid leukemia (AML) subtype is characterized by the presence of the CBFbeta/MYH11 fusion transcript that can be used to detect minimal residual disease (MRD). However, qualitative RT-PCR studies of MRD have so far produced conflicting results and seem of limited prognostic value. We have evaluated retrospectively MRD in a large series of CBFbeta/MYH11-positive patients employing both qualitative and quantitative (real-time PCR) approaches. 186 bone marrow samples from 36 patients were examined with a median follow-up of 27.5 months; 15 patients relapsed during follow-up. In qualitative studies, carried out by 'nested' RT-PCR assay, all patients in complete remission (CR) immediately after induction/consolidation therapy were found to be PCR positive. However, follow-up samples at later time points were persistently negative (except one case) in patients remaining in continuous CR (CCR) for more than 12 months. 16 patients were evaluated by quantitative real-time PCR assay: CBFbeta/MYH11 transcript copy number was normalized for expression of the housekeeping gene ABL, expressed as fusion gene copy number per 10(4) copies of ABL. A 2-3 log decline in leukemic transcript copy number was observed after induction/consolidation therapy. After achieving CR, the mean copy number was significantly higher in patients destined to relapse compared to patients remaining in CCR (151 vs 9, P < 0.0001 by Mann-Whitney test). Moreover, in CCR patients, the copy number dropped below the detection threshold after the treatment protocol was completed and remained undetectable in subsequent MRD analysis in accordance with results obtained by qualitative RT-PCR. On the contrary, in the seven patients who relapsed, the copy number in CR never declined below the detection threshold; thus a cut-off value discriminating these two groups of patients could be established. The findings of our study, if confirmed, might confer an important predictive value to quantitative real-time PCR determinations of MRD in patients with inv(16) leukemia.

Cytotoxic T lymphocyte precursor frequency as a predictor of acute graft-versus-host disease in bone marrow transplantation from HLA-identical siblings.

The measurement of precursor frequencies of donor anti-recipient cytotoxic T lymphocytes (CTL-p) has been shown to predict the incidence and the severity of acute graft-versus-host disease (aGVHD) in unrelated donor bone marrow transplantation (BMT). In HLA-identical sibling BMT, where aGVHD is most likely caused by minor histocompatibility antigen mismatches, this assay did not appear to be sensitive enough to provide similar predictive information. In this study, the CTL-p frequencies and the incidence and severity of aGVHD in 51 onco-hematological patients transplanted from HLA-identical siblings were compared. Sibling donors were selected on the basis of HLA identity using serological typing for HLA-A, B, C antigens, whereas HLA-DRB was tested by molecular analysis. Sibling identity was also confirmed by DNA heteroduplex analyses. Fifteen out of 21 (71%) patients with high precursor frequency (>1:100 x 10(3)) and 12 out of 30 (40%) with low precursor frequency (<1:100 x 10(3)) experienced clinically significant (II-IV) aGVHD. A significant correlation (P = 0.04) between CTL-p frequency and severe aGVHD was demonstrated. Moreover there was a positive trend for a high frequency response according to an increasing grade of aGVHD, which was statistically significant (P = 0.04). In our experience the CTL-p assay is a helpful predictive test for aGVHD in HLA-identical sibling BMT, indicating high risk patients possibly requiring additional prophylaxis.

Dose-intensive melphalan with stem cell support (CM regimen) is effective and well tolerated in elderly myeloma patients.

BACKGROUND AND OBJECTIVE: Multiple myeloma (MM) typically afflicts elderly patients. High-dose therapy has recently been shown to lead to a better outcome than standard treatment, mainly in younger patients. The extent to which older subjects can benefit from intensified approaches without excessive toxicity is examined in this study. DESIGN AND METHODS: Between December 1994 and May 1997, 12 Italian Multiple Myeloma Study Group institutions entered 68 patients at diagnosis (median age 65) into an intensified chemotherapy regimen: cyclophosphamide (CY) 3 g/m(2) plus melphalan 60 mg/m(2) followed by peripheral blood progenitor cells (PBPC) and G-CSF (CM regimen). CY (day 0) and G-CSF were used to mobilize PBPC harvested by a single leukapheresis on day 10. Melphalan was infused on day 11. PBPC were kept unprocessed at 4 degrees C for 48 hours and reinfused on day 12. Three CM regimens were delivered at 6-month intervals. RESULTS: Sufficient PBPC to support the first CM cycle were available (median CD34(+) harvest: 4.9x10(6)/kg), but dropped significantly after the second (median CD34(+) harvest: 2x10(6)/kg) and the third (median CD34(+) harvest: 0.9x10(6)/kg). The median durations of severe neutropenia (absolute neutrophil count < 500 microL) were 3, 4, and 3 days, and those of severe thrombocytopenia (platelets < 25,000/microL) were 2.5, 2, and 1 days, after the first, second and third courses, respectively. The frequency of extramedullary toxicities was low. Treatment-related mortality (TRM) was 3% after the first CM, only. Complete remission (CR) was 14% after the first, 16% after the second and 27% after the third CM. After a median follow-up of 34 months (range 19-49 months), median event-free survival was 35.6 months. INTERPRETATION AND CONCLUSIONS: These results indicate that dose-intensity of melphalan can be increased by reinfusing PBPC with acceptable low toxicity. The combination of CY and melphalan followed by PBPC is an effective chemotherapy for elderly myeloma patients. Repeated melphalan infusion hampered subsequent CD34(+) harvests.

An analysis of which subgroups of multiple myeloma patients, divided according to b(2)-microglobulin and plasma cell labeling index, benefit from high dose vs conventional chemotherapy.

BACKGROUND AND OBJECTIVE: The clinical advantage of high-dose therapy (HDT) over standard treatment for multiple myeloma (MM) patients has been recently assessed. Which patient subgroups benefit most from this approach is unclear. DESIGN AND METHODS: To address this issue, the outcome of 54 patients under 55 years old treated with HDT was compared with that of 101 age-matched controls selected from 390 patients who received standard melphalan and prednisone (MP) chemotherapy in a national multi-center trial (M90 protocol). RESULTS: The complete response (CR) rate was 50% in the HDT group compared to 5% in the MP group. Event-free survival (EFS) was three times longer for the HDT patients (median 34.5 vs 12.2 months, p<0. 0001), though the controls enjoyed a prolonged survival after relapse, and hence there was no statistically significant difference in OS. Overall survival (OS) was analyzed in relation to to two major prognostic factors: b(2)-microglobulin (b(2)-M) and bone marrow plasma cell labeling index (LI). HDT significantly improved OS in poor prognosis patients with a high LI (>1.2%), (median 49.5 vs 32.5 months, p<0.03), whereas it did not prolong OS in poor prognosis patients with high b(2 )-M (> 3 mg/L). INTERPRETATION AND CONCLUSIONS: In conclusion, HDT has a major impact on CR and EFS, and is the treatment of choice for patients with a high LI. Alternative strategies should be adopted in poor prognosis patients with high b(2 )-M.

Nucleolar organizer region counts predict complete remission, remission duration, and survival in adult acute myelogenous leukemia patients.

PURPOSE: The analysis of the nucleolar organizer regions (AgNORs) was performed in patients with acute myelogenous leukemia (AML) to verify the role of cell proliferation in predicting complete remission (CR) and survival. MATERIALS AND METHODS: Bone marrow biopsies from 40 adult patients with AML were stained with the argyrophilic method. The mean AgNOR number (AgNOR count) was calculated for each case. After induction therapy, patients who achieved CR received intensive consolidation; two underwent autologous and four allogeneic bone marrow transplantations (BMT). RESULTS: The mean AgNOR count for the whole series was 6.6 (SD = 1.35); it was higher in CR patients than in resistant ones (P = .02). The median duration of CR was 26 months for patients with an AgNOR count greater than 6.6, but only 6 months for those with lower counts (P = .01). Sixteen patients who achieved a CR relapsed and 14 reached a second CR; the median duration of second CR was 16 months for patients with AgNOR count greater than 6.6, but only 5 months for those with lower counts (P = .01). The median survival time for the whole series was 14 months, with 30% of patients alive and in continuous CR at 103 months. Survival was longer for patients with an AgNOR count greater than 6.6 (33 months) than for those with lower counts (6 months; P = .0009). In multivariate analysis, when CR was excluded from the model, AgNOR count appeared as an independent prognostic variable (P = .005). CONCLUSION: AgNOR analysis is a suitable method to assess cell proliferation in bone marrow biopsies and can predict CR, remission duration, and survival in AML patients.

Risk groups of myeloma patients by histologic pattern and proliferative activity.

We investigated the histologic pattern and the cell proliferative activity of myeloma cells by the analysis of the nucleolar organizer regions (AgNORs) in bone marrow biopsy specimens from 150 multiple myelomas at diagnosis. The objective was an attempt to define risk groups of myeloma patients. On univariate analysis, the percentage of bone marrow plasma cells (BMPC%), the pattern of infiltration, the degree of plasma cell (PC) atypia, the marrow fibrosis, and the number of AgNOR/PC were correlated with survival time. On multivariate analysis, only AgNOR counts and pattern of infiltration retained independent prognostic significance. At 4-year followup, all patients with BMPC% < or = 20, interstitial pattern of invasion, and well-differentiated (G1) PC plus AgNOR/cell < or = 3.32 were alive, while no patient with BMPC% >50, diffuse pattern of infiltration, and poorly differentiated (G3) PC plus AgNOR/cell >5.15 survived (p < 0.0001). In conclusion, the histologic pattern and proliferative activity of myeloma cells, evaluated by AgNOR counts, are reliable predictors of survival in myeloma. Both parameters can be easily assessed in the same biopsy specimen, are reproducible, and permit identification of a group of patients with favourable outcome at 4-year followup. Thus, bone marrow biopsy should always be included in the diagnostic procedures for myeloma patients.

Conventional induction treatments do not influence overall survival in multiple myeloma.

A retrospective analysis was performed on two subsequent myeloma patient series treated with the same conventional induction treatments, melphalan and prednisone or alternating VMCP/VBAP: 273 were enrolled in the multicentre M83 trial (M83 trial group) from 1983 to 1986; 160 were referred to a single institution (Haemat. To group) from 1986 to 1994. Response to treatment was very similar in the two groups (53% v 50.3%). Remission duration curves merely overlapped (median 20 v 21 months). However, overall survival was significantly longer in the Haemat. To group (43.2 v 33 months, P < 0.04). This difference was due to a prolonged period from relapse or progression to death (21 v 8 months, P < 0.01; 20.8 v 7 months, P < 0.009). Prolonged survival was also observed in poor-prognosis patients with a serum beta2-microglobulin level > 3 mg/l, in the Haemat. To group (31.8 v 24.2 months, P < 0.04). The same induction treatments produced almost identical response rate and remission duration in both groups, but overall survival was 10 months longer for one group. However, it could be argued that treatment salvage modalities and support therapies have been improved in a decade. Lastly, induction treatments did not influence overall survival.

Intensified and high-dose chemotherapy with granulocyte colony-stimulating factor and autologous stem-cell transplantation support as first-line therapy in high-risk diffuse large-cell lymphoma.

PURPOSE: In our previous study with MACOPB, we identified a high-risk group of patients with a poor 3-year survival rate of 29%. These patients were defined as having at diagnosis advanced-stage disease with high tumor burden (TB) and elevated lactate dehydrogenase (LDH) level or bone marrow (BM) involvement. A novel therapeutic scheme was investigated to improve the outcome of these patients. PATIENTS AND METHODS: Fifty patients with high-risk diffuse large-cell lymphoma (DLCL) were enrolled. The therapeutic scheme includes three phases: induction with 8 weeks of MACOPB; intensification with a 3-day course of mitoxantrone 8 mg/m2 plus high-dose cytarabine (HDARA-C) 2 g/m2 every 12 hours plus dexamethasone 4 mg/m2 every 12 hours (MAD protocol) and granulocyte colony-stimulating factor (G-CSF) 5 microg/kg on days 4 to 17 to harvest peripheral-blood progenitor cells (PBPC); consolidation with carmustine (BCNU), etoposide, ARA-C, and melphalan (BEAM) regimen; plus autologous stem-cell transplantation (ASCT) with PBPC, marrow, or both. RESULTS: Thirty-six patients (72%) achieved a complete response (CR), 11 (22%) showed no response (NR), and three (6%) died of toxicity. Among the 22 PRs or NRs after the induction phase, 56% of patients achieved a CR with subsequent intensified therapy. With a median follow-up duration of 32 months, the overall survival and failure-free survival rates were 56% and 50%, respectively. The disease-free survival rate is 69% at 32 months. Leukapheresis after MAD and G-CSF yielded a median of 32 x 10(6)/kg CD34+ cells and 80 x 10(4)/kg granulocyte-macrophage colony-forming units (CFU-GM). Thirty-nine patients were autografted and 11 did not undergo ASCT: six because of disease progression, four due to toxicity, and one because of patient refusal. The median times to achieve engrafment were 11 days (range, 7 to 19) to a neutrophil count greater than 0.5 x 10(9)/L and 12 days (range, 8 to 60) to a platelet count greater than 50 x 10(9)/L. CONCLUSION: This sequential scheme with intensified and high-dose chemotherapy with ASCT is feasible with moderate toxicity and may improve the outcome in high-risk DLCL.

Correlation between argyrophilic nucleolar organizer region counts and labelling index in multiple myeloma.

The correlation between the bromodeoxiuridine (BrdU)-labelling index (LI) of plasma cells and a new proliferation marker, the Argyrophilic Nucleolar Organizer Regions (AgNORs), was investigated in 44 myeloma patients at diagnosis. A preliminary analysis was made to verify the reproducibility of the assessment of plasma cell infiltration (PC%) in bone marrow aspirates, used to collect cells for LI determination, and in bone marrow biopsies, used for AgNORs evaluation. Although an overall good correlation was observed between PC% in biopsies and aspirates (r=0.58, p=0.001), the ratio between PC% in biopsies and in aspirates ranged form 0.35 to 7.5. Only 17 patients (38.6%) were within the 0.5-1.5 range. A positive correlation between LI and AgNORs was observed in these patients (r=0.68, p=0.003), whereas the correlation was lost in patients with higher ratio between PC% in biopsies and in aspirates (r=0.08, p=0.69). The prognostic significance of AgNORs was confirmed by survival analysis, showing a reduced survival for patients with high (>4.4) AgNOR counts (14 months vs 35 months, p=0.004). The AgNORs analysis therefore allows the simultaneous evaluation of myeloma cell infiltration, degree of differentiation and kinetics of growth in bone marrow biopsies. AgNOR counts deserve to be included in the procedures for diagnosis and prognostic evaluation of myeloma patients.

Expansion of T cells expressing low CD4 or CD8 levels in B-cell chronic lymphocytic leukemia: correlation with disease status and neoplastic phenotype.

Peripheral blood (PB) T cells from 56 patients with B-cell chronic lymphocytic leukemia (B-CLL) were analyzed by two- and three-color immunofluorescence (IF) to determine the expansion of distinct T-cell subsets and their relationship with the clinical and biological features of the disease. We detected the expansion of an unusual T-cell subpopulation expressing lower CD4 or CD8 levels (CD4lo, CD8lo) than classic T cells (CD4hi, CD8hi). This subpopulation also expressed low levels of the CD3/TCR alpha/beta complex and was CD19-CD13-CD14-. A phenotypic analysis probing the activation level of CD4lo, CD8lo, CD4hi, and CD8hi cells showed that they comprised increased counts of HLA-DR+, CD11b+, CD45R0+, and CD45RA+ cells. Subset expansion ranged from 2.1- to 13.6-fold. Statistical analysis showed that the size of some of these subsets was correlated to intrinsic features of the tumor. First, CD4loHLA-DR+ cell counts were higher in patients with stage A than those with stages B and C disease. Second, CD8loHLA-DR+ cell counts were higher in patients in stable remission than in those at diagnosis. Third, CD4loHLA-DR+, CD4loCD45R0+, CD4loCD45RA+, and CD4hiCD11b+ cell counts were higher in patients whose tumor cells expressed high levels of surface immunoglobulin (sIg) than in those expressing low levels. The involvement of CD4lo and CD8lo cells in most of these correlations suggests that they may be tumor-reactive cells. Similar cells described in human and murine autoimmune disease have been shown to be autoreactive anergic cells, which may derive from nonclassic pathways of T-cell development.

AgNORs and myeloma prognosis.

The argyrophilic nucleolar organizer regions (AgNORs) were analysed in bone marrow biopsies from 80 patients with multiple myeloma (MM) at presentation. The mean AgNOR number per MM cell (AgNOR counts) and their distribution within the nucleus (configuration) were assessed. AgNOR counts were significantly associated with several recognized prognostic factors: Durie and Salmon clinical staging system (p = 0.02), percentage of plasma cells (PCs) in aspirates (p = 0.01) and in bone marrow biopsies (p = 0.0000), pattern of bone marrow involvement (p = 0.0003), calcaemia (p = 0.0005) and creatininaemia (p = 0.0003). AgNOR counts were also associated with the degree of PC differentiation (p = 0.0000). A single central cluster of 2-3 large-sized AgNORs (configuration A) was evident in most G1 MM; one cluster of 4-5 medium-sized dots or two clusters of 2-4 dots (configuration B) were seen in most G2 MM; many small-sized, scattered dots were present in G3 MM (configuration C). AgNOR counts and configuration were related to the prognosis: in the univariate analysis, the 5 year survival rate was 7% for cases with > 4.5 AgNORs/cell and 46% for cases with < or = 4.5 AgNORs/cell (p = 0.01), 53% for configuration A, 12% for configuration B and 0% for configuration C (p = 0.0000). AgNOR counts (p = 0.02) and configuration (p = 0.000) were independent prognostic variables in the multivariate analysis. The AgNOR counts were significantly higher in "fulminant myeloma" than in less aggressive cases (p = 0.002). The plasma cell labelling index (LI%), evaluated in 44 MM patients, showed significant correlation with prognosis: the 5 year survival rate was 51% for LI% < or = 1 and 17% for LI% > 1 (p = 0.02). More than 70% of patients with low LI% had low AgNOR counts and more than 70% of patients with high LI% had high AgNOR counts (p = 0.007). AgNOR counts and configuration reflect the myeloma cell mass, the degree of differentiation and the kinetics of the myeloma cells. They offer an exact evaluation of the tumour characteristics and can be useful additional parameters for MM prognosis.

Argyrophilic nucleolar organizer region counts and prognosis in multiple myeloma.

The prognostic significance of argyrophilic nucleolar organizer regions (AgNORs) has been evaluated in bone marrow trephine biopsies from 64 patients with multiple myeloma (MM) prior to therapy. The univariate Kaplan-Meyer survival analysis showed a significant correlation between survivals and AgNOR counts (median of survival 51.3 months for cases with < or = 4.62 AgNORs per plasma cell (PC) versus 16 months for cases with > 4.62 AgNORs per PC; P = 0.0000) or AgNOR distribution in PC nucleus (AgNOR configuration) (median of survival 71.67 months for cases with tightly grouped AgNORs, 16.26 for partially grouped and 11.74 for dispersed AgNORs; P = 0.001). Significant prognostic correlations were also found for monoclonal immunoglobulin type (P = 0.008), platelet counts (P = 0.0078), serum creatinine level (P = 0.0001), Durie's clinical stage (P = 0.02), percentage of plasma cells in bone marrow biopsies (BMPC%) (P = 0.005), pattern of medullary involvement (P = 0.003) and PC atypia (P = 0.009). Borderline result was detected for the percentage of PCs in aspirates (P = 0.06). No significant correlation was found between prognosis and patients age, sex, haemoglobin level, serum albumin or calcium level, marrow cellularity and excess of haemosiderin. Multivariate survival analysis showed that only two variables were significantly correlated with prognosis: AgNOR counts (P = 0.003) and AgNOR configuration (P < 0.001). In addition, the analysis of variance showed significant association between AgNOR number and platelet counts, haemoglobin level, calcaemia, creatininaemia, clinical stage, percentage of PCs in aspirates, BMPC%, pattern of medullary involvement, PC atypia, marrow cellularity and configuration of AgNORs. Our results indicate that AgNOR counts and configuration have prognostic and diagnostic value and therefore they are useful independent parameters to assess the pretherapeutic aggressiveness of multiple myeloma.

Argyrophilic nucleolar organizer region counts in multiple myeloma: a histopathological study on bone marrow trephine biopsies.

Argyrophilic nucleolar organizer region (Ag-NOR) analysis was performed on bone marrow biopsies from 90 patients with multiple myeloma (MM) at presentation. The pattern of AgNOR expression and its relationship to histological features were evaluated. The mean AgNOR number per plasma cell was directly correlated with the degree of MM differentiation (3.18 for G1, 4.36 for G2, 6.13 for G3; P less than 0.0001), with the percentage of bone marrow plasma cells (BMPC%) (3.06 for BMPC% less than or equal to 20, 4.28 for BMPC% 21-50, 5.14 for BMPC% greater than 50; P less than 0.0001), with the pattern of medullary involvement (3.63 for interstitial, 4.44 for nodular, 5.17 for diffuse involvement; P less than 0.001) and with medullary fibrosis (5.23 for cases with fibrosis, 4.29 for cases without fibrosis; P less than 0.05). The plasma cells of G1 MM showed 2-3 large AgNORs, tightly grouped in a central nuclear cluster; those of G2 MM showed a central nuclear cluster composed of 4-5 medium-size dots and/or two clusters of 2-3 dots; the G3 MM plasma cells showed many small dots scattered in the nucleolus or dispersed in the nucleus. Our results indicate the diagnostic value of AgNOR analysis in MM and suggest the use of this method for identifying clones of atypical plasma cells with different proliferative activity in bone marrow biopsies. It allows simultaneous evaluation of the morphology and kinetics of MM cells in routinely fixed, decalcified, paraffin-embedded material.

Prognostic significance of serum albumin in chronic lymphocytic leukemia.

BACKGROUND: Low levels of serum albumin have been reported to be associated with a poor prognosis in lymphoproliferative disorders. METHODS AND RESULTS: Clinical and laboratory data were retrospectively evaluated in a series of 342 patients with chronic lymphocytic leukemia (CLL). In univariate analysis, survival was significantly influenced (p less than 0.01) by traditional prognostic factors: number of lymphoid areas involved, volume of adenopathies, presence and degree of hepatomegaly and splenomegaly, anemia, thrombocytopenia, peripheral blood lymphocytosis (greater than 60 x 10(9)/l), percentage of bone marrow lymphocytes (greater than 50%). Among variables not included in the traditional staging systems, age over 70, hypoproteinemia (less than 6 gr/dl) and hypoalbuminemia (less than 3.5 gr/dl) adversely affected prognosis. All the most widely adopted staging systems recognize no more than three groups of patients with statistically different outcomes. In multivariate analysis, the prognostic value of serum albumin was independent of both age and the group of variables included in each staging system considered. CONCLUSIONS: We suggest that evaluation of the serum albumin level could be useful, in future multicenter studies, for further implementation of the staging of CLL.

Lack of correlation between objective response and death rate in multiple myeloma patients treated with oral melphalan and prednisone.

An analysis of survival by response category was performed on 76 patients with stage II and III multiple myeloma, who were treated with oral melphalan and prednisone. The analysis demonstrated a survival advantage for responders over non-responders only in stage III patients (32.3 months for responders vs. 15.6 months for non-responders, p = 0.03). However, two possible sources of error must be considered: a) the poor prognosis of early responders that may adversely affect the survival of all responders, and b) the bias introduced by the 'guarantee time' of responders (i.e., the time on-study required to detect the response). Exclusion from the analysis of the unfavourable subgroup of 'early' responders (median survival 14.7 mos.) provided an improvement of the difference in survival between the remaining 'slow' responders and non-responders in stage III (p = 0.005) as well as in the series as a whole (p = 0.025). Because of the consistent 'guarantee time' of slow responders, the Mantel-Byar test (which credits survival to responders only after the response has been obtained) was then applied. The survival advantage of slow responders over non-responders, previously observed in all patients, particularly those with stage III, was not confirmed by the Mantel-Byar test (chi-square 0.831 and 1.457, respectively), thus supporting the hypothesis of an equal death rate over time in each response category. It therefore appears that the usual response criteria (which require at least a 50% reduction of the myeloma protein) should perhaps be reassessed, as they seem to be an inadequate parameter for evaluation of treatment effectiveness in multiple myeloma.

Multiple myeloma: VMCP/VBAP alternating combination chemotherapy is not superior to melphalan and prednisone even in high-risk patients.

The efficacy of alternating vincristine, melphalan (M), cyclophosphamide, prednisone/vincristine, carmustine, doxorubicin, and prednisone (VMCP/VBAP) polychemotherapy was compared with the M and prednisone (MP) regimen as induction treatment in multiple myeloma (MM). Three hundred four MM patients entered this study between March 1983 and July 1986; the analysis was performed in December 1989. The treatment groups did not show significant differences with respect to major prognostic factors. Median overall survival was 33.8 months. In the VMCP/VBAP and MP arms, after 12 induction chemotherapy cycles, 59.0% and 47.3% (P less than .068) of the patients achieved an M component reduction greater than 50%. No significant difference was observed in the two treatment arms in terms of remission duration (21.3 v 19.6 months, P less than .66) and survival (31.6 v 37.0 months, P less than .28). Patients younger than 65 years did not show any advantage from the alternating polychemotherapy. At diagnosis, the plasma cell labeling index (LI) and serum beta-2 microglobulin (beta 2-m) were evaluated in 173 and 183 patients, respectively. A significantly reduced survival was observed for patients with LI greater than or equal to 2% (16.4 months) or beta 2-m greater than or equal to 6 mg/L (20.4 months). Even in these poor-risk subgroups, VMCP/VBAP was not superior to MP.

Quantitation of melphalan in plasma of patients by reversed-phase high-performance liquid chromatography with electrochemical detection.

An analytical procedure for the separation and determination of melphalan in human plasma was carried out. A simple high-performance liquid chromatographic method with electrochemical detection was developed taking advantage of the high sensitivity of the electrode redox reaction. The sample pretreatment consisted of a direct extraction of the interferents rather than of melphalan, owing to the difficulty of extraction of the drug, and was very simple, rapid and reproducible.