Immune response in breast cancer surgery. A comparative and prospective study of different anesthetic techniques.

INTRODUCTION: The main reason for high mortality in breast cancer is local recurrence and metastasis, despite surgery as the first therapeutic option. The anesthesia used in the operation room can determine the immune response. METHODS: A prospective, comparative and non- randomised study in patients undergoing breast cancer surgery was conducted in our hospital after obtaining approval from the Hospital's Institutional Review Board. Patients were divided in two groups: Group A received general anesthesia with propofol and opioids. Group B, in addition to general anesthesia, three interfascial blocks (Pec I, Pec II and BRILMA) were performed in all patients. Three blood samples were taken 1) previous anesthetic induction; 2) two hours after the end of the surgery and 3) 24-48 h after surgery. Leukocytes, CD3, CD4, CD8 and Natural Killer cells were determined at each time. RESULTS: 103 patients were included. 59 (group A) received general anesthesia and 54 (group B) general anesthesia and interfascial blocks. Regarding baseline characteristics, age was significantly higher in the group that received general anesthesia and mastectomy was more frequent in the group that received interfascial blocks. We observed after surgery an increase in leukocytes level that returns close to baseline levels. On the other hand, a reduction in the immune response was observed that also returns to the previous level 48 h after surgery. Group A and B get similar results and also subgroups of hormonal receptors (HER+, PR and/or ER+). CONCLUSIONS: Interfascial blocks in chest wall added to general anesthesia in breast cancer surgery has not shown a significant difference in the inflammatory response or immunological depression compared to general anesthesia as the only anesthetic technique. It seems to trend less immunological depression in the interfascial block group.

Respuesta inmunológica en cirugía del cáncer de mama. Estudio comparativo y prospectivo de diferentes técnicas anestésicas / Immune response in breast cancer surgery. A comparative and prospective study of different anesthetic techniques

Introducción: El principal motivo de la alta mortalidad en el cáncer de mama es la recurrencia local y las metástasis, siendo la cirugía la primera opción terapéutica. La técnica anestésica utilizada en quirófano puede modificar la respuesta inmunológica del paciente. Métodos: Estudio prospectivo, comparativo y no aleatorizado en pacientes intervenidos de cáncer de mama en el Hospital Universitario de Getafe (Madrid) tras la aprobación del Comité Ético del Hospital.Dividimos a los pacientes en dos grupos: grupo A, que recibió anestesia general con propofol y fármacos opiáceos; grupo B, en el que además de la anestesia general, se realizaron tres bloqueos interfasciales (Pec I, Pec II y BRILMA) en todos los pacientes. Se obtuvieron tres muestras sanguíneas: 1) antes de la inducción anestésica; 2) 2h después de finalizar la cirugía y 3) 24-48h posquirúrgicas. En cada muestra, se analizaron el número de leucocitos, células CD3, CD4 y CD8, así como las células natural killer (NK). Resultados: Se incluyeron en el estudio un total de 103 pacientes; 59 (grupo A) recibieron anestesia general y 54 (grupo B) anestesia general y bloqueos interfasciales. Según las características basales, la edad fue significativamente superior en las pacientes que recibieron anestesia general. La mastectomía se realizó con más frecuencia en el grupo que recibió bloqueos interfasciales. Observamos que después de la cirugía hay un aumento en el número de leucocitos pero regresa a los niveles basales a las 48h, comportamiento que se repite a nivel inmunológico: disminuye después de la cirugía pero vuelve a niveles previos a las 48h de la cirugía. Los grupos A y B presentan resultados similares en el resto de parámetros estudiados, al igual que los subgrupos según los receptores hormonales (HER+, PR y/o ER+).(AU)

Introduction: The main reason for high mortality in breast cancer is local recurrence and metastasis, despite surgery as the first therapeutic option. The anesthesia used in the operation room can determine the immune response. Methods: A prospective, comparative and non-randomized study in patients undergoing breast cancer surgery was conducted in our hospital after obtaining approval from the Hospital's Institutional Review Board. Patients were divided in two groups: Group A received general anesthesia with propofol and opioids. Group B, in addition to general anesthesia, three interfascial blocks (Pec I, Pec II and BRILMA) were performed in all patients. Three blood samples were taken 1) previous anesthetic induction; 2) two hours after the end of the surgery and 3) 24-48hours after surgery. Leukocytes, CD3, CD4, CD8 and Natural Killer cells were determined at each time. Results: 103 patients were included. 59 (group A) received general anesthesia and 54 (group B) general anesthesia and interfascial blocks. Regarding baseline characteristics, age was significantly higher in the group that received general anesthesia and mastectomy was more frequent in the group that received interfascial blocks.We observed after surgery an increase in leukocytes level that returns close to baseline levels. On the other hand, a reduction in the immune response was observed that also returns to the previous level 48hours after surgery. Group A and B get similar results and also subgroups of hormonal receptors (HER+, PR and/or ER+). Conclusions: Interfascial blocks in chest wall added to general anesthesia in breast cancer surgery has not shown a significant difference in the inflammatory response or immunological depression compared to general anesthesia as the only anesthetic technique. It seems to trend less immunological depression in the interfascial block group.(AU)

Cross-sectional validation study of patient-reported outcomes in patients with paroxysmal nocturnal haemoglobinuria.

BACKGROUND: Paroxysmal nocturnal haemoglobinuria (PNH) is a rare, acquired, clonal haemopoietic stem cell disorder that causes chronic intravascular haemolysis, increases the risk of thrombosis and results in significant patient morbidity and mortality. The symptoms of PNH may have a major impact on patient quality of life. AIMS: To assess patient fatigue and health-related quality of life in 29 patients with PNH using the Functional Assessment of Chronic Illness Therapy Fatigue subscale version 4 (FACIT-Fatigue) and the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire-C30, version 3 (EORTC QLQ-C30). METHODS: Following completion of the questionnaires, patients were interviewed to assess the validity, clarity, relevance and comprehensiveness of the assessments. RESULTS: Overall, patients considered both the FACIT-Fatigue and EORTC QLQ-C30 instruments to be relevant and adequate in assessing the level of PNH-associated fatigue and other quality-of-life measures. The FACIT-Fatigue questionnaire was considered to be clear and to comprehensively cover PNH-related fatigue. The EORTC QLQ-C30 instrument was considered to be easy to understand, but of an overall lower relevance, although some differences between countries were observed. Patients suggested additional questions that could be incorporated into future EORTC QLQ-C30 versions to make it more relevant to PNH. CONCLUSIONS: This study confirms the validity of the FACIT-Fatigue and the EORTC QLQ-C30 questionnaires in this patient population and their routine use should be considered in the management of patients with PNH.

[Mononeuropathy in chronic lymphatic leukaemia]. / Mononeuropatía en la leucemia linfática crónica.

INTRODUCTION: Chronic lymphatic leukaemia (CLL) is the most frequent form of leukaemia in the adult population in western countries. Only 7.2% of the complications of CLL are neurological and most of them are secondary to an infection by herpes zoster virus. CASE REPORT: We report the case of a 71-year-old female with B-type CLL in stage IV or type C that was progressing and becoming diffuse large B-cell lymphoma (Richter's syndrome), who developed an incomplete axonotmesis of the left peroneal nerve and numerous violet-coloured nodules under the skin in the left knee. Magnetic resonance imaging showed signs of diffuse infiltration into the subcutaneous tissue and the muscles of the left leg; a biopsy study of one of the subcutaneous nodules revealed a lymphoid infiltration by large B-cells. In this patient, the injury to the left peroneal nerve was probably secondary to a lymphoid infiltration of the nerve from adjacent infiltrated soft tissues. CONCLUSION: Peripheral neuropathy due to direct infiltration can be a neurological complication of CLL that has not be reported to date, but which is known to occur in other lymphoproliferative processes.

Mononeuropatía en la leucemia linfática crónica / Monotherapy in chronic lymphatic leukaemia

Introducción. La leucemia linfática crónica (LLC) es la leucemia de la población adulta más frecuente en los países occidentales. Sólo un 7,2% de las complicaciones de la LLC son neurológicas y la mayoría es secundaria a una infección por el virus herpes zoster. Caso clínico. Mujer de 71 años con LLC de tipo B en estadio IV o de tipo C en progresión y transformación a linfoma B difuso de células grandes (síndrome de Richter), que desarrolla una axonotmnesis incompleta del nervio peroneo izquierdo y múltiples nódulos violáceos subcutáneos en la rodilla izquierda. La resonancia magnética objetivó signos de infiltración difusa en el tejido subcutáneo y en los músculos de la pierna izquierda, y la biopsia de uno de los nódulos subcutáneos, una infiltración linfoide por célula B grande. En esta paciente, la lesión del nervio peroneo izquierdo probablemente fue secundaria a una infiltración linfoide del nervio proveniente de los tejidos blandos infiltrados adyacentes. Conclusión. La neuropatía periférica por infiltración directa puede ser una complicación neurológica de la LLC, no descrita hasta ahora, pero conocida en otros procesos linfoproliferativos

Introduction. Chronic lymphatic leukaemia (CLL) is the most frequent form of leukaemia in the adult population in western countries. Only 7.2% of the complications of CLL are neurological and most of them are secondary to an infection by herpes zoster virus. Case report. We report the case of a 71-year-old female with B-type CLL in stage IV or type C that was progressing and becoming diffuse large B-cell lymphoma (Richter’s syndrome), who developed an incomplete axonotmesis of the left peroneal nerve and numerous violet-coloured nodules under the skin in the left knee. Magnetic resonance imaging showed signs of diffuse infiltration into the subcutaneous tissue and the muscles of the left leg; a biopsy study of one of the subcutaneous nodules revealed a lymphoid infiltration by large B-cells. In this patient, the injury to the left peroneal nerve was probably secondary to a lymphoid infiltration of the nerve from adjacent infiltrated soft tissues. Conclusion. Peripheral neuropathy due to direct infiltration can be a neurological complication of CLL that has not be reported to date, but which is known to occur in other lymphoproliferative processes

Revisión de los métodos de screening en hipoacusias / Revision of screening methods in hypoacusis

Introducción: La detección precoz de la hipoacusia tieneimportancia para instaurar rehabilitación auditiva tempranay conseguir el desarrollo normal del lenguaje. Por estemotivo se han desarrollado programas de screening auditivoen neonatos, que se iniciaron en pacientes con factores deriesgo de hipoacusia. El estudio neurofisiológico de potencialesevocados auditivos del troncocerebral (PEATC) constituyeun método objetivo de detección precoz de trastornosde la audición y evaluación funcional de la vía auditiva.Objetivos: Estudiar la incidencia de hipoacusia en neonatosy niños con factores de riesgo en nuestra área asistencialasí como hacer una revisión de los métodos de screeningde hipoacusia con análisis coste-efectividad.Métodos: Se realizó PEATC, años 2001 y 2002, a todoslos neonatos y niños que presentaron algún factor de riesgo audiológico o neurológico, basándose en los criterios de la Comisión Española para la Detección Precoz de Hipoacusia. El estudio incluyó 157 niños con edades desde el nacimiento hasta los 5 años. Conclusiones: El resultado muestra en niños con factoresde riesgo una incidencia de 7,6% de hipoacusia neurosensorial y 2,5% de hipoacusia neurosensorial profunda bilateral. El realizar este programa de screening permitió disminuir la edad de detección de la hipoacusia en los neonatos antes de los 6 meses de edad. Los PEATC convencionales son el método más sensible de valoración de la audición en niños; sin embargo, son demasiado costosos y en tiempo empleado como método inicial de screening. El uso de equipamientos automatizados de screening universal, puede reducir el coste e incrementar el coste-efectividad

Cord blood megakaryocytes do not complete maturation, as indicated by impaired establishment of endomitosis and low expression of G1/S cyclins upon thrombopoietin-induced differentiation.

Cord blood (CB) has successfully been used as a stem cell source for haemopoietic reconstitution. However, a significant delay in platelet engraftment is consistently found in CB versus adult peripheral blood (PB) or bone marrow transplants. We sought to determine whether or not CB megakaryocytes have reached terminal maturation and, hence, full thrombopoietic potential. A comparative analysis of megakaryocytes cultured from either CB or PB progenitors in the presence of thrombopoietin (TPO) showed a similar differentiation response, although proliferation was 2.4 times higher in CB than in PB cells. Importantly, the TPO-induced ploidy level was notably different: whereas 82.7% of CB megakaryocytes remained diploid (2N) at the end of the culture, more than 50% of PB megakaryocytes had reached a DNA content equal to or higher than 4N. Western blot and flow cytometry analyses revealed that only polyploid PB megakaryocytes expressed cyclins E, A and B, whereas cyclin D3 was detected in both fetal and adult megakaryocytic nuclei. These data suggest that establishment of endomitotic cycles is impaired in CB megakaryocytes, associated with a differential regulation of G1/S cell cycle factors. We believe that the relative immaturity of fetal megakaryocytes could be a contributing factor to the delayed platelet engraftment in cord blood transplantation.

Aberrant immunophenotypes detected by flow cytometry in acute lymphoblastic leukemia.

The present study was designed to analyse the proportion of ALL patients in which the phenotypic detection of minimal residual disease (MRD) is feasible, based on the presence of aberrant phenotypes: lineage infidelity, asynchronous expression, overexpression and ectopic phenotype. For this purpose we have prospectively investigated the phenotype of blast cells from 25 patients at diagnosis using a large panel of monoclonal antibodies by multiparametric flow cytometry. The mean age was 23.3 +/- 17.3 with 10 children and 15 adults. 14 patients were classified as L1, 9 L2 and 2 L3 according to the FAB classification. 17 cases were B-lineage ALL and 8 T-ALL. 23 out of 25 cases (92%) included in this study displayed phenotypic aberrations at diagnosis (15 out of 17 cases of B-lineage ALL and all T-ALL patients). 76% of patients displayed two or more than two aberrancies. The phenotypic aberrations were lineage infidelity, found in 12 patients, asynchronous antigen expression detected in 17 patients, antigen overexpression in 4 patients and ectopic phenotype in 7 patients. In summary our results show that when a large panel of MoAbs is used for the immunophenotypical characterization of ALL, most patients display aberrant phenotypes, the coexistence of more than two aberrant antigen expressions being frequently detected. These results suggest that the use of immunological methods for the detection of MRD in ALL based on the existence of aberrant phenotypes could be of great help for the follow-up of patients in complete remission.

Comparative intracellular cytokine production by in vitro stimulated T lymphocytes from human umbilical cord blood (HUCB) and adult peripheral blood (APB).

To date over 400 HUCB transplants have been reported from different centers. It has been suggested that there is a reduced graft-versus-host-disease (GVHD) with HUCB compared to bone marrow transplantation. Since cytokine production by a cell is an indication of the cells function it is important to determinate the differences between APB and HUCB with respect to production of these soluble factors. Our aim was to analyse the intracellular cytokine production by HUCB and APB T lymphocytes with and emphasize on their possible role in GVHD. Heparinized HUCB samples from 8 normal full-term deliveries and 10 normal blood donors were stimulated 4 hours at 37 degrees C and 5% CO2 with phorbol 12-myristate 13-acetate (PMA) and lonomycin in the presence of brefeldine. Afterwards cells were stained with CD3, CD4 or CD8 in different combinations. Finally, after cell permeabilization, cells were stained with Il-2, Il-4 or IFN-gamma. Data acquisition was performed on a FACScan flow cytometer. Compared to APB, HUCB T lymphocytes produced less Il-2, Il-4 and IFN-gamma. In HUCB, Il-2, Il-4 and IFN-gamma were produced predominantly by CD4+ T cells. In APB, Il-2 and Il-4 were also produced predominantly by CD4+ cells compared with CD8+ T lymphocytes, however, IFN-gamma was produced by both CD4+ and CD8+ T cells. These results indicate that there are clear differences in the cytokine profile between T cells in APB and HUCB.

CD79b expression in B cell chronic lymphocytic leukemia: its implication for minimal residual disease detection.

The surface expression of CD79b, using the monoclonal antibody (Mab) CB3-1, on B lymphocytes from normal individuals and patients with B cell chronic lymphocytic leukemia (CLL) has been analyzed using triple-staining cells for flow cytometry. In addition, the clinical significance of CD79b expression in CLL patients and its possible value for the evaluation of minimal residual disease (MRD) was explored. A total of 15 peripheral blood (PB) samples from healthy blood donors, five bone marrow (BM) samples from normal donors and 40 PB samples from CLL untreated patients were included in the study. In addition we studied the expression of CD79b in B lymphocytes from five CLL patients after fludarabine treatment in order to support our method. The expression of CD79b in B lymphocytes from PB was analyzed by flow cytometry, using simultaneous staining with the Mabs CD22, CD79b, CD19 and CD5, CD79b and CD19. Since normal immature bone marrow B cells are CD79b-/dim+ on their surface, in BM samples we used the combination CD45, CD79b and CD19 selecting mature B lymphocytes according to their bright CD45 intensity. Cell acquisition was performed in two consecutive steps using a live gate drawn on SSC/CD19+ cells. For data analysis, the PAINT-A-GATE PRO software (Becton Dickinson) was used. Dilution experiments of CD79b- CLL cells and CD79bdim+ CLL cells with normal PB and BM cells were performed in order to assess the sensitivity level of the technique for detection of CD79b-/dim+residual CLL cells. All B lymphocytes from normal samples showed reactivity for the CD79b antigen. In contrast, CD79b was absent in 18/40 CLL patients (42.5%) and 20/40 CLL cases (50%) exhibited a low CD79b expression. Therefore, CD79b- B lymphocytes would be restricted to the CLL population and thus could be considered a 'tumor phenotype' for monitoring MRD in CLL patients. Dilution experiments indicate that the detection limit with this marker almost reaches the levels obtained by molecular biology methods as the PCR technique. All cases studied after fludarabine presented leukemic cells in their PB or BM samples detected by flow cytometry. Upon comparing the clinical and morphological characteristics of CD79b- and CD79b+ cases, all atypical CLL cases included in the present study were CD79b+ and advanced clinical stage (B and C Binet stage) was most frequently observed in CD79b+ cases than in CD79b- cases.

Acute myeloid leukemia M2 and t(8;21)(q22;q22) with an unusual phenotype: myeloperoxidase (+), CD13 (-), CD14 (-), and CD33(-).

Cases of myeloid surface antigen-negative acute myeloid leukemia (AML) are rare. We describe the morphological, cytochemical, immunologic, and cytogenetic features of two patients with AML with maturation (FAB M2) and the phenotype MPO+, CD13 (-), CD33(-), CD56(+). Cytogenetic studies demonstrated t(8;21)(q22;q22). These findings suggest an association between the lack of CD13 and CD33 in myeloperoxidase-positive AML and the presence of t(8;21).

Pure red cell aplasia associated with large granular lymphocytic leukemia: a rare association in Western countries.

The coexistence of large granular lymphocytic leukemia (LGLL) and pure red cell aplasia (PRCA) has been previously described, but is rare in Western countries (7% in a recent series of LGLL cases). We present the clinical features, hematological parameters and immunophenotype of two patients with PRCA associated with CD3+ LGLL.

Acquired pure red cell aplasia: a study of six cases.

Persistent infection by parvovirus B19 associated with pure red cell aplasia (PRCA) has been documented in immunocompromised patients. Bone marrow failure is associated with conditions in which immune surveillance is impaired, and in these instances occult parvovirus infection may be suspected. In this study we have assessed by serological and molecular methods whether parvovirus B19 infection may be a more frequent cause of PRCA than hitherto suspected and whether it may be present in the absence of a typical bone marrow picture. Six patients with PRCA--two with isolated PRCA and no apparent underlying disease, two with a lymphoproliferative disease, one with thymoma, and one with chronic myelomonocytic leukemia--have been studied. Four of the six patients had overt PCRA and were clearly immunocompromised. Parvovirus B19 was not detected in any of the six patients by PCR analysis and serology investigating the presence of IgM or IgG antibodies. Although parvovirus B19 infection needs to be ruled out in PRCA it represents only one, and probably not the most frequent, etiological factor of PRCA.