Topic: 4. Acute myeloid leukemia - Clinical Background: It is known that blasts in acute myeloid leukemia with mutated nucleophosmin gene (NPM1) may have distinct morphological appearance described as „cup like“ nuclei. Aims: To evaluate frequency and predictive value of typical nuclear morphology at diagnosis in AML cases diagnosed at single academic center between 2019 to 2022, enabling early identification of NPM1 status. Methods: Presence and frequency of „cup like“ nuclear morphology was evaluated on 500 blast cells by two independent observers (LJ, AB). Predictive values were calculated with MedCalc® software towards NPM1 mutated status determined by RQ-PCR (Qiagen®) in patients with normal karyotype. Results: Our main group included 265 consequtive AML cases. In 52 patients (19.6%) NPM1 mutation was confirmed. “Cup like” morphology was revealed at diagnosis in 19 pts (36.5%), with median 26% of nuclei (range 11-54%). Wrong call was present in 3 of 213 pts. Statistical evaluation shown that early identification of “cup like” nuclei suggesting NPM1 status has accuracy of 86.4%, specificity of 98.6%, sensitivity of 36.5%; positive and negative predictive values are 86.3% and 86.4% respectively. Group with typical morphology consists of predominant AML with and without maturation, with high median blast count of 80% (range 57-96%), while only 2 patients had morphological dysplastic features. On the contrary, in group of patients without specific nuclear morphology and with NPM1 mutation, most of patients have dominant morphological dysplasia (21/33) or monoblastic appearance (7/33), with lower median blast count (51%, range 24-80%) Summary/Conclusion: Careful observation of nuclear morphology in AML patients enables early prediction of NPM1 status with high sensitivity, positive predictive value and accuracy.Keywords: Gene mutation, Mutation status, Cytogenetic abnormalities, Acute myeloid leukemia
Thrombopoietin receptor agonists (TPO-RAs) increase platelet counts (PC) in the majority of patients with chronic immune thrombocytopaenia (ITP). Platelet kinetics study (PKS) might contribute to the understanding of mechanisms that lead to durable response.To evaluate the effects of TPO-RAs on PKS parameters in chronic ITP patients.Fifteen chronic ITP patients, aged 59 years [range: 22-84], female/male: 10/5, splenectomised 7/15, were treated with TPO-RAs (eltrombopag/romiplostim: 11/4). Durable response was defined as PC ≥30 × 109 /L at 6 months. Autologous 111 Indium-oxinate PKS was performed before and 5 months after TPO-RAs initiation. Accordingly, platelet survival (PS), platelet turnover, production ratio and sequestration site were assessed.Durable response was achieved in 13/15 of patients (eltrombopag/romiplostim: 10/3). Pre-treatment parameters were: PC 10 × 109 /L [range: 1-110], PS 0.5 days [range: 0.1-1.7 (normal values: 7-10)], platelet turnover 30 857 Plt/μL/day [range: 944-103 500] and platelet production ratio 0.64 [range: 0.01-3.2 (normal values: 1 ± 0.2)]. Post-treatment assessment showed significantly higher: PC 92.5 × 109 /L [range: 28-260, p = .001], PS 2.2 days [range: 0.1-3.6, p = .008], platelet turnover 70 213 Plt/μL/day [range: 2800-462 236, p = .02] and platelet production ratio 1.8 [range: 0.5-37.9, p = .011] compared to the pre-treatment values. Platelet sequestration site altered in 3/15 treated with TPO-RAs.TPO-RAs could increase PC by simultaneous increasing of platelet production and decreasing of platelet destruction.
Topic: 3. Acute myeloid leukemia - Biology & Translational Research Background: Deregulation of the apoptotic process underlies the pathogenesis of many cancers, including leukemia, but is also important for the success rate of chemotherapy. Therefore, the gene expression profile of main apoptotic factors, such as anti-apoptotic BCL2 (B-cell lymphoma protein 2) and pro-apoptotic BAX (BCL2-associated X), as well as genes involved in the multi-drug resistance (MDR1), could have significant impact on the prognosis of acute myeloid leukemia (AML). Aims: The influence of BCL2, BAX, and MDR1 expression on prognosis in AML patients with normal karyotype (AML-NK). Methods: We analyzed the expression of BCL2, BAX, and MDR1 in bone-marrow samples collected at diagnosis from 51 adult patients (age 18-65 years), male/female (26/25) with de novo AML-NK using real-time polymerase chain reaction method (PCR), and examined their prognostic potential. Baseline detection of FLT3-ITD and NPM1 mutations were analyzed also by PCR. All patients received induction chemotherapy with daunorubicin and cytarabine (3 + 7) followed by three consolidation cycles of high/intermediate doses of cytarabine. Median gene expression values were as follows: BCL2 1.22 (range 0.13-8.97), BAX 0.92 (range 0.27-2.64), BAX/BCL2 ratio 0.62 (range: 0.11-7.77), MDR1 0.16 (range 0.00-13.74). Based on the median expression values, patients were divided into: higher than median (BCL2+, BAX+, BAX/BCL2high and MDR1+) and lower than median (BCL2-, BAX-, BAX/BCL2low and MDR1-) expression groups. Overall and disease-free survival (OS and DFS) were calculated, while patients undergoing hematopoietic stem cell transplantation were censored at the time of transplantation (15 patients). Standard statistical methods were performed. Results: Increased expression of BCL2 (BCL2+) was associated with chemoresistance (p=0.018), while patients with low BAX expression (BAX-) were more prone to relapse (p=0.034). Analysis of the combined effect of BCL2 and BAX expression showed that 87% of patients with BAX/BCL2low ratio were refractory to chemotherapy (p=0.024). High expression of MDR1 (MDR1+) was associated with BCL2+ status (p<0.001), and with absence of NPM1 and FLT3-ITD mutations (p=0.048 and p=0.010, respectively). None of the analyzed genes influenced OS and DFS. Summary/Conclusion: Our analysis of BCL2, BAX and MDR1 gene expression profiles is the first study focusing exclusively on AML-NK patients. Preliminary results showed that patients with high BCL2 expression are likely to be chemo resistant, and possibly may benefit from specific anti-BCL2 treatment. Further investigations conducted on a larger number of patients could elucidate actual prognostic significance of these genes in AML-NK patients. Keywords: AML, ABC transporter, BCL2, Bax
Introduction: Vitamin D3 is a prohormone, which has neuroprotective, immunomodulating and anti - inflammatory effects on the CNS. The oxidised form of vitamin C - dehydroascorbic acid (DHA) also has a protective ejfect on the CNS. Aim: The aim of this study was to investigate the effects of vitamins D and dehydroascorbic acid to the content of malonyl dialdehyde (MDA), the activity of the enzyme superoxide dismutase (SOD) and catalase (CAT), in the brains of gerbils exposed to transient global cerebral ischemia. Materials and methods: Eight - week - old gerbils were divided into 5 groups: I group - control, II group - ischemia reperfusion (I/R); III group - I/R+vit D3; IVgroup - I/R+DHA; Vgroup -I/R+vit D3+DHA. The active form of vitamin D (1,25(OH)2D3) was administrated intraperitoneally (i.p.) on a daily basis for 8 days before ischemia at a dose of 1 pg/kg. DHA was applied once, 30 min before ischemia (50 mg/kg, ip). Ischemia was achieved by ligation of both common carotid arteries for 10 minutes. Reperfusion lasted for 24 hours, after which the animals were sacrificed. The indicators of oxidative stress from the samples of brain tissue were determined by spectrophotometry. Results: Statistically significant increase in MDA content in the cortex and hippocampus was demonstrated in groups I/R, I/R+DHA and I/R+vit D3+DHA. A significant increase in SOD activity was shown in experimental groups compared to the control group, both in the cortex and the hippocampus. CAT activity was decreased in the cortex of groups I/R+DHA and I/R+vit D3+DHA compared to the control and I/R. Also, a decrease in CAT activity in the hippocampus was present in all the groups compared to the control group. Conclusion: Application of vitamin D3 showed protective effect in I/R injury while DHA acted as a prooxidant.
Inferior vena cava (IVC) anomalies are uncommon congenital causes of deep vein thrombosis (DVT). KILT syndrome (kidney and IVC abnormalities with leg thrombosis) has only been described as case reports in the literature. Therefore, the characteristics, evaluation, and management of patients with KILT syndrome have not yet been standardized. This study aimed to systematically review and analyze the clinical and radiographic data and treatment of previously reported cases of KILT syndrome. In this systematic review, we performed a literature search of the PubMed, Scopus, and Web of Science databases in December 2023, with no restrictions on the publication date. After duplicate extractions, 4195 articles were screened. Case reports and case series reporting on KILT syndrome were included. In addition to previously published cases, we included a new case of a previously healthy 25-year-old man with KILT syndrome in the analysis. A total of 34 cases were therefore included in this study. The majority (76.5%) were male patients with a median age of 24 years. In most patients, unprovoked bilateral iliofemoral thrombosis was diagnosed, and 64.7% had left kidney abnormalities. Our study suggests that anomalies of the IVC should be suspected in all young patients, especially male patients, with proximal, recurrent, or idiopathic DVT. If an IVC anomaly is confirmed, the kidneys should be examined to monitor and preserve healthy kidneys in cases of KILT syndrome. The data collected from all patients emphasize the requirement of long-term anticoagulation and risk factor control. Surgical measures may be effective for treating symptomatic refractory cases.
Background: During the past one year different protocols addressing the treatment of acute leukemia (AL) during the coronavirus disease 2019 (COVID-19) outbreak have emerged. However, reliable data regarding this topic are still deficient, since only case series with heterogeneous patient population with different hematologic malignancies are available. Aims: To determine clinical characteristics of COVID-19 and to assess risk factors for mortality in patients with AL. Methods: This prospective study included 51 consecutive adult patients actively treated for AL, with verified SARS-CoV-2 infection treated at two Clinical Centres in Central Serbia. The study enrolled all symptomatic and asymptomatic patients regardless of severity of the infection. Baseline data including age, sex, body mass index, comorbidities, AL type, disease status (newly diagnosed, complete remission (CR), relapsed/ refractory (RR)), treatment (intensive, low-intensity chemotherapy, supportive care), time since AL diagnosis, outcome, laboratory parameters at the onset of infection were collected. Moreover, dana regarding COVID-19 symptoms, disease severity, COVID-19-specific therapies and time to PCR negativity were collected. Methods of descriptive and analytical statistics were used. Results: Most patients (80.4%) had acute myeloid leukemia (AML). At time of COVID-19 diagnosis 35.3% of patients were newly diagnosed with AL. Concurrent diagnosis of COVID-19 and AML was made in 5.89% patients, 23.5% were RR and 41.2% were in CR. Intensive chemotherapy was administered in 80.4% of our patients. At the time of COVID-19 diagnosis 29.4% patients had bone marrow aplasia. Intrahospital transmission was probable in 50.98% patients. Five patients who were initially asymptomatic andwith negative PCR test at the time of admission developed COVID19 symptoms within the first 48 hours. The most common symptoms of COVID-19 were fever (70.4%), fatigue (66.7%) and dyspnea (39.2%). Asymptomatic, mild to moderate, severe and critical COVID-19 was registered in 9.8%, 43.1%, 37.3% and 9.8% patients, respectively. Median time to PCR negativity was 18 days (range 10-50). Mortality for the entire cohort was 17/51 (29.4%). In all cases death was associated with COVID-19 pneumonia. Among COVID-19 symptoms dyspnea (OR 12.536 (95% CI: 3.106 - 50.597)), cephalgia (OR 5.36 (95% CI: 1.200 - 26.482) and fatigue (OR 5.921(95% CI: 1.168 - 30.019) were associated with higher mortality. Patients newly diagnosed with AL (OR 6.00 (95% CI 1.133 - 15.188) and patients with bone marrow aplasia (OR 4.148 (95% CI 1.133 - 15.188) had a significantly worse outcome in comparison with patients in CR. Additionally, pneumonia severity (OR 14.963 (95% CI 3.212 - 69.700) and need for oxygen therapy (OR 6.455 (95% CI 2.56 - 20.262) were associated with higher mortality risk. Among laboratory parameters lower platelet count (OR 0.985 (95% CI 0.973 - 0.996)), prolonged prothrombin time (OR 1.554 (95% CI 1.104 - 2.186)), higher ISTH DIC score (OR 2.122 (95% CI 1.258 - 3.576), C-reactive protein (OR 1.011 (95% CI 1.004 - 1018) and LDH (OR 1.001 (95% CI 1.000 - 1.003) were predictive for death. Summary/Conclusion: Baring in mind high mortality rate, and rate of intrahospital transmission, rigorous isolation of AL patients, permanent symptoms monitoring and prompt testing should be prioritized. Careful risk-benefit assessment regarding the continuing of anticancer therapy is required in patients receiving palliative therapy and intensive induction therapy. Conversely, there is no reason to withhold therapy for the patients in CR.
Abstract Paroxysmal nocturnal haemoglobinuria (PNH) is a rare, acquired clonal haematological disease characterized by complement-mediated haemolysis, bone marrow failure and venous thrombosis. Anticomplement therapy eculizumab improves survival and reduces complications. Severe acute respiratory distress syndrome corona virus 2 (SARS-CoV-2) disease 2019 (COVID-19) is associated with high incidence of both venous and arterial thrombosis in hospitalized patients with pneumonia. Deep venous thrombosis (DVT) as the presenting symptom of COVID-19 is a rare event. We describe a well-controlled PNH patient on eculizumab for more than 5 years who presented with DVT, while on warfarin, as the first sign of COVID-19. To our knowledge, this is the first described case of DVT in a PNH patient with COVID-19.
Autoimmune hemolytic anemia (AIHA) is a rare, very heterogeneous, and sometimes life-threatening acquired hematologic disease characterized by increased red blood cell (RBC) destruction by autoantibodies (autoAbs), either with or without complement involvement. Recent studies have shown that the involvement of T- and B-cell dysregulation and an imbalance of T-helper 2 (Th2) and Th17 phenotypes play major roles in the pathogenesis of AIHA. AIHA can be primary (idiopathic) but is more often secondary, triggered by infections or drug use or as a part of other diseases. As the location of origin of autoAbs and the location of autoAb-mediated RBC clearance, as well as the location of extramedullary hematopoiesis, the spleen is crucially involved in all the steps of AIHA pathobiology. Splenectomy, which was the established second-line therapeutic option in corticosteroid-resistant AIHA patients for decades, has become less common due to increasing knowledge of immunopathogenesis and the introduction of targeted therapy. This article provides a comprehensive overview of current knowledge regarding the place of the spleen in the immunological background of AIHA and the rapidly growing spectrum of novel therapeutic approaches. Furthermore, this review emphasizes the still-existing expediency of laparoscopic splenectomy with appropriate perioperative thromboprophylaxis and the prevention of infection as a safe and reliable therapeutic option in the context of the limited availability of rituximab and other novel therapies.
Background/Aim. The availability of thrombopoietin receptor agonists (TPO-RA) for treating primary immune thrombocytopenia (ITP) has transformed its management over the last decade. The aim of this study was to assess the efficacy of TPO-RA in adults with chronic ITP treated at the University Clinical Center of Serbia. Methods. A total of 28 adult ITP patients ( 10 m ales and 18 females), who were given eltrombopag and/or romiplostim, were enrolled in the study. Data on demographic characteristics, ITP duration, previous therapeutic modalities, comorbidities, concomitant therapy both for comorbidities and ITP, indications for TPO-RA, bleeding episodes before and during TPO-RA, TPO-RA doses, adverse events, and response rates were collected from the patients? medical records. TPO-RAs were administered in patients with chronic refractory ITP when splenectomy was contraindicated/unfeasible and as preparation for splenectomy. Favorable treatment response was defined as a stable platelet count ? 50 ? 109/L. Results. A total of 22 (78.57%) and 14 (50.0%) patients were treated with eltrombopag and romiplostim, respectively. A good treatment response (GTR) was achieved in 81.8% of the patients receiving eltrombopag and 71.4% of those treated with romiplostim. The non-responders to eltrombopag (4 patients) and those who had lost their response to eltrombopag (4 patients) were switched to romiplostim. Six of 8 patients achieved a GTR. At the time of TPO-RA initiation, 46.4% of the patients used concomitant ITP therapy, which was ceased in all those with a GTR. The following adverse effects of TPO-RA were registered: transaminitis and transient ischemic attack for eltrombopag ? one patient each, and pulmonary embolism in one romiplostim-treated patient. Conclusion. Our study showed that TPO-RAs are an effective and safe treatment option since the majority of patients achieved stable remission without bleeding episodes.
Acute myeloid leukemia (AML) is a heterogeneous malignant disease both on clinical and genetic levels. AML has poor prognosis and, therefore, there is a constant need to find new prognostic markers, as well as markers that can be used as targets for innovative therapeutics. Recently, the search for new biomarkers has turned researchers' attention towards non-coding RNAs, especially long non-coding RNAs (lncRNAs) and micro RNAs (miRNAs). We investigated the expression level of growth arrest-specific transcript 5 (GAS5) lncRNA in 94 younger AML patients, and also the expression level of miR-222 in a cohort of 39 AML patients with normal karyotype (AML-NK), in order to examine their prognostic potential. Our results showed that GAS5 expression level in AML patients was lower compared to healthy controls. Lower GAS5 expression on diagnosis was related to an adverse prognosis. In the AML-NK group patients had higher expression of miR-222 compared to healthy controls. A synergistic effect of GAS5low/miR-222high status on disease prognosis was not established. This is the first study focused on examining the GAS5 and miR-222 expression pattern in AML patients. Its initial findings indicate the need for further investigation of these two non-coding RNAs, their potential roles in leukemogenesis, and the prognosis of AML patients.