Expression of CD56 is an unfavorable prognostic factor for acute promyelocytic leukemia with higher initial white blood cell counts

Risk factors and remaining challenges in the treatment of acute promyelocytic leukemia

The treatment of acute promyelocytic leukemia (APL) has evolved with the introduction of all-trans retinoic acid (ATRA) and subsequent arsenic trioxide (ATO), particularly in standard-risk APL with an initial white blood cell count (WBC) < 10,000/μL, where a high cure rate can now be achieved. However, for some patients with risk factors, early death or relapse remains a concern. Insights from the analysis of patients treated with ATRA and chemotherapy have identified risk factors such as WBC, surface antigens, complex karyotypes, FLT3 and other genetic mutations, p73 isoforms, variant rearrangements, and drug resistance mutations. However, in the ATRA + ATO era, the significance of these risk factors is changing. This article provides a comprehensive review of APL risk factors, taking into account the treatment approach, and explores the challenges associated with APL treatments.

Biochemical and Hematologic Profiles in B-Cell Acute Lymphoblastic Leukemia Children

B-cell acute lymphoblastic leukemia is the most common type of leukemia found in children. Timely diagnosis, white blood cell count, age of onset, and sex are considered the most important prognostic factors in childhood leukemia. Hematological and biochemical profiles are crucially important to infer the health of leukemia patient pre-chemotherapy and post-chemotherapy treatment. In the current study 200 cases were taken and evaluated for hematological (complete blood count and white blood differential count) and biochemical parameters (renal function tests, liver function tests, serum electrolytes and serum proteins) by comparison with normal reference values. Most of the cases were male under 5 years of age. Hematology parameters including red blood cells, hemoglobin and platelet levels were relatively low whereas white blood cells level was high in cases as compared with normal reference value. Sex-wise and age-wise comparison of biochemical profile showed significant difference among B-cell acute lymphoblastic leukemia cases whereas hematological profile did not show any visible difference.

Evaluating the prognostic value of CD56 in pediatric acute myeloid leukemia

BACKGROUND

Many cytogenetic changes and gene mutations are associated with acute myeloid leukemia (AML) survival outcomes. CD56 is related to poor prognosis when expressed in adult AML patients. However, the prognostic value of CD56 in children with AML has rarely been reported. In this research, we aimed to evaluate the prognostic value of CD56 in childhood AML.

METHODS

The present retrospective study included 145 newly diagnosed pediatric patients with de novo AML (excluding AML-M3) in two hospitals between January 2015 and April 2021.

RESULTS

The total median (range) age was 75 (8-176) months, and the median follow-up time was 35 months. No significant difference in the 3-year overall survival rate was noted between the CD56-positive and CD56-negative groups (67.0% vs. 79.3%, P = 0.157) who received chemotherapy. However, among high-risk patients, the CD56-positive group had a worse overall survival rate and event-free survival rate (P < 0.05). Furthermore, among high-risk patients, the CD56-positive group had higher relapse and mortality rates than the CD56-negative group (P < 0.05).

CONCLUSIONS

CD56 represents a potential factor of poor prognosis in specific groups of children with AML and should be considered in the risk stratification of the disease. Given the independent prognostic value of CD56 expression, we should consider integrating this marker with some immunophenotypic or cytogenetic abnormalities for comprehensive analysis.

Clinicopathological Significance of Common Genetic Alterations in Patients With Acute Promyelocytic Leukemia

OBJECTIVE/BACKGROUND

Acute myeloid leukemia (AML) is one of the common forms of hematological malignancy and acute promyelocytic leukemia (APL) is a unique subtype of AML conferring favorable prognosis. We aimed to determine the prevalence and prognostic impact of Fms-like tyrosine kinase 3 (FLT3), nucleophosmin 1 (NPM1) mutation, epidermal growth factor receptor (EGFR), and flow marker's expression in patients with APL.

METHODS

In the present study, 165 de novo APL patients were molecularly characterized for promyelocytic leukemia (PML) breakpoint and additional genetic alterations. Reverse transcriptase polymerase chain reaction (PCR) and real-time PCR assays were used to detect genetic alterations.

RESULTS

PML/RARα was detected in 29/165 (17.5%) samples with breakpoint cluster region 1 (bcr1) in 17/29 (58.5%) and bcr3 in 12/29 (41.5%) samples. The prevalence of FLT3-ITD, NPM1, and EGFR were detected in 5/29 (17.5%), 11/29 (38%), and 5/29 (17.5%) patients, respectively. Patients expressing bcr-3 hybrid transcript had lower overall survival compared with bcr1 ( p = .254). White blood cell (WBC) count was significantly higher in bcr3 in comparison with bcr1 patients ( p = .002). Patients with positive EGFR expression ( p = .042) and higher WBC ( p = .002) were significantly associated with poor survival ( p < .05).

CONCLUSIONS

We documented the higher prevalence of bcr1 and confirmed that the association of FLT3-ITD significantly reduced the chances of survival in APL. The mortality rate of bcr3 was comparatively higher than that of bcr1. Higher WBC count and EGFR expression were significantly associated with poor survival.

Re-Expression of Poly/Oligo-Sialylated Adhesion Molecules on the Surface of Tumor Cells Disrupts Their Interaction with Immune-Effector Cells and Contributes to Pathophysiological Immune Escape

Glycans linked to surface proteins are the most complex biological macromolecules that play an active role in various cellular mechanisms. This diversity is the basis of cell-cell interaction and communication, cell growth, cell migration, as well as co-stimulatory or inhibitory signaling. Our review describes the importance of neuraminic acid and its derivatives as recognition elements, which are located at the outermost positions of carbohydrate chains linked to specific glycoproteins or glycolipids. Tumor cells, especially from solid tumors, mask themselves by re-expression of hypersialylated neural cell adhesion molecule (NCAM), neuropilin-2 (NRP-2), or synaptic cell adhesion molecule 1 (SynCAM 1) in order to protect themselves against the cytotoxic attack of the also highly sialylated immune effector cells. More particularly, we focus on α-2,8-linked polysialic acid chains, which characterize carrier glycoproteins such as NCAM, NRP-2, or SynCam-1. This characteristic property correlates with an aggressive clinical phenotype and endows them with multiple roles in biological processes that underlie all steps of cancer progression, including regulation of cell-cell and/or cell-extracellular matrix interactions, as well as increased proliferation, migration, reduced apoptosis rate of tumor cells, angiogenesis, and metastasis. Specifically, re-expression of poly/oligo-sialylated adhesion molecules on the surface of tumor cells disrupts their interaction with immune-effector cells and contributes to pathophysiological immune escape. Further, sialylated glycoproteins induce immunoregulatory cytokines and growth factors through interactions with sialic acid-binding immunoglobulin-like lectins. We describe the processes, which modulate the interaction between sialylated carrier glycoproteins and their ligands, and illustrate that sialic acids could be targets of novel therapeutic strategies for treatment of cancer and immune diseases.

A narrative review of central nervous system involvement in acute leukemias

Acute leukemias (both myeloid and lymphoblastic) are a group of diseases for which each year more successful therapies are implemented. However, in a subset of cases the overall survival (OS) is still exceptionally low due to the infiltration of leukemic cells in the central nervous system (CNS) and the subsequent formation of brain tumors. The CNS involvement is more common in acute lymphocytic leukemia (ALL), than in adult acute myeloid leukemia (AML), although the rates for the second case might be underestimated. The main reasons for CNS invasion are related to the expression of specific adhesion molecules (VLA-4, ICAM-1, VCAM, L-selectin, PECAM-1, CD18, LFA-1, CD58, CD44, CXCL12) by a subpopulation of leukemic cells, called “sticky cells” which have the ability to interact and adhere to endothelial cells. Moreover, the microenvironment becomes hypoxic and together with secretion of VEGF-A by ALL or AML cells the permeability of vasculature in the bone marrow increases, coupled with the disruption of blood brain barrier. There is a single subpopulation of leukemia cells, called leukemia stem cells (LSCs) that is able to resist in the new microenvironment due to its high adaptability. The LCSs enter into the arachnoid, migrate, and intensively proliferate in cerebrospinal fluid (CSF) and consequently infiltrate perivascular spaces and brain parenchyma. Moreover, the CNS is an immune privileged site that also protects leukemic cells from chemotherapy. CD56/NCAM is the most important surface molecule often overexpressed by leukemic stem cells that offers them the ability to infiltrate in the CNS. Although asymptomatic or with unspecific symptoms, CNS leukemia should be assessed in both AML/ALL patients, through a combination of flow cytometry and cytological analysis of CSF. Intrathecal therapy (ITT) is a preventive measure for CNS involvement in AML and ALL, still much research is needed in finding the appropriate target that would dramatically lower CNS involvement in acute leukemia.

The diagnostic power of CD117, CD13, CD56, CD64, and MPO in rapid screening acute promyelocytic leukemia

Objective

The same immuno-phenotype between HLA-DR-negative acute myeloid leukemia (AML) and acute promyelocytic leukemia (APL) causes APL rapid screening to become difficult. This study aimed to identify the associated antigens for APL and the best model in clinical uses.

Results

A total of 36 APL (PML–RARA+) and 29 HLA-DR-negative non-APL patients enrolled in this study. When a cut-off point of 20% events was applied to define positive or negative status, APL and non-APL patients share a similar immuno-phenotype of CD117, CD34, CD11b, CD13, CD33, and MPO (P > 0.05). However, expression intensity of CD117 (P = 0.002), CD13 (P < 0.001), CD35 (P < 0.001), CD64 (P < 0.001), and MPO (P < 0.001) in APL are significantly higher while CD56 (P = 0.049) is lower than in non-APL subjects. The Bayesian Model Averaging (BMA) analysis identified CD117 (≥ 49% events), CD13 (≥ 88% events), CD56 (≤ 25% events), CD64 (≥ 42% events), and MPO (≥ 97% events) antigens as an optimal model for APL diagnosis. A combination of these factors resulted in an area under curve (AUC) value of 0.98 together with 91.7% sensitivity and 93.1% specificity, which is better than individual markers (AUC were 0.76, 0.84, 0.65, 0.82, and 0.85, respectively) (P = 0.001).

The prognostic value of CD2, CD4, and HLA-DR expression and FLT3-ITD mutation in adult acute promyelocytic leukemia

In order to explore the prognostic value of CD2, CD4, and human leucocyte antigen-DR (HLA-DR) expression and Fms-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD) mutation in leukemia cells in the bone marrow of patients with acute promyelocytic leukemia (APL), we retrospectively collected and analyzed the immunophenotype, molecular features and clinical characteristics of 219 newly diagnosed adult patients with APL in Henan Provincial People's Hospital from January 2010 to December 2019. It turned out that the relapse rates of patients with CD2, CD4, or HLA-DR expression and the early mortality rates of patients with CD2 expression, HLA-DR expression, or FLT3-ITD mutation were higher than those of their counterparts. Moreover, reduced overall survival was found for patients who showed CD2 expression, HLA-DR expression or FLT3-ITD mutation. Therefore, CD2 expression, HLA-DR expression and FLT3-ITD mutation were adverse prognostic factors in adults with APL.

Impact of CD56 Continuously Recognizable as Prognostic Value of Acute Promyelocytic Leukemia: Results of Multivariate Analyses in the Japan Adult Leukemia Study Group (JALSG)-APL204 Study and a Review of the Literature

BACKGROUND

After long-term analysis of the JALSG-APL204 study we recently reported that maintenance therapy with tamibarotene was more effective than all-trans retinoic acid (ATRA) by reducing relapse in APL patients. Here, the clinical significance of other important prognostic factors was evaluated with multivariate analyses.

PATIENTS AND METHODS

Newly diagnosed acute promyelocytic leukemia (APL) patients were registered with the study. Induction was composed of ATRA and chemotherapy. Patients who achieved molecular remission after consolidation were randomly assigned to maintenance with tamibarotene or ATRA.

RESULTS

Of the 344 eligible patients, 319 (93%) achieved complete remission (CR). After completing consolidation, 269 patients underwent maintenance random assignment-135 to ATRA, and 134 to tamibarotene. By multivariate analysis, overexpression of CD56 in blast was an independent unfavorable prognostic factor for relapse-free survival (RFS) (p = 0.006) together with more than 10.0 × 10⁹/L WBC counts (p = 0.001) and the ATRA arm in maintenance (p = 0.028). Of all phenotypes, CD56 was related most clearly to an unfavorable prognosis. The CR rate, mortality rate during induction and overall survival of CD56⁺ APL were not significantly different compared with CD56^- APL. CD56 is continuously an independent unfavorable prognostic factor for RFS in APL patients treated with ATRA and chemotherapy followed by ATRA or tamibarotene maintenance therapy.

[Application of immunophenotypic analysis and molecular genetics in the diagnosis of acute promyelocytic leukemia]

目的

研究免疫表型分析及分子遗传学在急性早幼粒细胞白血病（APL）诊断中的应用价值。

方法

对2012年5月–2017年12月门诊或住院的798例APL患者的流式细胞术（FCM）免疫分型、染色体核型及染色体荧光原位杂交（FISH）进行回顾性分析，并深入研究FCM免疫表型及分子遗传学在APL诊断中的应用价值。

结果

FCM诊断APL敏感性为91.9%，特异性为98.7%。APL具有独特免疫表型特点：典型APL的表型为侧向（SSC）偏大，CD34和HLA-DR表达缺失，表达或强表达CD33，均一表达CD13、CD9、CD123，可伴有CD56、CD7、CD2的表达。约10%的患者为非典型APL表型，一般伴有CD34和（或）HLA-DR表达，SSC减小，经常伴有CD2表达，而FCM免疫分型很难明确诊断为APL，需要依赖遗传学或者分子生物学检查结果。约1/3的患者除存在t（15;17）（q22;q21）外，还存在额外染色体异常；伴有t（15；17）的复杂核型、变异易位或者t（11;17）、t（5;17）等变异型的APL，FCM表型与单纯t（15；17）APL差异无统计学意义（P>0.05）。

结论

FCM能够快速诊断APL，伴有额外染色体异常患者和单纯t（15；17）患者FCM免疫表型没有明显差异。遗传学是诊断APL的金标准，免疫分型中约10%的患者依赖于分子遗传学来确诊。

[The analysis of prognosis-associated factors in adults with acute promyelocytic leukemia]

目的

探讨CD34、CD2、CD56表达和FLT3-ITD突变在成人急性早幼粒细胞白血病（APL）中的预后价值。

方法

分析2010年1月至2016年3月确诊的137例成人APL患者的免疫表型及分子学特点，探讨CD34、CD2、CD56表达及FLT3-ITD突变与初诊WBC、完全缓解率、早期死亡率、复发率、总生存（OS）率及无病生存（DFS）率的关系。

结果

①137例APL患者中，伴CD34表达者占26.3%，伴CD2表达者占25.5%，伴CD56表达者占10.2%，FLT3-ITD突变率为17.5%。CD34、CD2、CD56表达和FLT3-ITD突变在高危组患者中的发生率分别为43.2%、47.7%、18.2%和27.3%；在中/低危组患者中的发生率分别为18.3%、15.1%、6.5%和12.9%，差异均有统计学意义（χ²值分别为9.561、16.764、4.480、4.268，P值分别为0.002、<0.001、0.034、0.039）。②中位随访41个月，完全缓解率为96.9%，早期死亡率为6.6%，复发率为7.3%。与阴性者比较，伴CD34或CD2表达者的复发率增加（18.8%对3.3%，χ²=8.462，P=0.004；16.1%对4.3%，χ²=4.382，P=0.028）；伴CD56表达或FLT3-ITD突变者早期死亡率增加（21.4%对4.9%，χ²=5.610，P=0.018；16.7%对4.4%，χ²=4.833，P=0.028）。③137例患者的OS率为88.3%，DFS率为84.7%；CD34、CD56表达或FLT3-ITD突变者的OS及DFS较阴性者差（P值均<0.05）。

结论

在成人APL患者中，CD34、CD2、CD56表达及FLT3-ITD突变是一种不良预后因素。

Predictive factors of postoperative survival among patients with pulmonary neuroendocrine tumor

Background

Pulmonary neuroendocrine tumor (NET) occurs with 20% of all lung cancers, and there are a limited number of literatures about the molecular aberrations, treatment and prognosis; especially in resected cases, as the operation indication for large cell neuroendocrine carcinoma (LCNEC) and small cell lung carcinoma (SCLC) is rare due to their aggressive behaviors. We investigated the relationship between postoperative survival and molecular expression patterns of pulmonary NET to establish a more effective treatment strategy.

Methods

In the present study, the curative surgical resection of pulmonary NET was reviewed retrospectively. A total of 105 patients with pulmonary NET, who underwent complete resection between 1978 and 2016, were subjected to analysis with respect to histological characterization and clinical behaviors of pulmonary NET using immunohistochemistry (IHC) of neuroendocrine markers and programmed cell death-ligand 1 (PD-L1).

Results

The pathological types included 67 SCLC, 18 LCNEC, 14 typical carcinoids (TCs) and 6 atypical carcinoids (ACs). The ACs had significantly worse prognosis than TCs. PD-L1 expression ratio in SCLC/LCNEC/TC/AC was 26.1%/50%/15.4%/20%, respectively. However, it was not significantly correlated with each prognosis. Therefore, the SCLC patients were analyzed, the overall 5-year survival of SCLC patients was found to be 47.3%. In the univariate analysis of the molecular expression of SCLC, neuroendocrine markers such as chromogranin-A (CGA) and synaptophysin (SYN) showed poor prognosis, albeit without significant differences.

Conclusions

The neuroendocrine markers such as CGA and SYN might assist the prediction of prognosis and probably influence the decision for adjuvant chemotherapy or follow-up intervals after surgery in SCLC patients; however additional studies are essential.

CD56 and CD11b Positivity with Low Smac/DIABLO Expression as Predictors of Chemoresistance in Acute Myeloid Leukaemia: Flow Cytometric Analysis

Background: Resistance to chemotherapy is a major obstacle to curing acute myeloid leukaemia (AML), and several antigens are claimed to play primary roles in this resistance. Purpose: The aim of this study was to evaluate the roles of CD56, CD11b and Smac/DIABLO gene expression levels as prognostic markers of the clinical outcome, response to chemotherapy and survival of AML patients. Materials and Methods: A cross-sectional observational study was conducted on 60 naïve-AML patients who received induction therapy with mitoxantrone and cytarabine combined with a high dose of cytarabine. The CD56,CD11b and Smac/DIABLO expression levels were assessed using flow cytometry at diagnosis and were analysed for correlation with the possible associated risk factors, response to chemotherapy, and median duration of disease-free survival (DFS) and overall survival (OS). Results: The overall results revealed that AML patients who exhibited positive expression for CD56 and CD11b had short median durations of DFS and OS.(P = 0.019, 0.006, 0.029 and 0.024, respectively). Additionally, low Smac/DIABLO expression had a negative impact on treatment outcome in terms of CR rate (p=0.012) and reduced DFS (p=0.000) and OS(p=0.000) values. Conclusions: CD56 and CD11b positivity and low Smac/DIABLO expression are important predictive factors for the occurrence of chemoresistance, in addition to other risk factors, among AML patients.

An analysis of the impact of CD56 expression in de novo acute promyelocytic leukemia patients treated with upfront all-trans retinoic acid and anthracycline-based regimens

Out of 956, there were 95 (10%) CD56+ APL patients treated with PETHEMA ATRA and chemotherapy. CD56+ expression was associated with high WBC, BCR3 isoform, and co-expression of CD2, CD34, CD7, HLA-DR, CD15, and CD117 antigens. CD56+ vs CD56- APL presented higher induction death rate (16% vs 8%, p = .02) and 5-years cumulative incidence of relapse (33% versus 10%, p = .006), irrespectively of the Sanz score (low-risk 47% versus 5%, p < .001; intermediate 23% versus 7%, p < .001; and high-risk 42% versus 21%, p = .007). In the multivariate analysis, CD56 + (p < .0001), higher relapse-risk score (p = .001), and male gender (p = .05) retained the independent predictive value. CD56+ APL also showed a greater risk of CNS relapse (6% versus 1%, p < .001) and lower 5-year OS (75% versus 83%, p = .003). The AIDA-based LPA2012 trial, with an intensified consolidation schedule for CD56+ APL, will elucidate whether an intensified consolidation schedule could mitigate the relapse rate in this setting.

Factors Affecting Early Death and Survival of Patients With Acute Promyelocytic Leukemia Treated With ATRA-Based Therapy Regimens

PURPOSE

To perform a retrospective analysis of the prognostic relevance of clinicopathologic parameters in a well-documented cohort of patients treated with all-trans-retinoic acid (ATRA)-based induction regimens in order to discover which indicators can predict a high risk of early death (ED) and patient survival.

PATIENTS AND METHODS

We analyzed data of 288 newly diagnosed adult acute promyelocytic leukemia patients in Hangzhou, China. The median follow-up time was 32 months (range, 6-78 months).

RESULTS

The 3-year disease-free and overall survival rates were 90.83% and 91.69%, respectively. In the multivariable analysis, older age (≥ 60 years) was the only independent risk factor for ED (hazard ratio [HR] = 15.057; P = .004). High white blood cell count was not a risk factor for ED (P = .055), but it was for relapse (HR = 2.7; P = .009). FLT3 mutation (HR = 3.9; 95% confidence interval, 1.4 to 10; P = .007) and older age (≥ 60 years) (HR = 5.3; 95% confidence interval, 2.4 to 11; P < .001) were prognostic factors for poorer disease-free and overall survival. Interestingly, CD15 negativity (HR = 0.23; P = .049) was a prognostic factor for relapse. The ED rate was 5.9% (17/288 patients).

CONCLUSION

The perceived impact of the identification of these high-risk factors should be described in order to decide whether any modifications to treatment strategy should be entertained.

Validation of a Molecular Risk Score for Prognosis of Patients With Acute Promyelocytic Leukemia Treated With All-trans Retinoic Acid and Chemotherapy-containing Regimens

INTRODUCTION

Although treatment of acute promyelocytic leukemia (APL) has evolved dramatically during the past decades, especially with the introduction of all-trans retinoic acid, risk stratification remains an important issue. To date, relapse risk can be predicted by leukocyte and platelet counts only. In the present report, we present a validation study on 3 candidate genes and a newly developed molecular risk score for APL in 2 independent patient cohorts.

PATIENTS AND METHODS

An integrative risk score combining the expression levels of BAALC, ERG, and WT1 was calculated for 79 de novo APL patients from the original cohort and 76 de novo APL patients from a validation cohort. Gene expression analysis was executed the same for both cohorts, and the results regarding the effect on patient outcomes were compared.

RESULTS

The expression levels of BAALC, ERG, and WT1 were similar in both cohorts compared with the healthy controls. The relapse and survival rates were not different between the low- and high-risk patients according to the Sanz score. However, application of the molecular risk score on the validation cohort distinctly discriminated patients according to their risk of relapse and death just as in the original APL cohort, although single gene analyses could not reproduce the negative prognostic impact.

CONCLUSION

The analysis clearly validated the prognostic effect of the integrative risk score on the outcome in APL patients. The value was further empowered because the single gene analyses did not show similar results. Whether the integrative risk score retains its prognostic power in the chemotherapy-free setting should be investigated further.

Microgranular acute promyelocytic leukemia presenting with leukopenia and an unusual immunophenotype

The microgranular variant (M3v) of acute promyelocytic leukemia (APL) is rare, and the diagnosis can be delayed due to variability in how this condition presents. M3v blasts often have folded nuclei, but unlike traditional APL blasts, they often possess faint granules without Auer rods. In addition, microgranular APL often presents with an elevated or normal white blood cell count in contrast with the leukopenia seen in traditional APL. In APL, delayed diagnosis can lead to early death from disseminated intravascular coagulation (DIC), which is the main cause of mortality in an otherwise treatable, and often curable, leukemia. We describe a 19-year-old male with microgranular APL who presented with leukopenia and many blasts resembling non-APL AML blasts with an unexpected immunophenotypic pattern. He was treated for DIC and initiated on all-trans-retinoic acid and arsenic trioxide; he achieved complete molecular remission after induction therapy. Suspicion for APL should always remain high in the presence of clinical manifestations of the disease in order that appropriate treatment can be initiated rapidly to prevent early death.

Isolated Central Nervous System (CNS) Relapse in Paediatric Acute Promyelocytic Leukaemia: A Systematic Review

INTRODUCTION

Extramedullary disease, as a whole, is rare in Acute Promyelocytic Leukaemia (APML). If at all relapse occurs, following sites are involved: Central Nervous System (CNS), skin, testes, mediastinum, gingiva, and ear. Isolated CNS relapses after complete morphological and molecular remission is rarer particularly in children.

AIM

To review the literature systematically to find out the incidence of isolated CNS relapse in paediatric APML cases.

MATERIALS AND METHODS

A systematic search of major databases (Medline, Pubmed and Google Scholar) was conducted. We included all types of studies that reported about incidence or prevalence of isolated CNS relapse in children upto 18 years of age with APML.

RESULTS

A total of nine studies (with 10 cases of isolated CNS relapse) were included. Majority (70%) was high risk patients, and 60% were ≤six-year-old. Nearly, 50% were having the mean time to relapse <12 months and most (60%) of them were male. The children who died were having shorter time to CNS relapse (around 12 months), and were older (>6 to 18 years).

CONCLUSION

In the present review, disease in the high-risk group, male sex, younger age (≤six-years-old), and Promyelocytic Leukaemia/Retinoic Acid Receptor Alpha (PML-RARA) detection was found to be associated with isolated CNS relapse in children with APML. Cerebrospinal fluid (CSF) examination along with immunophenotyping and Reverse Transcription polymerase Chain Reaction (RT-PCR) for PML-RARA is required for a definite diagnosis and early treatment of patients to improve overall survival.

CEA Level, Radical Surgery, CD56 and CgA Expression Are Prognostic Factors for Patients With Locoregional Gastrin-Independent GNET

Gastrin-independent gastric neuroendocrine tumors (GNETs) are highly malignant. Radical resections and lymphadenectomy are considered to be the only possible curative treatment for these tumors. However, the prognosis of gastrin-independent GNETs is not well defined. In this study, we identified prognostic factors of locoregional gastrin-independent GNETs.All patients diagnosed with locoregional gastrin-independent GNETs between 2000 and 2014 were included in this retrospective study. Clinical characteristics, blood tests, pathological characteristics, treatments, and follow-up data of the patients were collected and analyzed.Of the 66 patients diagnosed with locoregional gastrin-independent GNETs, 57 (86.4%) received radical resections, 7 (10.6%) with palliative resection, 1 (1.5%) with gastrojejunostomy, and 1 (1.5%) with exploration surgeries. The median survival time for these patients was 19.0 months (interquartile range, 11.0-38.0). The 1-, 3-, and 5-year survival rates were 72%, 34%, and 28%, respectively. Multivariate analysis indicated that carcinoembryonic antigen (CEA) level (P = 0.04), radical resection (P = 0.04), and positive Cluster of Differentiation 56 (CD56) expression (P = 0.016) were significant prognostic factors on overall survival rate. Further univariate and multivariate analysis of 57 patients who received radical resections found that CgA expression (P = 0.35) and CEA level (P = 0.33) are independent prognostic factors.Gastrin-independent GNETs had poor prognosis. Serum CEA level, radical surgery, CD56 and CgA expression are markers to evaluate the survival of patients with locoregional gastrin-independent GNETs.

Minimal Coexpression of CD34+/CD56+ in Acute Promyelocytic Leukemia Is Associated With Relapse

OBJECTIVES

Surface CD56 expression on leukemic cells in acute promyelocytic leukemia (APML) is considered an indicator of poorer outcome even in patients receiving conventional treatment.

METHODS

In the present case, at initial diagnosis, the hallmark phenotype of APML was found (strong CD33 and cytoplasmic MPO expression, absence of HLA-DR expression).

RESULTS

Both CD34 and CD56 antigen expression was considered negative. The patient relapsed 3 years after reaching complete remission, and the hallmark surface antigen combination for APML was again found. In contrast, the leukemic cells now clearly coexpressed CD34 and CD56. Retrospective analysis revealed the presence of small CD34+ and CD56+ populations at initial diagnosis (<20%).

CONCLUSIONS

This case report suggests that the presence of a clone with minimal coexpression of CD34/CD56 in APML at initial diagnosis should not be neglected since it may be associated with earlier relapse.

Prognostic factors of patients with newly diagnosed acute promyelocytic leukemia treated with arsenic trioxide-based frontline therapy

Prognostic factors for patients with acute promyelocytic leukemia (APL) treated in the context of arsenic trioxide (ATO)-based frontline regimes have not been established clearly. We retrospectively analyzed the clinical features, immunophenotypes, Fms-like tyrosine kinase-3 internal tandem duplication (FLT3-ITD), and outcomes of 184 consecutive newly diagnosed APL patients treated by intravenous ATO-based therapy. The median age was 40 years (14-77 years). The early death rate was 4.9% (9/184 patients). With a median follow-up time of 36 months (9-74 months), the 3-year relapse-free survival (RFS) and overall survival (OS) were 93.3% and 92.2%, respectively. Interestingly, there was no meaningful association between 3-year RFS and initial white blood cell count, FLT3-ITD status, or type of PML-RARA isoforms. In multivariable analysis, the CD56 expression was the only independent risk factor in terms of RFS (hazard ratio, 4.70; P=0.005). These results suggested that ATO-based therapy may ameliorate the unfavorable influence of previously known high-risk features; moreover, CD56 expression remains to be a potentially unfavorable prognostic factor in APL patients.

Predictors of survival after operation among patients with large cell neuroendocrine carcinoma of the lung

BACKGROUND

Large cell neuroendocrine carcinoma (LCNEC) represents a rare entity in non-small cell lung cancer, with only partially understood biology and poor survival. A diagnosis is difficult to obtain on the basis of small biopsy specimens, but surgical procedures may be indicated in only a small fraction of patients. The aim of this study was to assess the clinical and immunohistochemical features of patients with LCNEC to identify predictors of outcome and long-term survival.

METHODS

The clinical and pathologic data of 57 surgical patients with LCNEC between March 2003 and December 2012 were retrospectively reviewed. The tumor specimens were examined for expression of neuronal specific enolase, synaptophysin, CD 56, chromogranin-A, and the somatostatin receptor by immunohistochemistry. Statistical analysis was performed to determine significant predictors for overall survival and recurrence-free survival.

RESULTS

Fifty-seven patients (41 men, 16 women) underwent thoracic operations with curative intent. Complete resection was achieved in 91% of cases. The results of staining for CD56, synaptophysin, neuronal specific enolase, chromogranin-A, and somatostatin were positive in 86%, 81%, 68%, 61%, and 21%, respectively. Recurrence occurred in 28 patients (49%). Overall survival and recurrence-free survival were 50% and 45%, respectively, after 3 years. Advanced nodal status (N1, p < 0.025; N2, p < 0.02) and simultaneous expression of CD56 and chromogranin-A (p < 0.04) were significantly associated with poorer outcome.

CONCLUSIONS

LCNEC is a rare neuroendocrine pulmonary malignancy that is associated with poor prognosis and high recurrence rates. Surgical treatment can achieve satisfactory results in selected cases. Neuroendocrine marker profiles may predict prognosis and may influence the decision for adjuvant therapy or follow-up intervals.

"Tear drops" in the cerebrospinal fluid: Correct by scatter, but pathognomonic by site

Extramedullary relapse in acute promyelocytic leukemia (APL) is rare, but occurs most commonly in central nervous system (CNS), generally in high-risk cases (total leucocyte count≥10,000/µL, atypical morphology or disseminated intravascular coagulation at presentation), and concomitant with bone marrow (BM) relapse. Here, we describe a case of APL who except for CD56 positivity was low risk but had a CNS relapse without concomitant BM involvement. Diagnosis of isolated CNS relapse was based on characteristic tear-drop pattern for CD45/side scatter plot on flow cytometry, a full compatible immunophenotype and cytomorphology in the cerebrospinal fluid. The case illustrates the value of the latter and the importance of including CD56 in risk assessment of APL.