The Extent of Surgery for Thyroid Medullary Cancer

Aims

Evaluation of the impact of the extent of primary surgery and reintervention on the outcome of patients with medullary thyroid carcinoma.

Methods

Seventy-two patients with medullary thyroid carcinoma (MTC) were surgically treated between 1967 and 1992.

Results

Fifty-five cases were sporadic, 5 patients had MEN 2A, 4 MEN 2B syndrome and 8 familial non-MEN MTC; 1 patient had stage I disease, 30 patients stage II, 36 stage III and 5 stage IV. Sixty-four had their initial treatment at our center, and 8 came for subsequent treatment. At first treatment, 8 patients were subjected to partial thyroidectomy, 10 to total thyroidectomy, 53 to total thyroidectomy with neck dissection, and 1 to only radical neck dissection; postoperative serum calcitonin (Ct) levels returned to normal in 3, 6 and 27 patients, respectively. In the patient with only radical neck dissection, Ct levels remained elevated. No patient with Ct normalization after surgery became responsive to pentagastrin in the follow-up. Thirteen patients had a reoperation due to nodal relapse. At a mean follow-up of 5.7 years (6-252 months), the 10-year survival rate was 84.5% with a significant difference between patients under and over 40 years of age (96.4 vs 57%), between stage I-II (100%) and stage III, IV (83.8%, 0% respectively). At the last follow-up, 36 (50%) patients were alive and disease free and 26 were alive with disease (15 with distant metastases). Of the 10 deaths, 7 were due to tumor recurrence, 3 to 120 months after surgery.

Conclusions

Data suggest that an earlier diagnosis rather than more extensive surgery could improve survival and reduce recurrences. However, the least treatment required is total thyroidectomy plus central neck and upper mediastinum clearance and in addition, according to the extent of nodal involvement, mono- or bilateral neck dissection. To avoid ineffective reoperation due to distant (mainly liver) micro-metastases, persistent residual microscopic disease requires a more aggressive restaging.

Thyroid Cancer in Children and Adolescents

Aims and background

It was the aim of this paper to report clinical and pathologic characteristics and outcome of treatment in terms of relapse-free and overall survival in 36 patients under 20 years of age and treated for thyroid cancer at Padua University Hospital from January 1968 to December 1988 and followed until December 1992.

Methods

The median follow-up was 112 months (range 3 to 228 months). Age at diagnosis ranged from 4 to 20 years with a mean age of 15 years and a male/female ratio of 1:2.9. A thyroid nodule or a laterocervical mass was the most frequent sign of presentation. The routine diagnosis schedule included thyroid scintigram, neck echotomography and in the last decade fine needle aspiration biopsy.

Results

Sixteen (28%) patients had a family history of thyroid disease. Histology revealed that papillary carcinoma was present in 43 patients (76.8%), follicular carcinoma in 9 (16%), medullary carcinoma in 2 (3.6%) and lymphoma in 2 (3.6%). Fifty-four patients were treated with total thyroidectomy, of these 34 had bilateral neck dissection and 20 unilateral nodal dissection; 2 patients underwent simple lobectomy with unilateral dissection. Nodal involvement was present in 41 (73%) cases, and synchronous visceral metastases were detected with scan and/or chest X-ray in 10 (18%) cases. In the case of differentiated thyroid carcinoma, patients with residual disease or thyroid remnants were treated with 131I metabolic therapy. All patients were put on suppressive hormone therapy. At this writing, 52 (93%) patients were in complete remission and 4 (7%) had persistent disease. Recurrences developed in 2 (3.5%) patients: one presented lung metachronus metastases and one local recurrence; no deaths have occurred.

Conclusions

From this experience, total thyroidectomy appears to be the appropriate approach for differentiated tumors in children and adolescents because the disease is often diffuse, secondary deposits may be easily detected, and the value of thyroglobulin measurement can be improved. Following this strategy, overall recurrence risk was low and 131I therapy was curative in patients with nodal and lung metastases.

Metastatic Angiosarcoma of the Spleen. A Case Report and Treatment Approach

We report a case of a 28-year-old man with angiosarcoma of the spleen and liver metastases. The aim of this paper is to underline the importance of planned splenectomy in these patients even if they have metastatic disease, and to propose an intensive chemotherapy regimen consisting of anthracyclines, ifosfamide and mesna with G-CSF support.

Hematopoietic Growth Factor support in the Elderly treated with Chemotherapy

The 60% of tumors affected patients >65years of age and the future previsions are considering an amount of 70% after 2030. Elderly Patients presents multiple comorbidity, polipharmacy, and disability. Geriatric assessment helps physicians to take the best therapeutic decisions. Clinical conditions influence efficacy and tolerability of chemotherapy. Prophylactic use of G-CSF after chemotherapy lowers the rate and length of severe neutropenia , and decreases the episodes of febrile neutropenia. Anemia is a hematologic condition associated with ageing , but is frequently associated to concomitant chronic disease. Stem cells display increasing resistance to erythropoietin in the elderly patients and this is connected with the onset of pro-inflammatory cytokines characteristic of this age . Anemia is a common adverse event in cancer patients receiving chemotherapy. Several of the symptoms associated with anemia, such as fatigue, syncope, palpitations and dyspnea, reduce patient activity and have a profound effect on the quality of life [QOL]. Considering the unfit or frail status of elderly patient the at home use of pegfilgrastim and weekly or three weekly erythropoietin administration could be preferred for this setting of patients that lack of specialized nursing care or facilities. Further studies, considering the several differences in health organizations in vary countries, could be held to state the real impact of the biosimilars in comparison to the long acting originators in the reduction of costs in this group of patients.

Pharmacokinetic Comparison of 120-Hour InfusionVersusHyperfractionated Oral Administration of Idarubicin

The aim of this study was to compare the pharmacokinetics of idarubicin (IDA) and its active metabolite idarubicinol (IDOL) after chronic oral and continuous intravenous (i.v.) IDA administration in order to establish the oral doses needed to reach the i.v. equiactive plasma drug exposure. The pharmacokinetic profile of IDA and IDOL was investigated in 23 patients receiving 12 mg/m2 IDA by 120-h i.v. infusion (2.4 mg/m2/day) combined with cyclophosphamide, etoposide and prednisone in comparison to 28 patients receiving oral IDA doses ranging from 2 to 10 mg/day for 21 days in a phase I study. We found that IDA AUC24h/dose/m2 was 4.7-fold greater during i.v. than oral administration, whereas IDOL AUC24h/dose/m2 was only about 2-fold higher after i.v. administration. The metabolic ratio between IDOL AUC24h and IDA AUC24h in plasma was about 3-fold higher after oral administration. Based on these results we were able to estimate that equiactive plasma drug exposure was reached with an approximately 2.5-fold greater oral dose/m2 of IDA than the corresponding i.v. dose.

Antiblastic treatment of haematological malignancies during pregnancy: a crucial decision

Antiblastic treatment of hematological malignancies during pregnancy poses a number of issues related to the curability of the maternal disease, the need of a prompt treatment and the potential toxicity of chemotherapy for the fetus. Here we report the results of a systematic literature search about the management of the most frequent hematological malignancies that may occur during pregnancy, focusing on specific issues related to gestational age at diagnosis, fetal toxicity and efficacy on the maternal side. The standard approach in non-pregnant women is illustrated as reference.

Knowledge and skills needs for health professions about pharmacogenomics testing field

BACKGROUND

Promise in the future, a disease could be ranked into genetic categories, allowing bespoke tailoring of medicine to maximize therapeutic effects and to reduce the potential for adverse drug response. This new feature requires for health professionals to have competencies not only for the basic skills of their discipline, but also for the understanding on why, when, and how that knowledge should be applied to improve personalized therapies for their patients. Current opinion on basic competences of health professions includes knowledge and skills on two fundamental features: (1) genetics of disease, to allow the understanding and the identification of diseases associated to genetic variations, and to facilitate the development of new genomic tests; and (2) ethical, social and economical implications that are fundamental to identify those factors that might contribute to a successful integration of pharmacogenomics into international health and public policy.

AIM

Briefly, we described (1) current knowledge on genetic variations that interact with therapies and the need to detect them; (2) the most common available methods for detecting mutations; and (3) ethical, social and economic issues related to pharmacogenetic testing and recording of genetic information (e.g., critical evaluation of the development of new tests, privacy, the current absence of public reimbursement, etc).

CONCLUSIONS

These could be useful recommendations for academic institutions and educational programs to prepare health professionals with the necessary abilities for their future practice.

Preclinical ex vivo expansion of peripheral blood CD34+ selected cells from cancer patients mobilized with combination chemotherapy and granulocyte colony-stimulating factor

BACKGROUND AND OBJECTIVES

Ex vivo peripheral blood progenitor cell (PBPC) expansion has been proposed as a strategy to increase the number of haematopoietic progenitors available for cell transplantation. We have expanded CD34+ cells from PBPCs obtained from four patients with haematological malignancies and one patient with an Ewing's sarcoma.

MATERIALS AND METHODS

Cells were expanded in the Dideco 'Pluricell system'. After 12 days in culture, we evaluated cell phenotype, total nucleated cells, CD34+ fold increase, cell apoptosis and colony assay of expanded cells. Cell engraftment has been evaluated by transplanting two groups of irradiated non-obese diabetic/severe combined immunodeficient (NOD-SCID) mice with expanded and non-expanded cell populations.

RESULTS

Total nucleated cells and CD34+ cells increased 59.5 and 4.0 times, respectively. The expanded cells were mainly constituted of myeloid and megakaryocytic cells. A significant increase in the number of colony-forming unit-granulocyte macrophage (CFU-GM) was observed in the CFU assay. Ten mice transplanted with expanded cells showed a best overall survival (80%) compared to 10 mice transplanted with non-expanded cells (20%). Human CD45+ cells were detected by flow cytometry and polymerase chain reaction in bone marrow and spleen of transplanted animals. The relative low engraftment level obtained with the expanded cells suggests a loss of SCID repopulating cells maybe due to cell differentiation during expansion.

CONCLUSIONS

We have demonstrated the feasibility of the ex vivo expansion of mobilized PBPCs from cancer patients, evidencing a clonal expansion of CFUs and the ability of the expanded cells to engraft the bone marrow and spleen of immunosuppressed mice. The differentiation of the CD34+ stem cell compartment could be further minimized by ameliorating the expansion conditions.

Factors influencing tymic function in 55 patients with lymphomas: Candidates to autologous stem cell transplantation (ASCT)

18512

Background: Signal joint T cell receptor excision circles (sjTRECs) have been reported to be a clinical marker to evaluate the tymic reservoir after immunosuppression treatments. Methods: We studied the sjTRECs levels in a mono-institutional series of a cohort of 26 HIV-positive and 29 HIV-negative pts with relapsed or refractory lymphomas, candidates to ASCT, considering important biological and clinical characteristics, virological parameters and immunological settings including age, type of lymphoma, number of first line CT cycles, time from the end of first line chemotherapy to the enrolment (TECT), HIV infection and T subpopulations. Results: The overall study subjects, showed lower sjTRECs levels than healthy donors (p<0.01), but no differences in the sjTRECs content were seen between HIV-negative and HIV-positive pts (536 vs. 401 TRECs/106 PBMCs, respectively) as well as in the T cell naive count. We found a significant correlation between the sjTRECs decay and the increase of age (r=-0.32, p=0.02), CD4 and CD8 naive cell count and the sjTRECs level; on the contrary we did not observe any significant correlation between CT cycles number TECT, lymphoma type in both subgroups. HIV-positive viremic pts showed significant lower level of sjTRECs level than averimic pts. Conclusions: Our analyses suggest that de novo T cell generation is partially maintained in lymphoma pts’ candidates to ASCT and could contribute to restore the immune function after transplantation. Chemotherapeutic treatments seem to induce a similar influence on thymic output despite their intensity and, surprisingly, HIV infection is not a detrimental factor on thymic reservoir at the time of lymphoma relapse, and a good control of HIV replication seems to preserve thymic reservoir.

No significant financial relationships to disclose.

R-Dhaox, high dose chemotherapy (HDC) and rituximab maintenance as salvage treatment in relapsed/refractory (R/R) follicular (F) and mantle cells (MC) lymphomas (NHL)

8036

Second line regimens in NHL are mainly based on cisplatin (DDP). The substitution of DDP with oxaliplatin in DHAP- like regimens may result in lower toxicity and higher activity. In R/R CD20+ follicular (F) and mantle cell (MC) NHL the sinergistic activity of rituximab with chemotherapy and the maintenance immunotherapy obtain and prolong clinical and molecular remission. We assessed the tolerability and the activity in terms of clinical and molecular remission of R-Dhaox (rituximab 375 mg/m2 i.v., day 1, dexametazone 40 mg i.v. days 1–4, Oxaliplatin 130 mg/m2, day 2 and cytarabine 2,000 mg/m2 i.v. twice a day day 3) regimen for 4 courses in phase II study. The pts in response underwent to HDC with the scheme BEAM-R and further were treated with maintenance therapy with rituximab 375 mg/m2 i.v. 75+ from ABMT. After three monthly doses, pts were treated with further five every 4 months (for a total of two years). From June 2002 to September 2006, 31 pts were enrolled. 19 were male and 12 female. Median age was 51 (30–66). 21 (68%) pts were follicular G1-G2, 9 (29%) mantle cells and 1 a transformed follicular. The stage was III for 8 (26%) and IV for 23 (74%) pts. 22 (70%) pts were previous treated with rituximab and 30 (96%) with adryamicin based schedules. CD34+ harvest was after 4th cycle with a median collection of 5,5 ×106/Kg (2,1–20); 2 were positive for BCL-2 and 1 for BCL-1. Overall clinical response before ABMT was 94% for F and 100% for MC. 26 pts underwent ABMT with the schedule BEAM-R. At relapse 54% (12/22) of F were BCL-2 positive and 66% (6/9) of MC for BCL-1. Before ABMT 4/17 pts were BCL-2 positive and 1/9 for BCL-1. Among F, 3 pts relapsed after ABMT: 2 with reexpression of BCL-2 and 1 without. No relapse among MC, all negative for BCL-1 after ABMT. No pt showed severe or fatal infections during maintenance immunotherapy. Three- year projected free survival was 100% for MC and 68% for F NHL. These preliminary data suggested that R-DHAOX, HDC and rituximab maintenance is a novel approach highly effective for R/R F and MC NHL.

No significant financial relationships to disclose.

Metastatic angiosarcoma of the kidney: a case report with treatment approach and review of the literature

Angiosarcomas are rare soft tissue malignancies. Typically they originate from the skin of the scalp or face, whereas visceral sarcomas are very rare. We report the case of a 67-year-old man affected by a large angiosarcoma of the kidney. After surgical removal, a rapid peritoneal, visceral and cutaneous diffusion developed. Palliative chemotherapy, based on anthracycline and ifosfamide, which are normally used to treat all other high-grade spindle cell sarcomas, was totally inactive. On the basis of these results and of the biological characteristics of these rare neoplasms it is mandatory to develop other therapeutic approaches. Antiangiogenetic agents are of interest for this disease due to the peculiar origin of the cells of these sarcomas.

R-DHAOX as salvage treatment in CD20+ relapsed/refractory (R/R) non-Hodgkin lymphomas (NHL). An institutional experience

17508

Background: Second line chemotherapeutic regimens in NHL are mainly based on cisplatin (DDP) and are frequently employed as cytoreductive regimens for preparation to high dose chemotherapy (HDC). The substitution of DDP with oxaliplatin in DHAP-like regimens can result in a lower toxicity and higher activity. In R/R CD20+ NHL the synergistic activity of Rituximab with chemotherapy has been shown to improve the outcome. We assessed the tolerability and efficacy of R-DHAOX (Rituximab 375 mg/m2, i.v. day 1, Dexametasone 40 mg i.v. days 1–4, Oxaliplatin 130 mg/m2 i.v. day 2 and Cytarabine 2000 mg/m2 i.v. twice a day, day 3) regimen in a fase II study including 35 pts (M/F = 22/13; median age 55 yrs, range 38–74) affected by R/R CD20+ NHL and enrolled from November 2002 until September 2005. 34 (97%) pts were staged III-IV. 31 pts (89%) were relapsed and 4 (11%) refractory. International Prognostics Index at relapse (s-IPI) was >2 for 10 (71%) DLBCL, 2 (14%) FL and 2 (29%) MCL. A total of 147 cycles were administered (range 1–7). Dose reduction due to Oxaliplatin neuropathy or Cytarabine haematological toxicity occurred in 13% and in 58% of pts, respectively. NCI G3-G4 toxicities were thrombocytopenia (58%), neutropenia (55%), anaemia (13%), infection (10%) and neurotoxicity (3%). No renal failure was observed. Results spitted according to histology were summarised in the table . R-DHAOX had significant clinical activity both in FL and MCL patients (overall response rates (OR) of 93% and 86%, respectively), as well as in DLBCL (OR of 79%) despite the very high S-IPI score observed. R-DHAOX allowed adequate stem cell harvest with G-CSF mobilisation in 25/35 (71%) pts. Three-yrs projected overall survival, according to the histology, were 71% for FL, 67% for MCL and 28% for DLBCL. These data suggested that the R-DHAOX is a novel combination highly effective for R/R CD20+ NHL.

[Table: see text]

No significant financial relationships to disclose.

Sequence analysis of the immunoglobulin antigen receptor of hepatitis C virus-associated non-Hodgkin lymphomas suggests that the malignant cells are derived from the rheumatoid factor-producing cells that occur mainly in type II cryoglobulinemia

Analysis of the immunoglobulin receptor (IGR) variable heavy- and light-chain sequences on 17 hepatitis C virus (HCV)-associated non-Hodgkin lymphomas (NHLs) (9 patients also had type II mixed cryoglobulinemia [MC] syndrome and 8 had NHL unrelated to MC) and analysis of intraclonal diversity on 8 of them suggest that such malignant lymphoproliferations derive from an antigen-driven pathologic process, with a selective pressure for the maintenance of a functional IgR and a negative pressure for additional amino acid mutations in the framework regions (FRs). For almost all NHLs, both heavy- and light-chain complementarity-determining regions (CDR3) showed the highest similarity to antibodies with rheumatoid factor (RF) activity that have been found in the MC syndrome, thus suggesting that a common antigenic stimulus is involved in MC syndrome and in HCV-associated lymphomagenesis. Moreover, because HCV is the recognized pathologic agent of MC and the CDR3 amino acid sequences of some HCV-associated NHLs also present a high homology for antibody specific for the E2 protein of HCV, it may be reasonable to speculate that HCV E2 protein is one of the chronic antigenic stimuli involved in the lymphomagenetic process. Finally, the use of specific segments, in particular the D segment, in assembling the IgH chain of IgR seems to confer B-cell disorders with the property to produce antibody with RF activity, which may contribute to the manifestation of an overt MC syndrome.

In vitro and in vivo effects of 2'-deoxycoformycin (Pentostatin) on tumour cells from human gammadelta+ T-cell malignancies

Hepatosplenic gammadelta+ T-cell lymphoma represents a rare neoplasm of post-thymic phenotype, characterized by an aggressive clinical course and a poor response to conventional chemotherapy. In the present study, we have examined the cytotoxic effects of the purine analogue 2'-deoxycoformycin (dCF) on cultured mononuclear cells and purified gammadelta+ tumour cells from bone marrow or peripheral blood of four patients with hepatosplenic gammadelta+ T-cell lymphoma. At a concentration of 10 microM, dCF, in the presence of 2'-deoxyadenosine (dAdo), displayed an early and selective cytotoxic effect on gammadelta+ tumour T cells. After 48 h of in vitro exposure to dCF, the absolute number of viable CD3+/gammadelta+ tumour T cells was reduced by more than 90% in all samples with respect to control cultures, with absolute counts of viable CD3+/alphabeta+ lymphocytes being reduced only by 6-40% of the initial cell input. Analysis of cultures after 5 d of exposure to dCF plus dAdo revealed the persistence of normal CD3+/alphabeta+ T cells, which accounted, however, for only 20-25% of the initial cell input. Accordingly, the combination of dCF (10-100 microM) plus dAdo was able to induce a dose-dependent inhibition of clonogenic growth and [3H]-thymidine incorporation in purified CD3+/CD4-/CD8- gammadelta+ tumour cells. We also report that one patient with hepatosplenic gammadelta+ T-cell lymphoma in terminal leukaemic phase showed a striking haematological response to single-agent dCF given as fourth-line treatment. In particular, the selective clearance of gammadelta+ tumour T cells in peripheral blood and bone marrow was observed starting after the second course of treatment. Our results suggest that dCF may represent a potentially active drug for the management of this aggressive form of T-cell lymphoma.

Rituximab (IDEC-C2B8): validation of a sensitive enzyme-linked immunoassay applied to a clinical pharmacokinetic study

Rituximab is a chimeric monoclonal antibody (MAb) directed against the B-cell CD20 antigen that has been approved for therapy of relapsed and resistant follicular non-Hodgkin's lymphoma (NHL). This study describes the development and validation of a highly sensitive, rapid, accurate, precise enzyme-linked immunosorbent assay (ELISA) to measure Rituximab serum concentrations. This study also describes the application of the ELISA method to a pharmacokinetic study in a homogeneous group of patients with follicular lymphoma who received 4 weekly doses of MAb at the standard dose of 375 mg/m2 as consolidation of chemotherapy. In the patients in this study, the median Rituximab serum concentrations increased during therapy, and showed a slow decline during the posttreatment period. The Rituximab elimination half-life of approximately 20 days accounts for the demonstrated accumulation of MAb in serum samples. Because previous pharmacokinetic studies showed a correlation between Rituximab serum levels and tumor response, the ELISA method used in this study, which allows a precise control of serum concentrations, could be useful for predicting the final response to the MAb and for selecting patients able to benefit from higher dosage or repeated drug administration.

Gastric non-Hodgkin's lymphoma: analysis of 252 patients from a multicenter study

AIMS AND BACKGROUND

The stomach is the most common site of primary extranodal non-Hodgkin's lymphoma (NHL) and no agreement has been reached so far on the best therapeutic approach. The main objects of this study were to report the long-term results and to evaluate the importance of some possible prognostic factors in a large series of patients. NHL was considered primary gastric if the main symptoms at presentation were those of gastric disease.

METHODS AND STUDY DESIGN

We analyzed 252 consecutive patients treated between 1980 and 1993 in five hospitals in north-east Italy. According to the Working Formulation, 98 patients had low grade lymphoma, 59 intermediate grade (D to F), 81 G or high grade and 14 were not classified. The patients were divided into two groups: one including patients with limited disease (localized to the stomach or perigastric lymph nodes: 165 patients) and one including those with advanced disease (87 patients). The treatment consisted of surgery, chemotherapy, radiotherapy or combinations of these. Sixteen patients received only supportive therapy.

RESULTS

The five-year overall survival was 65.4%: 80.3% for patients with limited disease and 36.7% for those with advanced disease (P < 0.0001). Among the limited disease patients the five-year survival was 84.4% for those treated with gastrectomy alone and 88.7% for those who received also adjuvant chemotherapy (P = 0.11). However, while chemotherapy did not improve survival in low grade NHL, it seemed to produce a better survival in the intermediate and high grade groups (P = 0.06). Twelve patients were treated with primary chemotherapy and the five-year survival was 71.2%. In multivariate regression analysis the most important variable for overall survival was surgery for the whole group of 252 patients (P < 0.0001), while it was age for the group with limited disease (P = 0.0008).

CONCLUSIONS

Surgery alone can be curative for most patients with gastric lymphoma limited to the stomach or to the perigastric lymph nodes; surgery followed by chemotherapy seems to produce better results than surgery alone in intermediate and high grade lymphomas. Also a non-surgical approach with first-line chemotherapy is associated with a high rate of complete remissions and five-year survival. In advanced disease the five-year survival is similar to that of nodal NHL.

Differential expression of the RET gene in human acute myeloid leukemia

The RET proto-oncogene product is a receptor tyrosine kinase representing the signal-transducing molecule of a multi-subunit membrane receptor complex for at least two different types of transforming growth factor (TGF)-beta-related neurotrophic factors. We have previously shown that RET gene expression in acute myeloid leukemia (AML) occurs more frequently in AMLs displaying either a monocytic (FAB M4/M5) or intermediate-mature myeloid phenotype (FAB M2/M3) than in leukemias reflecting an earlier stage of myeloid differentiation (FAB M0/M1). To further verify the association between RET expression and the relative maturation stage of AML cells, we have performed a quantitative estimation of relative abundances of RET transcripts among various FAB subtypes of AMLs. By analyzing 13 AML samples and normal hematopoietic cells through a competitive-quantitative RT-PCR approach, we were able to show that the relative levels of RET-specific mRNAs continuously increase with blast cell maturation in human AML, i.e., the amounts of RET gene-specific transcripts differ among RET-expressing AMLs, being higher in the more differentiated FAB phenotypes. In addition, we provide evidence that the relative amounts of RET transcripts increase upon in vitro and in vivo differentiation of leukemic promyelocytes from FAB M3 AML patients, becoming overall comparable to those found in normal granulocytes. These results indicate that RET expression in human AMLs is maturation-associated, probably mirroring the developmental regulation of this gene during differentiation of normal hematopoietic cells.

Hepatitis C virus, non-Hodgkin's lymphomas and hepatocellular carcinoma

In a case-control study in northeastern Italy hepatitis C virus infection seemed to increase by about 50-fold the risk of non-Hodgkin's lymphoma involving the liver and major salivary glands (i.e. larger than that for hepatocellular carcinoma) and by about fourfold the risk of lymphomas at other sites.

Hodgkin's disease: a disorder of dysregulated cellular cross-talk

Hodgkin's disease (HD) is a peculiar type of human malignant lymphoma characterized by a very low frequency of tumor cells, the so called Hodgkin and Reed-Sternberg (H-RS) cells, embedded in a hyperplastic background of non-neoplastic (reactive) cells recruited and activated by H-RS cells-derived cytokines. H-RS cells can be functionally regarded as antigen-presenting cells (APC) able to elicit an intense, but anergic and ineffective, T-cell mediated immune response along with a hyperplastic inflammatory reaction which involves several cell types including T- and B-cells, neutrophils, eosinophils, plasma cells, fibroblasts and stromal cells. In tissues involved by HD, malignant H-RS cells and their reactive neighboring cells are able to cross-talk via a complex network of cytokine- and cell contact-dependent interactions. As a result of such interactions, mediated by specific surface receptors and adhesion molecules on both tumor and non-neoplastic cells, H-RS cells may receive several proliferative and anti-apoptotic signals favoring the cellular expansion and tumor cell survival in HD. The ineffective T-cell immune response elicited by the abnormal APC function of H-RS cells may further contribute to the biologic and clinical progression of HD. Innovative therapeutic strategies aimed at blocking the pathways of dysregulated cellular cross-talk among H-RS cells and bystander reactive cell populations might be beneficial in the treatment of HD patients.

Human granulocyte-macrophage colony-stimulating factor supports the clonogenic growth of B-lineage acute lymphoblastic leukemias expressing myeloid antigens

The effects of granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-3 and IL-6 on clonogenic growth of blast-cell progenitors from 19 immunologically defined CD10-positive B-lineage acute lymphoblastic leukemias (ALL) coexpressing (My+ALLs) or not (My-ALLs) myeloid antigens have been studied. Our results demonstrate that GM-CSF was able to support the clonogenic growth of blast cells from My+ALLs, being totally ineffective on My-All samples. Accordingly, both alpha and beta chains of GM-CSF receptor (R) were expressed by My+ALL blasts, as investigated by reverse-transcriptase polymerase chain reaction (RT-PCR). Colony cells from GM-CSF-stimulated My+ALL cultures displayed the same immunophenotype as primary leukemic cells at diagnosis (CD10+, CD19+, CD22+), and retained the expression of myeloid-associated antigens and of GM-CSF-R transcripts. Moreover, My+ALL blasts showed a preferential sensitivity to the growth-promoting activity of IL-3 and IL-6, as compared with My-ALL cells. In addition to rearrangements of the JH region of immunoglobulin genes, My+ALL cells showed aberrant rearrangements of gamma (three cases) and beta (two cases) T-cell receptor genes, as well as of bcr sequences (three cases). Our data, showing an unexpected cross-lineage response of My+ALLs to GM-CSF, and their preferential stimulation by IL-3 and IL-6, as compared with My-ALLs, further support the concept that My+ALLs represent a separate entity with unique biological features.

Treatment of multiple myeloma and acute myelogenous leukemia in the elderly: an update

The optimal management of hematopoietic malignancies in the elderly requires the development of specific therapeutic strategies based on the peculiar clinico-biologic features of aged patients. Multiple myeloma arising in elderly patients remains at this time an incurable disease, while attention to supportive therapy and palliation can make a great impact on the quality of life. Fortunately advances have been made in last years in this field. Therapy at the time of diagnosis is usually recommended for patients with symptomatic disease, or for those who may be asymptomatic, but have evidence of high tumor burden of a biologically aggressive disease, and may be expected to progress and develop complications over a short period of time. Melphalan combined with prednisone remains the standard therapy choice in elderly patients. Radiotherapy maintains an important place in the palliation of destructive bone disease in poorly controlled myeloma, particularly in elderly patients. In Acute Myelogenous Leukemia, age has been concordantly reported as an adverse prognostic indicator in affecting both remission rates and survival. The overall unsatisfactory therapeutic results appear connected with host-related factors, and intrinsic differences in the biology of leukemia. Patients with standard risk should be included in collaborative trials aimed at improving the long-term results of conventional therapy. Patients with high risk and unfavorable prognostic factors, could be enrolled in controlled studies aimed at better assessing, in the elderly, the long term results of newer drug combinations. A watch and wait strategy, consisting of transfusion support and leukocytosis control, should be limited to patients with extremely poor performance status (PS), very limited life-expectancy and/or severe comorbidity displaying unfavorable biologic factors, including secondary Acute Myelogenous Leukemia.