Expectations and outcomes of varying treatment strategies for CML presenting during pregnancy

Diagnosing chronic myeloid leukaemia (CML) during pregnancy is rare. Tyrosine kinase inhibitors (TKIs) have traditionally been contraindicated owing to their teratogenicity. Management decisions should consider the risks to mother and foetus of uncontrolled disease and teratogenic medications. Further cases are required to build upon the paucity of current literature. We report 22 cases of CML diagnosed during pregnancy from 2002 to date. Twenty-one pregnancies resulted in healthy babies and one patient miscarried. Some patients remained untreated throughout pregnancy but the majority received one or both of interferon-α and leucapheresis. One patient was started on imatinib at Week 26, and one on hydroxycarbamide in the third trimester. We report haematological parameters during pregnancy to provide clinicians with realistic expectations of management. There were no fetal abnormalities related to treatment during pregnancy. Seventeen patients achieved at least major molecular response on first-line TKI. A diagnosis of CML during pregnancy can be managed without significant consequences for mother or child. Leucapheresis and interferon-α are generally safe throughout pregnancy. Despite having been avoided previously, there is growing evidence that certain TKIs may be used in particular circumstances during the later stages of pregnancy. Future work should aim to further elucidate this safety profile.

Bilateral subdural hygromas following administration of intrathecal methotrexate chemotherapy

We report the case of a previously well 58-year-old man who presented with headache and confusion 4 days postadministration of intrathecal methotrexate. He was undergoing intensive chemotherapy (CODOX-M/IVAC, cyclophosphamide, doxorubicin, vincristine, methotrexate, etoposide, ifosfamide, cytarabine) for the treatment of leukaemic phase CD20 negative diffuse large B-cell lymphoma. A CT of the head demonstrated the presence of bilateral subdural hygromas complicated by haemorrhage resulting from coexisting chemotherapy induced thrombocytopenia. Surgical drainage of the hygroma was undertaken but the patient died of overwhelming sepsis. In patients with high-risk lymphoma, directed central nervous system (CNS) therapy is administered either systemically or intrathecally. It is thought that subdural hygromas result from cerebrospinal fluid (CSF) accumulation in the inner dural layers of the cerebral convexities from CSF leak and reduction in CSF pressure post-lumbar puncture. We describe a rare but potentially fatal complication of intrathecal chemotherapy that haemato-oncologists need to be mindful of.

Leucoerythroblastosis and thrombocytopenia as clues to metastatic malignancy

The association of metastatic breast cancer presenting as thrombocytopenia and anaemia is demonstrated in the following case of a 79-year-old woman. Her main symptoms were abdominal pain, altered bowel habit and weight loss. Without a clear causative pathology, she underwent a CT scan which demonstrated multiple sclerotic bone lesions. With a raised CA15-3 and strong oestrogen receptor positivity on immunohistochemistry on a trephine bone marrow biopsy, a diagnosis of metastatic lobular breast cancer was made. Interestingly, only a small breast mass was noted on mammography. The patient was managed conservatively and initiated on supportive therapy. This case report summarises the varying presentation of bone marrow suppression secondary to metastatic infiltration, especially in the absence of classical symptoms associated with primary solid tumour. Accurate bone marrow analysis is also vital in establishing the final diagnosis.

Atypical blood and bone marrow lymphocytes in ALK-positive anaplastic T-cell lymphoma: important lessons

A 42-year-old man presented with a short history of fever, significant weight loss and bilateral neck swelling. A CT scan revealed widespread lymphadenopathy and hepatosplenomegaly. Lymph node morphology and immunohistochemistry confirmed a diagnosis of anaplastic lymphoma kinase (ALK)-positive anaplastic T-cell non-Hodgkin's lymphoma. Both the peripheral blood (PB) and bone marrow (BM) revealed atypical lymphocytes with cleaved nuclei, vacuolation and granulation, suggestive of disease involvement at both sites. However, BM and PB immunophenotyping and immunohistochemistry did not reveal typical markers (ALK and CD30) at either site. All features resolved with a short remission after conventional chemotherapy. Despite salvage chemotherapy and an autologous stem cell transplant, a relapse of the PB and BM features with stable radiological findings was noted. Rapid decline followed with pancytopenia resulting in death 12 months after the initial diagnosis.

Two novel aspirin analogues show selective cytotoxicity in primary chronic lymphocytic leukaemia cells that is associated with dual inhibition of Rel A and COX-2

OBJECTIVES

Non-steroidal anti-inflammatory drugs have been shown to induce apoptosis in primary B-cell chronic lymphocytic leukaemia (CLL) cells, but the molecular mechanisms that underpin this observation have not been fully elucidated. Here, we have analysed the effect two novel aspirin analogues, 2-hydroxy benzoate zinc (2HBZ) and 4-hydroxy benzoate zinc (4HBZ), on primary CLL samples.

MATERIALS AND METHODS

Cytotoxic effects of 2HBZ and 4HBZ were analysed in primary CLL cells derived from 52 patients, and normal B- and T-lymphocytes. Mechanisms of action of these agents were also elucidated.

RESULTS

Both analogues induced apoptosis in a dose-dependent and time-dependent manner. Apoptosis was associated with activation of caspase-3 that could be partially abrogated by the caspase-9 inhibitor (Z-LEHD.fmk). Importantly, both agents demonstrated preferential cytotoxicity in CLL cells when compared to normal B- and T-lymphocytes. In terms of their molecular mechanisms of action, 4HBZ and 2HBZ inhibited COX-2 transcription and protein expression and this was associated with upstream inhibition of transcription factor Rel A. Co-culture of CLL cells with CD40 ligand-expressing mouse fibroblasts significantly increased COX-2 expression and inhibited spontaneous apoptosis. Importantly, the most potent analogue, 4HBZ, overcame pro-survival effects of the co-culture system and significantly repressed COX-2. Finally, elevated COX-2 expression was associated with poor prognostic subsets and increased sensitivity to 4HBZ.

CONCLUSIONS

Our results demonstrate therapeutic potential of 4HBZ and are consistent with a mechanism involving suppression of Rel A nuclear translocation and inhibition of COX-2 transcription.

Sub-millimolar concentration of the novel phenol-based compound, 2-hydroxy benzoate zinc, induces apoptosis in human HT-1080 fibrosarcoma cells

OBJECTIVES

To examine the effect of a novel phenolic-based compound, 2-hydroxy benzoate zinc (2HBZ), and acetylsalicylic acid (ASA) on human HT-1080 fibrosarcoma cells.

MATERIALS AND METHODS

MTT assay was used to assess cell proliferation while different methods were used to detect apoptosis morphologically and immunohistochemically in Human HT-1080 fibrosarcoma cells. Apoptosis was determined by Annexine-V labelling, and caspase-3 activation. In addition, western blot was used to analyse p21, p53 and Bax and flow cytometry was to analyse the cell cycle.

RESULTS

2HBZ exhibited a more than 5-fold increase in cytotoxic potency when compared with ASA with mean LD50 values of 210 and 1100 lM respectively (P < 0.0001). The cytotoxic effects of 2HBZ were both time- and dosedependent with marked apoptosis being evident only after 24 h at concentrations as low as 200 mM. In contrast, ASA-induced apoptosis was observed only at concentrations in excess of 1000 mM at the same time point. Both 2HBZ and ASA induced caspase-3 activation in the cells, which confirmed that their cytotoxic effects were the result of apoptotic cell death. These findings were further confirmed by immunomorphological studies for the detection of apoptosis including haematoxylineosin, methyl green/pyronin Y staining and scanning electron microscopy. In addition, 2HBZ caused a marked increase in p21, p53 and Bax protein expressions and these effects were associated with an increase in G1 and G2 arrest of the cell cycle and a reduction in S-phase.

CONCLUSIONS

These results demonstrate that the novel phenolic compound 2HBZ is a potent apoptosis-inducing agent in HT-1080 cells and warrants further investigation as a potential chemotherapeutic agent in primary cancer cell models.

Calcium salicylate-mediated apoptosis in human HT-1080 fibrosarcoma cells

Salicylates are novel biologically active compounds that exhibit multiple therapeutic activities. The anti-cancer effectiveness of calcium salicylate has been investigated on human HT-1080 fibrosarcoma cell lines at relatively low concentrations (predominantly 0.4 mM) compared to those previously reported. Although low calcium salicylate concentrations did not retard tumour growth progression significantly, as measured by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and time-lapse assays, its cytotoxic characteristics were proven to be prominent by various morphological and immunocytological techniques. The results here demonstrate evidence for approximately 25% apoptosis after treatment with calcium salicylate, which up-regulatd the expression of p53, p21 and Bax, and down-regulated Bcl-2 in HT-1080 cells.

The historical analysis of aspirin discovery, its relation to the willow tree and antiproliferative and anticancer potential

For several millennia, the willow tree and salicin have been associated with salicylic acid, the key precursor molecule that has contributed to the discovery of acetylsalicylic acid, traded as aspirin. These molecules have been shown to possess phyto- and chemotherapeutic activities as analgesic drugs. In recent decades, aspirin has become the focus of extensive investigation into antiproliferative and anticancer activities. The historical steps that led to the discovery of aspirin, and its antiproliferative and anticancer potential are highlighted in this review.