[Acute myeloid leukemia in those over 70 years of age. Experience using low-dose ara-C treatment]

PURPOSE

The treatment of elderly patients with acute myeloid leukaemia (AML) remains controversial. We present the results of the treatment of a group of patients aged above 70 years with AML diagnosed in our Hospital since 1990.

PATIENTS AND METHODS

We have studied retrospectively the cases of AML in patients older than 70 years diagnosed in our Service since January 1990 to June 1996. Induction treatment was performed, in all cases but one, with two cycles of Ara-C 10 mg/m2/12 h s.c. for 21 days and after haematological recuperation, if complete remission had been achieved, monthly maintenance treatment with Ara-C (25 mg/m2/12 h oral x 5 days), prednisone (40 mg/m2/day x 5 days) y vincristine (1 mg/m2 i.v. x 1 day) was begun.

RESULTS

During the period of study 48 patients with AML have been diagnosed in our Service, among them 22 (45.8%) were older than 70 years. One of them could not be considered for the study as not all data from him could be compiled. Among the other 21 patients 5 presented previous haematological processes (4 myelodysplastic syndrome and 1 Waldenström's macroglobulinemia). Initial diagnosis according to FAB classification for AML was as follows: 7 M1, 6 M2, 4 M4, 2 M5 and 2 M6. From these 21 patients 2 received no treatment due to rapid progression and death, among the other 19, one was directly treated with a modification of the maintenance treatment with vincristine and prednisone without response (survival 2 months). The other 18 patients were treated with low-dose Ara-C (described above), among them 3 (16.7%) were not evaluable as they did not finish the first cycle of induction treatment; 8 (44.4%) showed no response; 2 (11.1%) achieved partial remission and 5 (27.8%) complete remission. One patient did not show any response after two cycles of low-dose Ara-C but she obtained complete remission when treated with Ara-C and idaurubicin. Overall mean survival was 5.7 months (median 2; 95% confidence interval 1.6-9.8 months). In the group of patients treated with low-dose Ara-C mean survival was 6.6 months (median 3.5; 95% confidence interval 1.9-11.2 months).

CONCLUSION

We consider that the treatment with low-dose Ara-C is a valid option in the treatment of elderly patients (aged 70 or above) with AML because 28% complete remissions can be achieved, specially in those ones in which other more aggressive treatments are not possible.

[Comparative study of the stability of oral anticoagulant treatments (warfarin vs acenocoumarol)]

PURPOSE

To compare the stability of the effect of two oral anticoagulants, one of them (acenocoumarol) with a short half life and the other one with a long half life (warfarin) in patients in the stable phase of treatment (at least 2 months with treatment before entering the study).

PATIENTS AND METHODS

During a year period (January-December 1993) a comparative study of two groups of 53 patients each was performed: group 1 patients were treated with warfarin and group 2 with acenocoumarol. Both groups were paired with respect to age, sex, diagnosis for anticoagulant therapy and desired therapeutic range (INR 3-4.5). The mean value of controls per patient, the dosage changes, the evolutive controls and the incidence of haemorrhagic and thromboembolic episodes were studied.

RESULTS

The controls performed in group 1 were 728 in total with a mean value of 13.74 per patient and 800 in group 2 with a mean value of 15.09 per patient. A change in the dosage was performed in 214 controls in patients of group 1 and in 269 of group 2. Seventeen patients had 38 haemorrhagic episodes (2 major and 36 minor) in group 1, and 6 of group 2 had 20 episodes (2 major and 18 minor). Significant differences were observed in the mean value of controls (p = 0.04), the evolutive controls (p < 0.001), the global incidence of haemorrhages (p = 0.008) and incidence of minor ones (p = 0.006). No significant differences in dosage were observed. In both groups no thromboembolic episodes during the period of study were reported.

CONCLUSIONS

Anticoagulant treatment with warfarin is more stable than with acenocoumarol. The total controls and the mean value of controls per patient are decreased. Nevertheless with warfarin we have observed a greater incidence of haemorrhagic episodes.

[Human recombinant erythropoietin in the treatment of myelodysplastic syndromes anemia. Meta-analytic study]

PURPOSE

To study the usefulness of different published epidemiological and analytic parameters to decide the treatment with human recombinant erythropoietin (rHuEPO) of anaemic patients with myelodysplastic syndromes (MDS).

PATIENTS AND METHODS

We have revised 10 published series compiling 115 patients, studying age, sex, initial diagnosis, route of administration and posology, criteria of response, duration of the study, dosis with the response was obtained, response according to initial diagnosis, duration of responses, and effect of the treatment on other hematopoietic series. We have made a comparison between responders and non-responders based on epidemiological and analytical parameters.

RESULTS

We have compiled 115 patients with a rate of global response of 23.5%. We have not found significative differences between the route (s.c. or i.v.) or frequency of administration, however the number of responses was higher when rHuEPO was administered three times weekly. A great variability in the criteria of response was observed among the different studies. Most of studies have a duration of three months but we have observed significative differences in the number of responses when the study is longer. We have not found significative differences between responders and non-responders with respect to age, sex, used dosis, transfusional dependency and degree of transfusional dependency, basal serum erythropoietin, time since diagnosis, transfusional period, haemoglobin level among non-transfusion dependent patients and haemoglobin level among transfusion dependent patients. We have found significative differences with respect to initial diagnosis, a higher rate of responses was observed in the refractory anaemia with excess of blasts (RAEB) group. We have not found a higher rate of transformations into acute myeloid leukaemia (AML) among these patients. The effects of the treatment on other haematopoietic series can be considered as anecdotical.

CONCLUSION

The different epidemiological and analytic parameters published up to now are not useful in the decision of including an anaemic patient with MDS in the treatment with rHuEPO. Those patients with RAEB can be benefited with the treatment with rHuEPO. The concomitant use of other cytokines could improve these results.

[Treatment with oral anticoagulants (acenocoumarol): influence of the initial doses in the incidence of hemorrhagic and thromboembolic episodes]

PURPOSE

To compare two initial doses of oral anticoagulant (acenocoumarin) studying the haemorrhagic and thromboembolic episodes occurred during the first month of treatment, the mean time and necessary controls until achievement of the desired level of anticoagulation.

PATIENTS AND METHODS

From january 1992 to december 1993; a comparative study of two groups of patients was performed: group 1, compiling 129 patients chosen at random and retrospectively, who begun oral anticoagulant treatment with 4 daily mg of acenocoumarin; and group 2, compiling 129 patients chosen prospectively, who begun with 2 mg daily. In both groups the mean time and the number of controls performed until achieving the desired level of anticoagulation were analyzed, as well as the haemorrhagic episodes occurred during the first month of treatment, their severity (classified into major and minor ones), the level of anticoagulation when they occurred and their possible causes. In the same way the thromboembolic processes occurred during that period in both groups were studied.

RESULTS

The mean time necessary to achieve the desired level of anticoagulation was 3.8 days in group 1 and 6.3 in group 2; the mean number of controls performed in group 1 was 1.2 and in group 2 it was 1.8. We have observed 19 haemorrhagic episodes, 15 in group 1 (4 minor and 11 major); and 4 in group 2 (2 minor and 2 major). We have found significant differences with respect to the mean time (p < 0.01), number of controls (p < 0.01) and incidence of hemorrhages (p = 0.017) between groups 1 and 2. One thromboembolic episode was registered in each group: in group 1 a deep venous thrombosis and in group 2 a stroke.

CONCLUSION

The initial daily doses of acenocoumarin of 2 mg is as effective as the 4 mg one in the prevention of thromboembolic episodes, with a significant reduction in the number of haemorrhages observed during the first month of treatment. However this produces a prolongation in the necessary mean time and more number of controls performed until the achievement of the desired level of anticoagulation.

[Lymphoma of the ocular adnexa]

Ocular adnexa are rarely involved in lymphomas. Four cases are reported of lymphoma involving the ocular adnexa. In two cases a previous systemic involvement existed or simultaneous to the ocular involvement; another patient had systemically a different histological pattern to that observed in the ocular region, and the fourth patient only had ocular region, and the fourth patient only had ocular symptoms; we therefore recorded two cases of primary ocular lymphoma. The lymphoma was located at the orbit in two cases and at the conjunctiva in the other two cases; the condition was bilateral in three cases. The most common symptom was exophtalmus; other major symptoms were diplopia and disturbances in ocular motility. The histological examination revealed three low grade lymphomas and one case of intermediate grade. Management of patients included radiotherapy and different chemotherapeutic regimens with a good response in all cases. A higher ocular relapse rate was observed in those patients with systemic involvement; in one primary case the condition resolved spontaneously. A review of the literature on clinical, diagnostic and therapeutic issues is made.

[Hemorrhagic complications in patients treated with oral anticoagulants]

PURPOSE

We have studied the haemorrhagic episodes occurred in patients treated with oral anticoagulants, with special reference to their type, frequency and severity and analyzing the risk factors that could influence in their production.

PATIENTS AND METHODS

We carried out a retrospective study in 435 patients of the haemorrhagic episodes occurred since January 1989 to December 1991, determining in each one the prothrombin time expressed as INR, the time from the beginning of treatment, the patient's age and the known or underlying pathologies that could predispose to haemorrhage; depending on their severity these episodes were classified as moderate and major.

RESULTS

We observed 50 haemorrhagic episodes in 50 patients (11.5%) which represents 7 x 100 patient/years, 30 (6.8% of the total patients or 4.2 x 100 patient-years) were moderate and 20 (4.5% of the total patients or 2.8 x 100 patient/years) were major. The mean age in patients with haemorrhage was 50.5 years. The incidence of hemorrhages in the first month of treatment was 60.8 x 100 patient/years; 9.4 x 100 patient/years in the period from the first month to the first year of treatment; and 3.6 x 100 patient/years in the period from the first year of treatment. The most frequent type of haemorrhage among the moderate ones was haematuria (46%) and among major ones digestive haemorrhages (26%). Depending on the coagulation level, 37 patients (66%) were within therapeutical range. Depending on patients' sex, the incidence was 23 (46%) males and 27 (54%) females. We observed at risk predisposing factors hypertension (18%), stroke (12%), hepatic disease (8%) and myocardial infarction (8%).

CONCLUSION

We have found no relationship between haemorrhagic episodes and patients' age or sex. The risk of haemorrhage is higher at the beginning of the treatment and increases with the level of anticoagulation, which makes the beginning of treatment with lower doses more desirable, increasing them progressively until the desired level is achieved. Previous hypertension, stroke, hepatic disease and myocardial infarction are factors predisposing to haemorrhage.

[Chronic neutrophilic leukemia associated with myeloma. Simultaneous presentation]

A case of chronic neutrophilic leukaemia associated with multiple myeloma is reported. The patient had a 6 months history of bruising and weight loss, and showed mature neutrophilic leukocytosis, hepatosplenomegaly, high neutrophil alkaline phosphatase score, hyperuricaemia, neutrophils with pseudotoxic granulation and scarce Döhle bodies; moreover, a monoclonal IgG lambda was detected amounting 57.3 g/L. The bone marrow was grossly hypercellular with marked myeloid hyperplasia and aggregates of immature plasma cells. After treatment during 1 year with melphalan and prednisone she is well, although persisting with neutrophilic leukocytosis, slight splenomegaly, and the monoclonal IgG decreased to 25.8 g/L.