Platelet-Rich Plasma (PRP) to promote corneal healing in firework-related ocular burn and total limbal stem cell deficiency (LSCD)

PURPOSE

To report the case of persistent corneal epithelial defect in total limbal stem cell deficiency (LSCD) after severe firework-related ocular burn treated with autologous Platelet-Rich Plasma (PRP).

CASE DESCRIPTION

A young patient, victim of fireworks trauma, presented with a large persistent epithelial defect affecting the central cornea of his left eye and progressing to stromal melting, in the context of grade VI ocular surface burn with 12 h limbal involvement. Impression cytology to the cornea confirmed a complete LSCD. Assessment of corneal sensitivity by Cochet Bonnet esthesiometer revealed complete corneal anesthesia. Based on progressive clinical worsening under conventional therapy, the patient was started on very pure autologous PRP eye drops obtained using the Hy-Tissue PRP® technology. Six times a day eye drops administration for 30 days was scheduled in the affected eye. At the end of treatment, the epithelial defect had disappeared being replaced by advancing conjunctiva.

CONCLUSION

Our findings provide information on management of ocular burns from fireworks, a subject of current interest and concern. Autologous PRP eye drops prepared using the Hy-Tissue PRP® system and administered in the presence of total LSCD and complete corneal anesthesia, prevented corneal stromal melting to progress and allowed the ocular surface epithelial coverage to re-establish. This paved the way for later successful restorative and reconstructive intervention. Also, first description of the Hy-tissue PRP procedure for ophthalmological use is reported.

Clinical Features of Ocular Syphilis: a Retrospective Clinical Study in an Italian Referral Centre

Purpose: To describe the clinical characteristics and visual prognosis of ocular involvement in syphilis.Design: A retrospective cohort study.Methods: We studied the charts of 24 patients who visited our Ophthalmological Centre in Rome, Italy. All patients with serological evidence of syphilitic infection were included.Results: Ocular involvement was the first manifestation of syphilitic disease in 96% and Human Immunodeficiency Virus (HIV) seropositivity was found in 29% of the cases. The most frequent ocular manifestation was posterior uveitis. Vitreous involvement was frequent. Patients with papillitis at onset showed better visual outcome with antisyphilitic treatment. Posterior uveitis at onset and HIV seropositivity were negative prognostic factors for visual outcome. HIV-positive patients showed more severe and frequent bilateral course of ocular involvement in syphilis.Conclusions: The ophthalmologist should suspect syphilis in patien ts with uveitis or optic neuropathy associated with high-risk sexual behaviour and/or HIV, or in patients with posterior placoid chorioretinitis, necrotising retinitis, or interstitial keratitis.

Retinal microvascular abnormalities in neurofibromatosis type 1

PURPOSE

The aim of this study was to provide a classification of the different retinal vascular arrangements in neurofibromatosis 1 (NF1), with appropriate qualitative and quantitative information.

METHODS

This study was conducted on 334 consecutive patients with NF1 and 106 sex-matched and age-matched healthy control subjects. Each patient underwent a comprehensive ophthalmological examination inclusive of near-infrared reflectance retinography by using the spectral domain Optical coherence tomography (OCT), a complete dermatological examination and 1.5 T MRI scan of the brain to assess the presence of optic nerve gliomas. To evaluate the predictability and the diagnostic accuracy of our identified retinal microvascular arrangements, we calculated the diagnostic indicators for each pattern of pathology, with corresponding 95% CI. In addition, we evaluated the association between the microvascular arrangements and each National Institutes of Health diagnostic criteria.

RESULTS

Microvascular abnormalities were detected in 105 of 334 NF1 patients (31.4%), the simple vascular tortuosity was recognised in 78 of 105 cases (74.3%) and whether the corkscrew pattern and the moyamoya-like type showed a frequency of 42.8% (45 of 105 cases) and 15.2% (16 of 105 cases), respectively. We found a statistically significant correlation between the presence of retinal microvascular abnormalities and the patient age (p=0.02) and between the simple vascular tortuosity, the patient age and the presence of neurofibromas (p=0.002 and p=0.05, respectively).

CONCLUSIONS

We identified microvascular alterations in 31.4% of patients and a statistically significant association with patient age. Moreover, the most frequent type of microvascular alterations, the simple vascular tortuosity, resulted positively associated with age and with the presence of neurofibromas.

Intravitreal Injection of Ozurdex(®) Implant in Patients with Persistent Diabetic Macular Edema, with Six-Month Follow-Up

AIM

To evaluate the efficacy of intravitreal dexamethasone injections in diabetic macular edema (DME).

METHODS

A 700 μg slow-release intravitreal dexamethasone implant (Ozurdex®) was placed in the vitreal cavity of 17 patients (19 eyes) affected with persistent DME. Best corrected visual acuity (BCVA) was assessed through Early Treatment Diabetic Retinopathy Study (ETDRS). Central macular thickness (CMT) was measured by spectral-domain optical coherence tomography. BCVA and CMT examinations were carried out at baseline (T0) and repeated after three days, one month (T1), three months (T3), four months (T4), and six months (T6) post injection.

RESULTS

Dexamethasone implant induced an improvement in ETDRS at T1, T3, T4, and T6 post injection. CMT was reduced at T1, T3, and T4, while at T6, CMT values were not statistically different from baseline. No complications were observed during the follow-up.

CONCLUSION

Our data suggest that dexamethasone implant is effective in reducing DME symptoms within a six-month frame.

Abnormal F-18 Fluorodeoxyglucose Uptake of the Lung in Immunocompromised Lymphoma Patients in Complete Remission: Report of Two Cases and Revision of Literature

Limited data suggest that F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) may have a role in diagnosing infection. Here we present two cases of lymphoma patients in complete response (CR) who presented during follow-up dry cough and fever. Physical examination and serum evaluations were negative for lymphoma while whole body FDG-PET showed lung uptake which posed a differential diagnosis between relapse of lymphoma and an atypical pneumonia due to persistent lymphopenia. In both cases, cytology examination of sputum suggested Pneumocystis Jiroveci pneumonia (PJP). After appropriate antibiotic treatment, the follow-up examination showed complete resolution of the lung changes revealed by FDG-PET. False-positive results on FDG-PET were supposed to be due to the high uptake of FDG in non-neoplastic inflammatory cellular elements such as macrophages and lymphocytes. Our findings suggest that in cases of FDG-PET positive images in immunocompromised patients with previous hematologic disease, caution must be used, and differential diagnosis might include infections such as PJP in addition to relapse of disease.

Combined intravitreal ranibizumab and verteporfin photodynamic therapy versus ranibizumab alone for the treatment of age-related macular degeneration

PURPOSE

To compare same-day combined therapy of photodynamic therapy with verteporfin (PDT-V) and intravitreal ranibizumab versus monotherapy with ranibizumab for the treatment of choroidal neovascularization.

METHODS

IN THIS PROSPECTIVE STUDY, THE TOTAL NUMBER OF EYES WAS RANDOMIZED INTO TWO GROUPS: in the first, treatment consisted of a combined therapy of PDT-V and ranibizumab 0.5 mg on the same day; in the second, ranibizumab 0.5 mg in 3 monthly injections. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) on optical coherence tomography (OCT) were recorded before and 6 months after treatment.

RESULTS

A total of 47 eyes of 47 subjects were enrolled in the study. In the combined-therapy group (group 1), the mean baseline BCVA ± standard deviation (SD) was 32.65 ± 11.09 letters (Snellen equivalent, 20/59); in the ranibizumab-alone group (group 2), 29.13 ± 9.03 letters (20/70). At 6 months' follow-up, in group 1 the mean baseline BCVA was 39.06 ± 10.12 letters (20/42); in group 2, 33.87 ± 12.06 letters (20/57). Improvement was significant in both group 1 (P = 0.03) and group 2 (P = 0.002). In group 1, the mean CMT at baseline ± SD was 315 ± 95.49 μm; in group 2, 306.33 ± 71.61 μm. At 6 months' follow-up, in group 1 it was 202 ± 52.02 μm; in group 2, 226 ± 65.58 μm. Reduction was significant in both group 1 (P = 0.0007) and group 2 (P = 0.00001). After 6-months, the rate of retreated eyes was 29.4% in group 1 and 43.3% in group 2. The need for retreatment did not depend on the treatment protocol (P = 0.34).

CONCLUSIONS

From a functional and anatomic point of view, the two treatments showed equivalent efficacy, with fewer retreatments in group 1. No serious adverse events, such as retinal detachment, endophthalmitis, or ocular hypertension occurred in either group.

Choroidal neovascularization in pathologic myopia: intravitreal ranibizumab versus bevacizumab--a randomized controlled trial

PURPOSE

To compare the short-term efficacy and safety of intravitreal ranibizumab versus bevacizumab in treating myopic choroidal neovascularization (CNV).

DESIGN

Prospective, comparative, randomized, interventional study.

METHODS

Thirty-two eyes from 32 patients with myopic CNV were consecutively enrolled and randomly treated, in a 1:1 ratio, with intravitreal ranibizumab (0.5 mg) or bevacizumab (1.25 mg) as needed, after the first injection. ETDRS best-corrected visual acuity (BCVA), foveal center thickness (FCT) on optical coherence tomography (OCT), and fluorescein angiographic findings were examined before and after treatment. Patients were followed up for 6 months.

RESULTS

No statistically significant difference in the BCVA improvement, as well as in the FCT reduction, was found between groups during follow-up (P value at 1, 3, 6 months > .05). Complete resolution of fluorescein leakage was observed in all 16 bevacizumab-treated eyes and in 15 out of 16 (93.7%) ranibizumab-treated eyes. No ocular or systemic adverse effects from treatment were encountered.

CONCLUSION

This randomized clinical study cannot determine a statistically significant difference in anti-VEGF treatment effect between ranibizumab and bevacizumab for the treatment of CNV secondary to pathologic myopia. A larger study is required to determine the relative efficacy and duration of action of these drugs.

Adverse events after infusions of cryopreserved hematopoietic stem cells depend on non-mononuclear cells in the infused suspension and patient age

BACKGROUND

Adverse events (AE) represent a significant clinical problem after infusion of cryopreserved HPC. However, the factors playing a role in the pathogenesis have not yet been fully established.

METHODS

We prospectively collected data on AE that occurred with 179 HPC infusions performed on patients affected with hematologic neoplasm after high-dose chemotherapy. The stem cell source was hemopoietic progenitor cells aphaeresis (HPC-A) in 157 cases and hemopoietic progenitor cell BM (HPC-BM) in 22 cases. In all cases, an endotoxin-free DMSO was used.

RESULTS

One or more AE were registered in 51/179 infusions (28.6%). The frequency of AE was higher after HPC-A than after HPC-BM (31.3% vs. 4.5%; chi(2) test, P =0.008). With univariate logistic regression, other factors found important for AE were age (P =0.028), number of total nucleated cells infused per kilogram (P =0.002), volume per kilogram infused (P =0.057), volume of packed RBC (P =0.019), a content of non-mononuclear cells >0.5 x 10(8)/kg (<P =0.0001) and actual time of infusion (P =0.058). When all aforementioned factors were evaluated with a multivariate logistic regression, only age of patient (P =0.024) and a content of non-mononuclear cells >0.5 x 10(8)/kg (P =0.0003) remained significant. A significant correlation existed between reduction of cardiac frequency both with volume per kilogram infused (r =0.221, P =0.02) and actual time of infusion (r =0.269, P =0.005).

DISCUSSION

Cardiovascular changes are influenced by volume per kilogram infused and by actual time of infusion, while non-cardiovascular AE are dependent on patient age and contamination by non-mononuclear cells in apheretic harvests.

Is endoscopic ultrasound clinically useful for follow-up of gastric lymphoma?

BACKGROUND

Endoscopic ultrasound (EUS) is considered the best technique for locoregional staging at diagnosis but its role in the follow-up of patients with gastric lymphoma after organ-conserving strategies has not been established.

DESIGN AND METHODS

We retrospectively evaluated 23 patients with primary gastric lymphoma treated with a stomach-conservative approach. Sixteen of them were affected by MALT lymphoma and seven by diffuse large-B-cell lymphoma (DLBCL). Five patients were treated with Helicobacter pylori (HP) eradication therapy alone (omeprazole + amoxicillin + clarithromycin); eight patients received a treatment including HP eradication and chemotherapy and the remaining 10 patients were treated with chemotherapy alone.

RESULTS

At the end of treatment, a complete remission was documented in 21 (91%) patients by endoscopy with biopsy (E-Bx) but in only seven (30%) patients by EUS. A total of 99 evaluations with both EUS and E-Bx were evaluated and we found concordance between the two methods in 33 occasions (33%) only. No significant difference on the percentage of concordance was recorded between MALT and DLBCL. After a median follow-up of 36.5 months we have not observed any relapse in 12 patients (six DLBCL and six MALT) with a persistent positive EUS but negative E-Bx.

CONCLUSIONS

Although the length of follow-up cannot exclude late relapse, we think that in restaging and follow-up of gastric lymphoma, EUS seems not to be a reliable tool if it is abnormal and E-Bx still remains the gold standard. Therefore, after conventional conservative treatment, persistence of EUS abnormality with a negative histology should not be considered as a clinically relevant persistence of disease and should not be a reason for further treatment.

Survivin silencing sensitizes imatinib-resistant CML cells to the cytotoxic effect of hydroxyurea

13119

Background: Imatinib Mesylate (IM), a semi-specific inhibitor of the BCR-ABL tyrosine kinase, is currently the treatment of choice for Chronic Myeloid Leukemia (CML). However, about one third of CML patients treated with IM develop resistance to the drug because of reactivation of BCR-ABL kinase activity. This phenomenon is usually ascribed to the amplification of the BCR-ABL gene or to the selection of leukemic clones harboring point mutations that abrogate IM binding. To identify novel anti-apoptotic signaling pathways employed by BCR-ABL and devise strategies capable of killing IM-resistant CML cells, we investigated the interplay between BCR-ABL and the Inhibitor of Apoptosis Protein Survivin. Methods: Murine hematopoietic cells (32D) transduced with p210 BCR-ABL and human cell lines either positive (K562, KCL22, KYO1 and LAMA84) or negative (HL60) for the BCR-ABL oncoprotein, were analyzed for Survivin expression by western blot before and after IM treatment. Three different pathways (MAPK, PI3K and JAK2/STA3) potentially involved in BCR-ABL-mediated induction of Survivin were studied using inhibitors specific for each signaling cascade. The effect of Survivin on the proliferation and viability of IM-sensitive and IM-resistant CML cells was investigated after silencing Survivin expression with small interfering RNAs. Results: BCR-ABL tyrosine kinase activity induced an over-expression of Survivin in both human and murine hematopoietic cell lines. This over-expression was both at the transcriptional and the translational level and required the JAK2/STAT3 pathway. Survivin silencing by siRNA increased IM cytotoxicity in IM-sensitive cells but failed to restore IM efficacy in IM-resistant cells. However, Survivin silencing sensitized CML cells to the cytotoxic effect of hydroxyurea and enhanced the efficacy of this compound on three different murine cell lines are insensitive to IM because of point mutations in the BCR-ABL kinase domain (Ba/F3p210Y253F, Ba/F3p210D276G and Ba/F3p210T315I). Conclusions: Reduction of Survivin expression improves the efficacy of IM and increases the sensitivity of IM-resistant CML cells to hydroxyurea. Survivin may represent an attractive therapeutic target for both IM-sensitive and IM-resistant CML patients.

No significant financial relationships to disclose.

Treatment of elderly patients (> or =60 years) with newly diagnosed acute promyelocytic leukemia. Results of the Italian multicenter group GIMEMA with ATRA and idarubicin (AIDA) protocols

In all, 134 elderly patients (median age 66 years, range 60-75 years) with newly diagnosed acute promyelocytic leukemia (APL) were enrolled in two successive protocols of the Italian multicenter group GIMEMA. All patients received an identical induction with all-trans retinoic acid and idarubicin; 116 (86%) entered complete remission (CR), two (2%) were resistant and 16 (12%) died during induction. After CR, 106 patients received further therapy whereas 10 did not, because of refusal (n=5) or toxicity (n=5). Consolidation consisted of three chemotherapy courses in the AIDA protocol (AIDA, 67 patients) or, since 1997, of an amended protocol including only the first cycle (amended AIDA, aAIDA, 39 patients). In the AIDA group, 43 patients (64%) completed consolidation, while seven (11%) and 17 (25%) patients were withdrawn after first and second courses, respectively; nine patients (13%) died in CR and 12 (18%) relapsed. In the aAIDA group, all patients received the assigned treatment; two patients (5%) died in CR and six (15%) relapsed. In the AIDA and aAIDA series, the 3-year overall and discase-free survival rates were 81 and 83% (P=NS), 73 and 72% (P=NS), respectively. We highlight here the frequency and severity of complications linked to intensive chemotherapy in this clinical setting and suggest that, in APL of the elderly, less intensive postremission therapy allows significant reduction of severe treatment-related toxicity and may be equally effective.

G-CSF alone vs cyclophosphamide plus G-CSF in PBPC mobilization of patients with lymphoma: results depend on degree of previous pretreatment

We performed a randomized study to compare 'G-CSF alone' (administered at dose of 10 mcg/kg/day) and 'cyclophosphamide plus G-CSF' (cyclophosphamide at dose of 4 g/m(2) and G-CSF at dose of 10 microg/kg/day), as PBPC mobilization schedules in 52 patients with NHL or HD. Randomization was stratified according to the amount of previous chemotherapy (< or =2 and >2 lines of previous chemotherapy). Mean CD34+ cell peak in P.B., mean 'Total CD34+ cells' harvested and percentage of patients successfully mobilized, in the group mobilized with 'G-CSF alone' vs the group mobilized with 'cyclophosphamide plus G-CSF', were: 35.3 x 10(6) vs 45.8 x 10(6)/l (P=0.3), 5.4 x 10(6) vs 6.8 x 10(6)/kg (P>0.9) and 50 vs 61% (P=0.4). No differences were observed in the stratum of less pretreated patients. However, in the stratum of patients who had previously received more than two lines of chemotherapy, CD34+cell peak (P=0.05) and percentage of successful mobilization (P=0.01) were higher when 'cyclophosphamide plus G-CSF' was used. Using logistic regression, both age and mobilization with 'G-CSF alone' were significantly associated with a low CD34+ cell peak in P.B. However, in the stratum of less pretreated patients, only age was significantly associated with this risk.

Angiogenesis in chronic myeloproliferative diseases

Increased angiogenic activity has been demonstrated in myelofibrosis with myeloid metaplasia (MMM), chronic myeloid leukemia (CML), and essential thrombocythemia (ET) by both bone marrow microvessel density evaluation and measurement of circulating angiogenic factors. MMM is probably the disease with the more pronounced angiogenesis among myeloproliferative disorders but the significance of this finding remains speculative since the angiogenic activity is not correlated with any of the clinical and laboratory features of the disease. Circulating serum levels of angiogenic factors such as vascular endothelial growth factor (VEGF) and hepatocyte growth factor (HGF) were found increased in MMM, CML and ET but the frequent thrombocytosis that accompanies these diseases could limit the interpretation of these data since platelets and megakaryocytes may be considered a major source at least for VEGF. However, CML patients treated with interferon were found to have lower VEGF and HGF levels than untreated or hydroxyurea-treated patients, thus suggesting a possible antiangiogenic mechanism of this drug. In addition, preliminary experiences with the antiangiogenic drug thalidomide have shown therapeutic activity in some myeloproliferative disorders.

Elevated vascular endothelial growth factor (VEGF) serum levels in idiopathic myelofibrosis

An increase of angiogenesis has been shown in idiopathic myelofibrosis with myeloid metaplasia (MMM) by microvessel density count method but evaluation of circulating angiogenic factors is still incomplete. In 31 patients affected by MMM and in 12 healthy subjects we evaluated the serum levels of VEGF (vascular endothelial growth factor) and correlated VEGF with clinical and laboratory features of disease. We found that MMM patients had circulating VEGF concentrations much higher than controls (Median 1208 ng/ml vs 138 ng/ml, P < 0.0001). No correlation was found between VEGF and Hb, WBC, PLT, LDH, creatinine, bone marrow cellularity, fibrosis, splenomegaly, hepatomegaly, and therapy. However, in the subgroup of patients with a normal or low VEGF concentration, a direct correlation between VEGF and platelet count (r = 0.90, P = 0.002) was detected. Moreover, patients with a platelet count < 300 x 10(9)/l had VEGF serum levels lower than patients with a higher PLT count (median VEGF 864 vs 1557 pg/ml, P = 0.001). In six patients and in eight controls we also had the opportunity to measure VEGF in the plasma and we calculated that VEGF concentration was much higher in platelet-rich than in platelet-poor plasma and that platetets of MMM patients contained four times more VEGF than those of healthy controls. These results indicate that VEGF is overproduced in MMM, thus confirming an increased angiogenic activity. Platelets are probably a major source of VEGF in MMM but not the only one.

Retrospective study of the prognostic role of serum thymidine kinase level in CLL patients with active disease treated with fludarabine

BACKGROUND

Previous studies have shown that the serum thymidine kinase (TK) level can be used to determine prognosis in patients with lymphoproliferative diseases, but mainly those with multiple myeloma and non-Hodgkin's lymphoma. In patients with chronic lymphocytic leukemia (CLL), TK levels may provide prognostic information independent of stage and other prognostic factors, but it is still unclear whether they can be used to predict the response to treatment and length of survival.

PATIENTS AND METHODS

To determine whether TK levels can be used to predict response and survival, we retrospectively examined the serum TK level in 188 previously treated and untreated patients with active or advanced CLL who were then treated with fludarabine alone or in combination with prednisone. The correlation of the TK level with other prognostic features and with outcome was then assessed.

RESULTS

Serum TK levels were elevated in 92% of the patients, and the levels proved to associate with previous treatment, stage of disease, and other tumor-burden related features (i.e., white blood cell counts, absolute lymphocyte count, bone marrow cellularity). The levels were also directly associated with indicators of tumor cell turnover (i.e., beta2-microglobulin and lactate dehydrogenase levels). Of particular importance, we found that the TK level was a significant prognostic indicator of both response to treatment and survival. Specifically, 83% of patients with a TK level of < 10 U/L responded (complete and partial response) to treatment with fludarabine, whereas only 45% of patients with a TK level of > or = 10 U/l responded to treatment (P < 0.01). This difference was maintained when we separately analyzed untreated and previously treated patients, and in patients divided according to the Binet stage. The TK level also added prognostic information about response to a predictive model based on the hemoglobin and, albumin levels and the extent of prior treatment. Of further importance, the median survival rate in patients with a TK level of < 10 U/l was 65%, as opposed to a rate of 22% in patients with a TK level of > or = 10 U/l (P = 0.000).

CONCLUSIONS

The serum TK level in CLL patients provides useful prognostic information regarding both response to therapy and length of survival and should be used in planning appropriate therapy. In particular, patients with a TK level of > or = 10 U/l have a poor prognosis and should be considered for aggressive treatment.

In vitro apoptotic response of freshly isolated chronic myeloid leukemia cells to all-trans retinoic acid and cytosine arabinoside

Chronic myeloid leukemia (CML) is a hematological malignancy resulting from clonal expansion and massive accumulation of leukemic myeloid cells that retain differentiation and maturation capacity. Since CML cell accumulation has been related to apoptosis inhibition by the product of the BCR-ABL gene, attempts to eradicate leukemic cells would require therapeutic drugs able to overcome this inherent resistance. Here, we investigated in vitro the apoptotic effect of all-trans retinoic acid (ATRA) and cytosine arabinoside (ARA-C), employed alone, in combination or in sequence, on freshly isolated cells from 10 patients with chronic-phase CML. Our cell cultures showed that both ATRA and ARA-C were able to induce apoptosis in CML cells, even if ARA-C resulted more effective than ATRA. The combined use of ATRA and ARA-C seemed to have only an additive effect while the sequential use did not show any advantage. These in vitro observations indicate that ATRA and ARA-C may be effective in reducing CML cells through apoptosis induction, suggesting that it could be worthwhile to examine ATRA and ARA-C combinations in the therapy of CML.

Angiogenic factors in multiple myeloma: higher levels in bone marrow than in peripheral blood

BACKGROUND AND OBJECTIVES

To study the role of some soluble factors in the process of angiogenesis that accompanies multiple myeloma (MM).

DESIGN AND METHODS

The concentrations of three well-known angiogenic peptides, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and hepatocyte growth factor (HGF) were evaluated by an ELISA method. All of these factors were measured in the plasma obtained from peripheral blood (PB) and bone marrow (BM) aspirates of 34 patients affected by plasma cell disorders. This series included one patient with a solitary extramedullary plasmacytoma, 17 patients with MM at diagnosis, and 16 with previously treated MM.

RESULTS

In all the patients, the concentration of each angiogenic factor was higher in bone marrow than in peripheral blood. Mean values of the three angiogenic factors in BM or in PB were lower in stage I than stage II-III. One patient with extramedullary solitary myeloma had high levels of VEGF and bFGF but this increase was not found in the other 6 patients with extramedullary disease when compared with patients without extramedullary disease. VEGF and bFGF did not correlate with each other while HGF showed a weak correlation with VEGF and a stronger one with bFGF. Moreover, VEGF correlated with features of disease activity, such as C-reactive protein, and 2-microglobulin, while both bFGF and HGF showed an inverse correlation with albumin level. No correlation was found between VEGF, bFGF and HGF levels and age, M protein level, osteolytic lesions, or percentage of BM plasma cells. Since angiogenic factors may be released by normal cells in response to hypoxia, we also evaluated erythropoietin (EPO) levels (which correlate with the hypoxic stimulus) both in PB and BM plasma of these patients but none of the measured angiogenic factors correlated with EPO levels. Interpretation and Conclusions. Several soluble factors may play a role in the angiogenic activity described in MM but their contribution to the progression of disease may be different. The finding of higher levels of these factors in BM than in PB might indicate that the bone marrow environment is their major source. Concentrations of angiogenic factors parallel the activity of disease and are independent of the hypoxic stimulus.

Predictive factors of response to splenectomy in adult chronic idiopathic thrombocytopenic purpura

A total of 26 surgical patients with chronic idiopathic thrombocytopenic purpura (ITP) were reviewed and results of splenectomy were statistically related to age and sex, length of and response to pre-operative corticosteroid therapy, pre-operative platelet count and time interval between diagnosis and surgery. Median age was 37 years (range, 17-81 years) and the male:female ratio was 1.16. Pre-operative platelet count ranged from 2-70 x 10(9)/l. The length of pre-surgical corticosteroid therapy (prednisone 1-2 mg/kg/day) varied from 2 weeks to 3 years. Steroid therapy was unsuccessful in 15 patients and only achieved temporary remission in the remaining 11 cases. The time interval between diagnosis and splenectomy ranged from 4-60 months. There were 21 responders (80.4%) and 5 non-responders (19.6%) to splenectomy. Using the chi-square test, differences in age, length and response to pre-operative steroid therapy and diagnosis-to-splenectomy interval did not achieve statistical significance when responder and non-responder groups to splenectomy were compared. Conversely, a significant difference was found comparing male to female groups, since 92.9% of males and only 66.7% of females were successfully treated by surgery (P approximately 0.01). In addition, patients with a pre-operative platelet count less than 30 x 10(9)/l responded at an higher rate (100% versus 70.6%; P approximately 0.05) to splenectomy.

All-trans-retinoic-acid- and growth-factor- mediated induction of alkaline phosphatase activity in freshly isolated chronic myeloid leukemia cells

Reduced or absent neutrophil alkaline phosphatase (NAP) activity is a common feature of neutrophilic granulocytes from patients with chronic myeloid leukemia (CML). In this study we examined whether NAP activity could be restored in vitro by stimulating CML cells with different promoters such as all-trans-retinoic acid (ATRA), granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF). The results obtained indicated that ATRA and G-CSF, either alone or in combination, were effective in inducing NAP activity in CML cells, whereas GM-CSF was not. Further, NAP restoration in ATRA- and G-CSF-treated cultures was accompanied by increased morphologic differentiation of the CML clone. It might be concluded that the CML clone could be driven in vitro by ATRA and G-CSF both to achieve granulocytic maturation and to correct functional NAP-related defects.

Mutation and haplotype studies of familial Mediterranean fever reveal new ancestral relationships and evidence for a high carrier frequency with reduced penetrance in the Ashkenazi Jewish population

Familial Mediterranean fever (FMF) is a recessive disorder characterized by episodes of fever with serositis or synovitis. The FMF gene (MEFV) was cloned recently, and four missense mutations were identified. Here we present data from non-Ashkenazi Jewish and Arab patients in whom we had not originally found mutations and from a new, more ethnically diverse panel. Among 90 symptomatic mutation-positive individuals, 11 mutations accounted for 79% of carrier chromosomes. Of the two mutations that are novel, one alters the same residue (680) as a previously known mutation, and the other (P369S) is located in exon 3. Consistent with another recent report, the E148Q mutation was observed in patients of several ethnicities and on multiple microsatellite haplotypes, but haplotype data indicate an ancestral relationships between non-Jewish Italian and Ashkenazi Jewish patients with FMF and other affected populations. Among approximately 200 anonymous Ashkenazi Jewish DNA samples, the MEFV carrier frequency was 21%, with E148Q the most common mutation. Several lines of evidence indicate reduced penetrance among Ashkenazi Jews, especially for E148Q, P369S, and K695R. Nevertheless, E148Q helps account for recessive inheritance in an Ashkenazi family previously reported as an unusual case of dominantly inherited FMF. The presence of three frequent MEFV mutations in multiple Mediterranean populations strongly suggests a heterozygote advantage in this geographic region.

Evaluation of Taxol cytotoxicity on B-CLL cells in vitro

Taxol is a new antimicrotubule agent that, besides a well known efficacy against solid tumors, has shown activity in non-Hodgkin's lymphomas too. We therefore investigated its in vitro cytotoxic activity against cells from patients affected by chronic lymphocytic leukemia (CLL). Peripheral blood lymphocytes from 46 CLL patients were incubated for four days with Taxol at doses ranging from 0.01 to 10 mM and the cytotoxicity was evaluated by a colorimetric method (XTT). In most samples Taxol was inactive and the IC50 was > 10 mM in 40 out of 46 patients. It is worthwhile noting that four of the six in vitro responsive patients had unfavourable clinical features. In three unresponsive patients we also observed that Taxol was not able to induce apoptosis in vitro. In conclusion, based on in vitro data, it seems that Taxol is not an active drug in standard CLL but we cannot exclude some efficacy in other more rapidly proliferating lymphoproliferative disorders.

A good response rate to recombinant erythropoietin alone may be expected in selected myelodysplastic patients. A preliminary clinical study

The use of recombinant erythropoietin for treatment of anemia in myelodysplastic patients has so far produced poorer results than expected. Most clinical studies have been conducted without any selection of patients. In the present study we report our experience with the use of rhEPO in a population of selected MDS subjects. Only patients affected by refractory anemia according to FAB criteria, without significant WBC and platelets reduction, with normal LDH and short history of disease were eligible for the study and were treated with rhEPO at a dosage of 150 mg/kg three times a week for 2 months. Among the 12 so treated patients, 7 (58.3%) achieved complete remission, 2 partial remission and 3 failed to respond. This high response rate makes more than acceptable the cost/benefit ratio for rhEPO in RA patients and may identify a subgroup of patients that can be treated successfully with rhEPO alone.

Cutaneous vasculitis in non Hodgkin's lymphoma

Cutaneous vasculitis has been described in association with various hematological malignancies, but it seems to be very uncommon among non Hodgkin's lymphomas (NHL). For this reason no attention has been given to the peculiarity of this rare association. We identified 5 cases of cutaneous vasculitis among 315 NHL patients examined at our Institution from 1984 through 1990 and after the appearance of vasculitis, we observed some heterogeneity in either the degree of activity or in the clinical outcome of the NHL. The onset of cutaneous vasculitis appeared to mark two different clinical patterns: a vasculitis present from diagnosis characterized an indolent course of the neoplasia, while a late-appearing vasculitis was followed by rapid lymphoma progression and short survival.

In vitro sensitivity of B-CLL cells to fludarabine and interferons

In this study we evaluated the cytotoxicity of Fludarabine (FAMP) both alone and in combination with alpha and beta interferon (IFN) against B-cells from patients affected by chronic lymphocytic leukemia (CLL). We used an in vitro colorimetric assay based on the bioreduction of the tetrazolium salt XTT by viable cells. Fludarabine concentrations ranging from 0.03 to 30 microM were tested on cells collected from 22 B-CLL patients. For each fludarabine concentration, 800 I.U. of either alpha or beta IFN were added. Interferon alone did not exert any cytotoxic effect, while Fludarabine showed a strong cytotoxicity against B-CLL cells. The concentration of Fludarabine required to induce a 50% cytotoxicity (IC50) was below 3 microM (the achievable serum level after standard dose in vivo administration) for 19 out of 22 patients. After IFNs supplementation to Fludarabine, it was possible to identify three groups of samples. The first in which IFNs addition did not produce almost any significant change in Fludarabine cytotoxicity (13/22), the second in which there was an improvement in FAMP IC50 (6/22), and finally the third group in which IFNs worsened it (3/22). Stage of disease was the only identified factor accounting for these different results. The second group included samples from 5 patients at stage A and one at stage B, while in the third group all three samples were from patients at stage C. Interferon-alpha and -beta induced the same degree of FAMP IC50 variation.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple myeloma and renal transplant

Until now, no case of multiple myeloma (MM) had been reported among the B-lymphoproliferative disorders occurring in organ-transplant recipients. The history of a 58-year-old man who developed IgG-kappa MM 31 months after a cadaveric renal transplant is described. A possible relationship between drug-mediated immunosuppression and the development of MM is discussed.

Autoimmune hemolytic anemia in chronic lymphocytic leukemia patients treated with fludarabine

Autoimmune hemolytic anemia (AHA) is a frequent complication of chronic lymphocytic leukemia (CLL). Although the pathogenesis of AHA is still unknown, an imbalance of normal residual T cells is believed to play a central role. Since fludarabine is reported to affect primarily T lymphocytes, we conducted a retrospective study to evaluate the incidence and outcome of AHA in 112 CLL patients treated with fludarabine alone. Eight patients had AHA before therapy; only one achieved remission of both CLL and AHA after fludarabine alone. In the other seven patients, we observed no effect or even a worsening of AHA, although the CLL was responding to fludarabine. Five patients developed AHA from 1 to 19 months after fludarabine therapy while the CLL was responding. One additional patient developed pure red cell aplasia (PRCA) 3 months after starting therapy. Most patients in both groups responded to steroids or other immunosuppressive therapy. The study showed that in these patients, AHA evolved independently of CLL and was not affected by fludarabine.

Early response to alpha interferon in a patient affected by hairy cell leukemia

A 61-year-old splenectomized male patient affected by hairy cell leukemia (HCL) in relapse was treated with interferon (IFN) at a dosage of 3 x 10(6) U/day. After only 11 days of treatment, IFN was stopped because the patient developed fever, jaundice and respiratory distress. Upon recovery from this infectious episode, the patient was judged to be in complete remission of HCL on the basis of clinical and laboratory findings, and he remained off-therapy for 2 years. When an overt relapse occurred, the patient was again treated with IFN and, after a very short time, he achieved a new, good partial remission that is maintained 28 months later without treatment. This observation remains speculative for understanding the mechanism of action of IFN in other comparable HCL cases.

Unusual onset of severe varicella in adult immunocompromised patients

Abdominal and back pain has until now been reported as a first sign of severe varicella in immunocompromised children only. We report two adult leukemia patients in whom these symptoms preceded visceral dissemination of varicella infection. Recognizing that this syndrome may occur in adult patients is of clinical importance, since it allows early diagnosis and treatment of the infection.