Autoimmune hemolytic anemia in patients with de novo acute myelocytic leukemia

Autoantibody against erythrocytes has occasionally been observed in patients with de novo acute myelocytic leukemia (AML). However, it is not clear whether this autoantibody in AML patients induces frank hemolysis (autoimmune hemolytic anemia, AIHA), as seen in lymphoid neoplasms. We present two de novo AML patients who showed hemolysis due to antiglobulin test-positive and test-negative AIHA, respectively. AIHA should be considered as one cause of anemia in de novo AML patients, and blood transfusions should be given carefully in such cases to avoid harmful hemolysis.     

急性白血病骨髓中的血管生成的研究

目的 研究血管生成在急性白血病发病，预后中的作用。方法 应用免疫组化法检测30例初治急性白血病患者的骨髓活检组织治疗前后微血管密度（MVD）及血管内皮生长因子（VEGF）的变化。结果 初治急性白血病患者骨髓病理组织中的MVD和VEGF阳性率明显高于正常对照组；骨髓完全缓解后其MVD及VEGF阳性率明显下降，与正常对照组无显著性差异；治疗后未完全缓解组的MVD及VEGF阳性率较治疗前无显著性下降。结论 急性白血病骨髓中存在血管生成，可能与急性白血病的预后有关。     

Angiogenesis and acute myeloid leukemia

Background

Angiogenesis is a word of Greek origin, ‘angeio’ refers to blood vessel, and genesis refers to creation, meaning the generation of new blood vessels. This process is essential for vertebrate development and plays a key role in human diseases. Angiogenesis is generally understood to be essential for the growth and metastasis of solid tumors and is also important in acute myeloid leukemia (AML).

Methods

This review summarizes the essential features of physiological and tumoral angiogenesis and the methods used for their assessment.

Results

Technologies for evaluating angiogenesis in AML are discussed and the prognostic significance of angiogenic factors is considered in the context of optimizing treatment.

Conclusion

As acute myelogenous leukemia and endothelial cells depend on each other for survival and proliferation, therapy directed against several pro-angiogenic factors might help to enhance the AML outcome.     

急性白血病止凝血异常的预后意义

目的：探讨急性白血病（AL）患者的止凝血异常及其与预后的关系。方法：运用ELISA或发色底物法对56例AL患者血浆一系列止凝血指标进行了检测。结果：治疗前血浆血栓调节蛋白（TM）、P－选择素、可溶性纤维蛋白单体复合物（SFMC）、组织纤溶酶原激活性（t－PA）、D－二聚体水平显著升高,蛋白C抗原（PC：Ag）、纤溶酶原激活抑制物（PAI）水平低于正常,纤维蛋白原（Fg)、蛋白C活性（PC：A）、蛋白S水平（PS）与正常对照组差异无显著性意义,治疗后除蛋白C活性外均恢复至正常范围内;治疗前后TM升高、治疗前PS降低及PAI升高者预后较差,其中治疗后TM和治疗前PAI是决定患者无复归生存时间的预后因素,治疗后TM、治疗前PS和PAI水平是决定患者总生存时间的预后因素。结论：AL发病过程中存在血管内皮细胞损伤、血小板活化以及凝血、抗凝、纤溶系统的激活,并随病情的好转而逐渐改善;血管内皮损伤、PS消耗及纤溶抑制活性增强与患者的预后密切相关。     

急性白血病患者骨髓血管新生的研究及临床意义

目的　研究急性白血病 (AL)患者骨髓血管新生、骨髓液血管内皮生长因子 (VEGF)水平并探讨其临床意义。方法　采用免疫组化方法 ,以兔抗人Ⅷ相关抗原多克隆抗体标记骨髓内皮细胞 ,光学显微镜下计数骨髓全切片微血管数 ;用ELISA方法检测骨髓液VEGF水平。结果　骨髓微血管数在初发未治组 (2 2 82 /× 4 0 0视野 )明显高于正常对照组 (7 17/× 4 0 0视野 )及骨髓缓解组(8 5 7/× 4 0 0视野 ) (P值均 <0 0 0 1) ,而骨髓缓解组仍高于正常对照组 (P <0 0 5 ) ,初发未治组与复发难治组 (2 1 83/× 4 0 0视野 )之间的差异无显著性 (P >0 0 5 )。初发未治组中 ,骨髓微血管数在 2 3例急性淋巴细胞白血病 (ALL)患者 (2 3 0 9/× 4 0 0视野 )与 4 3例急性非淋巴细胞白血病 (ANLL)患者(2 2 37/× 4 0 0视野 )、FAB亚型M1～ 3 (2 2 91/× 4 0 0视野 )与M4～ 5患者 (2 1 4 6 /× 4 0 0视野 )之间的差异均无显著性 (P值均 >0 0 5 ) ,而骨髓微血管数与骨髓原始细胞百分数呈正相关性 (r =0 311,P <0 0 1)。骨髓液VEGF水平 ,在初发未治组 (188 88ng/L)显著高于骨髓缓解组 (78 74ng/L)和正常对照组 (79 5 2ng/L) (P值均 <0 0 1) ,而后两者之间的差异无显著性 (P >0 0 5 ) ;在ANLL组(2 70 12ng/L)显著高于ALL组 (1     

去甲氧柔红霉素联合HA方案治疗急性髓细胞白血病初治患者的临床观察

目的:探讨去甲氧柔红霉素(IDA)联合HA方案[(高三尖杉酯碱(HH)加阿糖胞苷(Ara-C)]治疗初发急性髓细胞白血病(AML)的疗效和不良反应。方法:14例AML患者,年龄17～62岁(中位年龄40岁),男8例,女6例,均为初治AML病例。诱导方案为IDA10mg/d,第1～3天,HH3mg/d第1～7天,Ara-C100mg.m-2.d-1第1～7天,静脉滴注。结果:总有效率92.9(13/14),完全缓解率78.6(11/14),治疗过程中未发生早期死亡。化疗的不良反应主要为骨髓抑制和粒细胞缺乏所致感染,未见严重的非造血系统不良反应。结论:IDA联合HA方案为初治AML的高效、安全的方案。     

血管内皮生长因子、环氧化酶-2在急性白血病中的表达及其与血管新生的关系

目的探讨血管内皮生长因子（VEGF）、环氧化酶-2（COX-2）在急性白血病（AL）的表达及与血管新生的关系。方法应用酶联免疫吸附试验（EHSA）测定23例AL初发未治,21例完全缓解（CR）,18例复发患者血清中VEGF、COX-2的含量,并与正常对照组比较。结果AL初发未治组、复发组患者血清VEGF、COX-2的含量明显高于正常对照组,差异有统计学意义（P〈0．01）;CR组患者血清VEGF、COX-2的含量较初发未治组明显下降,与正常对照组比较,差异无统计学意义（P〉0．05）;复发组血清VEGF、COX-2的含量明显高于CR组,差异有统计学意义（P〈0．01）。结论VEGF、COX-2与AL的发生、发展密切相关,COX-2可能通过上调VEGF促进AL的血管新生及发生、发展,抗VEGF和COX-2有望成为白血病治疗新的靶点。     

Kinetics and apoptotic profile of circulating endothelial cells as prognostic factors for induction treatment failure in newly diagnosed acute myeloid leukemia patients

The circulating endothelial cells (CEC) are proposed to be a noninvasive marker of angiogenesis. Recent data suggest that endothelial cells may enhance the survival and proliferation of leukemic blasts and mediate chemotherapy resistance in acute myeloid leukemia (AML). We analyzed CEC count by the four-color flow cytometry in AML and healthy subjects. We evaluated the kinetics of mature CEC, both resting (rCEC) and activated (aCEC), as well as progenitor (CEPC) and apoptotic CEC (CEC^AnnV+) in AML patients treated with standard chemotherapy and their influence on response to treatment and overall survival. We found significantly higher numbers of aCEC, rCEC, CEPC, and CEC^AnnV+ in AML patients than in healthy controls. The elevated CEPC and absolute blood counts in peripheral blood as well as the low CEC^AnnV+ number were associated with higher probability of induction treatment failure. aCEC, rCEC, CEPC, and CEC^AnnV+ counts determined in complete remission (CR) were significantly lower than those found at diagnosis. In those CR patients, a significant decrease in the CEC count and increase in the number of CEC^AnnV+ were observed already 24h after the first dose of chemotherapy. In refractory AML, the aCEC, rCEC, CEPC, and CEC^AnnV+ counts assessed before and after induction chemotherapy did not differ significantly, and a significant decrease in CEC count and increase in CEC^AnnV+ number were noted only after the last dose of chemotherapy. The number of CEC is significantly higher in AML patients than in healthy subjects and correlates with response to treatment. The evaluation of CEC kinetics and apoptotic profile may be a promising tool to select AML patients with poor response to chemotherapy who may benefit from antiangiogenic therapies.     

Outcome of bone marrow transplantation in patients with extramedullary involvement of acute leukemia

Summary Infiltration of extrahemopoietic tissue with leukemic cells was evaluated as a prognostic indicator in 18 patients with acute leukemia undergoing bone marrow transplantation. When compared to 107 patients who did not have extramedullary leukemia at any time prior to marrow grafting, the patients with leukemic invasion into organs outside the hemopoietic system had a significant increase of leukemic recurrence and a significant decrease in survival after marrow transplantation. Extramedullary leukemia may be a negative prognostic indicator for bone marrow transplantation candidates.This work was supported by NCI Grants CA 30206 and CA 33572     

Bone marrow microvessel density is a prognostic factor for survival in patients with multiple myeloma

 The importance of neoangiogenesis for the progressive growth and viability of solid tumors is well established. Recently, there has been growing evidence that angiogenesis might also be important in hematological malignancies, but only few data are available. In this report, we have studied the impact of bone marrow microvessel density and survival in patients with multiple myeloma (MM). Immunohistochemical CD34 stained paraffin-embedded bone marrow biopsies of 44 patients with newly diagnosed MM were studied. Microvessels were counted in 400× magnification and the mean number of vessels per area in each sample was noted as the microvessel density (MVD). The median MVD was 48 vessels/mm², the range was 0–125 vessels/mm². Using a cut-off value of the median MVD in the Kaplan-Meier analysis, the median survival was 22.2 months in the group with the higher MVD and was not reached in the group with the lower MVD (P<0.01). In a multivariate Cox regression analysis, using previously identified prognostic factors β2-microglobulin, C-reactive protein (CRP), and age, MVD remained significant as a prognostic factor (P<0.03). Received: 3 May 2000 / Accepted: 24 July 2000     

Long-term leukemia-free survival after allogeneic marrow transplantation in patients with acute myelogenous leukemia

Between February 1982 and April 1995, 62 patients (37 male, 25 female) with acute myelogenous leukemia (AML) with a median age of 32 years (19–51 years) received allogeneic marrow grafts from an HLA-identical sibling (n=60) or an HLA-mismatched family member (n=2). At the time of transplant, 35 patients were in first complete remission (CR), five in second CR, eight were primary refractory, eight were in untreated relapse and six in refractory relapse. The FAB subtypes were as follows: M1 (n=17), M2 (n=13), M3 (n=6), M4 (n=19), M5 (n=6), M6 (n=1). For conditioning most patients were given total body irradiation combined with cyclophosphamide (CY,n=50) or CY and busulfan (n=9). For graft-versus-host disease prophylaxis patients received cyclosporin A (CSA) and methotrexate (MTX) (n=32), MTX alone (n=12), CSA and methylprednisone (n=5), or CSA alone (n=13). As of April 1995, probability of leukemia-free survival projected at 10 years after BMT was 60% for patients transplanted in first CR compared with 10% for patients transplanted beyond first CR. Transplant-related mortality was 11% after BMT in first CR and 39% after BMT beyond first CR. Probability of relapse projected at 10 years after BMT is 32% for patients who received transplants in first CR and 81% for patients who received transplants beyond first CR. Thus, high-dose chemo/radiotherapy followed by allogeneic marrow infusion has a high curative potential for patients with AML who receive transplants in first CR and offers the chance of long-term disease-free survival for some patients with advanced disease.     

急性髓系白血病患者中期因子基因表达与化疗耐药及预后的关系

目的：探讨中期因子（Midkine，MK）与急性髓系白血病（AML）患者预后的关系。方法：采用半定量逆转录一聚合酶链反应方法检测65例初治及复发AML患者、15例缓解期患者及15例正常人骨髓单个核细胞（MNCs）MK、mdr-1、bcl-2mRNA的表达，并采用蛋白印迹（Westernblot）法检测20例AML患者和5例正常人MNCs孵育24h后，培养基中MK的蛋白表达。结果：65例初治及复发AML患者中25例MK基因表达阳性，15例正常人MK基因表达均阴性。MK基因表达阳性患者的完全缓解（CR）率明显低于表达阴性者（分别为63．16％和93．55％，P〈0．05）；MK基因表达阳性患者的复发率（100％）明显高于表达阴性者（40．00％），P〈0．05。MK与bcl-2基因表达呈正相关（r=0．556，P〈O．01）。结论：AML患者白血病细胞可以产生MK，且MK阳性率的高低与AML病期相关，MK过度表达可能导致临床化疗耐药，是影响AML患者近期预后的重要因素之一。     

Prognostic significance of VEGF immunohistochemical expression and tumor angiogenesis in head and neck squamous cell carcinoma

PURPOSE: Tumor angiogenesis is crucial for both the growth of the primary tumor and the development of metastases. Among the factors causing tumor angiogenesis, vascular endothelial growth factor (VEGF) is considered as a leading candidate. We aimed to assess the prognostic significance of VEGF and tumor angiogenesis in head and neck squamous cell carcinoma (HNSCC). METHODS: We performed a retrospective study of 69 patients with HNSCC, in order to investigate whether VEGF immunohistochemical expression and tumor angiogenesis correlate with clinicopathological parameters and outcome. Tumor angiogenesis was estimated by determining microvessel density (MVD), and VEGF expression was assessed quantitatively. RESULTS: Vascular endothelial growth factor and MVD correlated statistically significant with the clinical stage, but not with the presence of lymph node metastasis at the time of diagnosis. Tumors located in the oral cavity and larynx more often expressed high VEGF immunostaining compared with tumors located in the lower lip. High VEGF expression was associated with higher clinical stage and worse overall survival in this cohort of patients. CONCLUSIONS: Vascular endothelial growth factor expression may have prognostic significance for patients with HNSCC.     

急性脑卒中时血浆同型半胱氨酸浓度变化及其预后意义

目的　探讨急性脑卒中时 ,患者血浆同型半胱氨酸浓度水平与预后的相关性。　方法　采用同型半胱氨酸微孔板分析技术 ,对 75例急性脑卒中患者 (其中脑出血 3 6例 ,脑梗死 3 9例 )检测了血浆浓度 ,并结合病情程度、血脂、血糖及血液流变学和预后转归等进行对照分析。　结果　脑出血组为 3 4 4μmol L± 14 7μmol L(男3 7 9μmol L± 18 4μmol L ,女 3 1 9μmol L± 11 2 μmol L) ,其中重型患者为 3 9 6μmol L± 19 5μmol L ,中型为 3 7 7μmol L± 14 3 μmol L ,轻型为 2 9 4μmol L± 11 0 μmol L ,死亡 6例 ,均值为 3 7 7μmol L± 16 2 μmol L。梗死组为 2 7 4μmol L±11 6μmol L(男 3 0 4μmol L± 12 3 μmol L ,女 2 2 6μmol L± 8 8μmol L) ,其中属轻型的为 2 6 4μmol L± 11 5μmol L ,中型3 1 2 μmol L± 11 8μmol L。　 结论　急性脑卒中患者血浆同型半胱氨酸水平能反映病情的严重程度 ,有助评估患者的预后 ,指导临床治疗的意义     

Increased angiogenesis in bone marrow of children with acute lymphoblastic leukaemia has no prognostic significance

The importance of angiogenesis for the growth and viability of solid tumours has been established. Similarly, prognostic information may be gained from the extent of angiogenesis in these tumours. Haematopoietic malignancies should have equal requirements for angiogenesis and important prognostic information may be derived from quantification of bone marrow angiogenic activity. We retrospectively investigated 82 bone marrow trephine biopsies from 41 children with acute lymphoblastic leukaemia (ALL) at diagnosis and following treatment. Nine normal bone marrow trephines from age-matched children were also analysed as controls. The microvessels were stained immunohistochemically with anti-Factor VIII-related antigen (antivWF) and antithrombomodulin (anti-THR). Angiogenesis was quantified manually by two independent observers and was highly reproducible (Pearson's r = 0.91). Staining with anti-vWF and anti-THR was highly specific for microvessels and thetwo stains closely correlated (r = 0.68). Microvessel densities (MVD) at presentation were significantly increased in the majority of patients in comparison with controls (P < 0.0001) and MVD dropped towards normal in remission (P < 0.0001). Of interest, the difference in total vessel counts between leukaemic and normal/remission marrows was contributed solely by small microvessels. There was no significant difference in MVD at presentation or remission from children in poor prognostic groups or those who subsequently relapsed. Similarly, we could not find an association with age, sex, cytogenetic abnormality or disease phenotype.     

Salvage by timed sequential chemotherapy in primary resistant acute myeloid leukemia: analysis of prognostic factors

Primary resistant acute myeloid leukemia (AML) has a very poor prognosis. Etoposide-mitoxantrone-cytarabine (EMA) timed sequential chemotherapy including a first sequence combining mitoxantrone (12 mg/m² per day over 3 days) with cytarabine (500 mg/m² per day over the same period), and a second sequence consisting in etoposide (200 mg/m² per day for 3 days) and cytarabine as in the first sequence, has been proposed as a salvage regimen. Over a 10-year period, 66 primary resistant AML patients have been treated by EMA salvage chemotherapy. All patients displayed intermediate- or high-risk karyotypic abnormalities. Of the 66 patients, 24 [36%, 95% confidence interval (CI): 25–49%] achieved complete remission (CR). Thirty-eight patients were resistant to EMA chemotherapy and four patients died from toxicity during aplasia. After CR achievement, 18 patients received consolidation therapy. Five patients with an HLA-identical sibling donor underwent allogeneic stem cell transplantation (SCT), one patient received autologous SCT, two patients received a second course of EMA chemotherapy, and ten were scheduled for 6-monthly maintenance courses (mini-EMA). Median follow-up was 7.3 years. At the time of analysis, 21 of the 24 patients (87%) who achieved CR have relapsed. Median disease-free survival (DFS) was 5 months (95% CI: 4.3–7.7 months). Median overall survival (OS) was 5 months (95% CI: 3.8–6.7 months). There were only two long-term remitters (3%). In the univariate analysis, CR achievement was mainly related to white blood cell (WBC) count at the time of starting salvage therapy with poorer outcome for patients with more aggressive leukemia (WBC count 10×10⁹/l) (CR rates: 50% vs 10%, p<0.001). Overall survival was also influence by WBC count (median OS: 7.2 months vs 2.8 months, respectively, for WBC <and 10×10⁹/l, p<0.0001). Initial karyotype was not a significant prognostic factor either for CR achievement or for DFS or OS when comparing patients with normal karyotype and those with chromosomal abnormality. In multivariate analysis, WBC count less than 10×10⁹/l with the absence of circulating blasts at the time of starting salvage therapy appeared to be of favorable prognostic value for CR achievement (p=0.002), while WBC count less than 10×10⁹/l appeared to be of favorable prognostic value for survival (p<0.0001). Using these two objective parameters of proven significance, we devised a prognostic system of immediate clinical utility for prognostic stratification and risk-adapted therapeutic choices. Patients with both factors (WBC count <10×10⁹/l and no circulating blasts) or with at least one at the time of starting salvage therapy had a CR rate of 50% and were therefore candidates for intensified post-remission therapy. All other patients displayed a very poor outcome and must be oriented after failure of first-line therapy to alternate therapeutic programs based on investigational drugs.     

Allogeneic bone marrow tranplantation for young adult patients with newly diagnosed acute myeloid leukemia: HLA-Matched sibling donor availability does not improve treatment ouctome

In order to assess the place of HLA-identical allogeneic bone marrow transplantation (BMT) and to compare it to other post-induction therapies, we analyzed patient outcome in intention-to-treat based on the presence or not of an HLA-identical familial donor in young adults with de novo acute myeloid leukemia (AML) in first complete remission (CR). Between 1985 and 1998, 152 consecutive AML patients aged less than 41 years old, seen in our institution, were treated according to 3 different successive protocols (LYLAM85, LAM90, AML10). 144/152 patients entered our prospective study in which they were registered at time of diagnosis for presence or absence of HLA-identical donor and analyzed in intention-to-treat. In this study, 52 patients (36%), who had at least one identical sibling donor (group 1), were offered allogeneic BMT after CR achievement. The 92 patients without donor were allocated to group 2 and were assigned to receive chemotherapy or autologous transplantation as post-remission according to the protocol they were initially included in. Patients from both groups had similar disease characteristics at diagnosis. Karyotypes at diagnosis were defined as low risk (t(8;21) or t(15;17) or chromosome 16 abnormalities(, intermediate risk (normal karyotypes), or high risk (other abnormalities). Overall, 114/152 patients (75%) achieved a CR. Of the 144 eligible patients, 46/52 (88%) with a donor and 68/92 (74%) without a donor achieved a CR. The median follow-up duration of the 144 patients was 21.2 months. The relapse rate was higher in group 2 (56%) than in group 1 (31%). However, the overall survival was not different between patients with and without donor (median survival respectively at 16.7 months and 26.6 months with estimated survival at 5 years respectively at 32% and 34%). Thirty-four patients from group 1 (65%) were actually transplanted in first CR. The probability of 5-year survival for patients receiving effectively allogeneic BMT was 44% and was not significantly better than that of patients who did not. In univariate as in multivariate analysis, karyotypic status was the main prognostic factor for CR achievement (p = 0.002), CR duration (p < 0.0001), and overall survival (p < 0.0001). There were no significant differences between group 1 and group 2 when survivals were compared with adjustment for karyotypes.We conclude that the availability of an HLA-identical sibling donor did not confer any prognostic advantage in terms of outcome for young adults with AML in first CR. These results make allogeneic BMT process questionable as systemic post-remission therapy in patients with an HLA-identical familial donor.