tjh-v38i2

Volume 38 Issue 2

June 2021

E-ISSN: 1308-5263

Research Articles

Impact of the HEAD-US Scoring System for Observing the Protective Effect of Prophylaxis in Hemophilia

Patients: A Prospective, Multicenter, Observational Study

Kaan Kavaklı, Süha Süreyya Özbek, Ali Bülent Antmen, Fahri Şahin, Şevkiye Selin Aytaç, Alphan Küpesiz,

Bülent Zülfikar, Mehmet Sönmez, Ümran Çalışkan, Can Balkan, Tuğana Akbaş, Taner Arpacı, İpek Tamsel,

Turgut Seber, Berna Oğuz, Can Çevikol, Mesut Bulakçı, Polat Koşucu, Demet Aydoğdu, İlgen Şaşmaz,

Gülen Tüysüz, Başak Koç, Hüseyin Tokgöz, Zuhal Mehrekula, Burcu Özkan; İzmir, Adana, Ankara, İstanbul,

Trabzon, Konya, Antalya, Turkey

Highlighting the Prognostic Importance of Measurable Residual Disease Among Acute Myeloid Leukemia Risk

Factors

Zehra Narlı Özdemir, Uğur Şahin, Klara Dalva, Mehmet Akif Baltacı, Atilla Uslu, Cemaleddin Öztürk,

Güldane Cengiz Seval, Selami Koçak Toprak, Meltem Kurt Yüksel, Pervin Topçuoğlu, Önder Arslan, Muhit Özcan,

Meral Beksaç, Osman İlhan, Günhan Gürman, Sinem Civriz Bozdağ; Ankara, Turkey

Impact of Concomitant Aberrant CD200 and BCL2 Overexpression on Outcome of Acute Myeloid Leukemia:

A Cohort Study from a Single Center

Mario Tiribelli, Angela Michelutti, Margherita Cavallin, Sara Di Giusto, Renato Fanin, Daniela Damiani;

Udine, Italy

Allogeneic Hematopoietic Stem Cell Transplantation in Extranodal Natural Killer/T-cell Lymphoma

Yin-yin Peng, Yi-ying Xiong, Li-xia Zhang, Jing Wang, Hong-bin Zhang, Qing Xiao, Shu-liang Guo;

Chongqing, China

Comparison of Risk Scoring Systems in HLA-Matched Related Allogeneic Hematopoietic Stem Cell

Transplantation: A Retrospective Cohort Study

Elifcan Aladağ, Haluk Demiroğlu, Yahya Büyükaşık, Hakan Göker; Ankara, Turkey

Cover Picture:

Abibatou Sall, Moussa Seck, Diama

Samb, Blaise Faye, Macoura Gadji,

Saliou Diop, Awa Oumar Touré

Flower-Like Plasma Cell Nuclei in

Multiple Myeloma

2

Editor-in-Chief

Reyhan Küçükkaya

İstanbul, Turkey

rkucukkaya@hotmail.com

Associate Editors

A. Emre Eşkazan

İstanbul University-Cerrahpaşa, İstanbul, Turkey

emre.eskazan@istanbul.edu.tr

Ali İrfan Emre Tekgündüz

Memorial Bahçelievler Hospital, İstanbul, Turkey

emretekgunduz@yahoo.com

Ayşegül Ünüvar

İstanbul University, İstanbul, Turkey

aysegulu@hotmail.com

Cengiz Beyan

Ankara, Turkey

cengizbeyan@hotmail.com

Hale Ören

Dokuz Eylül University, İzmir, Turkey

hale.oren@deu.edu.tr

İbrahim C. Haznedaroğlu

Hacettepe University, Ankara, Turkey

haznedar@yahoo.com

Selami Koçak Toprak

Ankara University, Ankara, Turkey

sktoprak@yahoo.com

Semra Paydaş

Çukurova University, Adana, Turkey

sepay@cu.edu.tr

Şule Ünal


suleunal2003@hotmail.com

Assistant Editors

Claudio Cerchione

University of Naples Federico II Napoli,

Campania, Italy

Ebru Koca

Başkent University Ankara Hospital,

Clinic of Hematology, Ankara, Turkey

Elif Ünal İnce


İnci Alacacıoğlu

Dokuz Eylül University, İzmir, Turkey

Mario Tiribelli

University of Udine, Udine, Italy

Müge Sayitoğlu

İstanbul University, İstanbul, Turkey

Nil Güler

Ondokuz Mayıs University, Samsun, Turkey

Olga Meltem Akay

Koç University, İstanbul, Turkey

Veysel Sabri Hançer

İstinye University, İstanbul, Turkey

Zühre Kaya

Gazi University, Ankara, Turkey

International Review Board

Nejat Akar

TOBB University of Economics and Technology Hospital, Ankara, Turkey

Görgün Akpek

Maryland School of Medicine, Baltimore, USA

Serhan Alkan

Cedars-Sinai Medical Center, Los Angeles, USA

Çiğdem Altay

Ankara, Turkey

Meral Beksaç


Koen van Besien

Weill Cornell Medicine, New York, USA

M. Sıraç Dilber Karolinska University, Stockholm, Sweden

Ahmet Doğan

Memorial Sloan Kettering Cancer Center, New York, USA

Peter Dreger

Heidelberg University, Heidelberg, Germany

Thierry Facon

Lille University, Lille, France

Jawed Fareed

Loyola University, Maywood, USA

Burhan Ferhanoğlu

Koç University, İstanbul, Turkey

Gösta Gahrton

Karolinska University Hospital, Stockholm, Sweden

Dieter Hoelzer

Frankfurt University, Frankfurt, Germany

Marilyn Manco-Johnson University of Colorado Anschutz Medical Campus, Aurora, USA

Andreas Josting

University Hospital Cologne, Cologne, Germany

Emin Kansu


Winfried Kern

Albert Ludwigs University, Freiburg im Breisgau, Germany

Nigel Key

University of North Carolina School of Medicine, NC, USA

Korgün Koral

Southwestern Medical Center, Texas, USA

Abdullah Kutlar

Medical College of Georgia at Augusta University, Augusta, USA

Luca Malcovati

Pavia Medical School University, Pavia, Italy

Robert Marcus

Kings College Hospital, London, UK

Jean Pierre Marie

Pierre et Marie Curie University, Paris, France

Ghulam Mufti

King’s Hospital, London, UK

Gerassimos A. Pangalis Athens University, Athens, Greece

Antonio Piga

Torino University, Torino, Italy

Ananda Prasad

Wayne State University School of Medicine, Detroit, USA

Jacob M. Rowe

Hebrew University of Jerusalem, Jerusalem, Israel

Jens-Ulrich Rüffer

University of Köln, Köln, Germany

Norbert Schmitz

AK St Georg, Hamburg, Germany

Orhan Sezer

Charité Comprehensive Cancer Center, Berlin, Germany

Anna Sureda

Santa Creu i Sant Pau Hospital, Barcelona, Spain

Ayalew Tefferi

Mayo Clinic, Rochester, Minnesota, USA

Nükhet Tüzüner

İstanbul Cerrahpaşa University, İstanbul, Turkey

Catherine Verfaillie

Katholieke Universiteit Leuven, Leuven, Belgium

Srdan Verstovsek

The University of Texas MD Anderson Cancer Center, Houston, USA

Claudio Viscoli

San Martino University, Genoa, Italy

Past Editors

Erich Frank

Orhan Ulutin

Hamdi Akan

Aytemiz Gürgey

Senior Advisory Board

Yücel Tangün

Osman İlhan

Muhit Özcan

Teoman Soysal

Ahmet Muzaffer Demir

Language Editor

Leslie Demir

Statistic Editor

Hülya Ellidokuz

Editorial Office

İpek Durusu

Bengü Timoçin Efe

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Publishing

Services

GALENOS PUBLISHER

Molla Gürani Mah. Kaçamak Sk. No: 21/1, Fındıkzade, İstanbul, Turkey

Phone: +90 212 621 99 25 • Fax: +90 212 621 99 27 • www. galenos.com.tr

Contact Information

Editorial Correspondence should be addressed to Dr. Reyhan Küçükkaya

E-mail : rkucukkaya@hotmail.com

All Inquiries Should be Addressed to

TURKISH JOURNAL OF HEMATOLOGY

Address : Turan Güneş Bulv. İlkbahar Mah. Fahreddin Paşa Sokağı (eski 613. Sok.) No: 8 06550 Çankaya, Ankara / Turkey

Phone : +90 312 490 98 97

Fax : +90 312 490 98 68

E-mail : tjh@tjh.com.tr

E-ISSN: 1308-5263

Publishing Manager

Muhlis Cem Ar

Management Address

Türk Hematoloji Derneği

Turan Güneş Bulv. İlkbahar Mah. Fahreddin Paşa Sokağı (eski 613. Sok.)

No: 8 06550 Çankaya, Ankara / Turkey

Online Manuscript Submission

http://mc.manuscriptcentral.com/tjh

Web Page

www.tjh.com.tr

Owner on Behalf of the Turkish Society

of Hematology

Güner Hayri Özsan

International scientific journal published quarterly.

Publishing House

Molla Gürani Mah. Kaçamak Sk. No: 21,

34093 Fındıkzade, İstanbul / Turkey

Tel: +90 212 621 99 25

Fax: +90 212 621 99 27

E-mail: info@galenos.com.tr

Publisher Certificate Number: 14521

Publication Date

01.06.2021

Cover Picture

Abibatou Sall, Moussa Seck, Diama Samb, Blaise Faye,

Macoura Gadji, Saliou Diop, Awa Oumar Touré

Flower-Like Plasma Cell Nuclei in Multiple Myeloma

A) Plasma cells with dysmorphic nuclei. B) Flower-like nuclei (red

arrow) and rouleaux (light blue circle). C, E) Flower-like nuclei. D)

Mitotic event (blue arrow). Lymphoplasmacytic cells (black arrows).

Red arrow: plasma cell with a prominent nucleolus. F) Monoclonal

gamma globulin peak on protein electrophoresis. G, H) Flow

cytometry showing CD38/138+, CD45 weak , and CD56+.

The Turkish Journal of Hematology is published by the commercial enterprise

of the Turkish Society of Hematology with Decision Number 6 issued by the

Society on 7 October 2008.

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AIMS AND SCOPE

The Turkish Journal of Hematology is published quarterly (March, June,

September, and December) by the Turkish Society of Hematology. It is an

independent, non-profit peer-reviewed international English-language

periodical encompassing subjects relevant to hematology.

The Editorial Board of The Turkish Journal of Hematology adheres to the

principles of the World Association of Medical Editors (WAME), International

Council of Medical Journal Editors (ICMJE), Committee on Publication

Ethics (COPE), Consolidated Standards of Reporting Trials (CONSORT) and

Strengthening the Reporting of Observational Studies in Epidemiology

(STROBE).

The aim of The Turkish Journal of Hematology is to publish original

hematological research of the highest scientific quality and clinical relevance.

Additionally, educational material, reviews on basic developments, editorial

short notes, images in hematology, and letters from hematology specialists

and clinicians covering their experience and comments on hematology

and related medical fields as well as social subjects are published. As of

December 2015, The Turkish Journal of Hematology does not accept case

reports. Important new findings or data about interesting hematological

cases may be submitted as a brief report.

General practitioners interested in hematology and internal medicine

specialists are among our target audience, and The Turkish Journal of

Hematology aims to publish according to their needs. The Turkish Journal of

Hematology is indexed, as follows:

- PubMed Medline

- PubMed Central

- Science Citation Index Expanded

- EMBASE

- Scopus

- CINAHL

- Gale/Cengage Learning

- EBSCO

- DOAJ

- ProQuest

- Index Copernicus

- Tübitak/Ulakbim Turkish Medical Database

- Turk Medline

- Hinari

- GOALI

- ARDI

- OARE

Impact Factor: 1.685

Open Access Policy

Turkish Journal of Hematology is an Open Access journal. This journal

provides immediate open access to its content on the principle that making

research freely available to the public supports a greater global exchange of

knowledge.

Open Access Policy is based on the rules of the Budapest Open Access

Initiative (BOAI) http://www.budapestopenaccessinitiative.org/.

Subscription Information

The Turkish Journal of Hematology is published electronically only as of

2019. Therefore, subscriptions are not necessary. All published volumes are

available in full text free-of-charge online at www.tjh.com.tr.

Address: Turan Güneş Bulv. İlkbahar Mah. Fahreddin Paşa Sokağı (eski 613.

Sok.) No: 8 06550 Çankaya, Ankara / Turkey

Telephone: +90 312 490 98 97

Fax: +90 312 490 98 68

Online Manuscript Submission: http://mc.manuscriptcentral.com/tjh

Web page: www.tjh.com.tr

E-mail: tjh@tjh.com.tr

Permissions

Requests for permission to reproduce published material should be sent to

the editorial office.

Editor: Professor Dr. Reyhan Küçükkaya

Adress: Turan Güneş Bulv. İlkbahar Mah. Fahreddin Paşa Sokağı (eski 613.

Sok.) No: 8 06550 Çankaya, Ankara / Turkey

Telephone: +90 312 490 98 97

Fax: +90 312 490 98 68

Online Manuscript Submission: http://mc.manuscriptcentral.com/tjh

Web page: www.tjh.com.tr

E-mail: tjh@tjh.com.tr

Publisher

Galenos Yayınevi

Molla Gürani Mah. Kaçamak Sk. No:21 34093 Fındıkzade-İstanbul, Turkey

Telephone : +90 212 621 99 25

Fax : +90 212 621 99 27

info@galenos.com.tr

Instructions for Authors

Instructions for authors are published in the journal and at www.tjh.com.tr

Material Disclaimer

Authors are responsible for the manuscripts they publish in The Turkish

Journal of Hematology. The editor, editorial board, and publisher do not

accept any responsibility for published manuscripts.

If you use a table or figure (or some data in a table or figure) from another

source, cite the source directly in the figure or table legend.

Editorial Policy

Following receipt of each manuscript, a checklist is completed by the Editorial

Assistant. The Editorial Assistant checks that each manuscript contains all

required components and adheres to the author guidelines, after which time

it will be forwarded to the Editor in Chief. Following the Editor in Chief’s

evaluation, each manuscript is forwarded to the Associate Editor, who in

turn assigns reviewers. Generally, all manuscripts will be reviewed by at least

three reviewers selected by the Associate Editor, based on their relevant

expertise. Associate editor could be assigned as a reviewer along with the

reviewers. After the reviewing process, all manuscripts are evaluated in the

Editorial Board Meeting.

Turkish Journal of Hematology’s editor and Editorial Board members are active

researchers. It is possible that they would desire to submit their manuscript

to the Turkish Journal of Hematology. This may be creating a conflict of

interest. These manuscripts will not be evaluated by the submitting editor(s).

The review process will be managed and decisions made by editor-in-chief

who will act independently. In some situation, this process will be overseen

by an outside independent expert in reviewing submissions from editors.

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TURKISH JOURNAL OF HEMATOLOGY

INSTRUCTIONS FOR AUTHORS

The Turkish Journal of Hematology accepts invited review articles,

research articles, brief reports, letters to the editor, and hematological

images that are relevant to the scope of hematology, on the condition

that they have not been previously published elsewhere. Basic science

manuscripts, such as randomized, cohort, cross-sectional, and casecontrol

studies, are given preference. All manuscripts are subject

to editorial revision to ensure they conform to the style adopted by

the journal. There is a double-blind reviewing system. Review articles

are solicited by the Editor-in-Chief. Authors wishing to submit an

unsolicited review article should contact the Editor-in-Chief prior to

submission in order to screen the proposed topic for relevance and

priority.

The Turkish Journal of Hematology does not charge any article

submission or processing charges.

Manuscripts should be prepared according to ICMJE guidelines (http://

www.icmje.org/). Original manuscripts require a structured abstract.

Label each section of the structured abstract with the appropriate

subheading (Objective, Materials and Methods, Results, and Conclusion).

Letters to the editor do not require an abstract. Research or project

support should be acknowledged as a footnote on the title page.

Technical and other assistance should be provided on the title page.

Original Manuscripts

Title Page

Title: The title should provide important information regarding the

manuscript’s content. The title must specify that the study is a cohort

study, cross-sectional study, case-control study, or randomized study (i.e.

Cao GY, Li KX, Jin PF, Yue XY, Yang C, Hu X. Comparative bioavailability

of ferrous succinate tablet formulations without correction for baseline

circadian changes in iron concentration in healthy Chinese male

subjects: A single-dose, randomized, 2-period crossover study. Clin Ther

2011;33:2054-2059).

The title page should include the authors’ names, degrees, and

institutional/professional affiliations and a short title, abbreviations,

keywords, financial disclosure statement, and conflict of interest

statement. If a manuscript includes authors from more than one

institution, each author’s name should be followed by a superscript

number that corresponds to their institution, which is listed separately.

Please provide contact information for the corresponding author,

including name, e-mail address, and telephone and fax numbers.

Important Notice: The title page should be submitted separately.

Running Head: The running head should not be more than 40

characters, including spaces, and should be located at the bottom of

the title page.

Word Count: A word count for the manuscript, excluding abstract,

acknowledgments, figure and table legends, and references, should be

provided and should not exceed 2500 words. The word count for the

abstract should not exceed 300 words.

Conflict of Interest Statement: To prevent potential conflicts of

interest from being overlooked, this statement must be included in each

manuscript. In case there are conflicts of interest, every author should

complete the ICMJE general declaration form, which can be obtained at

http://www.icmje.org/downloads/coi_disclosure.zip

Abstract and Keywords: The second page should include an abstract

that does not exceed 300 words. For manuscripts sent by authors in

Turkey, a title and abstract in Turkish are also required. As most readers

read the abstract first, it is critically important. Moreover, as various

electronic databases integrate only abstracts into their index, important

findings should be presented in the abstract.

Objective: The abstract should state the objective (the purpose of the

study and hypothesis) and summarize the rationale for the study.

Materials and Methods: Important methods should be written

respectively.

Results: Important findings and results should be provided here.

Conclusion: The study’s new and important findings should be

highlighted and interpreted.

Other types of manuscripts, such as reviews, brief reports, and

editorials, will be published according to uniform requirements.

Provide 3-10 keywords below the abstract to assist indexers. Use

terms from the Index Medicus Medical Subject Headings List

(for randomized studies a CONSORT abstract should be provided: http://

www.consort-statement.org).

Introduction: The introduction should include an overview of the

relevant literature presented in summary form (one page), and whatever

remains interesting, unique, problematic, relevant, or unknown about

the topic must be specified. The introduction should conclude with the

rationale for the study, its design, and its objective(s).

Materials and Methods: Clearly describe the selection of observational

or experimental participants, such as patients, laboratory animals, and

controls, including inclusion and exclusion criteria and a description of

the source population. Identify the methods and procedures in sufficient

detail to allow other researchers to reproduce your results. Provide

references to established methods (including statistical methods),

provide references to brief modified methods, and provide the rationale

for using them and an evaluation of their limitations. Identify all drugs

and chemicals used, including generic names, doses, and routes of

administration. The section should include only information that was

available at the time the plan or protocol for the study was devised

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(https://www.strobe-statement.org/fileadmin/Strobe/uploads/checklists/

STROBE_checklist_v4_combined.pdf).

Statistics: Describe the statistical methods used in enough detail to

enable a knowledgeable reader with access to the original data to verify

the reported results. Statistically important data should be given in the

text, tables, and figures. Provide details about randomization, describe

treatment complications, provide the number of observations, and specify

all computer programs used.

Results: Present your results in logical sequence in the text, tables, and

figures. Do not present all the data provided in the tables and/or figures

in the text; emphasize and/or summarize only important findings, results,

and observations in the text. For clinical studies provide the number of

samples, cases, and controls included in the study. Discrepancies between

the planned number and obtained number of participants should be

explained. Comparisons and statistically important values (i.e. p-value

and confidence interval) should be provided.

Discussion: This section should include a discussion of the data. New and

important findings/results and the conclusions they lead to should be

emphasized. Link the conclusions with the goals of the study, but avoid

unqualified statements and conclusions not completely supported by the

data. Do not repeat the findings/results in detail; important findings/results

should be compared with those of similar studies in the literature, along with

a summarization. In other words, similarities or differences in the obtained

findings/results with those previously reported should be discussed.

Study Limitations: Limitations of the study should be detailed. In

addition, an evaluation of the implications of the obtained findings/

results for future research should be outlined.

Conclusion: The conclusion of the study should be highlighted.

References

Cite references in the text, tables, and figures with numbers in square

brackets. Number references consecutively according to the order in

which they first appear in the text. Journal titles should be abbreviated

according to the style used in Index Medicus (consult List of Journals

Indexed in Index Medicus). Include among the references any paper

accepted, but not yet published, designating the journal followed by “in

press”.

Examples of References:

1. List all authors

Deeg HJ, O’Donnel M, Tolar J. Optimization of conditioning for marrow

transplantation from unrelated donors for patients with aplastic anemia

after failure of immunosuppressive therapy. Blood 2006;108:1485-1491.

2. Organization as author

Royal Marsden Hospital Bone Marrow Transplantation Team. Failure of

syngeneic bone marrow graft without preconditioning in post-hepatitis

marrow aplasia. Lancet 1977;2:742-744.

3. Book

Wintrobe MM. Clinical Hematology, 5th ed. Philadelphia, Lea & Febiger, 1961.

4. Book Chapter

Perutz MF. Molecular anatomy and physiology of hemoglobin. In:

Steinberg MH, Forget BG, Higs DR, Nagel RI, (eds). Disorders of Hemoglobin:

Genetics, Pathophysiology, Clinical Management. New York, Cambridge

University Press, 2000.

5. Abstract

Drachman JG, Griffin JH, Kaushansky K. The c-Mpl ligand (thrombopoietin)

stimulates tyrosine phosphorylation. Blood 1994;84:390a (abstract).

6. Letter to the Editor

Rao PN, Hayworth HR, Carroll AJ, Bowden DW, Pettenati MJ. Further

definition of 20q deletion in myeloid leukemia using fluorescence in situ

hybridization. Blood 1994;84:2821-2823.

7. Supplement

Alter BP. Fanconi’s anemia, transplantation, and cancer. Pediatr Transplant

2005;9(Suppl 7):81-86.

Brief Reports

Abstract length: Not to exceed 150 words.

Article length: Not to exceed 1200 words.

Introduction: State the purpose and summarize the rationale for the study.

Materials and Methods: Clearly describe the selection of the observational

or experimental participants. Identify the methods and procedures in

sufficient detail. Provide references to established methods (including

statistical methods), provide references to brief modified methods, and

provide the rationale for their use and an evaluation of their limitations.

Identify all drugs and chemicals used, including generic names, doses, and

routes of administration.

Statistics: Describe the statistical methods used in enough detail to

enable a knowledgeable reader with access to the original data to verify

the reported findings/results. Provide details about randomization,

describe treatment complications, provide the number of observations,

and specify all computer programs used.

Results: Present the findings/results in a logical sequence in the text, tables,

and figures. Do not repeat all the findings/results in the tables and figures in

the text; emphasize and/or summarize only those that are most important.

Discussion: Highlight the new and important findings/results of the

study and the conclusions they lead to. Link the conclusions with the

goals of the study, but avoid unqualified statements and conclusions not

completely supported by your data.

Invited Review Articles



Review articles should not include more than 100 references. Reviews

should include a conclusion, in which a new hypothesis or study about the

subject may be posited. Do not publish methods for literature search or level

of evidence. Authors who will prepare review articles should already have

published research articles on the relevant subject. The study’s new and

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important findings should be highlighted and interpreted in the Conclusion

section. There should be a maximum of two authors for review articles.

Perspectives in Hematology

“Perspectives” are articles discussing significant topics relevant to

hematology. They are more personal than a Review Article. Authors

wishing to submit a Perspective in Hematology article should contact

the Editor in Chief prior to submission in order to screen the proposed

topic for relevance and priority. Articles submitted for “Perspectives

in Hematology” must advance the hot subjects of experimental and/

or clinical hematology beyond the articles previously published or in

press in TJH. Perspective papers should meet the restrictive criteria of

TJH regarding unique scientific and/or educational value, which will

impact and enhance clinical hematology practice or the diagnostic

understanding of blood diseases. Priority will be assigned to such

manuscripts based upon the prominence, significance, and timeliness of

the content. The submitting author must already be an expert with a

recognized significant published scientific experience in the specific field

related to the “Perspectives” article.



References: Should not include more than 50 references

Images in Hematology


Authors can submit for consideration illustrations or photos that are

interesting, instructive, and visually attractive, along with a few lines

of explanatory text and references. Images in Hematology can include

no more than 200 words of text, 5 references, and 3 figures or tables.

No abstract, discussion, or conclusion is required, but please include a

brief title.

Letters to the Editor


Letters can include no more than 500 words of text, 5-10 references,

and 1 figure or table. No abstract is required, but please include a brief

title. The total number is usually limited to a maximum of five authors

for a letter to the editor.

Tables

Supply each table in a separate file. Number tables according to the order

in which they appear in the text, and supply a brief caption for each.

Give each column a short or abbreviated heading. Write explanatory

statistical measures of variation, such as standard deviation or standard

error of mean. Be sure that each table is cited in the text.

Figures

Figures should be professionally drawn and/or photographed. Authors

should number figures according to the order in which they appear in

the text. Figures include graphs, charts, photographs, and illustrations.

Each figure should be accompanied by a legend that does not exceed

50 words. Use abbreviations only if they have been introduced in the

text. Authors are also required to provide the level of magnification for

histological slides. Explain the internal scale and identify the staining

method used. Figures should be submitted as separate files, not in

the text file. High-resolution image files are not preferred for initial

submission as the file sizes may be too large. The total file size of the

PDF for peer review should not exceed 5 MB.

Authorship

Each author should have participated sufficiently in the work to assume

public responsibility for the content. Any portion of a manuscript that is

critical to its main conclusions must be the responsibility of at least one

author.

Contributor’s Statement

All submissions should contain a contributor’s statement page. Each

statement should contain substantial contributions to idea and design,

acquisition of data, and analysis and interpretation of findings. All persons

designated as an author should qualify for authorship, and all those that

qualify should be listed. Each author should have participated sufficiently

in the work to take responsibility for appropriate portions of the text.

Acknowledgments

Acknowledge support received from individuals, organizations, grants,

corporations, and any other source. For work involving a biomedical

product or potential product partially or wholly supported by corporate

funding, a note stating, “This study was financially supported (in part)

with funds provided by (company name) to (authors’ initials)”, must

be included. Grant support, if received, needs to be stated and the

specific granting institutions’ names and grant numbers provided when

applicable.

Authors are expected to disclose on the title page any commercial or

other associations that might pose a conflict of interest in connection

with the submitted manuscript. All funding sources that supported the

work and the institutional and/or corporate affiliations of the authors

should be acknowledged on the title page.

Ethics

When reporting experiments conducted with humans indicate that

the procedures were in accordance with ethical standards set forth

by the committee that oversees human subject research. Approval of

research protocols by the relevant ethics committee, in accordance with

international agreements (Helsinki Declaration of 1975, revised 2013

available at https://www.wma.net/policies-post/wma-declaration-ofhelsinki-ethical-principles-for-medical-research-involving-humansubjects/),

is required for all experimental, clinical, and drug studies.

Patient names, initials, and hospital identification numbers should not be

used. Manuscripts reporting the results of experimental investigations

conducted with humans must state that the study protocol received

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institutional review board approval and that the participants provided

informed consent.

Non-compliance with scientific accuracy is not in accord with scientific

ethics. Plagiarism: To re-publish, in whole or in part, the contents of

another author’s publication as one’s own without providing a reference.

Fabrication: To publish data and findings/results that do not exist.

Duplication: Use of data from another publication, which includes republishing

a manuscript in different languages. Salami slicing: To create

more than one publication by dividing the results of a study unnecessarily.

We disapprove of such unethical practices as plagiarism, fabrication,

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A-VII

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A-VIII

CONTENTS

Research Articles

101 Impact of the HEAD-US Scoring System for Observing the Protective Effect of Prophylaxis in

Hemophilia Patients: A Prospective, Multicenter, Observational Study

Kaan Kavaklı, Süha Süreyya Özbek, Ali Bülent Antmen, Fahri Şahin, Şevkiye Selin Aytaç, Alphan Küpesiz, Bülent Zülfikar, Mehmet Sönmez,

Ümran Çalışkan, Can Balkan, Tuğana Akbaş, Taner Arpacı, İpek Tamsel, Turgut Seber, Berna Oğuz, Can Çevikol, Mesut Bulakçı, Polat Koşucu,

Demet Aydoğdu, İlgen Şaşmaz, Gülen Tüysüz, Başak Koç, Hüseyin Tokgöz, Zuhal Mehrekula, Burcu Özkan; İzmir, Adana, Ankara,

İstanbul, Trabzon, Konya, Antalya, Turkey

111 Highlighting the Prognostic Importance of Measurable Residual Disease Among Acute Myeloid

Leukemia Risk Factors

Zehra Narlı Özdemir, Uğur Şahin, Klara Dalva, Mehmet Akif Baltacı, Atilla Uslu, Cemaleddin Öztürk, Güldane Cengiz Seval,

Selami Koçak Toprak, Meltem Kurt Yüksel, Pervin Topçuoğlu, Önder Arslan, Muhit Özcan, Meral Beksaç, Osman İlhan, Günhan Gürman,

Sinem Civriz Bozdağ; Ankara, Turkey

119 Impact of Concomitant Aberrant CD200 and BCL2 Overexpression on Outcome of Acute Myeloid

Leukemia: A Cohort Study from a Single Center

Mario Tiribelli, Angela Michelutti, Margherita Cavallin, Sara Di Giusto, Renato Fanin, Daniela Damiani; Udine, Italy

126 Allogeneic Hematopoietic Stem Cell Transplantation in Extranodal Natural Killer/T-cell Lymphoma

Yin-yin Peng, Yi-ying Xiong, Li-xia Zhang, Jing Wang, Hong-bin Zhang, Qing Xiao, Shu-liang Guo; Chongqing, China

138 Comparison of Risk Scoring Systems in HLA-Matched Related Allogeneic Hematopoietic Stem Cell

Transplantation: A Retrospective Cohort Study

Elifcan Aladağ, Haluk Demiroğlu, Yahya Büyükaşık, Hakan Göker; Ankara, Turkey

Brief Report

145 Autoimmune Lymphoproliferative Syndrome in Children with Nonmalignant Organomegaly, Chronic

Immune Cytopenia, and Newly Diagnosed Lymphoma

Zühre Kaya, Melek Işık, Nihan Oruklu, Serap Kirkiz, Emin Ümit Bağrıaçık, Luis M. Allende, María J. Díaz-Madroñero, Raquel Ruiz-García,

Faruk Güçlü Pınarlı, Pınar Göçün Uyar, Ülker Koçak; Ankara, Turkey; Madrid, Spain

Images in Hematology

151 Unusual Spherical Bodies in Bone Marrow of a Patient with Monoclonal Gammopathy of Undetermined

Significance

Habib Moshref Razavi; British Columbia, Canada

153 Flower-Like Plasma Cell Nuclei in Multiple Myeloma

Abibatou Sall, Moussa Seck, Diama Samb, Blaise Faye, Macoura Gadji, Saliou Diop, Awa Oumar Touré; Dakar, Senegal

Letters to the Editor

155 Immune Thrombotic Thrombocytopenic Purpura in a Patient with Suspected COVID-19:

Hydroxychloroquine Culprit or Just Happenstance?

Tajamul H. Mir; Srinagar, India

A-IX

157 Antithrombin, COVID-19, and Fresh Frozen Plasma Treatment

Rujitttika Mungmungpuntipantip, Viroj Wiwanitkit; Bangkok, Thailand; Pune, India

159 Is Sickle Cell Trait Really Innocent?

Mahmut Yeral, Can Boğa; Adana, Turkey

161 Novel Mutation p.Asp374Val of SERPINC1 in a Turkish Family with Inherited Antithrombin

Deficiency

Deniz Aslan; Ankara, Turkey

163 An Interesting Case: Sunitinib-Induced Microangiopathic Hemolytic Anemia and Nephrotic

Syndrome

Veysel Haksöyler, Semra Paydaş; Adana, Turkey

165 Kimura Disease Associated with Minimal Change Disease

Rafet Eren, Enes Cömert, İlknur Mansuroğlu, Esma Evrim Doğan, Gülay Kadıoğlu; İstanbul, Turkey

167 Acute Kidney Injury Due to Leukemic Infiltration in a Patient with Chronic Lymphocytic Leukemia

Gizem Kumru Şahin, Hasan Emre Kocabay, Saba Kiremitçi, Osman İlhan, Kenan Keven; Ankara, Turkey

169 Gastric Cancer or Plasmacytoma in a Seemingly Well-Controlled Multiple Myeloma Patient?

Wanlu Ma, Boju Pan, Lu Zhang; Beijing, China

171 Prolonged Severe Watery Diarrhea in a Long-Term Myeloma Survivor: An Unforeseen Infection with

Cystoisospora belli

Tarık Onur Tiryaki , Kadir Uluç Anıl, Melek Büyük, Ahmet Yasir Yıldırım, Alp Atasoy, Aslı Çiftçibaşı Örmeci, Sevgi Kalayoğlu Beşışık;

İstanbul, Turkey

173 Persistent Polyclonal B-Cell Lymphocytosis with Binucleated Lymphocytes

Berrin Balık Aydın, Yaşa Gül Mutlu, Ömür Gökmen Sevindik; İstanbul, Turkey

A-X

BAŞSAĞLIĞI / CONDOLENCES

Üyelerimizden,

İstanbul Üniversitesi İstanbul Tıp Fakültesi

Hematoloji Bilim Dalı emekli öğretim üyesi

Prof. Dr. Melih Aktan’ın

zamansız vefatı hepimizi çok üzdü.

Değerli hocamızın ailesine, yakınlarına ve tüm hematoloji

camiasına başsağlığı dileriz.

The untimely loss of our member,

a retired faculty member of İstanbul Faculty of Medicine,

Department of Hematology,

Prof. Dr. Melih Aktan,

has made us all very sad.

We extend our condolences to our esteemed professor’s family,

his relatives, and the entire hematology community.

Kavaklı K. et al: Ultrasound and Monitoring for Hemophilia

RESEARCH ARTICLE

DOI: 10.4274/tjh.galenos.2021.2020.0717

Turk J Hematol 2021;38:101-110

Impact of the HEAD-US Scoring System for Observing the

Protective Effect of Prophylaxis in Hemophilia Patients:

A Prospective, Multicenter, Observational Study

Hemofili Hastalarında Profilaksinin Koruyucu Etkisinin Gözlenmesinde HEAD-US Skorlama

Sisteminin Önemi: Prospektif, Çok Merkezli ve Gözlemsel Bir Çalışma

Kaan Kavaklı 1 , Süha Süreyya Özbek 2 , Ali Bülent Antmen 3 , Fahri Şahin 4 , Şevkiye Selin Aytaç 5 , Alphan Küpesiz 6 ,

Bülent Zülfikar 7 , Mehmet Sönmez 8 , Ümran Çalışkan 9 , Can Balkan 1 , Tuğana Akbaş 10 , Taner Arpacı 10 , İpek Tamsel 2 ,

Turgut Seber 11 , Berna Oğuz 11 , Can Çevikol 12 , Mesut Bulakçı 7 , Polat Koşucu 13 , Demet Aydoğdu 14 , İlgen Şaşmaz 3 ,

Gülen Tüysüz 6 , Başak Koç 7 , Hüseyin Tokgöz 9 , Zuhal Mehrekula 4 , Burcu Özkan 15

1Ege University Children’s Hospital, Clinic of Children’s Health and Diseases, Division of Pediatric Hematology, İzmir, Turkey

2Ege University Medical Faculty Hospital, Clinic of Radiology, Division of Hematology, İzmir, Turkey

3Acıbadem Adana Hospital, Clinic of Pediatric Hematology, Adana, Turkey

4Ege University Medical Faculty Hospital, Clinic of Internal Diseases, Division of Hematology, İzmir, Turkey

5Hacettepe University Faculty of Medicine, Department of Children’s Health and Diseases, Division of Pediatric Hematology, Ankara, Turkey

6Akdeniz University Hospital, Clinic of Children’s Health and Diseases, Antalya, Turkey

7İstanbul University Hemophilia Comprehensive Care Center, İstanbul, Turkey

8Karadeniz Technical University Medical Faculty Farabi Hospital, Clinic of Internal Diseases, Division of Hematology, Trabzon, Turkey

9Necmettin Erbakan University Meram Medical Faculty Hospital, Department of Children’s Health and Diseases, Konya, Turkey

10Acıbadem Adana Hospital, Clinic of Radiology, Adana, Turkey

11Hacettepe University Faculty of Medicine, Department of Radiology, Ankara, Turkey

12Akdeniz University Hospital, Clinic of Radiology, Antalya, Turkey

13Karadeniz Technical University Medical Faculty Farabi Hospital, Clinic of Radiology, Trabzon, Turkey

14Necmettin Erbakan University Meram Medical Faculty Hospital, Clinic of Radiology, Konya, Turkey

15Pfizer Pharmaceuticals, Rare Disease Department, İstanbul, Turkey

Abstract

Objective: This study aimed to observe the preventive effect of

prophylactic treatment on joint health in people with hemophilia (PwH)

and to investigate the importance of integration of ultrasonographic

examination into clinical and radiological evaluation of the joints.

Materials and Methods: This national, multicenter, prospective,

observational study included male patients aged ≥6 years with the

diagnosis of moderate or severe hemophilia A or B from 8 centers

across Turkey between January 2017 and March 2019. Patients were

followed for 1 year with 5 visits (baseline and 3 rd , 6 th , 9 th , and 12 th

month visits). The Hemophilia Joint Health Score (HJHS) was used for

physical examination of joints, the Pettersson scoring system was used

for radiological assessment, point-of-care (POC) ultrasonography was

used for bilateral examinations of joints, and the Hemophilia Early

Arthropathy Detection with Ultrasound (HEAD-US) score was used for

evaluation of ultrasonography results.

Öz

Amaç: Bu çalışmada hemofili hastalarında profilaksinin eklem sağlığı

üzerindeki koruyucu etkisini gözlemlemek ve eklemlerin klinik ve

ultrasonografik olarak değerlendirilmesinin öneminin araştırılması

amaçlandı.

Gereç ve Yöntemler: Ulusal, çok merkezli, prospektif ve gözlemsel olan

araştırma Ocak 2017 - Mart 2019 arasında 8 ayrı merkezde takip edilen

erkek ve 6 yaşından büyük orta seviyede veya ağır hemofili-A ve hemofili-B

hastalarını kapsıyordu. Hastalar 1 yıllık takip sırasında toplam 5 ayrı vizitte

(başlangıç, 3. ay, 6. ay, 9. ay ve 12. ay) değerlendirildi. Hemofili Eklem

Sağlığı Skoru (HJHS) eklemlerin fiziksel bakısında kullanılırken Petterson

skorlama sistemi radyolojik bakı sırasında değerlendirildi. Ayrıca, hasta

başı ultrasonografisiyle bilateral eklem incelemeleri yapılarak HEAD-US

skorlama yöntemiyle eklem skorları belirlendi.

©Copyright 2021 by Turkish Society of Hematology

Turkish Journal of Hematology, Published by Galenos Publishing House

Address for Correspondence/Yazışma Adresi: Kaan Kavaklı, M.D., Ege University Children’s Hospital,

Clinic of Children’s Health and Diseases, Division of Pediatric Hematology, İzmir, Turkey

Phone : +90 542 432 87 38

E-mail : kaan.kavakli61@gmail.com ORCID: orcid.org/0000-0003-1174-1958

Received/Geliş tarihi: November 30, 2020

Accepted/Kabul tarihi: January 26, 2021

101



Abstract

Results: Seventy-three PwH, of whom 62 had hemophilia A and

11 had hemophilia B, were included and 24.7% had target joints at

baseline. The HJHS and HEAD-US scores were significantly increased

at the 12 th month in all patients. These scores were also higher in the

hemophilia A subgroup than the hemophilia B subgroup. However,

in the childhood group, the increment of scores was not significant.

The HEAD-US total score was significantly correlated with both the

HJHS total score and Pettersson total score at baseline and at the 12 th

month.

Conclusion: The HEAD-US and HJHS scoring systems are valuable

tools during follow-up examinations of PwH and they complement

each other. We suggest that POC ultrasonographic evaluation and the

HEAD-US scoring system may be integrated into differential diagnosis

of bleeding and long-term monitoring for joint health as a routine

procedure.

Keywords: Hemophilic arthropathy, Joint Scores, HJHS, Ultrasonography

Öz

Bulgular: Çalışmada 62’si hemofili A ve 11’I hemofili B olan 73 hastanın

%24,7’sinde hedef eklem varlığı mevcuttu. HJHS ve HEAD-US skorlarının

tüm hastalarda takibin 12. ayında anlamlı olarak arttığı gözlendi. Hemofili

A hastalarında daha yüksek skorlar saptandı. Skor artımı alt gruplarda

değerlendirildiğinde çocukluk yaş grubunda artışın anlamlı olmadığı

gözlendi. Başlangıçta ve 12. ayda yapılan üçlü bakıda HJHS, HEAD-US ve

Petterson skorlarının anlamlı olarak korele olduğu saptandı.

Sonuç: HJHS eklem skoru ile HEAD-US radyolojik skorlamasının hemofili

hastalarının eklem sağlığının takibinde çok değerli olup birbirlerini

destekledikleri yakından gözlendi. Hasta başı US skorlama sistemlerinin

günümüzde hemofilide eklem sağlığının rutin takip ve izlemi sürecinde

hem kanama ayırıcı tanısı hem de uzun dönemli takip açısından oldukça

değerli bir yeri olacağını düşünüyoruz.

Anahtar Sözcükler: Hemofilik artropati, Eklem skorları, HJHS, Ultrasonografi

Introduction

The goal of hemophilia treatment is to prevent bleeding by

replacement of factor concentrates or substitution of missing

coagulation factors. Coagulation factors can be given for

prophylaxis (primary and secondary prophylaxis, etc.) or

for treatment when needed [1]. Prevention of bleeding via

prophylaxis is considered the gold-standard treatment in cases

of severe hemophilia [1,2]. Provision of early prophylaxis for

severely hemophilic children can completely or largely prevent

life-threatening bleeding, chronic joint diseases, and disabilities;

thus, requirements for surgical interventions can be decreased

and both health and social well-being of people with hemophilia

(PwH) can be improved [1,2,3].

Evaluation of joint status is crucial not only for staging joint

disease but also for the follow-up of prophylaxis and for

evaluating outcomes of replacement therapy. Joint function

is widely assessed by the Hemophilia Joint Health Score

(HJHS), but implementation of the HJHS requires training and

experience. The Pettersson scoring system, a radiological joint

scoring system, gives quite reliable outcomes when applied by

an experienced radiologist [4,5]. Magnetic resonance imaging

(MRI) is a more sensitive imaging method than plain radiogram

in evaluating the joints. Nevertheless, MRI has disadvantages

such as long scanning period, high cost, limited availability,

and need for sedation in young children [4,5]. However,

ultrasonography may provide advantages such as appropriate

cost, availability, repeatability, faster examination, no need for

sedation while examining children, and scanning of multiple

joints and dynamic examination of joints in a single session.

The present study aimed to observe the preventive effect

of prophylactic treatment on joint health in PwH and to

investigate the importance of integration of point of-care (POC)

ultrasonographic examination into clinical and radiological

evaluation of the joints.

Materials and Methods

Patients

The current study was designed as a national, multicenter,

prospective, non-interventional, observational study. A total of 8

centers across Turkey were selected and the data were collected

from January 2017 through March 2019. Male patients aged

≥6 years with the diagnosis of moderate or severe hemophilia A

or hemophilia B (factor level <2%) were included in the study.

The pediatric group (47.9%) ranged in age from 6 to 18 years

while the adult group (52.1%) ranged in age from 19 to 70 years

(Table 1).

Patients with communication difficulties (unable to understand

or speak Turkish) or cognitive dysfunction and patients with

inhibitors were excluded. The study was approved by the Clinical

Research Ethics Committee of the Ege University Faculty of

Medicine and written informed consent was obtained from the

patients or their legal representatives.

Procedure

After enrollment in the study, the patients were followed for

12 months with a total of 5 visits (baseline and 3 rd , 6 th , 9 th ,

and 12 th months). In the study centers, patient data concerning

demographic features and hemophilia history were recorded on

case report forms at the baseline visit. Physical examinations

of elbow, knee, and ankle joints were performed with the HJHS

during each visit. Annual bleeding rate (ABR) was recorded

every 3 months during clinical visits.

102



Additionally, ultrasonographic examinations of the bilateral

elbow, ankle, and knee joints were performed during each visit.

Ultrasonography results of the patients were evaluated with

the Hemophilia Early Arthropathy Detection with Ultrasound

(HEAD-US) scoring system. Evaluations were performed by

expert physiotherapists and radiologists. The same experts in

each center performed the evaluations at different time points

to prevent variability.

For all patients, quality of life (QoL) questionnaires were

administered at the baseline, 6 th month, and 12 th month visits.

Compliance of prophylaxis and bleeding episodes were recorded

every 3 months in clinical visits.

Measurements

The HJHS is a scoring system used to assess physical joint damage

in PwH and recommended for routine follow-up assessments of

joint health. Using the HJHS, the six most commonly involved

joints (elbows, knees, and ankles) are evaluated in PwH and

total scores are within the range of 0-124. High scores indicate

damage/impairment [6].

The Pettersson scoring system allows detailed evaluation of

radiological changes in the joints. Posterior-anterior and lateral

X-ray images of the joints are evaluated. Scores range from 0 to

13 for a single joint and the maximum possible total score is 78

when 6 joints are evaluated [7,8].

Table 1. Demographics of 73 patients receiving prophylaxis.

Group Children Adults All

Patients, n 35 38 73

(%) (47.9%) (52.1%) (100%)

Ages (years)

Range 6-17 18-70 6-70

Median 14 36 18

Mean ± SD 11.3±6.2 39.6±26.4 22.1±14.5

Body mass index

Range 13.2-24.8 24.1-35.2 13.2-35.2

Median 15.9 28.6 23.8

Mean ± SD 16.1±5.6 25.6±14.2 23.4±5.2

Type of hemophilia All patients Hemophilia A Hemophilia B

n 73 62 11

Ages (years)

Range 6-70 12-60

Median 17.5 19.0

Mean ± SD 21.3±14.1 26.5±16.7

Severity

Severe 68 58 10

Moderate 5 4 1

*Presence of target joint 18 (24.3%) 15 3

*Orthopedic operation history 23 (31.5%) 20 3

*Radioisotope synovectomy 6 (8.2%) 5 1

Joint bleeding

Knee-right 15 13 2

Knee-left 15 13 2

Elbow-right 18 15 3

Elbow-left 14 12 2

Ankle-right 20 17 3

Ankle-left 14 13 1

All patients had severe HA or HB.

SD: Standard deviation.

N

103



The HEAD-US scoring system was developed by Martinoli et al.

[9]. It is based on three markers for the three main sets of joints

(knees, elbows, and ankles): synovitis (score of 0-2), cartilage

(score of 0-4), and subchondral bone (score of 0-2), with a

maximum score of 8 points per joints.

The Short Form-36 (SF-36) is a questionnaire widely used to

assess health-related QoL. Based on the scores of 8 dimensions

of health (physical functioning, bodily pain, role limitations due

to physical health problems, role limitations due to personal or

emotional problems, general mental health, social functioning,

energy/fatigue or vitality, and general health perceptions),

two component summaries (physical component summary

and mental component summary) are obtained. Higher scores

indicate better health status [10].

The EuroQol-5 Dimension (EQ-5D) is another questionnaire

frequently used to assess health-related QoL. Five parameters

of health (mobility, self-care, usual activities, pain/discomfort,

and anxiety/depression) are evaluated. Higher scores indicate

better QoL [11]. In the present study, the three-level version

(EQ-5D-3L) was used.

Patients receiving prophylaxis were evaluated using scoring

systems and QoL parameters. Prospective evaluations of patients

were provided for the one-year observational period.

Bleeding frequency and target joint availability are main reasons

for starting prophylaxis for patients with moderate hemophilia.

They were mostly receiving secondary prophylaxis.

Children below 10 years of age were in the primary prophylaxis

group, whereas older children (10-18 years) received secondary

prophylaxis. Most of the adult group received secondary or

tertiary prophylaxis. Primary prophylaxis was started at once

weekly and then increased to twice and thrice weekly. Most

secondary prophylaxis patients received infusions twice or

thrice weekly.

Sample Size

The sample size was calculated as 80 PwH with the assumptions of

the rate of damaged joints being 8% in PwH receiving prophylactic

treatment and the rate of damaged joints being 25% in PwH not

receiving prophylactic treatment, with 80% power when the

statistical significance level was presumed as 0.05.

Statistical Analysis

Data analysis was performed using PASW Statistics for Windows,

Version 18.0 (SPSS Inc., Chicago, IL, USA). For descriptive

statistics, numerical variables were expressed as mean, standard

deviation, median, and minimum-maximum and categorical

variables were expressed as number and percentage. Student’s

t-test was performed in comparisons of ultrasonography scores

and QoL scores at each visit when the condition of normal

distribution was fulfilled. The Mann-Whitney U test was used

when the condition of normal distribution was not fulfilled.

For normally distributed data, repeated measures analysis was

performed for the comparison of change in ultrasonography

scores and QoL scores with time in the groups. When the normal

distribution condition was not fulfilled, the Friedman test was

performed separately in the groups. Spearman’s rho correlation

test was used for correlation analysis.

The statistical significance level was set at p<0.05.

Results

The present study included 78 male hemophilic patients, of

whom 73 received prophylactic treatment and 5 received

on-demand treatment in case of bleeding. The 73 patients receiving

prophylaxis were included in the analyses. Of those patients, 62 had

hemophilia A (58 severe and 4 moderate) and 11 had hemophilia B

(10 severe and 1 moderate). General characteristics of the patients

and disease-related data are presented in Table 1.

Among the included patients, 24.7% had target joints at baseline.

The most commonly affected joint was the right ankle (27.4%).

Overall, 31.5% of the included patients underwent major or minor

surgical procedures and radioactive synovectomy was performed

for only 6 patients. More than half of the patients were not able

to go to work because of hemophilia in the last 3 months (Table 1).

The ABRs for all patients, for children, and for adults are shown

in Table 2. The elevation of ABR rates was not significant for

children or for adults.

Table 2. ABR rates for all patients and children and adults.

All patients Children Adults

0 th 12 th 0 th 12 th 0 th 12 th

Median 0 3 0 3.5 1 3

Range 0-45 1-4 0-12 1-12 0-45 1-45

Mean ± SD 2.6±6.2 6.1±8.2 1.3±8.0 4.6±3.6 3.9±8.0 6.8±9.6

P value >0.05 >0.05 >0.05

0 th means: Retrospectively recorded one-year ABR data before trial.

12 th means: Prospectively recorded ABR data by clinical visits in every 3 months.

SD: Standard deviation.

104



Moreover, joint scores of all patients at the baseline and

follow-up visits are shown in Tables 3-6. When the scores at

the baseline and 12 th month were compared, there were

significant increases in both the HJHS and HEAD-US scores at

the 12 th month in all patients. Separating the patients by age,

no significant increase in any of the scores was observed in

children, but significant increases in the HJHS, HEAD-US, and

Pettersson scores were seen in the adult group.

Evaluation of the patients in terms of hemophilia A and

hemophilia B subgroups showed significant increases in the

HJHS and HEAD-US scores at the 12 th month in the hemophilia A

subgroup (Tables 3 and 6). However, the number of hemophilia B

patients included in this study is much smaller in comparison to

the hemophilia A subgroup. For subgroup analysis by prophylaxis

groups, results are shown in Tables 4 and 5. The elevated scores

found in the adult group were statistically significant compared

to the children.

Correlation analyses were performed for the joint scores at the

baseline and 12 th month. Among all patients, the HJHS total

score was found to significantly correlate with the HEAD-US

total score at the baseline and 12 th month. Moreover, there

was a significant correlation between the Pettersson total score

and the HEAD-US total score at baseline and the 12 th month

(Table 7). Strong correlation was found among the three scoring

systems (HJHS, HEAD-US, and Pettersson) at baseline and after

12 months of observation (p<0.001).

There were no significant differences in the QoL scores between

the baseline and 12 th month in all patients.

Neither pediatric vs. adult group nor hemophilia A vs. hemophilia

B comparisons were significant.

Comparisons of the QoL scores of the patients between the

baseline and 12 th month are presented in Table 8.

Table 3. Joint scores of all patients at baseline and follow-up visits.

Baseline 60

3 rd month 58

6 th month 58

9 th month 53

12 th month 56

n

HJHS

Total score

Mean ± SD

Median (min-max)

9.97±12.41

3 (0-48)

11.1±13.42

5.5 (0-55)

13.95±16.92

5 (0-56)

9.79±13.4

3 (0-50)

11.18±14.55

3 (0-57)

n

61

56

50

41

53

HEAD-US

Total score

Mean ± SD

Median (min-max)

9.70±9.25

7 (0-33)

9.75±9.87

7 (0-36)

9.48±10.41

6.5 (0-40)

9.73±10.31

6 (0-40)

11.51±10.61

8 (0-40)

n

15

- -

- -

- -

13

Pettersson

Total score

Mean ± SD

Median (min-max)

15.4±15.71

11 (0-47)

17.23±17.14

14 (0-48)

HJHS: Hemophilia Joint Health Score; HEAD-US: Hemophilia Early Arthropathy Detection with Ultrasound; SD: standard deviation; min-max: minimum-maximum.

Table 4. Both scoring systems and relationship with frequency of prophylaxis.

HJHS

Total score

Mean ± SD

Median (min-max)

n

Baseline 35

3 rd

month

6 th

month

9 th

month

12 th

month

34

29

28

31

Receiving

prophylaxis

1-2 times a week

11.74±13.32

8 (0-48)

12.06±13.22

6.5 (0-48)

12.14±14.55

4 (0-48)

8.46±12.59

3 (0-48)

10.48±13.44

3 (0-48)

n

15

16

18

16

14

Receiving

prophylaxis

≥3 times a week

5.87±9

2 (0-29)

5.75±6.81

3 (0-25)

11.94±15.52

5.5 (0-54)

10.13±12.09

6 (0-38)

10.79±13.41

5 (0-41)

P

HEAD-US

Total score

Mean ± SD

Median (min-max)

n

0.517 39

0.973 31

0.410 28

0.739 23

0.557 32

Receiving

prophylaxis

1-2 times a week

10.05±10.05

7 (0-33)

10.61±11.45

7 (0-36)

9.46±12

4 (0-40)

9.87±11.25

6 (0-40)

11.44±11.83

7 (0-40)

n

13

16

13

11

11

Receiving

prophylaxis

≥3 times a week

6.69±6.17

5 (0-20)

8.19±6.96

7 (0-22)

8.38±6.05

9 (0-23)

8.27±5.9

8 (0-22)

10.45±6.19

10 (0-22)


p

0.172

0.244

0.895

0.366

0.795

105



Discussion

In all patients, there were significant increases in the HEAD-

US and HJHS scores during the one-year follow-up period

despite prophylaxis. This was consistent with the results

obtained from the study by Warren et al. [12], in which only

a small number of PwH had no damage in their joints when

they reached adolescence, in spite of early prophylaxis. In the

present study, subgroup evaluation according to age revealed

a significant increase in the joint scores from baseline to

the 12 th month in the adult group but not in the pediatric

group. In other words, prophylactic treatment slowed down

the progression upon onset of arthropathy in children, but

degenerative arthropathic changes persisted in adult patients.

Subgroup analysis results supported the importance of early

prophylaxis in childhood.

Similarly, Warren et al. [12] reported that the risks of

osteochondral damage on MRI and increased ABR and joint

ABR were significantly higher in the children who began

using prophylactic factor VIII after 6 years of age compared to

children for whom prophylaxis was initiated before 2.5 years of

age. These results show the importance of preventing initiation

of joint damage by means of prophylaxis at an early stage in

life, because the earlier the damage occurs, the more difficult

it is to prevent its progression. For this reason, examination

of the joints by means of regular follow-up is important for

early detection and prevention of arthropathic changes in PwH.

Geraghty et al. [13] showed that nonadherence to treatment

was higher among adults compared to children with hemophilia.

As adolescent and adult patients are prone to failures to adhere

to clinical practice, we used reminders about compliance every

3 months during clinical visits.

Early initiation of prophylactic treatment and good adherence

to treatment are important factors to reduce the incidence of

bleeding and to preserve joint functions in PwH [14,15].

Hemophilic arthropathy is a progressive condition and negatively

impacts the QoL of patients as damage progresses. It has been

reported that QoL is lower in PwH as compared to the general

population [16]. Earlier studies have demonstrated poorer QoL

in patients with severe joint problems [16,17,18]. These data

support the importance of appropriate treatment to limit

joint injury. In the present study, QoL was assessed using the

Table 5. Prophylaxis regimens and relationship with scores in subgroups of children and adults.

Total scores

Children (6-17 years)

HJHS 29

<3 years of age 17

≥3 years of age 10

HEAD-US 29

<3 years of age 17

≥3 years of age 9

Adults (≥18 years)

HJHS 23

Receiving <10 years of treatment 3

Receiving ≥10 years of treatment 20

HEAD-US 23

Receiving <10 years of treatment 4

Receiving ≥10 years of treatment 19

Baseline

n

Mean ± SD

Median (min-max)

1.86±3.07

1 (0-13)

1.41±2.67

0 (0-11)

2.7±3.86

2 (0-13)

4.03±4.59

2 (0-16)

4.53±5.57

1 (0-16)

3.44±2.96

3 (0-9)

17.96±12.55

17 (0-48)

21.33±4.51

21 (17-26)

17.45±13.35

13.5 (0-48)

17.3±8.96

18 (0-33)

21.25±6.29

22 (14-27)

16.47±9.35

17 (0-33)

HJHS: Hemophilia Joint Health Score; HEAD-US: Hemophilia Early Arthropathy Detection with Ultrasound.

12 th month

Mean ± SD

Median (min-max)

3.17±7.07

1 (0-36)

3.24±8.55

1 (0-36)

3.6±4.86

2 (0-16)

4.69±4.35

5 (0-14)

4.94±4.6

5 (0-14)

4.67±4.58

5 (0-11)

22.43±15.4

22 (0-57)

23.67±2.08

23 (22-26)

22.25±16.55

20 (0-57)

19.78±10.34

22 (0-40)

26±4.08

24.5 (23-32)

18.47±10.83

19 (0-40)

P

0.166

0.158

0.438

0.322

0.623

0.395

0.017

-

0.031

0.006

-

0.023

106



EQ-5D-3L and SF-36 questionnaires. The QoL scores of the

patients were generally high, indicating a better QoL, and

the mean scores were similar at the baseline and 12 th month.

Assessment of QoL not only gives information about clinical

statuses of patients but also provides an objective criterion

for measuring benefit gained from treatment [19,20]. Better

adherence of patients to treatment is associated with better

outcomes and is a factor that improves QoL [21,22,23].

During the follow-up of PwH, joint function is assessed by

physical examination and the HJHS is widely used for scoring.

However, implementation of the HJHS requires training and

experience [24]. Plain radiographs have also long been used

to evaluate the musculoskeletal system. The Pettersson scoring

system, a radiological joint scoring system, gives quite reliable

outcomes when applied by an experienced radiologist [24].

MRI is a more sensitive imaging method than plain radiogram

Table 6. Comparison of the joint scores at the baseline and 12 th month.

Total scores

All patients

HJHS 52

HEAD-US 52

Baseline

n

Mean ± SD

Median (min-max)

8.98±11.76

3 (0-48)

9.90±9.51

7 (0-33)

12 th month

Mean ± SD

Median (min-max)

11.69±14.93

3 (0-57)

11.37±10.67

8 (0-40)

p

0.007

0.007

Pettersson 13

17.00±16.32

12 (0-47)

17.23±17.14

14 (0-48)

0.631


HJHS 29

1.86±3.07

1 (0-13)

3.17±7.07

1 (0-36)

0.166

HEAD-US 29

4.03±4.59

2 (0-16)

4.69±4.35

5 (0-14)

0.322

Pettersson 6

3.83±4.45

2.5 (0-11)

2.67±2.66

2.5 (0-7)

0.197


HJHS 23

17.96±12.55

17 (0-48)

22.43±15.4

22 (0-57)

0.017

HEAD-US 23

17.3±8.96

18 (0-33)

19.78±10.34

22 (0-40)

0.006

Pettersson 7

28.29±13.94

32 (12-47)

29.71±13.7

32 (14-48)

0.041

Hemophilia A patients

HJHS 42

8.76±11.56

2.5 (0-48)

10.95±13.61

3 (0-48)

0.020

HEAD-US 43

9.35±9.63

6 (0-33)

10.86±10.58

7 (0-40)

0.010

Pettersson 10

18.9±17.91

11.5 (0-47)

18.7±18.99

10.5 (0-48)

0.752

Hemophilia B patients

HJHS 10

9.9±13.16

3.5 (0-36)

14.8±20.15

5 (0-57)

0.232

HEAD-US 9

12.56±8.99

13 (1-30)

13.78±11.4

11 (0-33)

0.338

Pettersson 3

10.67±8.74

13 (1-18)

12.33±9.61

14 (2-21)

0.102


107



in evaluating the joints. Nevertheless, MRI has practical

disadvantages such as the long scanning period, high cost,

limited availability, and need for sedation in young children [24].

There is a need for an easy, cost-effective, repeatable, efficient,

and reliable joint scoring system. Therefore, ultrasonography

has become an attractive method in the last years for objective

evaluation of joint status and for early detection of changes

during periodic follow-up [25,26,27,28,29]. Ultrasonography

provides advantages such as appropriate cost, availability,

repeatability, faster examination, no need for sedation while

examining children, and scanning of multiple joints and dynamic

examination of joints in a single session [30]. Ultrasonography

Table 7. Petterson score and its correlation with HJHS and

HEAD-US Scorring system.*

Baseline

12 th month

n RHO p n RHO p

HEAD-US 14 0.842 <0.001 13 0.861 <0.001

HJHS 14 0.828 <0.001 13 0.827 <0.001

*Spearsman’s rho correlation test.

HJHS: Hemophilia Joint Health Score; HEAD-US: Hemophilia Early Arthropathy

Detection with Ultrasound.

allows detection and quantitation of signs of disease activity

(fluid collection in the joint, synovial hypertrophy, etc.) and

degenerative cases (osteochondral changes, etc.) and it is also

beneficial in discriminating inflammatory (serous) effusion from

hemarthrosis. Ultrasonography, as a simple and practical tool, is

a powerful potential tool to be utilized in routine hemophilia

care in the near future [28].

Several scoring systems have recently been proposed to provide

objectivity in ultrasonographic evaluation; the HEAD-US is one

of them [28]. The HEAD-US scoring system has advantages

such that it can be applied by non-imaging specialists.

However, even though this scoring system can be performed

by non-radiologists after a short training period, the speed of

the exam is dependent on the sonographer’s experience level

[24,31].

There are studies using the HEAD-US scoring to assess joint

status in PwH and evaluating its correlation with HJHS scores.

In a study evaluating joint status in children with severe

hemophilia A receiving prophylaxis, 85.3% of the joints were

found normal by the HJHS, whereas 79.0% of the joints were

found normal by the HEAD-US scoring system [32]. While there

Table 8. Comparison of the quality of life scores of the patients between the baseline and 12 th month.

All patients

EQ5D 61

SF-36, total 49


EQ5D 31

SF-36, total 24


EQ5D 30

SF-36, total 25

Hemophilia A patients

EQ5D 51

SF-36, total 43

Hemophilia B patients

EQ5D 10

SF-36, total 6

Baseline

n

Mean ± SD

Median (min-max)

0.803±0.209

0.783 (0.043-1)

77.2±15.94

80.88 (30.75-97.25)

0.913±0.123

1 (0.624-1)

84.09±10.51

85.13 (59-97.25)

0.689±0.22

0.713 (0.043-1)

70.59±17.58

75.75 (30.75-92)

0.797±0.217

0.783 (0.043-1)

77.65±16.33

82.13 (30.75-97.25)

0.835±0.171

0.806 (0.48-1)

74.02±13.67

76.75 (57.88-93.38)

EQ-5D: European Quality of Life-5 Dimensions; SF-36: Short Form-36; SD: standard deviation; min-max: minimum-maximum.

12 th month

Mean ± SD

Median (min-max)

0.806±0.191

0.783 (0.239-1)

77.2±18.02

83.38 (31.88-98)

0.870±0.156

1 (0.48-1)

87.17±6.42

87.44 (73-98)

0.740±0.203

0.78 (0.239-1)

67.64±20.38

69.13 (31.88-96)

0.800±0.198

0.783 (0.239-1)

76.75±18.56

83.38 (31.88-98)

0.839±0.153

0.783 (0.57-1)

80.46±14.44

82.44 (53.25-96)

p

0.777

0.739

0.154

0.331

0.381

0.628

0.752

0.957

1.000

0.249

108



was a correlation between the HEAD-US scores and bleeding

scores, no correlation was determined between the HEAD-US

and HJHS scores. Nevertheless, the HJHS and HEAD-US scores

were concordant for 73.4% of the joints. Ultrasound detected

minimal changes in 19.6% of the joints with normal physical

functioning, whereas 12.2% of the joints that were considered

normal on ultrasound showed changes according to the HJHS.

As a consequence, ultrasound detected a higher percentage of

abnormalities than physical examination [32]. Jiménez-Yuste

et al. [33] carried out a study of hemophilia B patients and

concluded that using the HEAD-US scoring system in routine

practice provided patients with better and more objective

evaluation and contributed to personalization of treatment.

Li et al. [34] determined a significant correlation between

the HEAD-US and HJHS scores in PwH receiving prophylactic

treatment. Banchev et al. [35] reported a strong correlation

between three-year joint bleeding rates and HEAD-US total

scores for ankle and knee joints in hemophilia A patients receiving

secondary/tertiary prophylaxis. Plut et al. [36] conducted a

study of patients with severe hemophilia and determined a

very high correlation between the overall HEAD-US scores and

overall International Prophylaxis Study Group MRI scores. They

suggested the HEAD-US protocol as a fast, reliable, and accurate

method for detecting hemophilic arthropathy and determining

its degree. In the present study, considering all patients, the

HEAD-US total scores showed a correlation with both the HJHS

total score and the Pettersson total score. Joint tissue activity

and damage examination (the JADE protocol) was developed

for soft tissue and osteochondral measurements for a POC

ultrasound scoring system in the United States, patented by the

University of California-San Diego [37]. The JADE protocol has

similar principles, is easy to learn and administer, and is ideal

for use in routine practice as well as achieving useful outcomes

as a research tool. Both protocols (JADE and HEAD-US) appear

feasible for quantifying hemophilic intraarticular abnormalities

with lower variabilities.

Study Limitations

The main limitation of the present study was not including

more patients receiving on-demand treatment and thereby not

comparing the data of patients receiving prophylactic treatment

with those receiving on-demand treatment. Another limitation

was missing some patients during the prospective evaluation

due to data deficiencies. Even though we were able to calculate

statistical analysis, without any missing patients we would have

been able to provide even better results.

Conclusion

The HEAD-US and HJHS scoring systems are valuable tools during

follow-up examinations of patients and they complement each

other. We suggest that POC ultrasonographic evaluation and

the HEAD-US scoring system may be integrated into differential

diagnosis not only for bleeding and but also for long-term

monitoring of joint health of PwH as a routine procedure. It

would thereby be possible to provide PwH maximum benefit by

means of early diagnosis of joint changes and bleedings that

might be overlooked during physical examination and, in turn,

to personalize prophylactic treatment.

Ethics

Ethics Committee Approval: Ege University Faculty of Medicine

Clinical Research Ethics Committee (date: 15.5.2016/no: 16-

5.1/47).

Informed Consent: Obtained.

Authorship Contributions

Design: K.K.; Data Collection or Processing: K.K., S.S.Ö., A.B.A.,

F.Ş., Ş.S.A., A.K., B.Z., M.S., Ü.Ç., C.B., T.A., T.Ar., İ.T., T.S., B.O.,

C.Ç., M.B., P.K., D.A., İ.Ş., G.T., B.K., H.T., Z.M., B.Ö.; Analysis or

Interpretation: K.K.

Conflict of Interest: No conflict of interest was declared by the

authors.

Financial Disclosure: K. Kavaklı reports scientific advisory board

and funding research from Pfizer, Bayer, Novo Nordisk, Roche,

and Takeda. F. Şahin reports advisory board and funding research

from Pfizer, Takeda, Bayer, and Novo Nordisk. B. Zülfikar reports

advisory board and/or consultancy funding from Pfizer, Shire,

Novo Nordisk, Roche, Sobi, Bayer, and Biomarin. C. Balkan

reports advisory board and funding research from Pfizer, Takeda,

Bayer, Novo Nordisk, and Roche. B. Özkan is an employee of

Pfizer Pharmaceuticals. The remaining authors state that they

had no interests that might be perceived as posing a conflict

or bias.

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110

Narlı Özdemir Z. et al: Pre- and Post-Transplant Measurable Residual Disease in Acute Myeloid Leukemia Patients

RESEARCH ARTICLE

DOI: 10.4274/tjh.galenos.2020.2020.0157


Highlighting the Prognostic Importance of Measurable Residual

Disease Among Acute Myeloid Leukemia Risk Factors

Akut Myeloid Lösemi Risk Faktörleri Arasında Ölçülebilir Kalıntı Hastalığın Prognostik

Öneminin Vurgulanması

Zehra Narlı Özdemir 1 , Uğur Şahin 2 , Klara Dalva 3 , Mehmet Akif Baltacı 4 , Atilla Uslu 3 , Cemaleddin Öztürk 3 ,

Güldane Cengiz Seval 3 , Selami Koçak Toprak 3 , Meltem Kurt Yüksel 3 , Pervin Topçuoğlu 3 , Önder Arslan 3 , Muhit Özcan 3 ,

Meral Beksaç 3 , Osman İlhan 3 , Günhan Gürman 3 , Sinem Civriz Bozdağ 3

1Ankara City Hospital, Clinic of Hematology, Ankara, Turkey

2Medicana International Ankara Hospital, Clinic of Hematology, Ankara, Turkey

3Ankara University Faculty of Medicine, Department of Hematology, Ankara, Turkey

4Ankara University Faculty of Medicine, Department of Internal Medicine, Ankara, Turkey

Abstract

Objective: The optimal timing of measurable residual disease (MRD)

evaluation in acute myeloid leukemia (AML) patients has not been

well defined yet. We aimed to investigate the impact of MRD in

pre- and post-allogeneic hematopoietic stem cell transplantation

(AHSCT) periods on prognostic parameters.

Materials and Methods: Seventy-seven AML patients who underwent

AHSCT in complete morphological remission were included. MRD

analyses were performed by 10-color MFC and 10 -4 was defined as

positive. Relapse risk and survival outcomes were assessed based on

pre- and post-AHSCT MRD positivity.

Results: The median age of the patients was 46 (range: 18-71)

years, and 41 (53.2%) were male while 36 (46.8%) were female. The

median follow-up after AHSCT was 12.2 months (range: 0.2-73.0).

The 2-year overall survival (OS) in the entire cohort was 37.0%, with

a significant difference between patients who were MRD-negative

and MRD-positive before AHSCT, estimated as 63.0% versus 16.0%,

respectively (p=0.005). MRD positivity at +28 days after AHSCT was

also associated with significantly inferior 2-year OS when compared

to MRD negativity (p=0.03). The risk of relapse at 1 year was 2.4 times

higher (95% confidence interval: 1.1-5.6; p=0.04) in the pre-AHSCT

MRD-positive group when compared to the MRD-negative group

regardless of other transplant-related factors, including pre-AHSCT

disease status (i.e., complete remission 1 and 2). Event-free survival

(EFS) was significantly shorter in patients who were pre-AHSCT

MRD-positive (p=0.016). Post-AHSCT MRD positivity was also related

to an increased relapse risk. OS and EFS were significantly inferior

among MRD-positive patients at +28 days after AHSCT (p=0.03 and

p=0.019).

Conclusion: Our results indicate the importance of MRD before and

after AHSCT independently of other factors

Keywords: Acute myeloid leukemia, Measurable residual disease,

Multiparameter flow cytometry

Öz

Amaç: Akut myeloid lösemi (AML) hastalarında ölçülebilir kalıntı

hastalık (MRD) değerlendirmesinin optimal zamanlaması henüz tam

olarak tanımlanmamıştır. Allojeneik hematopoietik kök hücre nakli

(AHKHN) öncesinde ve sonrasında MRD’nin prognostik parametreler

üzerindeki etkisini araştırdık.

Gereç ve Yöntemler: Tam morfolojik remisyonda AHKHN yapılan

77 AML hastası çalışmaya dahil edildi. MRD analizleri 10 renkli akım

sitometri ile yapıldı ve 10 -4 pozitif olarak tanımlandı. Nüks riski ve

sağkalım sonuçları AHKHN öncesi ve sonrası MRD pozitifliğine göre

değerlendirildi.

Bulgular: Hastaların ortanca yaşı 46 (18-71) yıl olup, bunların 41’i

(%53,2) erkek, 36’sı (%46,8) kadındı. AHKHN sonrası medyan takip

süresi 12,2 aydı (0,2-73 ay). Tüm kohortta 2 yıllık genel sağkalım (OS)

%37 olup, nakil öncesi MRD-negatif ve MRD-pozitif olan hastalar

arasında anlamlı sağkalım farkı saptandı (%63 vs %16, p=0,005). İki

yıllık OS AHKHN sonrası +28 günde MRD pozitif olan hastalarda, MRD

negatif olanlar ile karşılaştırıldığında önemli ölçüde kısa bulundu

(p=0,03). Bir yıllık nüks riski nakil öncesi hastalık durumu da dahil

olmak üzere diğer nakil ile ilişkili faktörlerden bağımsız olarak, nakil

öncesi MRD pozitif olanlarda MRD negatif hastalara kıyasla 2,4 kat

(%95 güven aralığı: 1,1-5,6; p=0,04) daha yüksek bulundu. AHKHN

öncesi MRD pozitif olan hastalarda olaysız sağkalım (EFS) anlamlı

olarak daha kısaydı (p=0,016) ve nakil sonrası MRD pozitifliği artmış

nüks riskiyle ilişkiliydi. OS ve EFS, nakil sonrası +28 günde MRD pozitif

olan hastalar arasında daha kısa saptandı (p=0,03 ve p=0,019).

Sonuç: Sonuçlarımız diğer faktörlerden bağımsız olarak AHKHN

öncesi ve sonrası MRD’nin önemini göstermektedir.

Anahtar Sözcükler: Akut myeloid lösemi, Ölçülebilir kalıntı hastalık,

Çok renkli akım sitometri



Address for Correspondence/Yazışma Adresi: Zehra Narlı Özdemir, M.D., Ankara City Hospital,

Clinic of Hematology, Ankara, Turkey

E-mail : zehranarli@hotmail.com ORCID: orcid.org/0000-0003-3237-320X

Received/Geliş tarihi: April 7, 2020

Accepted/Kabul tarihi: October 24, 2020

111



Introduction

Acute myeloid leukemia (AML) is a biologically aggressive

and heterogeneous disease characterized by a large number

of molecular abnormalities [1]. Although achievement of

morphological complete remission (CR) is still an important

end point, this cut-off allows for the presence of up to 10 10

leukemic blasts or more [2]. Approximately two-thirds of CR

patients may relapse within a few years after frontline therapy

[3,4]. At diagnosis multiple factors have prognostic impact for

outcome, including clinical parameters and cytogenetics, as well

as molecular factors and biological properties of the leukemic

cells. Risk factors at diagnosis were shown to correlate with

quality of remission as reflected by measurable residual disease

(MRD) [5,6].

Allogeneic hematopoietic stem cell transplantation (AHSCT)

may be the curative treatment option for patients with AML.

The outcome of AHSCT depends on various factors including

conditioning regimen, CR status, cytogenetic risk group and

molecular markers, graft-versus-host disease (GvHD) prophylaxis,

and presence of chronic GvHD [7]. According to a report of

the European Society for Blood and Marrow Transplantation,

approximately 40% of AML patients will relapse after AHSCT

and have poor prognosis with 2-year survival of <20% [7].

Transplant-related mortality and disease relapse remain the

most significant barriers for long-term survival of AML patients.

In previous studies, MRD positivity after induction and

post-remission therapy have been widely analyzed. However,

the optimal timing of MRD monitorization in AML patients has

not been clearly defined yet. Data about the impact of MRD in

the AHSCT setting are limited [8,9].

In the present study, we analyzed AML patients undergoing

AHSCT in morphological CR for whom pre- and post-AHSCT

MRD assessments by multicolor flow cytometry were available.

Besides ascertaining the relationship between pre/post-AHSCT

MRD and post-AHSCT outcomes, we also investigated whether

MRD is more important than other risk factors including

conditioning regimen [myeloablative (MA) or non-MA (NMA)],

pre-AHSCT disease status (CR 1 or >CR 1 ), cytogenetic risk, donor

type, the presence of acute GvHD, and cytomegalovirus (CMV)

reactivation.


Patients

We retrospectively evaluated 77 AML patients who were older

than 18 years and underwent AHSCT while in morphological

CR between January 2013 and December 2018 in the Ankara

University School of Medicine. The patients without MRD data

before and after AHSCT were excluded from the study.

The medical records of the Ankara University Faculty of Medicine

were reviewed in terms of age, sex, conditioning regimen (MA or

NMA), pre-AHSCT disease status (CR 1 or >CR 1 ), donor type [fully

matched, single antigen-mismatched (SAM), or haploidentical],

cytogenetic risk (favorable, standard, or high), presence of acute

GvHD, CMV reactivation, and presence of MRD before AHSCT

and at day +28 after AHSCT. Information on post-transplant

outcomes was obtained via the follow-up program through

medical records from our outpatient clinic.

The diagnosis of AML was based on clinical, morphological, and

immunophenotypical features identified based on the 2008

revision of the World Health Organization (WHO) classification

of AML and related neoplasms for those who were diagnosed

before 2016 [10]. Revised WHO criteria were used to define AML

after 2016 [11]. CR was defined as <5% blasts by morphology

in pre-transplant BM aspirates. The 2017 European Leukemia

Network risk stratification by genetics was used to assign

cytogenetic risk [12].

Detection of MRD

Multiparameter flow cytometry (MFC) was performed for all

patients as a routine clinical test on bone marrow aspirates as

a baseline assessment before AHSCT as well as on day +28 after

AHSCT. MRD assessments were performed during pre-transplant

workup and at days 28±7 after AHSCT in patients who achieved

engraftment. Neutrophil and platelet engraftment were obtained

in all patients before MRD assessment, except one who underwent

a second AHSCT with haploidentical graft. Engraftment was

defined as an absolute neutrophil count greater than 500 cells

per liter (absolute neutrophil count >0.5x10 9 /L) on the first day

of three consecutive days and platelet count greater than 20,000

cells per liter (platelet count >20x10 9 /L) on the first day of seven

consecutive days without transfusion support.

Ten-color MFC was used for MRD assessment and MRD was

identified by visual inspection as a cell population showing

deviation. The approaches used to detect MRD by MFC were

identification of leukemia-associated immunophenotypes that

differed from the majority of normal hematopoietic cells and

identification of different-from-normal patterns [13,14].

Core markers were selected for the backbone of the panel to

identify myeloid blast populations, combined with markers

from lymphoid/myelomonocytic maturation groups to define

the AML MRD panel. An AML MRD panel consisting of antibody

combinations recognizing CD4, CD5, CD7, CD11b, CD13, CD14,

CD15, CD16, CD19, CD33, CD34, CD38, CD45, CD45RA, CD56,

CD64, CD71, CD117, CD123, and HLA-DR was used for MRD

detection. A total of 100,000 to 500,000 nucleated cells were

examined and 10 -4 was the threshold for the sensitivity of MRD

detection [15]. The acquisition of the cells was performed using

a Navios flow cytometer (3-laser, 10-color, Beckman Coulter).

112



The collected data were analyzed using Kaluza software (Navios,

Beckman Coulter, USA). When an abnormal population was

identified, it was quantified as a percentage of the total CD45+

white cell events. Any measurable level of MRD was considered

positive [16].


The main objective of this study was detecting a significant

survival advantage, if any, among MRD-negative patients

(either pre- or post-AHSCT) when compared to MRD-positive

patients. Relapse and transplant-related mortality rates were

also evaluated as secondary objectives. Three major outcomes

were assessed accordingly: overall survival (OS), event-free

survival (EFS), and non-relapse mortality (NRM), which were

calculated from the time of transplant. The survival estimations

were performed by Kaplan-Meier method and the log-rank test

was used for comparison of survival distribution among groups.

Patient age, sex, donor type, cytogenetic risk, disease status at

AHSCT (CR 1 or >CR 1 ), type of conditioning regimen, presence

of CMV reactivation, and cumulative incidences of acute and

chronic GvHD were compared by chi-square, Fisher exact,

Student t, and Mann-Whitney U tests as appropriate. GvHD

could not be calculated as a cumulative incidence function or

considered a competing mortality risk due to a lack of data on

GvHD onsets.

Retrospective power analysis with a two-sided log rank test

demonstrated 86.0% power at a 0.05 significance level to

detect a difference of 0.25 between 0.63 and 0.38, which are

the calculated 1-year estimated OS rates in the pre-AHSCT

MRD-negative and MRD-positive cohorts, respectively.

Cox regression analysis was used to determine the effects of MRD

positivity adjusted for potential confounding factors. In order to

analyze the effects of factors associated with at least borderline

significance (p<0.20) in the univariate analysis on the outcomes

of OS, EFS, and NRM, they were entered via backwards selection

into a Cox proportional hazards model, which was assessed by

means of residual (Schoenfeld and Martingale) analysis. Cohort

size limited the number of factors in each model to those

with suggested association in univariate analysis. Multivariate

analyses were performed for only pre-AHSCT MRD since no

factors with statistical significance were suggested in the

univariate analyses of post-AHSCT MRD. Multivariate analyses

for pre-AHSCT MRD included pre-AHSCT disease status and the

presence of acute GvHD as potential confounders.

The statistical software packages PASS version 11.0 (NCSS, LLC,

Kaysville, UT, USA) and IBM SPSS Statistics for Windows version

25.0 (IBM Corp., Armonk, NY, USA) were used for power analysis

and for the rest of the statistical analysis, respectively. Type I

error of 5% (two-sided) was used to infer statistical significance

in all analyses.

Results

Forty-one male (53.2%) and 36 female (46.8%) patients

were included in the study (n=77). The median age was 46

(range: 18-71) years. Nine (11.7%) patients had favorable

cytogenetic risk profiles and 68 (88.3%) patients had

standard-high risk. t(v;11q23.3) (MLL rearranged) was observed in

1 patient, inversion 16 (inv 16) in 3 patients, t(8,21) in 3 patients,

and NPM1 mutation in 3 patients at the pre-transplantation

workup. Forty-four (57.1%) patients underwent AHSCT from a

fully matched donor, 27 (35.1%) from a SAM donor, and 6 (7.8%)

from a haploidentical donor. Fifty-two (67.5%) and 25 (32.5%)

patients underwent transplantation in CR 1 and CR 2 , respectively.

Sixty-four (83.1%) patients received MA and 13 (16.9%) NMA

conditioning regimens. Forty-four (57.1%) patients were

pre-AHSCT MRD-negative whereas 43 (55.8%) of patients had

MRD negativity at post-transplantation assessment (Table 1).

Of the 44 patients who were MRD-negative prior to transplant,

34 (77%) remained MRD-negative and 10 patients (22.7%)

had detectable MRD. Of the 33 patients MRD-positive before

transplant, 9 achieved MRD negativity after transplantation

(Table 2).

Relationships Among MRD Status, Survival, Relapse, and NRM

No significant differences were observed between

MRD-negative and MRD-positive groups in terms of age,

cytogenetic risk, donor type, pre-AHSCT disease status (CR 1 or

>CR 1 ), conditioning regimen, presence of acute and chronic

GvHD, or CMV reactivation, neither in the pre-AHSCT nor the

post-AHSCT period (p>0.05) (Table 3).

Table 1. General characteristics of patients.

Age, median (min-max) 46 (18-71)

Gender, n (%)

Cytogenetic risk, n (%)

Donor type, n (%)

Pre-AHSCT disease status, n (%)

Conditioning regimen, n (%)

Pre-AHSCT MRD, n (%)

Post-AHSCT MRD, n (%)

Male 41 (53.2)

Female 36 (46.8)

Favorable 9 (11.7)

Standard and high 68 (88,3)

Fully matched 44 (57.1)

SAM 27 (35.1)

Haploidentical 6 (7.8)

CR 1 52 (67.5)

>CR 1 25 (32.5)

MA 64 (83.1)

NMA 13 (16.9)

Negative 44 (57.1)

Positive 33 (42.9)

Negative 43 (55.8)

Positive 34 (44.2)

AHSCT: Allogeneic hematopoietic stem cell transplantation; MRD: measurable residual

disease; SAM: single antigen-mismatched; CR: complete remission; MA: myeloablative;

NMA: non-myeloablative; min: minimum; max: maximum.

113



The median follow-up after AHSCT was 12.2 months

(range: 0.2-73.0) with no patients lost to follow-up. The risk of

relapse at 1 year was estimated to increase by 2.4 times [95%

confidence interval (CI): 1.1-5.6; p=0.04] in the pre-AHSCT

MRD-positive group when compared to the MRD-negative

group. EFS was significantly shorter in patients who had pre-

AHSCT MRD positivity (p=0.016; Figure 1). Post-AHSCT MRD

positivity was also associated with increased relapse risk. EFS

was significantly poorer in patients who were MRD-positive on

day +28 after AHSCT (p=0.019) (Figure 2). MRD positivity before

and after AHSCT did not show a significant association with

NRM (p=0.97 and 0.56, respectively).

The 2-year estimate of OS in the entire cohort was 37.0%. A

significant difference in OS was observed between patients who

were MRD-negative and MRD-positive before AHSCT, estimated

as 63.0% versus 16.0% at 2 years (p=0.005) (Figure 1). Patients

who were MRD-negative on day +28 after AHSCT had higher

OS rates when compared to MRD-positive patients at 1 year

Table 2. Changes of MRD status according to AHSCT.

Post-AHSCT

MRD+

Post-AHSCT

MRD-

Pre-AHSCT MRD- 10 34 n=44

Pre-AHSCT MRD+ 24 9 n=33

n=34 n=43 n=77

AHSCT: Allogeneic hematopoietic stem cell transplantation; MRD: measurable residual

disease.

(63.0% vs. 41.0%) and at 2 years (55.0% vs. 23.0%), respectively

(p=0.03) (Figure 2).

Patients who were MRD-negative before and after AHSCT had

the best OS and EFS (p=0.035 and 0.057, respectively). Patients

who underwent AHSCT with positive MRD status and those who

came out of the transplant again with the presence of MRD had

the worst OS and EFS (p=0.035 and 0.057, respectively) (Figures

3 and 4). In Cox regression analysis, patients with negative MRD

status before and after AHSCT had significantly better OS and

EFS compared with patients who were MRD-positive before and

after transplantation (p=0.006 and 0.008, respectively). OS and

EFS were better in patients with pre-AHSCT MRD negativity

and post-AHSCT MRD positivity and those with pre-AHSCT

MRD positivity and post-AHSCT MRD negativity compared

with patients with pre- and post-AHSCT positive MRD status;

however, this did not reach statistical significance.

In the pre-AHSCT MRD-negative group, the presence of

acute GvHD was related to inferior OS and EFS rates (p=0.02

and 0.006, respectively) (Figure 5). Acute GvHD occurred in

27 (35%) patients, cutaneous acute GvHD in 14 (51.9%) patients,

gastrointestinal system (GIS) GvHD in 7 (25.9%) patients,

cutaneous and GIS acute GvHD in 3 (11.1%) patients, GIS and

liver acute GvHD in 2 (7.4%) patients, and cutaneous, GIS, and

liver acute GvHD in 1 (3.7%) patient. Grade 3-4 acute GvHD

according to the Glucksberg criteria was observed in 10 (37%)

patients. Multivariate analyses including pre-AHSCT MRD status

Table 3. Distribution of studied parameters according to pre- and post-MRD positivity.

Pre-AHSCT MRD

Post-AHSCT MRD

p

Negative Positive Negative Positive

Age, median (min-max) 47 (18-71) 44 (19-67) 0.40 47 (18-71) 46 (19-63) 0.57

Cytogenetic risk, n (%)

Donor type, n (%)

Pre-AHSCT disease status, n (%)

Conditioning regimen, n (%)

Acute GvHD, n (%)

Chronic GvHD, n (%)

CMV reactivation, n (%)

Favorable 5 (55.6) 4 (44.4)

4 (66.7) 2 (33.3)

0.92

Standard and high 39 (57,4) 29 (42.6) 35 (53.8) 30 (46.2)

Fully matched 25 (56.8) 19 (33.2)

22 (53.7) 19 (46.3)

SAM 16 (59.3) 11 (40.7) 0.92 15 (60.0) 10 (40,0)

Haploidentical 3 (50.0) 3 (50.0) 2 (40.0) 3 (60.0)

CR 1 31 (59.6) 21 (40.4)

30 (62.5) 18 (37.5)

0.53

>CR 1 13 (52.0) 12 (48.0) 9 (39.1) 14 (60.9)

MA 35 (54.7) 29 (45.3)

31 (53.4) 27 (46.6)

0.33

NMA 9 (69.2) 4 (30.8) 8 (61.5) 5 (38.5)

Absent 29 (58.0) 21 (42.0)

27 (61.4) 17 (38.6)

0.84

Present 15 (55.6) 12 (44.4) 12 (44.4) 15 (55.6)

Absent 37 (57.8) 27 (42.2)

32 (55.2) 26 (44.8)

0.84

Present 6 (54.5) 5 (45.5) 5 (45.5) 6 (54.5)

Absent 27 (55.1) 22 (44.9)

25 (58.1) 18 (41.9)

0.63

Present 17 (60.7) 11 (39.3) 14 (50.0) 14 (50.0)

AHSCT: Allogeneic hematopoietic stem cell transplantation; MRD: measurable residual disease; SAM: single antigen-mismatched; CR: complete remission; MA: myeloablative; NMA:

non-myeloablative; GvHD: graft-versus-host disease; CMV: cytomegalovirus.

p

0.55

0.69

0.06

0.60

0.16

0.55

0.50

114



and the presence of acute GvHD showed that an OS advantage

remained in patients who were MRD-negative in the pre-AHSCT

period even if acute GvHD occurred after transplantation

(hazard ratio: 2.5, 95% CI: 1.3-4.9; p=0.008).

In the presence of pre-AHSCT MRD, other variables known

to have prognostic significance including age, cytogenetic

risk, donor type, pre-AHSCT disease status (CR 1 or >CR 1 ), and

conditioning regimen had no effect on the transplant outcome.

The presence of these variables was not strong enough to

change the negative effect of the presence of pre-AHSCT MRD.

Discussion

The presence of MRD is a strong, independent prognostic

marker of increased risk of relapse and shorter survival in

patients with AML. Testing for MRD can be used to refine

risk stratification and treatment response assessment, and

it may help guide post-remission treatment strategies like

proceeding with AHSCT or not [17]. The optimal timing of

MRD assessment has not been exactly defined. However, MRD

after induction and remission has been studied. The HOVON

Group prospectively evaluated bone marrow specimens

of 389 patients younger than 61 years. After all courses of

therapy, low MRD values distinguished patients with relatively

favorable outcomes from those with high relapse rates and

adverse relapse-free survival (RFS) and OS. They showed that

residual disease detected by MFC was related to higher 4-year

relapse risk (72% and 42%, respectively) and adverse RFS at

4 years (23% and 52%, respectively) [18]. Also, MRD analysis

in the pre- and post-transplantation settings may have a

crucial role in long-term outcomes. In our study, we identified

33 patients who had MRD positivity before transplantation,

and 9 of these patients could achieve MRD negativity in the

post-transplantation period. The presence of pre-AHSCT MRD

was related to a significantly higher (2.4-fold) relapse rate and

shorter EFS. There was no difference in NRM rates between

the pre-AHSCT MRD-positive and MRD-negative groups. We

also found OS to be significantly lower in pre-transplant

MRD-positive patients. Our results were comparable with

those of previous studies. Oran et al. [19] showed that MRD

status at transplantation could independently predict 1-year

Figure 1. Association between pre-AHSCT MRD status and transplant outcomes.

AHSCT: Allogeneic hematopoietic stem cell transplantation; MRD: measurable residual disease.

Figure 2. Association between post-AHSCT MRD status and transplant outcomes.

AHSCT: Allogeneic hematopoietic stem cell transplantation; MRD: measurable residual disease.

115



relapse incidence in patients with AML. Relapse incidence at 1

year was higher in AML patients with MRD (32.6% vs. 14.4%,

p=0.002). Leukemia-free survival (43.6% vs. 64%, p=0.007)

and OS (48.8% vs. 66.9%, p=0.008) rates were also inferior

in patients with MRD [19]. A meta-analysis reported that

pre-transplant MRD was associated with worse leukemia-free

survival, OS, and cumulative incidence of relapse but not NRM.

Associations between MRD status and outcome held regardless

of MRD detection method, intensity of conditioning regimen,

and patient age [2]. In our study, in cases of pre-AHSCT MRD,

conditioning regimen intensity did not show any impact on

outcome. All MRD detection was performed by flow cytometry

so we did not analyze the influence of the detection method.

Figure 3. Overall survival according to pre- and post-AHSCT MRD

status.

AHSCT: Allogeneic hematopoietic stem cell transplantation; MRD:

measurable residual disease.

Figure 4. Event-free survival according to pre- and post-AHSCT

MRD status.

AHSCT: Allogeneic hematopoietic stem cell transplantation; MRD:

measurable residual disease.

Walter et al. suggested that pre-AHSCT MRD by MFC is associated

with increased risk of relapse and death after MA AHSCT for

AML patients in CR 1 regardless of other risk factors. Two-year

estimates of OS were 30.2% and 76.6% for MRD-positive and

MRD-negative patients while 2-year estimates of relapse were

64.9% and 17.6%, respectively [13]. In a subsequent study, they

reported similar outcomes in patients who underwent AHSCT in

CR 1 or CR 2 , which was significantly dependent on MRD status

prior to transplant [20]. Similarly to that study, we showed MRD

positivity as an independent factor regardless of performing

transplantation in CR 1 or CR 2 .

Relapse after AHSCT remains a problem in AML patients. Can

MRD follow-up after AHSCT predict relapse and improve

the outcomes? In one study, MRD positivity at the 30 th

post-transplantation day predicted the relapse risk in 1 year

(group 1: 1-year relapse incidence, 78%) [21]. The authors claimed

that the positivity of MRD at any time after transplantation

in patients with morphological CR was related to relapse that

might occur within 2 months. In our study, 34 patients were

MRD-positive at the 28 th day after transplantation, and 24 of

them were those in the pre-AHSCT group. We showed that MRD

positivity on the 28 th post-transplantation day was related to

significantly higher relapse risk and poor EFS and OS in patients

with AML.

However, there is a relative lack of data regarding MRD and

MRD-guided interventions following AHSCT. Post-transplant

MRD is related to an increased incidence of relapse, but

clinical effects of MRD kinetics are not clearly defined yet

[22]. Platzbecker et al. [23] reported that MRD-guided

treatment with azacitidine can prevent or delay hematological

relapse in patients with myelodysplastic syndrome and AML.

Discontinuation of immunosuppression and donor lymphocyte

infusion (DLI) may be beneficial in patients with post-AHSCT

MRD, but there is no convincing evidence that preventive

intervention strategies will improve the outcome [22]. Our

institutional policy is to taper immunosuppression or intervene

with DLI. Targeted therapies like Flt3 inhibitors have also been

116



Figure 5. The impact of acute GvHD on survival among pre-AHSCT MRD-negative patients.

AHSCT: Allogeneic hematopoietic stem cell transplantation; MRD: measurable residual disease; GvHD: graft-versus-host disease.

preferred in patients with mutations. However, a limitation of

our study is our not analyzing the impact of these therapies on

outcome per patient.

Conclusion

Our study showed that the presence of MRD both in pre- and

post-transplantation settings was related to significantly poorer

outcomes as an independent prognostic marker for increased

relapse risk and shorter survival for AML patients.

Ethics

Ethics Committee Approval: This study was approved by the

Ankara University Faculty of Medicine Human Research Ethics

Committee (no: İ4-148-19).

Informed Consent: Retrospective study.


Surgical and Medical Practices: P.T., U.Ş., A.U., C.Ö., G.C.S., M.K.Y.,

M.Ö., Ö.A., G.G., S.K.T., O.İ., M.B., S.C.B.; Concept: S.C.B., Z.N.Ö.;

Design: S.C.B., Z.N.Ö.; Data Collection or Processing: M.A.B.,

Z.N.Ö., U.Ş.; Analysis or Interpretation: U.Ş., Z.N.Ö., S.C.B., K.D.,

M.Ö.; Literature Search: Z.N.Ö., U.Ş.; Writing: Z.N.Ö., S.C.B.


authors.

Financial Disclosure: The authors declared that this study

received no financial support.

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118

Tiribelli M. et al: CD200 and BCL2 in AML

RESEARCH ARTICLE

DOI: 10.4274/tjh.galenos.2021.2020.0728


Impact of Concomitant Aberrant CD200 and BCL2 Overexpression

on Outcome of Acute Myeloid Leukemia: A Cohort Study from

a Single Center

Eşzamanlı Anormal CD200 ve BCL2 Aşırı Ekspresyonunun Akut Myeloid Löseminin Sonucu

Üzerindeki Etkisi: Tek Merkezden Bir Grup Çalışması

Mario Tiribelli, Angela Michelutti, Margherita Cavallin, Sara Di Giusto, Renato Fanin, Daniela Damiani

University of Udine, Department of Medical Area, Division of Hematology and Stem Cell Transplantation, Udine, Italy

Abstract

Objective: CD200 and BCL2 overexpression is independently

associated with inferior survival in acute myeloid leukemia (AML),

and these two factors are frequently co-expressed; however, no data

are available on the role of concomitant aberrant CD200 and BCL2

expression on outcome of AML patients. We aimed to elucidate the

prognostic role of CD200/BCL2 co-expression and its association with

specific leukemia subsets.

Materials and Methods: We analyzed 242 adult AML patients

uniformly treated with intensive chemotherapy, evaluating the impact

of CD200 and BCL2 expression on complete remission (CR), diseasefree

survival, and overall survival (OS).

Results: CD200 and BCL2 were expressed in 139 (57.4%) and 137

(56.6%) cases, respectively, with 92 patients (38%) displaying double

positivity (DP), 58 (24%) displaying double negativity (DN), and 92

patients expressing only either CD200 (n=47) or BCL2 (n=45). CR

was achieved in 71% of cases, being less frequent in DP patients

(60%) compared to other groups (76%-81%, p<0.001). In the whole

population 3-year OS was 44%, being lower in DP patients (28%)

than in patients with single CD200 or BCL2 expression (47%) or DN

cases (60%; p=0.004). Other factors associated with worse OS were

advanced age, CD34 positivity, secondary AML, and high white blood

cell count at diagnosis; combining these 4 factors with CD200/BCL2

DP, we identified 6 groups with significantly different rates of survival

(3-year OS ranging from 90% to 0%).

Conclusion: Our data support a synergistic effect of CD200 and BCL2

in AML cells, conferring an enhanced survival capacity in a permissive

microenvironment and resulting in worse prognosis.

Keywords: CD200, BCL2, Acute myeloid leukemia, Prognosis, Survival

Öz

Amaç: CD200 ve BCL2 aşırı ekspresyonu, bağımsız olarak, akut myeloid

lösemide (AML) düşük hayatta kalma ile ilişkilidir ve bu 2 faktör

sıklıkla birlikte ifade edilir; bununla birlikte, AML hastalarının akıbeti

üzerindeki eşzamanlı anormal CD200 ve BCL2 ekspresyonunun rolü

hakkında hiçbir veri mevcut değildir. CD200/BCL2 birlikte ifadesinin

prognostik rolünü ve bunun spesifik lösemi alt kümeleri ile ilişkisini

aydınlatmayı amaçladık.

Gereç ve Yöntemler: CD200 ve BCL2 ekspresyonunun tam remisyon

(CR), hastalıksız sağkalım (DFS) ve genel sağkalım (OS) üzerindeki

rolünü değerlendirerek, yoğun kemoterapi ile eşit şekilde tedavi edilen

242 yetişkin AML hastasını analiz ettik.

Bulgular: CD200 ve BCL2 sırasıyla 139 (%57,4) ve 137 (%56,6)

olguda ifade edildi; 92 hastada (%38) çift pozitiflik (DP), 58 (%24)

hastada çift negatiflik (DN) ve 92 hastada sadece CD200 (47) veya

sadece BCL2 (45) ifadesi vardı . Hastaların %71’inde CR elde edildi, CR,

DP hastalarında (%60) diğer gruplara göre (%76-81, p<0,001) daha

düşüktü. Tüm popülasyonda 3 yıllık OS %44 olup, DP hastalarında

(%28), tek CD200 veya BCL2 ekspresyonu olan hastalara (%47) göre

ve DN olgularına göre (%60; p=0,004) daha düşüktür. Daha kötü OS

ile ilişkili diğer faktörler ileri yaş, CD34 pozitifliği, ikincil AML ve tanıda

yüksek WBC idi; Bu 4 faktörü CD200/BCL2 DP ile birleştirerek, önemli

ölçüde farklı sağkalıma sahip 6 grup belirledik (3 yıllık OS %90 ila 0

arasında değişir).

Sonuç: Verilerimiz, CD200 ve BCL2’nin AML hücrelerinde sinerjistik

etkisini ve kısıtlanmamış bir mikro ortamda gelişmiş bir hayatta

kalma kapasitesi sağlayarak daha kötü bir prognoza neden oluşu

desteklemektedir.

Anahtar Sözcükler: CD200, BCL2, Akut myeloid lösemi, Prognoz,

Sağkalım



Address for Correspondence/Yazışma Adresi: Mario Tiribelli, M.D., University of Udine,

Department of Medical Area, Division of Hematology and Stem Cell Transplantation, Italy

Phone : +39-0432-559604

E-mail : mario.tiribelli@uniud.it ORCID: orcid.org/0000-0001-9449-2621

Received/Geliş tarihi: December 4, 2020

Accepted/Kabul tarihi: February 11, 2021

119



Introduction

The increased knowledge acquired in the last years on the genetic

basis of acute myeloid leukemia (AML) has not yet translated

into a significant increase in the curability of this tragic disease.

Resistance to chemotherapy remains a major challenge and

accounts for the high rate of disease recurrence experienced by

most patients and, consequently, the disappointing long-term

outcome of AML. It is well known that many factors are involved

in poor response to treatment. Intrinsic disease characteristics

confer an advantage to leukemic cells in terms of proliferation,

expansion, and survival, in part due to reduced sensitivity

to drugs or multidrug resistance [1,2,3,4] and in part due to

the induction of a permissive microenvironment favoring the

evasion of neoplastic clones from anti-tumor immune control

[5,6,7,8,9]. The interest in the immunogenicity of leukemic cells

has increased in parallel with the development of drugs able

to inhibit or modulate the crosstalk between tumor cells and

components of the innate or adoptive immune system, such

as checkpoint inhibitors [10,11]. Moreover, in the past years,

the role of the inhibition of apoptotic pathways, well known

in lymphoproliferative disorders, has also emerged in acute

leukemia [12,13,14,15,16,17]. Since we have observed a frequent

association of BCL2 positivity and CD200 overexpression in

AML patients [18], we aimed to elucidate the prognostic role

of CD200/BCL2 co-expression and its association with specific

leukemia subsets in our cohort of AML patients treated with

intensive chemotherapy, with the purpose of identifying

patients suitable for new targeted treatments.


A total of 242 patients with non-promyelocytic AML, admitted

between January 2009 and June 2018 to the Division of

Hematology of the University of Udine, were included in the

study. Cytological diagnosis was performed based on bone

marrow and peripheral blood.

Multiparametric flow cytometry (FACSDiva II, BD) was employed

to evaluate leukemia-associated antigens. CD200 was expressed

as the percentage of positive cells (with 20% as a cut-off value)

and as the mean fluorescence intensity (MFI) obtained by

the ratio of fluorescence intensity of the test and its isotypic

control. Cases with MFI =1 were considered negative, MFI <11

as low expression, and MFI ≥11 as high expression. BCL2 was

considered overexpressed for MFI ≥17 (i.e., above the median

value of the population). Cytogenetic risk was classified

according to Medical Research Council criteria [19]. FLT3 and

NPM1 mutations were evaluated as previously described [20].

All patients received intensive induction chemotherapy based

on fludarabine, cytarabine, and idarubicin, followed by at

least one consolidation course of high-dose cytarabine. In

high-risk cases (defined by at least one of the following:

secondary AML, poor response to induction chemotherapy,

unfavorable cytogenetic or combined genetic risk, early relapse),

allogeneic stem cell transplantation from a related or unrelated

donor was pursued as post-induction therapy.


Complete remission (CR) was defined as complete peripheral

hematological recovery and the absence of bone marrow disease

upon morphological, immunophenotypic, or molecular evaluation.

Overall survival (OS) was calculated from diagnosis to death

(irrespective of its cause). Disease-free survival (DFS) was defined

as the time from the date of CR to the date of relapse of AML.

Patients lost to follow-up were censored at the time last seen alive.

Categorical variables were compared with the Fisher exact test or

Yates corrected chi-square test as required. Factors affecting CR

were assessed by univariate and multivariate logistic regression

and expressed as odds ratios (ORs) with 95% confidence

intervals (CIs). Survival curves were constructed by the

Kaplan-Meier method and differences among groups were

calculated by log-rank test. The Cox proportional hazard

regression model was used to examine the potential prognostic

factors for survival; all variables with values of p≤0.10 in

univariate analysis were included in the multivariate model and

a forward procedure was applied to identify significant factors.

Statistical analysis was performed with NCSS 11 Statistical

Software (NCSS Statistical Software, Kaysville, UT, USA). All

p-values are 2-sided at a significance level of 0.05.

Results

The median age of the whole population was 58 (range: 18-

81) years, and 143/242 (59%) patients were older than 55

years. One hundred ten patients (45.5%) were female and 132

(55.5%) were male. Seventy-one patients (29%) had secondary

AML, developed from an antecedent myeloproliferative disease

or after chemotherapy for a solid or hematologic neoplasm.

Eighty-nine patients (37%) had high white blood cell (WBC)

counts at diagnosis, defined as ≥30x10 9 /L, while the karyotype

was favorable in 14 (6%), intermediate in 154 (64%), unfavorable

in 61 (25%), and not evaluable in 13 (5%) cases, respectively.

CD200 was expressed in 139/242 cases (57.4%) and BCL2 was

overexpressed in 137/242 (56.6%) cases. CD200 positivity and

concomitant BCL2 overexpression (double positivity, DP) was

found in 92/242 (38%) patients, while 58 (24%) revealed double

negativity (DN) and 92 expressed only CD200 (47, 19.4%) or

BCL2 (45, 18.6%).

Clinical and biological characteristics of patients according

to CD200 and BCL2 expression are summarized in Table 1.

CD200/BCL2 DP cases were more frequent among patients with

WBC counts of <30x10 9 /L (64/92, 69.5% vs. 79/150, 56.5%;

120



p=0.04), in CD34+ AML (57/92, 62% vs. 64/150, 42.7% in

CD34-negative patients; p=0.004), and in cases of

NPM1-wt (71/88, 80.7% vs. 73/130, 35.9% in NPM1 mutated

cases; p<0.001).

Response to Therapy

All patients received intensive induction chemotherapy and

were evaluable for response. CR was obtained in 171/242 cases

(70.7%).

In Table 2 factors affecting CR probability in univariate and

multivariate analysis are listed. The CR rate was significantly

lower in patients with CD200 expression (88/139, 63.3%)

compared to CD200-negative cases (83/103, 80.6%; p=0.006),

while BCL2 positivity was associated only with inferior CR

rate (90/137, 65.7% vs. 81/105, 77.1%; p=0.07). According to

CD200 and BCL2 expression, CR was reached by 55/92 (59.8%)

DP patients, by 70/92 (76.1%) patients with either CD200 or

BCL2 expression, and by 54/58 (81.0%) DN patients, resulting

in a significantly lower CR rate among DP patients compared to

all other groups (p<0.001). CR probability was also negatively

affected by age of ≥55 years (89/143, 62.2% vs. 82/99, 82.8%;

p=0.0005), secondary AML (33/71, 46.5% vs. 138/171, 80.7%;

p<0.0001), unfavorable cytogenetics (33/61, 54.1% vs. 129/168,

76.8%; p=0.0008), CD34 positivity (69/121, 57% vs. 102/121,

84.3%; p<0.0001), and NPM1-wt (101/159, 63.5% vs. 64/74,

86.5%; p=0.0003).

In multivariate analysis statistical significance was maintained

by advanced age (OR 2.1, 95% CI 1.07-4.21), secondary AML

(OR 3.6, 95% CI 1.89-7.0), CD34 positivity (OR 3.1, 95% CI 1.62-

6.0), and CD200/BCL2 DP (OR 1.9, 95% CI 1.03-3.7).

Disease-Free Survival

At the time of analysis 61/171 patients had relapsed and 110/171

remained in CR, with a 3-year DFS of 60% (95% CI 10-68).

Neither CD200 nor BCL2, alone or in association, influenced DFS.

In univariate analysis an adverse effect on DFS was found only

for unfavorable cytogenetics (3-year DFS 34%, 95% CI 17-52

vs. 65%, 95% CI 55-74 in other cytogenetics groups; p=0.001)

and CD34 positivity (3-year DFS 46%, 95% CI 32-60 vs. 68%,

95% CI 58-78 in CD34-negative patients; p=0.01). Multivariate

analysis confirmed their negative role for DFS, with a relapse

risk of 1.4 (95% CI 1.04-2.94) for unfavorable cytogenetics and

2.6 (95% CI 1.17-3.5) for CD34 positivity.

Overall Survival

At the time of analysis, of 242 patients included in the study,

139 (57%) had died, with a 3-year OS in the whole population

of 44% (95% CI 38-51). As shown in Table 3, in univariate

analysis OS was negatively affected by age of ≥55 (3-year OS

34%, 95% CI 26-43 vs. 58%, 95% CI 48-68 in patients aged

less than 55 years; p=0.0001), secondary AML (3-year OS 29%,

95% CI 16-41 vs. 50%, 95% CI 42-58 in de novo patients;

Table 1. Patients’ characteristics according to CD200 positivity and BCL2 overexpression.

Age

≥55

<55

Type of leukemia

Secondary

De novo

WBC

≥30x10 9 /L

<30x10 9 /L

CD34+

CD34-

CD56+

CD56-

Cytogenetics

Favorable

Intermediate

Unfavorable

FLT3-ITD+

FLT3-ITD-

NPM1 wild-type

NPM1 mutated

WBC: White blood cell count.

CD200+/BCL2+ (n=92) CD200/BCL2+ (n=45) CD200+/BCL2- (n=47) CD200/BCL2- (n=58)

60

32

32

58

28

64

57

35

14

78

5

55

28

21

71

74

18

28

17

9

36

17

28

15

30

11

34

0

35

10

11

33

22

22

24

23

19

28

14

23

34

13

11

36

8

24

11

6

38

38

7

31

27

10

47

30

28

15

43

31

27

1

41

12

18

33

23

28

121



p=0.0005), high WBC count at diagnosis (3-year OS 34%, 95%

CI 24-45 vs. 51%, 95% CI 42-59 in patients with lower WBC

counts; p=0.03), unfavorable cytogenetics (3-year OS 29%, 95%

CI 17-41 vs. 49%, 95% CI 41-57 for favorable or intermediate

karyotypes; p=0.003), NPM1-wt (3-year OS 39%, 95%

CI 30-47 vs. 56%, 95% CI 44-68 in NPM1-mutated cases;

p=0.005), and CD34 positivity (3-year OS 29%, 95% CI 20-38

vs. 59%, 95% CI 50-69 in CD34-negative cases; p<0.0001).

Considering CD200 and BCL2, DP patients had a 3-year OS of

28% (95% CI 18-39) compared to 47% (95% CI 35-60) among

patients with isolated CD200 or BCL2 overexpression and 60%

(95% CI 46-73) among DN patients (p=0.004; Figure 1). In

multivariate analysis, statistical significance was retained by

age of ≥55 (OR 2.0, 95% CI 1.4-2.9), secondary AML (OR 1.58,

95% CI 1.07-2.32), high WBC count (OR 2.0, 95% CI 1.36-2.9),

CD34 positivity (OR 2.2, 95% CI 1.5-3.2), and CD200/BCL2 DP

(OR 1.5, 95% CI 1.05-2.1).

Finally, the five variables found significant by multivariate

analysis were combined in a score predicting very different OS

probabilities: 3-year OS was 90% (95% CI 76-100) for patients

without risk factors, 67% (95% CI 53-80) for those with 1 risk

factor, 42% (95% CI 31-54) for those with 2 risk factors, 25%

(95% CI 11-38) for those with 3 risk factors, 10% (95% CI 0-23)

for those with 4 risk factors, and 0% if all 5 risk factors were

present (p<0.0001; Figure 2).

Figure 1. Overall survival of the entire population according to

CD200 and BCL2 expression.

Table 2. Factors associated with low remission rate in univariate and multivariate analysis.

Univariate

Multivariate

Variable Z-value p Z-value p

Age ≥55 3.38 0.0007 2.2 0.027

WBC ≥30x10 9 /L 0.5 0.6 / /

Secondary AML 4.98 <0.0001 3.6 0.0003

Unfavorable cytogenetics 3.20 0.001 0.9 0.35

FLT3-ITD+ 0.38 0.69 / /

NPM1 wild-type 3.1 0.0015 0.57 0.56

CD34+ 4.79 0.0002 3.3 0.0007

CD56+ 0.15 0.87 / /

CD200+ 3.86 0.004

BCL2+ 1.7 0.09 / /

CD200+/BCL2+ 3.1 0.0012 2.0 0.03

WBC: White blood cell count; AML: acute myeloid leukemia.

Table 3. Univariate and multivariate analysis for factors affecting overall survival.

Univariate

Multivariate

Variable Z-value p Z-value p

Age ≥55 16.4 0.0001 3.38 0.0007

Secondary leukemia 12.0 0.005 2.3 0.02

WBC ≥30x10 9 /L 4.3 0.03 3.8 0.0001

Unfavorable cytogenetics 11.4 0.003 0.34 0.72

Flt3-ITD+ 0.03 0.8 / /

NPM1 wild-type 7.8 0.005 0.06 0.94

CD34+ 19.0 <0.0001 4.1 <0.0001

CD56+ 1.2 0.2 / /

CD200+/BCL2+ 10.1 0.001 2.58 0.009

WBC: White blood cell count.

122



natural killer cells, defective NK cytolytic activity, reduced

CD4 Th1 memory and memory cytotoxic response, and high

Treg frequency in cases of AML with CD200 expression, thus

explaining the increased relapse risk and the worse survival

among these patients [32,33,34]. We have observed an increase

of myeloid precursors with suppressive activity, suggesting that

the binding of CD200R on myeloid cells could play a role in

the development of a leukemia-permissive micro-environment

and in the reduction of the anti-infective immune response

(personal data, unpublished).

Figure 2. Overall survival by number of prognostic factors.

Discussion

The dysregulation of several pathways compromising the

differentiation ability or promoting proliferation and

survival has been proposed for the development and clinical

characterization of AML [21]. Overexpression of anti-apoptotic

BCL2 family proteins resulting from chromosomal translocation,

gene amplification, increased gene transcription, or alteration

of post-transcriptional processing has been found for many

solid and hematologic neoplasms [22,23]. In AML, high BCL2

expression has been associated with poor prognosis. Campos

et al. [24] observed heterogeneous flow cytometric expression

of BCL2 among 82 patients with de novo AML, but patients

with >20% BCL2-positive leukemic cells had significantly lower

CR rates and shorter survival. Karakas et al. [25] analyzed the

BCL2 transcript in 152 patients with newly diagnosed AML,

confirming a negative impact on CR, DFS, and OS. Del Poeta

et al. described a negative impact on outcome by evaluating

the ratio between pro-apoptotic BAX and anti-apoptotic BCL2

protein [17]. Mehta et al. [15] reported a significant reduction

of DFS in patients with BCL2 overexpression and FLT3 internal

tandem duplication. We previously reported a negative

correlation between high BCL2 expression and OS and, for the

first time, we observed a frequent association between BCL2

overexpression and aberrant expression of CD200 [18]. CD200

is a member of the immunoglobulin family expressed on the

membrane of many cell types, such as thymocytes, activated

T-cells, B-cells, dendritic cells, vascular endothelial cells, and

central nervous cells. In humans CD200 exclusively binds to

its inhibitory receptor, CD200R, physiologically acting as a

regulator of the antimicrobial immune response controlling

the return to homeostasis [26,27]. Moreover, there is a body of

evidence suggesting that the CD200-CD200R axis is involved

in the regulation of antitumor response and in cancer evasion

[5,28,29,30]. In AML an aberrant expression of CD200 has

been associated with poor survival in all cytogenetic risk

groups [18,31]. Coles et al. observed a reduction of activated

In the present work we associate, for the first time, BCL2 and

CD200 concomitant expression with a lower survival probability

when compared to cases with isolated BCL2 or CD200 expression

or DN. The negative impact of BCL2/CD200 co-expression on OS

was also maintained in multivariate analysis, along with known

prognostic factors such as advanced age, high WBC count (a

surrogate of leukemic burden), secondary AML, and CD34

positivity. The combination of these five factors in a risk score

based on their presence or absence defined five subgroups with

very different survival probabilities.

The mechanism by which BCL2 synergizes with CD200 in

affecting prognosis is far from being clarified. The deregulation

of BCL2 proteins has been mostly associated with a survival

advantage of neoplastic cells, but the increasing knowledge of

the structural and functional diversity of BCL2 family members

and their different cellular localizations has highlighted their

involvement in cell functions other than apoptotic control

[35]. In cancer cell lines BCL2 overexpression seems able to

promote cell migration, increasing metastatic potential [36,37],

by regulating Ca 2+ homeostasis and by indirectly inducing

the production of MMP-9, able to detach leukemic cells from

their extracellular matrix [38,39,40]. Thus, double-positive

BCL2/CD200 leukemic cells could take advantage not only

of a higher intrinsic survival capacity but also an enhanced

dissemination ability in a CD200-induced permissive microenvironment.

Conclusion

In the era of targeted therapies, these data suggest the

intriguing possibility of killing leukemic cells by normalizing

the balance between anti- and pro-apoptotic activities of BCL2

family members, e.g., by using the BH3 mimetic venetoclax,

and simultaneously restoring the antitumor immune activity by

anti-CD200 antibodies blocking the CD200 pathway.

Ethics

Ethics Committee Approval: All procedures performed in

studies involving human participants were in accordance with

the ethical standards of the institutional review board of the

Department of Medical Area of the University of Udine, which

123



approved the study. This study was performed according to the

1964 Declaration of Helsinki and its later amendments.

Informed Consent: Informed consent was obtained from all

individual participants included in the study at the time of the

start of treatment.


Surgical and Medical Practices: A.M., M.C., S.G.; Concept: M.T.,

R.F., D.D.; Design: M.T., D.D.; Data Collection or Processing: A.M.,

M.C., S.G.; Analysis or Interpretation: M.T., R.F., D.D.; Literature

Search: M.T., D.D.; Writing: M.T., D.D.


authors.



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125

Peng Y. et al: Allo-HSCT in Extranodal Lymphoma

RESEARCH ARTICLE

DOI: 10.4274/tjh.galenos.2021.2020.0438


Allogeneic Hematopoietic Stem Cell Transplantation in Extranodal

Natural Killer/T-cell Lymphoma

Ekstranodal Doğal Öldürücü/T-hücreli Lenfomada Allojeneik Hematopoetik Hücre

Transplantasyonu

Yin-yin Peng 1 , Yi-ying Xiong 1 , Li-xia Zhang 1 , Jing Wang 1 , Hong-bin Zhang 1 , Qing Xiao 1 , Shu-liang Guo 2

1First Affiliated Hospital of Chongqing Medical University, Department of Hematology, Chongqing, China

2First Affiliated Hospital of Chongqing Medical University, Department of Respiratory Medicine, Chongqing, China

Abstract

Objective: Extranodal NK/T-cell lymphoma (ENKL) is aggressive

and resistant to chemotherapy and radiotherapy. Allogeneic

hematopoietic stem cell transplantation (allo-HSCT) is a potentially

curative treatment for high-risk lymphomas owing to its associated

graft-versus-lymphoma (GVL) effect. However, its application to ENKL

is limited. We aim to summarize the characteristics of allo-HSCT for

ENKL and, more importantly, evaluate whether allo-HSCT could offer

any benefits for ENKL

Materials and Methods: A systematic review and data analysis were

performed to evaluate the performance of allo-HSCT in the treatment

of ENKL using studies obtained from PubMed, Medline, and Embase

from January 2000 to December 2019 in the English language.

Results: A total of 136 cases from 17 eligible publications were

included in this study. It was found that after allo-HSCT, with

an average follow-up time of 34 months (range: 1-121 months),

37.5% (52) of 136 patients had acute graft-versus-host disease

(GVHD) and 31.6% (43) had chronic GVHD. Furthermore, 35.3%

(48) of the patients were reported to have relapsed, but 2 of those

relapsed only locally and achieved complete remission (CR) again with

additional irradiation, chemotherapy, and donor lymphocyte infusions

for one and rapid tapering and discontinuation of cyclosporine for

the other, earning more than one year of extra survival. Finally,

of the 136 patients, 51.5% (70) died because of primary disease

progression (42.9%), infection (20.0%), GVHD (11.4%), organ failure

(7.1%), hemorrhage (4.3%), and other causes (not specified/unknown)

(14.3%).

Conclusion: Allo-HSCT may be a treatment option for advanced

or relapsed/refractory ENKL, but its role still requires more rigorous

future studies.

Keywords: Extranodal NK/T-cell lymphoma, Chemotherapy,

Radiotherapy, Allogeneic hematopoietic stem cell transplantation

Öz

Amaç: Ekstranodal NK/T-hücreli lenfoma (ENKL) agresiftir ve

kemoterapi ve radyoterapiye dirençlidir. Allojenik hematopoetik kök

hücre transplantasyonu (allo-HSCT), ilişkili graft-lenfoma (GVL) etkisi

nedeniyle, yüksek riskli lenfomalara yönelik potansiyel olarak iyileştirici

bir tedavidir. Bununla birlikte, ENKL’ye uygulanması sınırlıdır. Bu

çalışmada ENKL için allo-HSCT’nin/AHKHN’nin özelliklerini özetlemeyi

ve daha da önemlisi allo-HSCT’nin ENK için herhangi bir fayda sağlayıp

sağlamayacağını değerlendirmeyi amaçlıyoruz.

Gereç ve Yöntemler: Ocak 2000’den Aralık 2019’a kadar İngilizce

dilinde PubMed, Medline ve Embase literatürleri kullanılarak

allo-HSCT’nin ENKL’ye performansını değerlendirmek için sistematik

bir inceleme ve veri analizi gerçekleştirildi.

Bulgular: Bu çalışmaya 17 uygun yayından toplam 136 olgu dahil

edildi. 1) allo-HSCT’den sonra, 34 aylık ortalama takip süresine göre

(aralık: 1-121 ay), 136 hastanın %37,5’inde (52) akut graft-versushost

hastalığı (GVHD), %31,6’sında (43) kronik GVHD vardı; 2) rapor

edildiğinde, hastaların %35,3’ünde (48) relaps vardı, ancak bunlardan

ikisi sadece lokal olarak nüks etti ve bunlardan birine ek ışınlama,

kemoterapi, donör lenfosit infüzyonu ile tekrar tam remisyon (CR)

sağladı, diğerine siklosporinin hızlı azaltılması ve kesilmesi bir yıldan

fazla ekstra sağkalım kazandırdı; 3) 136 hastanın %51,5’i (70) primer

hastalık ilerlemesi (%42,9), enfeksiyon (%20,0), GVHD (%11,4), organ

yetmezliği (%7,1), kanama (%4,3) ve diğerleri (belirtilmedi/bilinmiyor)

(%14,3) nedeniyle öldü.

Sonuç: Allo-HSCT, ilerlemiş veya nükseden/refrakter ENKL için bir

tedavi seçeneği olabilir, ancak rolü hala daha titiz gelecek çalışmaları

gerektirmektedir.

Anahtar Sözcükler: Ekstranodal NK/T-hücreli lenfoma, Kemoterapi,

Radyoterapi, Allojeneik hematopoetik kök hücre nakli



Address for Correspondence/Yazışma Adresi: Yin-yin Peng, M.D., First Affiliated Hospital of Chongqing Medical

University, Department of Hematology, Chongqing, China

Phone : 86-15123312126

E-mail : pengyinyin802320@163.com ORCID: orcid.org/0000-0002-7978-4826

Received/Geliş tarihi: July 30, 2020


126



Introduction

Natural killer cell tumors are categorized as extranodal NK/Tcell

lymphoma (ENKL), aggressive NK-cell leukemia and chronic

NK-cell lymphoproliferative disorders according to the 2016

World Health Organization (WHO) classification [1]. Among them,

ENKL is relatively more common. ENKLs include both nasal and

extra-nasal ENKL categories of disease in the current 2016 WHO

classification [2]. It is rarely diagnosed in Western countries but

relatively more common in East Asian countries, being closely

associated with Epstein-Barr virus (EBV). Pathologically, ENKL

shows a highly aggressive clinical behavior. It usually involves

the nasal cavity, nasopharynx, upper aerodigestive tract,

skin, gastrointestinal tract, or other parts of the body, which

have poorer survival. Limited-stage ENKL responds relatively

much better to radiotherapy or to concurrent radiation and

chemotherapy than advanced or relapsed/refractory ENKL. So

far, there is no standard management for relapsed or refractory

disease.

Although ENKL’s clinical features and prognostic factors

have been well characterized in the last decades, optimal

treatment strategies still remain unclear. The tumor

cells lack L-asparagine synthetase and are susceptible

to L-asparaginase, which depletes L-asparagine in NK

lymphoma cells [1]. Regimens containing L-asparagine were

effective for limited-stage ENKL; however, when used in

patients with advanced-stage disease, these regimens were

not so satisfactory. Some studies showed that the complete

remission (CR) rate with the L-asparagine, etoposide, and

dexamethasone (AspaMetDex) regimen for patients with

advanced-staged disease was 30%, and the 5-year survival

rate with the L-asparagine, vincristine, and dexamethasone

(LVD) regimen was only 25% [3,4]. As advanced-stage or

relapsed/refractory ENKL is highly progressive and sometimes

multidrug-resistant, L-asparaginase-based therapy is still a

challenge [5].

Allogeneic hematopoietic stem cell transplantation (allo-HSCT)

is a potentially curative treatment for high-risk lymphoma

patients owing to its associated graft-versus-lymphoma (GVL)

effect. Furthermore, ENKL cells almost invariably express EBV

antigens, providing an alloreactive target to enhance the GVL

effect [1]. Although allo-HSCT is an effective way to treat

hematologic tumors, its applications for ENKL remain limited.

Some small series of studies have demonstrated a disease-free

survival (DFS) of 30%-50%, but with high transplant-related

mortality of about 25% [1,6-9]. Problems still remain: (1)

undoubtedly, both infection and acute graft-versus-host disease

(GVHD) during allo-HSCT often cause death; (2) the heavy

psychological pressure during allo-HSCT is still overwhelming;

(3) and, furthermore, human leukocyte antigen (HLA) donors

and patients are still hard to match for allo-HSCT. Therefore, in

this study we aim to summarize the characteristics of allo-HSCT

for ENKL and, more importantly, evaluate whether allo-HSCT

could offer any benefits for ENKL.


Literature Review

We searched PubMed, Medline, and Embase for publications

in the English language from January 2000 to December 2019.

The following terms were used: “natural killer/T-cell tumors” or

“natural killer/T-cell neoplasm” or “natural killer/T-cell lymphoma”

or “extranodal natural killer/T-cell lymphoma” or “extranodal

natural killer/T-cell lymphoma nasal type” or “angiocentric

lymphoma” and “hematopoietic stem cell transplantation” or

“transplantation” or “therapy” or “treatment.”

Study Selection

Studies were considered eligible in the analysis if they met the

following inclusion criteria: (1) patients were diagnosed with

ENKL according to REAL and WHO classifications; (2) patients did

not suffer from a second primary malignancy before or together

with ENKL; (3) patients were treated with allo-HSCT; (4) studies

provided data including overall survival (OS), progression-free

survival (PFS), and/or DFS or other markers describing the

survival outcome.

Studies that met any of the following criteria were excluded: (1)

non-English literature; (2) repeated studies; (3) studies without

relevant outcome indicators.

Data Extraction

Data were extracted by two independent authors and checked

by another. Disagreements were resolved in consultation with

the third author. For each study, the following information

was extracted: (1) basic information such as the author, date,

country, patient numbers and characteristics, etc.; (2) specific

intervention details; (3) outcome indicators and measures such

as OS, PFS, and DFS.

Data Analysis

The measurement data were expressed in percentages and

composition ratios and then the “average age” and “average

follow-up time” after allo-HSCT were calculated. The “average

age” is only an average value of the “referred ages” of all the

references. “Referred age” here means the “mean age” or “median

age” in different papers, which are not identical. Theoretically,

if all references calculate “mean age” of patients in their case

studies, our “average value” of their “referred ages” in this study

should equal the mean age of the 136 patients. However, some

references calculated “median age” and we had no opportunity

to obtain their original data. Thus, we had to take the “median

ages” as approximate indicators of the mean ages and finally

127



calculate an average value of those indicators. For instance, if

we had collected m references, and if in publication i totally N i

patients were reported, and if the paper said the average age

(or mean age, or median age) of the N i

patients was A i

, then the

“average age” A of all the patients in the m references selected

in this study was calculated as follows:

The calculation for “average follow-up time” basically follows

the same idea as that for “average age.” In this study, we only

calculated these two “average” values. The percentages (for sex,

clinical stage, etc.) in Table 1 and Supplementary Table 1 were

all calculated using the original counts from the references.

Results

Literature Review and Selection

We searched among the articles available in PubMed, Medline,

and Embase. Only 17 eligible articles reporting 136 patients were

found in this analysis. The male/female ratio of the 136 patients

was 1.6:1 and the average age was 40 years (Supplementary

Table 1). The detailed clinical features of the 136 patients are

listed in Table 2 and Supplementary Table 1.

Table 1. The clinical features of the 136 patients.

Clinical characteristics

Sex

Clinical stage

Disease status at

transplantation

L-asparaginase-containing chemotherapy before allo-HSCT

Radiation before allo-HSCT

Conditioning regimens

Source of hematopoietic stem cells

Donor matching

GVHD

Cause of death (n=70)

(corresponding rates in the last column for each cause calculated in terms

of the number and the total deaths, n=70)

CR: Complete remission; HSCT: hematopoietic stem cell transplantation; GVHD: graft-versus-host disease.

Male 83 (61.1%)

Female 53 (38.9%)

I/II 52 (38.2%)

III/IV 54 (39.7%)

Others 30 (22.1%)

CR 63 (46.3%)

Residual, refractory/relapsed disease 63 (46.3%)

Unknown 10 (7.4%)

Yes 54 (39.7%)

No/unknown 82 (60.3%)

Yes 48 (35.3%)

No/unknown 88 (64.7%)

Myeloablative 76 (55.5%)

Reduced-intensity 58 (42.3%)

Missing 3 (2.2%)

From peripheral blood stem cell donors 99 (72.3%)

Bone marrow 23 (16.8%)

Cord blood 14 (10.2%)

Not reported clearly 1 (0.7%)

Matched-related donor 76 (55.5%)

Matched-unrelated donor 32 (23.4%)

Umbilical cord blood 6 (4.4%)

Haploidentical-related donor 14 (10.2%)

Unknown 9 (6.6%)

Acute GVHD 52 (37.5%)

Chronic GVHD 43 (31.6%)

Primary disease progression 30 (42.9%)

Infection 14 (20.0%)

GVHD 8 (11.4%)

Organ failure 5 (7.1%)

Hemorrhage 3 (4.3%)

Other (not specified)/unknown 10 (14.3%)

Number (percentage)

128



Status and Treatment before Allo-HSCT

At initial diagnosis, 38.2% (52) of the 136 patients had

early-stage (I/II) disease, 39.7% (54) had advanced (III/IV)

disease, and the staging of the other 22.1% (30) was unknown.

When receiving allo-HSCT, 46.3% (63) were in CR without

disease, 46.3% (63) had residual/refractory/relapsed disease,

and the status of the other 7.4% (10) was unknown. Among

the 63 patients who were in CR before allo-HSCT, 58.7% (37)

were in CR 1 , 39.7% (25) were in CR 2 , and the status of the other

1.6% (1) was unknown. Before allo-HSCT, 39.7% (54) of the 136

patients received L-asparaginase-containing chemotherapy and

35.3% (48) received radiotherapy (Table 1).

The 136 patients received a total of 137 successful allo-HSCTs

without any graft failure, including one patient who underwent

the procedure twice [10]. The patient who underwent treatment

twice first received an allogeneic peripheral blood stem cell

transplantation (allo-PBSCT) from an HLA-identical donor

(younger brother) after myeloablative pretreatment, but 2

months later, he relapsed and had a lymphoma-associated

hemophagocytic syndrome. He then received salvage SMILE

chemotherapy and high-dose intravenous methylprednisolone;

thus, he underwent the second allo-PBSCT from a haplo-identical

donor (son) after non-myeloablative (reduced-intensity)

pretreatment. Unfortunately, his disease still progressed,

and he died of multiple-organ failure [10]. Among the 137

allo-HSCTs, 55.5% (76) of the donors were matched-related,

23.4% (32) were matched-unrelated, 10.2% (14) were

haploidentical-related, 4.4% (6) were umbilical cord blood

transplantations, and the other 6.6% (9) were unknown.

Among the 136 patients, before allo-HSCT 55.5% (76) received

myeloablative conditioning regimens, 42.3% (58) received

reduced-intensity conditioning regimens, and the regimens

of the other 2.2% (3) were unknown. As for the source of the

hematopoietic stem cells, 72.3% (99) were from peripheral blood

stem cells, 16.8% (23) were from bone marrow, and 10.2% (14)

were from cord blood, while the other 0.7% (1) was unknown.

GVHD

GVHD prophylaxis for these 136 patients included calcineurin

inhibitor (cyclosporine A or tacrolimus), mycophenolate

mofetil, short-course methotrexate, and their combinations. At

the average follow-up time of 34 months after allo-HSCT, 51

patients (37.5%) had developed acute GVHD and 43 patients

(31.6%) had developed chronic GVHD. As the reviewed studies

reported, most of these were cases of mild GVHD (grade I or II)

(Table 1 and Supplementary Table 1).

Survival

At the time of the publication of the reviewed studies, 48

patients (35.3%) had relapsed and 70 patients (51.5%) had

died. Two of the 48 patients with relapsed ENKL were locally

Table 2. The reviewed studies on 136 ENKL patients undergoing allo-HSCT.

Authors n PFS OS Rate of relapse Results

Kanate et al. [19] 82 28% (3-year PFS) 34% (3-year OS) 42% (34 patients) 63.4% (52 patients) died

Tse et al. [23] 18 51% (5-year PFS) 57% (5-year OS) 27.8% (5 patients) 44.4% (8 patients) died

Li et al. [32] 2 100% (3-year PFS) 100% (3-year OS) 0

CR and alive for 3 years and 5 years,

respectively

Yagi et al. [33] 1 0 CR and alive for 18 months

Takenaka et al. [34] 1 0 CR and alive for 11 months

Shustov et al. [35] 1 0 CR and alive for 49.1 months

Suzuki et al. [7] 6 50% (3-year PFS) 50% (3-year OS) 16.7% (1 patient)

50% (3 patients) died, the other 3 patients

CR and alive for 30+, 56+, 78+ months,

respectively

Yokoyama et al. [36] 1 0 CR and alive for 33 months

Ennishi et al. [37] 12 53% (3-year PFS) 55% (3-year OS) 33.3% (4 patients) 41.7% (5 patients) died

Ito et al. [11] 1 0 CR and alive for 4 years

Makita et al. [38] 1 0 CR and alive for 2 years

Mori et al. [39] 1 0 CR and alive for 18 months

Matsuo et al. [10] 1 100% Died

Yokoyama et al. [40] 5 60% (3-year PFS) 60% (3-year OS) 0

CR and alive for a median follow-up of 63.7

months (range: 29.6-87.2 months)

Kako et al. [12] 1 100% CR and alive for more than 1 year

Wakabayashi et al. [41] 1 100% Died

Czajczynska et al. [42] 1 0 CR and alive for 46+ months

PFS: Progression-free survival; OS: overall survival; CR: complete remission.

129



relapsed. One patient received additional irradiation, a course of

chemotherapy, and donor lymphocyte infusions [11], while the

other one [12] relapsed when her cyclosporine dose was rapidly

tapered and discontinued from 80 mg/day, and lesions regressed

gradually. These 2 patients achieved and maintained CR again

and survived for one additional year. Causes of death included

primary disease progression in 30 patients (42.9%), infection in

14 patients (20.0%), GVHD in 8 patients (11.4%), organ failure

in 5 patients (7.1%), hemorrhage in 3 patients (4.3%), and other

unknown reasons in 10 patients (14.3%) (Table 1).

Discussion

ENKL is a unique clinical entity characterized by an aggressive

clinical course. Both the strategy and the outcome of its

treatment depend on disease stage. For patients at lower

stages (I/II), combined chemotherapy and radiation therapy is

recommended, which achieves a 5-year OS rate ranging from

42% to 83% [13]. In contrast, patients at advanced stages

(III/IV) have not been shown to benefit from the addition of

radiotherapy and systemic chemotherapy. The overall prognosis

of ENKL is poor and its expected 5-year OS is less than 20%

[14]. It must also be noted that, although L-asparaginase-based

regimens have shown particularly high activity in ENKL patients,

a significant number of ENKL patients still relapse after primary

therapy, even with the significant toxicity of these regimens.

Therefore, people still have substantial interest in alternate

treatment strategies [3,15,16,17]. Currently, autologous

hematopoietic stem cell transplantation is commonly performed

in cases of advanced or relapsed/refractory ENKLs, and

allo-HSCT is also reported in some studies.

Allo-HSCT is a potential curative treatment for high-risk

lymphoma patients owing to its associated GVL effect. A recent

publication by the American Society for Blood and Marrow

Transplantation (ASBMT) suggested that allo-HSCT should

be limited to advanced-stage and relapsed/refractory ENKL

[18]. Recently, several research groups have also investigated

the benefit of allo-HSCT in patients with newly diagnosed or

relapsed/refractory disease. However, besides case reports, highquality

data on the application of allo-HSCT in ENKL are still

limited.

Among the 136 patients reviewed in this study, more

patients were middle-aged males with advanced-stage

ENKL. Before allo-HSCT, only 39.7% (54) of the 136 patients

received L-asparaginase-containing chemotherapy; 35.3%

(48) received radiotherapy; 46.3% were in CR (CR 1 : 27.2%

+ CR 2 : 18.4% + unknown: 0.7%) and another 46.3% were

in partial remission (PR) or had refractory/relapsed disease.

More patients received myeloablative conditioning regimens,

and more donors for patients receiving allo-HSCT were

matched-related. As for the source of hematopoietic stem

cells, more were from peripheral blood stem cells. GVHD is

unavoidable in allo-HSCT, but, fortunately, most cases were

mild GVHD, such as grade I/II. Finally, the calculated overall

mortality for the studies in Table 1 was 51.5%, while in a

recent large-scale study of 82 ENKL patients, the mortality

rate was as high as 63.4% [19]. The most common reason for

death was primary disease progression, still attributed to the

highly malignant and aggressive tumor cells.

Clinically, ENKL is characterized by a predominance in young

males, is seen in a large proportion as localized stage I and

II disease, is refractory to conventional chemotherapy, and is

sensitive to radiotherapy [20]. The reported OS varies widely

between series. It is known that even limited-stage ENKL has a

poor prognosis. The 5-year OS rates with CHOP and involvedfield

radiotherapy in cases of local nasal ENKL were reported

as <50% [21,22]. Some chemotherapy regimens containing

L-asparaginase or pegaspargase, such as SMILE, AspaMetDex,

and GELOX, have exhibited promising responses. A multicenter

analysis from the Asia Lymphoma Study Group [23] reported

that patients who had received SMILE chemotherapy before

allo-HSCT had significantly better OS and PFS than patients

treated with other regimens. However, another study [24]

showed that L-asparaginase-containing and L-asparaginaselacking

regimens did not yield a significant difference in 2-year

OS and PFS for advanced-stage ENKL, while radiotherapy was

associated with significantly prolonged survival in OS and

PFS in subgroup analysis. As for the 136 patients reviewed in

this study, only 39.7% (54) of them received L-asparaginasecontaining

chemotherapy, while 35.3% (48) received

radiotherapy. Thus, if more patients receive L-asparaginasecontaining

chemotherapy and radiotherapy before

allo-HSCT, it may influence the prognosis, but this needs more

verification.

A recent retrospective study from Japan reported the

limitations of the new therapeutic strategies and novel

regimens, finding almost no improvement in early disease

progression and 1-year PFS, while approximately 20% of

patients died or experienced disease relapse [25]. Even worse,

some studies reported the relapse rate to be as high as nearly

30% in early-stage ENKL [26,27]. Once an aggressive ENKL

tumor develops outside the original site, it can grow rapidly

and even disseminate with fever, hemophagocytic syndrome,

or disseminated intravascular coagulation. Some neoplasms

are also multidrug-resistant, leading to relapsed/refractory

cases and seriously affecting the prognosis. Therefore, the

prognosis of advanced and relapsed/refractory ENKL is poor

and the mortality is high. In this study, the overall mortality

rate of the 136 patients was 51.5% and the main reason for

mortality was primary disease progression. There are two

main explanations for this mortality. First of all, although the

proportions of advanced-stage and early-stage disease were

130



close (39.7% vs. 38.2%), the other 22.1% of cases (unknown

disease stage) may also have included some advanced-stage

patients. Second, some patients had refractory/relapsed

disease before allo-HSCT with poor prognosis. In such cases,

the disease is more likely to progress and even lead to death

after allo-HSCT. The second leading cause of death after

allo-HSCT was infection, followed by GVHD, organ failure, and

hemorrhage. Infection and GVHD are still two major causes

of death after allo-HSCT for hematological malignancies. The

high treatment-related mortality limits its widespread use.

The prognosis of ENKL is relatively poor. Most diagnosed

patients survived <2 years. It was reported that the overall

response rate (ORR) after conventional therapy was 36% for

newly diagnosed stage IV ENKL and was <10% for relapsed/

refractory ENKL [28]. In this study of 136 patients, the ORR was

48.5%, higher than that seen among advanced (or relapsed/

refractory) ENKL patients not receiving allo-HSCT. The longest

time for maintaining CR after allo-HSCT for these 136 patients

was 2617 days. In the follow-up period, only 33.8% (46) of

the 136 patients failed to achieve CR after allo-HSCT, but

35.3% (48) relapsed again after allo-HSCT. A multicenter analysis

from the Asia Lymphoma Study Group reported that the 5-year

OS was 57% and the 5-year PFS was 51% [23]. A large-scale

study reported that no transplant recipient had relapsed in 2

years after transplantation, suggesting potent GVL effects [19].

Therefore, allo-HSCT is still a viable therapy option for a subset

of ENKL patients. The most important thing is to reduce the

high treatment-related mortality.

However, obviously, the toxicity of the pre-allo-HSCT

conditioning regimen and possibly the acute post-allo-HSCT

GVHD lead to more deaths. A combined analysis [6] of 28

NK-cell neoplasms patients (22 with ENKL) showed that

treatment-related mortality was higher in patients receiving

conventional myeloablative stem cell transplantation

(30% vs. 20%) than that in patients receiving reducedintensity

stem cell transplantation, while the ORRs of the

two patient groups had no significant difference (60% vs.

52%). However, non-myeloablative conditioning regimens

may lead to high relapse rates, GVHD, and non-engraftment,

so the role of non-myeloablative HSCT remains undefined.

As the GVL effect has not been definitively established for

NK-cell lymphoma, the use of non-myeloablative

conditioning should be reserved for patients unsuitable

for myeloablative regimens in the setting of clinical trials

[29]. In these 136 patients, 72.3% of 137 allo-HSCTs were

peripheral HSCTs, perhaps because of collection convenience

and the therapy effect being as good as that of bone marrow

transplantation. While 10.2% of these 137 allo-HSCTs were

cord blood HSCTs, the applicability of umbilical cord blood

HSCT needs to be further defined.

The occurrence of GVHD during allo-HSCT cannot be completely

avoided. It was reported [23] that the development of acute

GVHD had a significant negative impact on OS but not on

PFS. Chronic GVHD had an insignificant impact on survival in

univariate analysis, while in multivariate analysis, acute GVHD

was no longer a significant factor for OS and PFS. In this

study, it has been seen that 37.5% (51) of the 136 patients

had acute GVHD and 31.6% (43) had chronic GVHD, but the

GVHD-induced mortality rate was 11.4%, indicating that the

GVHD was generally controllable.

In the authors’ own department, we have treated more than 100

ENKL patients, but only 2 such patients underwent allo-HSCT in

the past 5 years. Both of those patients were in an advanced stage

(IV) of disease. Of the 2 patients, a female patient had PR after

receiving CHOP chemotherapy, then achieved CR after treatment

with SMILE regimens. Three months later, she underwent

allo-PBSCT from an HLA-related sibling. The IBUCY conditioning

regimen was used (idarubicin at 12 mg/m 2 on days -11 to -9,

busulfan at 0.8 mg/kg q6h on days -6 to -4, cyclophosphamide

at 50 mg/kg on days -3 and -2). She maintained CR and survived

for more than 66 months without any acute or chronic GVHD.

The second patient, male, still remained in PR after 4 courses

of GLIDE (gemcitabine, ifosfamide, etoposide, dexamethasone,

pegaspargase) + methotrexate, and then he received allo-PBSCT

from an HLA-related brother, conditioned with FLAG + BUCY

(fludarabine at 30 mg/m 2 on days -10 to -7, cytarabine at

2 g/m 2 on days -10 to -7, busulfan at 0.8 mg/kg q6h on days -6

to -4, cyclophosphamide at 50 mg/kg on days -3 and -2). He has

now been well for 50 months in CR without acute or chronic

GVHD.

Limitations and Conclusion

Due to the rarity of ENKL and the difficulty of conducting

randomized controlled trials, the optimal treatment regimen

of ENKL has not yet been determined. Consequently, a heavy

selection bias might exist. In patients from isolated case

reports, a reporting bias toward successful treatment outcomes

is apparent. Finally, as none of the studies included in this

study were controlled, the outcome of comparable patients

treated with conventional chemotherapy and radiotherapy

was not available to judge whether allo-HSCT had affected the

outcome. Some important information (like remission status,

chemosensitivity, overall survival, Kaplan-Meier analysis, etc.)

was not elaborate enough in the available references, and this

is a shortcoming of the present study. Based on this limited

information, we can conclude that allo-HSCT can be considered

an option for ENKL, but it should be limited to cases of

advanced or relapsed/refractory ENKL. Novel treatments such

as anti-CD30 antibody [30] and programmed death protein

ligand 1 [31] were reported to be feasible choices for relapsed/

refractory ENKL, which have been promising in ongoing trials

131



to confirm their therapy results and help discover combination

therapies.

Acknowledgment: The authors thank the editors of this journal

for their help during manuscript preparation.

Ethics

Ethics Committee Approval: Ethical approval was not required

in this study because all cases were collected from published

papers.


Concept: Y.Y.P., H.B.Z., S.L.G.; Design: Y.Y.P., H.B.Z., S.L.G.;

Data Collection or Processing: Y.Y.P., H.B.Z., S.L.G.; Analysis or

Interpretation: Y.Y.P., Y.Y.X., S.L.G., Q.X.; Literature Search: Y.Y.P.,

Y.Y.X., L.X.Z., J.W.; Writing: Y.Y.P., Y.Y.X., S.L.G.


authors.



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133



Supplemental Table 1. Detailed clinical features of the 17 eligible references reporting 136 patients, and those of 2 other additional patients from

the authors’ department.

Authors Year Country n

Kanate

et al. [19]

Mean or

median

age, years

Sex, male

(%)

2018 USA 82 44 54 (65.8%)

Clinical stage

I/II: 35

(42.7%); III/

IV: 22 (26.8%);

Unknown: 25

(30.5%)

Chemotherapy before allo-HSCT

Chemotherapy alone, 41 (50%): CHOPor

HyperCVAD-like, 20 (24%); DeVIC

or VIPD, 4 (5%); SMILE, 11 (13%);

AspaMetDex, 2 (2%); gemcitabinebased,

2 (2%); others, 2(2%).

Chemotherapy + radiation, 27 (32.9%):

CHOP- or HyperCVAD-like + radiation,

14 (17%); De-VIC or VIPD + radiation,

8 (10%); SMILE + radiation, 2 (2%);

AspaMetDex + radiation, 2 (2%); other

+ radiation, 1 (1%)

L-asp-based

chemotherapy

before allo-

HSCT

31 (38%)

Radiation

before allo-

HSCT

Chemotherapy

+ radiation:

27 (32.9%);

Radiation alone:

5 (6.1%)

Tse

et al. [23]

2014

Hong

Kong,

China

18 40.5 14 (77.8%)

I/II:5(27.8%),

III/IV:13(72.2%)

SMILE: 14 (78%), CHOP: 2 (11%), ICE: 1

(6%), CALGB 19802: 1 (6%)

14 (78%) 1 (6%)

Li

et al. [32]

2011 China 2 28.5 0.00% IIB/IIIB

BCHOP, CHOPE, ESHAP, MOLP, MINE +

CHOP, BCHOP, MIME, DOLP

No 2 (100%)

Yagi

et al. [33]

2003 Japan 1 19 1 (100%) Unknown MACOP-B No Yes

Takenaka

et al. [34]

2009 Japan 1 26 0.00% I EPOCH No Yes

Shustov

et al. [35]

2010 USA 1 63 1 (100%) NE Unknown Unknown Unknown

Suzuki

et al. [7]

2006 Japan 6 24.8 1 (16.7%)

I/II: 2 (33.3%);

III/IV: 4 (66.7%)

Unknown Unknown Unknown

Yokoyama

et al. [36]

2007 Japan 1 36 0.00% IIIB DeVIC, L-asp/VCR/PSL Yes Yes

Ennishi

et al. [37]

2011 Japan 12 28 5 (41.7%)

I/II: 4 (33.3%);

III/IV: 8 (66.7%)

CHOP + MEPP, CHOP + MINE, EPOCH,

CHOP + DeVIC + EPOCH, DeVIC +

EPOCH, SMILE, CHOP, DeVIC + SMILE,

SMILE, SMILE + DeVIC, DeVIC + HD-

Ara-C, DeVIC + SMILE

5 (41.7%) 4 (33.3%)

Allo-HSCT: Allogeneic hematopoietic stem cell transplantation; L-asp: L-asparagine; PFS: progression-free survival; OS: overall survival; GVHD: graft-versus-host

disease (a: acute, c: chronic); CR: complete remission; PR: partial remission; PD: progressive disease; RIC: reduced-intensity conditioning regimen; MC: myeloablative

conditioning regimen; BM: bone marrow; PBSC: peripheral blood stem cell; CB: cord blood.

134



Time from

diagnosis to

allo-HSCT

Disease status at

transplantation

Conditioning

regimens

Regimen

intensity

Source of

hematopoietic

stem cells

Donor

matching

PFS

OS

Rate of

relapse

Result

GVHD

Unknown

CR: 37 (45%),

PR: 25 (30%),

chemorefractory:

10 (12%),

untreated/

unknown: 10

(12%)

Unknown

RIC: 48

(59%), MC:

31 (38%),

Unknown:

3 (4%)

BM: 4 (5%),

PBSC: 73

(89.0%), CB: 5

(6%)

Matched-related

donor: 50

(61%), unrelated

donor: 23 (28%),

umbilical cord

blood: 5 (6%),

haploidenticalrelated

donor: 3

(4%), unknown:

1 (1%)

28%

(3-year

PFS)

34%

(3-year

OS)

34

patients

(42%)

relapsed

52 patients

(63.4%) died

aGVHD:

29 (40%),

2-year

cGVHD: 29

(40%)

Unknown

18 months/

Unknown

CR: 16 (88.9%)

(CR 1 , n=9; CR 2 ,

n=7), PR: 1 (6%),

PD: 1 (6%)

Relapse, PR2/

Non-CR

CY/TBI: 8

(44%), CY/

TBI/antithymocyte

globulin:

1 (6%),

etoposide/

TBI: 1 (6%),

TBI: 1 (6%),

CY/BCNU/

etoposide: 2

(11%), BU/

CY: 1 (6%),

fludarabine/

melphalan: 4

(22%)

BU/CY/Vm26/

Ara-C; BU/

CY/MeCCNu/

Ara-C

RIC: 4

(22.2%),

MC: 14

(77.8%)

MC: 2

(100%)

BM: 7 (39%),

PBSC: 11

(61.1%)

PBSC: 2

(100%)

6 months Non-CR BU/CY/VP16 MC PBSC

5 months PR TBI/CY MC PBSC

9 months CR TBI + Flu RIC NE

6.3 months

Unknown

6 months

CR 2 : 1 (16.7%),

1 st relapse: 2

(33.3%), primary

refractory: 3

(50%)

Recurrence, not

CR

CR: 4 (33.3%)

(CR 1 : 2, CR 2 : 2),

PR: 4 (33.3%), PD:

4 (33.3%)

Unknown +

TBI

TBI + Ara-C

+ CTX

CY + TBI: 8

(66.7%), Flu

+ CY + TBI:

3 (25%), CA

+ CY + TBI: 1

(8.3%)

MC: 6

(100%)

BM: 3 (50%),

PBSC: 3 (50%)

Matched-related

donor: 12

(67%), matchedunrelated

donor:

6 (33%)

Matched-related

donor: 2 (100%)

Haploidenticalrelated

donor

Matched-related

donor

Matched-related

donor

Matchedrelated

donor:

5 (83.3%),

matchedunrelated

donor:

1 (16.7%)

51%

(5-year

PFS)

100%

(3-year

PFS)

50%

(3-year

PFS)

57%

(5-year

OS)

100%

(3-year

OS)

50%

(3-year

OS)

MC CB CB 0

RIC: 3

(25%), MC:

9 (75%)

BM: 4 (33.3%),

PBSC: 3 (25%),

CB: 5 (41.7%)

Unknown

53%

(3-year

PFS)

55%

(3-year

OS)

5

patients

(27.8%)

relapsed

0

0

0

0

1 patient

(16.7%)

relapsed

4

patients

(33.3%)

relapsed

8 patients

(44.4%) died

CR and alive

for 3 years

and 5 years,

respectively

CR and

alive for 18

months

CR and

alive for 11

months

CR and alive

for 49.1

months

3 patients

(50%) died;

the other 3

patients CR

and alive for

30+, 56+,

78+ months,

respectively

CR and

alive for 33

months

5 patients

died

aGVHD: 9

(grade 1-2:

n=7, grade

3-4: n=2),

cGVHD:

4(mild:

n=3;

severe:

n=1)

No aGVHD

or cGVHD

aGVHD:

grade II,

cGVHD:

mild oral

mucosa

No aGVHD

or cGVHD

No aGVHD

or cGVHD

Unknown

aGVHD:

gut, grade

I; cGVHD:

oral

mucosa

aGVHD

(I, II): 6

(50%),

cGVHD: 1

(8.3%)

135



Supplemental Table 1. Continued.

Authors Year Country n

Mean or

median

age, years

Sex, male

(%)

Clinical stage

Chemotherapy before allo-HSCT

L-asp-based

chemotherapy

before allo-

HSCT

Radiation

before allo-

HSCT

Ito et al. [11] 2011 Japan 1 29 1 (100%) IIE CHOP, DeVIC No Yes

Makita

et al. [38]

2002 Japan 1 26 0.00% Unknown EPOCH No Yes

Mori

et al. [39]

2010 Japan 1 52 0.00% IVB

Dexamethasone + methotrexate

+ ifosfamide + L-asparaginase +

etoposide/DeVIC

Yes

Yes

Matsuo

et al. [10]

2015 Japan 1 55 1 (100%) Unknown SMILE Yes No

Yokoyama

et al. [40]

2010 Japan 5 31 3 (60%)

I/II: 3 (60%); III/

IV: 2 (40%)

DeVIC, L-asp, DeVIC, CHOP + MCVC

+ auto-PBSCT, CHOP

1 (20%) 3 (60%)

Kako

et al. [12]

2007 Japan 1 43 0.00% IV

HyperCVAD/MA + dexamethasone,

etoposide, ifosphamide, and

carboplatin

No

No

Wakabayashi

et al. [41]

2009 Japan 1 47 1 (100%) IVB DeVIC No No

Czajczynska

et al. [42]

2013 Germany 1 11 1 (100%) Unknown CLAEG No Unknown

Authors’

department

China 2 37 1 (50%) IVB CHOP + SMILE, GLIDE + MTX 2 (100%) No

136



Time from

diagnosis to

allo-HSCT

Disease status at

transplantation

Conditioning

regimens

Regimen

intensity

Source of

hematopoietic

stem cells

Donor

matching

PFS

OS

Rate of

relapse

Result

GVHD

Unknown Recurrence CY + TBI MC BM

Unknown PD CY + TBI MC PBSC

Matched-related

donor

Matched-related

donor

7 months PD CY + TBI MC CB CB 0

4 months, 9

months

Unknown

Relapsed

locally

Non-CR MC/RIC MC/RIC PBSC Relapsed Died

Relapse and

CR 2 : 3 (60%),

refractory: 1

(20%), relapse: 1

(20%)

CA/CY/TBI, TBI/

CY, CA/CY/TBI,

CY/TBI, CA/

CY/TBI

MC: 5

(100%)

Unknown Relapse CY + TBI MC PBSC

6 months CR

Unknown

3 months, 5

months

PR

PR-CR, PR

Fludarabine

+ melphalan

+ TBI

BEAM/Cam

(alemtuzumab)

IBUCY, FLAG +

BUCY

RIC

MC

MC

BM: 3 (60%),

CB: 2 (40%)

BM

PBSC

PBSC

Matched-related

donor: 2 (40%),

CB: 2 (40%),

unknown: 1

(20%)


donor

Matchedunrelated

donor


donor

Matched-related

donor: 2 (100%)

60%

(3-year

PFS)

60%

(3-year

OS)

0

0

Relapsed

locally

Relapsed

0

0

CR and alive

for 4 years

CR and alive

for 2 years

CR and

alive for 18

months

CR and alive

for median

follow-up

time of 1911

days (range:

888-2617

days)

CR and alive

for more

than 1 year

Died

CR and alive

for 1400

days

CR and

alive for 66

months and

50 months,

respectively

cGVHD:

skin and

liver

cGVHD:

oral

mucosa

and liver

aGVHD:

skin (grade

3), cGVHD:

skin and

pericardial

effusion

aGVHD:

skin

aGVHD:

2 (40%),

cGVHD: 3

(60%)

aGVHD

(grade II)

of skin,

cGVHD of

liver

No aGVHD

or cGVHD

aGVHD

(grade II),

no cGVHD

No aGVHD

or cGVHD

137

Aladağ E. et al: Risk Scores in Stem Cell Transplantation

RESEARCH ARTICLE

DOI: 10.4274/tjh.galenos.2020.2020.0178


Comparison of Risk Scoring Systems in HLA-Matched Related

Allogeneic Hematopoietic Stem Cell Transplantation:

A Retrospective Cohort Study

HLA-Uyumlu Allojenik Hematopoetik Kök Hücre Akraba Nakillerinde Risk Skor Sistemlerinin

Kıyaslanması: Retrospektif Kohort Çalışması

Elifcan Aladağ, Haluk Demiroğlu, Yahya Büyükaşık, Hakan Göker

Hacettepe University Faculty of Medicine, Department of Hematology, Ankara, Turkey

Abstract

Objective: Allogeneic hematopoietic stem cell transplantation (AHSCT)

is a potentially curative treatment of choice for many hematological

diseases. However, there are some transplantation-related risks.

Predicting the risk-benefit ratio prior to AHSCT facilitates the choice

of conditioning regimens and posttransplant follow-up. Hence, many

risk models have been developed. The aim of the present study was to

compare 6 different risk models that are clinically used.

Materials and Methods: A total of 259 patients were enrolled in this

study. The European Society for Blood and Marrow Transplantation

(EBMT), Hematopoietic Cell Transplantation Comorbidity Index

(HCT-CI), Age-Adjusted Hematopoietic Cell Transplantation

Comorbidity Index (HCT-CI-Age), revised Pretransplant Assessment of

Mortality (rPAM), Acute Leukemia-EBMT (AL-EBMT), and Disease Risk

Index (DRI) risk models were applied retrospectively.

Results: The AL-EBMT, HCT-CI, and HCT-CI-Age scoring systems were

found to be predictive for 2-year overall survival (OS) and 2-year

non-relapse mortality (NRM) (2-year OS: AL-EBMT, reference vs.

score 8.5-10, HR: 1.3, p=0.035; AL-EBMT, reference vs. score >10, HR:

3.8, p=0.001; HCT-CI: reference vs. score 1-2, HR: 1.4, p=0.018; HCT-

CI: reference vs. score ≥3, HR: 2.5, p<0.001; HCT-CI-Age: reference

vs. score 1-2, HR: 1.3, p<0.001; HCT-CI-Age: reference vs. score ≥3,

HR: 3.2, p<0.001) (2-year NRM: AL-EBMT: reference vs. score 8.5-10,

HR: 1.61, p<0.001; AL-EBMT: reference vs. score >10, HR: 3.3, p<0.001;

HCT-CI: reference vs. score 1-2, HR: 1.3, p=0.028; HCT-CI: reference

vs. score ≥3, HR: 2.3, p=0.011; HCT-CI-Age: reference vs. score 1-2,

HR: 1.3, p=0.01; HCT-CI-Age: reference vs. score ≥3, HR: 2.4, p=0.003).

In terms of the Kaplan-Meier estimates of 2-year OS and 2-year NRM,

the risk scoring system with the highest predictive power was found

to be AL-EBMT (2-year AUC: 0.59 and 0.60, respectively). The other

scores were not found to be predictive for 2-year OS and NRM.

Conclusion: In the present study at our bone marrow and stem cell

transplant center, it has been demonstrated that the HCT-CI, HCT-CI-

Age, and AL-EBMT are good predictors of 2-year NRM and OS.

Keywords: Hematopoietic stem cell transplantation, Risk scoring,

Acute leukemia

Öz

Amaç: Allojeneik hematopoetik kök hücre nakli (AHKHN) birçok

hematolojik hastalıkta kullanılan potansiyel küratif bir tedavi

seçeneğidir. Bununla birlikte nakil ilişkili bazı riskler bulunmaktadır.

AHKHN öncesi risk-fayda oranının belirlenmesi, kullanılacak hazırlık

rejimlerinin seçimi ve nakil sonrası hasta takibini kolaylaştırmaktadır.

Bu nedenle birçok risk modeli geliştirilmiştir. Bu çalışmanın amacı,

klinik kullanımı olan 6 farklı risk modelini karşılaştırılmasıdır.

Gereç ve Yöntemler: Bu çalışmaya çeşitli hematolojik nedenlerle

AHKHN yapılan 259 hasta alınmıştır. Avrupa Kan ve Kemik iliği Nakli

Derneği (EBMT), Hematopoetik Hücre Transplantasyon Komorbidite

İndeksi (HCT-CI), yaşa göre düzenlenmiş Hematopoetik Hücre

Transplantasyon Komorbidite İndeksi (HCT-CI-Yaş), düzenlenmiş nakil

öncesi mortalite değerlendirme skoru (rPAM), akut lösemi-EBMT skoru

(AL-EBMT) ve hastalık risk indeksi (DRI) risk modelleri geriye dönük

olarak uygulanmıştır.

Bulgular: HCT-CI, HCT-CI-Age ve AL-EBMT risk modelleri 2 yıllık

genel sağkalım (OS) ve 2 yıllık NRM için prediktif bulundu (2 yıllık OS;

AL-EBMT: referans vs skor 8,5-10 HR: 1,3 p=0,035 referans vs skor

>10 HR: 3,8 p=0,001, HCT-CI: referans vs score 1-2 HR: 1,4 p=0,018

referans vs skor ≥3 HR: 2,5 p<0.001, HCT-CI-Age referans vs skor

1-2 HR: 1,3 p<0,001 referans vs skor ≥3 HR: 3,2 p<0,001 2 yıllık

NRM: AL-EBMT: referans vs skor 8,5-10 HR: 1,61 p<0,001 referans vs

skor >10 HR: 3,3 p<0,001 HCT-CI: referans vs skor 1-2 HR: 1,3 p=0,028

referans vs skor ≥3 HR: 2,3 p=0,011 HCT-CI-Age referance vs skor

1-2 HR: 1,3 p=0,01 referans vs skor ≥3 HR: 2,4 p=0,003). İki yıllık OS

ve 2 yıllık NRM için, prediktif gücü en yüksek olan test AL-EBMT idi

(sırasıyla 2 yıllık AUC; 0,59-0,60). Diğer modeller 2 yıllık OS ve NRM

için prediktif değildi.

Sonuç: Referans nakil merkezimizde yapılan bu çalışmada, HCT-CI,

HCT-CI-Yaş ve AL-EBMT risk modellerinin 2 yıllık NRM ve OS için iyi

birer belirteç olduğu gösterilmiştir.

Anahtar Sözcükler: Hematopoetik kök hücre nakli, Risk skoru, Akut

lösemi



Address for Correspondence/Yazışma Adresi: Hakan Göker, M.D., Prof., Hacettepe University Faculty of Medicine,

Department of Hematology, Ankara, Turkey

E-mail : hgoker1@yahoo.com ORCID: orcid.org/0000-0002-1039-7756

Received/Geliş tarihi: April 17, 2020

Accepted/Kabul tarihi: June 16, 2020

138



Introduction

Allogeneic hematopoietic stem cell transplantation (AHSCT)

has been successfully applied as a curative treatment option

for many hematological diseases. AHSCT treatment has shown

a marked upward trend in the last 20 years [1]. However, this

occurred together with an increase in non-relapse mortality

(NRM) due to the transplantation. NRM is often related to

acute and chronic graft-versus-host disease (GvHD), infections,

and transplantation-related toxicities [2]. A decrease in

NRM increases the expected overall survival (OS) of patients.

Therefore, the selection of a suitable donor and a suitable

conditioning regimen to prevent NRM has been a challenge

for clinicians [3]. For this purpose, many scoring systems have

been developed to evaluate transplantation-related risks. While

these predictive risk scores guide clinicians in AHSCT decisions,

they also assist in the selection of preparatory regimens and

appropriate care after transplantation according to expected

risks [4]. These scores can be based on 3 types of systems: a)

patient-specific (i.e., CMV serology, donor/recipient age-HLA

match, sex match/mismatch, patient comorbidities); b) diseasespecific

(i.e., underlying disease, disease status, disease stage,

time for transplantation); and c) combined patient-, disease-,

and center-specific (experience of the transplantation center)

[4,5]. A number of retrospective studies have been conducted,

especially on 6 different clinical scoring systems [6,7,8,9,10,11].

Of these, the Hematopoietic Stem Cell Transplantation

Comorbidity Index (HCT-CI) and its derivative, the HCT-CI-

Age Index (HCT-CI-Age), are two scoring systems based on

17 different pretransplant comorbidities of patients. They

provide objective and reliable data on the causes of NRM and

posttransplant complications based on objective laboratory data

and defined morbidities [7,12]. The European Society for Blood

and Marrow Transplantation (EBMT) scoring is one of the oldest

modeled risk scoring systems and EBMT risk groups have been

shown to predict 5-year OS and transplant-related mortality

[13,14]. The Acute Leukemia-EBMT (AL-EBMT) scoring system

was first developed in 2015 as a machine-learning algorithm to

facilitate clinical decision-making in cases of acute leukemias.

These calculations provide a 100-day mortality risk for patients.

A validation study also demonstrated its strong predictive

features for 2-year OS, leukemia-free survival, and 2-year NRM

[15]. For the Pretransplant Assessment of Mortality (PAM) score,

the age of the patient, donor type, disease risk, preparation

regimens, serum creatinine and alanine aminotransferase

levels, and forced expiratory volume in one second (FEV1)

and diffusing capacity for carbon monoxide (DLCO) values are

used. It has been shown to have significant ability to predict

especially 2-year OS. However, not many validation studies

have been performed [16,17]. A revised PAM (rPAM) scoring

system including 5 parameters (age of the patient, donor type,

disease risk, FEV1, and patient/recipient CMV serology) was

developed in 2015, simplifying the previous one [9]. Another

risk assessment model is the Disease Risk Index (DRI). A limited

study demonstrated that the DRI risk groups predicted 4-year

OS, progression-free survival, incidence of relapse, and NRM,

although less effectively so for the last parameter [18,19].

In the present study, we have sought to validate and compare 6

different scoring systems in patients who underwent allogeneic

stem cell transplantation in our bone marrow and stem cell

transplant center and to demonstrate whether the risk groups

predicted 2-year OS and NRM.


All clinical and laboratory data were obtained retrospectively

from the electronic medical database system of the Hacettepe

University Medical School’s Bone Marrow Transplant Center.

The study included 259 patients aged 18 years and older

who underwent allogeneic stem cell transplantation between

2006 and 2019 from a matched related donor. Patients whose

necessary data for the scoring systems (e.g., patient and donor

CMV serology, pretransplant disease assessment) were missing

were excluded from the study. Conditioning regimens were

categorized as defined by Bacigalupo et al. [20] as either

myeloablative (MA) or reduced intensity conditioning (RIC)

[21,22].

Prognostic scores were calculated for each patient using the

definitions provided in the publications of the respective

prognostic indices: the EBMT, AL-EBMT, rPAM score, HCT-CI, HCT-

CI-Age, and DRI. The rPAM score was calculated as per online

instructions (http://pamscore.org/) and an online calculator was

used for the AL-EBMT score (http://bioinfo.lnx.biu.ac.il/~bondi/

web1.html) [15]. The DRI was not applicable in patients with

aplastic anemia, and the AL-EBMT score was applied only for

patients with acute leukemia. The EBMT score of the patients

was evaluated in 4 risk groups as 0-2, 3, 4, and >5 [23]. The

rPAM score was evaluated in four categories of <17, 17-21,

21-30, and >30 [24]. The HCT-CI-Age score was evaluated in 3

groups as scores of 0, 1-2, and >3 [25]. The 17 comorbidities of

the HCT-CI were assessed as previously defined [25,26]. The DRI

risk score was analyzed in 4 groups of low, intermediate, high,

and very high risk [27]. AL-EBMT scoring was applied according

to the expected 100-day mortality value obtained from the

online calculator. Patients were divided into 3 risk groups based

on 100-day mortality as <8.5%, 8.5%-10%, and >10%.


The primary endpoint of the study was NRM, accepted as the

period between the 0 th day of transplantation and mortality

due to any causes other than relapse/progressive disease. The

secondary endpoint was OS, accepted as the period from the

0 th day of transplantation to mortality due to any reason. All

139



analyses were performed using SPSS software (version 20.0; IBM

Corp., Armonk, NY, USA).

The 2-year OS ratio of the patients was calculated using

Kaplan-Meier curves and the survival difference between the

risk groups was compared using the log-rank test. A univariate

Cox regression model was used to estimate the impact of the

different pretransplant predictive scores on NRM and OS. Cases

of p<0.05 were considered statistically significant.

C statistics were used to show the possibility of risk groups to

predict the endpoints. A C statistical value of 1 represented

the highest concordance, while values of less than 0.5 were

considered to signify low concordance.

Results

Patient Characteristics

Patient characteristics are shown in Table 1. A total of 259

patients were enrolled. The median age of patients at the time of

transplantation was 38 years (range: 18 to 64 years). Performance

statuses of all patients were low during transplantation. In 3%

of the patients, the Karnofsky performance status was observed

to be <80%. A second AHSCT was performed for 10 patients

and all the remaining patients were scored according to the

values prior to the first AHSCT. While 48.6% of the patients

had acute myeloid leukemia, 32.4% had acute lymphocytic

leukemia, 7.7% had chronic myeloid leukemia, 6.9% had

myelodysplastic syndrome, and 4.2% had non-Hodgkin

lymphoma or Hodgkin lymphoma. Transplantations were

performed from HLA-matched related donors for all patients.

Median follow-up duration after transplantation was 46.6

months. The most common comorbidity was infection (11.9%),

followed by diabetes mellitus (9.2%). The least seen side effect

was psychiatric disorders (1.5%). Solid tumors and heart valve

disease, which have been shown as predictive in HCT-CI scoring,

were not seen in any patients.

Outcomes

Non-relapse Mortality

Non-relapse mortality was seen in 8.5% of patients. The most

common causes of NRM were infection (n=13) and acute GvHD

(gastrointestinal system GvHD in 2 patients, GvHD and infection

in 6 patients). As shown in Table 2, NRM rates were significantly

different among the AL-EBMT, HCT-CI, and HCT-CI-Age risk

groups, and those risk scores were found to be positively predictive

for 2-year NRM (AL-EBMT: reference vs. score 8.5-10, HR: 1.61,

p<0.001; AL-EBMT: reference vs. score >10, HR: 3.3, p<0.001;

HCT-CI: reference vs. 1-2, HR: 1.3, p=0.028; HCT-CI: reference vs.

score ≥3, HR: 2.3, p=0.011; HCT-CI-Age: reference vs. score 1-2,

HR: 1.3, p=0.01; HCT-CI-Age: reference vs. score ≥3, HR: 2.4,

p=0.003).

The C statistics of these scoring systems for 2-year NRM were

0.60, 0.51, and 0.52, respectively. The 2-year NRM calculated

with the AL-EBMT was 3.1%, 14.3%, and 27% based on low,

intermediate, and high risk, respectively. The 2-year NRM

values according to the HCT-CI and HCT-CI-Age were 11.2%,

16.2%, and 21.6% and 4.1%, 14.6%, and 21.2% based on low,

intermediate, and high risk, respectively (Table 2).

Overall Survival

The OS values did not show any statistically significant

difference when scores were calculated based on the rPAM,

DRI, and EBMT scoring systems. In univariate analysis, AL-EBMT,

HCT-CI, and HCT-CI-Age risk groups had significant impacts

Table 1. Baseline characteristics of the patient population.

Characteristics

Number (%) or

Median (range)

Age (years) 38 (18-64)

Diagnosis

Acute myeloid leukemia 126 (48.6)

Acute lymphoid leukemia 84 (32.4)

Myelodysplastic syndrome 18 (6.9)

Chronic myeloid leukemia

Lymphoma (NHL/HL)

20 (7.7)

9/2 (3.4/0.7)

Serum creatinine (mg/dL) 0.79 (0.64-2.3)

FEV1 (%)

Karnofsky performance status

<80

≥80

Conditioning regimen

90 (42-107)

12 (4.6)

247 (95.4)

Myeloablative 117 (45)

Reduced intensity conditioning 142 (55)

CMV serology

Recipient/donor negativity 36 (13)

Recipient or donor negativity 30 (10)

Recipient/donor positivity 223 (77)

Time from diagnosis to AHSCT (months) 7.7 (2-173)

Sex mismatch

Male recipient/female donor

Comorbidities

Infection

Diabetes mellitus

Cardiac diseases

Hepatic diseases

Pulmonary diseases

Peptic ulcer

Psychiatric disorders

Renal diseases

140 (48.8)

72 (27.7)

31 (11.9)

24 (9.2)

18 (6.9)

11 (4.2)

8 (3)

6 (2.3)

4 (1.5)

7 (2.7)

NHL: Non-Hodgkin lymphoma; HL: hodgkin lymphoma; FEV1: forced expiratory

volume in one second; AHSCT: allogeneic hematopoietic stem cell transplantation.

140



on 2-year OS (AL-EBMT: reference vs. score 8.5-10, HR: 1.3,

p=0.035; AL-EBMT: reference vs. score >10, HR: 3.8, p=0.001;

HCT-CI: reference vs. score 1-2, HR: 1.4, p=0.018; HCT-CI:

reference vs. score ≥3, HR: 2.5, p<0.001; HCT-CI-Age: reference

vs. score 1-2, HR: 1.3, p<0.001; HCT-CI-Age: reference vs. score

≥3, HR: 3.2, p<0.001) (Figure 1). C statistics of these scoring

systems for 2-year OS were 0.59, 0.52, and 0.56, respectively.

While OS was not observed in the group with rPAM scores of

17-24, 2-year OS was found to be significantly higher in patients

with rPAM scores of 24-30 and >30 compared to the reference

group (rPAM: reference vs. score 24-30, HR 1.8, p=0.037; rPAM:

reference vs. score >30, HR 3.6, p=0.012).

Discussion

The aim of the present study was to test and validate 6 different

transplantation risk scores in a patient group. We found high

predictive value for 2-year NRM and 2-year OS using the HCT-

CI, HCT-CI-Age, and AL-EBMT scores. In our study, the C statistics

for both models were rather low (<0.65), and there was a trend

toward better predictive capacity for the AL-EBMT compared

with the HCT-CI and HCT-CI-Age scores.

The vast majority of risk-based scoring systems are validated

with well-defined broad cohorts. Many studies have been

published comparing these scoring systems. However, studies

generally only evaluate 2 different scores [8,11,28,29]. The

present study contributes to the literature in terms of applying

6 different scoring systems for the same patients. To the best

of our knowledge, there is only one study in the literature that

compared more than 3 risk scoring systems [6]. In that study, 8

different scoring systems were evaluated among 528 patients

(EBMT, HCT-CI, Comorbidity-Age, Comorbidity-EBMT, rDRI,

PAM, rPAM, and EASIx); among all of them, the models with

Table 2. Two-year overall survival and non-relapse mortality according to the risk scoring systems.

EBMT

n 2-year OS, % (95% CI) HR p 2-year NRM (95% CI) HR p

0-2 135 87.2 (72-91.2) Reference 7.1 (6.9-7.3) 1

3 73 78.6 (72.2-81.1) 1.1 (0.7-1.8) 0.476 9.4 (7.3-14.6) 1.2 (1.1-1.5) 0.272

4 23 80.2 (52.2-81.4) 1.3 (0.5-2.2) 0.673 11.1 (8-14.1) 1.4 (1.1-2.7) 0.284

5 28 60.9 (55.6-65.6) 1.8 (1-3.1) 0.043 14.4 (11.2-19.1) 2.4 (1.4-4.3) 0.001

AL-EBMT

<8.5 163 81.2 (74.1-97.2) Reference 3.1 (1-5.1) Reference

8.5-10 23 77.4 (70.2-81.5) 1.3 (0.6-2.7) 0.035 14.3 (11.6-21.1) 1.6 (0.8-3.1) <0.001

>10 24 33.1 (30.6-36.1) 3.8 (2.1-6.7) 0.001 27 (18-29.1) 3.3 (1.9-4.8) <0.001

rPAM

<17 217 84.2 (72.1-86.2) Reference 9.1 (7.7-12.1) Reference

17-24 14 80.2 (55.1-79,8) 2 (0.9-4.2) 0.056 10.2 (6.4-16.1) 1.8 (0.8-4) 0.109

24-30 24 61.2 (52.3-63.4) 1.8 (1-3.3) 0.037 17.2 (4.1-19.2) 1.7 (0.9-3.1) 0.055

>30 4 50.1 (22.2-57.3) 3.6 (1.3-9.9) 0.012 - 2.7 (1.1-8.7) 0.084

HCT-CI

0 175 84.2 (72.1-86.1) Reference 11.2 (8.2-14.1) Reference

1-2 66 72.2 (59.1-79.9) 1.4 (0.9-2.3) 0.018 16.2 (13-17.2) 1.3 (1.2-2.1) 0.028

≥3 18 56.2 (41.3- 57.2) 2.5 (1.2-5) <0.001 24.6 (14.6-26.2) 2.3 (1.2-4.6) 0.011

HCT-CI-A

0 106 84.2 (76.2-83.3) Reference 4.1 (1.3-5.2) Reference

1-2 117 71.9 (66.1-79.9) 1.3 (1.03-2.1) <0.001 14.6 (11.1-16.4) 1.3 (1.1-2) 0.01

≥3 36 49.1 (42.3-57.1) 3.2 (5.8-3.9) <0.001 21.2 (16.2-24.4) 2.4 (1.3-4.4) 0.003

DRI

Low 40 81.5 (74.2-85.2) Reference 7.4 (6.9-8.2) Reference

Intermediate 174 80 (62.9-79.1) 1.1 (0.6-1.9) 0.68 9.1 (6.7-13.4) 1.1 (0.6-2) 0.31

High 31 65.7 (57.7-71.5) 1.6 (0.8-3.4) 0.11 13.5 (12.2-16.2) 2.3 (1.1-4.7) 0.12

Very high 14 47.6 (42.8-62.6) 1.7 (0.7-4.3) 0.22 - - -

OS: Overall survival, NRM: non-relapse mortality; HR: hazard ratio; CI: confidence interval; EBMT: European Society for Blood and Marrow Transplantation; AL-EBMT: Acute Leukemia-

EBMT score; rPAM: revised Pretransplant Assessment of Mortality Score; HCT-CI: Hematopoietic Cell Transplantation Comorbidity Index; HCT-CI-A: Age-Adjusted Hematopoietic Cell

Transplantation Comorbidity Index; DRI: Disease Risk Index.

141



Figure 1. Kaplan-Meier curves of survival in risk groups as defined by HCT-CI (A), HCT-CI-Age (B), and AL-EBMT (C).

the highest predictive power for these outcomes were shown to

be PAM and rPAM. The PAM score combines patient-, donor-,

and disease-related factors. With its update in 2015, replacing

DLCO and serum alanine aminotransferase and serum creatinine

concentrations with donor/recipient CMV serostatus, the C

statistic was similar in the revised and original versions of the

PAM scoring system (0.65 versus 0.64) [9]. There are disparate

results in the literature for PAM scores. A second study found

an association between PAM score and NRM in recipients of MA

AHSCT, but not in the subset of reduced intensity recipients,

suggesting the lack of utility of the PAM index in patient

cohorts with high rates of comorbidities [30,31]. Similarly, we

observed that rPAM was predictive for 2-year OS in patients

with advanced scores (24-30 and >30). However, the same trend

was not observed for 2-year NRM. This may be a result of the

tendency toward RIC in our patients.

In this study, the area under the curve (AUC) value of all

scoring systems was found to vary between 0.51 and 0.60.

These values were found to be low, possibly due to the low

number of patients or to the abnormal distribution of patients

in the risk groups. Since some components of the scores used

in this study were the same for all patients, this might have

decreased the predictive power of the scoring systems. For

example, donor type, which is used in the EBMT score and may

be predictive for NRM, was the same for all of our patients

(HLA-matched related donors), and this might have reduced

the predictivity of the model for NRM [13]. Likewise, we know

that seropositive patients receiving grafts from seropositive

donors have improved OS compared to seronegative donors

if they have received MA conditioning [32]. The 77% rate of

double CMV seropositivity in the patient population may have

led to positive selection for the AL-EBMT and rPAM scores.

Similarly, the age component was the same in all patients

(<65 years) for the rPAM score and matched-related siblings

were the donors in all cases, and this caused the majority

of patients to be grouped in the low-risk group (score: 17).

This might have reduced the predictive power of the rPAM

model in this patient group. In addition, this model provides

a higher predictive difference in patients undergoing a MA

conditioning regimen according to the literature findings.

Though subgroup analysis was not performed for patients

receiving RIC and MA conditioning regimens, the number of

patients transplanted using RIC regimens was observed to be

higher.

The novel aspect of this study is that it is a clinical study in which

the AL-EBMT model is compared with other scoring systems

for the first time. The AL-EBMT score was developed using

non-parametric data, unlike all other scoring systems. Although

it is predictive for 100-day mortality in patients with acute

leukemia, NRM has also been shown to predict leukemia-free

survival and 2-year OS. In the validation study performed with

1848 patients in 2017, the hazard ratio of 2-year OS and NRM

in intermediate and high risk groups with the reference being

the low risk group was 1.3 and 1.24, respectively, and 2.79 and

1.84, respectively (p<0.001; p=0.029) [15]. In the present study,

the C statistics of AL-EBMT revealed that the 2-year predictive

power was higher both for OS and NRM than that of all other

scores. However, this scoring system can only be applied in

patients with acute leukemia and this might be considered a

source of bias.

Conclusion

Six different risk scoring systems used for risk assessment prior

to AHSCT for patients referred to a tertiary care transplant

center were compared in the present study. The AL-EBMT,

HCT-CI, and HCT-CI-Age scoring systems were shown to be

significantly predictive for 2-year OS and 2-year NRM. These

scoring systems are used in many centers since they allow

individualized conditioning of the patients for transplantation

and guide physicians for better patient follow-up. Future larger

multicenter studies are needed to further elucidate the role of

these different risk assessment scores and to obtain the most

reliable results.

Ethics

Ethics Committee Approval: The research was approved by the

Hacettepe University Ethics Committee (GO 20/1097).

142



Informed Consent: As a result of application standards of the

hospitals of Hacettepe Medical School, it has been recognized

from the patient records that all of the studied patients had

given informed consent at the time of hospitalization and

before the administration of chemotherapy and other relevant

diagnostic/therapeutic standards of care.


Concept: H.G., H.D.; Design: Y.B.; Data Collection or Processing:

Y.B., E.A.; Analysis or Interpretation: E.A.; Writing: E.A.


authors.



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144

Kaya Z. et al: ALPS in Chronic Immune Cytopenia and Lymphoma

BRIEF REPORT

DOI: 10.4274/tjh.galenos.2020.2020.0618


Autoimmune Lymphoproliferative Syndrome in Children with

Nonmalignant Organomegaly, Chronic Immune Cytopenia, and

Newly Diagnosed Lymphoma

Malign Olmayan Organomegali, Kronik İmmün Sitopeni ve Yeni Tanı Lenfomalı Çocuklarda

Otoimmün Lenfoproliferatif Sendrom

Zühre Kaya 1 , Melek Işık 1 , Nihan Oruklu 2 , Serap Kirkiz 1 , Emin Ümit Bağrıaçık 2 , Luis M. Allende 3 ,

María J. Díaz-Madroñero 3 , Raquel Ruiz-García 3 , Faruk Güçlü Pınarlı 4 , Pınar Göçün Uyar 5 , Ülker Koçak 1

1Gazi University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey

2Gazi University Faculty of Medicine, Department of Immunology and Life Science Research Center, Ankara, Turkey

3Immunology Department and Research Institute i+12, Hospital Universitario 12 de Octubre, Madrid, Spain

4Gazi University Faculty of Medicine, Department of Pediatric Oncology, Ankara, Turkey

5Gazi University Faculty of Medicine, Department of Pathology, Ankara, Turkey

Abstract

This study investigated the frequency of and predictive factors

for autoimmune lymphoproliferative syndrome (ALPS) in children

with lymphoma, chronic immune cytopenia, and nonmalignant

organomegaly. Thirty-four children with suspected ALPS (n=13,

lymphoma; n=12, immune cytopenia; n=9, nonmalignant

organomegaly) were included. Double-negative T-cells, lymphocyte

apoptosis, and genetic findings were analyzed. Patients were stratified

into two groups as proven/probable ALPS and clinically suspected

patients according to the ALPS diagnostic criteria. Of the 34 patients,

18 (53%) were diagnosed with proven/probable ALPS. One patient had

a mutation (c.652-2A>C) in the FAS gene. The remaining 16 (47%)

patients were defined as clinically suspected patients. Predictive

factors for ALPS were anemia and thrombocytopenia in patients with

lymphoma, splenomegaly and lymphadenopathy in patients with

immune cytopenia, and young age in patients with nonmalignant

organomegaly. ALPS may not be rare in certain risk groups. Our study

indicates that screening for ALPS may be useful in children having

lymphoma with cytopenia at diagnosis, in those having nonmalignant

organomegaly with immune cytopenia, and in those having chronic

immune thrombocytopenic purpura or autoimmune hemolytic anemia

with organomegaly developing during follow-up.

Keywords: Autoimmune lymphoproliferative syndrome, Immune

cytopenia, Lymphoma

Öz

Bu çalışmanın amacı malign olmayan organomegali, kronik immün

sitopeni ve lenfomalı çocuklarda otoimmün lenfoproliferatif sendrom

(OILS) sıklığını ve belirleyici faktörlerini araştırmaktır. Bu çalışmaya

OILS şüpheli 34 hasta dahil edildi (13 hasta lenfoma, 5 hasta otoimmün

hemolitik anemi, 7 hasta kronik immün trombositopenik purpura

ve 9 hasta malign olmayan organomegali). Çift negatif T-hücreler,

lenfosit apoptozis ve genetik bulgular analiz edildi. Hastalar OILS

tanı kriterlerine göre kesin ve yüksek olasılıklı OILS’li hastalar ve

klinik şüpheli OILS’li hastalar olarak iki gruba ayrıldı. Çalışmaya dahil

edilen 34 hastanın, 18’i (%53) kesin ve yüksek olasılıklı OILS’di. Malign

olmayan organomegalisi olan bir çocukta FAS geninde mutasyon

(c.652-2A>C) saptandı. Klinik şüpheli hasta 16 (%47) idi. OILS için

belirleyici faktörler; lenfomalı hastalarda anemi ve trombositopeni,

kronik immün sitopenili hastalarda splenomegali ve lenfadenopati;

malign olmayan organomegalisi olan hastalarda genç yaş idi. OILS

belirli risk gruplarında nadir olmayabilir. Çalışmamız, ilk tanıda

sitopenisi olan lenfomalı çocuklarda, immün sitopenisi olan nonmalign

organomegalili çocuklarda ve izlem sırasında organomegalisi gelişen

kronik immün trombositopenik purpura ve otoimmün hemolitik

anemili çocuklarda OILS taramasının yararlı olabileceğine işaret

etmektedir.

Anahtar Sözcükler: Otoimmün lenfoproliferatif sendrom, İmmün

sitopeni, Lenfoma



Address for Correspondence/Yazışma Adresi: Zühre Kaya, M.D., Gazi University Faculty of Medicine,

Department of Pediatric Hematology, Ankara, Turkey

E-mail : zuhrekaya@gazi.edu.tr ORCID: orcid.org/0000-0002-3798-7246

Received/Geliş tarihi: October 16, 2020

Accepted/Kabul tarihi: December 29, 2020

145



Introduction

Autoimmune lymphoproliferative syndrome (ALPS) is

characterized by nonmalignant organomegaly, immune

cytopenia, and an increased risk for lymphoma, as well as mutation

in the FAS-mediated apoptotic pathway [1,2,3,4,5,6,7,8,9,10].

Few studies have considered the identification of ALPS in

certain populations, such as patients with Evans syndrome or

lymphoma [11,12,13,14,15,16].

The aim of the present study was to investigate the frequency

and predictive factors of ALPS in children with recently

diagnosed lymphoma, chronic nonmalignant organomegaly,

and chronic immune cytopenia.


In total, 34 consecutive patients were included in this study with

a two-stage cross-sectional design: those with nonmalignant

organomegaly, chronic immune thrombocytopenic purpura

(cITP), or autoimmune hemolytic anemia (AIHA) (n=21) between

March 2011 and April 2013, and those with newly diagnosed

lymphoma (n=13) between June 2013 and March 2015. Patients

were also stratified into two groups as proven/probable ALPS

(Group 1, n=18) and clinically suspected patients (Group 2,

n=16) according to the ALPS diagnostic criteria [17] (Figure 1).

The institutional review board approved the study.

Serum vitamin B12 (>1500 ng/L) and immunoglobulin levels,

soluble FAS ligand (>200 pg/mL), and interleukin (IL)-10 levels

(>20 pg/mL) were measured. Double-negative T-lymphocytes

(DNTs; CD3+ T-cell receptor (TCR) αβ+ CD4-, and CD8- DNTs

≥2.5% of the patient’s CD3+ lymphocyte count) were analyzed

by flow cytometry [17]. Apoptotic cells were detected by flow

cytometry using annexin V-FITC [18]. Nine exons of the FAS

gene were analyzed by Sanger sequencing. Data analysis was

performed using SPSS 15.0.

Results

The demographic data for ALPS are summarized in Table 1.

Of the 34 patients enrolled, 18 (53%) fulfilled the diagnostic

criteria for proven ALPS (n=13; 38%) or probable ALPS (n=5;

15%) in Group 1. The remaining 16 (47%) were clinically

suspected patients in Group 2. There were significant

differences in terms of age between Group 1 and Group 2

(p<0.05). The median age of the patients with nonmalignant

organomegaly in Group 1 was significantly lower than that of

the nonmalignant organomegaly patients in Group 2 (3 vs. 10

years; p<0.05). The proportions of patients with splenomegaly

and lymphadenopathy were significantly higher among the cITP

and AIHA subgroups in Group 1 than among the cITP and AIHA

subgroups in Group 2 (p<0.05). The proportions of patients with

anemia and thrombocytopenia were significantly higher among

the lymphoma subgroups in Group 1 than among the lymphoma

subgroups in Group 2 (p<0.05).

All relevant data of the 18 patients with proven and probable

ALPS are given in Table 2. Of them, 7 (38%) had lymphoma,

5 (28%) had nonmalignant organomegaly, 4 (22%) had cITP,

and 2 (12%) had AIHA. Of the seven children with lymphoma,

histopathological examination revealed five with Hodgkin

lymphoma. Only two of them were positive for Epstein-Barr

virus (EBV). Heterozygous splicing mutation in the FAS gene

(c.652-2A>C in intron 7) was identified in Case 10 as shown

in Table 2. The FAS mutation rate was found to be 20% among

patients with nonmalignant organomegaly (n=5).

Five of the 18 children in Group 1 had been scheduled for

splenectomy for massive splenomegaly. Splenectomy was

canceled after the diagnosis of ALPS. Three of them responded

to steroids and mycophenolate mofetil (MMF), one was

unresponsive to steroids and MMF but responded to sirolimus,

and one received an allogeneic stem cell transplantation. The

Figure 1. Flow chart of the study participants.

ALPS: Autoimmune lymphoproliferative syndrome; NMO: nonmalignant organomegaly; cITP: chronic immune thrombocytopenic purpura; OIHA:

autoimmune hemolytic anemia.

146



Table 1. Demographic characteristics, frequency, clinical features, and laboratory parameters for the patient groups.

Group 1

(n=18)

Group 2

(n=16)

Median age (range) in years 10 (1-18) 14 (5-18) 0.02

Sex, male/female, n (%) 12 (66%)/6 (34%) 6 (38%)/10 (62%) 0.08

Frequency

Lymphoma, n (%) 7 (38%) 6 (37%) 0.80

Nonmalignant organomegaly, n (%) 5 (28%) 4 (25%) 0.58

Chronic immune thrombocytopenia, n (%) 4 (22%) 3 (19%) 0.57

Autoimmune hemolytic anemia, n (%) 2 (12%) 3 (19%) 0.44

Clinical features

Hepatomegaly, n (%) 10 (55%) 4 (25%) 0.07

Splenomegaly, n (%) 13 (72%) 6 (38%) 0.04

Lymphadenopathy, n (%) 17 (94%) 7 (44%) 0.002

Laboratory findings

Hemoglobin, g/dL 9.3±2.9 11.5±1.6 0.04

Platelets, 10 3 /µL 94.110±20.390 203.645±49.620 0.01

Mean platelet volume, fL 9.8 ±1.7 8.1±1.5 0.19

Vitamin B12, ng/L 734.2±111.2 430.5±54.1 0.04

IgG, mg/dL 1874.1±296.2 1645.1±211.4 0.26

AST, IU/dL 28.5±1.8 28.6±2.3 0.98

ALT, IU/dL 18.3±1.5 16.4±1.9 0.24

sFAS level, pg/mL 227.1±45.3 159.7±15.5 0.14

Interleukin-10 level, pg/mL 28.3±11.8 16.1±4.5 0.16

Positive Coombs test, n (%) 9 (50.0%) 4 (25.5%) 0.12

Treatment

Steroids, n (%) 11 (62%) 7 (44%) 0.25

Mycophenolate mofetil, n (%)

Other treatment (chemotherapy, transplantation, IVIG), n (%)

7 (38%)

12 (66%)

IgG: Immunoglobulin; AST: aspartate transaminase; ALT: alanine transaminase; IVIG: intravenous immunoglobulin.

1 (6%)

9 (56%)

p

0.03

0.39

remaining seven patients with lymphoma received chemotherapy.

Four patients with cITP received mostly on-demand treatment

with either steroids or IVIG. Two patients with AIHA received

steroids and rituximab, which initially controlled the anemia.

MMF was given to both patients who were diagnosed with cITP

and AIHA (Cases 13 and 17 in Table 2).

Predictive Factors for ALPS

Presence of anemia (odds ratio [OR]: 3.2; 95% confidence

interval [CI]: 1.0-11.4) and thrombocytopenia (OR: 4.2; 95%

CI: 1.4-27.2) in patients with newly diagnosed lymphoma,

presence of splenomegaly (OR: 4.1; 95% CI: 1.2-13.2) and

lymphadenopathy (OR: 7.0; 95% CI: 1.1-42.1) in patients with

chronic immune cytopenia, and young age (OR: 2.0; 95% CI:

3.4-12.9) in patients with nonmalignant organomegaly were

identified as predictive factors for ALPS.

Discussion

Patients with ALPS have heterogeneous phenotypes that can

mimic malignancy and infectious or autoimmune diseases.

Long-term follow-up studies demonstrated ALPS mutation in

15% and 85% of involved subjects [3,7,8,9,10]. In this study,

proven or probable ALPS was recorded in 53% of suspected

patients. However, the FAS mutation rate was found to be 20%

among patients with nonmalignant organomegaly.

Lymphadenopathy and splenomegaly are the most common

clinical signs of ALPS, as described in our study [19]. Most

patients with type Ia develop lymphoproliferation at a median

age of 1.8 years [20]. The same clinical pattern was also described

incidentally in a 1-year-old girl with FAS mutation in our study.

However, the median age at presentation was 4.9 years in

patients with undefined ALPS type III [20]. Accordingly, we found

the median diagnostic age as 3 years in undefined ALPS patients

147



Table 2. The clinical and laboratory findings and outcomes in proven and probable patients with autoimmune lymphoproliferative syndrome.

Therapy Outcome

Direct

Coombs

Platelets

(10 3 /µL)

ANC

(mm 3 )

Hb

(g/dL)

IgG

(mg/dL)

IL-10

(pg/mL)

Vit B12

(ng/L)

sFASL

(pg/mL)

Defective

apoptosis

DNT

(%)

FAS

mut.

Biopsy

ALPS

criteria

Primary

diagnosis

LAP/

SPM

Age/

gender

No.

1 12/boy +/+ HL Proven + - 5.0 Yes 170 425 11 1280 12 4180 76200 - Chemotherapy Alive

Dead

Chemotherapy,

auto-HSCT

2 5/boy +/+ NHL Proven + - 7.3 Yes 185 1281 116 1200 7 1400 41700 -

3 18/girl +/- HL Proven + - 3.5 Yes 189 1164 10.9 3058 9 3340 128000 - Chemotherapy Alive

4 18/girl +/+ HL Proven + - 6.9 Yes 201 1038 11.3 2446 8 4930 119000 - Chemotherapy Alive

5 17/girl +/- HL Proven + - 4.6 Yes 180 226 11.3 1300 9 3000 250000 - Chemotherapy Alive

Alive

Chemotherapy,

auto-HSCT

6 11/boy +/+ NHL Proven + - 8.4 Yes 177 1650 11.5 2580 8 15600 149000 -

7 6/girl +/+ HL Proven + - 5.4 Yes 177 345 11.5 1950 7 2150 306000 - Chemotherapy Alive

8 6/girl +/+ NMO Proven + - 25.0 Yes 215 841 21 1040 12 7400 111000 + Steroids, MMF Alive

Alive

Steroids, MMF,

sirolimus

9 3/boy +/- NMO Proven + - 14.2 Yes 180 495 9.5 566 10 540 192000 +

10 1/girl +/+ NMO Proven + + 6.2 Yes 1000 1500 200 2500 9 1200 36000 + Steroids, MMF Alive

Alive

Steroids, MMF,

allo-HSCT

11 2/boy +/+ NMO Proven + - 19.1 Yes 174 460 13 6090 7 7300 84700 +

12 4/boy +/+ NMO Probable + - 7.4 No 179 353 13 2089 2 1440 29100 + Steroids, MMF Alive

Alive

Steroids/IVIG,

MMF

13 15/boy +/+ ITP Proven - - 6.8 Yes 180 312 13 1080 11 4800 3900 +

14 13/boy +/- ITP Probable - - 6.5 No 174 379 9.3 1518 12 683 39200 - Steroids/IVIG Alive

15 17/boy +/+ ITP Probable - - 6.3 No 175 421 22.1 1310 16 2980 25700 - Steroids/IVIG Alive

16 14/boy +/- ITP Probable - - 6.5 No 175 311 10 1570 12 4900 85700 + Steroids/IVIG Alive

Alive

Steroids,

rituximab,

MMF

17 13/boy +/+ AIHA Proven - - 3.7 Yes 187 1027 9.6 583 8 1340 13300 +

Alive

Steroids,

rituximab

18 6/boy -/+ AIHA Probable - - 12.7 No 175 1010 10.5 1579 9 1210 194000 +

LAP: Lymphadenopathy; SPM: splenomegaly; HL: Hodgkin lymphoma; NHL: non-Hodgkin lymphoma; NMO: nonmalignant organomegaly; DNT: double-negative T lymphocytes; Hb: hemoglobin; ANS: absolute neutrophil count; MMF: mycophenolate

mofetil; HSCT: hematopoietic stem cell transplantation; IVIG: intravenous immunoglobulin.

with nonmalignant organomegaly. Our

findings indicate that patients with

lymphoproliferation detected incidentally

in the infancy period should be closely

monitored for ALPS.

Autoimmunity is the second most

common sign with the highest probability

of requiring medical intervention. The

frequencies of ALPS in the subjects

with chronic immune cytopenia and

in patients with Evans syndrome

were 37% and 45%, respectively

[7,8,9,10,11,12,13,19]. Similarly, we found

ALPS in 34% of patients in Group 1.

Children with immune cytopenia with

the occurrence of lymphadenopathy/

splenomegaly during follow-up were

approximately 4- to 7-fold more likely

to develop ALPS. These findings indicate

that lymphadenopathy/splenomegaly

may not appear simultaneously in

patients with chronic immune cytopenia.

Furthermore, positive Coombs tests

and hypergammaglobulinemia are

frequently observed in patients with

Evans syndrome [11,12,13]. We observed

that nearly half of the ALPS patients

had hypergammaglobulinemia and

positive Coombs tests. Development of

lymphadenopathy, splenomegaly, and

autoantibodies during follow-up in

children with cITP and AIHA should alert

the physician to a possible diagnosis of

ALPS.

Lymphoma is usually diagnosed in

patients with ALPS at advanced ages.

Lymphoma at a median age of 17 years

in both adults and children with ALPS

was reported in one study [8]. However,

the median age of lymphoma patients

was found as 12 years in our study.

Most reported patients with ALPS have

Hodgkin lymphoma, and EBV is positive

in these cases [15,16]. Similarly, our

patients were mostly diagnosed with

Hodgkin lymphoma, but investigations

of these patients revealed only two cases

with EBV. In addition, children with newly

diagnosed lymphoma with the presence

of anemia and thrombocytopenia were

approximately 3- to 4-fold more likely

148



to develop ALPS. Our study indicated that the presence of

anemia and thrombocytopenia in patients with lymphoma at

diagnosis may be useful for ALPS screening.

Splenectomy and rituximab are not recommended in

ALPS because of sepsis and recurrence risk in most cases

[1,2,3,21,22,23,24]. We canceled the scheduled splenectomies

for five patients with massive splenomegaly. Furthermore, some

patients with cITP and AIHA might be resistant to standard

treatment, as in previous reports [25,26]. Partial response

to rituximab was observed in cases of AIHA. We believe that

treatment response could help the physician reach a possible

diagnosis of ALPS in children with cITP, AIHA, and nonmalignant

organomegaly. The major limitations of the present study were

that the other ALPS-related genes [27,28,29,30] were not

studied due to lack of resources and all lymphoma cases/adult

cases were not included.

Our data indicate that investigation of ALPS is warranted in

children with lymphoma presenting with cytopenia, in cases of

chronic nonmalignant organomegaly with immune cytopenia,

and probably in patients with cITP and AIHA developing

organomegaly during follow-up.

Acknowledgment: This study was supported by the Medical

Faculty of Gazi University.

Ethics

Ethics Committee Approval: The Institutional Review Board of

the Medical School of Gazi University approved the study.

Informed Consent: The parents of all participants gave informed

consent.


Design: Z.K., M.I.; Data Collection or Processing: Z.K., M.I., S.K.,

F.G.P., Ü.K.; Analysis or Interpretation: N.0., U.B., L.M.A., M.J.D-M.,

R.R-G., P.G.U., E.Ü.B.; Writing: Z.K.


authors.



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LM. Decreased activation-induced cell death by EBV-transformed B-cells

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150

Razavi HM: Spherical bodies in MGUS

IMAGES IN HEMATOLOGY

DOI: 10.4274/tjh.galenos.2020.2020.0309


Unusual Spherical Bodies in Bone Marrow of a Patient with

Monoclonal Gammopathy of Undetermined Significance

Önemi Belirlenemeyen Monoklonal Gammopatili Bir Hastanın Kemik İliğinde Olağandışı

Küresel Cisimcikler

Habib Moshref Razavi 1,2

1Royal Columbian Hospital, Department of Pathology, New Westminster, British Columbia, Canada

2British Columbia University, Department of Pathology and Laboratory Medicine, Vancouver, British Columbia, Canada

Figure 1. Bone marrow trephine biopsy, 10 x (A). H&E shows normocellular bone marrow

where large/giant spherical entities are noted (black arrows in A). CD138 (B, 20 x ) and

kappa (C, 10 x )/lambda (D, 40 x ) stains show that large spherical bodies are not cellfree

structures and exist as giant spherical plasma cells with overstuffed/ballooning

cytoplasm with cellular effacement.



Address for Correspondence/Yazışma Adresi: Habib Moshref Razavi, M.D., Royal Columbian Hospital,

Department of Pathology, New Westminster, British Columbia, Canada and British Columbia University,

Department of Pathology and Laboratory Medicine, Vancouver, British Columbia, Canada

E-mail : habib.moshrefrazavi@fraserhealth.ca ORCID: orcid.org/0000-0002-1374-5963

Received/Geliş tarihi: June 5, 2020

Accepted/Kabul tarihi: June 14, 2020

151

Razavi HM: Spherical bodies in MGUS


A 78-year-old male patient with mild cytopenias (hemoglobin

120 g/L with platelet count of 114x10 9 /L) and low lambda clonal

paraprotein (6.9 g/L) is described. A bone marrow biopsy showed

the presence of trilinear hematopoiesis with occasional plasma

cells (<10%). A trephine biopsy showed the presence of large

spherical bodies (Figure 1A, black arrows), which were proved

not to be cell-free by CD138/kappa/lambda stains, existing as

inclusions in lambda-restricted plasma cells (Figures 1B-1D).

With <10% clonal plasmacytosis, lack of end organ damage,

and paraprotein at <30 g/L, monoclonal gammopathy of

undetermined significance was diagnosed. Plasma cell inclusions

were first described by Russell in 1890 [1]. Inclusions in the

cytoplasm (Russell bodies) and overlaying the nucleus (Dutcher

bodies) usually leave the cellular morphology intact. H&E

morphology and immunohistochemistry in this case showed

complete cellular effacement with cytoplasmic ballooning. A

variety of intracytoplasmic inclusions have been reported and

include mulberry-type inclusions in Mott cells, vermillion-tinged

deposits in immunoglobulin A-type flame cells, and even Auer

rod-like inclusions [2]. The nature of the inclusions has been

elucidated as amalgamation of condensed immunoglobulins in

dilated vesicles associated with ER cisternae. The significance of

their presence in disease progression is unknown.

Keywords: Monoclonal gammopathy of undetermined

significance, Plasma cell inclusions, Russell bodies,

Immunohistochemistry

Anahtar Sözcükler: Önemi belirlenemeyen monoklonal

gammopati, Plazma hücre inklüzyonları, Russell cisimsikleri,

İmmünohistokimya

Financial Disclosure: The author declared that this study


References

1. Russell W. An address on characteristic organism of cancer. Br Med J

1890;2:1356-1360.

2. Metzgeroth G, Back W, Maywald O, Schatz M, Willer A, Hehlmann R, Hastka

J. Auer rod-like inclusions in multiple myeloma. Ann Hematol 2003;82:57-

60.

152

Sall A. et al: Flower-Like Plasma Cell Nuclei in Multiple Myeloma

IMAGES IN HEMATOLOGY

DOI: 10.4274/tjh.galenos.2020.2020.0471


Flower-Like Plasma Cell Nuclei in Multiple Myeloma

Multipl Myelomda Çiçek Benzeri Plazma Hücre Nukleusu

Abibatou Sall 1 , Moussa Seck 2 , Diama Samb 1 , Blaise Faye 1 , Macoura Gadji 1 , Saliou Diop 1 , Awa Oumar Touré 1,3

1Dalal Jamm Hospital, Laboratory of Hematology, Dakar, Senegal

2Cheikh Anta Diop University-Hematology, Hematology Clinic Department, Dakar, Senegal

3Aristide Le Dantec Hospital-Laboratory of Hematology Pasteur Avenue, Dakar, Senegal

Figure 1. A) Plasma cells with dysmorphic nuclei. B) Flower-like nuclei (red arrow) and rouleaux (light blue

circle). C, E) Flower-like nuclei. D) Mitotic event (blue arrow). Lymphoplasmacytic cells (black arrows). Red

arrow: plasma cell with a prominent nucleolus. F) Monoclonal gamma globulin peak on protein electrophoresis.

G, H) Flow cytometry showing CD38/138+, CD45 weak , and CD56+.



Address for Correspondence/Yazışma Adresi: Abibatou Sall, M.D., Dalal Jamm Hospital,

Clinic of Hematology, Dakar, Senegal

E-mail : sallabibatou@gmail.com ORCID: orcid.org/0000-0001-5685-4417

Received/Geliş tarihi: August 12, 2020

Accepted/Kabul tarihi: September 28, 2020

153

Sall A. et al: Flower-Like Plasma Cell Nuclei in Multiple Myeloma


A 43-year-old Senegalese man with no known past medical

history was referred to our hospital for asthenia and bone pain.

The blood count showed moderate leukocytosis (12x10 9 /L),

severe anemia (hemoglobin: 53 g/L), and a normal platelet

count (315x10 9 /L), while the blood smear examination showed

marked rouleaux formation. Protein electrophoresis showed a

monoclonal gamma peak (82 g/L, Figure 1F). Immunofixation

revealed a monoclonal immunoglobin G kappa band.

The diagnosis of multiple myeloma was confirmed by bone

marrow aspiration. Giemsa-stained marrow smears showed

hypercellularity with a large majority of very atypical plasma

cells, namely medium-sized to large cells with nuclear

abnormalities (budding: Figure 1A), flower-shaped nuclei

that are quite uncommon in myeloma (Figures 1B-1E), and

prominent nucleoli (Figure 1D, red arrow). Lymphoplasmacytic

cells were also present, as well as several mitotic events (Figure

1D, black and blue arrows).

On flow cytometry the plasma cells expressed weak CD45, CD38,

CD138, and CD56 (Figures 1G and 1H) and cytoplasmic kappa

light chain. CD19, CD20, CD79a, and CD10 were negative. HIV,

HBV, HCV, and HTLV-1 serology were negative. FISH was not

available; thus, we could not calculate the Revised International

Staging System score. However, the International Staging

System result was stage III (β2 microglobulin = 5.9 mg/L).

Multiple myeloma is becoming more and more frequent in

African populations. The key difference between African and

Caucasian populations is the age of onset: 45-50 years in

African populations and more than 60 years in Caucasians [1]. In

addition, we note the presence of many poor prognosis factors

in African patients resulting in earlier death. Delayed diagnosis

and unavailability of new therapeutic agents and autografting

could contribute to the poor outcome. However, genetic

background and environmental factors could play a critical role

and merit further studies [2].

Keywords: Plasma cell, Morphologic abnormalities, Multiple

myeloma

Anahtar Sözcükler: Plazma hücresi, Morfolojik anormallikleri,

Multipl myelom


Surgical and Medical Practices: M.S., B.F., S.D.; Concept: A.S.,

A.O.T.; Design: A.S., B.F.; Data Collection or Processing: A.S., M.S.;

Analysis or Interpretation: A.S., A.O.T.; Literature Search: A.S.,

D.S., M.G.; Writing: A.S., M.S., D.S., A.O.T.


authors.



References

1. Kazandjian D. Multiple myeloma epidemiology and survival: a unique

malignancy. Semin Oncol 2016;43:676-681.

2. Smith CJ, Ambs S, Landgren O. Biological determinants of health disparities

in multiple myeloma. Blood Cancer J 2018;8:85.

154

LETTERS TO THE EDITOR



Immune Thrombotic Thrombocytopenic Purpura in a Patient

with Suspected COVID-19: Hydroxychloroquine Culprit or Just

Happenstance?

COVID-19 Şüpheli Bir Hastada İmmün Trombotik Trombositopenik Purpura: Hidroksiklorokin

Suçlu mu Yoksa Sadece Rastlantı mı?

Tajamul H. Mir

Khyber Medical Institute Srinagar, Department of Nephrology and Lupus/Vasculitis Centre, Srinagar, India

To the Editor,

I read with great interest the recently published letter to

the editor by Arıkan et al. [1] about hydroxychloroquine

(HCQ)-associated thrombotic thrombocytopenic purpura

(TTP) together with some queries raised by Sookaromdee and

Wiwanitkit and the original authors’ reply [1,2]. There are some

pertinent points to note. First and foremost, HCQ-induced TTP

is an extremely rare but nevertheless recognized entity with

only a few cases reported in the literature, which have not

been thoroughly evaluated. Most of the data regarding this

complication have been extrapolated against the background

of HCQ’s parent compound, quinine. Quinine-induced and

presumably HCQ-induced TTP is characterized by generation

of antiplatelet antibodies, which cross-react with the

endothelium and cause TTP. However, typical drug-induced

TTP, including quinine-induced TTP, is not associated with

a critical drop in ADAMTS13 levels or with the presence of

an ADAMTS13 inhibitor, but the patient presented by Arıkan

et al. had both. This is an important differentiating feature

of quinine-induced TTP from immune TTP (iTTP) and it calls

into question the diagnosis made by Arıkan et al. [1] or even

suggests iTTP after HCQ as a novel complication [3]. I would

not straight away repudiate the observation made by Arıkan

et al. [1] because, first of all, there is a definite temporal

profile that links the medicine with iTTP, and, furthermore,

some drugs like the thienopyridine group of antiplatelets

have been associated with classic iTTP leading to a critical

drop in ADAMTS13 levels and the presence of an inhibitor

[4]. At least five cases of thrombotic microangiopathy of iTTP/

HUS (hemolytic uremic syndrome) in coronavirus disease-19

(COVID-19) have been reported in the literature with an

obvious temporal relation between HCQ and the development

of iTTP, which seems to have been ignored by most authors in

light of COVID-19 infection and everything being attributed

to this novel virus [5,6,7,8]. It needs to be emphasized that

quinine-induced thrombotic microangiopathy can occur

hours, days, or months after exposure to the drug and HCQ

has a very long elimination half-life of 40 days after a

single dose. The typical COVID-19-induced TTP-like illness is

secondary to diffuse endothelial damage secondary to virusinduced

endotheliitis further aggravated by complement

overactivity, causing an over-spilling of von Willebrand factor

(vWF) from the damaged endothelial network overwhelming

the ADAMTS13 protease and producing the relative ADAMTS

deficiency typically seen as an ADAMTS13/vWF ratio of <10,

but without a critical drop in ADAMTS13 levels and in the

absence of a circulating ADAMTS inhibitor [9]. Nevertheless,

some cases of classic iTTP have occurred in association

with COVID-19 infection, possibly due to some novel

mechanism triggered by the virus or maybe the unmasking

of a latent disease with the virus possibly acting as a second

hit. Differentiating primary from secondary thrombotic

microangiopathy is not always easy since many genetic or even

acquired variants could be clinically silent, becoming manifest

later in life following a second hit such as an infection, drug,

surgical stress, or pregnancy. In the case presented by Arıkan

et al. [1], I feel that at least immunoglobulin G anti-COVID

antibodies should have been examined and, if possible, novel

in vitro HCQ sensitization testing should be performed as well

[10]. Although re-exposure to the drug could easily solve the

diagnostic dilemma, it would be absolutely unethical and risky

since the second exposure could be more devastating if the

drug were in fact the culprit. The initial illness in the patient

could have been any trivial infection or maybe a mild COVID

case (though not documented). I am sure the authors must

have thoroughly evaluated the patient for other mimickers

and ruled them out, and systemic lupus erythematosus seems

very unlikely. The role of HCQ in causing iTTP in the given case

cannot be absolutely ruled out.

Keywords: COVID-19-induced iTTP, Hydoxychloroquineinduced

TTP, ADAMTS13, Von Willebrand factor, Thrombotic

microangiopathy

155



Anahtar Sözcükler: COVID-19 ilişkili iTTP, Hidroksiklorokin

ilişkili TTP, ADAMTS-13, Von Willebrand faktör, Trombotik

mikroanjiyopati



References

1. Arıkan F, Yıldız Y, Ercan T, Oruç Ö, Akçay S, Yılmaz F, Toptaş T.

Hydroxychloroquine-associated thrombotic thrombocytopenic purpura.

Turk J Hematol 2020;37:302-304.

2. Sookaromdee P, Wiwanitkit V. Hydroxychloroquine, TTP, COVID-19 and SLE.

Turk J Hematol 2021;38:99-100.

3. Page EE, Little DJ, Vesely SK, George JN. Quinine-induced thrombotic

microangiopathy a report of 19 patients. Am J Kidney Dis 2017;70:686-695.

4. Zakarija A, Kwaan HC, Moake JL, Bandarenko N, Pandey DK, McKoy JM,

Yarnold PR, Raisch DW, Winters JL, Raife TJ, Cursio JF, Luu TH, Richey EA,

Fisher MJ, Ortel TL, Tallman MS, Zheng XL, Matsumoto M, Fujimura Y, Bennett

CL. Ticlopidine and clopidogrel-associated thrombotic thrombocytopenic

purpura (TTP): review of clinical, laboratory, epidemiological, and

pharmacovigilance findings (1989-2008). Kidney Int Suppl 2009;112:20-24.

5. Albiol N, Awol R, Martino R. Autoimmune thrombotic thrombocytopenic

purpura (TTP) associated with COVID-19. Ann Hematol 2020;99:1673-1674.

6. Hindilerden F, Yonal-Hindilerden I, Akar E, Kart-Yasar K. Covid-19 associated

autoimmune thrombotic thrombocytopenic purpura: Report of a case.

Thromb Res 2020;195:136-138.

7. Capecchi M, Mocellin C, Abbruzzese C, Mancini I, Prati D, Peyvandi F.

Dramatic presentation of acquired thombotic thrombocytopenic purpura

associated with COVID-19. Haematologica 2020;105:540.

8. Al-Ansari RY, Bakkar M, Abdalla L, Sewify K. Critical care COVID-19 patient

with a picture of thrombotic thrombocytopenic purpura. Eur J Case Rep

Intern Med 2020;7:002143.

9. Galbiati V, Papale A, Kummer E, Corsini E. In vitro models to evaluate druginduced

hypersensitivity: Potential test based on activation of dendritic

cells. Front Pharmacol 2016;7:204.

10. Martinelli N, Montagnana M, Pizzolo F, Friso S, Salvagno GL, Forni GL,

Gianesin B, Morandi M, Lunardi C, Lippi G, Polati E, Olivieri O, De Franceschi

L. A relative ADAMTS13 deficiency supports the presence of secondary

microangiopathy in COVID 19. Thromb Res 2020;193;170-172.



Address for Correspondence/Yazışma Adresi: Tajamul H. Mir, M.D., Khyber Medical Institute Srinagar,

Department of Nephrology and Lupus/Vasculitis Centre, Srinagar, India

Phone : 91 07006508596

E-mail : thmir@rediffmail.com ORCID: orcid.org/0000-0003-2514-3158

Received/Geliş tarihi: January 20, 2021


DOI: 10.4274/tjh.galenos.2021.2021.0057

REPLY FROM THE AUTHORS

To the Editor,

We thank our colleague for his interest and excellent comments.

We totally agree that the case that we reported is not a typical

case of quinine-induced thrombotic thrombocytopenic purpura

(TTP) [1]. As Mir emphasized, a significant decrease in the activity

of ADAMTS13 or the presence of inhibitors is not an expected

finding in quinine-associated TTP. However, infections as well

as drugs can act as a second hit in some patients with silent

genetic or acquired TTP variants, as Mir stated. Furthermore,

HCQ could act as a second hit in the patient, or HCQ could also

cause TTP with low ADAMTS13 activity in some patients, similar

to other drugs such as the thienopyridine group of antiplatelet

drugs. That is why we assume that this was a case of antibodymediated

TTP, possibly induced by HCQ.

There are some reported cases of severe acute respiratory

syndrome causing coronavirus-2 presenting with TTP in the

literature. In most of these cases, lung CT showed significant

infiltration with positive polymerase chain reaction tests

by nasopharyngeal swab [2] or positivity for specific

immunoglobulin (Ig) G [3]. Our limitation was that specific IgG

could not be determined serologically. In addition, there were no

laboratory abnormalities that suggested coronavirus disease-19

(COVID-19), such as lymphopenia or high serum ferritin or

fibrinogen. We also excluded cardiovascular, autoimmune, and

malignant diseases. After the patient was discharged, we tried

to contact the patient, but we learned that this individual had

moved to another city. Interestingly, we were informed that

the patient was diagnosed with COVID-19 by rapid testing and

specific clinical findings in a different hospital 4 months later. At

that time, the patient was not using HCQ. The patient improved

without significant sequelae. Furthermore, we could not

determine specific IgG levels related to the illness complicated

with TTP during the first hospitalization.

HCQ has some well-known hematological side effects including

anemia, thrombocytopenia, agranulocytosis, leukopenia, and

aplastic anemia. There are two case reports from before the

COVID-19 pandemic in the literature in terms of possible HCQrelated

TTP, but these relations were suspicious because these

patients had respective medical histories of systemic lupus

erythematosus and rheumatoid arthritis [4,5].

In conclusion, it is not possible to confidently insist that HCQ has

a definite role in the etiology of thrombotic microangiopathy,

but our observation should be kept in mind as HCQ might be

associated with TTP.

Fatma Arıkan, Yasin Yıldız, Tarık Ercan, Özen Oruç, Seçkin Akçay,

Fergun Yılmaz, Tayfur Toptaş, Tülin Tuğlular

156



References

1. Arıkan F, Yıldız Y, Ercan T, Oruç Ö, Akçay S, Yılmaz F, Toptaş T, Tuğlular T.

Hydroxychloroquine-associated thrombotic thrombocytopenic purpura.

Turk J Hematol 2020;37:302-304.

2. Hindilerden F, Yonal-Hindilerden I, Akar E, Kart-Yasar K. COVID-19

associated autoimmune thrombotic thrombocytopenic purpura: report of

a case. Thromb Res 2020;195:136-138.

3. Capecchi M, Mocellin C, Abbruzzese C, Mancini I, Prati D, Peyvandi F.

Dramatic presentation of acquired thombotic thrombocytopenic purpura

associated with COVID-19. Haematologica 2020;105:e540.

4. Fromm LM. Suspected hydroxychloroquine-induced thrombotic

thrombocytopaenic purpura. J Pharm Pract Res 2018;48:72-75.

5. Mar N, Mendoza Ladd A. Acquired thrombotic thrombocytopenic purpura:

puzzles, curiosities and conundrums. J Thromb Thrombolysis 2011;31:119-

121.

6. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, Janecek

E, Domecq C, Greenblatt DJ. A method for estimating the probability of

adverse drug reactions. Clin Pharmacol Ther 1981;30:239-245.

Antithrombin, COVID-19, and Fresh Frozen Plasma Treatment

Antitrombin, COVID-19 ve Taze Dondurulmuş Plazma Tedavisi

Rujitttika Mungmungpuntipantip 1 , Viroj Wiwanitkit 2

1Private Academic Consultant, Bangkok, Thailand

2Honorary Professor, Dr DY Patil University, Pune, India

To the Editor,

We found the article entitled “Prognostic value of

antithrombin levels in COVID-19 patients and impact of

fresh frozen plasma treatment: a retrospective study” very

interesting [1]. Considering antithrombin (AT) levels and

fresh frozen plasma (FFP) in these patients, Anaklı et al. [1]

concluded that “AT activity could be used as a prognostic

marker for survival and organ failure in COVID-19-associated

ARDS patients. AT supplementation therapy with FFP in

patients with COVID-19-induced hypercoagulopathy may

improve thrombosis prophylaxis and thus have an impact

on survival” [1]. Indeed, plasma therapy is a widely discussed

alternative option for management of severe coronavirus

disease-19 (COVID-19). Some medical scientists have

proposed the usefulness of non-convalescent plasma therapy.

In a recent report, Bajpai et al. [2] found that the median

improvement in PaO2/FiO2 in COVID-19 patients treated with

non-convalescent plasma was significantly superior to results

of FFP at 48 hours. Additionally, an important consideration

for any kind of plasma therapy is the safety. The major

consideration is possible pathogenic contamination in plasma

[3]. Finally, the exact pathomechanism of COVID-19-related

coagulopathy is not well clarified but it is believed to be an

immunopathological process [4]. The use of FFP therapy is

not direct management for the underlying immunological

problem; a more appropriate management might be plasma

exchange therapy [5].

Keywords: Antithrombin, COVID-19, Fresh frozen plasma

Anahtar Sözcükler: Antitrombin, COVID-19, Taze dondurulmuş

plazma

Ethics

Informed Consent: Informed consent is not required (no

human/animal involvement).


Concept: R.M., V.W.; Design: R.M., V.W.; Data Collection or

Processing: R.M., V.W.; Analysis or Interpretation: R.M., V.W.;

Literature Search: R.M., V.W.; Writing: R.M., V.W.


authors.



References

1. Anaklı İ, Ergin Özcan P, Polat Ö, Orhun G, Alay GH, Tuna V, Çeliksoy E, Kılıç

M, Mercan M, Ali A, Beşışık S, Esen F. Prognostic value of antithrombin

levels in COVID-19 patients and impact of fresh frozen plasma treatment: a

retrospective study. Turk J Hematol 2021;38:15-21.

2. Bajpai M, Kumar S, Maheshwari A, Chhabra K, Kale P, Gupta A, Narayanan

A, Gupta E, Trehanpati N, Bihari C, Agarwal R, Gupta K, Gupta UK, Bhardwaj

A, Kumar G, Islam M, Singh R, Yadav P, Maiwall R, Sarin SK. Efficacy of

convalescent plasma therapy compared to fresh frozen plasma in severely ill

COVID-19 patients: a pilot randomized controlled trial. medRxiv Preprints.

Available at https://doi.org/10.1101/2020.10.25.20219337.

3. Joob B, Wiwanitkit V. Convalescent plasma and covid-19 treatment.

Minerva Med (in press).

4. Iba T, Levy JH, Levi M, Thachil J. Coagulopathy in COVID-19. J Thromb

Haemost 2020;18:2103-2109.

5. Tabibi S, Tabibi T, Conic RRZ, Banisaeed N, Streiff MB. Therapeutic plasma

exchange: a potential management strategy for critically ill COVID-19

patients. J Intensive Care Med 2020;35:827-835.

157





Address for Correspondence/Yazışma Adresi: Rujitttika Mungmungpuntipantip, M.D., Private Academic

Consultant, Bangkok, Thailand

E-mail : rujittika@gmail.com ORCID: orcid.org/0000-0003-0078-7897

Received/Geliş tarihi: March 1, 2021

Accepted/Kabul tarihi: March 10, 2021

DOI: 10.4274/tjh.galenos.2021.2021.0155

REPLY FROM THE AUTHORS

We would like to thank the editor for the opportunity to respond

to the issues raised in this letter and to clarify aspects of our

methodology in relation to these concerns. In our study, we

found that acute antithrombin (AT) deficiency may contribute

to both the development of thrombosis and failure to achieve

maintained therapeutic anticoagulation in patients with

coronavirus disease-2019 (COVID-19). AT supplementation may

increase the anticoagulant effect of heparin, so low AT activity

levels (<75%) were treated with fresh frozen plasma (FFP) in

COVID-19-related acute respiratory distress syndrome patients.

We observed an increase in AT levels after FFP treatment (from

53% to 80%), and much higher levels were achieved in survivors

than nonsurvivors (82% vs. 76%). Thromboembolic events (TEs)

were not seen in those patients who had AT activity of ≥75%

after FFP treatment and D-dimer levels were significantly

reduced after supplementation [1]. In the present letter, the

authors mention the usefulness of non-convalescent plasma

therapy. However, there is no clear evidence about the usefulness

of non-convalescent plasma therapy, the optimal dose, or the

time point for this therapy [2]. Studies are limited to small case

series, so it is not a drug that is used for a long time and the

safety of plasma has not been confirmed. In past studies, there

was no significant difference between convalescent plasma and

FFP in terms of viral load, cytokine levels, mortality, duration

of hospitalization or intensive care stay, and days free of

mechanical ventilation [3]. The pathogenic contamination risk is

also similar with FFP and finding a donor is not always possible.

A substantial proportion of COVID-19 patients develop

thrombotic complications due to the uncontrolled

immunothrombotic response. We aimed to prevent TEs and

organ dysfunction related to hypercoagulability by using AT

supplementation. However, AT concentrates are not available in

Turkey, so we treated patients with FFP for AT supplementation.

Therapeutic plasma exchange (TPE) has been used for rescue

therapy in critically ill patients with COVID-19 who do not

respond to conventional therapies [4]. Although used as

alternative therapy in COVID-19 patients, extracorporeal

therapies may lead to increased cytokine release, thrombosis,

and disseminated intravascular coagulation. Studies about

extracorporeal membrane oxygenation showed that continuous

contact surface between the humoral and cellular components

of the blood and the extracorporeal circuit may cause a

systemic activation of coagulation and inflammation pathways

[5]. Another problem is hemodynamic changes during TPE.

Hypotension, arrhythmias, and shock can be seen during TPE.

Hypersensitivity and pathogen contamination risk may be

higher than in our protocol due to the need for higher FFP

volumes for TPE. Also, the efficacy of drugs used for COVID-19

treatment may decrease during TPE because of the removal or

dilution of the drugs by TPE. Blood supply difficulties and high

costs are other problems related to TPE. It requires skilled staff,

special equipment, and extra catheter insertion, so it may not

be readily available in many locations. Furthermore, the time

frame for TPE is controversial.

Globally, more than 100 million confirmed cases of COVID-19

have been recorded, with more than two million deaths [6].

Various therapeutic agents have been used for COVID-19

patients, all of which remain experimental. More studies need

to be done for more effective treatment suggestions.

İlkay Anaklı, Perihan Ergin Özcan, Özlem Polat, Günseli Orhun,

Gülçin Hilal Alay, Verda Tuna, Emre Çeliksoy, Mehmet Kılıç, Mutlu

Mercan, Achmet Ali, Sevgi Beşışık, Figen Esen

References

1. Anaklı İ, Ergin Özcan P, Polat Ö, Orhun G, Alay GH, Tuna V, Çeliksoy E, Kılıç

M, Mercan M, Ali A, Beşışık S, Esen F. Prognostic value of antithrombin

levels in COVID-19 patients and impact of fresh frozen plasma treatment: a

retrospective study. Turk J Hematol 2021;38:15-21.

2. Balcells ME, Rojas L, Le Corre N, Martínez-Valdebenito C, Ceballos ME,

Ferrés M, Chang M, Vizcaya C, Mondaca S, Huete Á, Castro R, Sarmiento M,

Villarroel L, Pizarro A, Ross P, Santander J, Lara B, Ferrada M, Vargas-Salas

S, Beltrán-Pavez C, Soto-Rifo R, Valiente-Echeverría F, Caglevic C, Mahave

M, Selman C, Gazitúa R, Briones JL, Villarroel-Espindola F, Balmaceda C,

Espinoza MA, Pereira J, Nervi B. Early versus deferred anti-SARS-CoV-2

convalescent plasma in patients admitted for COVID-19: a randomized

phase II clinical trial. PLoS Med 2021;18:e1003415.

3. Bajpai M, Kumar S, Maheshwari A, Chhabra K, kale P, Gupta A, Narayanan

A, Gupta E, Trehanpati N, Bihari C, Agarwal R, Gupta K, Gupta UK, Bhardwaj

A, Kumar G, Islam M, Singh R, Yadav P, Maiwall R, Sarin SK. Efficacy of

convalescent plasma therapy compared to fresh frozen plasma in severely ill

COVID-19 patients: a pilot randomized controlled trial. medRxiv Preprints.

Available at https://doi.org/10.1101/2020.10.25.20219337.

158



4. Fernandez J, Gratacos-Ginès J, Olivas P, Costa M, Nieto S, Mateo D, Sánchez

MB, Aguilar F, Bassegoda O, Ruiz P, Caballol B, Pocurull A, Llach J, Mustieles

MJ, Cid J, Reverter E, Toapanta ND, Hernández-Tejero M, Martínez JA,

Claria J, Fernández C, Mensa J, Arroyo V, Castro P, Lozano M; Covid Clinic

Critical Care (CCCC) Group. Plasma exchange: an effective rescue therapy in

critically ill patients with coronavirus disease 2019 infection. Crit Care Med

2020;48:e1350-e1355.

5. Von Bahr V, Millar JE, Malfertheiner MV, Ki KK, Passmore MR, Bartnikowski

N, Redd MA, Cavaye M, Suen JY, McAuley DF, Fraser JF. Mesenchymal stem

cells may ameliorate inflammation in an ex vivo model of extracorporeal

membrane oxygenation. Perfusion 2019;34:15-21.

6. World Health Organization. WHO Coronavirus Disease (COVID-19)

Dashboard. Geneva, WHO, 2021. Available at https://covid19.who.int/.

Is Sickle Cell Trait Really Innocent?

Orak Hücre Taşıyıcılığı Gerçekten Masum mu?

Mahmut Yeral,

Can Boğa

Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Training and Research Center, Clinic of Hematology, Adana, Turkey

To the Editor,

Sickle cell trait (SCT) is seen in about 13.6% of the population

living in the Mediterranean region of Turkey [1]. In areas where

carriage is common, SCT is considered important for genetic

counseling before marriage. Even carriers in widespread regions

do not have sufficient information about SCT. Physicians,

on the other hand, know that SCT may rarely cause serious

complications, but this is often overlooked in daily practice. Is

SCT as innocent as it is deemed to be? We explore this further

with a clinical case.

After 8 h of exposure to cold-weather conditions below 0 °C, a

55-year-old man was admitted to the emergency department

with severe abdominal pain. On physical examination,

there was widespread guarding and rigidity. Laboratory

examination results showed that he had a leukocyte level of

14,000/µL (70% neutrophils), hemoglobin level of 14 g/dL, and

platelet level of 450,000/µL. Abdominal tomography images

revealed widespread infarct areas in the spleen. Splenectomy

had to be performed due to uncontrolled abdominal pain

despite narcotic analgesics. At approximately 2 weeks after

the splenectomy, the patient was readmitted with severe

abdominal pain. Widespread thrombosis was detected in the

portal vein. The patient was started on anticoagulant therapy.

He lacked personal or family history of thrombosis and was

investigated for myeloproliferative diseases and thrombophilia

factors. Tests for JAK 2V617F and major BCR/ABL mutations

were negative. A bone marrow examination revealed normal

cellularity and the absence of fibrosis. Protein S, protein C,

and antithrombin III values were within the normal reference

ranges; tests for factor V Leiden, prothrombin gene mutations,

and antinuclear antibodies were negative. A flow cytometric

study performed with the FLAER method showed that the

granulocytes and erythrocytes did not exhibit paroxysmal

nocturnal hemoglobinuria. The Hb electrophoresis results were

38.7% for HbS, 2.9% for HbA2, and 58.4% for HbA. SCT, which

is triggered by cold-weather conditions, had started the chain

of complications.

In SCT, pathogenesis causing spleen infarction and other

complications can triggered by factors such as dehydration,

increased viscosity, high altitude, and temperature changes

[2,3]. Hypoxia in the renal medulla increases sickling, leading to

increased cytokines and microthrombi in capillaries and the vasa

recta. Microscopic or macroscopic hematuria and abdominal

pain develop after ischemia and necrosis. In addition to

SCT-associated renal papillary necrosis, chronic kidney disorders

and cases of renal medullary carcinoma with poor prognosis and

metastasis have been reported [4,5].

There is some information in the literature on athletes

and those working in severe conditions who experience

exertion-related rhabdomyolysis and sudden death. To prevent

serious complications, some countries have implemented

national screening programs for newborns, soldiers, and

individuals engaged in active sports [3,6]. Harmon et al. [7]

reported a 37-fold higher risk of exertion death in football

players with SCT than in their unaffected peers.

We think that a national newborn-screening program for

diagnosing sickle cell disease should be implemented in

regions where HbS carriers are common. The aim of the

Hemoglobinopathy Control Program implemented in Turkey

since 2003 is to provide genetic counseling to HbS carriers

detected via premarital screening, direct them to prenatal

diagnosis, and follow children with hemoglobinopathy after

birth [8]. It should not be forgotten that SCT is not innocent.

Individuals heterozygous for HbS should be informed about

clinical problems caused by SCT and recommendations should

be made. We believe that adequate information and counseling

can minimize complications associated with SCT, such as

morbidity and mortality. Screening of this risk group before

certain professional or social situations can be life-saving for

some carriers. These programs can create ethical and social

159



problems; however, ethical problems in screening programs can

be reduced if they are only used for training and information

purposes, instead of being used to prevent people from carrying

out certain activities.

Under the current conditions, screening programs, at least

during prenatal genetic counseling prior to marriage, should

give HbS carriers the opportunity to receive information from

first-degree healthcare professionals and hematologists about

SCT complications and prevention.

Keywords: Sickle cell trait, Splenic infarct, Complication

Anahtar Sözcükler: Orak hücre taşıyıcılığı, Dalak infarktı,

Komplikasyon

Ethics



Surgical and Medical Practices: M.Y.; Concept: C.B.; Design: C.B.;

Data Collection or Processing: M.Y.; Analysis or Interpretation:

M.Y.; Literature Search: M.Y., C.B.; Writing: M.Y.


authors.



References

1. Karacaoglu PK, Asma S, Korur A, Solmaz S, Buyukkurt NT, Gereklioglu C,

Kasar M, Ozbalcı D, Unal S, Kaya H, Gurkan E, Yeral M, Sariturk Ç, Boga

C, Ozdogu H. East Mediterranean region sickle cell disease mortality trial:

retrospective multicenter cohort analysis of 735 patients. Ann Hematol

2016;95:993-1000.

2. Goodman J, Hassell K, Irwin D, Witkowski EH, Nuss R. The splenic syndrome

in individuals with sickle cell trait. High Alt Med Biol 2014;15:468-471.

3. Naik RP, Smith-Whitley K, Hassell KL, Umeh NI, de Montalembert M, Sahota

P, Haywood C Jr, Jenkins J, Lloyd-Puryear MA, Joiner CH, Bonham VL, Kato

GJ. Clinical outcomes associated with sickle cell trait: a systematic review.

Ann Intern Med 2018;169:619-627.

4. Naik RP, Derebail VK, Grams ME, Franceschini N, Auer PL, Peloso GM, Young

BA, Lettre G, Peralta CA, Katz R, Hyacinth HI, Quarells RC, Grove ML, Bick

AG, Fontanillas P, Rich SS, Smith JD, Boerwinkle E, Rosamond WD, Ito K,

Lanzkron S, Coresh J, Correa A, Sarto GE, Key NS, Jacobs DR, Kathiresan

S, Bibbins-Domingo K, Kshirsagar AV, Wilson JG, Reiner AP. Association

of sickle cell trait with chronic kidney disease and albuminuria in African

Americans. JAMA 2014;312:2115-2125.

5. Shetty A, Matrana MR. Renal medullary carcinoma: a case report and brief

review of the literature. Ochsner J 2014;14:270-275.

6. Key NS, Derebail VK. Sickle-cell trait: novel clinical significance. Hematology

Am Soc Hematol Educ Program 2010;2010:418-422.

7. Harmon KG, Drezner JA, Klossner D, Asif IM. Sickle cell trait associated with a

RR of death of 37 times in National Collegiate Athletic Association football

athletes: a database with 2 million athlete-years as the denominator. Br J

Sports Med 2012;46:325-330.

8. Turkish Ministry of Health. Hemoglobinopati Kontrol Programı. Ankara,

Ministry of Health, 2017. Available at https://hsgm.saglik.gov.tr/tr/

cocukergen-tp-liste/hemoglobinopati-kontrol-program%C4%B1.html.



Address for Correspondence/Yazışma Adresi: Mahmut Yeral, M.D., Başkent University Faculty of Medicine,

Adana Dr. Turgut Noyan Training and Research Center, Clinic of Hematology, Adana, Turkey

Phone : +90 322 327 27 27-2023,

E-mail : drmyeral@gmail.com ORCID: orcid.org/0000-0002-9580-628X

Received/Geliş tarihi: June 22, 2020


DOI: 10.4274/tjh.galenos.2020.2020.0344

160



Novel Mutation p.Asp374Val of SERPINC1 in a Turkish Family with

Inherited Antithrombin Deficiency

Kalıtsal Antitrombin Eksikliği Olan Bir Türk Ailede SERPINC1 Geninde Yeni Bir Mutasyon

(p.asp374val)

Deniz Aslan

Gazi University Faculty of Medicine, Department of Pediatrics, Division of Hematology, Ankara, Turkey

To the Editor,

Antithrombin (AT) is a major inhibitor of blood coagulation. It

is a serine protease inhibitor (SERPIN) that degrades thrombin,

factor (F) IXa, FXa, FXIa, and FXIIa. It is constantly active, but the

presence of heparan sulfate or the administration of heparins

will further increase this inactivation [1]. Inherited AT deficiency

(ATD) (OMIM #107300) is a rare autosomal dominant disorder

associated with an increased risk of venous thromboembolism

(VTE), which usually develops in young and middle-aged adults

[2].

The AT gene (SERPINC1) contains seven exons and six introns

[2]. Approximately 400 distinct mutations in SERPINC1 have

been described [3]. ATD is characterized by either a reduced level

of circulating protein (quantitative, type I) or by the presence

of variant proteins (qualitative, type II) [4]. We herein report

a novel mutation, a base pair substitution (c.1121A>T) leading

to p.Asp374Val, in SERPINC1 in a patient with inherited ATD

presenting with cerebral sinovenous thrombosis.

The proband was a 16-year-old Turkish male with a family

history of deep venous thrombosis (DVT). He was hospitalized

after two days of recurrent headache. Diffusion magnetic

resonance imaging (MRI) and venography showed thrombosis

in the right transverse sinus and right sigmoid sinus. He was

diagnosed with cerebral sinovenous theombosis.

He had no acquired risk factors such as obesity, infection,

immobility, or trauma. Hematological work-up revealed reduced

AT activity (8%; normal range: 80%-120%) (STA®-Stachrom®

AT III Kit). Factor V Leiden (FVL), prothrombin 20210A mutation,

presence of antiphospholipid and anticardiolipin antibodies,

and protein C or S deficiency were excluded. Fibrinogen and

thrombin time results were within normal limits. His mother

and maternal aunt had been treated for unprovoked DVT during

their thirties without thorough investigation of the underlying

cause. The remaining family members had no history of DVT.

Hematological evaluation of the core family revealed a reduced

AT level in the mother (Figure 1). The level of AT in the maternal

aunt was not available. None of the family members had liver

or kidney disease, and there were no other factors contributing

to AT reduction.

The patient was successfully treated with subcutaneous

enoxaparin at 1.0 mg/kg twice a day (adjusted according to

Figure 1. The pedigree of the proband. A double circle or square represents an individual with a definite history of venous

thromboembolism. Wt, wild-type; mut*, the p.Asp374Val mutation of SERPINC1, the mutation identified in the proband.

161



anti-FXa levels), which was continued for 18 months, when full

recanalization of the affected sinuses was observed. The AT level

gradually increased over the course of therapy and stabilized at

around 60%. The two-year follow-up without prophylaxis was

uneventful.

After obtaining informed consent, the exons and intron-exon

boundaries of SERPINC1 were studied by direct sequencing [5].

A mutation of p.Asp374Val present in the heterozygous state

was found (Figure 2). An in silico study [6] confirmed that

this mutation could be detrimental. A search of the published

literature revealed that this mutation, named “AT Ankara”, has

not been previously reported.

VTE is a multifactorial disease determined by a combination

of environmental and genetic risk factors. Inherited ATD

is a recognized strong genetic risk factor for VTE [7,8,9]. A

meta-analysis of observational studies showed a high risk of

first (16-fold) and recurrent (4-fold) VTE in ATD [10].

This novel c.1121A>T, a missense mutation, causes the

replacement of a charged amino acid (Asp) with a

non-polar one (Val), leading to p.Asp374Val. The change in the

amino acid alters the AT protein, leading to a loss of specific

inhibitory activity, and increases the risk of thrombosis at a

young age. Another mutation at this position (c.1121A>G),

leading to p.D374G associated with type II deficiency, has

been previously described [11]. Different amino acid changes

at the same position, causing distinct clinical phenotypes,

have been described in other diseases [12]. The clinical severity

of VTE due to AT Ankara and the risk of arterial thrombosis

Figure 2. Sequence diagram showing heterozygous c.1121A>T in

the proband (A) and, for comparison, normal sequencing in the

father (B). The position of the mutational base is indicated with

an arrow.

development, if any, are not yet clear; accumulating reports

of further cases carrying the same mutation will clarify these

points.

Our patient, with a young age and an active lifestyle, was

followed without prophylaxis since he had no predisposing

factors and the other affected family members had no

recurrence. Furthermore, no recurrence was observed in the

previous patient with a mutation in the same position despite

additional risk factors of arterial hypertension and heterozygous

state of FVL [11]. However, management of inherited ATD should

be determined on an individual basis and prophylaxis should be

considered in cases with predisposing factors.

In conclusion, we have presented herein a novel mutation in

SERPINC1 as the genetic cause of VTE in a Turkish family.

Keywords: p.Asp374Val mutation, SERPINC1, Inherited

antithrombin deficiency

Anahtar Sözcükler: p.Asp374Val mutasyonu, SERPINC1, Kalıtsal

antitrombin eksikliği

Ethics




Acknowledgments: The author thanks the proband and his

family for their willing participation in this study, Dr. Martine

Alhenc-Gelas (Hématologie biologique, AP-HP Hôpital Européen

G Pompidou, Hôpitaux Universitaires Paris Ouest, Paris, France)

for her analysis of the mutation in this family, Yekta Yakal for

preparing the figures, and Corinne Logue Can for her language

editing.

References

1. Sarangi SN, Acharya SA. Disorders of Coagulation. In: Lanzkowsky P, Lipton

JM, Fish JD (eds). Lanzkowsky’s Manual of Pediatric Hematology and

Oncology. New York, Academic Press, 2016.

2. Olds RJ, Lane DA, Chowdhury V, De Stefano V, Leone G, Thein SL. Complete

nucleotide sequence of the antithrombin gene: evidence for homologous

recombination causing thrombophilia. Biochemistry 1993;32:4216-4224.

3. Zhang H, Liu S, Luo S, Jin Y, Yang L, Xie H, Pan J, Wang M. Two novel

mutations cause hereditary antithrombin deficiency in a Chinese family.

Acta Haematol 2020;143:260-265.

4. Patnaik MM, Moll S. Inherited antithrombin deficiency: a review.

Haemophilia 2008;14:1229-1239.

5. Picard V, Dautzenberg MD, Villoutreix BO, Orliaguet G, Alhenc-Gelas M,

Aiach M. Antithrombin Phe229Leu: a new homozygous variant leading to

spontaneous antithrombin polymerization in vivo associated with severe

childhood thrombosis. Blood 2003;102:919-925.

6. Richards S, Aziz N, Bale S, Bick D, Das S, Gastier-Foster J, Grody WW, Hegde

M, Lyon E, Spector E, Voelkerding K, Rehm HL; ACMG Laboratory Quality

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162



sequence variants: a joint consensus recommendation of the American

College of Medical Genetics and Genomics and the Association for

Molecular Pathology. Genet Med 2015;17:405-424.

7. Carrell RW, Lomas DA. Alpha1-antitrypsin deficiency--a model for

conformational diseases. N Engl J Med 2002;346:45-53.

8. Sarper N, Orlando C, Demirsoy U, Gelen SA, Jochmans K. Homozygous

antithrombin deficiency in adolescents presenting with lower extremity

thrombosis and renal complications: two case reports from Turkey. J Pediatr

Hematol Oncol 2014;36:190-192.

9. de la Morena-Barrio B, Orlando C, de la Morena-Barrio ME, Vicente V,

Jochmans K, Corral J. Incidence and features of thrombosis in children with

inherited antithrombin deficiency. Haematologica 2019;104:2512-2518.

10. Di Minno MN, Ambrosino P, Ageno W, Rosendaal F, Di Minno G, Dentali F.

Natural anticoagulants deficiency and the risk of venous thromboembolism:

a meta-analysis of observational studies. Thromb Res 2015;135:923-932.

11. Castaldo G, Cerbone AM, Guida A, Tandurella I, Ingino R, Tufano A, Ceglia

C, Di Minno MN, Ruocco AL, Di Minno G. Molecular analysis and genotypephenotype

correlation in patients with antithrombin deficiency from

Southern Italy. Thromb Haemost 2012;107:673-680.

12. Bradley JF, Collins DL, Schimke RN, Parrott HN, Rothberg PG. Two distinct

phenotypes caused by two different missense mutations in the same codon

of the VHL gene. Am J Med Genet 1999;87:163-167.



Address for Correspondence/Yazışma Adresi: Deniz Aslan, M.D., Gazi University Faculty of Medicine,

Department of Pediatrics, Division of Hematology, Ankara, Turkey

Phone : +90 312 202 60 20

E-mail : drdagutf@ttmail.com ORCID: orcid.org/0000-0002-5250-787X

Received/Geliş tarihi: November 24, 2020


DOI: 10.4274/tjh.galenos.2021.2020.0702

An Interesting Case: Sunitinib-Induced Microangiopathic

Hemolytic Anemia and Nephrotic Syndrome

İlginç Bir Olgu: Sunutinib İlişkili Mikroanjiyopatik Hemolitik Anemi ve Nefrotik Sendrom

Veysel Haksöyler 1 , Semra Paydaş 2

1Private Adana Medline Hospital, Adana, Turkey

2Çukurova University Faculty of Medicine, Department of Oncology, Adana, Turkey

To the Editor,

Sunitinib is a heterodimeric oral tyrosine kinase inhibitor

that targets a large number of receptors, including VEGFR

and PDGFR. Anti-VEGF treatments can cause hypertension,

proteinuria, neutropenia, anemia, and thrombocytopenia [1]. It

has been shown in animal experiments that vascular endothelial

growth factor (VEGF) contributes to the repair of glomerular

endothelium in experimental microangiopathia and anti-VEGF

antibodies cause proteinuria by glomerular dissociation and

downregulation of nephrin receptors [2]. The increase of VEGF

levels in the blood 2-3 weeks after thrombotic microangiopathy

(TMA) supports the idea of VEGF-mediated repair of the

glomerular endothelium [3]. Anti-VEGF treatment may cause

thrombosis due to the procoagulant phospholipids released as a

result of the disruption of plasma membrane integrity and due

to the decrease in the levels of nitric oxide and prostaglandin I2,

which contributes to the production of VEGF [4].

A 54-year-old woman was receiving sunitinib for a metastatic

gastrointestinal stromal tumor (GIST). She presented to

the clinic 8 months after the initiation of therapy with

microangiopathic hemolytic anemia (MAHA) and nephrotic

syndrome (NS). Proteinuria (3.5 g) was detected in the 24-h

urine collection. The platelet count was 35000/mm 3 , white

blood cell count was 6700/mm 3 , and hemoglobin was 7 g/dL.

In the blood smear, normochromic normocytic anemia, diffuse

schistocytes, and fragmented erythrocytes were present (Figure

1). Sunitinib was discontinued and methylprednisone was

Figure 1. Peripheral blood smear showed rare schistocytes and

mild thrombocytopenia.

163



started with the resolution of symptoms. MAHA and NS relapsed

with re-challenge with sunitinib. Symptoms resolved after the

discontinuation of sunitinib.

Bollee et al. published the case of a patient with malignant skin

hidradenoma who developed hypertension and proteinuria.

Renal biopsy showed microangiopathic anemia [5]. A second

reported case involved metastatic renal cell carcinoma;

hypertension, nephrotic proteinuria, azotemia, creatinine

increase, oliguria, thrombocytopenia, and anemia developed

and kidney biopsy showed focal segmental glomerulosclerosis

and TMA. After the cessation of sunitinib, the patient recovered

[6]. A third case involved hypertension and proteinuria; a

kidney biopsy showed TMA. This patient improved with the

cessation of sunitinib and steroids [7]. In a fourth case of

metastatic GIST, the patient presented with hypertension, loss

of vision, seizures, anemia, thrombocytopenia, acute renal

failure, and posterior leukoencephalopathy with schistocytes

in the blood smear. After the cessation of sunitinib, he

improved [8]. A fifth case involved metastatic renal cell

carcinoma with nephrectomy as well as nephrotic proteinuria.

TMA was confirmed by kidney biopsy. Kidney functions and

proteinuria almost entirely improved after stopping sunitinib

and starting steroids [9]. In another case of metastatic renal

cell carcinoma, three weeks after the start of sunitinib,

hypertension, proteinuria, thrombocytopenia, and anemia

developed. Schistocytes were noticed in the blood smear. The

patient’s symptoms improved after the discontinuation of

sunitinib [10].

In contrast to many cases discussed, the case that we

present here was not a case of renal cell carcinoma but

rather metastatic GIST. Generally, sunitinib is used in the

first line of treatment for renal cell carcinoma, but it is used

after imatinib in GIST treatment, as we did for this patient.

Therefore, it is interesting that this toxicity developed

after the second tyrosine kinase inhibitor. In this regard, it

is an infrequent phenomenon. Similar to other patients

mentioned, hypertension was detected in our patient before

the development of toxicity. As in most of the other cases,

our patient’s condition improved almost completely after

stopping sunitinib. Our patient did not undergo a kidney

biopsy because she had thrombocytopenia and therefore

rejected the kidney biopsy. Furthermore, the diagnosis was

made clinically, so a biopsy was not required.

The use of anti-VEGF drugs has become widespread and there

are limited published data about such severe toxicities (Table

1). For this reason, we wanted to present this rare case that we

found and we believe that it can contribute to the literature.

Keywords: Sunitinib, Nephrotic syndrome, Hemolytic anemia,

Microangiopathic hemolytic anemia

Table 1. Naranjo algorithm assessment.

Anahtar Sözcükler: Sunitinib, Nefrotik sendrom, Hemolitik

anemi, Mikroanjiyopatik hemolitik anemi

Ethics

Informed Consent: Since the patient died, consent was not

obtained.


Concept: V.H., S.P.; Analysis or Interpretation: V.H., S.P.; Literature

Search: V.H., S.P.; Writing: V.H., S.P.


authors.



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5. Bollée G, Patey N, Cazajous G, Robert C, Goujon JM, Fakhouri F, Bruneval

P, Noël LH, Knebelmann B. Thrombotic microangiopathy secondary to VEGF

pathway inhibition by sunitinib. Nephrol Dial Transplant 2009;24:682-685.

6. Costero O, Picazo ML, Zamora P, Romero S, Martinez-Ara J, Selgas R.

Inhibition of tyrosine kinases by sunitinib associated with focal segmental

glomerulosclerosis lesion in addition to thrombotic microangiopathy.

Nephrol Dial Transplant 2010;25:1001.

7. Noronha V, Punatar S, Joshi A, Desphande RV, Prabhash K. Sunitinibinduced

thrombotic microangiopathy. J Cancer Res Ther 2016;12:6-11.

8. Kapiteijn E, Brand A, Kroep J, Gelderblom H. Sunitinib induced hypertension,

thrombotic microangiopathy and reversible posterior leukencephalopathy

syndrome. Ann Oncol 2007;18:1745-1747.

9. Jha PK, Vankalakunti M, Siddini V, Bonu R, Prakash GK, Babu K, Ballal HS.

Sunitinib induced nephrotic syndrome and thrombotic microangiopathy.

Indian J Nephrol 2013;23:67-70.

10. Choi MK, Hong JY, Jang JH, Lim HY. TTP-HUS associated with sunitinib.

Cancer Res Treat 2008;40:211-215.



Address for Correspondence/Yazışma Adresi: Veysel Haksöyler, M.D., Private Adana Medline Hospital,

Adana, Turkey

Phone : +90 532 396 67 31

E-mail : dr.haksoyler@gmail.com ORCID: orcid.org/0000-0001-5124-8362

Received/Geliş tarihi: September 2, 2020


DOI: 10.4274/tjh.galenos.2020.2020.0532

Kimura Disease Associated with Minimal Change Disease

Minimal Değişiklik Hastalığı ile İlişkili Kimura Hastalığı

Rafet Eren 1 , Enes Cömert 2 , İlknur Mansuroğlu 3 , Esma Evrim Doğan 1 , Gülay Kadıoğlu 4

1University of Health Sciences Turkey, Prof. Dr. Cemil Taşcıoğlu City Hospital, Department of Hematology, İstanbul, Turkey

2University of Health Sciences Turkey, Prof. Dr. Cemil Taşcıoğlu City Hospital, Department of Internal Medicine, İstanbul, Turkey

3University of Health Sciences Turkey, Prof. Dr. Cemil Taşcıoğlu City Hospital, Department of Pathology, İstanbul, Turkey

4University of Health Sciences Turkey, Prof. Dr. Cemil Taşcıoğlu City Hospital, Department of Nephrology, İstanbul, Turkey

To the Editor,

Kimura disease is a benign chronic inflammatory disease

with unknown etiology, which usually presents with

lymphadenopathies in the head and neck, peripheral blood

eosinophilia, and elevated serum immunoglobulin E (IgE) levels.

It is mostly observed in young males of Asian descent in the

second and third decades of life, but sporadic cases in other

ethnic groups have also been reported [1,2]. Here we present

a patient with Kimura disease and concomitant nephrotic

syndrome who presented with lymphadenopathies of atypical

locations.

A 25-year-old male patient presented with new-onset

hypertension, decreased urine output, and lower extremity

swelling. His past medical history was unremarkable with no

history of allergies. On examination, his blood pressure was

140/100 mmHg, heart rate was 90/min, and body temperature

was 37 °C. He had bilateral 2+ pitting edema of the bilateral

lower extremities and an enlarged, soft, nontender 3-cm

left inguinal lymph node. Laboratory evaluation results

were as follows: white blood cells, 6790/µL; eosinophils,

1280/µL (18.9%); normal hemoglobin level and platelet

count; serum creatinine, 0.66 mg/dL; urea, 26 mg/dL; albumin,

2.4 g/dL; triglyceride, 295 mg/dL; erythrocyte sedimentation rate,

81 mm/h; total IgE, 3318 kU/L (<87). Urinalysis showed

3+ protein and the spot urine protein/creatinine ratio was

7819 mg/g. Viral serologies and rheumatologic markers

were negative. Serum C3, C4, IgG, IgA, and IgM levels were

also normal. A percutaneous renal biopsy was performed

for nephrotic syndrome. Pathological examination of the

specimen revealed no significant changes by light microscopy

and was negative for immunofluorescence, indicating

minimal change disease. The patient was started on low-dose

perindopril with a gradual increase to 10 mg/day. Positron

emission tomography-computed tomography (CT) performed

to assess any associated malignancy showed hypermetabolic

activity in the inguinal and right external iliac regions (SUV max

:

2.5). The left inguinal lymph node was excised. The pathology

was reported to be consistent with Kimura disease (Figure 1).

During follow-up, his creatinine levels progressively increased

to 2 mg/dL and he was started on methylprednisolone at

1 mg/kg. At week 1, his creatinine regressed to baseline. At

week 3, complete remission of proteinuria was achieved and

165



Figure 1. Lymph node biopsy: (a) markedly hyperplastic follicles with reactive germinal centers, (b) well-defined peripheral mantle zone,

and (c) intense diffuse eosinophilia with formation of eosinophilic microabscesses. Paracortical plasma cells were also present. IgG4 was

increased with a value of 0.8%, which was below the 40% threshold for IgG4-related disease.

the steroid was tapered slowly. Abdominal CT performed in

the fourth month showed significant decrease in the number

and size of lymph nodes. Steroid treatment was discontinued

at the seventh month. To date, the patient has no symptoms

and is being followed recurrence-free.

There are many reports of renal involvement in Kimura disease.

A review of 175 patients with Kimura disease found renal

involvement in 12% [3]. Renal biopsies of patients with renal

involvement of Kimura disease showed mesangioproliferative

glomerulonephritis, minimal change disease, focal

segmental glomerulosclerosis, membranous nephropathy,

membranoproliferative glomerulonephritis, and acute tubular

necrosis [4]. The treatment, however, remains unclear. While

excision is considered adequate in patients without renal

involvement, systemic steroids are recommended in patients

who have renal involvement or relapse after excision [5].

Here, we have presented a patient who was diagnosed with

minimal change disease and Kimura disease and responded

to steroid treatment. Kimura disease should be considered in

patients investigated for lymphadenopathies in the presence of

elevated serum IgE levels and renal disease.

Keywords: Kimura disease, Lymphadenopathy, Eosinophilia,

Minimal change disease

Anahtar Sözcükler: Kimura hastalığı, Lenfadenopati, Eozinofili,

Minimal değişiklik hastalığı


Surgical and Medical Practices: R.E., E.C., G.K.; Concept: E.E.D.;

Design: R.E., İ.M.; Data Collection or Processing: E.C., E.E.D.;

Analysis or Interpretation: R.E., İ.M.; Literature Search: R.E., G.K.;

Writing: R.E., G.K.


authors.



References

1. Kumar V, Mittal N, Huang Y, Balderracchi J, Zheng HX, Li Z, Xu Y. A case series

of Kimura’s disease: a diagnostic challenge. Ther Adv Hematol 2018;9:207-

211.

2. Yu B, Xu G, Liu X, Yin W, Chen H, Sun B. Kimura’s disease affecting multiple

body parts in a 57-year-old female patient: a case report. Allergy Asthma

Clin Immunol 2019;15:84.

3. Yamada A, Mitsuhashi K, Miyakawa Y, Kosaka K, Takehara K, Iijima M, Tanaka

K, Shibata S. Membranous glomerulonephritis associated with eosinophilic

lymphfolliculosis of the skin (Kimura’s disease): report of a case and review

of the literature. Clin Nephrol 1982;18:211-215.

4. Chen Y, Wang J, Xu F, Zeng C, Liu Z. Clinicopathological features and

prognosis of Kimura’s disease with renal involvement in Chinese patients.

Clin Nephrol 2016;85:332-339.

5. Su S, Chen X, Li J, Yu J, Zhang L. Kimura’s disease with membranoproliferative

glomerulonephritis: a case report with literature review. Ren Fail

2019;41:126-130.

Ethics

Informed Consent: The patient provided informed consent for

this publication.



Address for Correspondence/Yazışma Adresi: Rafet Eren, M.D., University of Health Sciences Turkey, Prof.

Dr. Cemil Taşcıoğlu City Hospital, Department of Hematology, İstanbul, Turkey

Phone : +90 531 996 18 42

E-mail : drrafeteren@gmail.com ORCID: orcid.org/0000-0003-0973-6279

Received/Geliş tarihi: August 14, 2020

Accepted/Kabul tarihi: September 29, 2020

DOI: 10.4274/tjh.galenos.2020.2020.0477

166



Acute Kidney Injury Due to Leukemic Infiltration in a Patient with

Chronic Lymphocytic Leukemia

Kronik Lenfositik Lösemide Lösemik İnfiltrasyona Bağlı Akut Böbrek Yetmezliği

Gizem Kumru Şahin 1 , Hasan Emre Kocabay 2 , Saba Kiremitçi 3 , Osman İlhan 4 , Kenan Keven 1

1Ankara University Faculty of Medicine, Department of Nephrology, Ankara, Turkey

2Ankara University Faculty of Medicine, Department of Internal Medicine, Ankara, Turkey

3Ankara University Faculty of Medicine, Department of Medical Pathology, Ankara, Turkey

4Ankara University Faculty of Medicine, Department of Hematology, Ankara, Turkey

To the Editor,

The kidneys are among the organs most affected by leukemic

involvement in chronic lymphocytic leukemia (CLL) patients in

postmortem autopsy series (63%-90%) [1,2]. However, leukemic

infiltration (LI) of the kidneys has been a rare cause of renal

impairment in CLL patients [3,4]. Here we describe a case of CLL

presenting with severe acute kidney injury (AKI) due to LI.

A 72-year-old white male without any renal disease presented

with general malaise and weight loss. He had been diagnosed

with stage B(1) B-CLL four years before and was treated with

a bendamustine and rituximab protocol. Physical examination

revealed general lymphadenopathy and hepatomegaly.

Complete blood count findings were as follows: hemoglobin,

11.3 g/dL; leukocytes, 411.4x10 9 /L (lymphocytes: 60%); platelets,

247x10 9 /L. The blood film appearances were suggestive of CLL.

The following biochemical tests were abnormal: blood urea

nitrogen, 44 mg/dL (normal: 8-22); serum creatinine (sCr),

6.16 mg/dL (normal: 0.7-1.3); CKD-EPI estimated-glomerular

filtration rate, 8 mL/min/1.73 m 2 (normal: >60). His urine had

no leukocytes or casts, with 3 erythrocytes/field and proteinuria

in the non-nephrotic range (1779 mg/24 h). Serological tests

for hepatitis B, hepatitis C, HIV, and autoimmune kidney

disorders were negative. Serum-free light chain (sFLC) kappa

was 317.5 mg/dL (normal: 3.3-19.4) and sFLC lambda was

22.2 mg/dL (normal: 5.71-26.3), but no monoclonal bands

in serum or urine immunofixation were detected. Renal

ultrasound showed normal-sized kidneys with no evidence

of obstructive nephropathy. A renal biopsy was performed,

which demonstrated heavy infiltration of diffuse monomorphic

neoplastic lymphocytes in the interstitium (Figure 1A). Six of

21 glomeruli were globally sclerotic and acute tubular necrosis

and disruption were seen. Immunohistochemistry revealed that

these infiltrative cells were positive for CD20 and CD5 (Figures

1B and 1C) without any amyloid or light chain deposition.

The clinical picture was consistent with AKI due to LI of the

kidneys. Therapeutic leukapheresis and treatment with highdose

methylprednisolone and rituximab were administered.

His renal functions were restored with no need to perform

hemodialysis and complete response in CLL was achieved

(leukocytes: 10.3x10 9 /L). After a year of follow-up, his renal

function had improved to sCr of 2.04 mg/dL, and a complete

blood count revealed hemoglobin of 14.7 g/dL, leukocytes of

9.15x10 9 /L, and platelets of 294x10 9 /L.

Besides LI, renal impairment in CLL patients can be associated

with prerenal azotemia, thrombotic microangiopathy,

acute tubular necrosis, acute interstitial nephritis, uric acid

nephropathy, light chain nephropathy, amyloidosis, obstructive

nephropathy, glomerulonephritis, and cryoglobulinemia [5]. LI of

the kidneys is common in CLL, but it is unlikely to be associated

with severe AKI [4]. Although the mechanism of this clinical

presentation is unclear, it was suggested that the compression of

the tubular lumen and microvasculature by CLL cells may cause

intrarenal obstruction and ischemia [6]. No clear association

was demonstrated between CLL stage, intensity of interstitial

infiltration, and severity of renal impairment [7]. Relapsed or

refractory CLL and presentation with AKI are supportive for LI

Figure 1. (A) Diffuse monomorphic neoplastic lymphocytic

infiltrate in the renal tissue (H&E, 200 x ). (B) Lymphocytic infiltration

showing immunopositivity for CD20 (immunohistochemistry,

300 x ). (C) Lymphocytic infiltration showing immunopositivity for

CD5 (immunohistochemistry, 300 x ).

167



as the primary cause of renal impairment [6,8]. After exclusion

of other causes, kidney biopsy should be performed to confirm

the diagnosis. Significant improvement in renal function was

reported after CLL treatment in a majority of patients [8,9]. Our

case shows that LI of the kidneys can cause AKI as the initial

manifestation of CLL and physicians should be aware of the

atypical presentations of the disease.

Keywords: Acute kidney injury, Chronic lymphocytic leukemia,

Leukemic infiltration

Anahtar Sözcükler: Akut böbrek yetmezliği, Kronik lenfositik

lösemi, Lösemik infiltrasyon

Ethics

Informed Consent: Informed consent was obtained from the

patient included in the study.


Medical Practices: G.K.Ş., H.E.K., S.K.; Concept: G.K.Ş., O.İ., K.K.;

Design: G.K.Ş., O.İ., K.K.; Data Collection or Processing: G.K.Ş.,

H.E.K., S.K.; Analysis or Interpretation: G.K.Ş., K.K.; Literature

Search: G.K.Ş.; Writing: G.K.Ş.


authors.

Financial Disclosure: The authors declare that this study


References

1. Barcos M, Lane W, Gomez GA, Han T, Freeman A, Preisler H, Henderson E. An

autopsy study of 1206 acute and chronic leukemias (1958 to 1982). Cancer

1987;60:827-837.

2. Schwartz J, Shamsuddin A. The effects of leukemic infiltrates in various

organs in chronic lymphocytic leukemia. Hum Pathol 1981;12:432-440.

3. Da’as N, Polliack A, Cohen Y, Amir G, Darmon D, Kleinman Y, Goldfarb

AW, Ben-Yehuda D. Kidney involvement and renal manifestations in non-

Hodgkin’s lymphoma and lymphocytic leukemia: a retrospective study in

700 patients. Eur J Haematol 2001;67:158-164.

4. Shanafelt TD, Rabe KG, Hanson CA, Call TG, Schwager S, Parikh SA, Nasr H,

Leung N. Renal disease in patients with chronic lymphocytic leukemia (CLL).

Blood 2013;122:5302 (abstract).

5. Wanchoo R, Ramirez C, Barrientos J, Jhaveri K. Renal involvement in chronic

lymphocytic leukemia. Clin Kidney J 2018;11:670-680.

6. Kowalewska J, Nicosia RF, Smith KD, Kats A, Alpers CE. Patterns of glomerular

injury in kidneys infiltrated by lymphoplasmacytic neoplasms. Hum Pathol

2011;42:896-903.

7. Poitou-Verkinder AL, Francois A, Drieux F, Lepretre S, Legallicier B, Moulin

B, Godin M, Guerrot D. The spectrum of kidney pathology in B-cell chronic

lymphocytic leukemia / small lymphocytic lymphoma: a 25-year multicenter

experience. PLoS One 2015;10:e0119156.

8. Strati P, Nasr SH, Leung N, Hanson CA, Chaffee KG, Schwager SM, Achenbach

SJ, Call TG, Parikh SA, Ding W, Kay NE, Shanafelt TD. Renal complications

in chronic lymphocytic leukemia and monoclonal B-cell lymphocytosis: the

Mayo Clinic experience. Haematologica 2015;100:1180-1188.

9. Uprety D, Peterson A, Shah BK. Renal failure secondary to leukemic

infiltration of kidneys in CLL - A case report and review of literature. Ann

Hematol 2013;92:271-273.



Address for Correspondence/Yazışma Adresi: Gizem Kumru Şahin, M.D., Ankara University Faculty of

Medicine, Department of Nephrology, Ankara, Turkey

Phone : +90 507 428 91 11

E-mail : gizemkumru@gmail.com ORCID: orcid.org/0000-0001-7529-3010

Received/Geliş tarihi: September 30, 2020

Accepted/Kabul tarihi: November 4, 2020

DOI: 10.4274/tjh.galenos.2020.2020.0595

168



Gastric Cancer or Plasmacytoma in a Seemingly Well-Controlled

Multiple Myeloma Patient?

Görünüşte İyi Kontrol Edilen Bir Multipl Myelom Hastasında Mide Kanseri Veya

Plazmasitom

Wanlu Ma 1 , Boju Pan 2 , Lu Zhang 3

1Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Department of Endocrinology,

Beijing, China

2Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Department of Pathology,

Beijing, China

3Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College,Department of Hematology,

Beijing, China

To the Editor,

An 89-year-old man complained of hip joint pain accompanied

by fatigue, anorexia, nausea, and vomiting for 1 year. Lab

assessments showed anemia with hemoglobin (Hgb) of 68 g/L.

Liver and renal functions and serum calcium were normal.

Computed tomography (CT) and positron emission-computer

tomography exhibited multiple osteolytic lesions throughout

the whole body. Serum protein electrophoresis showed

elevated M protein (31.4 g/L). Serum and urine immunofixation

electrophoresis revealed strong positive immunoglobin G λ.

Urine light chain (24 hours) was negative (below the lower

limit of detection). A bone marrow smear showed myeloma

cells at a rate of 12.5%. Fluorescence in situ chromosome

hybridization did not detect 1q21+, 17p-, t(14;16), t(4;14), or

t(11;14). Multiple myeloma (MM) (DS IIIA, ISS II, R-ISS II) was

diagnosed with albumin of 22 g/L, serum β2-microglobulin of

5.05 mg/L, and lactate dehydrogenase of 308 U/L (normal range:

97-270). An LD regimen (lenalidomide at 25 mg per day for

21 days, dexamethasone at 10 mg per week) was administered

for 8 months. His condition improved with normal Hgb

(120 g/L). Serum M protein gradually decreased to 0.3 g/L for

7 months before he suffered from hematemesis and melena.

Thoracoabdominal CT showed irregularly thickened gastric

wall of the sinuses and greater curvature of the body of the

stomach. Gastroscopy showed a giant tumor extending from

the fundus to the stomach horn and anterior wall of the gastric

antrum, which resembled gastric cancer (Figures 1a and 1b).

However, to our surprise, pathology revealed plasmacytoma

(plasmoblast type), which suggested disease progression despite

well-controlled serum M protein (2.2 g/L) (Figures 1c and 1d).

Urine light chain also reached 476 mg/24 h despite a negative

urine light chain level at baseline. The patient progressed rapidly

and his general condition worsened as he suffered from not only

gastric hemorrhage but also pulmonary infection. Bortezomib

was intended to be given but, considering his older age,

extremely poor condition, and the wishes of the patient and his

family, palliative care was given. Unfortunately, the patient died

of pulmonary infection 10 days later.

MM is a neoplastic proliferation of monoclonal plasma cells

[1,2]. Gastrointestinal (GI) involvement is not common and GI

hemorrhage is rarely reported [3]. Here we have presented a

case of MM and a giant gastric tumor. We did not expect the

tumor to be a plasmacytoma before pathology, mainly due to

three reasons. First, involvement of the GI system is rare in MM

[1]. Previous series suggested little or no GI involvement in

autopsied MM patients [2]. A systematic review of 2584 MM

patients identified only 24 cases (0.93%) with involvement of

Figure 1. a, b) Gastroscopy showed a giant tumor in the stomach

cavity, extending from the fundus and stomach to the stomach

horn and anterior wall of the gastric antrum, with ulcers on the

surface, covered with moss-like growth and bloody scab. c, d)

Pathology of the body of the stomach confirmed plasmacytoma

(plasmoblast type). c) Hematoxylin and eosin staining magnified

100 times. d) CD138 immunohistochemical staining magnified

100 times.

169



the GI system [1]. Among the 4 cases with stomach involvement,

only 1 case showed symptoms of upper GI bleeding with

a mass of 4x10 cm [1]. Second, this patient seemed to have

well-controlled myeloma with decreased M protein compatible

with a very good partial response (VGPR) [3] and normalization

of hemoglobin. It would be even rarer if a patient suffered

from a rare manifestation of myeloma with well-controlled

disease. Third, MM could be accompanied by second primary

malignancies and the reported rate (3.5%-4.52%) was higher

than that of gastric involvement (0.93%) in MM patients [1,4].

However, pathology showed plasmacytoma, which indicated

progression of MM [3]. Moreover, despite a negative 24-h urine

light chain level at baseline and marked decrease of intact serum

M protein compared to baseline (31.2 g/L decreased to 2.2 g/L),

significantly elevated urine light chain levels also suggested

disease progression. This phenomenon was termed “light chain

escape,” and clinicians should examine urine light chain even in

patients with normal 24-h urine light chain level at baseline [5].

Previous studies showed that extramedullary plasmacytoma

at relapse had the worst prognosis (progression-free survival

of 13.6 months and overall survival of 11.4 months) [6] and

patients who progress within 18 months of initial therapy

have particularly poor outcomes [7]. Considering the age, poor

general condition, possible outcomes, and wishes of the patient

and his family members, palliative care was given. Despite

sufficient supportive treatment, the patient died soon.

We report a case of GI hemorrhage rarely seen in MM. Due to

spatial heterogeneity, malignant cells at different anatomical

locations may display different levels of sensitivity.

Keywords: Multiple myeloma, Gastrointestinal plasmacytoma,

Gastric hemorrhage

Anahtar Sözcükler: Multipl myelom, Gastrointestinal

plazmasitom, Mide kanaması


Data Collection or Processing: B.P.; Analysis or Interpretation:

L.Z.; Writing: W.M.


authors.

Financial Disclosure: The National Natural Science Foundation

of China (81900202, for ZL) and the Fundamental Research

Funds for the Central Universities (3332018036, for ZL).

References

1. Talamo G, Cavallo F, Zangari M, Barlogie B, Lee CK, Pineda-Roman M, Kiwan

E, Krishna S, Tricot G. Clinical and biological features of multiple myeloma

involving the gastrointestinal system. Haematologica 2006;91:964-967.

2. Pasmantier MW, Azar HA. Extraskeletal spread in multiple plasma cell

myeloma. A review of 57 autopsied cases. Cancer 1969;23:167-174.

3. Kumar S, Paiva B, Anderson KC, Durie B, Landgren O, Moreau P, Munshi

N, Lonial S, Bladé J, Mateos MV, Dimopoulos M, Kastritis E, Boccadoro

M, Orlowski R, Goldschmidt H, Spencer A, Hou J, Chng WJ, Usmani SZ,

Zamagni E, Shimizu K, Jagannath S, Johnsen HE, Terpos E, Reiman A, Kyle

RA, Sonneveld P, Richardson PG, McCarthy P, Ludwig H, Chen W, Cavo M,

Harousseau JL, Lentzsch S, Hillengass J, Palumbo A, Orfao A, Rajkumar

SV, Miguel JS, Avet-Loiseau H. International Myeloma Working Group

consensus criteria for response and minimal residual disease assessment in

multiple myeloma. Lancet Oncol 2016;17:e328-e346.

4. Popova JG, Nenov I, Spasova M, Yaneva M, Beleva E, Ananoshtevet

N. Multiple myeloma in association with second malignancy. J BUON

2013;18:448-452.

5. Hobbs JA, Drayson MT, Sharp K, Harding S, Bradwell AR, Mead GP. Frequency

of altered monoclonal protein production at relapse of multiple myeloma.

Br J Haematol 2010;148:659-661.

6. Beksac M, Seval GC, Kanellias N, Coriu D, Rosiñol L, Ozet G, Goranova-

Marinova V, Unal A, Bila J, Ozsan H, Ivanaj A, Balić LI, Kastritis E, Bladé

J, Dimopoulos MA. A real world multicenter retrospective study on

extramedullary disease from Balkan Myeloma Study Group and Barcelona

University: analysis of parameters that improve outcome. Haematologica

2020;105:201-208.

7. Shah N, Chari A, Scott E, Mezzi K, Usmani SZ. B-cell maturation antigen

(BCMA) in multiple myeloma: rationale for targeting and current

therapeutic approaches. Leukemia 2020;34:985-1005.

Ethics

Informed Consent: Informed consent for publication was

obtained from the patient.



Address for Correspondence/Yazışma Adresi: Lu Zhang, M.D., Peking Union Medical College Hospital, Chinese

Academy of Medical Sciences and Peking Union Medical College, Department of Hematology, Beijing, China

Phone : +86-010-69155001

E-mail : pumczhanglu@126.com ORCID: orcid.org/0000-0002-0860-9625

Received/Geliş tarihi: October 28, 2020


DOI: 10.4274/tjh.galenos.2021.2020.0645

170



Prolonged Severe Watery Diarrhea in a Long-Term Myeloma

Survivor: An Unforeseen Infection with Cystoisospora belli

Uzun Süredir Myelom Tanısıyla Takipli Hastada Uzamış Sulu İshalin Öngörülemeyen Nedeni:

Cystoisospora belli

Tarık Onur Tiryaki 1 , Kadir Uluç Anıl 2 , Melek Büyük 3 , Ahmet Yasir Yıldırım 3 , Alp Atasoy 4 , Aslı Çiftçibaşı Örmeci 4 ,

Sevgi Kalayoğlu Beşışık 1

1İstanbul University İstanbul Medical Faculty, Department of Internal Medicine, Division of Hematology, İstanbul, Turkey

2İstanbul University İstanbul Medical Faculty, Department of Internal Medicine, İstanbul, Turkey

3İstanbul University İstanbul Medical Faculty, Department of Pathology, İstanbul, Turkey

4İstanbul University İstanbul Medical Faculty, Department of Internal Medicine, Division of Gastroenterohepatology, İstanbul, Turkey

To the Editor,

The parasite Cystoisospora belli (formerly known as Isospora

belli), referred to as coccidian, infects the epithelial cells of

the small intestine and is one of the least common intestinal

coccidia that infect humans. Infections have been sporadically

reported in a wide variety of immunocompromised patients,

including patients with concurrent Hodgkin’s disease, non-

Hodgkin’s lymphoma, and acute lymphoblastic leukemia, and

can sometimes be fulminant in immunocompromised patients

[1,2]. Chronic diarrhea is the major clinical manifestation,

sometimes associated with headache, fever, malaise, abdominal

pain, vomiting, dehydration, and weight loss. Extraintestinal

infections with tissue cyst-like stages have been observed in the

lymph nodes, liver, and spleen of patients with AIDS. Infections

of immunosuppressed patients with C. belli have been reported

in association with viral infections other than HIV, especially

human T-cell leukemia virus type 1 (HTLV-1) [3].

Multiple myeloma (MM)-related immunodeficiency involves

B-cell dysfunction, such as hypogammaglobulinemia, as well

as T-cell, dendritic cell, and NK-cell abnormalities [4,5,6,7]. In

addition to the disease-related inherent immunodeficiency,

some studies have described a changing spectrum of

infections in MM, possibly related to the more intensive or

immunomodulating treatment approaches of recent years.

Among MM cases, infections are a significant cause of morbidity

and a leading cause of death. We present here a case of C. belli

infection in a MM patient who developed persistent diarrhea in

the late responsive period.

A 66-year-old male patient was diagnosed as having

immunoglobulin (Ig) G kappa-type MM of Durie-Salmon stage

IIIA in 2007. He underwent autologous stem cell transplantation

(ASCT) following high-dose melphalan (200 mg/m 2 ) after

second-line treatment. A bortezomib-based regimen was used

again due to progression in the first year after ASCT. A second

ASCT was performed for consolidation, this time followed by

lenalidomide maintenance. He achieved complete response, but

at the 24 th month of maintenance, he relapsed. Pomalidomide,

cyclophosphamide, and dexamethasone were started. Treatment

regimens and disease characteristics are summarized in Table 1.

In the 4 th month of this treatment, he developed severe watery

diarrhea with abdominal pain, which became persistent despite

supportive measures. MM disease status showed biochemical

remission. Infectious causes were excluded by variable tests

including ova and parasite screening. Acute phase markers

were not remarkable. Metronidazole (500 mg orally, every 8 h

for 5 days) and ciprofloxacin (500 mg orally, b.i.d.) were started

empirically. There was no fat, blood, or leukocytes in the stool.

Accompanying viral infection was not detected in our patient,

such as HIV or HTLV-1. Anti-tissue transglutaminase IgA and

anti-gliadin IgA antibodies were negative. Thyroid hormone

levels, vasoactive intestinal peptide, and urine 5-HIAA levels

were within normal ranges. Gastroscopy showed non-erosive

antral gastritis and edematous and erythematous duodenum.

He continuously lost weight and became pale, but had no fever.

There was no gross pathology in colonoscopy except distinct thin

vascular structures. Multiple biopsies were obtained randomly to

evaluate amyloidosis. Contrast-enhanced abdominal CT did not

reveal any abnormality. Endoscopic biopsy samples demonstrated

mild duodenitis and colitis characterized by increased numbers

of plasma cells and lymphocytes but no villous atrophy or crypt

hyperplasia (Figure 1B). Amyloid staining proved to be negative.

No inclusion bodies were found, pointing to viral infection. In

the duodenal epithelium, beneath the nuclei, a different image

was striking. There were PAS-stained granules (Figure 1D) and

oocysts were identified, which were consistent with C. belli.

Several developmental stages of C. belli parasites in duodenal

epithelial cells were identified (Figures 1A-1C). Treatment with

trimethoprim (TMP)-sulfamethoxazole (160 mg of trimethoprim

and 800 mg of sulfamethoxazole [STX]) as one double-strength

tablet b.i.d. orally for 10 days improved the clinical picture

171



Table 1. Treatment regimens and disease characteristics.

Regimen/state Cycle(s) Response Date

VAD (vincristine, doxorubicin, and dexamethasone) x2 Minimal response

CyBorD (bortezomib, cyclophosphamide, and dexamethasone) x6 Very good partial response

Autologous stem cell transplantation with high-dose melphalan

(200 mg/m 2 )

September 2007-November

2007

December 2007-September

2008

N/A Complete response January 2009

First relapse N/A N/A February 2011

CyBorD (bortezomib, cyclophosphamide, and dexamethasone) x8 Very good partial response February 2011-October 2011

Second autologous stem cell transplantation with high-dose

melphalan (140 mg/m 2 )

N/A Very good partial response April 2012

Serological relapse/Progression N/A N/A July 2013

Len-Dex (lenalidomide, dexamethasone) x24 Complete response June 2013-January 2016

Second serological relapse/Progression N/A N/A February 2016

Pom-Cyclo-Dex (pomalidomide, cyclophosphamide, and

dexamethasone)

x40 Complete response February 2016-…

Figure 1. Sections of the duodenum (H&E stain, 1000 x ).

Cystoisospora belli is present inside the epithelium (arrows)

with a halo around it (A, B, C). There are also many eosinophils,

neutrophils, and lymphocytes in the lamina propria (B).

Pink granular staining of parasite with periodic acid-Schiff

histochemical staining (D) (PAS, 1000 x ).

dramatically and the patient began to gain weight. His MM

status is still CR and he is on TMP/STX prophylaxis.

Cystoisospora belli infections are essentially cosmopolitan

in distribution but are more common in tropical and

subtropical regions [8]. Clinical presentation may mimic

inflammatory bowel disease and irritable bowel syndrome. In

immunocompromised patients, infection is often severe, with

a secretory-like diarrhea that may lead to dehydration and

require hospitalization, sometimes associated with fever and

weight loss [6,8]. For our patient, the infection presentation

was chronic watery diarrhea, which contributed to severe

weight loss. C. belli diagnosis is performed by detection of the

oocysts in stool samples by direct microscopy or by modified

Ziehl-Neelsen staining methods and autofluorescence

technique. There is no reported serological test at present

[3]. In our case, direct microscopy did not capture oocysts.

Oocysts may rarely be detected in gastrointestinal epithelium

or bile samples. However, careful examination of intestinal

biopsy samples has helped detect PAS-positive granules and

oocysts [8]. In Turkey, C. belli infection has been reported

sporadically. Cystoisosporiasis can be prevented with adequate

sanitation, measures to protect food and water supplies, and

increased public awareness of the means of transmission

[8,9]. Immunocompetent hosts generally respond very

rapidly and tend to improve in 2-3 days with antiparasitic

therapy [9]. Immunocompromised hosts also respond well,

though less rapidly. However, these individuals relapse at a

high rate once therapy is stopped. Such patients may need

life-long suppressive treatment with TMP-STX. Intravenous

administration of TMP-STX is more effective when the disease

is extraintestinal. Cessation of diarrhea and the disappearance

of C. belli oocysts from stool samples are the endpoints for

monitoring therapy.

Increased susceptibility to bacterial infections is a common

manifestation of MM, arising mainly from a defect in humoral

immunity and associated with major morbidity and mortality

[4,7,10]. The risk is highest in the first three months after

diagnosis and decreases with treatment. Rarely, opportunistic

infections may also be seen mainly in the late period [6,11].

Parasitic infections are very uncommon among MM patients [11].

In MM diarrhea points mainly to infection in acute or chronic

form. Other intestinal or hormonal diseases should be excluded.

AL amyloidosis is a plasma cell disease-related reason. We wish

to attract attention to this rare case of parasitic infection in

MM. To our knowledge, this the first case of a patient with MM

with C. belli infection.

172



Keywords: Cystoisospora belli, Prolonged watery diarrhea,

Multiple myeloma

Anahtar Sözcükler: Cystoisospora belli, Uzamış sulu ishal,

Multipl myelom

Ethics

Informed Consent: Informed consent was obtained.


Surgical and Medical Practices: M.B., A.Y.Y., A.A., A.Ç.Ö., S.K.B.;

Concept: T.O.T., K.U.A., S.K.B.; Design: T.O.T., K.U.A.; Data Collection

or Processing: T.O.T., M.B., A.Y.Y.; Analysis or Interpretation:

S.K.B.; Literature Search: T.O.T., K.U.A.; Writing: T.O.T., K.U.A.


authors.



References

1. Usluca S, Inceboz T, Unek T, Aksoy U. Isospora belli in a patient with liver

transplantation. Turkiye Parazitol Derg 2012;36:247-250.

2. Yazar S, Tokgöz B, Yaman O, Sahin I. Isospora belli infection in a patient

with a renal transplant. Turkiye Parazitol Derg 2006;30:22-24.

3. Dubey JP, Almeria S. Cystoisospora belli infections in humans: the past 100

years. Parasitology 2019;146:1490-1527.

4. Brimnes MK, Svane IM, Johnsen HE. Impaired functionality and phenotypic

profile of dendritic cells from patients with multiple myeloma. Clin Exp

Immunol 2006;144:76-84.

5. Heijink IH, Vellenga E, Borger P, Postma DS, de Monchy JG, Kauffman HF.

Interleukin-6 promotes the production of interleukin-4 and interleukin-5

by interleukin-2-dependent and -independent mechanisms in freshly

isolated human T cells. Immunology 2002;107:316-324.

6. Nucci M, Anaissie E. Infections in patients with multiple myeloma in the era

of high-dose therapy and novel agents. Clin Infect Dis 2009;49:1211-1225.

7. Carbone E, Neri P, Mesuraca M, Fulciniti MT, Otsuki T, Pende D, Groh V, Spies

T, Pollio G, Cosman D, Catalano L, Tassone P, Rotoli B, Venuta S. HLA class I,

NKG2D, and natural cytotoxicity receptors regulate multiple myeloma cell

recognition by natural killer cells. Blood 2005;105:251-258.

8. Ros Die A, Nogueira Coito JM. Isospora belli. Clin Microbiol Infect

2018;24:43-44.

9. Pape JW, Verdier RI, Johnson WD Jr. Treatment and prophylaxis of Isospora

belli infection in patients with the acquired immunodeficiency syndrome. N

Engl J Med 1989;320:1044-1047.

10. Campbell JD, Cook G, Robertson SE, Fraser A, Boyd KS, Gracie JA, Franklin

IM. Suppression of IL-2-induced T cell proliferation and phosphorylation of

STAT3 and STAT5 by tumor-derived TGF beta is reversed by IL-15. J Immunol

2001;167:553-561.

11. Ziogas DC, Terpos E, Gavriatopoulou M, Migkou M, Fotiou D, Roussou M,

Kanellias N, Tatouli I, Eleutherakis-Papaiakovou E, Panagiotidis I, Ntanasis-

Stathopoulos I, Kastritis E, Dimopoulos MA. Coexistence of leishmaniasis

and multiple myeloma in the era of monoclonal antibody (anti-CD38 or

anti-SLAMF7) containing triplets: one shared story of two exceptional

cases. Leuk Lymphoma 2018;59:983-987.



Address for Correspondence/Yazışma Adresi: Tarık Onur Tiryaki, M.D., İstanbul University İstanbul Medical

Faculty, Department of Internal Medicine, Division of Hematology, İstanbul, Turkey

Phone : +90 506 216 86 95

E-mail : tonurtiryaki@gmail.com ORCID: orcid.org/0000-0002-0096-5684

Received/Geliş tarihi: July 19, 2020


DOI: 10.4274/tjh.galenos.2020.2020.0414

Persistent Polyclonal B-Cell Lymphocytosis with Binucleated

Lymphocytes

Çift Çekirdekli Lenfositler ile Karakterize, Kalıcı Poliklonal B-Hücreli Lenfositoz

Berrin Balık Aydın, Yaşa Gül Mutlu, Ömür Gökmen Sevindik

Medipol İstanbul University, Department of Hematology, İstanbul, Turkey

To the Editor,

A 46-year-old female was admitted to our clinic suffering

from long-standing leukocytosis. She was evaluated at another

hospital regarding this lymphocytic leukocytosis (absolute

lymphocyte count: 10770/µL) with no final diagnosis despite

further work-up including bone marrow sampling.

She was a heavy smoker for at least 50 pack-years. We wanted

to reassess the underlying disease and ordered a new complete

blood count and a peripheral blood smear (Figure 1). We noticed

the abundance of binucleated lymphocytes in the peripheral

smear.

Persistent polyclonal B-cell lymphocytosis (PPBL) does not have

a distinctive phenotype. Flow cytometry is performed for the

exclusion of a clonal B lymphoid disorder (Figure 2). The patient

was diagnosed with PPBL according to the further work-up and

was informed about the benign nature of the disease.

173



are commonly negative for CD5, CD10, CD23, and CD38, with a

normal kappa/lambda light chain ratio [2,3]. PPBL often shows

an indolent, stable course over many years or slight progress with

continued smoking, so the diagnosis of PPBL is crucial in order

to avoid unnecessary procedures and therapeutic measures.

Keywords: Lymphocytes, B-cell neoplasms, Lymphoid cell

neoplasms, Other lymphoproliferative disorders

Anahtar Sözcükler: Lenfositler, B-hücreli neoplaziler, Lenfoid

hücre neoplazileri, Diğer lenfoproliferatif hastalıklar

Figure 1. Abundant binucleated lymphocytes with some ghost

cells. May-Grunwald-Giemsa staining, 100 x .

Ethics



Surgical and Medical Practices: B.B.A., Y.G.M., Ö.G.S.; Concept:

B.B.A., Y.G.M., Ö.G.S.; Design: B.B.A., Y.G.M., Ö.G.S.; Data

Collection or Processing: B.B.A., Y.G.M., Ö.G.S.; Analysis or

Interpretation: B.B.A., Y.G.M., Ö.G.S.; Literature Search: B.B.A.,

Y.G.M., Ö.G.S.; Writing: B.B.A., Y.G.M., Ö.G.S.


authors.



Figure 2. Immunophenotypic features of non-clonal B lymphocytes.

PPBL is an infrequent benign disease first described in 1982,

characterized by the abundance of binucleated lymphocytes [1].

The immunophenotype of PPBL shows an expansion of B-cells

that usually express CD19, CD20, CD22, CD27, and CD79b and

References

1. Gordon DS, Jones BM, Browning SW, Spira TJ, Lawrence DN. Persistent

polyclonal lymphocytosis of B lymphocytes. N Engl J Med 1982;307:232-

236.

2. Cornet E, Lesesve JF, Mossafa H, Sébahoun G, Levy V, Davi F, Troussard

X; Groupe Français d’Hématologie Cellulaire (GFHC). Long-term followup

of 111 patients with persistent polyclonal B-cell lymphocytosis with

binucleated lymphocytes. Leukemia 2009;23:419-422.

3. Del Giudice I, Pileri SA, Rossi M, Sabattini E, Campidelli C, Starza ID, De

Propris MS, Mancini F, Perrone MP, Gesuiti P, Armiento D, Quattrocchi L,

Tafuri A, Amendola A, Mauro FR, Guarini A, Foà R. Histopathological and

molecular features of persistent polyclonal B-cell lymphocytosis (PPBL)

with progressive splenomegaly. Br J Haematol 2009;144:726-731.



Address for Correspondence/Yazışma Adresi: Ömür Gökmen Sevindik, Assoc. Prof., M.D., Medipol İstanbul

University, Department of Hematology, istanbul, Turkey

E-mail : ogsevindik@medipol.edu.tr ORCID: orcid.org/0000-0001-9636-4113

Received/Geliş tarihi: January 21, 2021

Accepted/Kabul tarihi: March 10, 2021

DOI: 10.4274/tjh.galenos.2021.2021.0061

174

Advisory Board of This Issue (June 2021)

Barbara J. Bain, United Kingdom

Brenda W. Cooper, USA

Celeste Bento, Portugal

Cristina Papayannidis, Italy

Duran Canatan, Turkey

Fatih Köse, Turkey

Hale Ören, Turkey

İsmet Aydoğdu, Turkey

John M. Bennett, USA

Levent Ümdar, Turkey

Maha Abdulrazak Badawi, Saudi Arabia

Massimo Martino, Italy

Meral Beksaç, Turkey

Mukul Aggarwal, India

Münci Yağcı, Turkey

Mutlu Arat, Turkey

Nelson Leung, USA

Nil Güler, Turkey

Nükhet Tüzüner, Turkey

Olga Meltem Akay, Turkey

Ömür Gökmen Sevindik, Turkey

Ömür Kayıkçı, Turkey

Orhan Sezer, Germany

Özlem Tüfekçi, Turkey

Pervin Topçuoğlu, Turkey

Prasad Mathew, USA

Rabi Hanna, USA

Rauf Haznedar, Turkey

Rezzan Eren Sadioğlu, Turkey

Saime Paydaş, Turkey

Şebnem İzmir Güner, Turkey

Seval Akpınar, Turkey

Tayfur Toptaş, Turkey

Veysel Sabri Hançer, Turkey

Yılmaz Ay, Turkey

Zühre Kaya, Turkey

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