12th Congress of the European Hematology ... - Haematologica

1265
POSACONAZOLE THERAPY IN REFRACTORY INVASIVE CANDIDIASIS IN AN AML PATIENT:
A CASE REPORT
M.K. Wennström, C. Wennerås, D. Stockelberg
Sahlgrenska University Hospital, GÖTEBORG, Sweden
Background. The incidence of systemic mycoses has increased, due to
improved survival among patients with impaired immunity. The mortality
rates associated with invasive fungal infections is high, in part
because, the diagnostics of these infections are difficult which leads to
treatment delay. Although there is an increasing range of antimycotic
drugs available, there are problems with tolerability and limited knowledge
regarding effectivity of combination therapy. Aim. We report the
case of a 27 year old man with AML t(8;21), thus a favourable risk group
of AML, who after final consolidation chemotherapy was diagnosed
with invasive candidiasis of the liver, spleen and kidneys. Case report. In
February 2003 a formerly healthy 27 year old man presented at our clinic
with AML t(8;21), which was treated according to local guidelines.
Complete remission was obtained after induction therapy. Prophylactic
fluconazole was given orally during induction and first consolidation
therapy. After final consolidation treatment, the patient developed a
severe neutropenia and persistent fever. Candida albicans was isolated
from mouth swabs and faeces. CT scans showed multiple, rounded infiltrates
in the spleen, liver and kidneys. Collectively, these findings led to
the diagnosis of probable fungal infection. The patient was initially treated
with liposomal amphotericin B for a month, then switched to
voriconazole orally for four months, with the addition of caspofungin
during the last month. Despite six months of antifungal treatment, the
patient had persistant fever and increased levels of C-reactive protein.
Hence a diagnostic splenectomy was performed which confirmed an
invasive Candida albicans infection by immunohistology and Candida
PCR of the splenic tissue. However, since viable Candida was not isolated,
antimycotic resistance determination could not be done. During
the coming eleven months, different combinations of voriconazole,
caspofungin, itraconazole, fluconazole, liposomal amphotericin B and
micafungin had no or minimal effect on the infection; C-reactive protein
levels remained high and fever persisted. The patient experienced side
effects of the drugs such as neuropathy and severe hypokalemia. After
seventeen months of treatment attempts with various antifungals the
infection was still not under control. A new azole, posaconazole became
available and was introduced. There was a prompt effect on the fever
and the levels of C-reactive protein. Control CT scan three months later
showed a discrete regression of the infiltrates in the liver. After six
months of posaconazole the patient started to work part time. Followup
CT scans and PET scans showed successive clearing of infiltrates.
After nineteen months of posaconazole, the treatment could be discontinued.
It is now four years after AML diagnosis, and seven months after
fungal treatment was terminated, and the patient works full time. Summary.
Invasive fungal infection is a diagnostic and therapeutic dilemma
for the haematologist. In this case the candida infection was diagnosed
by splenectomy. Clinically resistant to several antifungal drugs, finally
the new azole posaconazole resolved the infection of this patient.
1266
CYTOKINETIC STUDIES IN MULTIPLE MYELOMA: PROLIFERATION AND APOPTOSIS
IN EARLY RESPONDERS
J. Minarik, V. Scudla, M. Ordeltova, J. Bacovsky, M. Zemanova,
D. Jackuliakova, T. Pika
Faculty Hospital Olomouc, OLOMOUC, Czech Republic
Background. Proliferative (propidium-iodide, PC-PI/CD138) and apoptotic
(annexin-V, PC-AI/CD138) indices have a very close relation to
prognosis of multiple myeloma. High levels of proliferation and/or low
values of apoptosis predict groups of patients with poor prognosis. In our
study, we examined these cytokinetic parameters also within the group
of early responders, that is considered being a prognostically
infavourable group itself. Methods. Analysed group consists of 125
patients with multiple myeloma, all evaluated at the time of diagnosis,
before the start of therapy, devided into two subgroups-late responders
(90 patients, 72%) and early responders (35 patients, 28%). Early
response was interpreted as objective response within one month of
therapy (i.e. CR and PR according to EBMT criteria-decrease of MIG
more than 50%, more than 90% decrease of proteinuria). Therapy regimens
used included only conventional chemotherapy (regimens MP,
VBMCP,VAD, CyVAD and CIDEX), patients treated with HD therapy
with the support of autologous stem cell transplantation and patients
12 th Congress of the European Hematology Association
treated with novel agents (thalidomide, bortezomib) were not included
in this group. Within the subgroup of early responders, curves of overall
survival were constructed according to different values of proliferative
and apoptotic indices. Proliferative activity of plasma cells was measured
using propidium iodide index (PC-PI /CD138), rate of apoptosis
using annexin-V index (PC-AI/CD138), followed by method of flowcytometry
(DNA-Prep Reagents Kit, Coulter, Software Multicycle fy.
Phoenix). For statistical estimation non-parametric Mann-Whitney test,
Kaplan-Meier and log rank test were used. Results. In the whole group
of patients, there was a very small difference in curves of overall survival
(OS) in both of the groups (early and late responders), favorising slightly
the late responders, however without statistical significance (p=0,291).
If we compared the levels of propidium-iodide (proliferative) index in
both these groups, there was no difference, either (p=0,733). There was
a difference between the values of apoptotic index, with higher levels
of apoptosis within the group of early responders, on the border of statistical
significance (M 4,8-4,3, p=0,061). In the subgroup of early responders,
the OS regarding the levels of both, the proliferative and apoptotic
indices was not significantly different. Conclusions. Evaluation of cytokinetic
parameters (proliferation and apoptosis) is a useful method for
determination of prognosis in multiple myeloma patients. High levels of
apoptosis itself (but not proliferation) may moreover identify a group of
patients with early response. These observations suggest a possible relation
of apoptosis levels to the sensitivity of multiple myeloma to therapy.
Within the evaluated group, there was no significant difference in the
overall survival in late and early responders, and also the evaluation of
proliferation and apoptosis within this group only, did not bring any
further prognostic information.
Founded by MSM 6198959205.
1267
APOPTOSIS RELATED PROTEINS PATTERNS IN MYELODYSPLASTIC SYNDROMES
STRATIFIED ACCORDING TO INTERNATIONAL PROGNOSTIC SCORING SYSTEM (IPSS)
AND COMPARED TO ACUTE MYELOID LEUKAEMIA
R. Nikolova, G. Balatzenko, I. Amin, A. Stoimenov, M. Guenova
National Centre of Hematology, SOFIA, Bulgaria
Introduction. The myelodysplastic syndromes (MDS) are clonal stem
cell disorders characterized by an increased risk of leukemic transformation.
The excessive apoptosis of progenitor cells contributes to the ineffective
haematopoiesis in MDS whereas leukemic progression arises
through abrogation of apoptotic control, allowing long survival and
expansion of neoplastic clones. The outcome and transformation risk of
MDS is currently defined by the International Prognostic Scoring System
(IPSS). Whether a correlation exists between key apoptosis proteins with
IPSS of MDS and leukaemia development is undetermined. The aim of
the present study was to evaluate the intracellular quantity of proteins
with key role in apoptosis - active Caspase-3, bcl-2 and cleaved PARP, in
patients with MDS in correlation with IPSS score and to compare data
with acute myeloid leukemia (AML) samples. Patients and Methods. Cell
lysates from bone marrow were analyzed in 36 patients: 15 patients
with MDS [Refractory anemia (n=1), Refractory anemia with ringed
sideroblasts (n=4), Refractory cytopenia with/without trilineage dysplasia
(n=4), Refractory anemia with excess of blasts, RAEB (n=6)] and 21
patients with AML, diagnosed and subclassified according to WHO criteria.
IPSS for MDS patients was determined. The levels of aCaspase-3,
bcl-2 and cPARP were measured by flow cytometry using a CBA-based
platform (BD, USA). The expression of MLF1 gene was defined by RT-
PCR. Results. Flow cytometric data showed heterogeneous patterns of
intracellular levels of the studied proteins in MDS patients. The mean
values for aCaspase-3 (115,74±189,02 U/mL) and bcl-2 (984,88±932.50
U/mL), showed a significant correlation with cPARPs (24,59±29.97
U/mL) (R=0,67, p=0.006 and R=0,53, p=0.04, respectively). The patients
were stratified according to IPSS. Four low risk (LR), 5 intermediate risk
(IR)-1, 3 IR-2 and 3 high risk (HR) patients were identified. Analysis
revealed marked differences in the mean values of the parameters when
LR patients were compared to IR/HR. LR patients were characterized
with lower levels of aCaspase-3 (38,45±57,69 U/mL); cPARPs
(14,20±19,94 U/mL), and bcl-2 (453,62±381,47 U/mL), while in IR/HR
patients higher caspase activity (143,85±213,92 U/mL) and cPARPs
(28,37±32,84 U/mL), in parallel with the activation of anti-apoptotic
mechanisms: bcl-2 (1178,07±1009,85 U/mL), were observed. In comparison,
AML patients showed significant increase of bcl-2 levels
(3140,94±1998 U/mL), which inversely correlated with lower aCaspase
(29,31±48,30 U/mL) (R=-0,42, p=0.01) with comparable levels of cPARPs
(30,80±30,65 U/mL). A group of patients with AML/multilineage dysplasia
and bone marrow blast cells