Turkish Journal of Hematology Volume: 33 - Issue: 4
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<strong>Volume</strong> <strong>33</strong> <strong>Issue</strong> 4 December 2016 80 TL<br />
ISSN 1300-7777<br />
Research Articles<br />
Prognostic Factors and a New Prognostic Index Model for Children and Adolescents with Hodgkin’s Lymphoma<br />
Who Underwent Autologous Hematopoietic Stem Cell Transplantation: A Multicenter Study <strong>of</strong> the <strong>Turkish</strong> Pediatric<br />
Bone Marrow Transplantation Study Group<br />
Vural Kesik, et al.; Ankara, Kayseri, İzmir, İstanbul, Antalya, Samsun, Turkey<br />
The Role <strong>of</strong> Azacitidine in the Treatment <strong>of</strong> Elderly Patients with Acute Myeloid Leukemia: Results <strong>of</strong> a Retrospective<br />
Multicenter Study <br />
Anıl Tombak, et al.; Mersin, Eskişehir, Ankara, Adana, İzmir, Erzurum, Malatya, İstanbul, Kocaeli, Aydın, Denizli,<br />
Kayseri, Antalya, Düzce, Turkey<br />
The Prognosis <strong>of</strong> Adult Burkitt’s Cell Leukemia in Real-Life Clinical Practice<br />
Ümit Yavuz Malkan, et al.; Ankara, Turkey<br />
Expression Pr<strong>of</strong>iles <strong>of</strong> the Individual Genes Corresponding to the Genes Generated by Cytotoxicity Experiments<br />
with Bortezomib in Multiple Myeloma<br />
Mehdi Ghasemi, et al.; Ankara, Turkey<br />
The Effect <strong>of</strong> Hyperparathyroid State on Platelet Functions and Bone Loss<br />
Göknur Yorulmaz, et al.; Eskişehir, Turkey<br />
Warfarin Dosing and Time Required to Reach Therapeutic International Normalized Ratio in Patients with<br />
Hypercoagulable Conditions<br />
Pushpinderdeep Kahlon, et al.; Detroit, USA; Doha, Qatar; Multan, Pakistan<br />
Early Changes <strong>of</strong> Mannose-Binding Lectin, H-Ficolin, and Procalcitonin in Patients with Febrile Neutropenia: A<br />
Prospective Observational Study<br />
Sibel Işlak Mutcalı, et al.; İstanbul, Turkey<br />
Prospective Evaluation <strong>of</strong> Infection Episodes in Cancer Patients in a Tertiary Care Academic Center: Microbiological<br />
Features and Risk Factors for Mortality<br />
Nursel Çalık Başaran, et al.; Ankara, Turkey<br />
Effect <strong>of</strong> Hereditary Hemochromatosis Gene H63D and C282Y Mutations on Iron Overload in Sickle Cell Disease<br />
Patients<br />
Yunus Kasım Terzi, et al.; Ankara, Turkey<br />
Health-Related Quality <strong>of</strong> Life, Depression, Anxiety, and Self-Image in Acute Lymphocytic Leukemia Survivors<br />
Birol Baytan, et al.; Bursa, Turkey<br />
Cover Picture:<br />
Sunset, Lake Bafa<br />
Erden Atilla<br />
4
Editor-in-Chief<br />
Reyhan Küçükkaya<br />
İstanbul, Turkey<br />
Associate Editors<br />
Ayşegül Ünüvar<br />
İstanbul University, İstanbul, Turkey<br />
Cengiz Beyan<br />
TOBB University <strong>of</strong> Economics and<br />
Technology, Ankara, Turkey<br />
Hale Ören<br />
Dokuz Eylül University, İzmir, Turkey<br />
İbrahim C. Haznedaroğlu<br />
Hacettepe University, Ankara, Turkey<br />
M. Cem Ar<br />
İstanbul University Cerrahpaşa Faculty <strong>of</strong><br />
Medicine, İstanbul, Turkey<br />
Selami Koçak Toprak<br />
Ankara University, Ankara, Turkey<br />
Semra Paydaş<br />
Çukurova University, Adana, Turkey<br />
Assistant Editors<br />
A. Emre Eşkazan<br />
İstanbul University Cerrahpaşa Faculty <strong>of</strong><br />
Medicine, İstanbul, Turkey<br />
Ali İrfan Emre Tekgündüz<br />
Dr. A. Yurtaslan Ankara Oncology Training<br />
and Research Hospital, Ankara, Turkey<br />
Elif Ünal İnce<br />
Ankara University, Ankara, Turkey<br />
İnci Alacacıoğlu<br />
Dokuz Eylül University, İzmir, Turkey<br />
Müge Sayitoğlu<br />
İstanbul University, İstanbul, Turkey<br />
Nil Güler<br />
Ondokuz Mayıs University, Samsun, Turkey<br />
Olga Meltem Akay<br />
Koç University, İstanbul, Turkey<br />
Şule Ünal<br />
Hacettepe University, Ankara, Turkey<br />
Veysel Sabri Hançer<br />
İstanbul Bilim University, İstanbul, Turkey<br />
Zühre Kaya<br />
Gazi University, Ankara, Turkey<br />
International Review Board<br />
Nejat Akar<br />
Görgün Akpek<br />
Serhan Alkan<br />
Çiğdem Altay<br />
Koen van Besien<br />
Ayhan Çavdar<br />
M. Sıraç Dilber<br />
Ahmet Doğan<br />
Peter Dreger<br />
Thierry Facon<br />
Jawed Fareed<br />
Gösta Gahrton<br />
Dieter Hoelzer<br />
Marilyn Manco-Johnson<br />
Andreas Josting<br />
Emin Kansu<br />
Winfried Kern<br />
Nigel Key<br />
Korgün Koral<br />
Abdullah Kutlar<br />
Luca Malcovati<br />
Robert Marcus<br />
Jean Pierre Marie<br />
Ghulam Mufti<br />
Gerassimos A. Pangalis<br />
Antonio Piga<br />
Ananda Prasad<br />
Jacob M. Rowe<br />
Jens-Ulrich Rüffer<br />
Norbert Schmitz<br />
Orhan Sezer<br />
Anna Sureda<br />
Ayalew Tefferi<br />
Nükhet Tüzüner<br />
Catherine Verfaillie<br />
Srdan Verstovsek<br />
Claudio Viscoli<br />
Past Editors<br />
Erich Frank<br />
Orhan Ulutin<br />
Hamdi Akan<br />
Aytemiz Gürgey<br />
Senior Advisory Board<br />
Yücel Tangün<br />
Osman İlhan<br />
Muhit Özcan<br />
Teoman Soysal<br />
TOBB Economy Technical University Hospital, Ankara, Turkey<br />
Maryland School <strong>of</strong> Medicine, Baltimore, USA<br />
Cedars-Sinai Medical Center, USA<br />
Ankara, Turkey<br />
Chicago Medical Center University, Chicago, USA<br />
Ankara, Turkey<br />
Karolinska University, Stockholm, Sweden<br />
Mayo Clinic Saint Marys Hospital, USA<br />
Heidelberg University, Heidelberg, Germany<br />
Lille University, Lille, France<br />
Loyola University, Maywood, USA<br />
Karolinska University Hospital, Stockholm, Sweden<br />
Frankfurt University, Frankfurt, Germany<br />
Colorado Health Sciences University, USA<br />
University Hospital Cologne, Cologne, Germany<br />
Hacettepe University, Ankara, Turkey<br />
Albert Ludwigs University, Germany<br />
University <strong>of</strong> North Carolina School <strong>of</strong> Medicine, NC, USA<br />
Southwestern Medical Center, Texas, USA<br />
Georgia Health Sciences University, Augusta, USA<br />
Pavia Medical School University, Pavia, Italy<br />
Kings College Hospital, London, UK<br />
Pierre et Marie Curie University, Paris, France<br />
King’s Hospital, London, UK<br />
Athens University, Athens, Greece<br />
Torino University, Torino, Italy<br />
Wayne State University School <strong>of</strong> Medicine, Detroit, USA<br />
Rambam Medical Center, Haifa, Israel<br />
University <strong>of</strong> Köln, Germany<br />
AK St Georg, Hamburg, Germany<br />
Memorial Şişli Hospital, İstanbul, Turkey<br />
Santa Creu i Sant Pau Hospital, Barcelona, Spain<br />
Mayo Clinic, Rochester, Minnesota, USA<br />
İstanbul Cerrahpaşa University, İstanbul, Turkey<br />
University <strong>of</strong> Minnesota, Minnesota, USA<br />
The University <strong>of</strong> Texas MD Anderson Cancer Center, Houston, USA<br />
San Martino University, Genoa, Italy<br />
Language Editor<br />
Leslie Demir<br />
Statistic Editor<br />
Hülya Ellidokuz<br />
Editorial Office<br />
İpek Durusu<br />
Bengü Timoçin<br />
A-I<br />
Publishing<br />
Services<br />
GALENOS PUBLISHER<br />
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Phone: +90 212 621 99 25 • Fax: +90 212 621 99 27 • www. galenos.com.tr
Contact Information<br />
Editorial Correspondence should be addressed to Dr. Reyhan Küçükkaya<br />
E-mail : rkucukkaya@hotmail.com<br />
All Inquiries Should be Addressed to<br />
TURKISH JOURNAL OF HEMATOLOGY<br />
Address : İlkbahar Mahallesi, Turan Güneş Bulvarı 613. Sk. No:8 06550 Çankaya, Ankara / Turkey<br />
Phone : +90 312 490 98 97<br />
Fax : +90 312 490 98 68<br />
E-mail : info@tjh.com.tr<br />
ISSN: 1300-7777<br />
Publishing Manager<br />
Sorumlu Yazı İşleri Müdürü<br />
Güner Hayri Özsan<br />
Management Address<br />
Yayın İdare Adresi<br />
Türk Hematoloji Derneği<br />
İlkbahar Mahallesi, Turan Güneş Bulvarı 613. Sk.<br />
No: 8 06550 Çankaya, Ankara / Turkey<br />
Online Manuscript Submission<br />
http://mc.manuscriptcentral.com/tjh<br />
Web page<br />
www.tjh.com.tr<br />
Owner on behalf <strong>of</strong> the <strong>Turkish</strong> Society <strong>of</strong> <strong>Hematology</strong><br />
Türk Hematoloji Derneği adına yayın sahibi<br />
Ahmet Muzaffer Demir<br />
Üç ayda bir yayımlanan İngilizce süreli yayındır.<br />
International scientific journal published quarterly.<br />
Publishing House / Yayınevi<br />
Molla Gürani Mah. Kaçamak Sk. No: 21, 34093<br />
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Printing Date / Basım Tarihi<br />
30.11.2016<br />
Cover Picture<br />
Erden Atilla is currently working at the Ankara University Department <strong>of</strong><br />
<strong>Hematology</strong>, Ankara, Turkey.<br />
Türk Hematoloji Derneği, 07.10.2008 tarihli ve 6 no’lu kararı ile <strong>Turkish</strong><br />
<strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong>’nin Türk Hematoloji Derneği İktisadi İşletmesi<br />
tarafından yayınlanmasına karar vermiştir.<br />
A-II
AIMS AND SCOPE<br />
The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong> is published quarterly (March, June,<br />
September, and December) by the <strong>Turkish</strong> Society <strong>of</strong> <strong>Hematology</strong>. It is an<br />
independent, non-pr<strong>of</strong>it peer-reviewed international English-language<br />
periodical encompassing subjects relevant to hematology.<br />
The Editorial Board <strong>of</strong> The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong> adheres to<br />
the principles <strong>of</strong> the World Association <strong>of</strong> Medical Editors (WAME),<br />
International Council <strong>of</strong> Medical <strong>Journal</strong> Editors (ICMJE), Committee on<br />
Publication Ethics (COPE), Consolidated Standards <strong>of</strong> Reporting Trials<br />
(CONSORT) and Strengthening the Reporting <strong>of</strong> Observational Studies in<br />
Epidemiology (STROBE).<br />
The aim <strong>of</strong> The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong> is to publish original<br />
hematological research <strong>of</strong> the highest scientific quality and clinical<br />
relevance. Additionally, educational material, reviews on basic<br />
developments, editorial short notes, images in hematology, and letters<br />
from hematology specialists and clinicians covering their experience and<br />
comments on hematology and related medical fields as well as social<br />
subjects are published. As <strong>of</strong> December 2015, The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong><br />
<strong>Hematology</strong> does not accept case reports. Important new findings or data<br />
about interesting hematological cases may be submitted as a brief report.<br />
General practitioners interested in hematology and internal medicine<br />
specialists are among our target audience, and The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong><br />
<strong>Hematology</strong> aims to publish according to their needs. The <strong>Turkish</strong> <strong>Journal</strong><br />
<strong>of</strong> <strong>Hematology</strong> is indexed, as follows:<br />
- PubMed Medline<br />
- PubMed Central<br />
- Science Citation Index Expanded<br />
- EMBASE<br />
- Scopus<br />
- CINAHL<br />
- Gale/Cengage Learning<br />
- EBSCO<br />
- DOAJ<br />
- ProQuest<br />
- Index Copernicus<br />
- Tübitak/Ulakbim <strong>Turkish</strong> Medical Database<br />
- Turk Medline<br />
Impact Factor: 0.827<br />
Subscription Information<br />
The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong> is sent free-<strong>of</strong>-charge to members<br />
<strong>of</strong> <strong>Turkish</strong> Society <strong>of</strong> <strong>Hematology</strong> and libraries in Turkey and abroad.<br />
Hematologists, other medical specialists that are interested in hematology,<br />
and academicians could subscribe for only 40 $ per printed issue. All<br />
published volumes are available in full text free-<strong>of</strong>-charge online at www.<br />
tjh.com.tr.<br />
Address: İlkbahar Mah., Turan Güneş Bulvarı, 613 Sok., No: 8, Çankaya,<br />
Ankara, Turkey<br />
Telephone: +90 312 490 98 97<br />
Fax: +90 312 490 98 68<br />
Online Manuscript Submission: http://mc.manuscriptcentral.com/tjh<br />
Web page: www.tjh.com.tr<br />
E-mail: info@tjh.com.tr<br />
Permissions<br />
Requests for permission to reproduce published material should be sent to<br />
the editorial <strong>of</strong>fice.<br />
Editor: Pr<strong>of</strong>essor Dr. Reyhan Küçükkaya<br />
Adress: İlkbahar Mah, Turan Günes Bulvarı, 613 Sok., No: 8, Çankaya,<br />
Ankara, Turkey<br />
Telephone: +90 312 490 98 97<br />
Fax: +90 312 490 98 68<br />
Online Manuscript Submission: http://mc.manuscriptcentral.com/tjh<br />
Web page: www.tjh.com.tr<br />
E-mail: info@tjh.com.tr<br />
Publisher<br />
Galenos Yayınevi<br />
Molla Gürani Mah. Kaçamak Sk. No:21 34093 Fındıkzade-İstanbul, Turkey<br />
Telephone : +90 212 621 99 25<br />
Fax : +90 212 621 99 27<br />
info@galenos.com.tr<br />
Instructions for Authors<br />
Instructions for authors are published in the journal and at www.tjh.com.tr<br />
Material Disclaimer<br />
Authors are responsible for the manuscripts they publish in The <strong>Turkish</strong><br />
<strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong>. The editor, editorial board, and publisher do not<br />
accept any responsibility for published manuscripts.<br />
If you use a table or figure (or some data in a table or figure) from another<br />
source, cite the source directly in the figure or table legend.<br />
The journal is printed on acid-free paper.<br />
Editorial Policy<br />
Following receipt <strong>of</strong> each manuscript, a checklist is completed by the<br />
Editorial Assistant. The Editorial Assistant checks that each manuscript<br />
contains all required components and adheres to the author guidelines,<br />
after which time it will be forwarded to the Editor in Chief. Following the<br />
Editor in Chief’s evaluation, each manuscript is forwarded to the Associate<br />
Editor, who in turn assigns reviewers. Generally, all manuscripts will be<br />
reviewed by at least three reviewers selected by the Associate Editor, based<br />
on their relevant expertise. Associate editor could be assigned as a reviewer<br />
along with the reviewers. After the reviewing process, all manuscripts are<br />
evaluated in the Editorial Board Meeting.<br />
<strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong>’s editor and Editorial Board members are<br />
active researchers. It is possible that they would desire to submit their<br />
manuscript to the <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong>. This may be creating<br />
a conflict <strong>of</strong> interest. These manuscripts will not be evaluated by the<br />
submitting editor(s). The review process will be managed and decisions<br />
made by editor-in-chief who will act independently. In some situation, this<br />
process will be overseen by an outside independent expert in reviewing<br />
submissions from editors.<br />
A-III
TURKISH JOURNAL OF HEMATOLOGY<br />
INSTRUCTIONS TO AUTHORS<br />
The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong> accepts invited review articles, research<br />
articles, brief reports, letters to the editor, and hematological images that<br />
are relevant to the scope <strong>of</strong> hematology, on the condition that they have<br />
not been previously published elsewhere. Basic science manuscripts, such<br />
as randomized, cohort, cross-sectional, and case control studies, are given<br />
preference. All manuscripts are subject to editorial revision to ensure they<br />
conform to the style adopted by the journal. There is a double blind kind<br />
<strong>of</strong> reviewing system. Review articles are solicited by the Editor in Chief.<br />
Authors wishing to submit an unsolicited. Review Article should contact<br />
the Editor in Chief prior to submission in order to screen the proposed<br />
topic for relevance and priority.<br />
Manuscripts should be prepared according to ICMJE guidelines (http://<br />
www.icmje.org/). Original manuscripts require a structured abstract. Label<br />
each section <strong>of</strong> the structured abstract with the appropriate subheading<br />
(Objective, Materials and Methods, Results, and Conclusion). Letters to<br />
the editor do not require an abstract. Research or project support should<br />
be acknowledged as a footnote on the title page. Technical and other<br />
assistance should be provided on the title page.<br />
Original Manuscripts<br />
Title Page<br />
Title: The title should provide important information regarding the<br />
manuscript’s content. The title must specify that the study is a cohort<br />
study, cross-sectional study, case control study, or randomized study (i.e.<br />
Cao GY, Li KX, Jin PF, Yue XY, Yang C, Hu X. Comparative bioavailability<br />
<strong>of</strong> ferrous succinate tablet formulations without correction for baseline<br />
circadian changes in iron concentration in healthy Chinese male subjects:<br />
A single-dose, randomized, 2-period crossover study. Clin Ther. 2011; <strong>33</strong>:<br />
2054-2059).<br />
The title page should include the authors’ names, degrees, and institutional/<br />
pr<strong>of</strong>essional affiliations, a short title, abbreviations, keywords, financial<br />
disclosure statement, and conflict <strong>of</strong> interest statement. If a manuscript<br />
includes authors from more than one institution, each author’s name<br />
should be followed by a superscript number that corresponds to their<br />
institution, which is listed separately. Please provide contact information<br />
for the corresponding author, including name, e-mail address, and<br />
telephone and fax numbers.<br />
Running Head: The running head should not be more than 40 characters,<br />
including spaces, and should be located at the bottom <strong>of</strong> the title page.<br />
Word Count: A word count for the manuscript, excluding abstract,<br />
acknowledgments, figure and table legends, and references, should be<br />
provided not exceed 2500 words. The word count for an abstract should<br />
be not exceed 300 words.<br />
Conflict-<strong>of</strong>-Interest Statement: To prevent potential conflicts <strong>of</strong><br />
interest from being overlooked, this statement must be included in each<br />
manuscript. In case there are conflicts <strong>of</strong> interest, every author should<br />
complete the ICMJE general declaration form, which can be obtained at:<br />
http://www.icmje.org/coi_disclose.pdf.<br />
Abstract and Keywords: The second page should include an abstract<br />
that does not exceed 300 words. For manuscripts sent by authors in<br />
Turkey, a title and abstract in <strong>Turkish</strong> are also required. As most readers<br />
read the abstract first, it is critically important. Moreover, as various<br />
electronic databases integrate only abstracts into their index, important<br />
findings should be presented in the abstract.<br />
Objective: The abstract should state the objective (the purpose <strong>of</strong> the<br />
study and hypothesis) and summarize the rationale for the study.<br />
Materials and Methods: Important methods should be written<br />
respectively.<br />
Results: Important findings and results should be provided here.<br />
Conclusion: The study’s new and important findings should be<br />
highlighted and interpreted.<br />
Other types <strong>of</strong> manuscripts, such as reviews, perspectives, and<br />
editorials, will be published according to uniform requirements.<br />
Provide 3-10 keywords below the abstract to assist indexers. Use<br />
terms from the Index Medicus Medical Subject Headings List<br />
(for randomized studies a CONSORT abstract should be provided (http://<br />
www.consort-statement.org).<br />
Introduction: The introduction should include an overview <strong>of</strong> the<br />
relevant literature presented in summary form (one page), and what ever<br />
remains interesting, unique, problematic, relevant, or unknown about<br />
the topic must be specified. The introduction should conclude with the<br />
rationale for the study, its design, and its objective(s).<br />
Materials and Methods: Clearly describe the selection <strong>of</strong> observational<br />
or experimental participants, such as patients, laboratory animals, and<br />
controls, including inclusion and exclusion criteria and a description <strong>of</strong> the<br />
source population. Identify the methods and procedures in sufficient detail<br />
to allow other researchers to reproduce your results. Provide references<br />
to established methods (including statistical methods), provide references<br />
to brief modified methods, and provide the rationale for using them and<br />
an evaluation <strong>of</strong> their limitations. Identify all drugs and chemicals used,<br />
including generic names, doses, and routes <strong>of</strong> administration. The section<br />
should include only information that was available at the time the plan<br />
or protocol for the study was devised (http://www.strobe-statement.org/<br />
fileadmin/Strobe/uploads/checklists/STROBE_checklist_v4_combined.<br />
pdf).<br />
Statistics: Describe the statistical methods used in enough detail to<br />
enable a knowledgeable reader with access to the original data to verify<br />
the reported results. Statistically important data should be given in the<br />
A-IV
text, tables and figures. Provide details about randomization, describe<br />
treatment complications, provide the number <strong>of</strong> observations, and specify<br />
all computer programs used.<br />
Results: Present your results in logical sequence in the text, tables, and<br />
figures. Do not present all the data provided in the tables and/or figures<br />
in the text; emphasize and/or summarize only important findings, results,<br />
and observations in the text. For clinical studies provide the number <strong>of</strong><br />
samples, cases, and controls included in the study. Discrepancies between<br />
the planned number and obtained number <strong>of</strong> participants should be<br />
explained. Comparisons, and statistically important values (i.e. P value<br />
and confidence interval) should be provided.<br />
Discussion: This section should include a discussion <strong>of</strong> the data. New and<br />
important findings/results, and the conclusions they lead to should be<br />
emphasized. Link the conclusions with the goals <strong>of</strong> the study, but avoid<br />
unqualified statements and conclusions not completely supported by<br />
the data. Do not repeat the findings/results in detail; important findings/<br />
results should be compared with those <strong>of</strong> similar studies in the literature,<br />
along with a summarization. In other words, similarities or differences in<br />
the obtained findings/results with those previously reported should be<br />
discussed.<br />
Study Limitations: Limitations <strong>of</strong> the study should be detailed. In<br />
addition, an evaluation <strong>of</strong> the implications <strong>of</strong> the obtained findings/<br />
results for future research should be outlined.<br />
Conclusion: The conclusion <strong>of</strong> the study should be highlighted.<br />
References<br />
Cite references in the text, tables, and figures with numbers in parentheses.<br />
Number references consecutively according to the order in which they<br />
first appear in the text. <strong>Journal</strong> titles should be abbreviated according to<br />
the style used in Index Medicus (consult List <strong>of</strong> <strong>Journal</strong>s Indexed in Index<br />
Medicus). Include among the references any paper accepted, but not yet<br />
published, designating the journal and followed by, in press.<br />
Examples <strong>of</strong> References:<br />
1. List all authors.<br />
Deeg HJ, O’Donnel M, Tolar J. Optimization <strong>of</strong> conditioning for marrow<br />
transplantation from unrelated donors for patients with aplastic anemia<br />
after failure immunosuppressive therapy. Blood 2006;108:1485-1491.<br />
2. Organization as author<br />
Royal Marsden Hospital Bone Marrow Transplantation Team. Failure <strong>of</strong><br />
syngeneic bone marrow graft without preconditioning in post-hepatitis<br />
marrow aplasia. Lancet 1977;2:742-744.<br />
3. Book<br />
Wintrobe MM. Clinical <strong>Hematology</strong>, 5th ed. Philadelphia, Lea & Febiger,<br />
1961.<br />
4. Book Chapter<br />
Perutz MF. Molecular anatomy and physiology <strong>of</strong> hemoglobin. In:<br />
Steinberg MH, Forget BG, Higs DR, Nagel RI, (eds). Disorders <strong>of</strong> Hemoglobin:<br />
Genetics, Pathophysiology, Clinical Management. New York, Cambridge<br />
University Press, 2000.<br />
5. Abstract<br />
Drachman JG, Griffin JH, Kaushansky K. The c-Mpl ligand (thrombopoietin)<br />
stimulates tyrosine phosphorylation. Blood 1994;84:390a (abstract).<br />
6. Letter to the Editor<br />
Rao PN, Hayworth HR, Carroll AJ, Bowden DW, Pettenati MJ. Further<br />
definition <strong>of</strong> 20q deletion in myeloid leukemia using fluorescence in situ<br />
hybridization. Blood 1994;84:2821-2823.<br />
7. Supplement<br />
Alter BP. Fanconi’s anemia, transplantation, and cancer. Pediatr Transplant.<br />
2005;9(Suppl 7):81-86<br />
Brief Reports<br />
Abstract length: Not to exceed 150 words.<br />
Article length: Not to exceed 1200 words.<br />
Introduction: State the purpose and summarize the rationale for the study.<br />
Materials and Methods: Clearly describe the selection <strong>of</strong> the observational<br />
or experimental participants. Identify the methods and procedures in<br />
sufficient detail. Provide references to established methods (including<br />
statistical methods), provide references to brief modified methods, and<br />
provide the rationale for their use and an evaluation <strong>of</strong> their limitations.<br />
Identify all drugs and chemicals used, including generic names, doses, and<br />
routes <strong>of</strong> administration.<br />
Statistics: Describe the statistical methods used in enough detail to<br />
enable a knowledgeable reader with access to the original data to verify<br />
the reported findings/results. Provide details about randomization,<br />
describe treatment complications, provide the number <strong>of</strong> observations,<br />
and specify all computer programs used.<br />
Results: Present the findings/results in a logical sequence in the text,<br />
tables, and figures. Do not repeat all the findings/results in the tables and<br />
figures in the text; emphasize and/or summarize only those that are most<br />
important.<br />
Discussion: Highlight the new and important findings/results <strong>of</strong> the<br />
study and the conclusions they lead to. Link the conclusions with the<br />
goals <strong>of</strong> the study, but avoid unqualified statements and conclusions not<br />
completely supported by your data.<br />
Invited Review Articles<br />
Abstract length: Not to exceed 300 words.<br />
Article length: Not to exceed 4000 words.<br />
Review articles should not include more than 100 references. Reviews<br />
A-V
should include a conclusion, in which a new hypothesis or study about the<br />
subject may be posited. Do not publish methods for literature search or<br />
level <strong>of</strong> evidence. Authors who will prepare review articles should already<br />
have published research articles on therel evant subject. The study’s new<br />
and important findings should be highlighted and interpreted in the<br />
Conclusion section. There should be a maximum <strong>of</strong> two authors for review<br />
articles.<br />
Images in <strong>Hematology</strong><br />
Article length: Not exceed 200 words.<br />
Authors can submit for consideration an illustration and photos that is<br />
interesting, instructive, and visually attractive, along with a few lines <strong>of</strong><br />
explanatory text and references. Images in <strong>Hematology</strong> can include no<br />
more than 200 words <strong>of</strong> text, 5 references, and 3 figure or table. No<br />
abstract, discussion or conclusion are required but please include a brief<br />
title.<br />
Letters to the Editor<br />
Article length: Not to exceed 500 words.<br />
Letters can include no more than 500 words <strong>of</strong> text, 5-10 references, and<br />
1 figure or table. No abstract is required, but please include a brief title.<br />
Tables<br />
Supply each table on a separate file. Number tables according to the<br />
order in which they appear in the text, and supply a brief caption for<br />
each. Give each column a short or abbreviated heading. Write explanatory<br />
statistical measures <strong>of</strong> variation, such as standard deviation or standard<br />
error <strong>of</strong> mean. Be sure that each table is cited in the text.<br />
Figures<br />
Figures should be pr<strong>of</strong>essionally drawn and/or photographed. Authors<br />
should number figures according to the order in which they appear in the<br />
text. Figures include graphs, charts, photographs, and illustrations. Each<br />
figure should be accompanied by a legend that does not exceed 50 words.<br />
Use abbreviations only if they have been introduced in the text. Authors<br />
are also required to provide the level <strong>of</strong> magnification for histological<br />
slides. Explain the internal scale and identify the staining method used.<br />
Figures should be submitted as separate files, not in the text file. Highresolution<br />
image files are not preferred for initial submission as the file<br />
sizes may be too large. The total file size <strong>of</strong> the PDF for peer review should<br />
not exceed 5 MB.<br />
Authorship<br />
Each author should have participated sufficiently in the work to assume<br />
public responsibility for the content. Any portion <strong>of</strong> a manuscript that<br />
is critical to its main conclusions must be the responsibility <strong>of</strong> at least<br />
1 author.<br />
Contributor’s Statement<br />
All submissions should contain a contributor’s statement page. Each<br />
manuscript should contain substantial contributions to idea and design,<br />
acquisition <strong>of</strong> data, or analysis and interpretation <strong>of</strong> findings. All persons<br />
designated as an author should qualify for authorship, and all those that<br />
qualify should be listed. Each author should have participated sufficiently<br />
in the work to take responsibility for appropriate portions <strong>of</strong> the text.<br />
Acknowledgments<br />
Acknowledge support received from individuals, organizations, grants,<br />
corporations, and any other source. For work involving a biomedical<br />
product or potential product partially or wholly supported by corporate<br />
funding, a note stating, “This study was financially supported (in part)<br />
with funds provided by (company name) to (authors’ initials)”, must<br />
be included. Grant support, if received, needs to be stated and the<br />
specific granting institutions’ names and grant numbers provided when<br />
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Authors are expected to disclose on the title page any commercial or<br />
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with the submitted manuscript. All funding sources that supported the<br />
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When reporting experiments conducted with humans indicate that<br />
the procedures were in accordance with ethical standards set forth<br />
by the committee that oversees human experimentation. Approval <strong>of</strong><br />
research protocols by the relevant ethics committee, in accordance with<br />
international agreements (Helsinki Declaration <strong>of</strong> 1975, revised 2002<br />
available at http://www.wma.net/e/policy/b3.htm, “Guide for the Care and<br />
use <strong>of</strong> Laboratory Animals” www.nap.edu/catalog/5140.html/), is required<br />
for all experimental, clinical, and drug studies. Patient names, initials,<br />
and hospital identification numbers should not be used. Manuscripts<br />
reporting the results <strong>of</strong> experimental investigations conducted with<br />
humans must state that the study protocol received institutional review<br />
board approval and that the participants provided informed consent.<br />
Non-compliance with scientific accuracy is not in accord with scientific<br />
ethics. Plagiarism: To re-publish-whole or in part-the contents <strong>of</strong><br />
another author’s publication as one’s own without providing a reference.<br />
Fabrication: To publish data and findings/results that do not exist.<br />
Duplication: Use <strong>of</strong> data from another publication, which includes<br />
re-publishing a manuscript in different languages. Salamisation: To<br />
create more than one publication by dividing the results <strong>of</strong> a study<br />
preternaturally.<br />
We disapprove <strong>of</strong> such unethical practices as plagiarism, fabrication,<br />
duplication, and salamisation, as well as efforts to influence the<br />
review process with such practices as gifting authorship, inappropriate<br />
acknowledgements, and references. Additionally, authors must respect<br />
participant right to privacy.<br />
On the other hand, short abstracts published in congress books that do<br />
not exceed 400 words and present data <strong>of</strong> preliminary research, and<br />
A-VI
those that are presented in an electronic environment are not accepted<br />
pre-published work. Authors in such situation must declare this status on<br />
the first page <strong>of</strong> the manuscript and in the cover letter.<br />
(The COPE flowchart is available at: http://publicationethics.org)<br />
We use iThenticate to screen all submissions for plagiarism before<br />
publication.<br />
<strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong> uses plagiarism screening service to verify<br />
the originality <strong>of</strong> content submitted before publication.<br />
Conditions <strong>of</strong> Publication<br />
All authors are required to affirm the following statements before their<br />
manuscript is considered: 1. The manuscript is being submitted only<br />
to The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong>; 2. The manuscript will not be<br />
submitted elsewhere while under consideration by The <strong>Turkish</strong> <strong>Journal</strong><br />
<strong>of</strong> <strong>Hematology</strong>; 3. The manuscript has not been published elsewhere,<br />
and should it be published in The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong> it will<br />
not be published elsewhere without the permission <strong>of</strong> the editors (these<br />
restrictions do not apply to abstracts or to press reports for presentations<br />
at scientific meetings); 4. All authors are responsible for the manuscript’s<br />
content; 5. All authors participated in the study concept and design,<br />
analysis and interpretation <strong>of</strong> the data, drafting or revising <strong>of</strong> the<br />
manuscript, and have approved the manuscript as submitted. In addition,<br />
all authors are required to disclose any pr<strong>of</strong>essional affiliation, financial<br />
agreement, or other involvement with any company whose product<br />
figures prominently in the submitted manuscript.<br />
Authors <strong>of</strong> accepted manuscripts will receive electronic page pro<strong>of</strong>s and<br />
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Copyright<br />
At the time <strong>of</strong> submission all authors will receive instructions for<br />
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All accepted manuscripts become the permanent property <strong>of</strong> The <strong>Turkish</strong><br />
<strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong> and may not be published elsewhere-in whole or<br />
in part-without written permission.<br />
Note: We cannot accept any copyright that has been altered, revised,<br />
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Units <strong>of</strong> Measurement<br />
Measurements should be reported using the metric system, according<br />
to the International System <strong>of</strong> Units (SI). Consult the SI Unit Conversion<br />
Guide, New England <strong>Journal</strong> <strong>of</strong> Medicine Books, 1992.<br />
An extensive list <strong>of</strong> conversion factors can be found at http://www.unc.<br />
edu/~rowlett/units/scales/clinical_data.html. For more details, see http://<br />
www.amamanual<strong>of</strong>style.com/oso/public/jama/si_conversion_table.html.<br />
Example for CBC.<br />
<strong>Hematology</strong> component<br />
SI units<br />
RBC 6.7-11 x 10 12 /L<br />
WBC 5.5-19.5 x10 9 /L<br />
Hemoglobin<br />
PCV<br />
MCV<br />
MCHC<br />
MCH<br />
116-168 g/L<br />
0.31-0.46 L/L<br />
39-53 fL<br />
300-360 g/L<br />
19.5-25 pg<br />
Platelets 300-700 x 10 9 /L<br />
Source: http://www.vetstream.com/felis/Corporate/993fhtm/ha-mat.htm<br />
Abbreviations and Symbols<br />
Use only standard abbreviations. Avoid abbreviations in the title and<br />
abstract. The full term for an abbreviation should precede its first use<br />
in the text, unless it is a standard abbreviation. All acronyms used in the<br />
text should be expanded at first mention, followed by the abbreviation<br />
in parentheses; thereafter the acronym only should appear in the text.<br />
Acronyms may be used in the abstract if they occur 3 or more times<br />
therein, but must be reintroduced in the body <strong>of</strong> the text. Generally,<br />
abbreviations should be limited to those defined in the AMA Manual <strong>of</strong><br />
Style, current edition. A list <strong>of</strong> each abbreviation (and the corresponding<br />
full term) used in the manuscript must be provided on the title page.<br />
Online Manuscript Submission Process<br />
The <strong>Turkish</strong> <strong>Journal</strong> <strong>of</strong> <strong>Hematology</strong> uses submission s<strong>of</strong>tware powered<br />
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A-VII
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The Review Process<br />
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Online Early<br />
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manuscripts online in advance <strong>of</strong> their publication in print. Once an<br />
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Object Identifier (DOI) number. Both forms can be found at www.tjh.<br />
A-VIII
CONTENTS<br />
Research Articles<br />
265 Prognostic Factors and a New Prognostic Index Model for Children and Adolescents with Hodgkin’s Lymphoma Who Underwent<br />
Autologous Hematopoietic Stem Cell Transplantation: A Multicenter Study <strong>of</strong> the <strong>Turkish</strong> Pediatric Bone Marrow Transplantation Study Group<br />
Vural Kesik, Erman Ataş, Musa Karakükcü, Serap Aksoylar, Fatih Erbey, Nurdan Taçyıldız, Alphan Küpesiz, Haldun Öniz,<br />
Ekrem Ünal, Savaş Kansoy, Gülyüz Öztürk, Murat Elli, Zühre Kaya, Emel Ünal, Volkan Hazar, Şebnem Yılmaz Bengoa,<br />
Gülsün Karasu, Didem Atay, Ayhan Dağdemir, Hale Ören, Ülker Koçak, M. Akif Yeşilipek<br />
273 The Role <strong>of</strong> Azacitidine in the Treatment <strong>of</strong> Elderly Patients with Acute Myeloid Leukemia: Results <strong>of</strong> a Retrospective Multicenter Study<br />
Anıl Tombak, Mehmet Ali Uçar, Aydan Akdeniz, Eyüp Naci Tiftik, Deniz Gören Şahin, Olga Meltem Akay, Murat Yıldırım,<br />
Oral Nevruz, Cem Kis, Emel Gürkan, Şerife Medeni Solmaz, Mehmet Ali Özcan, Rahşan Yıldırım, İlhami Berber, Mehmet Ali Erkurt,<br />
Tülin Fıratlı Tuğlular, Pınar Tarkun, İrfan Yavaşoğlu, Mehmet Hilmi Doğu, İsmail Sarı, Mustafa Merter, Muhit Özcan,<br />
Esra Yıldızhan, Leylagül Kaynar, Özgür Mehtap, Ayşe Uysal, Fahri Şahin, Ozan Salim, Mehmet Ali Sungur<br />
281 The Prognosis <strong>of</strong> Adult Burkitt’s Cell Leukemia in Real-Life Clinical Practice<br />
Ümit Yavuz Malkan, Gürsel Güneş, Hakan Göker, İbrahim C. Haznedaroğlu, Kadir Acar, Eylem Eliaçık, Sezgin Etgül, Tuncay Aslan,<br />
Seda Balaban, Haluk Demiroğlu, Osman I. Özcebe, Nilgün Sayınalp, Salih Aksu, Yahya Büyükaşık<br />
286 Expression Pr<strong>of</strong>iles <strong>of</strong> the Individual Genes Corresponding to the Genes Generated by Cytotoxicity Experiments with Bortezomib in<br />
Multiple Myeloma<br />
Mehdi Ghasemi, Semih Alpsoy, Seyhan Türk, Ümit Y. Malkan, Şükrü Atakan, İbrahim C. Haznedaroğlu, Gürsel Güneş,<br />
Mehmet Gündüz, Burak Yılmaz, Sezgin Etgül, Seda Aydın, Tuncay Aslan, Nilgün Sayınalp, Salih Aksu, Haluk Demiroğlu,<br />
Osman İ. Özcebe, Yahya Büyükaşık, Hakan Göker<br />
293 The Effect <strong>of</strong> Hyperparathyroid State on Platelet Functions and Bone Loss<br />
Göknur Yorulmaz, Ayşen Akalın, Olga Meltem Akay, Garip Şahin, Cengiz Bal<br />
299 Warfarin Dosing and Time Required to Reach Therapeutic International Normalized Ratio in Patients with Hypercoagulable Conditions<br />
Pushpinderdeep Kahlon, Shahzaib Nabi, Adeel Arshad, Absia Jabbar, Ali Haythem<br />
304 Early Changes <strong>of</strong> Mannose-Binding Lectin, H-Ficolin, and Procalcitonin in Patients with Febrile Neutropenia: A Prospective Observational Study<br />
Sibel Işlak Mutcalı, Neşe Saltoğlu, İlker İnanç Balkan, Reşat Özaras, Mücahit Yemişen, Bilgül Mete, Fehmi Tabak, Ali Mert,<br />
Recep Öztürk, Seniz Öngören, Zafer Başlar, Yıldız Aydın, Burhan Ferhanoğlu, Teoman Soysal<br />
311 Prospective Evaluation <strong>of</strong> Infection Episodes in Cancer Patients in a Tertiary Care Academic Center: Microbiological Features and<br />
Risk Factors for Mortality<br />
Nursel Çalık Başaran, Ergun Karaağaoğlu, Gülşen Hasçelik, Mine Durusu Tanrıöver, Murat Akova<br />
320 Effect <strong>of</strong> Hereditary Hemochromatosis Gene H63D and C282Y Mutations on Iron Overload in Sickle Cell Disease Patients<br />
Yunus Kasım Terzi, Tuğçe Bulakbaşı Balcı, Can Boğa, Zafer Koç, Zerrin Yılmaz Çelik, Hakan Özdoğu, Sema Karakuş, Feride İffet Şahin<br />
326 Health-Related Quality <strong>of</strong> Life, Depression, Anxiety, and Self-Image in Acute Lymphocytic Leukemia Survivors<br />
Birol Baytan, Çiğdem Aşut, Arzu Çırpan Kantarcıoğlu, Melike Sezgin Evim, Adalet Meral Güneş<br />
Brief Reports<br />
<strong>33</strong>1 Clinical Courses <strong>of</strong> Two Pediatric Patients with Acute Megakaryoblastic Leukemia Harboring the CBFA2T3-GLIS2 Fusion Gene<br />
Mayu Ishibashi, Tomoko Yokosuka, Masakatsu D. Yanagimachi, Fuminori Iwasaki, Shin-ichi Tsujimoto, Koji Sasaki,<br />
Masanobu Takeuchi, Reo Tanoshima, Hiromi Kato, Ryosuke Kajiwara, Fumiko Tanaka, Hiroaki Goto, Shumpei Yokota<br />
A-IX
<strong>33</strong>5 Evaluation <strong>of</strong> Insulin-like Growth Factor-1 and Insulin-like Growth Factor Binding Protein-3 Expression Levels in Patients with Chronic<br />
Lymphocytic Leukemia<br />
Mesut Ayer, Abdullah Sakin, Selim Ay, Aylin Ayer, Elif Gökçen Sazak, Melih Aktan<br />
<strong>33</strong>9 The Frequency <strong>of</strong> HLA-A, HLA-B, and HLA-DRB1 Alleles in Patients with Acute Lymphoblastic Leukemia in the <strong>Turkish</strong> Population:<br />
A Case-Control Study<br />
Türkan Patıroğlu, H. Haluk Akar<br />
346 Varicella-Zoster Virus Infections in Pediatric Malignancy Patients: A Seven-Year Analysis<br />
Mine Düzgöl, Gülcihan Özek, Nuri Bayram, Yeşim Oymak, Ahu Kara, Bengü Demirağ, Tuba Hilkay Karapınar, Yılmaz Ay,<br />
Canan Vergin, İlker Devrim<br />
Images in <strong>Hematology</strong><br />
349 Chediak-Higashi Syndrome in Accelerated Phase Masquerading as Acute Leukemia<br />
Mili Jain, Ashutosh Kumar, Uma Shankar Singh, Rashmi Kushwaha<br />
351 Auer Rod-Like Inclusions in Reactive Plasma Cells in a Case <strong>of</strong> Acute Myeloid Leukemia<br />
Sarita Pradhan<br />
353 Coexistence <strong>of</strong> Chronic Lymphocytic Leukemia and Acute Myeloid Leukemia<br />
Ivana Milosevic<br />
Letters to the Editor<br />
355 Evaluation <strong>of</strong> Knowledge <strong>of</strong> Patients with Hemophilia Regarding Their Diseases and Treatment in Iran<br />
Mehran Karimi, Tahereh Zarei, Sezaneh Haghpanah, Zohreh Zahedi<br />
356 Therapeutic Plasma Exchange Ameliorates Incompatible Crossmatches<br />
Mehmet Özen, Sinan Erkul, Gülen Sezer Alptekin Erkul, Özlem Genç, Engin Akgül, Ahmet Hakan Vural<br />
358 Megaloblastic Anemia with Ring Sideroblasts Is Not Always Myelodysplastic Syndrome<br />
Neha Chopra Narang, Mrinalini Kotru, Kavana Rao, Meera Sikka<br />
360 Annular Erythematous Patches as the Presenting Sign <strong>of</strong> Extranodal Natural Killer/T-Cell Lymphoma<br />
Can Baykal, Algün Polat Ekinci, Şule Öztürk Sarı, Zeynep Topkarcı, Özgür Demir, Nesimi Büyükbabani<br />
362 Presentation <strong>of</strong> Diffuse Large B-Cell Lymphoma Relapse as a Penile Mass<br />
Birgül Öneç, Kürşad Öneç, Ali Ümit Esbah, Onur Esbah<br />
363 Successful Treatment <strong>of</strong> Disseminated Fusariosis with the Combination <strong>of</strong> Voriconazole and Liposomal Amphotericin B<br />
Nur Efe İris, Serkan Güvenç, Tülay Özçelik, Aslıhan Demirel, Safiye Koçulu, Esin Çevik, Mutlu Arat<br />
365 NOS3 27-bp and IL4 70-bp VNTR Polymorphisms Do Not Contribute to the Risk <strong>of</strong> Sickle Cell Crisis<br />
Henu Verma, Hrishikesh Mishra, P. K. Khodiar, P. K. Patra, L. V. K. S. Bhaskar<br />
367 Comment: In Response to “Auer Rod-Like Inclusions in Reactive Plasma Cells in a Case <strong>of</strong> Acute Myeloid Leukemia”<br />
Smeeta Gajendra<br />
368 Reply: “Auer Rod-Like Inclusions in Reactive Plasma Cells in a Case <strong>of</strong> Acute Myeloid Leukemia”<br />
Sarita Pradhan<br />
368 Auer Rods Are Not Seen in Non-Neoplastic Cells<br />
İrfan Yavaşoğlu, Zahit Bolaman<br />
370 Iron and Zinc Treatment in Iron Deficiency<br />
Beuy Joob, Viroj Wiwanitkit<br />
A-X
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6 th International Congress<br />
on<br />
Leukemia Lymphoma Myeloma<br />
May 11 - 13<br />
2017<br />
İSTANBUL<br />
TURKEY<br />
Radison Blu Hotel, Şişli<br />
www.icllm2017.org
RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2015.0280<br />
Turk J Hematol 2016;<strong>33</strong>:265-272<br />
Prognostic Factors and a New Prognostic Index Model for<br />
Children and Adolescents with Hodgkin’s Lymphoma Who<br />
Underwent Autologous Hematopoietic Stem Cell Transplantation:<br />
A Multicenter Study <strong>of</strong> the <strong>Turkish</strong> Pediatric Bone Marrow<br />
Transplantation Study Group<br />
Otolog Hematopoetik Kök Hücre Nakli Uygulanmış Hodgkin Lenfomalı Çocuk ve<br />
Adölesanlarda Prognostik Faktörler ve Yeni Bir Prognostik İndeks Modeli: Türk Pediatrik<br />
Kemik İliği Nakli Çalışma Grubundan Çok Merkezli Çalışma<br />
Vural Kesik 1 , Erman Ataş 1 , Musa Karakükcü 2 , Serap Aksoylar 3 , Fatih Erbey 4 , Nurdan Taçyıldız 5 , Alphan Küpesiz 6 , Haldun Öniz 7 ,<br />
Ekrem Ünal 2 , Savaş Kansoy 3 , Gülyüz Öztürk 4 , Murat Elli 8 , Zühre Kaya 9 , Emel Ünal 5 , Volkan Hazar 6 , Şebnem Yılmaz Bengoa 10 ,<br />
Gülsün Karasu 11 , Didem Atay 4 , Ayhan Dağdemir 8 , Hale Ören 10 , Ülker Koçak 9 , M. Akif Yeşilipek 11<br />
1Gülhane Training and Research Hospital Clinic <strong>of</strong> Pediatric Oncology, Ankara, Turkey<br />
2Erciyes University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatric <strong>Hematology</strong>-Oncology and Bone Marrow Transplantation Unit, Kayseri, Turkey<br />
Öz<br />
3Ege University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatric Oncology and Bone Marrow Transplantation Unit, İzmir, Turkey<br />
4Medical Park Bahçelievler Hospital, Pediatric Bone Marrow Transplantation Unit, İstanbul, Turkey<br />
5Ankara University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatric Oncology and Bone Marrow Transplantation Unit, Ankara, Turkey<br />
6Akdeniz University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatric <strong>Hematology</strong>-Oncology and Bone Marrow Transplantation Unit, Antalya, Turkey<br />
7Tepecik Training and Research Hospital, Clinic <strong>of</strong> Pediatric Oncology and Bone Marrow Transplantation Unit, İzmir, Turkey<br />
8Ondokuz Mayıs University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatric Oncology and Bone Marrow Transplantation Unit, Samsun, Turkey<br />
9Gazi University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatric <strong>Hematology</strong> and Bone Marrow Transplantation Unit, Ankara, Turkey<br />
10Dokuz Eylül University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatric <strong>Hematology</strong> and Bone Marrow Transplantation Unit, İzmir, Turkey<br />
11Medical Park Göztepe Hospital, Pediatric Bone Marrow Transplantation Unit, İstanbul, Turkey<br />
Abstract<br />
Objective: The prognostic factors and a new childhood prognostic<br />
index after autologous hematopoietic stem cell transplantation<br />
(AHSCT) in patients with relapsed/refractory Hodgkin’s lymphoma (HL)<br />
were evaluated.<br />
Materials and Methods: The prognostic factors <strong>of</strong> 61 patients who<br />
underwent AHSCT between January 1990 and December 2014 were<br />
evaluated. In addition, the Age-Adjusted International Prognostic<br />
Index and the Childhood International Prognostic Index (CIPI) were<br />
evaluated for their impact on prognosis.<br />
Results: The median age <strong>of</strong> the 61 patients was 14.8 years (minimummaximum:<br />
5-20 years) at the time <strong>of</strong> AHSCT. There were single<br />
relapses in 28 patients, ≥2 relapses in eight patients, and refractory<br />
disease in 25 patients. The chemosensitivity/chemorefractory ratio<br />
was 36/25. No pretransplant radiotherapy, no remission at the time <strong>of</strong><br />
Öz<br />
Amaç: Relaps/refrakter Hodgkin lenfomanın (HL) otolog hematopoetik<br />
kök hücre nakli (OHKHN) sonrasındaki prognozunu gösterecek<br />
belirteçler ve çocukluk çağında yeni bir prognostik skorlama araştırıldı.<br />
Gereç ve Yöntemler: Bu çalışmada, Ocak 1990-Aralık 2014 tarihleri<br />
arasında OHKHN uygulanan 61 hastanın OHKHN sonrası prognozunu<br />
etkileyen faktörlerin sağkalım üzerine etkisi araştırıldı. Aynı zamanda<br />
Yaşa Göre Düzeltilmiş Uluslararası Prognostik İndeks ve Çocukluk<br />
Dönemi Uluslararası Prognostik İndeks’lerinin (ÇDUPİ) prognoz<br />
üzerindeki etkisi değerlendirildi.<br />
Bulgular: Altmış bir hastanın ortanca yaşı OHKHN sırasında 14,8 yıl<br />
(5-20 yıl) idi. Hastalardan, 28 olguda bir relaps, 8 olguda ≥2 relaps<br />
ve 25 olguda refrakter hastalık vardı. Kemosensitivite/kemoterapiye<br />
dirençlilik oranı 36/25 idi. Nakil öncesi radyoterapi almamak, nakil<br />
öncesi remisyonda olmamak, nakil sonrası beyaz kan hücresi sayısının<br />
Address for Correspondence/Yazışma Adresi: Vural KESİK, M.D.,<br />
Gülhane Training and Research Hospital Clinic <strong>of</strong> Pediatric Oncology, Ankara, Turkey<br />
Phone : +90 312 304 43 94<br />
E-mail : vural73@yahoo.com<br />
Received/Geliş tarihi: July 29, 2015<br />
Accepted/Kabul tarihi: November 02, 2015<br />
265
Kesik V, et al: Prognostic Markers <strong>of</strong> Hodgkin’s Lymphoma after Autologous Hematopoietic Stem Cell Transplantation Turk J Hematol 2016;<strong>33</strong>:265-272<br />
transplantation, posttransplant white blood cell count over 10x10 3 /<br />
µL, posttransplant positron emission tomography positivity at day 100,<br />
and serum albumin <strong>of</strong>
Turk J Hematol 2016;<strong>33</strong>:265-272<br />
Kesik V, et al: Prognostic Markers <strong>of</strong> Hodgkin’s Lymphoma after Autologous Hematopoietic Stem Cell Transplantation<br />
largest deposit being >10 cm or the mediastinum being wider<br />
than one-third <strong>of</strong> the chest on chest X-ray [14].<br />
Time to relapse: Refractory disease was defined as occurring<br />
within 3 months after completion <strong>of</strong> therapy or during therapy.<br />
Early relapse was defined as disease recurring within 3-12<br />
months, and late relapse was defined as disease occurring more<br />
than 12 months from the end <strong>of</strong> therapy [5].<br />
Prognostic Indexes<br />
Karn<strong>of</strong>sky/Lansky a Status<br />
The Karn<strong>of</strong>sky/Lansky performance status is used to determine<br />
the functional status <strong>of</strong> the patient and is essential for all<br />
outcome-based analyses. The Karn<strong>of</strong>sky scale is designed<br />
for patients aged 16 years and older, and the Lansky scale is<br />
designed for those under 16 years. The Karn<strong>of</strong>sky/Lansky scores<br />
range from 100 to 0, with 100 indicating ‘perfect’ health and 0<br />
representing death [15].<br />
Childhood International Prognostic Index<br />
The original AAIPI incorporates serum LDH levels, Eastern<br />
Cooperative Oncology Group (ECOG) performance status, and<br />
Ann Arbor clinical stage at diagnosis. Based on these factors,<br />
patients are divided into four risk groups: 0, low risk; 1, lowintermediate<br />
risk; 2, high-intermediate risk; and 3, high risk [13].<br />
We adapted the AAIPI for children according to an LDH level<br />
<strong>of</strong> 500 IU/L instead <strong>of</strong> 250 IU/L because <strong>of</strong> its high prognostic<br />
predictively in childhood HL, and we used the Cotswold<br />
modification <strong>of</strong> the Ann Arbor clinical stage at diagnosis with<br />
an ECOG modification score according to the pretransplant<br />
Karn<strong>of</strong>sky/Lansky performance score [15] and the Childhood<br />
International Prognostic Index (CIPI).<br />
Types <strong>of</strong> Outcome Measures<br />
The definitions used as survival terms were as follows: 1) overall<br />
survival (OS) was calculated from the start <strong>of</strong> the treatment until<br />
death from any cause; 2) progression-free survival (PFS) was<br />
the achievement <strong>of</strong> stable disease without signs <strong>of</strong> progression,<br />
calculated from the day <strong>of</strong> transplant to the date <strong>of</strong> the next<br />
relapse or from the date <strong>of</strong> randomization for post-complete<br />
remission (CR) questions; and 3) event-free survival (EFS) was<br />
calculated from the date <strong>of</strong> the start <strong>of</strong> treatment to the date<br />
<strong>of</strong> the first event (failure to achieve CR, relapse, or death from<br />
any cause).<br />
Statistical Analysis<br />
Statistical analyses were performed using SPSS 15.0. Descriptive<br />
analyses were presented using medians or mean ± standard<br />
deviation for variables. The Kaplan-Meier method and logrank<br />
tests were used in the analysis. The risk factors described<br />
above were analyzed as prognostic factors for the survival rate<br />
with Cox regression analysis. Variables with values <strong>of</strong> p
Kesik V, et al: Prognostic Markers <strong>of</strong> Hodgkin’s Lymphoma after Autologous Hematopoietic Stem Cell Transplantation<br />
Turk J Hematol 2016;<strong>33</strong>:265-272<br />
Table 1. Demographic, clinical, and histopathological<br />
features <strong>of</strong> the patients with relapsed refractory Hodgkin’s<br />
lymphoma.<br />
Features Number %<br />
Sex<br />
Male 40 65.6<br />
Female 21 34.4<br />
Age (years)<br />
5-10 5 8.2<br />
11-15 26 42.6<br />
>15 30 49.2<br />
Subtype <strong>of</strong> Hodgkin’s lymphoma<br />
Lymphocyte-rich 3 4.9<br />
Nodular sclerosis 32 52.5<br />
Mixed cellularity 23 37.7<br />
Unclassified 3 4.9<br />
Primary localization<br />
Cervical 24 39.3<br />
Mediastinal 24 39.3<br />
Abdominal 9 14.8<br />
Inguinal 3 4.9<br />
Bone 1 1.6<br />
Other features and involvements<br />
Bulky tumor 21 34.4<br />
Extranodal 27 44.3<br />
Spleen <strong>33</strong> 54.1<br />
Bone 12 19.7<br />
Bone marrow 1 1.6<br />
Stage<br />
I 9 14.7<br />
II 12 19.7<br />
III 10 16.4<br />
IV 30 49.2<br />
Response to chemotherapy<br />
Chemosensitive 36 59.1<br />
Chemorefractory 25 40.9<br />
Type <strong>of</strong> relapse<br />
Refractory <strong>33</strong> 54.1<br />
Early 12 19.7<br />
Late 16 26.2<br />
Radiotherapy before AHSCT<br />
Yes 42 68.8<br />
No 19 31.2<br />
Table 1. Continuation<br />
Disease status at AHSCT<br />
CR2 28 45.9<br />
≥CR3 8 13.2<br />
Refractory 25 40.9<br />
Conditioning regimens<br />
BEAM 44 72.1<br />
Others 17 27.9<br />
PET-CT positivity before/after day 100 after AHSCT<br />
Yes 22/14 37/23<br />
No 49/47 63/77<br />
AHSCT: Autologous hematopoietic stem cell transplantation, CR: complete remission,<br />
PET-CT: positron emission tomography-computerized tomography.<br />
was 11 months (minimum-maximum: 1-105). Types <strong>of</strong> relapse<br />
were refractory disease in <strong>33</strong> (54.1%) patients, early relapse in<br />
12 (19.7%), and late relapse in 16 (26.2%). The PFS and OS rates<br />
for type <strong>of</strong> relapse were as follows: the 3-year PFS rates were<br />
93.8% for late relapse, 91.7% for early relapse, and 38.7% for<br />
refractory disease (p
Turk J Hematol 2016;<strong>33</strong>:265-272<br />
Kesik V, et al: Prognostic Markers <strong>of</strong> Hodgkin’s Lymphoma after Autologous Hematopoietic Stem Cell Transplantation<br />
Treatment Results<br />
The median (mean ± standard deviation, minimum-maximum)<br />
level <strong>of</strong> lymphocyte counts at day 15 after AHSCT was 0.45x10 3 /<br />
µL (0.51±0.38x10 3 /µL, 0.01-1.8). The median (mean ± standard<br />
deviation, minimum-maximum) levels <strong>of</strong> WBCs, lymphocytes,<br />
neutrophils, monocytes, platelets, and MPV at day 100 after<br />
AHSCT were 3.9x10 3 /µL (4.6±2.7x10 3 /µL, 1.2-14.6), 1.3x10 3 /<br />
µL (1.4±0.9x10 3 /µL, 0.02-5.1), 1.9x10 3 /µL (2.5±2.3x10 3 /µL, 0.3-<br />
12.4), 0.36x10 3 /µL (0.41±0.27x10 3 /µL, 0.04-1.43), 127x10 3 /<br />
µL (131±80x10 3 /µL, 14-308), and 7.5 fL (7.7±1.4 fL, 4.9-11.3),<br />
respectively. Three-year OS/PFS rates were 77.3% and 68.5%<br />
with a median follow-up <strong>of</strong> 27 months (minimum-maximum:<br />
1-114 months) for all patients, respectively. The prognostic<br />
factors affecting EFS and OS are presented in Tables 2 and 3.<br />
<strong>of</strong> 2 (p=0.36), while the 3-year OS rates were 80.0% for a score<br />
<strong>of</strong> 0 (death due to infection), 93.3% for a score <strong>of</strong> 1, and 75.0%<br />
for a score <strong>of</strong> 2 (p=0.46) (Figure 1).<br />
Patients were scored based on a WBC count <strong>of</strong> >10x10 3 /µL at<br />
100 days after AHSCT (0: no, 1: yes), RT before AHSCT (0: yes,<br />
1: no), remission status at AHSCT (0: yes, 1: no), PET-CT status<br />
at 100 days after AHSCT (0: negative, 1: positive), and serum<br />
albumin <strong>of</strong>
Kesik V, et al: Prognostic Markers <strong>of</strong> Hodgkin’s Lymphoma after Autologous Hematopoietic Stem Cell Transplantation<br />
Turk J Hematol 2016;<strong>33</strong>:265-272<br />
the following 3-year PFS rates: Group 0=100%, Group 1=66.7%,<br />
Group 2=50%, and Group >3=0% (p=0.001) (0: low risk, 1: lowintermediate<br />
risk, 2: high-intermediate risk, >3: high risk). For<br />
3-year OS, remission status at AHSCT (0: yes, 1: no), relapse after<br />
AHSCT (0: no, 1: yes), and bone marrow positivity at diagnosis<br />
(0: no, 1: yes) were scored and showed that Group 0=92%,<br />
Group 1=78.6%, and Group 2=40% (p10x10 3 /µL, posttransplant PET positivity at day 100,<br />
serum albumin <strong>of</strong>
Turk J Hematol 2016;<strong>33</strong>:265-272<br />
Kesik V, et al: Prognostic Markers <strong>of</strong> Hodgkin’s Lymphoma after Autologous Hematopoietic Stem Cell Transplantation<br />
for patients who underwent AHSCT was 77.3% in this study,<br />
and their PFS rate was 68.5%. Other studies on AHSCT reported<br />
the projected survival rate as 45% to 70% and PFS as 30% to<br />
89% [16,17,18,29]. Despite our short median follow-up period<br />
(27 months), our results are comparable to those found in other<br />
reports <strong>of</strong> children with relapsed/refractory HL who received<br />
AHSCT.<br />
Pretreatment factors such as advanced stage <strong>of</strong> disease (Stage<br />
IIB, IIIB, or IV), presence <strong>of</strong> B symptoms, histology, presence<br />
<strong>of</strong> bulky disease, extranodal extension, elevated erythrocyte<br />
sedimentation rate, leukocytosis (WBC count <strong>of</strong> ≥11.5x10 3 /<br />
µL), anemia (hemoglobin <strong>of</strong>
Kesik V, et al: Prognostic Markers <strong>of</strong> Hodgkin’s Lymphoma after Autologous Hematopoietic Stem Cell Transplantation<br />
Turk J Hematol 2016;<strong>33</strong>:265-272<br />
7. Dhakal S, Biswas T, Liesveld JL, Friedberg JW, Phillips GL, Constine LS.<br />
Patterns and timing <strong>of</strong> initial relapse in patients subsequently undergoing<br />
transplantation for Hodgkin’s lymphoma. Int J Radiat Oncol Biol Phys<br />
2009;75:188-192.<br />
8. Nachman JB, Sposto R, Herzog P, Gilchrist GS, Wolden SL, Thomson J, Kadin<br />
ME, Pattengale P, Davis PC, Hutchinson RJ, White K, Children’s Cancer<br />
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12. Metzger ML, Castellino SM, Hudson MM, Rai SN, Kaste SC, Krasin MJ, Kun<br />
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Rosenberg SA, Coltman CA, Tubiana M. Report <strong>of</strong> a committee convened<br />
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15. National Marrow Donor Program & The Medical College <strong>of</strong> Wisconsin.<br />
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Documents/appendix-l.pdf.<br />
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Agarwal R. High-dose therapy and autologous hematopoietic stem-cell<br />
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M, Maghfoor I. High-dose chemotherapy and autologous stem cell<br />
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TG, Warkentin P, Vlachos A, Harrison L, Cairo MS. Autologous peripheral<br />
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19. Jabbour E, Hosing C, Ayers G, Nunez R, Anderlini P, Pro B, Khouri I, Younes<br />
A, Hagemeister F, Kwak L, Fayad L. Pretransplant positive positron emission<br />
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refractory Hodgkin lymphoma. Cancer 2007;109:2481-2489.<br />
20. Wolden SL, Chen L, Kelly KM, Herzog P, Gilchrist GS, Thomson J, Sposto R,<br />
Kadin ME, Hutchinson RJ, Nachman J. Long-term results <strong>of</strong> CCG 5942: a<br />
randomized comparison <strong>of</strong> chemotherapy with and without radiotherapy<br />
for children with Hodgkin’s lymphoma--a report from the Children’s<br />
Oncology Group. J Clin Oncol 2012;30:3174-3180.<br />
21. Azab B, Shah N, Radbel J, Tan P, Bhatt V, Vonfrolio S, Habeshy A, Picon A,<br />
Bloom S. Pretreatment neutrophil/lymphocyte ratio is superior to platelet/<br />
lymphocyte ratio as a predictor <strong>of</strong> long-term mortality in breast cancer<br />
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22. Satwani P, Ahn KW, Carreras J, Abdel-Azim H, Cairo MS, Cashen A, Chen<br />
AI, Cohen JB, Costa LJ, Dandoy C, Fenske TS, Freytes CO, Ganguly S, Gale<br />
RP, Ghosh N, Hertzberg MS, Hayashi RJ, Kamble RT, Kanate AS, Keating A,<br />
Kharfan-Dabaja MA, Lazarus HM, Marks DI, Nishihori T, Olsson RF, Prestidge<br />
TD, Rolon JM, Savani BN, Vose JM, Wood WA, Inwards DJ, Bachanova V,<br />
Smith SM, Maloney DG, Sureda A, Hamadani M. A prognostic model<br />
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and young adults with Hodgkin lymphoma. Bone Marrow Transplant<br />
2015;50:1416-1423.<br />
23. Longo DL, Duffey PL, Young RC, Hubbard SM, Ihde DC, Glatstein E,<br />
Phares JC, Jaffe ES, Urba WJ, DeVita VT Jr. Conventional-dose salvage<br />
combination chemotherapy in patients relapsing with Hodgkin’s disease<br />
after combination chemotherapy: the low probability for cure. J Clin Oncol<br />
1992;10:210-218.<br />
24. Stoneham S, Ashley S, Pinkerton CR, Wallace WH, Shankar AG; United<br />
Kingdom Children’s Cancer Study Group. Outcome after autologous<br />
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25. Ataş E, Kesik V, Babacan O, Korkmazer N, Akyüz C. The timing <strong>of</strong> autologous<br />
stem cell transplantation and the prognostic factors affecting the<br />
prognosis in children with relapsed Hodgkin lymphoma. Pediatr Transplant<br />
2015;19:380-384.<br />
26. Marcais A, Porcher R, Robin M, Mohty M, Michalet M, Blaise D, Tabrizi R,<br />
Clement L, Ceballos P, Daguindau E, Bilger K, Dhedin N, Lapusan S, Bay JO,<br />
Pautas C, Garban F, Ifrah N, Guillerm G, Contentin N, Bourhis JH, Yakoub<br />
Agha I, Bernard M, Cornillon J, Milpied N. Impact <strong>of</strong> disease status and stem<br />
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chemotherapy followed by autologous stem cell transplantation for<br />
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272
RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2015.0203<br />
Turk J Hematol 2016;<strong>33</strong>:273-280<br />
The Role <strong>of</strong> Azacitidine in the Treatment <strong>of</strong> Elderly Patients with Acute<br />
Myeloid Leukemia: Results <strong>of</strong> a Retrospective Multicenter Study<br />
Akut Miyeloid Lösemili Yaşlı Hastaların Tedavisinde Azasitidinin Rolü: Retrospektif Çok<br />
Merkezli Bir Çalışmanın Sonuçları<br />
Anıl Tombak 1 , Mehmet Ali Uçar 1 , Aydan Akdeniz 1 , Eyüp Naci Tiftik 1 , Deniz Gören Şahin 2 , Olga Meltem Akay 2 , Murat Yıldırım 3 ,<br />
Oral Nevruz 3 , Cem Kis 4 , Emel Gürkan 4 , Şerife Medeni Solmaz 5 , Mehmet Ali Özcan 5 , Rahşan Yıldırım 6 , İlhami Berber 7 , Mehmet Ali Erkurt 7 ,<br />
Tülin Fıratlı Tuğlular 8 , Pınar Tarkun 9 , İrfan Yavaşoğlu 10 , Mehmet Hilmi Doğu 11 , İsmail Sarı 11 , Mustafa Merter 12 , Muhit Özcan 12 ,<br />
Esra Yıldızhan 13 , Leylagül Kaynar 13 , Özgür Mehtap 9 , Ayşe Uysal 14 , Fahri Şahin 14 , Ozan Salim 15 , Mehmet Ali Sungur 16<br />
1Mersin University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Mersin, Turkey<br />
2Osmangazi University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Eskişehir, Turkey<br />
3Gülhane Training and Research Hospital, Clinic <strong>of</strong> <strong>Hematology</strong>, Ankara, Turkey<br />
4Çukurova University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Adana, Turkey<br />
5Dokuz Eylül University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, İzmir, Turkey<br />
6Atatürk University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Erzurum, Turkey<br />
7İnönü University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Malatya, Turkey<br />
8Marmara University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, İstanbul, Turkey<br />
9Kocaeli University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Kocaeli, Turkey<br />
10Adnan Menderes University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Aydın, Turkey<br />
11Pamukkale University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Denizli, Turkey<br />
12Ankara University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Ankara, Turkey<br />
13Erciyes University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Kayseri, Turkey<br />
14Ege University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, İzmir, Turkey<br />
15Akdeniz University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Antalya, Turkey<br />
16Düzce University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Biostatistics, Düzce, Turkey<br />
Abstract<br />
Objective: In this study, we aimed to investigate the efficacy and<br />
safety <strong>of</strong> azacitidine (AZA) in elderly patients with acute myeloid<br />
leukemia (AML), including patients with >30% bone marrow (BM)<br />
blasts.<br />
Materials and Methods: In this retrospective multicenter study,<br />
130 patients <strong>of</strong> ≥60 years old who were ineligible for intensive<br />
chemotherapy or had progressed despite conventional treatment were<br />
included.<br />
Results: The median age was 73 years and 61.5% <strong>of</strong> patients had<br />
>30% BM blasts. Patients received AZA for a median <strong>of</strong> four cycles<br />
(range: 1-21). Initial overall response [including complete remission<br />
(CR)/CR with incomplete recovery/partial remission] was 36.2%.<br />
Hematologic improvement (HI) <strong>of</strong> any kind was documented in 37.7%<br />
<strong>of</strong> all patients. HI was also documented in 27.1% <strong>of</strong> patients who<br />
were unresponsive to treatment. Median overall survival (OS) was 18<br />
Öz<br />
Amaç: Bu çalışmada, kemik iliğindeki (Kİ) blast oranı >%30 olan olguları<br />
da içeren akut miyeloid lösemili (AML) yaşlı hastalarda, azasitidinin<br />
(AZA) etkinliğinin ve güvenliğinin araştırılmasını amaçladık.<br />
Gereç ve Yöntemler: Bu geriye dönük, çok merkezli çalışmaya,<br />
yoğun kemoterapi için uygun olmayan ya da konvansiyonel tedavilere<br />
rağmen hastalığı ilerleyen ≥60 yaştaki 130 hasta dahil edildi.<br />
Bulgular: Ortanca yaş 73 idi, hastaların %61,5’inde Kİ blast oranı<br />
>%30 olarak bulundu. Hastalar, ortanca 4 döngü (1-21 aralığında)<br />
AZA almıştı. Başlangıç genel yanıt oranı [tam yanıtı (TY)/eksik<br />
düzelmenin olduğu TY/kısmi yanıtı içeren] %36,2 idi. Herhangi bir<br />
hematolojik düzelme (HD), tüm hastaların %36,2’sinde tespit edildi.<br />
HD tedaviye yanıtsız hastaların %27,1’inde de saptandı. Ortanca<br />
genel sağkalım, yanıt verenlerde 18 ay, yanıt vermeyenlerde 12 ay idi<br />
(p=0,005). Tedaviye yanıtsız hasta grubunda HD’nin, HD olmayanlara<br />
kıyasla genel sağkalımı arttırdığı görüldü (ortanca sağkalım 14 aya<br />
Address for Correspondence/Yazışma Adresi: Anıl TOMBAK, M.D.,<br />
Mersin University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Mersin, Turkey<br />
Phone : +90 532 346 07 67<br />
E-mail : aniltombak@mersin.edu.tr<br />
Received/Geliş tarihi: May 17, 2015<br />
Accepted/Kabul tarihi: November 19, 2015<br />
273
Tombak A, et al: Azacitidine and Elderly Acute Myeloid Leukemia Patients<br />
Turk J Hematol 2016;<strong>33</strong>:273-280<br />
months for responders and 12 months for nonresponders (p=0.005).<br />
In the unresponsive patient group, any HI improved OS compared to<br />
patients without any HI (median OS was 14 months versus 10 months,<br />
p=0.068). Eastern Cooperative Oncology Group performance status <strong>of</strong><br />
30% bone marrow (BM) blasts.<br />
In this retrospective multicenter study, we aimed to investigate<br />
the efficacy and safety <strong>of</strong> AZA in elderly patients with AML<br />
(including patients with >30% BM blasts) defined according to<br />
the World Health Organization (WHO).<br />
Materials and Methods<br />
Patients and Eligibility Criteria<br />
Between June 2009 and June 2014, 130 patients <strong>of</strong> ≥60 years old<br />
with AML from 16 specialized centers for hematology in Turkey,<br />
defined according to WHO criteria, were included. Eligibility<br />
criteria included all ≥60-year-old AML patients who were treated<br />
kıyasla 10 ay, p=0,068). Doğu Kooperatif Onkoloji Grubu performans<br />
durumunun
Turk J Hematol 2016;<strong>33</strong>:273-280<br />
Tombak A, et al: Azacitidine and Elderly Acute Myeloid Leukemia Patients<br />
affected survival. Statistical analyses were performed with<br />
PASW v.18 s<strong>of</strong>tware (Predictive Analytics S<strong>of</strong>tware is a registered<br />
trademark <strong>of</strong> SPSS Inc.), and p0% 94 (72.3)<br />
Unknown 29 (22.3)<br />
Median (range), % 15 (0-90)<br />
Bone marrow blasts, n (%)<br />
20%-30% 36 (27.7)<br />
>30% (<strong>of</strong>f-label use) 80 (61.5)<br />
Unknown 14 (10.8)<br />
Median (range), % 49.5 (20-97)<br />
WBC count (10 9 /L), n (%)<br />
≤10x10 9 /L 77 (59.2)<br />
>10x10 9 /L 53 (40.8)<br />
Median (range), % 4.9 (0.7-146)<br />
ANC (10 9 /L), median (range) 1.1 (0.05-142.7)<br />
Hb (g/L), median (range) 8.7 (4.2-14)<br />
Platelet count (10 9 /L), median (range) 57 (5-786)<br />
LDH (IU/L)<br />
Tombak A, et al: Azacitidine and Elderly Acute Myeloid Leukemia Patients<br />
Turk J Hematol 2016;<strong>33</strong>:273-280<br />
Table 1. Continuation<br />
MRC cytogenetic risk, n (%)<br />
Not evaluable 14 (10.7)<br />
Good 58 (44.6)<br />
Intermediate 56 (43.1)<br />
High 1 (0.8)<br />
Comorbidities, n (%) 66 (50.8)<br />
Number <strong>of</strong> comorbidities, n (%) 7 (5.4)<br />
Turk J Hematol 2016;<strong>33</strong>:273-280<br />
Tombak A, et al: Azacitidine and Elderly Acute Myeloid Leukemia Patients<br />
following conventional chemotherapeutic approaches are poor.<br />
AZA is a hypomethylating agent, and owing to its acceptable<br />
tolerability pr<strong>of</strong>iles and emerging evidence <strong>of</strong> clinical efficacy,<br />
it may provide an exciting approach to the treatment <strong>of</strong> elderly<br />
patients with AML. It is licensed for patients with 20%-30%<br />
blasts and it confers a survival benefit in these patients [14];<br />
studies suggest 10%-20% CR rates with AZA [14,19,20,21] and<br />
these patients have OS rates equivalent or superior to other<br />
conventional treatments [14,19,21]. However, data on AZA<br />
activity in AML patients with BM blast counts <strong>of</strong> >30% are<br />
limited and the drug can be used <strong>of</strong>f-label in these patients,<br />
although several analyses have also suggested that AZA is active<br />
and well tolerated in patients with >30% BM blasts as well<br />
[11,12,15,20].<br />
Table 3. Univariate analysis for response and overall survival.<br />
Sex,<br />
Female/Male<br />
Age,<br />
60-69/70-79/≥80 years<br />
Absolute number <strong>of</strong><br />
comorbidities, 0%<br />
BM blast count,<br />
20%-30%/>30%<br />
AML type,<br />
t-AML/AML-RCA/AML-MRF/AML-NOS<br />
Treatment prior to AZA,<br />
No/Yes<br />
Leukocyte count at diagnosis, ≤10x10 9 /<br />
L/>10x10 9 /L<br />
LDH,<br />
≥225/
Tombak A, et al: Azacitidine and Elderly Acute Myeloid Leukemia Patients<br />
Turk J Hematol 2016;<strong>33</strong>:273-280<br />
In the current study, we retrospectively analyzed the efficacy and<br />
toxicity <strong>of</strong> AZA in 130 patients with AML who were ≥60 years<br />
<strong>of</strong> age, and this cohort also included 80 patients (61.5% <strong>of</strong> the<br />
cases) with >30% BM blasts. We found a CR rate similar to the<br />
CR rates <strong>of</strong> recent studies [14,19,20,21], which was documented<br />
in 13.1% <strong>of</strong> our patient cohort. Median OS was 12.3 months<br />
and OS was longer in responders compared to nonresponders.<br />
We also showed that AZA was effective in the group with >30%<br />
BM blasts and that BM blast count <strong>of</strong> 20%-30% versus >30%<br />
has no significant impact on response rate or OS. In addition,<br />
although the response rate and OS were somewhat poor<br />
with the presence <strong>of</strong> peripheral blasts, these results were not<br />
statistically significant. In a study conducted by van der Helm<br />
et al. it was shown that BM blast percentage had no impact<br />
on OS as well [22]. In a recent phase 3 study <strong>of</strong> AZA versus<br />
conventional care regimens in newly diagnosed AML patients<br />
<strong>of</strong> ≥65 years with >30% BM blasts, Dombret et al. confirmed<br />
the clinical observation that AZA can have meaningful clinical<br />
activity (e.g., transfusion independency) and improve survival,<br />
even though no CR is achieved [23]. Thus, we recommend that<br />
AML patients with >30% BM blasts should not be precluded<br />
from treatment with AZA and the presence <strong>of</strong> peripheral blasts<br />
should not be a reason for therapy cessation.<br />
HI was found to be a predictor <strong>of</strong> prolonged survival; significantly<br />
longer OS was observed in patients achieving any kind <strong>of</strong> HI<br />
compared to patients without any HI (p=0.002), and similar<br />
results have been shown in recent AML patient cohorts [15,20].<br />
However, interestingly, we also found that in the unresponsive<br />
(without CR/CRi/PR) patient group, OS was significantly longer<br />
for patients who achieved HI compared to those without any HI<br />
(p=0.068). In other words, although this was not a statistically<br />
significant result, HI without CR/CRi or PR was also associated<br />
with a better OS. If commonly used AML response criteria were<br />
to be applied [17], patients who experience HI without CR, CRi,<br />
or PR would be called nonresponders and treatment with AZA<br />
would be discontinued. With these results, we can conclude that,<br />
since cytopenias are the cause <strong>of</strong> mortality in the majority <strong>of</strong><br />
patients with AML, the goal <strong>of</strong> therapy with AZA should not just<br />
be CR or PR, and therapy should be continued in patients with<br />
any HI although there is not any simultaneous BM response.<br />
Another result <strong>of</strong> our study was that, as the number <strong>of</strong> AZA<br />
courses increased, response rate and OS increased. This is not<br />
a surprise, because the epigenetic therapeutic effects <strong>of</strong> AZA<br />
are dependent on the S-phase <strong>of</strong> the cell cycle and each cycle<br />
<strong>of</strong> therapy can only affect the fraction <strong>of</strong> the malignant clone<br />
that enters the S-phase. Thus, the best responses can occur after<br />
as many as 12 cycles <strong>of</strong> therapy, with a median <strong>of</strong> 3-3.5 cycles<br />
[24]. Therefore, the treatment should not be interrupted in the<br />
early stages <strong>of</strong> therapy and it should be continued as long as<br />
the response is durable and/or until overt clinical progression<br />
occurs.<br />
We confirm the results <strong>of</strong> previous studies [15,20,25] that WHO-<br />
AML type, treatment prior to AZA, sex, and age had no significant<br />
effect on OS. Not the age but rather the absolute number <strong>of</strong><br />
comorbidities may adversely affect OS. In our study, a cut-<strong>of</strong>f<br />
<strong>of</strong> 15x10 9 /L significantly affected OS [15,20], but<br />
the French publication showed a significant effect <strong>of</strong> leukocyte<br />
count <strong>of</strong> >15x10 9 /L on OS [25]. We think that AML patients with<br />
high leukocyte counts should not be precluded from treatment<br />
with AZA, and cytoreduction with hydroxyurea or low-dose<br />
cytarabine may be an appropriate approach in such patients.<br />
As expected, transfusion dependence prior to AZA was<br />
associated with reduced OS in our study in univariate analysis,<br />
which was, however, not statistically significant (p=0.077).<br />
Transfusion dependence was not a predictor <strong>of</strong> reduced OS in<br />
the multivariate analysis <strong>of</strong> the Austrian studies, as well [15,20].<br />
The most commonly observed toxicity was febrile neutropenia,<br />
at a rate higher than seen in the literature [12,13,15]. Other<br />
nonhematological toxicities were mild. However, due to the<br />
retrospective nature <strong>of</strong> this analysis, toxicities in general were<br />
probably underestimated.<br />
Certainly, our study has several shortcomings, since it was a<br />
retrospective study, the patient population was heterogeneous,<br />
and the effect <strong>of</strong> cytogenetics on response to treatment was<br />
not evaluated.<br />
In conclusion, AZA is effective and well tolerated in elderly<br />
comorbid AML patients with fewer required erythrocyte and<br />
platelet transfusions, irrespective <strong>of</strong> BM blast count. HI should<br />
be considered a sufficient response to continue treatment with<br />
AZA and treatment should not be interrupted since OS and<br />
278
Turk J Hematol 2016;<strong>33</strong>:273-280<br />
Tombak A, et al: Azacitidine and Elderly Acute Myeloid Leukemia Patients<br />
response to treatment increase with increasing numbers <strong>of</strong> AZA<br />
cycles.<br />
Ethics<br />
Ethics Committee Approval: This study was approved by<br />
Mersin University Ethics Committee, Informed Consent: It is a<br />
retrospective study.<br />
Authorship Contributions<br />
Concept: Anıl Tombak, Design: Anıl Tombak, Data Collection and<br />
Processing: Anıl Tombak, Mehmet Ali Uçar, Aydan Akdeniz, Eyüp<br />
Naci Tiftik, Deniz Gören Şahin, Olga Meltem Akay, Murat Yıldırım,<br />
Oral Nevruz, Cem Kis, Emel Gürkan, Şerife Medeni Solmaz,<br />
Mehmet Ali Özcan, Rahşan Yıldırım, İlhami Berber, Mehmet<br />
Ali Erkurt, Tülin Fıratlı Tuğlular, Pınar Tarkun, İrfan Yavaşoğlu,<br />
Mehmet Hilmi Doğu, İsmail Sarı, Mustafa Merter, Muhit Özcan,<br />
Esra Yıldızhan, Leylagül Kaynar, Özgür Mehtap, Ayşe Uysal, Fahri<br />
Şahin, Ozan Salim, Mehmet Ali Sungur; Analysis or Interpretation:<br />
Anıl Tombak, Mehmet Ali Uçar, Aydan Akdeniz, Eyüp Naci Tiftik,<br />
Deniz Gören Şahin, Olga Meltem Akay, Murat Yıldırım, Oral<br />
Nevruz, Cem Kis, Emel Gürkan, Şerife Medeni Solmaz, Mehmet<br />
Ali Özcan, Rahşan Yıldırım, İlhami Berber, Mehmet Ali Erkurt,<br />
Tülin Fıratlı Tuğlular, Pınar Tarkun, İrfan Yavaşoğlu, Mehmet Hilmi<br />
Doğu, İsmail Sarı, Mustafa Merter, Muhit Özcan, Esra Yıldızhan,<br />
Leylagül Kaynar, Özgür Mehtap, Ayşe Uysal, Fahri Şahin, Ozan<br />
Salim, Mehmet Ali Sungur; Literature Search: Anıl Tombak,<br />
Mehmet Ali Uçar, Aydan Akdeniz, Eyüp Naci Tiftik, Deniz Gören<br />
Şahin, Olga Meltem Akay, Murat Yıldırım, Oral Nevruz, Cem Kis,<br />
Emel Gürkan, Şerife Medeni Solmaz, Mehmet Ali Özcan, Rahşan<br />
Yıldırım, İlhami Berber, Mehmet Ali Erkurt, Tülin Fıratlı Tuğlular,<br />
Pınar Tarkun, İrfan Yavaşoğlu, Mehmet Hilmi Doğu, İsmail Sarı,<br />
Mustafa Merter, Muhit Özcan, Esra Yıldızhan, Leylagül Kaynar,<br />
Özgür Mehtap, Ayşe Uysal, Fahri Şahin, Ozan Salim, Mehmet Ali<br />
Sungur; Writing: Anıl Tombak.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
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14. Fenaux P, Mufti GJ, Hellström-Lindberg E, Santini V, Gattermann N,<br />
Germing U, Sanz G, List AF, Gore S, Seymour JF, Dombret H, Backstrom J,<br />
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15. Pleyer L, Burgstaller S, Girschik<strong>of</strong>sky M, Linkesch W, Stauder R, Pfeilstocker<br />
M, Schreder M, Tinchon C, Sliwa T, Lang A, Sperr WR, Krippl P, Geissler D,<br />
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Wheatley K, Harrison CJ, Burnett AK; National Cancer Research Institute<br />
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280
RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2015.0088<br />
Turk J Hematol 2016;<strong>33</strong>:281-285<br />
The Prognosis <strong>of</strong> Adult Burkitt’s Cell Leukemia in Real-Life<br />
Clinical Practice<br />
Erişkin Burkitt Hücreli Löseminin Klinik Pratikteki Seyri<br />
Ümit Yavuz Malkan 1 , Gürsel Güneş 1 , Hakan Göker 1 , İbrahim C. Haznedaroğlu 1 , Kadir Acar 2 , Eylem Eliaçık 1 , Sezgin Etgül 1 , Tuncay Aslan 1 ,<br />
Seda Balaban 1 , Haluk Demiroğlu 1 , Osman İ. Özcebe 1 , Nilgün Sayınalp 1 , Salih Aksu 1 , Yahya Büyükaşık 1<br />
1Hacettepe University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Ankara, Turkey<br />
2Gazi University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Ankara, Turkey<br />
Abstract<br />
Objective: Many studies reported an improved prognosis in<br />
patients with Burkitt’s lymphoma obviating the need <strong>of</strong> stem cell<br />
transplantation. However, prognosis <strong>of</strong> the advanced disease [i.e.<br />
Burkitt’s cell leukemia (BCL)] has not been reported with current<br />
treatment modalities except for a few prospective trials. The aim <strong>of</strong><br />
this study is to compare the prognoses <strong>of</strong> BCL patients with similarly<br />
treated and nontransplanted patients with other types <strong>of</strong> acute<br />
lymphoblastic leukemia (ALL) and with ALL patients that underwent<br />
allogeneic stem cell transplantation (ASCT) in their first remissions.<br />
Materials and Methods: In this retrospective analysis, BCL patients<br />
aged between 16 and 63 who were admitted between 2000 and 2014<br />
to the hospitals <strong>of</strong> Hacettepe or Gazi University and were treated with<br />
intensive therapies aimed at cure were included. All ALL patients who<br />
were treated with a similar protocol not including transplantation<br />
during the same period (NT-ALL group) and all ALL patients who<br />
underwent ASCT in the first complete remission during the same<br />
period (T-ALL group) served as control groups.<br />
Results: The central nervous system or extramedullary involvement<br />
rates, lactate dehydrogenase levels, and white blood cell counts at<br />
diagnosis were higher in the BCL group than the NT-ALL group and<br />
these differences were significant. BCL patients had disease-free<br />
survival (DFS) durations comparable with the T-ALL cohort but NT-<br />
ALL patients had significantly shorter DFS durations. Both cumulative<br />
relapse incidence and cumulative nonrelapse mortality were higher in<br />
NT-ALL patients compared to the T-ALL group and BCL patients.<br />
Conclusion: DFS in BCL patients treated with a widely accepted<br />
modern regimen, R-HyperCVAD, is comparable to results in other<br />
ALL patients receiving allogeneic transplantation. Our results are in<br />
agreement with a few prospective noncomparative studies suggesting<br />
no further need for stem cell transplantation in BCL.<br />
Keywords: Burkitt’s cell leukemia, Prognosis<br />
Amaç: Yapılan birçok çalışmada Burkitt lenfomanın seyrinin düzeldiği,<br />
hatta kemik iliği nakli ihtiyacının ortadan kalktığı ileri sürülmektedir.<br />
Ancak birkaç ileriye dönük çalışma haricinde, güncel tedavi yöntemleri<br />
altında hastalığın lösemik formunun seyri hakkında araştırma<br />
yapılmamıştır. Bu çalışmanın amacı Burkitt hücreli lösemi (BHL)<br />
hastalarının klinik seyrinin, benzer tedavi alan ve transplantasyon<br />
uygulanmayan diğer akut lenfoblastik lösemi (ALL) hastaları ve ilk<br />
remisyonlarında allojenik kök hücre nakli (AKHN) uygulanan ALL<br />
hastalarıyla kıyaslanmasıdır.<br />
Gereç ve Yöntemler: Geriye dönük olarak tasarlanan bu çalışmaya<br />
yaşları 16 ile 63 arasında değişen, 2000 ile 2014 yılları arasında<br />
Hacettepe ve Gazi Üniversitesi Hastaneleri’ne başvurup kür amacıyla<br />
intensif tedavi verilen BHL hastaları alınmıştır. Transplantasyon<br />
haricinde benzer tedavi protokolüyle tedavi edilen tüm ALL hastaları<br />
(NT-ALL) ve aynı dönemde ilk tam remisyonlarında AKHN uygulanan<br />
hastalar (T-ALL) kontrol grupları olarak çalışmaya alınmışlardır.<br />
Bulgular: Santral sinir sistemi ya da ekstra medüller tutulum<br />
hızları, tanı anındaki laktat dehidrogenaz düzeyleri ve beyaz küre<br />
sayısı BHL hastalarında NT-ALL hastalarına göre istatistiksel olarak<br />
anlamlı olacak şekilde daha yüksekti. BHL hastaları T-ALL hastalarıyla<br />
benzer hastalıksız sağkalım (HS) süresine sahip olmakla beraber, NT-<br />
ALL hastalarında HS süresi önemli oranda azalmıştı. Kümülatif nüks<br />
insidansı ve kümülatif nüks dışı ölümler NT-ALL hastalarında T-ALL ve<br />
BHL hastalarında kıyasla daha fazlaydı.<br />
Sonuç: Sonuç olarak, geniş kabul gören modern bir rejim olan<br />
R-HyperCVAD ile tedavi edilen BHL hastalarında HS süresi allojenik<br />
transplantasyon uygulanmış diğer ALL hastaları ile benzer bulundu.<br />
Bizim çalışmamızın sonuçları, literatürde ileri dönük dizayn edilmiş<br />
ancak kontrol grupları ile karşılaştırma olmadan yapılmış ve BHL’de<br />
transplantasyon gerekmediğini öne süren az sayıdaki çalışma ile<br />
örtüşmektedir.<br />
Öz<br />
Anahtar Sözcükler: Burkitt hücreli lösemi, Prognoz<br />
Address for Correspondence/Yazışma Adresi: Ümit Yavuz MALKAN, M.D.,<br />
Hacettepe University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Ankara, Turkey<br />
Phone : +90 532 778 00 87<br />
E-mail : umitmalkan@hotmail.com<br />
Received/Geliş tarihi: February 23, 2015<br />
Accepted/Kabul tarihi: December 14, 2015<br />
281
Malkan ÜY, et al: The Prognosis <strong>of</strong> Adult Burkitt’s Cell Leukemia Turk J Hematol 2016;<strong>33</strong>:281-285<br />
Introduction<br />
In the last decade, many studies reported an improved prognosis<br />
in patients with Burkitt’s lymphoma obviating the need for<br />
stem cell transplantation. There is a general consensus that the<br />
prognosis <strong>of</strong> Burkitt’s lymphoma is closely related to the disease<br />
stage and degree regarding the involvement <strong>of</strong> bone marrow and<br />
peripheral blood. However, prognosis <strong>of</strong> the advanced disease<br />
(i.e. Burkitt’s cell leukemia) specifically has not been reported<br />
with current treatment modalities except for a few prospective<br />
trials, which may not reflect everyday real-life clinical practices<br />
with their own limitations.<br />
The aim <strong>of</strong> this study is to compare the prognoses <strong>of</strong> Burkitt’s cell<br />
leukemia patients with similarly treated and nontransplanted<br />
patients with other types <strong>of</strong> acute lymphoblastic leukemia and<br />
with acute lymphoblastic leukemia patients that underwent<br />
allogeneic stem cell transplantation in their first remissions.<br />
Materials and Methods<br />
Study Population<br />
In this retrospective analysis, Burkitt’s cell leukemia patients<br />
aged between 16 and 63 years who were admitted between<br />
2000 and 2014 to the hospitals <strong>of</strong> Hacettepe or Gazi University<br />
and treated with intensive therapies aimed at cure were<br />
included in the study. Twenty-five patients who were treated<br />
with HyperCVAD ± rituximab were included in the study; as<br />
only one patient was treated with the R-EPOCH regimen,<br />
that patient was excluded from the study. The diagnosis<br />
<strong>of</strong> Burkitt’s cell leukemia was made based on the presence<br />
<strong>of</strong> characteristic morphological (FAB L3 morphology and<br />
>95% Ki-67 proliferation index) or cytogenetic/molecular<br />
(specific translocations involving MYC at band 8q24 or MYC<br />
rearrangement in fluorescence in situ hybridization analysis)<br />
properties and mature B-cell immunophenotype (TdT negativity<br />
plus sIg positivity <strong>of</strong> >20% or κ/λ light-chain clonality). The<br />
minimal criterion for the diagnosis <strong>of</strong> a leukemic disease<br />
condition was more than 25% bone marrow involvement. All<br />
acute lymphoblastic leukemia patients who were treated with a<br />
similar protocol not including transplantation during the same<br />
period (NT-ALL group) and all acute lymphoblastic leukemia<br />
patients who underwent allogeneic stem cell transplantation<br />
in the first complete remission during the same period (T-ALL<br />
group) served as control groups.<br />
Treatment Protocols<br />
Specifics <strong>of</strong> the HyperCVAD ± rituximab regimen, including<br />
central nervous system (CNS) prophylaxis and treatment<br />
strategies, were as described by Thomas et al. [1]. Chemotherapy<br />
consisted <strong>of</strong> 8 alternating courses without maintenance therapy.<br />
When given, rituximab was administered during courses 1 to 4.<br />
Odd courses (1, 3, 5, 7) were HyperCVAD. When given, rituximab<br />
was administered at 375 mg/m 2 i.v. over 2 to 6 h on days 1 and<br />
11 <strong>of</strong> HyperCVAD and on days 2 and 8 <strong>of</strong> MTX and ara-C, during<br />
the first 4 courses.<br />
Study End-Points and Statistical Analysis<br />
Numerical descriptive data were expressed as median (minimummaximum).<br />
Continuous and categorical data were compared with<br />
the t-test and chi-square test, respectively. Primary endpoints<br />
<strong>of</strong> the study were complete remission (CR) rate, disease-free<br />
survival (DFS), and overall survival (OS). OS was calculated<br />
from diagnosis to the date <strong>of</strong> mortality <strong>of</strong> any reason. DFS was<br />
analyzed in CR patients from date <strong>of</strong> CR attainment to relapse<br />
or death in remission. The patients who did not die and those<br />
who did not relapse or die in remission at last follow-up were<br />
censored at this time for OS and DFS computations, respectively.<br />
Cumulative relapse (CRI) and cumulative nonrelapse mortality<br />
incidences (CNRMI) were computed for patients who attained<br />
CR, from the date <strong>of</strong> CR until relapse or nonrelapse mortality<br />
(NRM), respectively. The patients who did not relapse or die in<br />
remission at last follow-up were censored at this time. Relapse<br />
was considered a competing risk for NRM, and NRM was<br />
considered a competing risk for relapse during CRI and CNRMI<br />
computations. Categorical and continuous data were compared<br />
by the chi-square and independent-samples t-test, respectively.<br />
Survival analyses were computed by the Kaplan-Meier method.<br />
Comparisons <strong>of</strong> survival rates were done by the log-rank test.<br />
CRI and CNRMI were calculated according to Gray’s test [2]<br />
as described by Scrucca et al. [3]. Cumulative incidences were<br />
calculated by means <strong>of</strong> the statistical s<strong>of</strong>tware environment<br />
R, Version 2.15.2 (The R Foundation for Statistical Computing,<br />
Vienna, Austria) [4]. SPSS 17.0 (SPSS Inc., Chicago, IL, USA) was<br />
used for other statistical analyses.<br />
Results<br />
T-ALL patients were frequently referred after remission attainment<br />
from other centers. Some <strong>of</strong> these patients’ baseline parameters<br />
were missing. There were 25, 44, and 48 patients in the Burkitt’s<br />
cell leukemia, NT-ALL, and T-ALL groups, respectively. Important<br />
baseline characteristics <strong>of</strong> Burkitt’s cell leukemia and NT-ALL<br />
patients are presented in Table 1. All 25 Burkitt’s cell leukemia<br />
patients had been treated with the HyperCVAD ± rituximab<br />
regimen and were not transplanted. Rituximab treatments were<br />
given to most <strong>of</strong> the Burkitt’s cell leukemia patients; only 3<br />
Burkitt’s cell leukemia patients had not received rituximab. Only<br />
nontransplanted acute lymphoblastic leukemia (NT-ALL) patients<br />
who were treated with HyperCVAD were selected as controls.<br />
Median numbers <strong>of</strong> HyperCVAD ± rituximab regimens given to<br />
Burkitt’s and NT-ALL patients were 8 and 7.5, respectively. The<br />
CNS or extramedullary involvement rate, lactate dehydrogenase<br />
levels, and white blood cell count at diagnosis were higher in<br />
282
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Malkan ÜY, et al: The Prognosis <strong>of</strong> Adult Burkitt’s Cell Leukemia<br />
the Burkitt’s group than the NT-ALL group and these differences<br />
were significant (p=0.008, p=0.016, and p=0.036, respectively).<br />
We also analyzed the chemotherapy intervals between<br />
treatment cycles. There was no significant difference between<br />
the intervals <strong>of</strong> treatment cycles for the Burkitt’s cell leukemia<br />
and NT-ALL groups. The median (95% confidence interval) OS<br />
time for all 25 Burkitt’s cell leukemia patients was 31.1 (3.1-<br />
59.1) months. The mean (95% confidence interval) DFS time<br />
for Burkitt’s cell leukemia patients was 50.0 (30.9-69.2) months<br />
(median not reached). After analyzing the prognosis, we further<br />
analyzed the induction chemotherapy results and OS in the<br />
patients with Burkitt’s cell leukemia receiving HyperCVAD and<br />
similarly treated nontransplanted acute lymphoblastic leukemia<br />
patients. Transplanted acute lymphoblastic leukemia patients<br />
were preferentially not included in this analysis because the<br />
majority <strong>of</strong> them had been referred after remission attainment<br />
from other centers. After the induction therapy, 5 patients died,<br />
19 patients achieved CR, and 1 patient had no response in the<br />
Burkitt’s cell leukemia group. Four patients died, <strong>33</strong> patients<br />
achieved CR, and 7 patients had no response in the NT-ALL<br />
group. We achieved a 76% CR rate in the Burkitt’s group and a<br />
75% CR rate in the NT-ALL group (p=0.182). The median (95%<br />
confidence interval) OS time for the Burkitt’s and NT-ALL groups<br />
were 31.1 (3.1-59.1) and 12.1 (7.0-17.3) months, respectively<br />
(p=0.261). There was no significant difference between the two<br />
groups (Figure 1). After obtaining these results, we analyzed the<br />
DFS, CRI, and CNRMI in the 3 groups. The mean DFS time for the<br />
Burkitt’s, NT-ALL, and T-ALL groups was 50.0±9.7, 31.4±6.7, and<br />
83.3±9.1 months, respectively (p=0.002). There was a significant<br />
statistical difference between these 3 groups (Figure 2). Burkitt’s<br />
cell leukemia patients had DFS durations comparable with<br />
the T-ALL cohort (50.0±9.7 vs. 83.3±9.1 months, respectively;<br />
p=0.17), but NT-ALL patients had significantly inferior DFS<br />
durations compared to the T-ALL group (31.4±6.7 vs. 83.3±9.1<br />
months, respectively; p=0.001). Both CRI (45.4% [standard error,<br />
SE: 9.8%], 38.2% [SE: 7.8%], and 35.7% [SE: 12.5%] at the 80 th<br />
month; p=0.04) and CNRMI (28.5% [SE: 8.8%], 6.8% [SE: 3.9%],<br />
and 11.5% [SE: 8%] at the 80 th month; p=0.03) were higher in<br />
NT-ALL patients compared to the T-ALL group and Burkitt’s cell<br />
leukemia patients (Figure 3).<br />
Discussion<br />
As stem cell transplantation for Burkitt’s cell leukemia has been<br />
abandoned in the modern era, we preferred to evaluate success<br />
<strong>of</strong> current treatment in these cases by comparing them with<br />
similarly treated NT-ALL and T-ALL patients. Currently, allogeneic<br />
stem cell transplantation is deemed necessary in adult acute<br />
lymphoblastic leukemia during the first complete remission.<br />
We thought that in the absence <strong>of</strong> possibilities <strong>of</strong> evaluating<br />
the value <strong>of</strong> allogeneic stem cell transplantation in Burkitt’s<br />
cell leukemia by a randomized study or by using a currently<br />
transplanted Burkitt’s cohort, the necessity <strong>of</strong> treatment could<br />
be weighed by comparison <strong>of</strong> Burkitt’s cell leukemia cases with<br />
T-ALL and NT-ALL patients. Transplanted acute lymphoblastic<br />
leukemia patients had the best DFS, significantly better than<br />
that <strong>of</strong> nontransplanted patients. However, no DFS advantage<br />
could be observed in transplanted patients compared to Burkitt’s<br />
cell leukemia patients.<br />
Figure 2. Disease-free survival time <strong>of</strong> Burkitt, NTxALL, and TxALL<br />
groups.<br />
Figure 1. Overall survival time for Burkitt and NTxALL groups.<br />
Figure 3. Cumulative relapse and cumulative nonrelapse mortality<br />
incidences <strong>of</strong> Burkitt, NTxALL, and TxALL groups.<br />
283
Malkan ÜY, et al: The Prognosis <strong>of</strong> Adult Burkitt’s Cell Leukemia Turk J Hematol 2016;<strong>33</strong>:281-285<br />
Table 1. Main baseline characteristics and follow-up durations <strong>of</strong> Burkitt’s cell leukemia and similarly treated non-transplant<br />
acute lymphoblastic leukemia patients.<br />
Parameters Burkitt’s Cell Leukemia Group Non-Transplant ALL Group p-value<br />
Number <strong>of</strong> cases 25 44<br />
Sex (Male/Female) 18/7 23/21 0.086<br />
ECOG performance score (0/1/2/3/4) 3/16/3/3/0 12/21/4/5/2 0.438<br />
Age (Median, range) 39 (16-63) 31 (16-63) 0.192<br />
LDH at diagnosis (U/L) 2035 (499-12000) 919 (<strong>33</strong>1-9820) 0.016<br />
Hemoglobin at diagnosis (g/dL) 10.0 (4.9-14.0) 9.1 (4.0-15.5) 0.920<br />
Leucocyte count at diagnosis (x10 9 /L) 9.6 (1.7-24.7) 8.8 (0.8-216.4) 0.036<br />
Platelet count at diagnosis (x10 9 /L) 103.5 (11-631) 53.5 (8-560) 0.141<br />
Chemotherapy Interval 1-2 nd , days 26.5 (18-<strong>33</strong>) 28.0 (17.0-45.0) 0.521<br />
Chemotherapy Interval 2-3 rd , days 26.5 (20.0-<strong>33</strong>.0) 26.0 (19.0-34.0) 0.878<br />
Chemotherapy Interval 3-4 th , days 24.0 (20.0-44.0) 26.0 (21.0-37.0) 0.613<br />
Chemotherapy Interval 4-5 th , days 25.0 (19.0-49.0) 25.0 (20.0-46.0) 0.676<br />
Chemotherapy Interval 5-6 th , days 30.0 (24.0-46.0) 29.0 (22.0-43.0) 0.395<br />
Chemotherapy Interval 6-7 th , days 37.5 (27.0-42.0) 29.0 (23.0-40.0) 0.087<br />
Chemotherapy Interval 7-8 th , days 31.0 (24.0-45.0) 29.0 (22.0-40.0) 0.148<br />
Central Nervous System or Extramedullary involvement (Y/N) 12/14 7/37 0.008<br />
Blasts in peripheral blood film (Y/N) 8/4 15/12 0.515<br />
Blasts in marrow 50% 1/0/11 0/1/24 0.275<br />
Follow-up time for surviving patients, months 22.7 (1.4-88.5) 38.6 (0.5-90.7)<br />
LDH: Lactate dehydrogenase, ECOG: The Eastern Cooperative Oncology Group, Y/N: Yes/No<br />
In our study, we achieved a 76% CR rate after induction<br />
therapy in Burkitt’s cell leukemia cases. In a study conducted<br />
by a German group, an 86% CR rate was achieved in Burkitt’s<br />
cell leukemia patients [5]. In another study conducted in Italy,<br />
investigators obtained a 79% CR, 8% no-response rate, and<br />
13% death rate in Burkitt’s lymphoma and leukemia patients<br />
after induction chemotherapy [6]. In our study, we obtained<br />
76% CR, 20% death, and 4% no-response rates in Burkitt’s<br />
cell leukemia patients. The induction death rate in our study<br />
was higher than that <strong>of</strong> the Italian study. The reason for this<br />
difference may be that participants were in an advanced stage<br />
<strong>of</strong> disease (Burkitt’s cell leukemia) in our study, whereas patients<br />
in the Italian study had both Burkitt’s lymphoma and leukemia.<br />
Furthermore, in the Italian study, investigators found a relapse<br />
rate <strong>of</strong> only 7% in patients treated with an intercycle interval <strong>of</strong><br />
≤25 days. We found the CRI <strong>of</strong> Burkitt’s cell leukemia patients<br />
as 35.7%, which was much higher. The intercycle interval could<br />
be the reason for this difference, because in our study the mean<br />
duration <strong>of</strong> all chemotherapy intercycles was longer than 25<br />
days. It is known that men are more commonly affected by<br />
Burkitt’s disease with a 3-4:1 ratio [7]. Similarly, in our cohort,<br />
men were more common, with a ratio <strong>of</strong> 2.5:1.<br />
In reported clinical trials, the prognosis for Burkitt’s lymphoma<br />
is generally favorable, with median survivals <strong>of</strong> 75%-90% with<br />
modern chemoimmunotherapy regimens [1,8]. An analysis <strong>of</strong><br />
the Surveillance Epidemiology and End Results (SEER) database<br />
was less encouraging, however, with a 5-year OS rate <strong>of</strong> 56%<br />
and better survival seen in younger patients with lowerrisk<br />
disease (87% and 71% for patients aged 0-19 years and<br />
for patients with low-risk disease, respectively) [9,10]. The<br />
impact <strong>of</strong> age on outcomes is likely multifactorial and reflects<br />
increased treatment toxicity or decreased treatment intensity<br />
in older individuals, as well as the potential misclassification<br />
<strong>of</strong> disease in this population. In our study the mean OS time<br />
for all 25 Burkitt’s cell leukemia patients was 43.6±9.2 months.<br />
Burkitt’s lymphoma principally involves the lymph nodes, bone<br />
marrow, and CNS, but it may also present with peripheral blood<br />
involvement [11]. In our study, peripheral blood involvement was<br />
present in 66% <strong>of</strong> cases. A limitation <strong>of</strong> our study is that in the<br />
T-ALL group DFS duration after first CR was found comparable<br />
but OS duration was not calculable.<br />
In conclusion, DFS in Burkitt’s cell leukemia patients treated<br />
with a widely accepted modern regimen, R-HyperCVAD, is<br />
comparable to that <strong>of</strong> allogeneic transplanted patients <strong>of</strong><br />
acute lymphoblastic leukemia. Although this study has some<br />
disadvantages inherent to its retrospective design, use <strong>of</strong> non-<br />
Burkitt’s control groups, and a limited patient numbers, we think<br />
that a better comparative study design is practically impossible<br />
due to the absence <strong>of</strong> a large transplanted Burkitt’s cohort<br />
and ethical issues in planning a prospective study including<br />
transplantation in these patients. Our results are in agreement<br />
with the few prospective noncomparative studies [12,13],<br />
284
Turk J Hematol 2016;<strong>33</strong>:281-285<br />
Malkan ÜY, et al: The Prognosis <strong>of</strong> Adult Burkitt’s Cell Leukemia<br />
suggesting no further need for stem cell transplantation in<br />
Burkitt’s cell leukemia.<br />
Ethics<br />
Informed Consent was taken during the hospital admission <strong>of</strong><br />
the patients, additional Ethics Committee Approval was not<br />
applicable based on the nature <strong>of</strong> this retrospective analysis.<br />
Authorship Contributions<br />
Medical Practices: Ümit Yavuz Malkan, Gürsel Güneş, Hakan<br />
Göker, İbrahim C. Haznedaroğlu, Kadir Acar, Eylem Eliaçık,<br />
Sezgin Etgül, Tuncay Aslan, Seda Balaban, Haluk Demiroğlu,<br />
Osman İ. Özcebe, Nilgün Sayınalp, Salih Aksu, Yahya<br />
Büyükaşık; Concept: Ümit Yavuz Malkan, Yahya Büyükaşık;<br />
Design: Ümit Yavuz Malkan, Yahya Büyükaşık; Data Collection<br />
or Processing: Ümit Yavuz Malkan, Gürsel Güneş, Hakan Göker,<br />
İbrahim C. Haznedaroğlu, Kadir Acar, Eylem Eliaçık, Sezgin Etgül,<br />
Tuncay Aslan, Seda Balaban, Haluk Demiroğlu, Osman İ. Özcebe,<br />
Nilgün Sayınalp, Salih Aksu, Yahya Büyükaşık; Analysis or<br />
Interpretation: Ümit Yavuz Malkan, Yahya Büyükaşık; Literature<br />
Search: Ümit Yavuz Malkan; Writing: Ümit Yavuz Malkan.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
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FB, Keating MJ, Cabanillas F, Kantarjian H. Chemoimmunotherapy with<br />
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Burkitt’s-type lymphoma or acute lymphoblastic leukemia. Cancer<br />
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285
RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2015.0145<br />
Turk J Hematol 2016;<strong>33</strong>:286-292<br />
Expression Pr<strong>of</strong>iles <strong>of</strong> the Individual Genes Corresponding to the<br />
Genes Generated by Cytotoxicity Experiments with Bortezomib in<br />
Multiple Myeloma<br />
Multipl Miyelomda Bortezomib ile Yapılan Sitotoksisite Çalışmalarında Ortaya Çıkan Genlere<br />
Karşılık Gelen Özgün Genlerin Ekspresyon Pr<strong>of</strong>ili<br />
Mehdi Ghasemi 1,2 , Semih Alpsoy 1,3 , Seyhan Türk 4 , Ümit Y. Malkan 5 , Şükrü Atakan 1,2 , İbrahim C. Haznedaroğlu 5 , Gürsel Güneş 5 ,<br />
Mehmet Gündüz 6 , Burak Yılmaz 1 , Sezgin Etgül 5 , Seda Aydın 5 , Tuncay Aslan 5 , Nilgün Sayınalp 5 , Salih Aksu 5 , Haluk Demiroğlu 5 ,<br />
Osman İ. Özcebe 5 , Yahya Büyükaşık 5 , Hakan Göker 5<br />
1Sentegen Biotechnology, Ankara, Turkey<br />
2Bilkent University Faculty <strong>of</strong> Science, Department <strong>of</strong> Molecular Biology and Genetics, Ankara, Turkey<br />
3METU Graduate School <strong>of</strong> Informatics Institute, Health Informatics Program, Clinic <strong>of</strong> Bioinformatics, Ankara, Turkey<br />
4Hacettepe University Faculty <strong>of</strong> Pharmacy, Department <strong>of</strong> Biochemistry, Ankara, Turkey<br />
5Hacettepe University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Internal Medicine, Division <strong>of</strong> <strong>Hematology</strong>, Ankara, Turkey<br />
6Atatürk Training and Research Hospital, Clinic <strong>of</strong> <strong>Hematology</strong>, Ankara, Turkey<br />
Abstract<br />
Objective: Multiple myeloma (MM) is currently incurable due to<br />
refractory disease relapse even under novel anti-myeloma treatment.<br />
In silico studies are effective for key decision making during<br />
clinicopathological battles against the chronic course <strong>of</strong> MM. The aim<br />
<strong>of</strong> this present in silico study was to identify individual genes whose<br />
expression pr<strong>of</strong>iles match that <strong>of</strong> the one generated by cytotoxicity<br />
experiments for bortezomib.<br />
Materials and Methods: We used an in silico literature mining<br />
approach to identify potential biomarkers by creating a summarized<br />
set <strong>of</strong> metadata derived from relevant information. The E-MTAB-783<br />
dataset containing expression data from 789 cancer cell lines<br />
including 8 myeloma cell lines with drug screening data from the<br />
Wellcome Trust Sanger Institute database obtained from ArrayExpress<br />
was “Robust Multi-array analysis” normalized using GeneSpring<br />
v.12.5. Drug toxicity data were obtained from the Genomics <strong>of</strong> Drug<br />
Sensitivity in Cancer project. In order to identify individual genes<br />
whose expression pr<strong>of</strong>iles matched that <strong>of</strong> the one generated by<br />
cytotoxicity experiments for bortezomib, we used a linear regressionbased<br />
approach, where we searched for statistically significant<br />
correlations between gene expression values and IC50 data. The<br />
intersections <strong>of</strong> the genes were identified in 8 cell lines and used for<br />
further analysis.<br />
Results: Our linear regression model identified 73 genes and some<br />
genes expression levels were found to very closely correlated with<br />
bortezomib IC50 values. When all 73 genes were used in a hierarchical<br />
Amaç: Multipl miyelom (MM) günümüzde uygulanan yeni MM<br />
tedavilerine rağmen, refrakter hastalığın relapsı nedeniyle kür<br />
edilemeyen bir hastalıktır. In silico çalışmalar, MM’nin kronik seyrine<br />
karşı verilen klinikopatolojik savaşta alınan kararlar açısından oldukça<br />
önemlidir. Buradaki in silico çalışmanın amacı, bortezomib için<br />
yapılmış sitotoksisite çalışmalarında ortaya çıkan genlerle eşleşen<br />
özgün genleri ortaya koymaktır.<br />
Gereç ve Yöntemler: Biz bu çalışmada, potansiyel biyobelirteçleri<br />
ortaya koymak için araştırma konusuna uygun bir şekilde türetilmiş<br />
özetleyici veri seti üreterek in silico literatür taraması gerçekleştirdik.<br />
“Wellcome Trust Sanger” enstitüsünün 8 miyelom hücre serisi de olmak<br />
üzere toplam 789 kanser hücre serisini ilaç tarama verileriyle beraber<br />
içeren E-MTAB-783 veri seti ArrayExpress’den elde edilip, GeneSpring<br />
v.12.5 kullanılarak “Robust Multi-array analysis” normalize edildi. İlaç<br />
toksisite verisi “Genomics <strong>of</strong> Drug Sensitivity in Cancer” projesinden<br />
elde edildi. Biz bu çalışmada, eşleşen genleri saptamak amacıyla, gen<br />
ekspresyon değerleri ve IC50 verileri arasındaki istatistiksel açıdan<br />
anlamlı korelasyonları lineer regresyon temelli yaklaşım uygulayarak<br />
araştırdık. Sekiz hücre serisinde gen kesişimi tespit edildi ve bu hücre<br />
serileri ileri analiz için kullanıldı.<br />
Bulgular: Kullandığımız lineer regresyon modeli sayesinde 73 genin<br />
ve bazı gen ekspresyon düzeylerinin, bortezomibin IC50 değeri ile çok<br />
yakın korelasyon gösterdiğini tespit ettik. Tüm 73 geni hiyerarşik küme<br />
analizi ile incelediğimizde, iki ana kümede toplanan hücrelerin, görece<br />
duyarlı ve dirençli hücreler olduğunu gördük. Bütün önemli genlerin<br />
Öz<br />
Address for Correspondence/Yazışma Adresi: İbrahim C. HAZNEDAROĞLU, M.D.,<br />
Hacettepe University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Internal Medicine, Division <strong>of</strong> <strong>Hematology</strong>, Ankara, Turkey<br />
Phone : +90 312 305 15 43<br />
E-mail : ichaznedaroglu@gmail.com<br />
Received/Geliş tarihi: April 02, 2015<br />
Accepted/Kabul tarihi: February 08, 2016<br />
286
Turk J Hematol 2016;<strong>33</strong>:286-292<br />
Ghasemi M, et al: Identification <strong>of</strong> Individual Genes for Bortezomib<br />
cluster analysis, two major clusters <strong>of</strong> cells representing relatively<br />
sensitive and resistant cells could be identified. Pathway and molecular<br />
function analysis <strong>of</strong> all the significant genes was also investigated, as<br />
well as the genes involved in pathways.<br />
Conclusion: The findings <strong>of</strong> our present in silico study could be<br />
important not only for the understanding <strong>of</strong> the genomics <strong>of</strong> MM<br />
but also for the better arrangement <strong>of</strong> the targeted anti-myeloma<br />
therapies, such as bortezomib.<br />
Keywords: Myeloma and other plasma cell dyscrasias, Neoplasia,<br />
Cytogenetics, Gene therapy, Molecular hematology<br />
moleküler yolak ve fonksiyon analizi, yolaklara dahil olan genlerle<br />
beraber incelenmiştir.<br />
Sonuç: Gerçekleştirdiğimiz bu in silico çalışmada ortaya konan veriler,<br />
MM genomiğinin anlaşılması ve bortezomib gibi hedefe yönelik<br />
miyelom tedavilerinin daha iyi yönetilebilmesi açısından önemlidir.<br />
Anahtar Sözcükler: Miyelom ve diğer plazma hücre diskrazileri,<br />
Neoplazi, Sitogenetik, Gen terapisi, Moleküler hematoloji<br />
Introduction<br />
Multiple myeloma (MM) is clinically, cytogenetically, and<br />
molecularly a very heterogeneous complicated neoplastic<br />
hematological disorder [1]. Numerous intra- and intercellular<br />
interactions, soluble/membrane-bound factors, and cell cycle<br />
machineries [2] represent potential targets <strong>of</strong> drug treatments in<br />
patients with MM [3]. Therefore, virtual drug treatments aimed<br />
at different targets can be explored using the computational<br />
models. Bortezomib is a targeted therapeutic drug for MM with<br />
high affinity, specificity, and selectivity for catalytic activity<br />
<strong>of</strong> proteasome. Bortezomib induces apoptosis in MM, inhibits<br />
the activation <strong>of</strong> nuclear factor-κB, suppresses survival <strong>of</strong> MM<br />
cells, and inhibits interleukin-6 triggered MM-cell proliferation,<br />
as well as inhibiting MM-cell adhesion in the bone marrow<br />
microenvironment [3,4,5,6,7]. Accurate preclinical predictions<br />
<strong>of</strong> the clinical efficacy <strong>of</strong> anti-MM drugs are needed.<br />
MM is currently incurable due to refractory disease relapse even<br />
under novel anti-myeloma treatment [8]. Current challenges for<br />
the management <strong>of</strong> MM, including bortezomib drug treatment,<br />
are resistance development to drugs, increased unsustainable<br />
cost [9,10], lack <strong>of</strong> standardization in the therapeutic steps<br />
including stem cell transplantation, and morbidity and<br />
mortality due to drugs and/or ongoing resistant incurable<br />
neoplastic myeloma disease [4,5,11,12,13]. In silico studies are<br />
effective for key decision making during clinicopathological<br />
battles against the chronic course <strong>of</strong> MM [3,7,14,15]. The aim<br />
<strong>of</strong> this present in silico study is to identify individual genes<br />
whose expression pr<strong>of</strong>iles match that <strong>of</strong> the one generated by<br />
cytotoxicity experiments for bortezomib. Elucidation <strong>of</strong> the<br />
gene expression pr<strong>of</strong>iles (GEP) <strong>of</strong> the proteasome inhibitors in<br />
the pharmacobiological basis <strong>of</strong> MM is extremely important for<br />
the clinical activity <strong>of</strong> anti-MM drugs with regards to effectivity,<br />
safety, tolerability, toxicity, and pharmacoeconomy. The use <strong>of</strong><br />
predictive simulation technology seems to be vital in designing<br />
therapeutics for targeting novel biological mechanisms using<br />
existing or novel chemistry [16].<br />
Materials and Methods<br />
Public Expression and Drug Cytotoxicity Data<br />
The myeloma cell line expression data were retrieved from<br />
ArrayExpress (E-MTAB-783) and consisted <strong>of</strong> transcriptomic<br />
pr<strong>of</strong>iles <strong>of</strong> 789 cancer cell lines from various types <strong>of</strong> cancer.<br />
Seven myeloma cell lines (ARH-77, IM-9, LP-1, L-363, OPM-<br />
2, RPMI-8226, and SK-MM-2) among the 789 cell lines were<br />
selected to be used in analyses after quality control. The drug<br />
cytotoxicity data <strong>of</strong> bortezomib, on the other hand, were<br />
retrieved from the Genomics <strong>of</strong> Drug Sensitivity in Cancer<br />
database <strong>of</strong> the Wellcome Trust Sanger Institute (http://www.<br />
cancerrxgene.org).<br />
Expression Data Preprocessing<br />
GeneSpring s<strong>of</strong>tware version 12.5 was used to extract raw data<br />
and background corrected gene expression data were generated.<br />
Further preprocessing was done using the Affy package for R<br />
and “Robust Multi-array analysis” normalization was applied to<br />
the data according to the Affy procedure.<br />
In Silico Classification <strong>of</strong> Myeloma Cell Lines and Identification<br />
<strong>of</strong> Candidate Gene Biomarkers<br />
We used an in silico literature mining approach to identify<br />
potential biomarkers by creating a summarized set <strong>of</strong> metadata<br />
derived from relevant information [17,18,19]. To do that, a linear<br />
regression model was used to discover genes whose expression<br />
pr<strong>of</strong>iles correlated with bortezomib sensitivity as measured<br />
for 7 myeloma cell lines by IC50 values from the Genomics <strong>of</strong><br />
Drug Sensitivity in Cancer database. All genes with a Pearson’s<br />
correlation coefficient related p-value below 0.01 and Pearson<br />
product-moment correlation coefficient value (r-value) higher<br />
than 0.9 were considered as candidate biomarker genes.<br />
Myeloma cell lines (SK-MM-2, OPM-2, U-266, RPMI-8226,<br />
ARH-77, L-363, IM-9, and LP-1) were hierarchically clustered<br />
based on determined biomarker genes, with Euclidian distance<br />
measures for both genes and arrays and complete linkage,<br />
using Cluster 3.0 s<strong>of</strong>tware. In addition, we mapped these genes<br />
in biological pathways by using the Protein ANalysis THrough<br />
Evolutionary Relationships (PANTHER) classification system<br />
tool. The gene expression levels <strong>of</strong> cell lines were correlated<br />
with drug screening data (IC50 data) <strong>of</strong> bortezomib from the<br />
Wellcome Trust Sanger Institute Database. Drug toxicity data<br />
were obtained from the Genomics <strong>of</strong> Drug Sensitivity in Cancer<br />
project (http://www.cancerrxgene.org).<br />
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Results<br />
In order to identify individual genes whose expression pr<strong>of</strong>iles<br />
matched that <strong>of</strong> the one generated by cytotoxicity experiments<br />
for bortezomib, we used a linear regression-based approach,<br />
where we searched for statistically significant correlations<br />
between gene expression values and IC50 data [17,18,19]. The<br />
intersections <strong>of</strong> the genes were identified in 7 cell lines and<br />
used for further analysis. IC50 values <strong>of</strong> 7 MM cell lines after 72<br />
h <strong>of</strong> treatment with bortezomib are shown in Figure 1. In this<br />
figure cells are sorted based on their sensitivity to bortezomib.<br />
Our linear regression model identified 73 genes. Genes with very<br />
good concordance between expression levels and bortezomib<br />
IC50 values are shown in Figure 2. When all 73 genes were used<br />
in a hierarchical cluster analysis, two major clusters <strong>of</strong> cells<br />
representing relatively sensitive and resistant cells could be<br />
identified, as seen in Figure 3. Pathway and molecular function<br />
analysis <strong>of</strong> all the significant genes is shown in Figure 4. Table<br />
1 shows the genes involved in pathways. Table 1 also presents<br />
the families and subfamilies <strong>of</strong> these genes, suggesting that<br />
other members <strong>of</strong> these families might have effects on and<br />
responsibility for drug resistance. All <strong>of</strong> the proteins coded by<br />
these genes have key roles in cancer progression and some in<br />
metastasis.<br />
Figure 3. Clustering <strong>of</strong> multiple myeloma cell lines based on<br />
candidate gene biomarkers. Hierarchical clustering <strong>of</strong> myeloma<br />
cell lines according to 73 genes whose expressions show significant<br />
association with bortezomib chemosensitivity. Two major clusters<br />
are demonstrable, one containing relatively resistant cells and<br />
one containing less sensitive cells.<br />
Figure 1. IC50 values for myeloma cell lines. As can be seen,<br />
the most resistant cell line to bortezomib is IM-9, while OPM-2<br />
presents the most sensitive pr<strong>of</strong>ile.<br />
Figure 2. The correlation between gene expression and bortezomib<br />
IC50 values. Fifty-three genes are positively correlated with drug<br />
resistance while the rest show negative correlations.<br />
Figure 4. Biological pathway and molecular function analysis:<br />
A) biological pathway analysis <strong>of</strong> the genes whose expressions<br />
are correlated with bortezomib resistance in multiple myeloma<br />
cell lines; B) molecular function analyses <strong>of</strong> 73 genes that show<br />
a significant correlation with bortezomib resistance in multiple<br />
myeloma cell lines.<br />
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Table 1. List <strong>of</strong> genes involved in specific pathways. The genes presented in this table are outcomes <strong>of</strong> Pearson correlation analysis done by using bortezomib<br />
chemosensitivity data and gene expression data for the multiple myeloma cell lines.<br />
Pathway Mapped<br />
ID<br />
Angiogenesis<br />
Cadherin signaling pathway<br />
Gonadotropin releasing hormone receptor pathway<br />
Gene Name/Gene Symbol PANTHER Family/Subfamily PANTHER Protein Class Species<br />
FGF2 FGF2; ortholog Fibroblast growth factor 2<br />
(PTHR11486:SF68)<br />
Growth factor Homo sapiens<br />
KRAS GTPase KRas; KRAS; ortholog GTPase KRAS (PTHR24070:SF186) Small GTPase Homo sapiens<br />
CDHS Cadherin 5; CDH5; ortholog Cadherin-5 (PTHR24027:SF89) Cell junction protein; cadherin Homo sapiens<br />
CSNK2A2 Casein kinase II subunit al pha’; CSNK2A2; ort Casein kinase II subunit alpha’<br />
(PTHR24054:SF3)<br />
SMAD4 Mothers against decapentaplegic homolog Mothers against decapentaplegic<br />
homolog 4<br />
Homo sapiens<br />
Transcription factor Homo sapiens<br />
GNAO1 Guanine nudeotide-binding protein G(o) subunit Guanine nucleotide-binding protein Heterotrimeric G- protein Homo sapiens<br />
Iflammation mediated by chemokine and cytokine signaling pathway<br />
Integrin signalling pathway<br />
Ubiquitin<br />
proteasome pathway<br />
Wnt signaling pathway<br />
FGF2: Fibroblast growth factor 2.<br />
ARRB2 Beta-arrestin-2; ARRB2; ortholog Beta-arrestin-2 (PTHR11792:SF20) Enzyme modulator Homo sapiens<br />
RGS4 Regulator <strong>of</strong> G protein signaling 4 Regulator <strong>of</strong> G protein signaling 4<br />
(PTHR10845:SF40)<br />
G protein modulator Homo sapiens<br />
GNAO1 Guanine nucleotide binding protein G (0) subunit Guanine nucleotide binding protein Heterotrimeric G protein Homo sapiens<br />
KRAS GTPase KRas; KRAS; ortholog GTPase KRAS (PTHR24070:SF186) Small GTPase Homo sapiens<br />
COL1A2 Collagen alpha-2(I) chain; COL1A2; ortholog Collagen alpha- 2(I) chain<br />
(PTHR24023:SF441)<br />
Transporter; surfactant; receptor;<br />
extracellular matrix<br />
Homo sapiens<br />
KRAS GTPase KRas; KRAS; ortholog GTPase KRAS (PTHR24070:SF186) Small GTPase Homo sapiens<br />
PSMD8 26S proteasome non- ATPase regulatory subunit 26S Proteasome non-atpase regulatory Enzyme modulator Homo sapiens<br />
ARRB2 Beta-arrestin-2; ARRB2; ortholog Beta-arrestin-2 (PTHR11792:SF20) Enzyme modulator Homo sapiens<br />
CDHS Cadherin 5; CDH5; ortholog Cadherin-5 (PTHR24027:SF89) Cell junction<br />
protein; cadherin<br />
SMAD4 Mothers against decapentaplegic omolog Mothers against decapentaplegic<br />
homolog 4<br />
CSNK2A2 Casein kinase II subunit al pha’; CSNK2A2; ort Casein kinase II subunit alpha’<br />
(PTHR24054:SF3)<br />
Homo sapiens<br />
Transcription factor Homo sapiens<br />
Homo sapiens<br />
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Discussion<br />
In this in silico study, the hierarchical clustering <strong>of</strong> myeloma cell<br />
lines according to bortezomib hemosensitivity biomarker genes<br />
has been described. The heat map represented the clustering <strong>of</strong> 8<br />
myeloma cell lines based on 73 genes disclosing either bortezomib<br />
resistance or less sensitive myeloma cells. Likewise, the concordances<br />
between gene expression and IC50 values <strong>of</strong> 8 myeloma cell lines<br />
are shown for 73 genes. Furthermore, the relevant biological<br />
pathway analyses <strong>of</strong> the genes whose expressions are concordant<br />
with bortezomib cytotoxicity were explored via the molecular<br />
functional analyses <strong>of</strong> the 73 genes (Figures 2, 3, and 4). The genes<br />
involved in specific pathways regarding the proteasome inhibitors,<br />
and particularly bortezomib, are related to the critical pathological<br />
events <strong>of</strong> MM such as tumor angiogenesis and neoplastic signaling<br />
pathways (cadherin, integrin, Wnt, GnRH, ubiquitin), as well as<br />
chemokine-mediated inflammation (Table 1). Those pathways<br />
are essentially important in the biology <strong>of</strong> myeloma, such as the<br />
ubiquitin proteasome system, which plays a role in the regulation<br />
<strong>of</strong> most cellular pathways, and its deregulation in MM represents a<br />
target for proteasome inhibition via bortezomib [20]. Proliferation<br />
and apoptosis pathways are pathologically regulated by the<br />
ubiquitin-proteasome system, resulting in cellular neoplastic<br />
transformation in MM [21]. Targeting pathological angiogenesis<br />
in MM via bortezomib may delay tumor growth and reduce<br />
cytokine paracrine loops mediated by angiogenic factors [22].<br />
Meanwhile, the signal transducers and activators <strong>of</strong> transcription<br />
proteins represent a family <strong>of</strong> cytoplasmic transcription factors<br />
that regulate a pleiotropic range <strong>of</strong> biological processes in MM<br />
[23]. Cell-cell interactions and cancer-initiating cells further<br />
complicate the biology <strong>of</strong> MM [24]. A previous study, in accordance<br />
with our present results, examined gene ontogeny related to<br />
bortezomib and suggested involvement in cellular development<br />
and carcinogenesis [25].<br />
In the present study, by performing in silico correlation analysis,<br />
we determined genes whose expressions are correlated with<br />
bortezomib chemosensitivity in MM cell lines. Among 73<br />
genes that are highly correlated with drug-resistant response<br />
(absolute Pearson r-value <strong>of</strong> >0.80), 20 genes showed a reverse<br />
correlation with chemosensitivity to bortezomib. This means that<br />
overexpression <strong>of</strong> these genes makes cancer cells more sensitive<br />
to bortezomib and the expressions <strong>of</strong> these genes are associated<br />
with good prognosis. Conversely, 53 genes are positively correlated<br />
to bortezomib response and make cells more resistant to drug<br />
treatment, and overexpression <strong>of</strong> these genes is associated with<br />
poor prognosis (supplementary data). We also tried to determine<br />
the pathways in which these genes are involved and figure out<br />
the relation between outcome and MM drug resistance pr<strong>of</strong>ile by<br />
using another classification system. The PANTHER classification<br />
system was designed to classify proteins and their genes in order to<br />
facilitate high-throughput analysis. Proteins have been classified<br />
according to family and subfamily, molecular function, biological<br />
process, and pathway. Further in vitro and clinical validation studies<br />
are needed to determine and validate the exact role <strong>of</strong> each gene<br />
or panel <strong>of</strong> genes that are suggested in the present study as gene<br />
biomarkers for bortezomib-resistant response in MM cancer.<br />
In 2007 Mulligan et al. assessed the feasibility <strong>of</strong> prospective<br />
pharmacogenomics research in multicenter international clinical<br />
trials <strong>of</strong> bortezomib in MM [26]. They tried to highlight those genes<br />
whose expressions are related to drug response and survival using<br />
bone marrow clinical samples by performing gene set enrichment<br />
analysis, analysis <strong>of</strong> clinical response, and overall survival analysis.<br />
The present study has two main differences from that study in<br />
terms <strong>of</strong> genomic approach and databases used. Our database<br />
came from established MM cell lines and the genomic approach<br />
was analysis <strong>of</strong> correlations between gene expression and drug<br />
response. Despite the two different approaches, we can see that<br />
many genes in this study and in that <strong>of</strong> Mulligan et al. overlap. On<br />
the other hand, our analysis shows some other genes that are able<br />
to predict response to bortezomib.<br />
Cancer cell lines have a notable role in cancer drug discovery.<br />
Jaeger et al. found that drug sensitivity in cancer cell lines is not<br />
tissue-specific and recommended that, to get the most trustable<br />
results using cell lines, it will be necessary to include those cell<br />
lines’ molecular characteristics [27]. Similarly, in this experiment we<br />
did integrate those data into biological analysis, such as pathway<br />
analysis and hierarchical clustering.<br />
The overall results <strong>of</strong> the present data mining study reveal the<br />
complicated nature <strong>of</strong> MM [28] and locate the drug bortezomib at<br />
the critical crossroads <strong>of</strong> the pathobiology <strong>of</strong> the disease, driving<br />
the clinical course <strong>of</strong> MM. For instance, the LP-1 cell line was<br />
found to be resistant to bortezomib in our present study (Figure<br />
3). A previous study suggested that the expression <strong>of</strong> Apaf-1 might<br />
be predictive <strong>of</strong> the response to proteasome inhibition [29]. Based<br />
on our present results, patients with MM mimicking the molecular<br />
pr<strong>of</strong>ile/behavior <strong>of</strong> LP-1 at any clinical evaluation point during the<br />
long-term clinical course <strong>of</strong> MM will be candidates for therapeutic<br />
regimens other than bortezomib. Ideally, those multiresistant<br />
MM patients should be single- or multiple-transplanted based<br />
on individual clinical responses [14]. We intend to test these<br />
hypotheses in future experiments designed to examine genomic<br />
pr<strong>of</strong>iles <strong>of</strong> the biological samples obtained from our MM patient<br />
cohort.<br />
The results <strong>of</strong> our present study represent the rational basis<br />
for future molecular studies dealing with biological myeloma<br />
samples (peripheral blood and/or bone marrow) obtained from<br />
‘real-life’ patients with MM. This issue is not just academically<br />
important since the proper selection <strong>of</strong> anti-myeloma drugs<br />
in everyday clinical practice during the long-term incurable<br />
advanced clinical forms <strong>of</strong> MM is challenging even to the<br />
most skilled clinicians. Randomized clinical trials (RCTs) usually<br />
compare drugs but do not decide on treatment strategies and<br />
proper selection <strong>of</strong> drug combinations [30], particularly for<br />
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Ghasemi M, et al: Identification <strong>of</strong> Individual Genes for Bortezomib<br />
the handicapped myeloma patients with already present organ<br />
toxicities that are usually excluded from RCTs [12,13,31]. For reallife<br />
myeloma clinics, the pharmacobiological pr<strong>of</strong>ile <strong>of</strong> the antimyeloma<br />
drug together with the resistance pr<strong>of</strong>ile [32] should<br />
be determined with the corresponding pathobiology <strong>of</strong> the MM<br />
disease course. This molecular approach could be particularly<br />
important for making decisions about hematopoietic stem cell<br />
transplantation for MM [14].<br />
MM is a very heterogeneous disease [1]. Genetic changes could play<br />
a major role in prognosis in MM. However, in contrast to leukemias,<br />
no “good-risk” abnormalities have been described. Molecular<br />
analyses using GEP dissected the genetic basis <strong>of</strong> MM. Although<br />
various GEP-based signatures have been reported to identify highrisk<br />
myeloma disease and predict prognosis, the inability <strong>of</strong> GEP to<br />
predict clinical response in MM is also evident [1].<br />
Barlogie et al., Shaughnessy et al., and Shaughnessy et al. showed<br />
the advantages <strong>of</strong> using GEP data to elucidate the molecular basis<br />
<strong>of</strong> resistance to chemotherapy as well as classification <strong>of</strong> MM<br />
patients in terms <strong>of</strong> poor prognosis and risk <strong>of</strong> relapse [<strong>33</strong>,34,35].<br />
In this study, we determined those genes whose expressions are in<br />
correlation with bortezomib using GEP data.<br />
Khin et al. generated patient-individualized estimations <strong>of</strong> initial<br />
response to chemotherapeutic agents in MM and time to relapse<br />
[36]. They designated an experimental platform with the specific<br />
intent <strong>of</strong> generating experimental parameters for a computational<br />
clinical model <strong>of</strong> personalized therapy in MM, while taking into<br />
consideration the limitations <strong>of</strong> working with patient primary<br />
cells and the need to incorporate elements <strong>of</strong> the myeloma tumor<br />
microenvironment. They suggested that myeloma patient-specific<br />
computational models, parameterized by in vitro platforms,<br />
could be combined with genomic datasets to better understand<br />
drug resistance in MM. Wang et al. developed a computational<br />
model <strong>of</strong> MM-bone marrow microenvironment interactions and<br />
clarified that intercellular signaling mechanisms implemented in<br />
this model appropriately drive MM disease progression [37]. Our<br />
findings in the present study also indicated that an understanding<br />
<strong>of</strong> the genomic myeloma dynamics might be useful for predictions<br />
<strong>of</strong> disease prognosis, as well as for proposing better therapeutic<br />
strategies for each patient with MM.<br />
Bortezomib is able to induce tumor cell death by degradation <strong>of</strong><br />
key proteins. It is employed as a first-line treatment in relapsed or<br />
resistant MM patients. However, bortezomib <strong>of</strong>ten induces a doselimiting<br />
toxicity in the form <strong>of</strong> painful sensory neuropathy, which<br />
can mainly be reduced by subcutaneous administration or dose<br />
modification. Richardson et al. showed that some <strong>of</strong> the genes<br />
that are shown to related to bortezomib resistancy in the present<br />
study are also interestingly related to bortezomib-associated<br />
neurotoxicity [38]. It is suggested that those genes are involved in<br />
the pathways that control toxicity and resistancy [26,38].<br />
The findings <strong>of</strong> our present in silico study could be important<br />
not only for the understanding <strong>of</strong> the genomics <strong>of</strong> MM but also<br />
for the better arrangement <strong>of</strong> targeted anti-myeloma therapies,<br />
such as bortezomib. Improvement in the understanding <strong>of</strong> MM<br />
pathogenesis will refine the molecular dissection <strong>of</strong> the disease,<br />
especially in the context <strong>of</strong> novel anti-myeloma drugs affecting<br />
the disease course. Genomics, proteomics, transcriptomics, and<br />
metabolomics studies (in silico, in vitro, in vivo) should be integrated<br />
to understand their significance in the management <strong>of</strong> MM, as<br />
well as to <strong>of</strong>fer better therapeutics and treatment strategies to<br />
patients with MM.<br />
Ethics<br />
Ethics Committee Approval: The research was performed in an in<br />
silico setting. Therefore, evaluation <strong>of</strong> the ethics committee was<br />
not required; Informed Consent: N/A.<br />
Authorship Contributions<br />
Concept: Mehdi Ghasemi, Semih Alpsoy, Seyhan Türk, Ümit Y.<br />
Malkan, Şükrü Atakan, İbrahim C. Haznedaroğlu, Gürsel Güneş,<br />
Mehmet Gündüz, Burak Yılmaz, Sezgin Etgül, Seda Aydın, Tuncay<br />
Aslan, Nilgün Sayınalp, Salih Aksu, Haluk Demiroğlu, Osman İ.<br />
Özcebe, Yahya Büyükaşık, Hakan Göker; Design: Mehdi Ghasemi,<br />
Semih Alpsoy, Seyhan Türk, Ümit Y. Malkan, Şükrü Atakan, İbrahim<br />
C. Haznedaroğlu, Gürsel Güneş, Mehmet Gündüz, Burak Yılmaz,<br />
Sezgin Etgül, Seda Aydın, Tuncay Aslan, Nilgün Sayınalp, Salih<br />
Aksu, Haluk Demiroğlu, Osman İ. Özcebe, Yahya Büyükaşık, Hakan<br />
Göker; Data Collection or Processing: Mehdi Ghasemi, Semih<br />
Alpsoy, Seyhan Türk, Ümit Y. Malkan, Şükrü Atakan, İbrahim C.<br />
Haznedaroğlu, Gürsel Güneş, Mehmet Gündüz, Burak Yılmaz,<br />
Sezgin Etgül, Seda Aydın, Tuncay Aslan, Nilgün Sayınalp, Salih Aksu,<br />
Haluk Demiroğlu, Osman İ. Özcebe, Yahya Büyükaşık, Hakan Göker;<br />
Analysis or Interpretation: Mehdi Ghasemi, Semih Alpsoy, Seyhan<br />
Türk, Ümit Y. Malkan, Şükrü Atakan, İbrahim C. Haznedaroğlu, Gürsel<br />
Güneş, Mehmet Gündüz, Burak Yılmaz, Sezgin Etgül, Seda Aydın,<br />
Tuncay Aslan, Nilgün Sayınalp, Salih Aksu, Haluk Demiroğlu, Osman<br />
İ. Özcebe, Yahya Büyükaşık, Hakan Göker; Literature Search: Mehdi<br />
Ghasemi, Semih Alpsoy, Seyhan Türk, Ümit Y. Malkan, Şükrü Atakan,<br />
İbrahim C. Haznedaroğlu, Gürsel Güneş, Mehmet Gündüz, Burak<br />
Yılmaz, Sezgin Etgül, Seda Aydın, Tuncay Aslan, Nilgün Sayınalp,<br />
Salih Aksu, Haluk Demiroğlu, Osman İ. Özcebe, Yahya Büyükaşık,<br />
Hakan Göker; Writing: Mehdi Ghasemi, Semih Alpsoy, Seyhan Türk,<br />
Ümit Y. Malkan, Şükrü Atakan, İbrahim C. Haznedaroğlu, Gürsel<br />
Güneş, Mehmet Gündüz, Burak Yılmaz, Sezgin Etgül, Seda Aydın,<br />
Tuncay Aslan, Nilgün Sayınalp, Salih Aksu, Haluk Demiroğlu, Osman<br />
İ. Özcebe, Yahya Büyükaşık, Hakan Göker.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts <strong>of</strong><br />
interest, including specific financial interests, relationships, and/or<br />
affiliations relevant to the subject matter or materials included.<br />
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292
RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2015.0087<br />
Turk J Hematol 2016;<strong>33</strong>:293-298<br />
The Effect <strong>of</strong> Hyperparathyroid State on Platelet Functions and<br />
Bone Loss<br />
Hiperparatiroidi Durumun Trombosit Fonksiyonları ve Kemik Kaybı Üzerine Olan Etkisi<br />
Göknur Yorulmaz 1 , Aysen Akalın 2 , Olga Meltem Akay 3 , Garip Şahin 4 , Cengiz Bal 5<br />
1Eskişehir State Hospital, Clinic <strong>of</strong> Endocrinology, Eskişehir, Turkey<br />
2Eskişehir Osmangazi University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Endocrinology, Eskişehir, Turkey<br />
3Eskişehir Osmangazi University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Eskişehir, Turkey<br />
4Eskişehir Osmangazi University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Nephrology, Eskişehir, Turkey<br />
5Eskişehir Osmangazi University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Biostatistics and Medical Informatics, Eskişehir, Turkey<br />
Abstract<br />
Objective: Coagulation and fibrinolysis defects were reported in<br />
primary hyperparathyroid patients. However, there are not enough<br />
data regarding platelet functions in this group <strong>of</strong> patients. Our aim<br />
was to evaluate the platelet functions in primary and secondary<br />
hyperparathyroid patients and to compare them with healthy subjects.<br />
Materials and Methods: In our study 25 subjects with primary<br />
hyperparathyroidism (PHPT), 25 subjects with secondary<br />
hyperparathyroidism (SHPT), and 25 healthy controls were included.<br />
Platelet functions <strong>of</strong> the subjects were evaluated by using plateletrich<br />
plasma and platelet aggregation tests induced with epinephrine,<br />
adenosine diphosphate (ADP), collagen, and ristocetin. Serum P<br />
selectin levels, which indicate platelet activation level, were measured<br />
in all subjects. Bone mineral densitometry was performed for all<br />
patients.<br />
Results: There was no significant difference between the groups<br />
with PHPT and SHPT and the control group regarding the platelet<br />
aggregation tests and serum P selectin levels. There was also no<br />
significant correlation between parathormone levels and aggregation<br />
parameters (ristocetin, epinephrine, collagen, and ADP: respectively<br />
p=0.446, 0.537, 0.346, and 0.302) and between P selectin (p=0.516)<br />
levels. When we separated the patients according to serum calcium<br />
levels, there was also no significant difference between aggregation<br />
parameters and serum P selectin levels between the patients with<br />
hypercalcemia and the patients with normocalcemia. We could not<br />
find any significant correlation between aggregation parameters, P<br />
selectin levels, and serum calcium levels in this group <strong>of</strong> patients.<br />
Bone loss was greater in patients with PHPT.<br />
Conclusion: There is no significant effect <strong>of</strong> PHPT or SHPT and serum<br />
calcium levels on platelet functions when evaluated by aggregation<br />
tests.<br />
Keywords: Hyperparathyroidism, Platelet function, P selectin,<br />
Calcium, Bone loss<br />
Öz<br />
Amaç: Koagülasyon ve fibrinoliz bozuklukları primer hiperparatiroidili<br />
hastalarda rapor edilmekle beraber bu hasta grubunda trombosit<br />
işlevlerine ilişkin yeterli veri yoktur. Bu nedenle primer ve sekonder<br />
hiperparatiroidisi olan hastalarda ve sağlıklı kontrol grubunda<br />
trombosit fonksiyonlarını değerlendirmeyi ve gruplar arasında farkı<br />
karşılaştırmayı amaçladık.<br />
Gereç ve Yöntemler: Çalışmamıza 25 primer hiperparatiroidisi<br />
(PHPT) olan hasta, 25 sekonder hiperparatiroidisi (SHPT) olan hasta<br />
ve 25 kontrol grubu dahil edildi. Trombosit fonksiyonları trombositten<br />
zengin plazma ve epinefrin, adenozin difosfat (ADP), kollajen ve<br />
ristosetinle trombosit agregasyon testleri yapılarak değerlendirildi.<br />
Trombosit aktivasyon düzeyini gösteren serum P selektin düzeyleri<br />
tüm hastalarda ölçüldü. Kemik mineral dansitometresi tüm hastalarda<br />
değerlendirildi.<br />
Bulgular: PHPT ve SHPT’li hastalar ve kontrol grubunun trombosit<br />
fonksiyon testleri ve serum P selektin düzeyleri arasında istatistiksel<br />
açıdan anlamlı bir fark saptanmadı. Parathormon düzeyi ile agregasyon<br />
parametreleri (ristosetin, epinefrin, kollajen, ve ADP: sırasıyla p=0,446,<br />
0,537, 0,346 ve 0,302) ve P selektin (p=0,516) düzeyi arasında da<br />
anlamlı bir korelasyon saptanmadı. Hastalar kalsiyum düzeylerine<br />
göre hiperkalsemik ve normokalsemik olarak ayrıldıklarında da<br />
agregasyon parametreleri ve P selektin düzeyleri arasında anlamlı fark<br />
saptanmadı. Hasta gruplarımızda trombosit fonksiyonları, P selektin<br />
düzeyi, serum kalsiyum düzeyileri arasında istatistiksel açıdan anlamlı<br />
fark bulunmadı. Kemik kaybı PHPT’li olan grupta daha belirgindi.<br />
Sonuç: Agregasyon testleri ile değerlendirildiğinde PHPT veya SHPT ve<br />
serum kalsiyum düzeylerinin trombosit fonksiyonları üzerine belirgin<br />
etkisi yoktur.<br />
Anahtar Sözcükler: Hiperparatiroidism, Trombosit fonksiyonları, P<br />
selektin, Kalsiyum, Kemik kaybı<br />
Address for Correspondence/Yazışma Adresi: Göknur YORULMAZ, M.D.,<br />
Eskişehir State Hospital, Clinic <strong>of</strong> Endocrinology, Eskişehir, Turkey<br />
Phone : +90 505 866 58 83<br />
E-mail : goknuryorulmaz@hotmail.com<br />
Received/Geliş tarihi: February 20, 2015<br />
Accepted/Kabul tarihi: June 15, 2015<br />
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Introduction<br />
Hemostasis is regulated by a balance between stimulators and<br />
inhibitors <strong>of</strong> platelet functions. The deterioration <strong>of</strong> the balance<br />
between inhibitors and stimulators <strong>of</strong> platelet functions results<br />
in thrombosis or bleeding. Platelets are involved in primary<br />
hemostasis, which includes the formation <strong>of</strong> a plug by the<br />
adhesion and activation <strong>of</strong> platelets in response to vascular<br />
damage or the loss <strong>of</strong> integrity <strong>of</strong> the vascular wall. Many<br />
physiological stimuli can activate platelets both in vivo and in<br />
vitro, such as collagen, proteolytic enzymes, and low-molecularweight<br />
compounds. Clinically platelet functions are evaluated<br />
by platelet aggregation and activation tests [1,2]. The use <strong>of</strong><br />
platelet agonists such as collagen, adenosine diphosphate (ADP),<br />
epinephrine, and ristocetin triggers classical platelet response<br />
and a great deal <strong>of</strong> information can be obtained from platelet<br />
aggregation. P selectin is a membrane glycoprotein within<br />
platelets and endothelial cells that is mobilized to the plasma<br />
membrane following cell activation and it is used to evaluate<br />
platelet activation [3,4].<br />
It is well known that primary hyperparathyroidism (PHPT) is<br />
associated with a high risk <strong>of</strong> cardiovascular disease and increased<br />
mortality and morbidity related to cardiovascular problems<br />
[5,6,7]. There are also studies that relate hyperparathyroidism<br />
with a potential tendency toward hypercoagulation [8,9].<br />
There are some cases <strong>of</strong> thrombotic events seen in the course<br />
<strong>of</strong> hyperparathyroidism [10]. However, knowledge about<br />
the effects <strong>of</strong> hyperparathyroidism on platelet functions is<br />
unsatisfactory and conflicting. Whereas elevated parathormone<br />
(PTH) levels and hypercalcemia are significant features <strong>of</strong> PHPT,<br />
PTH elevation does not accompany hypercalcemia in secondary<br />
hyperparathyroidism (SHPT). There are studies investigating<br />
the effect <strong>of</strong> serum calcium levels on platelet aggregation,<br />
coagulation, and thromboelastography in healthy people [11].<br />
However, it is not clear whether hyperparathyroidism disturbs<br />
platelet function and if so whether it is related to the high PTH<br />
levels per se or to the accompanying hypercalcemia.<br />
In this study we aimed to evaluate platelet functions in patients<br />
with both PHPT and SHPT.<br />
Materials and Methods<br />
Twenty-five subjects with PHPT, 25 subjects with SHPT, and<br />
25 healthy age-matched control subjects were included in the<br />
study. The diagnosis <strong>of</strong> PHPT was based on clinical assessment<br />
and laboratory findings. Parathyroid adenomas were shown in<br />
all <strong>of</strong> the PHPT patients on both parathyroid ultrasound and<br />
99m<br />
technetium scans <strong>of</strong> the parathyroids. Elevated PTH levels in the<br />
case <strong>of</strong> normal or low serum calcium level, vitamin D deficiency,<br />
and decreased urinary calcium excretion were regarded as signs<br />
<strong>of</strong> SHPT. Twenty-five healthy age- and sex-matched subjects with<br />
normal values <strong>of</strong> biochemical parameters were used as controls.<br />
The purpose and the procedure <strong>of</strong> the tests were explained to<br />
the subjects and written informed consent was obtained from<br />
each participant. The experimental protocol was designed and<br />
performed according to the principles <strong>of</strong> the Declaration <strong>of</strong><br />
Helsinki and it was approved by the Ethics Committee <strong>of</strong> the<br />
Eskişehir Osmangazi University Medical Faculty.<br />
Serum calcium, phosphorus, albumin, chloride, and creatinine<br />
levels were measured for each <strong>of</strong> the subjects. Serum intact PTH<br />
was measured from venous blood samples at a central laboratory<br />
using a solid-phase two-site chemiluminescent enzyme-labeled<br />
immunometric assay with a reference range <strong>of</strong> 15-65 pg/<br />
mL. Serum calcium, phosphorus, and creatinine levels were<br />
measured colorimetrically. Serum albumin levels were measured<br />
by immunoturbidimetric assay and serum creatinine levels were<br />
measured by using an ion-selective electrode. Twenty-four<br />
hour urine collections were used in order to calculate urinary<br />
calcium excretion rates. Creatinine clearance (Ccr) levels were<br />
calculated according to the Cockr<strong>of</strong>t-Gault formula. Patients<br />
with serum creatinine level above 1.2 mg/dL or Ccr level below<br />
70 mL/min were not included in the study in order to exclude<br />
the confounding effects <strong>of</strong> renal failure on platelet functions.<br />
Tubular reabsorption <strong>of</strong> phosphate was calculated as TRP=[1-<br />
(up/pp)x(pcr/ucr)]x100.<br />
Platelet functions <strong>of</strong> the subjects were evaluated by using<br />
platelet-rich plasma and platelet aggregation tests with<br />
epinephrine, ADP, collagen, and ristocetin. Serum P selectin<br />
levels, which indicate platelet activation level, were also<br />
measured in all subjects. Groups were matched with respect to<br />
age. Exclusion criteria included patients with known bleeding<br />
or other systemic disorders such as hepatic and endocrine<br />
diseases, acute infections, autoimmune disorders, or cancer, and<br />
a platelet count <strong>of</strong> less than 150x10 9 /L or more than 450x10 9 /L<br />
and a hemoglobin level <strong>of</strong> less than 10 g/dL. The patients did<br />
not receive agents that could affect platelet functions such as<br />
acetylsalicylic acid, ticlopidine, dipyridamole, or nonsteroidal<br />
antiinflammatory drugs in the 10 days prior to the platelet<br />
aggregation studies.<br />
Sample Collection and Laboratory Methods<br />
Citrated blood was collected under light tourniquet through<br />
19-gauge needles into 4.5-mL vacutainers (Becton Dickinson,<br />
USA) containing 3.2% trisodium citrate in a 9:1 blood/<br />
anticoagulant ratio. The collection was performed early in the<br />
morning after overnight fasting. Samples for blood counts<br />
were drawn into Becton Dickinson anticoagulated tubes and<br />
complete counts were made with a Beckman Coulter Gen-S<br />
SM (USA) automated blood counting device. Coagulation<br />
tests were performed with an ACL TOP Coagulation Analyzer<br />
(Instrumentation Laboratory, USA). Prothrombin time (PT) was<br />
measured with a HemosIL RecombiPlasTin kit (Instrumentation<br />
294
Turk J Hematol 2016;<strong>33</strong>:293-298<br />
Yorulmaz G, et al: Hyperparathyroidism and Platelet Functions<br />
Laboratory), activated partial thromboplastin time (aPTT) was<br />
measured with a HemosIL SynthASil kit (Instrumentation<br />
Laboratory), and fibrinogen was measured with a HemosIL<br />
Fibrinogen-C XL kit (Instrumentation Laboratory). The normal<br />
ranges for these tests in our laboratory are: aPTT, 24-36 s; PT,<br />
8-13 s; and fibrinogen, 200-400 mg/dL.<br />
Platelet aggregation studies were performed with a whole blood<br />
lumi-aggregometer (Model 540-Ca, Chrono-log Corporation,<br />
USA) using an optical method according to the manufacturer’s<br />
instructions. Whole-blood specimens were centrifuged for<br />
10 min at 200xg to obtain platelet-rich plasma. Plateletpoor<br />
plasma was obtained from the remaining specimens by<br />
recentrifugation at 200xg for 15 min. A platelet count was<br />
performed on the platelet-rich plasma and was adjusted to<br />
300x10 3 /µL with platelet-poor plasma. Next, 450 µL <strong>of</strong> this<br />
platelet-rich plasma was transferred into cuvettes (Chronolog<br />
No: P/N 312), each containing a disposable siliconized bar.<br />
After agonist addition, platelet aggregation was measured over<br />
6 min and expressed as a percentage <strong>of</strong> the maximal amplitude<br />
in platelet-rich plasma. The agonists used and their final<br />
concentrations were: ADP (Chrono Par 384), 5 µM; collagen<br />
(Chrono Par 385), 2 µg/mL; ristocetin (Chrono Par 396), 1.25 mg/<br />
mL; and epinephrine (Chrono Par 393), 5 µM. A commercially<br />
available ELISA method was used to determine serum P selectin<br />
levels (BBE6 catalog number, R&D Systems, USA). All analyses<br />
were performed in duplicate, and the mean value was used<br />
for statistical calculations. The levels <strong>of</strong> osteocalcin (2-22 ng/<br />
mL) and deoxypyridinoline (2.3-5.4 nM DPD/mM creatine) were<br />
measured. The bone mineral densitometry <strong>of</strong> the patients was<br />
studied and T scores were evaluated.<br />
All statistical analysis was performed using SPSS 15 and<br />
SigmaStat 3.5. The distibution <strong>of</strong> variables was checked initially<br />
by Shapiro-Wilk test. Parametric tests were applied to data having<br />
normal distribution. Comparisons between 2 different groups<br />
were assessed by independent t-test and changes <strong>of</strong> variables<br />
within groups were assessed by paired samples t-test. Pearson<br />
correlation analysis was used to evaluate the relationships<br />
between variables. P
Yorulmaz G, et al: Hyperparathyroidism and Platelet Functions<br />
Turk J Hematol 2016;<strong>33</strong>:293-298<br />
Patients with primary and SHPT were divided into two groups<br />
according to serum calcium levels (Table 4). The first group<br />
included the patients with serum calcium levels equal to or<br />
higher than 10.5 mg/dL and the second group included the<br />
patients with serum calcium levels lower than 10.5 mg/dL.<br />
There was no significant difference between the two groups in<br />
respect to platelet aggregation studies induced by epinephrine,<br />
ADP, collagen, and ristocetin. P selectin levels also did not<br />
differ significantly between the groups. We could not find<br />
any significant correlation between aggregation parameters,<br />
P selectin levels, and serum calcium levels in this group <strong>of</strong><br />
patients. Statistical values did not differ when serum calcium<br />
corrected for serum albumin level was used.<br />
Discussion<br />
Recent studies suggest that hyperparathyroidism has many<br />
systemic effects other than those on bone and mineral<br />
metabolism. PTH excess is strongly associated with prevalent<br />
and incident cardiovascular risk factors such as hypertension,<br />
diabetes, and cardiovascular diseases. There is also evidence<br />
connecting adverse cardiovascular outcomes, including death<br />
and incident coronary artery disease and myocardial infarction,<br />
to PTH excess [6,12,13,14]. Two biochemical features <strong>of</strong><br />
hyperparathyroidism, namely elevated PTH levels and elevated<br />
serum calcium levels, may be implicated with those adverse<br />
outcomes. Although there are some studies suggesting that<br />
severe PHPT could impair vascular compliance and PTH rather<br />
than serum calcium levels being the casual factor, it is still<br />
uncertain which <strong>of</strong> the parameters is the main <strong>of</strong>fending<br />
mediator in those circumstances [15].<br />
Abnormalities in coagulation and fibrinolysis pathways have<br />
also been detected in PHPT, mostly supported by small casecontrol<br />
studies, and the evidence is still conflicting [8,9].<br />
There are some case reports <strong>of</strong> thrombotic events associated<br />
with PHPT in which high serum calcium is accused <strong>of</strong> being<br />
a causative factor. In those cases, renal vein thrombosis and<br />
dermal necrosis due to thrombosis were encountered during the<br />
course <strong>of</strong> hyperparathyroidism [10,16,17]. Thrombotic events<br />
were reported also in SHPT [17]. The high incidence <strong>of</strong> vascular<br />
thrombosis seen in patients with hyperparathyroidism may<br />
represent a potential for hypercoagulation and may explain the<br />
increased cardiovascular morbidity in those patients.<br />
In an early study on this topic, bovine PTH was shown in vitro to<br />
inhibit platelet aggregation and activation strongly [18]. Later,<br />
however, another study showed that platelet functions were<br />
not affected by synthetically manufactured PTH. The irregular<br />
platelet functions in the previous study were attributed by the<br />
authors to the additives used during the preparation <strong>of</strong> the<br />
bovine PTH [19].<br />
In symptomatic primary hyperparathyroid patients, significantly<br />
higher plasma levels <strong>of</strong> tissue plasminogen activator and lower<br />
Table 2. Platelet aggregation studies and P selectin levels <strong>of</strong> the patients and the control group.<br />
Platelet Aggregation Parameters and P<br />
Selectin Levels<br />
PHPT, n=25 SHPT, n=25 Controls, n=25 p<br />
Ristocetin (ohm) 93.0 (84.2-101.25) 96.0 (84.25-101.25) 98 (92-103) NS<br />
Epinephrine (ohm) 92.0 (83-106) 99 (92.8-105) 100 (90.5-103) NS<br />
Collagen (ohm) 96 (89.5-100.3) 98 (98-100.3) 99 (97-104) NS<br />
ADP (ohm) 95 (90.5-109) 99 (93.7-104.3) 104 (95-108) NS<br />
Serum P selectin (ng/mL) 31.4 (23.6-38.3) 31.2 (24.4-38.6) 29.2 (20.9-36.6) NS<br />
PT (s) 10.78 (11.2-11.5) 10.85 (11.3-11.9) 10.7 (11.0-11.2) NS<br />
aPTT (s) 28.6±3.14 28.99±2.85 27.0±2.24
Turk J Hematol 2016;<strong>33</strong>:293-298<br />
Yorulmaz G, et al: Hyperparathyroidism and Platelet Functions<br />
Table 4. Platelet functions <strong>of</strong> the patients classified according to serum calcium levels.<br />
Platelet Aggregation Parameters and P Selectin<br />
Levels<br />
Serum Calcium ≥10.5 mg/dL, n=22 Serum Calcium
Yorulmaz G, et al: Hyperparathyroidism and Platelet Functions<br />
Turk J Hematol 2016;<strong>33</strong>:293-298<br />
Authorship Contributions<br />
Medical Practices: Göknur Yorulmaz; Concept: Göknur Yorulmaz,<br />
Aysen Akalın; Design: Göknur Yorulmaz, Aysen Akalın, Olga<br />
Meltem Akay; Data Collection or Processing: Göknur Yorulmaz,<br />
Aysen Akalın, Olga Meltem Akay, Garip Şahin, Cengiz Bal;<br />
Analysis or Interpretation: Göknur Yorulmaz, Aysen Akalın, Olga<br />
Meltem Akay, Garip Şahin; Literature Search: Göknur Yorulmaz,<br />
Aysen Akalın, Olga Meltem Akay, Garip Şahin, Cengiz Bal;<br />
Writing: Göknur Yorulmaz, Aysen Akalın, Olga Meltem Akay,<br />
Garip Şahin, Cengiz Bal.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Shebuski RJ, Kilgore KS. Role <strong>of</strong> inflammatory mediators in thrombogenesis.<br />
J Pharmacol Exp Ther 2002;300:729-735.<br />
2. Hayward CP, Pai M, Liu Y, M<strong>of</strong>fat KA, Seecharan J, Webert KE, Cook RJ,<br />
Heddle NM. Diagnostic utility <strong>of</strong> light transmission platelet aggregometry:<br />
results from a prospective study <strong>of</strong> individuals referred for bleeding disorder<br />
assessments. J Thromb Haemost 2009;7:676-684.<br />
3. Rand ML, Leung R, Packham MA. Platelet function assays. Transfus Apher<br />
Sci 2003;28:307-317.<br />
4. Zucker MB, Nachmias VT. Platelet activation. Arteriosclerosis 1985;5:2-18.<br />
5. Hedback G, Tisell LE, Bengtsson BA, Hedman I, Oden A. Premature death in<br />
patients operated on for PHPT. World J Surg 1990;14:829-835.<br />
6. Hedback G, Oden A. Increased risk <strong>of</strong> death from primary hyperparathyroidism:<br />
an update. Eur J Clin Invest 1998;28:271-276.<br />
7. Stefenelli T, Mayr H, Berger-Klein J, Globits S, Wolosczcuk W, Niederle B.<br />
Primary hyperparathyroidism: incidence <strong>of</strong> cardiac abnormalities and partial<br />
reversibility after successful parathyroidectomy. Am J Med 1993;95:197-202.<br />
8. Erem C, Kocak M, Hacihasanoglu A, Yilmaz M, Saglam F, Ersoz HO.<br />
Blood coagulation, fibrinolysis and lipid pr<strong>of</strong>ile in patients with primary<br />
hyperparathyroidism: increased plasma factor VII and X activities and<br />
D-dimer levels. Exp Clin Endocrinol Diabetes 2008;116:619-624.<br />
9. Erem C, Kocak M, Nuhoglu I, Yilmaz M, Ucuncu O. Increased plasma activator<br />
inhibitor-1, decreased tissue factor pathway inhibitor, and unchanged<br />
thrombin-activatable fibrinolysis inhibitor levels in patients with primary<br />
hyperparathyroidism. Eur J Endocrinol 2009;160:863-868.<br />
10. Franchello A, Camandona M, Gasparri G. Acute hyperparathyroidism and<br />
vascular thrombosis: an unrecognized association. J Endocrinol Invest<br />
2010;<strong>33</strong>:683.<br />
11. Li ZL, Chen XM, Yang LC, Deng XL, Fu SH, Cai LL, Zhou Y, Chen J, Bai J, Cong<br />
YL. Effects <strong>of</strong> extracellular calcium concentration on platelets aggregation,<br />
coagulation indices and thromboelastography. Zhonghua Yi Xue Za Zhi<br />
2010;90:1547-1550.<br />
12. Anderson JL, Vanwoerkum R, Horne BD, Bair TL, May HT, Lappe DL,<br />
Muhlestein JB. Parathyroid hormone, vitamin D, renal dysfunction, and<br />
cardiovascular disease: dependent or independent risk factors? Am Heart J<br />
2011;162:<strong>33</strong>1-<strong>33</strong>9.<br />
13. Han D, Trooskin S, Wang X. Prevalence <strong>of</strong> cardiovascular risk factors in male<br />
and female patients with primary hyperparathyroidism. J Endocrinol Invest<br />
2012;35:548-552.<br />
14. Kiernan TJ, O’Flynn AM, McDermott JH, Kearney P. Primary<br />
hyperparathyroidism and the cardiovascular system. Int J Cardiol<br />
2006;113:E89-92.<br />
15. Walker MD, Fleischer J, Rundek T, McMahon DJ, Homma S, Sacco R, Silverberg<br />
SJ. Carotid vascular abnormalities in primary hyperparathyroidism. J Clin<br />
Endocrinol Metab 2009;94:3849-3856.<br />
16. Smallman LA. Renal vein thrombosis complicating primary<br />
hyperparathyroidism. Postgrad Med J 1982;58:441-442.<br />
17. Huertas VE, Maletz RM, Weller JM. Dermal necrosis due to thrombosis in<br />
severe secondary hyperparathyroidism. Arch Intern Med 1976;136:712-716.<br />
18. Remuzzi G, Benigni A, Dodesini P, Schieppati A, Livio M, Poletti E, Mecca<br />
G, de Gaetano G. Parathyroid hormone inhibits human platelet function.<br />
Lancet 1981;12:1321-1323.<br />
19. Leithner C, Kovarik J, Sinzinger H, Woloszcuk W. Parathyroid hormone does<br />
not inhibit platelet aggregation. Lancet 1984;18:367-368.<br />
20. Chertok-Shacham E, Ishay A, Lavi I, Luboshitzky R. Biomarkers <strong>of</strong><br />
hypercoagulability and inflammation in primary hyperparathyroidism. Med<br />
Sci Monit 2008;14:628-632.<br />
21. Sitges-Serra A, García L, Prieto R, Peña MJ, Nogués X, Sancho JJ. Effect<br />
<strong>of</strong> parathyroidectomy for primary hyperparathyroidism on bone mineral<br />
density in postmenopausal women. Br J Surg 2010;97:1013-1019.<br />
22. Yilmaz H. Assessment <strong>of</strong> mean platelet volume (MPV) in primary<br />
hyperparathyroidism: effects <strong>of</strong> successful parathyroidectomy on MPV<br />
levels. Endocr Regul 2014;48:182-188.<br />
298
RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2015.0271<br />
Turk J Hematol 2016;<strong>33</strong>:299-303<br />
Warfarin Dosing and Time Required to Reach Therapeutic<br />
International Normalized Ratio in Patients with Hypercoagulable<br />
Conditions<br />
Hiperkoagülabilite Durumları Olan Hastalarda Terapötik Uluslararası Düzeltme Oranına<br />
Ulaşmak için Gerekli Warfarin Doz ve Süresi<br />
Pushpinderdeep Kahlon 1 , Shahzaib Nabi 1 , Adeel Arshad 2 , Absia Jabbar 3 , Ali Haythem 4<br />
1Wayne State University, Henry Ford Health System, Clinic <strong>of</strong> Internal Medicine, Detroit, USA<br />
2Weill Cornell University, Hamad Medical Corporation, Clinic <strong>of</strong> Internal Medicine, Doha, Qatar<br />
3Nishtar Hospital, University <strong>of</strong> Health Science, Multan, Pakistan<br />
4Wayne State University, Henry Ford Health System, Clinic <strong>of</strong> <strong>Hematology</strong>-Oncology, Detroit, USA<br />
Abstract<br />
Objective: The purpose <strong>of</strong> this study was to analyze the difference in<br />
duration <strong>of</strong> anticoagulation and dose <strong>of</strong> warfarin required to reach a<br />
therapeutic international normalized ratio [(INR) <strong>of</strong> 2 to 3] in patients<br />
with hypercoagulable conditions as compared to controls. To our<br />
knowledge, this study is the first in the literature to delineate such<br />
a difference.<br />
Materials and Methods: A retrospective chart review was performed<br />
in a tertiary care hospital. The total study population was 622.<br />
Cases (n=125) were patients with a diagnosis <strong>of</strong> a hypercoagulable<br />
syndrome who developed venous thromboembolism. Controls (n=497)<br />
were patients with a diagnosis <strong>of</strong> venous thromboembolism in the<br />
absence <strong>of</strong> a hypercoagulable syndrome and were matched for age,<br />
sex, and race.<br />
Results: The total dose <strong>of</strong> warfarin required to reach therapeutic INR<br />
in cases was higher (50.7±17.6 mg) as compared to controls (41.2±17.7<br />
mg). The total number <strong>of</strong> days required to reach therapeutic INR in<br />
cases was 8.9±3.5 days as compared to controls (6.8±2.9 days). Both<br />
<strong>of</strong> these differences were statistically significant (p
Kahlon P, et al: Therapeutic International Normalized Ratio in Hypercoagulable Conditions<br />
Turk J Hematol 2016;<strong>33</strong>:299-303<br />
Introduction<br />
It has been well documented that both acquired and<br />
hypercoagulable conditions play an important role in<br />
thrombophilia development. Studies suggest that important<br />
genetic factors that have notable significance include factor<br />
V Leiden mutation, prothrombin gene mutation, deficiency<br />
<strong>of</strong> protein S or protein C, antithrombin III deficiency, and<br />
hyperhomocysteinemia. Acquired hypercoagulability factors<br />
include non-modifiable factors, such as age and antiphospholipid<br />
antibodies, and modifiable factors, such as pregnancy, oral<br />
contraceptive and hormone replacement therapy, recent travel,<br />
and obesity, as well other factors such as malignancy, recent<br />
surgery, trauma, and prolonged immobility [1].<br />
Once a patient develops venous thromboembolism (VTE), the<br />
main mode <strong>of</strong> treatment has been warfarin, with recent advent<br />
<strong>of</strong> newer medications such as rivaroxaban [2]. Warfarin still<br />
remains one <strong>of</strong> the most commonly used medications for VTE in<br />
the United States. Previously there have been a few studies that<br />
have investigated warfarin dosing in specific hypercoagulable<br />
conditions, such as antiphospholipid antibodies and highversus<br />
low-intensity warfarin efficacy in recurrent deep vein<br />
thrombosis (DVT) prevention [3]. However, it is not known if a<br />
difference exists in the total dose and time <strong>of</strong> warfarin therapy<br />
necessary to reach a therapeutic international normalized ratio<br />
(INR) in patients with hypercoagulable conditions. The goal <strong>of</strong><br />
this study was to determine the difference in the time and dose<br />
<strong>of</strong> warfarin required to reach therapeutic INR (i.e. INR <strong>of</strong> 2 to<br />
3) in patients with hypercoagulable conditions as compared to<br />
controls.<br />
Materials and Methods<br />
The study was approved by our institutional review board. A<br />
retrospective chart review was performed for patients seen in our<br />
tertiary care facility from January 2002 to December 2012. The<br />
inclusion criteria for cases were patients with hypercoagulable<br />
conditions, which included patients with factor V Leiden<br />
mutation, prothrombin gene mutation, protein S or protein<br />
C deficiency, antithrombin III deficiency, dysfibrinogenemia,<br />
and antiphospholipid antibodies who developed unprovoked<br />
VTE (DVT, pulmonary embolism, or both). The diagnostic tests<br />
used were venous duplex for DVT and computed tomography<br />
angiogram or ventilation/perfusion lung scan for pulmonary<br />
embolism. Controls were age-, sex-, and race-matched patients<br />
who developed VTE but did not have a hypercoagulable<br />
syndrome. Confounding factors were assessed in both cases and<br />
controls and included end-stage renal disease, malignancies,<br />
recent surgery (within 1 month <strong>of</strong> development <strong>of</strong> VTE), and<br />
oral contraceptive use. Therapeutic INR was defined as an INR <strong>of</strong><br />
2-3 on 2 consecutive blood draws separated by a 24-h duration.<br />
All subjects received an initial 5-mg loading dose <strong>of</strong> warfarin<br />
and all <strong>of</strong> them received heparin at the time <strong>of</strong> diagnosis <strong>of</strong> VTE<br />
(bridging therapy). The total dose <strong>of</strong> warfarin required to reach<br />
a therapeutic INR and the number <strong>of</strong> days required to reach a<br />
therapeutic INR were analyzed.<br />
Statistical analysis with a primary aim <strong>of</strong> comparing cases to<br />
controls was performed. Data were described using standard<br />
descriptive statistics, i.e. counts, percentages, means, and<br />
standard deviations. Crude (unadjusted) odds ratios were<br />
obtained from univariate logistic regression models. All variables<br />
with a univariate p-value <strong>of</strong>
Turk J Hematol 2016;<strong>33</strong>:299-303<br />
Kahlon P, et al: Therapeutic International Normalized Ratio in Hypercoagulable Conditions<br />
Warfarin acts by interfering with the enzyme vitamin K epoxide<br />
reductase, which modulates the gamma carboxylation <strong>of</strong><br />
procoagulant factors II, VII, IX, and X and anticoagulant proteins<br />
C, S, and Z [6]. Because <strong>of</strong> the latter action, warfarin has the<br />
potential <strong>of</strong> exerting a transient procoagulant effect early in<br />
therapy. To counter that, heparin ‘bridging’ is recommended for<br />
a minimum <strong>of</strong> 5 days and until the INR is 2.0 or above for at least<br />
24 h [7]. As the antithrombotic effect <strong>of</strong> warfarin necessitates<br />
the inhibition <strong>of</strong> factor II, which has a very long half-life (60-72<br />
h) as compared to other factors (6-24 h), it takes approximately<br />
6 days for warfarin to exert its full efficacy even though the<br />
earliest changes in INR can be seen after 24 to 36 h [8,9,10,11].<br />
The average number <strong>of</strong> days to achieve therapeutic INR after<br />
starting warfarin is reported to be 5-6 days [12].<br />
Selection <strong>of</strong> an appropriate dose for warfarin initiation<br />
is challenging and controversial because <strong>of</strong> interpersonal<br />
variability in its pharmacokinetic and pharmacodynamic<br />
parameters. Kovacs et al. found that patients who were initiated<br />
with 10 mg <strong>of</strong> warfarin achieved therapeutic INR 1.4 days earlier<br />
than those who received 5 mg [13]. One study concluded that<br />
initiation with 5 mg <strong>of</strong> warfarin was associated with 5.6 days <strong>of</strong><br />
bridging with low-molecular-weight heparin [14]. The American<br />
College <strong>of</strong> Chest Physicians recommends initiation with 10 mg<br />
in patients healthy enough to be treated as outpatients, with<br />
dose modifications done as per the INR after 2 days [7]. From a<br />
practical point <strong>of</strong> view, adjusting the warfarin dose to achieve<br />
and maintain therapeutic INR is a challenging task that we<br />
face regularly during our day-to-day clinical encounters. A<br />
myriad <strong>of</strong> factors lead to this commonly observed interpatient<br />
variation in the warfarin dose requirement and number <strong>of</strong> days<br />
required to achieve the therapeutic INR. Our study compared<br />
these 2 variables in patients with and without hypercoagulable<br />
conditions. We found that patients with hypercoagulable<br />
conditions on average require higher doses and more days<br />
to achieve the target INR as compared to those without any<br />
hypercoagulable conditions. To our knowledge, this study is one<br />
<strong>of</strong> the first in the literature to delineate such a difference.<br />
Table 1. Patient characteristics along with univariate and multivariate analysis.<br />
Variable Response Cases (n=125) Controls<br />
(n=497)<br />
Univariate<br />
Analysis<br />
OR (95% CI)<br />
p-value<br />
Age Mean ± SD 60.4±15.0 60.5±16.0 1.00 (0.98, 1.01) 0.939<br />
Sex<br />
Race<br />
VTE<br />
Age at time <strong>of</strong><br />
VTE<br />
Cancer<br />
End-stage renal<br />
disease<br />
Surgery<br />
Antibiotics<br />
Oral<br />
contraceptive<br />
pills<br />
Total days to<br />
therapeutic INR<br />
Total dose to<br />
therapeutic INR<br />
Male<br />
Female<br />
55 (44%)<br />
70 (56%)<br />
72 (58%)<br />
Caucasian<br />
Other 1 15 (12%)<br />
African American 38 (30%)<br />
DVT<br />
PE<br />
Both<br />
44 (35%)<br />
53 (42%)<br />
28 (22%)<br />
207 (42%)<br />
290 (58%)<br />
293 (59%)<br />
160 (32%)<br />
44 (9%)<br />
201 (40%)<br />
211 (42%)<br />
85 (17%)<br />
1.10 (0.74, 1.64) 0.634<br />
1.04 (0.67, 1.60)<br />
1.44 (0.72, 2.85)<br />
0.66 (0.39, 1.14)<br />
0.76 (0.45, 1.29)<br />
0.556<br />
0.326<br />
Mean ± SD 53.0±14.9 53.5±15.0 0.99 (0.98, 1.01) 0.747<br />
No<br />
Yes<br />
No<br />
Yes<br />
No<br />
Yes<br />
No<br />
Yes<br />
No<br />
Yes<br />
122 (98%)<br />
3 (2%)<br />
122 (98%)<br />
3 (2%)<br />
118 (94%)<br />
7 (6%)<br />
102 (82%)<br />
23 (18%)<br />
122 (98%)<br />
3 (2%)<br />
450 (91%)<br />
47 (9%)<br />
489 (98%)<br />
8 (2%)<br />
371 (75%)<br />
126 (25%)<br />
407 (82%)<br />
90 (18%)<br />
478 (96%)<br />
19 (4%)<br />
Mean ± SD 8.9±3.5 (5.4 to 12.4) 6.8±2.9<br />
(3.9 to 9.7)<br />
Mean ± SD 50.7±17.6 (<strong>33</strong>.1 to 68.3) 41.2±17.7<br />
(23.5 to 58.9)<br />
Multivariate<br />
Analysis<br />
OR (95% CI)<br />
p-value<br />
0.24 (0.07, 0.77) 0.009 0.26 (0.08, 0.87) 0.029<br />
1.50 (0.39, 5.75) 0.549<br />
0.18 (0.08, 0.38)
Kahlon P, et al: Therapeutic International Normalized Ratio in Hypercoagulable Conditions<br />
Turk J Hematol 2016;<strong>33</strong>:299-303<br />
As described earlier, other factors might also affect the variables<br />
under study, which could have been potential confounders in<br />
our study. The elderly and females require a smaller weekly<br />
dose <strong>of</strong> warfarin than their counterparts. Even though there<br />
are no convincing data, it is generally preferred that the elderly<br />
be started on a low-dose warfarin regimen because <strong>of</strong> the<br />
exaggeration <strong>of</strong> anticoagulation response in this age group [15].<br />
One <strong>of</strong> the strongest and statistically significant patient-specific<br />
factors that can influence the warfarin dose requirement is the<br />
concomitant use <strong>of</strong> drugs that affect cytochrome P450 (17.2 mg<br />
additional dosage <strong>of</strong> warfarin per week) [16]. From antibiotics<br />
to anticonvulsants, ginger to ginseng, and spinach to spices,<br />
a tiring list <strong>of</strong> drugs, herbs, and foods is reported to interact<br />
with warfarin by multiple mechanisms, which can involve its<br />
absorption, bioavailability, metabolism, and excretion. Recent<br />
surgery was also assessed as a variable in this study. It should be<br />
noted that surgeries are generally considered to be transiently<br />
hypercoagulable states. Surgeries involving lower extremities<br />
(such as hip/knee replacement) carry the highest risk <strong>of</strong> VTE and<br />
should be managed carefully in patients with hypercoagulable<br />
states.<br />
Even though not recommended for general testing, genetic<br />
mutations can lead to variations in the dosage requirement <strong>of</strong><br />
warfarin among different patients, which ultimately affects<br />
the number <strong>of</strong> days required to achieve the therapeutic INR.<br />
Polymorphism in the VKORC1 gene, which codes for the target<br />
enzyme for warfarin, results in 2 haplotypes: A, which makes<br />
the patient sensitive to smaller doses, and B, which necessitates<br />
administration <strong>of</strong> higher doses to achieve and maintain the same<br />
range <strong>of</strong> INR. The Asp36Tyr missense mutation in VKORC1, found<br />
in 15% <strong>of</strong> the Ethiopian population in one study, was strongly<br />
associated with a warfarin requirement <strong>of</strong> >70 mg/week. On the<br />
other hand, CYP2C9 (and less commonly CYP1A1, CYPCA1, and<br />
CYP3A4), which metabolizes the more potent enantiomer <strong>of</strong> the<br />
warfarin molecule, has been found to have 2 relatively common<br />
variant forms with reduced activity (CYP2CP*2 and CYP2C9*3).<br />
Patients with these variants have less rapid clearance <strong>of</strong> warfarin,<br />
thus requiring lower dosage administrations [17]. In one study,<br />
VKORC1 was significantly associated with the time required to<br />
achieve the first therapeutic INR while CYP2C9 predicted the<br />
time to reach an INR above 4, which predisposes the patient to<br />
hemorrhagic complications [18,19].<br />
Gene polymorphisms are found to be more common in<br />
African Americans than Asians and Caucasians, which affects<br />
the number <strong>of</strong> days and the dose needed to achieve the first<br />
target INR. Other patient-specific factors that can affect the<br />
variables under study include body mass index/body surface<br />
area (especially height), poor compliance, comorbid conditions,<br />
and true warfarin resistance, which is a quite rare occurrence<br />
(0.01%) [19].<br />
The major limitation <strong>of</strong> this study is that it was a single-center,<br />
retrospective study and the results might not be applicable to the<br />
general population. Moreover, our ‘cases’ group was relatively<br />
small, likely secondary to the rarity <strong>of</strong> the above-mentioned<br />
hypercoagulable conditions. However, to compensate for this<br />
relatively small sample size, we used a large ‘control’ group to<br />
increase the power <strong>of</strong> the study. Every effort was made during<br />
data collection to avoid bias as much as possible.<br />
Conclusion<br />
In summary, this study lays the foundation <strong>of</strong> a novel idea<br />
<strong>of</strong> comparing warfarin dosage and the time required to<br />
achieve therapeutic INR in patients with and without known<br />
hypercoagulability conditions. The likely mechanism <strong>of</strong> the<br />
observed difference is inherent thrombogenic potential in<br />
hypercoagulable states with more natural resistance towards<br />
anticoagulation. With a few confounders playing a role, this<br />
proposition needs further consolidation with large-scale trials<br />
that might help us in predicting the initial dose to start with<br />
in patients with and without a procoagulant condition. The<br />
observed effect can, in another way, be studied retrospectively<br />
to understand the difference in the pathophysiology <strong>of</strong> the<br />
thromboembolism in these 2 populations, which may explain<br />
the etiological aspects <strong>of</strong> the results noticed.<br />
Acknowledgment<br />
We would like to acknowledge the great efforts <strong>of</strong> our<br />
exceptionally hard-working librarian, Stephanie Stebens, who<br />
helped us in the final editing <strong>of</strong> this manuscript. Her suggestions<br />
played a huge role in finalizing this manuscript.<br />
Ethics<br />
Ethics Committee Approval: The study was approved by the IRB/<br />
Ethics Committee; Informed Consent: Was not needed as this<br />
was a retrospective chart review.<br />
Authorship Contributions<br />
Concept: Pushpinderdeep Kahlon, Shahzaib Nabi, Adeel Arshad,<br />
Absia Jabbar, Ali Haythem; Design: Pushpinderdeep Kahlon,<br />
Shahzaib Nabi, Adeel Arshad, Absia Jabbar, Ali Haythem; Data<br />
Collection or Processing: Shahzaib Nabi and Pushpinderdeep<br />
Kahlon; Analysis or Interpretation: Pushpinderdeep Kahlon,<br />
Shahzaib Nabi, Adeel Arshad, Absia Jabbar, Ali Haythem;<br />
Literature Search: Pushpinderdeep Kahlon, Shahzaib Nabi, Adeel<br />
Arshad, Absia Jabbar, Ali Haythem; Writing: Pushpinderdeep<br />
Kahlon, Shahzaib Nabi, Adeel Arshad, Absia Jabbar, Ali Haythem.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts <strong>of</strong><br />
interest, including specific financial interests, relationships, and/<br />
or affiliations relevant to the subject matter or materials included.<br />
302
Turk J Hematol 2016;<strong>33</strong>:299-303<br />
Kahlon P, et al: Therapeutic International Normalized Ratio in Hypercoagulable Conditions<br />
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M, Wells PS. Systematic overview <strong>of</strong> warfarin and its drug and food<br />
interactions. Arch Intern Med 2005;165:1095-1106.<br />
6. Whitlon DS, Sadowski JA, Suttie JW. Mechanism <strong>of</strong> coumarin action:<br />
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7. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ; American<br />
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thrombosis panel. executive summary: antithrombotic therapy and<br />
prevention <strong>of</strong> thrombosis, 9th ed: American College <strong>of</strong> Chest Physicians<br />
Evidence-Based Clinical Practice Guidelines. Chest 2012;141(Suppl 2):7-47.<br />
8. Zivelin A, Rao LV, Rapaport SI. Mechanism <strong>of</strong> the anticoagulant effect<br />
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procoagulant vitamin K-dependent clotting factors. J Clin Invest<br />
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9. Weitz JI, Hudoba M, Massel D, Maraganore J, Hirsh J. Clot-bound thrombin<br />
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1990;86:385-391.<br />
10. Wessler S, Gitel SN. Warfarin. From bedside to bench. N Engl J Med<br />
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11. Kuruvilla M, Gurk-Turner C. A review <strong>of</strong> warfarin dosing and monitoring.<br />
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12. Harrison L, Johnston M, Massicotte MP, Crowther M, M<strong>of</strong>fat K, Hirsh J.<br />
Comparison <strong>of</strong> 5-mg and 10-mg loading doses in initiation <strong>of</strong> warfarin<br />
therapy. Ann Intern Med 1997;126:1<strong>33</strong>-136.<br />
13. Kovacs MJ, Rodger M, Anderson DR, Morrow B, Kells G, Kovacs J, Boyle E,<br />
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19. Sinxadi P, Blockman M. Warfarin resistance. Cardiovasc J Afr 2008;19:215-<br />
217.<br />
303
RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2014.0385<br />
Turk J Hematol 2016;<strong>33</strong>:304-310<br />
Early Changes <strong>of</strong> Mannose-Binding Lectin, H-Ficolin, and<br />
Procalcitonin in Patients with Febrile Neutropenia: A Prospective<br />
Observational Study<br />
Febril Nötropeni Olgularında Mannoz Bağlayan Lektin, H-Fikolin ve Prokalsitonin<br />
Düzeylerinde Erken Dönem Değişimleri<br />
Sibel Işlak Mutcalı 1 , Neşe Saltoğlu 1 , İlker İnanç Balkan 1 , Reşat Özaras 1 , Mücahit Yemişen 1 , Bilgül Mete 1 , Fehmi Tabak 1 , Ali Mert 2 ,<br />
Recep Öztürk 1 , Şeniz Öngören 3 , Zafer Başlar 3 , Yıldız Aydın 3 , Burhan Ferhanoğlu 4 , Teoman Soysal 3<br />
1İstanbul University Cerrahpaşa Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Infectious Diseases and Clinical Microbiology, İstanbul, Turkey<br />
2Medipol University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Internal Medicine, İstanbul, Turkey<br />
3İstanbul University Cerrahpaşa Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, İstanbul, Turkey<br />
4Koç University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Internal Medicine, Division <strong>of</strong> <strong>Hematology</strong>, İstanbul, Turkey<br />
Abstract<br />
Objective: The significance <strong>of</strong> mannose-binding lectin (MBL) and<br />
H-ficolin deficiency in febrile neutropenic (FN) patients and the<br />
correlation <strong>of</strong> these markers along with consecutive C-reactive protein<br />
(CRP) and procalcitonin (PCT) levels during the infectious process are<br />
investigated.<br />
Materials and Methods: Patients with any hematological<br />
malignancies who were defined to have “microbiologically confirmed<br />
infection”, “clinically documented infection”, or “fever <strong>of</strong> unknown<br />
origin” were included in this single-center prospective observational<br />
study. Serum levels <strong>of</strong> CRP, PCT, MBL, and H-ficolin were determined<br />
on 3 separate occasions: at baseline (between hospital admission and<br />
chemotherapy), at the onset <strong>of</strong> fever, and at the 72 nd hour <strong>of</strong> fever.<br />
Results: Forty-six patients (54% male, mean age 41.7 years) with<br />
61 separate episodes <strong>of</strong> FN were evaluated. Eleven patients (23.9%)<br />
had “microbiologically confirmed infection”, 17 (37%) had “clinically<br />
documented infection”, and 18 (39.1%) had “fever <strong>of</strong> unknown origin”.<br />
Fourteen (30.4%) patients had low (
Turk J Hematol 2016;<strong>33</strong>:304-310<br />
Işlak Mutcalı S, et al: Early Changes in MBL, H-Ficolin, Procalcitonin in Febrile Neutropenia<br />
Introduction<br />
Blood stream infections (BSIs) due to invasive bacterial and<br />
fungal pathogens are major causes <strong>of</strong> infection related mortality.<br />
Gram-negative and gram-positive bacteremia account for<br />
50%-60% <strong>of</strong> BSIs during febrile neutropenia (FN) episodes<br />
[1,2,3]. Nonspecific signs and symptoms and conventional<br />
microbiologic methods pose some problems in the diagnosis <strong>of</strong><br />
severe infections in neutropenic patients. Hemoculture is still<br />
the standard diagnostic method, but the positivity rate is only<br />
about 20-50% in FN episodes [4] and microbial identification<br />
takes 2-6 days [1]. Definition <strong>of</strong> early diagnostic markers that<br />
will guide antimicrobial treatment is critical [5].<br />
In current practice, antibacterial therapy is initiated<br />
immediately after blood cultures are obtained and before any<br />
other diagnostic procedures, in accordance with guidelines.<br />
Leukocytes and differential blood count, hemoglobin, platelets,<br />
serum glutamate oxaloacetate transaminase, serum glutamate<br />
pyruvate transaminase, lactate dehydrogenase, alkaline<br />
phosphatase, gamma glutamyltransferase, bilirubin, uric acid,<br />
creatinine, sodium, potassium, partial thromboplastin time,<br />
and C-reactive protein (CRP) are measured twice a week before<br />
and during therapy in the routine practice <strong>of</strong> our hematology<br />
section. Procalcitonin (PCT) is measured weekly throughout the<br />
neutropenic episode.<br />
Mannose-binding lectin (MBL) is a plasma collectin (C-type lectin<br />
with a collagen-like domain) thought to have an important<br />
role in innate immunity [6]. Its lectin domain recognizes sugar<br />
patterns typical <strong>of</strong> microbial surfaces, while its collagen-like<br />
region facilitates microbial uptake by phagocytic cells. MBL can<br />
activate the complement by a mechanism similar to the classical<br />
pathway, but using MBL-associated serine proteases instead<br />
<strong>of</strong> C1r and C1s. The complement system provides immediate<br />
defense against infection and has proinflammatory effects.<br />
MBL deficiency is defined as a serum level <strong>of</strong>
Işlak Mutcalı S, et al: Early Changes in MBL, H-Ficolin, Procalcitonin in Febrile Neutropenia<br />
Turk J Hematol 2016;<strong>33</strong>:304-310<br />
expected to fall below ≤500/mm 3 within 24-48 h. Fever was<br />
defined as a single measurement <strong>of</strong> tympanic fever <strong>of</strong> ≥38 °C or<br />
at least 2 consecutive measurements <strong>of</strong> tympanic fever <strong>of</strong> ≥37.8<br />
°C measured with 4 h intervals within 24 h <strong>of</strong> monitoring.<br />
Exclusion Criteria<br />
Patients lacking any <strong>of</strong> the 3 blood samples during follow-up<br />
were excluded, along with those under 18 years or pregnant.<br />
Antimicrobial Treatment<br />
There was no <strong>of</strong>f-protocol intervention regarding antimicrobial<br />
use in FN episodes during the study period.<br />
Laboratory Analysis<br />
Blood cultures were incubated for 7 days in an automated<br />
hemoculture system (BacT ALERT 3D, bioMérieux, France).<br />
Conventional biochemical methods and automated systems<br />
(API automation pour identification, bioMérieux) were used for<br />
identification.<br />
Antimicrobial susceptibility tests were performed using the<br />
disk diffusion method in accordance with the relevant Clinical<br />
and Laboratory Standards Institute recommendations [11].<br />
Blood samples were stored at -80 °C in accordance with the<br />
manufacturer’s recommendations (B.R.A.H.M.S., Hycult) and<br />
were tested after being thawed and centrifuged for 1 min.<br />
MBL, H-ficolin, and PCT levels were measured using Hycult MBL,<br />
enzyme-linked immunosorbent assay, and B.R.A.H.M.S. VIDAS<br />
methods, respectively.<br />
Statistical Analysis<br />
SPSS 16.0 was used for statistical analyses. Categorical variables<br />
were analyzed with chi-square tests and continuous variables<br />
were analyzed with Student t or Mann-Whitney U tests. The<br />
Spearman correlation test was used to evaluate correlation<br />
between continuous variables. A p-value <strong>of</strong> 0.05) (Figure 1b). The average H-ficolin level <strong>of</strong> the<br />
cases was measured as 18.470 ng/mL. Median baseline CRP level<br />
(CRP-0) was measured as 24 mg/L (normal range: 0-5 mg/L). The<br />
average CRP level was elevated to 84.8 mg/L on the first day <strong>of</strong><br />
FN episodes (CRP-1) and to 98 mg/L on the third day (CRP-2)<br />
(Figure 1c). This increase in the serial CRP levels was statistically<br />
significant (p
Turk J Hematol 2016;<strong>33</strong>:304-310<br />
Işlak Mutcalı S, et al: Early Changes in MBL, H-Ficolin, Procalcitonin in Febrile Neutropenia<br />
Median PCT levels (normal range:
Işlak Mutcalı S, et al: Early Changes in MBL, H-Ficolin, Procalcitonin in Febrile Neutropenia<br />
Turk J Hematol 2016;<strong>33</strong>:304-310<br />
Discussion<br />
Early diagnostic markers would ideally reflect the severity <strong>of</strong> the<br />
infection, help classify FN episodes as low-risk and high-risk in<br />
terms <strong>of</strong> likelihood <strong>of</strong> septic complications, and not be affected<br />
by the number <strong>of</strong> leukocytes and the course <strong>of</strong> underlying<br />
disease. CRP, as an acute phase marker and the most wellknown<br />
biochemical marker <strong>of</strong> inflammation in patients with<br />
FN, was not found to be useful in the differential diagnosis <strong>of</strong><br />
fever <strong>of</strong> unknown origin, bacteremia, and clinically documented<br />
infections in neutropenic patients. Similar to our study, CRP was<br />
found to be <strong>of</strong> no use in differential diagnosis in other studies<br />
[12,13,14]. False negativity that can be recognized in certain<br />
patient groups such as patients with leukemia, viral infections,<br />
systemic lupus erythematosus, progressive systemic sclerosis,<br />
dermatomyositis, ulcerative colitis, Sjögren’s syndrome, and<br />
cerebral infarction is an additional drawback for CRP as an<br />
acute phase marker [15].<br />
Although the levels <strong>of</strong> serum PCT were determined to be lower<br />
in neutropenic patients when compared to those with intact<br />
immune systems, studies have shown that neutropenic patients<br />
had significantly higher PCT levels on days 0 and 2 in the case<br />
<strong>of</strong> sepsis [16]. The relationship between CRP and PCT levels<br />
during FN episodes was investigated in our study, and it was<br />
found that CRP is not a sensitive marker <strong>of</strong> early infection in<br />
neutropenic patients, while PCT would be preferred in the early<br />
diagnosis <strong>of</strong> sepsis. The rise <strong>of</strong> CRP or PCT from day 1 to day 3<br />
in any patient group was evaluated as the expected peak serum<br />
levels related to the severity <strong>of</strong> infection rather than an ongoing<br />
uncontrolled sepsis. In our study, a slightly significant difference<br />
(p=0.055) was found between the first-day PCT levels (PCT-<br />
1) <strong>of</strong> FN episodes in bacteremic and nonbacteremic patients.<br />
Patients who had a microbiologically documented infection had<br />
significantly higher PCT levels on the third day (PCT-2) <strong>of</strong> the FN<br />
episode (p0.5 ng/mL) and 72 h after the first peak <strong>of</strong> fever (with<br />
a cut point <strong>of</strong> >3-fold rise) were correlated with bacteremia,<br />
and particularly with gram-negative bacteremia. Although<br />
Svaldi et al. [17] reported that PCT levels did not significantly<br />
differ whether gram-negative or gram-positive bacteria were<br />
present when leukocyte count was
Turk J Hematol 2016;<strong>33</strong>:304-310<br />
Işlak Mutcalı S, et al: Early Changes in MBL, H-Ficolin, Procalcitonin in Febrile Neutropenia<br />
follow-up period (p
Işlak Mutcalı S, et al: Early Changes in MBL, H-Ficolin, Procalcitonin in Febrile Neutropenia<br />
Turk J Hematol 2016;<strong>33</strong>:304-310<br />
5. Mancini N, Clerici D, Diotti R, Perotti M, Ghidoli N, De Marco D, Pizzorno<br />
B, Emrich T, Burioni R, Ciceri F, Clementi M. Molecular diagnosis <strong>of</strong> sepsis<br />
in neutropenic patients with hematological malignancies. J Med Microbiol<br />
2008;57:601-604.<br />
6. Kilpatrick DC. Mannan-binding lectin and its role in innate immunity.<br />
Transfus Med 2002;12:<strong>33</strong>5-352.<br />
7. Bronkhorst MW, Bouwman LH. Mannose-binding lectin deficiency. 2014.<br />
Available online at http://www.uptodate.com/contents/mannose-bindinglectin-deficiency.<br />
Accessed on 27 January 2015.<br />
8. Vekemans M, Robinson J, Georgala A, Heymans C, Muanza F, Paesmans<br />
M, Klastersky J, Barette M, Meuleman N, Huet F, Calandra T, Costantini S,<br />
Ferrant A, Mathissen F, Axelsen M, Marchetti O, Aoun M. Low mannosebinding<br />
lectin concentration is associated with severe infection in patients<br />
with hematological cancer who are undergoing chemotherapy. Clin Infect<br />
Dis 2007;44:1593-1601.<br />
9. Matsushita M, Fujita T. The role <strong>of</strong> ficolins in innate immunity.<br />
Immunobiology 2002;205:490-497.<br />
10. Link H, Böhme A, Cornely OA, Höffken K, Kellner O, Kern WV, Mahlberg R,<br />
Maschmeyer G, Nowrousian MR, Ostermann H, Ruhnke M, Sezer O, Schiel<br />
X, Wilhelm M, Auner HW; Diseases Working Party (AGIHO) <strong>of</strong> the German<br />
Society <strong>of</strong> <strong>Hematology</strong> and Oncology (DGHO); Group Interventional Therapy<br />
<strong>of</strong> Unexplained Fever, Arbeitsgemeinschaft Supportivmassnahmen in der<br />
Onkologie (ASO) <strong>of</strong> the Deutsche Krebsgesellschaft (DKG-German Cancer<br />
Society). Antimicrobial therapy <strong>of</strong> unexplained fever in neutropenic patients-<br />
-guidelines <strong>of</strong> the Infectious Diseases Working Party (AGIHO) <strong>of</strong> the German<br />
Society <strong>of</strong> <strong>Hematology</strong> and Oncology (DGHO), Study Group Interventional<br />
Therapy <strong>of</strong> Unexplained Fever, Arbeitsgemeinschaft Supportivmassnahmen<br />
in der Onkologie (ASO) <strong>of</strong> the Deutsche Krebsgesellschaft (DKG-German<br />
Cancer Society). Ann Hematol 2003;82(Suppl 2):S105-S117.<br />
11. Clinical and Laboratory Standards Institute. Performance Standards for<br />
Antimicrobial Susceptibility Testing, Twentieth Informational Supplement.<br />
M100-S20. Wayne, PA, USA, CLSI, 2010.<br />
12. Riikonen P, Saarinen UM, Teppo AM, Metsarinne K, Fyhrquist F, Jalanko H.<br />
Cytokine and acute-phase reactant levels in serum <strong>of</strong> children with cancer<br />
admitted for fever and neutropenia. J Infect Dis 1992;166:432-436.<br />
13. Akçay A. Association <strong>of</strong> serum levels <strong>of</strong> proinflammatory cytokines,<br />
C-reactive protein, procalcitonin and bacterial sepsis in febrile neutropenic<br />
children with cancer. Specialty thesis on pediatric hematology, İstanbul<br />
Medical School, Department <strong>of</strong> Children’s Health and Diseases, İstanbul,<br />
Turkey, 2009.<br />
14. von Lilienfeld-Toal M, Dietrich MP, Glasmacher A, Lehmann L, Breig P,<br />
Hahn C, Schmidt-Wolf IG, Marklein G, Schroeder S, Stuber F. Markers <strong>of</strong><br />
bacteremia in febrile neutropenic patients with hematological malignancies:<br />
procalcitonin and IL-6 are more reliable than C-reactive protein. Eur J Clin<br />
Microbiol Infect Dis 2004;23:539-544.<br />
15. Kawai T. Inflammatory markers, especially the mechanism <strong>of</strong> increased CRP.<br />
Rinsho Byori 2000;48:719-721a (in Japanese with English abstract).<br />
16. Al-Nawas B, Shah PM. Procalcitonin in patients with and without<br />
immunosuppression and sepsis. Infection 1996;24:434-436.<br />
17. Svaldi M, Hirber J, Lanthaler AI, Mayr O, Faes S, Peer E, Mitterer M.<br />
Procalcitonin reduced sensitivity and specificity in heavily leucopenic and<br />
immunosuppressed patients. Br J Haematol 2001;115:53-57.<br />
18. Secmeer G, Devrim I, Kara A, Ceyhan M, Cengiz B, Kutluk T, Buyukpamukcu<br />
M, Yetgin S, Tuncer M, Uludag AK, Tezer H, Yildirim I. Role <strong>of</strong> procalcitonin<br />
and CRP in differentiating a stable from a deteriorating clinical course in<br />
pediatric febrile neutropenia. J Pediatr Hematol Oncol 2007;29:107-111.<br />
19. de Bont ES, Vellenga E, Swaanenburg J, Kamps W. Procalcitonin: a diagnostic<br />
marker <strong>of</strong> bacterial infection in neutropenic cancer patients with fever?<br />
Infection 2000;28:398-400.<br />
20. Fleischhack G, Kambeck I, Cipic D, Hasan C, Bode U. Procalcitonin in<br />
paediatric cancer patients: its diagnostic relevance is superior to that<br />
<strong>of</strong> C-reactive protein, interleukin 6, interleukin 8, soluble interleukin 2<br />
receptor and soluble tumour necrosis factor receptor II. Br J Haematol<br />
2000;111:1093-1102.<br />
21. Sakr Y, Sponholz C, Tuche F, Brunkhorst F, Reinhart K. The role <strong>of</strong><br />
procalcitonin in febrile neutropenic patients: review <strong>of</strong> the literature.<br />
Infection 2008;36:396-407.<br />
22. Frakking FN, Israëls J, Kremer LC, Kuijpers TW, Caron HN, van de Wetering<br />
MD. Mannose-binding lectin (MBL) and the risk for febrile neutropenia and<br />
infection in pediatric oncology patients with chemotherapy. Pediatr Blood<br />
Cancer 2011;57:89-96.<br />
23. Schlapbach LJ, Aebi C, Otth M, Luethy AR, Leibundgut K, Hirt A, Ammann RA.<br />
Serum levels <strong>of</strong> mannose binding lectin and the risk <strong>of</strong> fever in neutropenia<br />
pediatric cancer patients. Pediatr Blood Cancer 2007;49:11-16.<br />
24. Kilpatrick DC, McLintock LA, Allan EK, Copland M, Fujita T, Jordanides<br />
NE, Koch C, Matsushita M, Shiraki H, Stewart K, Tsujimura M, Turner ML,<br />
Franklin IM, Holyoake TL. No strong relationship between mannan binding<br />
lectin or plasma ficolins and chemotherapy-related infections. Clin Exp<br />
Immunol 2003;134:279-284.<br />
25. Bergmann OJ, Christiansen M, Laursen I, Bang P, Hansen NE, Ellegaard J,<br />
Koch C, Andersen V. Low levels <strong>of</strong> mannose-binding lectin do not affect<br />
occurrence <strong>of</strong> severe infections or duration <strong>of</strong> fever in acute myeloid<br />
leukaemia during remission induction therapy. Eur J Haematol 2003;70:91-<br />
97.<br />
26. Horiuchi T, Gondo H, Miyagawa H, Otsuka J, Inaba S, Nagafuji K, Takase<br />
K, Tsukamoto H, Koyama T, Mitoma H, Tamimoto Y, Miyagi Y, Tahira T,<br />
Hayashi K, Hashimura C, Okamura S, Harada M. Association <strong>of</strong> MBL gene<br />
polymorphisms with major bacterial infection in patients treated with highdose<br />
chemotherapy and autologous PBSCT. Genes Immun 2005;6:162-166.<br />
27. Klostergaard A, Steffensen R, Møller JK, Peterslund N, Juhl-Christensen C,<br />
Mølle I. Sepsis in acute myeloid leukaemia patients receiving high-dose<br />
chemotherapy: no impact <strong>of</strong> chitotriosidase and mannose-binding lectin<br />
polymorphism. Eur J Haematol 2010;85:58-64.<br />
28. Peterslund NA, Koch C, Jensenius JC, Thiel S. Association between deficiency<br />
<strong>of</strong> mannose-binding lectin and severe infections after chemotherapy.<br />
Lancet 2001;358:637-638.<br />
29. Neth O, Hann I, Turner MW, Klein NJ. Deficiency <strong>of</strong> mannose-binding lectin<br />
and burden <strong>of</strong> infection in children with malignancy: a prospective study.<br />
Lancet 2001;358:614-618.<br />
30. Mullighan CG, Heatley S, Doherty K, Szabo F, Grigg A, Hughes TP, Schwarer<br />
AP, Szer J, Tait BD, Bik To L, Bardy PG. Mannose-binding lectin gene<br />
polymorphisms are associated with major infection following allogeneic<br />
hemopoietic stem cell transplantation. Blood 2002;99:3524-3529.<br />
310
RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2015.0216<br />
Turk J Hematol 2016;<strong>33</strong>:311-319<br />
Prospective Evaluation <strong>of</strong> Infection Episodes in Cancer Patients<br />
in a Tertiary Care Academic Center: Microbiological Features and<br />
Risk Factors for Mortality<br />
Kanser Hastalarındaki Enfeksiyon Ataklarının Prospektif Değerlendirmesi: Mikrobiyolojik<br />
Özellikler ve Mortalite için Risk Faktörleri<br />
Nursel Çalık Başaran 1 , Ergun Karaağaoğlu 2 , Gülşen Hasçelik 3 , Mine Durusu Tanrıöver 1 , Murat Akova 4<br />
1Hacettepe University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Internal Medicine, Ankara, Turkey<br />
2Hacettepe University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Biostatistics, Ankara, Turkey<br />
3Hacettepe University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Basic Microbiology, Ankara, Turkey<br />
4Hacettepe University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Infectious Diseases and Clinical Microbiology, Ankara, Turkey<br />
Abstract<br />
Objective: We aimed to determine the frequency, type, and etiology<br />
<strong>of</strong> infections and the risk factors for infections and mortality in<br />
hospitalized cancer patients.<br />
Materials and Methods: We prospectively enrolled adult cancer<br />
patients hospitalized in the internal medicine wards <strong>of</strong> a tertiary<br />
care academic center between January and August 2004. Patients<br />
were followed during their hospitalization periods for neutropenia,<br />
infections, culture results, and mortality.<br />
Results: We followed 473 cancer patients with 818 hospitalization<br />
episodes and 384 infection episodes in total. Seventy-nine percent<br />
<strong>of</strong> the infections were nosocomial, and febrile neutropenia (FN) was<br />
observed in 196 (51%) <strong>of</strong> the infection episodes. Bacteremia was<br />
found in 29% <strong>of</strong> FN episodes and in 8% <strong>of</strong> nonneutropenic patients.<br />
Gram-positive bacteria were the leading cause <strong>of</strong> bacteremia in both<br />
neutropenic and nonneutropenic cases (70% and 58%, respectively).<br />
Presence <strong>of</strong> an indwelling central catheter increased bacteremia risk<br />
by 3-fold. The overall mortality rate was 17%, whereas 34% <strong>of</strong> the<br />
patients with bloodstream infections died. Presence <strong>of</strong> bacteremia<br />
and advanced disease stage increased overall mortality by 6.1-fold<br />
and 3.7-fold, respectively.<br />
Conclusion: Nearly half <strong>of</strong> the cancer patients developed an infection<br />
during their hospital stays, with gram-positive bacteria being the<br />
predominant etiologic microorganisms. This demonstrates the<br />
changing trends in infections considering that, until 2004, gramnegative<br />
bacteria were the most predominant microorganisms among<br />
cancer patients in our institute.<br />
Keywords: Febrile neutropenia, Cancer, Mortality, Risk factors<br />
Öz<br />
Amaç: Enfeksiyonlar, kanser hastalarında önde gelen morbidite ve<br />
mortaliteleri nedeni olmuşlardır. Bu çalışmada hastanede yatan kanser<br />
hastalarında enfeksiyonların sıklığını, tiplerini, etiyolojilerini ve enfeksiyon<br />
gelişimi ve mortalite için risk faktörlerini belirlemeyi amaçladık.<br />
Gereç ve Yöntemler: Üçüncü basamak bir üniversite hastanesinin iç<br />
hastalıkları servislerinde Ocak-Ağustos 2004 tarihleri arasında izlenmiş<br />
olan erişkin kanser hastaları dahil edildi. Yatış süreleri boyunca<br />
nötropeni, enfeksiyonlar, kültür sonuçları ve mortalite açısından<br />
prospektif olarak izlendiler.<br />
Bulgular: Toplam 473 kanser hastasının 818 hastaneye yatış atağı<br />
izlendi. Toplam 818 yatış atağı sırasında 384 (%46) enfeksiyon atağı<br />
gözlendi- %79’u nozokomiyaldi. Febril nötropeni (FN) tüm atakların<br />
196’sında (%51) görüldü. Bakteremi, FN ataklarının %29’unda ve<br />
nötropenik olmayan hastaların %8’inde görüldü. Gram-pozitifler hem<br />
nötropenik olan hem de olmayan hastalardaki bakteremilerin önde<br />
gelen etkeni olarak görüldü (%70 ve %58, sırasıyla). Santral kateter<br />
varlığının bakteremi riskini 3 kat artırdığı görüldü. Toplam mortalite<br />
%17 iken bakteremisi olan hastalarda mortalite %34 saptandı.<br />
Bakteremi varlığı ve ileri evre hastalık toplam mortaliteyi, sırasıyla, 6,1<br />
ve 3,7 kat artırmaktaydı.<br />
Sonuç: Hastanede yatan kanser hastalarının neredeyse yarısında en<br />
azından bir enfeksiyon gelişmektedir ve bu enfeksiyonlarda grampozitifler<br />
hakimdir. Bu bilgiler, 2004 yılına kadar kanser hastalarında<br />
en sık görülen mikroorganizmaların gram-negatif mikroorganizmalar<br />
olduğu göz önüne alındığında, enfeksiyonlarda değişen eğilimler<br />
olduğunu göstermektedir.<br />
Anahtar Sözcükler: Febril nötropeni, Kanser, Mortalite, Risk faktörleri<br />
Address for Correspondence/Yazışma Adresi: Nursel ÇALIK BAŞARAN, M.D.,<br />
Hacettepe University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Internal Medicine, Ankara, Turkey<br />
Phone : +90 312 305 30 29<br />
E-mail : nurselcbasaran@gmail.com<br />
Received/Geliş tarihi: May 25, 2015<br />
Accepted/Kabul tarihi: January 11, 2016<br />
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Introduction<br />
Infections have become the leading cause <strong>of</strong> mortality and<br />
morbidity <strong>of</strong> cancer while supportive and curative treatment<br />
strategies prolong life [1,2]. Cancer and its treatment suppress<br />
the immune system, and long and recurrent hospitalizations<br />
predispose patients to various infections.<br />
Predominant infectious pathogens have been variable in<br />
time with changing cancer treatment strategies, antibacterial<br />
prophylaxis practices, and emerging resistance patterns in<br />
bacteria. Until the 1980s, the leading microorganisms in cancer<br />
patients were enteric gram-negative bacteria and Pseudomonas<br />
aeruginosa. As <strong>of</strong> the 1980s, gram-positive bacteria became the<br />
most common pathogens in these patients [1,3,4]. However,<br />
recently, nonfermenting gram-negative bacteria have emerged<br />
as the leading pathogens in cancer patients.<br />
It is important to know the risk factors for infections,<br />
changing epidemiology, and resistance patterns <strong>of</strong> pathogenic<br />
microorganisms for the proper management <strong>of</strong> infections<br />
in cancer patients. In this study, we aimed to determine the<br />
frequency, type, and etiology <strong>of</strong> infections and the risk factors<br />
for infections and mortality in hospitalized cancer patients.<br />
Materials and Methods<br />
Study Design and Patients<br />
This study was done in the internal medicine wards <strong>of</strong> a tertiary<br />
care university hospital. The institutional review board approved<br />
the study and adult cancer patients hospitalized between January<br />
and August 2004 were enrolled and followed prospectively.<br />
Demographic data, cancer type and stage, previous stem cell<br />
transplantation history and type, comorbidities, and presence<br />
<strong>of</strong> antibacterial utilization in the previous month were recorded<br />
upon admission. Presence <strong>of</strong> indwelling catheters (central or<br />
peripheral venous, arterial, urinary, or drainage), presence <strong>of</strong><br />
parenteral nutrition, requirement <strong>of</strong> intensive care unit and<br />
mechanical ventilation, therapy for cancer (chemotherapy,<br />
radiation, corticosteroids), vital signs, infections, antibiotic<br />
usage, culture results, and neutrophil counts were recorded<br />
throughout the admission episode. Descriptive data and further<br />
analyses were done based on the admission episodes unless<br />
otherwise specified. One patient might have had more than<br />
one admission. The infectious diseases department followed the<br />
patients and the researchers did not intervene in the diagnostic<br />
and therapeutic processes.<br />
Neutropenia was defined as an absolute neutrophil count<br />
below 500/mm 3 or below 20 mg/day (or equivalent) or over a period <strong>of</strong> 10<br />
days whatever the dose was. Antifungal prophylaxis was defined<br />
as oral fluconazole/itraconazole used in prophylactic doses.<br />
Microbiological Methods<br />
All the cultures were collected from different parts <strong>of</strong> the body<br />
according to the presumed infections. They were inoculated onto<br />
suitable media and incubated at 37 °C for 24-48 h. Catheter<br />
cultures were studied quantitatively. For blood cultures, a BD<br />
BACTEC 9000 Blood Culture System (Becton Dickinson Diagnostic<br />
Systems, Sparks, MD, USA) was used. All the microorganisms were<br />
identified by gram staining, conventional microbiological tests<br />
(such as hemolysis, catalase, oxidase, and coagulase reaction),<br />
and the Phoenix System (Becton Dickinson Diagnostic Systems).<br />
Antibiotic susceptibility tests were conducted with the Phoenix<br />
System and for Streptococcus pneumoniae by E-test (AB<br />
BIODISK, Solna, Sweden). Results were evaluated according to<br />
the Clinical and Laboratory Standards Institute 2004 standards.<br />
Statistical Analysis<br />
Data were analyzed by SPSS 11.5 for Windows (SPSS Inc.,<br />
Chicago, IL, USA). Distribution <strong>of</strong> data was analyzed by<br />
Kolmogorov-Smirnov test. Normally distributed data are<br />
presented as mean ± standard deviation, while abnormally<br />
distributed data are presented as median (minimum-maximum).<br />
Categorical variables were compared by chi-square test and<br />
Fischer’s exact test where appropriate, and continuous variables<br />
were analyzed by Student’s t-test. Risk analysis was performed<br />
by Fisher’s exact chi-square test and parameters that were found<br />
to be significant were introduced into a multivariate logistic<br />
regression model. Relative risk was computed for possible risk<br />
factors with 95% confidence interval and p
Turk J Hematol 2016;<strong>33</strong>:311-319<br />
Çalık Başaran N, et al: Infection Episodes in Cancer Patients<br />
admission episodes (7.7%) and half <strong>of</strong> them were allogeneic<br />
HSCTs.<br />
In the course <strong>of</strong> 818 hospitalization episodes, a total <strong>of</strong> 384<br />
(46%) infection episodes were observed and 79% <strong>of</strong> these<br />
were nosocomial. Febrile neutropenia (FN) was observed in<br />
126 patients having 196 (51%) infection episodes. Acute<br />
myeloid leukemia was the most common underlying disease<br />
(n=35, 35/126, 27%) in patients with FN. Mean duration <strong>of</strong><br />
neutropenia was longer in patients with an infection (16.2<br />
days) when compared to those without an infection (8.2 days)<br />
(p=0.002). Bacteremia was found in 29% <strong>of</strong> FN episodes and in<br />
8% <strong>of</strong> nonneutropenic infections (p
Çalık Başaran N, et al: Infection Episodes in Cancer Patients<br />
Turk J Hematol 2016;<strong>33</strong>:311-319<br />
Fluconazole as antifungal prophylaxis was given in 63 (7.7%)<br />
episodes as a part <strong>of</strong> the stem cell transplantation regimen.<br />
Corticosteroids were used in 215 (26.4%) <strong>of</strong> the admission<br />
episodes. Radiation therapy was performed in 5.1% (42) <strong>of</strong><br />
hospitalization episodes. Unfortunately, we had no data about<br />
granulocyte colony-stimulating factor use in this study.<br />
Nonneutropenic episodes constituted 71.4% <strong>of</strong> all the<br />
hospitalization episodes and in 77.3% <strong>of</strong> these cases an<br />
immunosuppressive treatment, including corticosteroids, was<br />
used. As expected, there was an immunosuppressive treatment<br />
in 94% <strong>of</strong> neutropenic episodes (p
Turk J Hematol 2016;<strong>33</strong>:311-319<br />
Çalık Başaran N, et al: Infection Episodes in Cancer Patients<br />
Possible risk factors for infection in cancer patients were<br />
analyzed by univariate analysis and then the risk factors found<br />
to increase the occurrence <strong>of</strong> an infection were introduced into<br />
a multivariate logistic regression model (Table 6). We found that<br />
advanced disease stage, neutropenia for more than 7 days, and<br />
radiation were related to an increased frequency <strong>of</strong> infection<br />
in cancer patients (p
Çalık Başaran N, et al: Infection Episodes in Cancer Patients<br />
Turk J Hematol 2016;<strong>33</strong>:311-319<br />
Table 5. Resistance patterns <strong>of</strong> microorganisms in neutropenic and nonneutropenic patients.<br />
Resistance Total, n (%) Nonneutropenic, n (%) Neutropenic, n (%) p-value<br />
Escherichia coli ESBL (-) 80 (70.7) 72 (75.7) 8 (44.4)<br />
ESBL(+) <strong>33</strong> (29.3) 23 (24.3) 10 (55.6)
Turk J Hematol 2016;<strong>33</strong>:311-319<br />
Çalık Başaran N, et al: Infection Episodes in Cancer Patients<br />
paper by Trecarichi et al. also reported the shift from grampositive<br />
to gram-negative bacteria in BSIs in hematologic<br />
malignancies and again they pointed out the increasing<br />
resistance among gram-negative bacteria [18]. Several studies<br />
demonstrated gram-negative predominance either in blood or<br />
other specimen cultures in hematologic or solid cancer patients,<br />
with a frequency ranging between 24.7% and 75.8% in different<br />
geographic places with high resistance rates, including ESBLpositive<br />
Enterobacteriaceae, multidrug-resistant Pseudomonas<br />
aeruginosa, Acinetobacter spp., and Stenotrophomonas<br />
maltophilia [19,20,21,22]. According to surveillance data<br />
between 2005 and 2009 from our institution, gram-negative<br />
bacteria became the predominant BSI etiology in hematological<br />
malignancies with high resistance patterns [23]. Our study<br />
differs from these other studies in two major points: first, in<br />
our study, we followed both hematological and solid cancer<br />
patients, and second, we accepted at least one positive culture<br />
with CoNS in the presence <strong>of</strong> fever or central venous catheter.<br />
The growing resistance problems, especially among gramnegative<br />
pathogens, require special efforts in infection control<br />
measures and rational antibiotic usage in cancer patients.<br />
In this study ESBL-positive E. coli (55%) and Klebsiella spp. (50%)<br />
were more frequent in neutropenic cases than nonneutropenic<br />
cases. A literature review revealed that ESBL positivity in cancer<br />
patients ranged from 12% to 75% for E. coli and K. pneumoniae<br />
in different studies [23,24,25,26,27,28,29]. It was also shown<br />
that ESBL positivity negatively affects mortality and morbidity<br />
[26,30,31]. Unfortunately, due to low case numbers, we could<br />
not analyze the mortality effect <strong>of</strong> resistant gram-negative<br />
bacteria.<br />
We found that patients who were neutropenic for 7 or more<br />
days were prone to infection 3.9-fold more so than others. Poor<br />
prognosis and advanced stage solid or hematologic cancers<br />
were also related to an increased infection risk by 3.1-fold.<br />
Radiation was another risk factor for infection. This might<br />
be explained by the characteristics <strong>of</strong> the patient group that<br />
received radiotherapy: poor performance status, palliation in<br />
advanced disease, advanced age, or total body radiation prior to<br />
stem cell transplantation.<br />
Indwelling central catheter was a risk factor for BSIs. In the last<br />
30 years, increased use <strong>of</strong> persistent indwelling catheters has<br />
brought about an increased infection risk, especially for CoNS<br />
BSIs [1,12,32,<strong>33</strong>]. Moreover, BSI was a risk factor for mortality in<br />
our study. In previous studies mortality in cancer patients with<br />
BSIs ranged between 20% and 35% and this changed according<br />
to the pathogenic microorganisms [21,34,35,36,37,38]. This also<br />
points to the importance <strong>of</strong> implementing catheter bundles to<br />
decrease catheter-associated BSI rates.<br />
Antifungal prophylaxis was part <strong>of</strong> the prophylaxis regimen in<br />
HSCT patients and it seemed to lower the mortality, although we<br />
could not show statistical significance. There are some reports<br />
showing azole-resistant breakthrough fungemia, but a recent<br />
study from the EORTC revealed that antifungal prophylaxis<br />
was protective in fungemia in cancer patients [39]. As there<br />
are various studies on different oral antifungal prophylaxes<br />
with different outcomes favoring posaconazole, itraconazole,<br />
or fluconazole use in high-risk patients, further studies are<br />
required about which drug to use for which patient and how<br />
long these drugs must be used [40,41,42].<br />
Conclusion<br />
Nearly half <strong>of</strong> the cancer patients developed an infection during<br />
their hospital stays, with gram-positive bacteria being the<br />
predominant etiologic microorganisms. This demonstrates the<br />
changing trends in infections considering that, until 2004, gramnegative<br />
bacteria were the most predominant microorganisms<br />
among cancer patients in our institute. Each patient must be<br />
evaluated individually for risk factors, and while antibiotic<br />
treatment is being planned, current local surveillance data and<br />
the resistance patterns <strong>of</strong> the microorganisms should be taken<br />
into account along with individual risk factors.<br />
Acknowledgment<br />
A part <strong>of</strong> this study was presented as a poster presentation at the<br />
Febrile Neutropenia Symposium, February 2005, Ankara, Turkey,<br />
and the Interscience Conference on Antimicrobial Agents and<br />
Chemotherapy, December 2005, Washington, DC, USA.<br />
Ethics<br />
Ethics Committee Approval: LUT 05/15; Informed Consent: It<br />
was taken.<br />
Authorship Contributions<br />
Concept: Nursel Çalık Başaran, Ergun Karaağaoğlu, Gülşen<br />
Hasçelik, Mine Durusu Tanrıöver, Murat Akova; Design: Nursel<br />
Çalık Başaran, Ergun Karaağaoğlu, Gülşen Hasçelik, Mine Durusu<br />
Tanrıöver, Murat Akova; Data Collection or Processing: Nursel<br />
Çalık Başaran, Ergun Karaağaoğlu, Gülşen Hasçelik, Mine Durusu<br />
Tanrıöver, Murat Akova; Analysis or Interpretation: Nursel Çalık<br />
Başaran, Ergun Karaağaoğlu, Gülşen Hasçelik, Mine Durusu<br />
Tanrıöver, Murat Akova; Literature Search: Nursel Çalık Başaran,<br />
Ergun Karaağaoğlu, Gülşen Hasçelik, Mine Durusu Tanrıöver,<br />
Murat Akova; Writing: Nursel Çalık Başaran, Ergun Karaağaoğlu,<br />
Gülşen Hasçelik, Mine Durusu Tanrıöver, Murat Akova.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
317
Çalık Başaran N, et al: Infection Episodes in Cancer Patients<br />
Turk J Hematol 2016;<strong>33</strong>:311-319<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
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RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2015.0254<br />
Turk J Hematol 2016;<strong>33</strong>:320-325<br />
Effect <strong>of</strong> Hereditary Hemochromatosis Gene H63D and C282Y<br />
Mutations on Iron Overload in Sickle Cell Disease Patients<br />
Orak Hücreli Anemi Hastalarında Herediter Hemokromatozis Geni H63D ve C282Y<br />
Mutasyonlarının Demir Birikimi Üzerindeki Etkisi<br />
Yunus Kasım Terzi 1 , Tuğçe Bulakbaşı Balcı 1 , Can Boğa 2 , Zafer Koç 3 , Zerrin Yılmaz Çelik 1 , Hakan Özdoğu 2 , Sema Karakuş 2 , Feride İffet Şahin 1<br />
1Başkent University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Medical Genetics, Ankara, Turkey<br />
2Başkent University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Ankara, Turkey<br />
3Başkent University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Radiology, Ankara, Turkey<br />
Abstract<br />
Objective: Hemochromatosis is an autosomal recessive disease that<br />
is one <strong>of</strong> the most important reasons for iron overload. Sickle cell<br />
disease is a hemoglobinopathy that occurs as a result <strong>of</strong> a homozygous<br />
mutation in the hemoglobin gene. Erythrocyte transfusion is<br />
frequently used in the treatment <strong>of</strong> this disease. Iron overload as a<br />
result <strong>of</strong> transfusion is important in the mortality and morbidity <strong>of</strong><br />
sickle cell anemia patients as well as in other hemoglobinopathies.<br />
In this study, the effect <strong>of</strong> hemochromatosis gene (HFE) p.H63D<br />
and p.C282Y mutations on transfusion-related cardiac and liver<br />
iron overload in sickle cell disease patients who carry homozygous<br />
hemoglobin S mutation has been investigated.<br />
Materials and Methods: This is a prospective single-center crosssectional<br />
study in patients with homozygous hemoglobin S mutation<br />
between the years 2008 and 2013. The patients were divided into<br />
two groups. The first group (group A, n=31) was receiving chelation<br />
therapy and the second group (group B, n=13) was not. Direct and<br />
indirect iron loads were analyzed by magnetic resonance imaging and<br />
biochemically, respectively. HFE gene mutations were analyzed by<br />
polymerase chain reaction-restriction fragment length polymorphism<br />
method. Statistical analyses were performed by independent samples<br />
t-test.<br />
Results: p.H63D mutation was detected in 10 (32.3%) patients in<br />
group A and in only 1 patient (7.7%) in group B. When the 2 groups<br />
were compared for iron overload, iron deposition in the liver was<br />
significantly higher in group B (p=0.046). In addition, in group A, iron<br />
deposition was significantly higher in HFE mutation carriers compared<br />
to patients without the mutation (p=0.05).<br />
Conclusion: Results <strong>of</strong> this study showed that HFE gene mutations<br />
are important in iron deposition in the liver in patients with sickle<br />
cell disease.<br />
Keywords: Hemochromatosis, HFE gene, Iron overload, p.C282Y,<br />
p.H63D, Sickle cell anemia<br />
Öz<br />
Amaç: Hemokromatozis, demir birikiminin önemli nedenlerinden<br />
biri olan otozomal resesif bir hastalıktır. Orak hücreli anemi,<br />
hemoglobin genindeki homozigot mutasyon sonucu ortaya çıkan bir<br />
hemoglobinopatidir. Eritrosit transfüzyonu, bu hastalığın tedavisinde<br />
sıklıkla kullanılmaktadır. Transfüzyonun yarattığı demir yükü diğer<br />
hemoglobinopatilerde olduğu gibi orak hücreli anemi hastalarının<br />
mortalite ve morbiditesinde önem kazanmaktadır. Bu çalışmada<br />
hemokromatozis geni (HFE) p.H63D ve p.C282Y mutasyonlarının,<br />
homozigot hemoglobin S mutasyonu taşıyan orak hücreli anemi<br />
hastalarında, kalp ve karaciğerde transfüzyonla ilişkili demir<br />
yüklenmesine olan etkisi araştırılmıştır.<br />
Gereç ve Yöntemler: Bu çalışma, homozigot hemoglobin S mutasyonu<br />
olan hastalarda 2008-2013 yıllarını kapsayan prospektif, tek merkezli<br />
kesitsel bir çalışmadır. Hastalar şelasyon tedavisi alan (n=31) ve<br />
almayan (n=13) olarak iki gruba ayrıldı. Hastalarda direk ve endirekt<br />
demir yükü sırasıyla manyetik rezonans görüntüleme ve biyokimyasal<br />
olarak analiz edildi. HFE geni mutasyon analizi polimeraz zincir<br />
reaksiyonu-restriksiyon fragment uzunluk polimorfizmi yöntemleri<br />
ile gerçekleştirildi. İstatistik analizi Independent samples t-testi<br />
uygulanarak gerçekleştirildi.<br />
Bulgular: p.H63D mutasyonu grup A’da 10 hastada (%32,3), grup B’de<br />
ise sadece 1 (%7,7) hastada saptandı. Demir birikimi açısından gruplar<br />
karşılaştırıldığında karaciğerde demir birikiminin grup B’de istatistiksel<br />
olarak anlamlı derecede yüksek olduğu görülmüştür (p
Turk J Hematol 2016;<strong>33</strong>:320-325<br />
Terzi YK, et al: HFE Mutations and Iron Overload<br />
Introduction<br />
Hereditary hemochromatosis (HH) is an autosomal recessive<br />
disease that is one <strong>of</strong> the important reasons for transfusionunrelated<br />
iron deposition [1]. The hemochromatosis (HFE) gene,<br />
encoding a transferrin receptor binding protein that regulates<br />
iron absorption from the intestine, is responsible for the disease<br />
and its point mutations result in increased iron absorption and<br />
accumulation [2,3].<br />
The penetrance <strong>of</strong> the disease is low, as only 1% <strong>of</strong> p.C282Y<br />
homozygous individuals have clinical presentations. The<br />
disease phenotype results from primary or secondary causes.<br />
Primary (hereditary) hemochromatosis is usually due to gene<br />
mutations including the HFE gene as well as other genes<br />
including transferrin receptor-2 and ferroportin. Secondary<br />
hemochromatosis is a result <strong>of</strong> inherited or acquired anemia<br />
requiring frequent erythrocyte transfusions [1]. The hereditary<br />
causes <strong>of</strong> secondary hemochromatosis include thalassemia,<br />
hereditary spherocytosis, and sideroblastic anemia, and the<br />
acquired diseases include anemia due to blood loss [1].<br />
Sickle cell anemia is a hemoglobinopathy resulting from<br />
a homozygous point mutation in the hemoglobin gene<br />
characterized by sickling <strong>of</strong> erythrocytes [4]. Sickling results in<br />
vaso-occlusion, hemolysis, and chronic anemia, which results in<br />
increased cardiac output due to volume overload and hypoxia as<br />
a result <strong>of</strong> vaso-occlusion, which ends with organ dysfunction<br />
[5]. Erythrocyte and blood transfusions are frequently used in<br />
the treatment <strong>of</strong> the disease. Transfusion-related iron overload<br />
is important in mortality and morbidity <strong>of</strong> sickle cell anemia<br />
patients like in other hemoglobinopathies [3,6]. Mutation<br />
frequencies are known to be different between ethnic groups.<br />
In the current study, the relationship between HFE gene p.H63D<br />
and p.C282Y mutations and iron deposition occurring during<br />
sickle cell anemia progress and their effect on cardiac and liver<br />
iron overload have been investigated.<br />
Materials and Methods<br />
Patients<br />
The study was performed as a prospective, single-center, crosssectional<br />
study on homozygous hemoglobin S mutation patients<br />
followed in the adult hematology department between 2008<br />
and 2013. A total <strong>of</strong> 45 patients aged between 20 and 42 years<br />
were enrolled in the study and divided into two groups according<br />
to administration <strong>of</strong> chelation treatment. Patients in group A<br />
(n=31) were receiving chelation treatment and those in group B<br />
(n=13) were not. There were 21 male and 10 female patients in<br />
group A and 4 male and 9 female patients in group B. Patients<br />
in group A received deferasirox (Exjade, Novartis, Switzerland)<br />
therapy when they had evidence <strong>of</strong> chronic transfusional iron<br />
overload. This evidence included the transfusion <strong>of</strong> at least<br />
100 mL/kg <strong>of</strong> packed red blood cells, or a serum ferritin level<br />
consistently greater than 1000 µg/L. Initial daily dose was 20<br />
mg/kg, per os. All patients required escalation <strong>of</strong> 5 to 10 mg/kg<br />
per daily dose to keep serum ferritin from consistently falling<br />
from baseline. If the serum ferritin fell below 500 µg/L, the<br />
therapy was interrupted. Duration <strong>of</strong> therapy was 30 months<br />
(range: 18-44 months).<br />
Patients with contraindications for magnetic resonance imaging<br />
(MRI) were excluded from the study. Clinical and laboratory<br />
information <strong>of</strong> the patients was obtained from the hospital<br />
information management system (Nucleus v9.3.39, Monad Ltd.,<br />
Ankara, Turkey).<br />
Hematological and Biochemical Analyses<br />
Blood cell count and aspartate aminotransferase and alanine<br />
aminotransferase levels were analyzed by automatized methods<br />
in the laboratory. Serum iron concentration (normal range: 59-<br />
158 µg/dL), transferrin saturation (normal range: 15%-75%),<br />
serum ferritin (normal range: 40-340 ng/mL for males and<br />
14-150 ng/mL for females), and C-reactive protein levels were<br />
detected by enzyme-linked immunosorbent assays.<br />
Magnetic Resonance Imaging Analyses<br />
All imaging analyses were performed as described previously<br />
with slight modifications, and a 1.5T MRI system was used for<br />
these analyses (Avanto, Siemens, Erlangen, Germany) [7,8,9].<br />
Briefly, liver and myocardial measurements included T2* value<br />
screenings. Screening time was 14 s. The scan duration was 14<br />
s. The T2* <strong>of</strong> the heart was assessed by a cardiac gated single<br />
breath-hold multiecho technique. Midventricular short-axis<br />
images were obtained using a gradient-echo sequence (FOV,<br />
440 mm; TR, 120 ms; TE, 3.0-21.7 ms [8 echo times]; flip<br />
angle, 20; slice thickness, 10 mm; matrix, 256x104; number <strong>of</strong><br />
averages, 1; bandwidth in Hz/pixel, 814). To measure the liver<br />
iron concentration (LIC), phased-array torso coils were used for<br />
signal detection. The lung was excluded on the axial plane as<br />
much as possible. Liver T2* values were assessed by single breathhold<br />
multiecho technique. Axial images through the liver were<br />
obtained using a gradient-echo sequence (FOV, 400; TR, 120 ms;<br />
TE, 4.3-20.2 ms [6 echo times]; flip angle, 20; slice thickness, 10<br />
mm; matrix, 256x80; number <strong>of</strong> averages, 1; bandwidth in Hz/<br />
pixel, 814). T2* measurements were performed with Thalassemia<br />
Tools (Cardiovascular Imaging Solutions, London, UK). A fullthickness<br />
region <strong>of</strong> interest was drawn in the interventricular<br />
septum. The signal intensity <strong>of</strong> this region for each echo time<br />
was measured and plotted as an exponential signal decay curve.<br />
The lower limit <strong>of</strong> normal for T2* in the detection <strong>of</strong> myocardial<br />
iron deposition has been reported as 20 ms, and this value was<br />
used as the cut-<strong>of</strong>f in this study [7,8,9]. A T2* value <strong>of</strong> >20<br />
ms indicated no cardiac iron overload, and ≤20 ms indicated<br />
321
Terzi YK, et al: HFE Mutations and Iron Overload<br />
Turk J Hematol 2016;<strong>33</strong>:320-325<br />
cardiac iron overload [10]. Liver iron deposition was evaluated<br />
by R2* value (R2*=1000/T2*). The R2* value was converted to<br />
a liver biopsy equation by using the calibration curve drawn<br />
during the study [11]. LIC in dry tissue <strong>of</strong> >1.6 mg Fe/g was<br />
regarded as hepatic siderosis.<br />
HFE Gene p.H63D and p.C282Y Mutation Analyses<br />
DNA isolation was done from peripheral blood samples <strong>of</strong> the<br />
patients who were included in the study and signed the informed<br />
consent form. HFE gene p.H63D and p.C282Y mutations were<br />
analyzed by polymerase chain reaction (PCR)-restriction<br />
fragment length polymorphism. Primer sequences and product<br />
sizes for p.H63D and p.C282Y mutations are shown in Table 1.<br />
PCR conditions were 15 min at 95 °C for initial denaturation,<br />
followed by 35 cycles <strong>of</strong> 45 s at 94 °C, 30 s at 58 °C, and 30 s<br />
at 72 °C. The PCR was completed after a final elongation step<br />
<strong>of</strong> 7 min at 72 °C. PCR products were digested with BclI and<br />
RsaI restriction endonucleases for H63D and C282Y mutation<br />
analyses, respectively. The band lengths after digestion are<br />
shown in Table 1. A gel image <strong>of</strong> the digested products is shown<br />
in Figure 1.<br />
Statistical Analysis<br />
A, liver iron deposition was significantly higher in patients<br />
with mutations compared to the patients without mutations<br />
(p=0.05) (Table 4). C282Y mutation was not observed in any <strong>of</strong><br />
the patients included in the study (Table 3).<br />
Discussion<br />
Humans do not have a physiologic mechanism to excrete excess<br />
iron absorbed from the intestine. Iron metabolism is strictly<br />
controlled by intestinal absorption [12]. In the case <strong>of</strong> increased<br />
iron absorption, iron deposits occur in all organs. As iron<br />
accumulation is a problem directly influencing the prognosis<br />
in sickle cell disease patients, we proposed that coexisting HFE<br />
mutations could contribute to the deposition process in these<br />
cases.<br />
HH is characterized by hepatic fibrosis, cirrhosis, diabetes,<br />
skin pigmentation, hypogonadism, and articular and cardiac<br />
disorders and, in advanced stages <strong>of</strong> the disease, iron deposition<br />
in other organs as a result <strong>of</strong> increased iron absorption from the<br />
intestines [10]. The disease occurs as a result <strong>of</strong> HFE gene H63D<br />
and C282Y mutations [13].<br />
The Kolmogorov-Smirnovtest was used to show the normal<br />
distribution <strong>of</strong> the data. Significant differences between groups<br />
were determined using t tests. Data were expressed as means.<br />
All statistical analyses and tests were performed with the SPSS<br />
statistical package (SPSS 17.0, Chicago, IL, USA) and p
Turk J Hematol 2016;<strong>33</strong>:320-325<br />
Terzi YK, et al: HFE Mutations and Iron Overload<br />
Table 2. Biochemical and magnetic resonance imaging results <strong>of</strong> patients in group A and group B. Liver iron deposition and<br />
platelet count were found to be significantly different in group A compared to group B (*p
Terzi YK, et al: HFE Mutations and Iron Overload<br />
Turk J Hematol 2016;<strong>33</strong>:320-325<br />
Table 4. Biochemical and magnetic resonance imaging measurement results <strong>of</strong> patients in group A. Liver iron deposition was<br />
found to be significantly higher (*p=0.05) in patients with HFE mutations compared to the patients without HFE mutations.<br />
Mean<br />
t-test<br />
Distributions Highest p-value<br />
HFE Mutation-negative HFE Mutation-positive Lowest<br />
Cardiac MRI (T2*, ms) 19.429 11.061 -7.43 24.17 0.283<br />
Liver MRI (Fe, mg/g) 0.892 2 -1.44 0.00 0.050*<br />
Ferritin (ng/mL) 444.5<strong>33</strong> 599.083 -675.17 366.07 0.528<br />
Transferrin saturation (%) 44.625 35 -56.17 75.42 0.740<br />
CRP (mg/L) 20.652 10 -13.22 34.67 0.364<br />
ALT (U/L) 21.350 20.857 -6.55 7.54 0.886<br />
AST (U/L) 34.650 47.500 -39.96 14.26 0.292<br />
Leukocyte count (x10 3 /µL) 12.271 12.549 -4.48 3.93 0.890<br />
Thrombocyte number (x10 3 /µL) 427.<strong>33</strong>3 434.125 -179.93 166.34 0.932<br />
Serum albumin (g/dL) 3.999 3.823 -1.46 1.81 0.781<br />
Creatinine (mg/dL) 0.893 0.566 -0.31 0.96 0.277<br />
Hemoglobin (g/dL) 9.255 9 -1.31 1.45 0.917<br />
MCV (fL) 90.300 84.025 -8.60 21.15 0.370<br />
MRI: Magnetic resonance imaging, CRP: C-reactive protein, ALT: alanine aminotransferase, AST: aspartate aminotransferase, MCV: mean corpuscular volume, HFE: Hemochromatosis<br />
gene.<br />
Although determination <strong>of</strong> ferritin level is an indirect method, it<br />
is one <strong>of</strong> the most valuable tools for follow-up <strong>of</strong> iron overload in<br />
patients with hemoglobinopathy. The source <strong>of</strong> the ferritin in the<br />
blood may be different. In the case <strong>of</strong> high levels <strong>of</strong> ferritin (3000<br />
µg/L), the possible source is blood and bone marrow; however, if<br />
the measurable level <strong>of</strong> ferritin is below 3000 µg/L, the possible<br />
source <strong>of</strong> ferritin is the reticuloendothelial system. Fluctuation <strong>of</strong><br />
the measured ferritin level may be observed in the case <strong>of</strong> infection<br />
or inflammations. It has already been shown that the most accurate<br />
indicator <strong>of</strong> total body ferritin load is liver ferritin level [9]. Although<br />
liver biopsy was not performed for the patients to determine the<br />
ferritin load <strong>of</strong> the liver, and this may be considered as a weakness<br />
<strong>of</strong> the study, MRI is one <strong>of</strong> the other valuable tools to determine<br />
ferritin load in the liver and heart, and reproducibility is one <strong>of</strong> the<br />
strong features <strong>of</strong> this method [11].<br />
Conclusion<br />
HFE gene mutations are effective on iron deposition in the liver<br />
in sickle cell disease patients. In patients for whom recurrent<br />
erythrocyte transfusions are required, genotyping <strong>of</strong> the HFE<br />
gene will be helpful while management with chelating agents<br />
is being planned.<br />
Acknowledgments<br />
This study was approved by the Başkent University Institutional<br />
Review Board (Project No: KA09/254) and supported by the<br />
Başkent University Research Fund.<br />
Ethics<br />
Ethics Committee Approval: This study was approved by Başkent<br />
University Institutional Review Board (Project no: KA09/254);<br />
Informed Consent: Written informed consent was obtained<br />
from all patients.<br />
Authorship Contributions<br />
Surgical and Medical Practices: Can Boğa, Hakan Özdoğu, Sema<br />
Karakuş, Zafer Koç; Concept: Tuğçe Bulakbaşı Balcı, Feride İffet<br />
Şahin, Zerrin Yılmaz Çelik, Can Boğa, Hakan Özdoğu, Sema<br />
Karakuş; Design: Tuğçe Bulakbaşı Balcı, Feride İffet Şahin,<br />
Zerrin Yılmaz Çelik, Can Boğa, Hakan Özdoğu, Sema Karakuş,<br />
Zafer Koç; Data Collection or Processing: Feride İffet Şahin,<br />
Zerrin Yılmaz Çelik, Can Boğa, Hakan Özdoğu, Sema Karakuş,<br />
Zafer Koç, Yunus Kasım Terzi; Analysis or Interpretation: Yunus<br />
Kasım Terzi, Feride İffet Şahin, Can Boğa, Hakan Özdoğu, Zafer<br />
Koç; Literature Search: Tuğçe Bulakbaşı Balcı, Feride İffet Şahin,<br />
Zerrin Yılmaz Çelik, Can Boğa, Hakan Özdoğu, Zafer Koç, Yunus<br />
Kasım Terzi; Writing: Feride İffet Şahin, Yunus Kasım Terzi, Can<br />
Boğa, Zafer Koç.<br />
Conflict <strong>of</strong> Interest: No conflict <strong>of</strong> interest was declared by the<br />
authors.<br />
Financial Disclosure: Support provided by Başkent University<br />
Research Foundation (Project no: KA09/254).<br />
324
Turk J Hematol 2016;<strong>33</strong>:320-325<br />
Terzi YK, et al: HFE Mutations and Iron Overload<br />
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9. Wood JC, Enriquez C, Ghugre N, Tyzka JM, Carson S, Nelson MD, Coates TD.<br />
MRI R2 and R2* mapping accurately estimates hepatic iron concentration<br />
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Mungan Z. HFE gene mutation, chronic liver disease, and iron overload in<br />
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325
RESEARCH ARTICLE<br />
DOI: 10.4274/tjh.2015.0356<br />
Turk J Hematol 2016;<strong>33</strong>:326-<strong>33</strong>0<br />
Health-Related Quality <strong>of</strong> Life, Depression, Anxiety, and<br />
Self-Image in Acute Lymphocytic Leukemia Survivors<br />
Akut Lenfoblastik Lösemi Tedavisi Almış Çocuklarda Yaşam Kalitesi, Depresyon, Anksiyete<br />
ve Kendilik İmajı Değerlendirmesi<br />
Birol Baytan 1 , Çiğdem Aşut 2 , Arzu Çırpan Kantarcıoğlu 1 , Melike Sezgin Evim 1 , Adalet Meral Güneş 1<br />
1Uludağ University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatrics, Division <strong>of</strong> Pediatric <strong>Hematology</strong>, Bursa, Turkey<br />
2Uludağ University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatrics, Bursa, Turkey<br />
Abstract<br />
Objective: With increasing survival rates in childhood acute<br />
lymphocytic leukemia (ALL), the long-term side effects <strong>of</strong> treatment<br />
have become important. Our aim was to investigate health-related<br />
quality <strong>of</strong> life, depression, anxiety, and self-image among ALL survivors.<br />
Materials and Methods: Fifty patients diagnosed with ALL and their<br />
siblings were enrolled. The Kovacs Children’s Depression Inventory,<br />
State-Trait Anxiety Inventory, Offer Self-Image Questionnaire, and<br />
Pediatric Quality <strong>of</strong> Life Inventory TM were used for collecting data.<br />
ANOVA tests were used to determine if there were any significant<br />
differences between groups.<br />
Results: ALL survivors had higher depression, more anxiety symptoms,<br />
lower quality <strong>of</strong> life, and more negative self-image when compared<br />
to their siblings.<br />
Conclusion: Continuous diagnostic and interventional mental health<br />
services might be necessary for possible emotional side effects <strong>of</strong><br />
treatment during and after the treatment. Rehabilitation and followup<br />
programs should be implemented for children during and after<br />
treatment for ALL.<br />
Keywords: Childhood leukemia, Depression, Anxiety, Self-image,<br />
Health-related quality <strong>of</strong> life<br />
Öz<br />
Amaç: Akut lenfoblastik lösemide (ALL) sağkalım oranlarının<br />
artmasıyla tedavinin uzun süreli yan etkileri önemli hale gelmiştir.<br />
Bu çalışmanın amacı da ALL sağkalanlarında, sağlıkla ilişkili yaşam<br />
kalitesi, depresyon, anksiyete ve kendilik imajını incelemektir.<br />
Gereç ve Yöntemler: ALL tanısı almış 50 çocuk ile onların aynı<br />
sayıdaki sağlıklı kardeşleri çalışmaya dahil edilmiştir. Verileri toplamak<br />
için, Kovaks Çocuklar için Depresyon Anketi, Durumluluk-Sürekli<br />
Kaygı Envanteri, Offer Kendilik İmajı anketi ve Pediatric Quality <strong>of</strong><br />
Life Inventory TM kullanılmıştır. Gruplar arası farklar ANOVA yöntemi<br />
kullanılarak araştırılmıştır.<br />
Bulgular: ALL sağkalanlarının, kardeşlerine göre, depresyon ve<br />
anksiyete puanları anlamlı olarak fazladır. Ayrıca, benlik imajlarının<br />
daha olumsuz, yaşam kalitelerinin daha düşük idi.<br />
Sonuç: ALL tedavisi sırasında ve sonrasında olası duygusal yan etkiler<br />
için sürekli tanısal ve girişimsel mental sağlık servisleri gerekli olabilir.<br />
Tedavi sırasında ve sonrasında ALL’li çocuklar için rehabilitasyon ve<br />
izlem programları uygulanmalıdır.<br />
Anahtar Sözcükler: Çocukluk çağı lösemisi, Depresyon, Anksiyete,<br />
Kendilik imajı, Sağlıkla ilişkili yaşam kalitesi<br />
Introduction<br />
Acute lymphoblastic leukemia (ALL) is the most common type<br />
<strong>of</strong> childhood cancer. Over the past decades, survival rates<br />
have improved substantially [1,2]. Among the advances in ALL<br />
treatment, Health-related quality <strong>of</strong> life (HRQL), which is a<br />
multidimensional construct that encompasses several domains<br />
such as physical, cognitive, social, and emotional functioning,<br />
was recognized as an important outcome measure <strong>of</strong> ALL<br />
survivors [3].<br />
Bansal et al. [4] found that children with ALL have significantly<br />
poorer social, physical, and emotional health and well-being<br />
than their peers and siblings. All treatment protocols <strong>of</strong> ALL<br />
contain higher cumulative doses <strong>of</strong> asparaginase, vincristine,<br />
and corticosteroids. Significant treatment-related toxicities<br />
might develop during the treatment period. These treatment<br />
outcomes might affect HRQL adversely [5].<br />
Besides poorer HRQL, behavioral and emotional problems,<br />
including withdrawal, depression, anxiety, and attention<br />
problems, have been reported among children with ALL [6].<br />
Address for Correspondence/Yazışma Adresi: Birol BAYTAN, M.D.,<br />
Uludağ University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatrics, Division <strong>of</strong> Pediatric <strong>Hematology</strong>, Bursa, Turkey<br />
Phone : +90 224 295 06 03<br />
E-mail : baytanbirol@yahoo.com<br />
Received/Geliş tarihi: October 12, 2015<br />
Accepted/Kabul tarihi: January 11, 2016<br />
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Baytan B, et al: Emotional Status and Health Quality in Childhood ALL<br />
Some studies determined that long-term survivors <strong>of</strong> childhood<br />
cancer experience a great number <strong>of</strong> problems with social<br />
competence and symptoms <strong>of</strong> depression compared to healthy<br />
children and siblings [7,8].<br />
Another important area <strong>of</strong> psychological outcome that has not<br />
been studied widely is the impact <strong>of</strong> cancer on the survivor’s<br />
self-image. This has been defined as a set <strong>of</strong> self-attitudes that<br />
reflect a description and an evaluation <strong>of</strong> one’s own behavior<br />
and attributes [9]. Self-image may be influenced by a chronic<br />
illness during childhood that affects physical appearance and<br />
opportunities for social interaction [10]. Having negative selfimage<br />
could be predictive <strong>of</strong> those survivors with adjustment<br />
problems [11].<br />
In the course <strong>of</strong> intensive therapy for ALL, there is a significant<br />
impairment in quality <strong>of</strong> life in the physical and psychosocial<br />
domains, but it improves significantly after a period <strong>of</strong> time<br />
[4]. Our study includes ALL patients in remission for 2-13 years.<br />
We analyzed the time periods in 3 different groups (2-5 years,<br />
6-10 years, and more than 10 years <strong>of</strong> survival) to determine the<br />
effect <strong>of</strong> the time after treatment on behavior and HRQL.<br />
The aim <strong>of</strong> this study, therefore, was to investigate HRQL, selfimage,<br />
depression, anxiety behaviors, and the impact <strong>of</strong> time<br />
period after treatment among ALL survivors.<br />
Materials and Methods<br />
The study group contained 50 children in the complete remission<br />
period <strong>of</strong> ALL. The control group consisted <strong>of</strong> ALL patients’<br />
siblings. The study group (standard and medium risk group)<br />
had no history <strong>of</strong> cranial radiation. The patients were treated<br />
with the BFM-9 leukemia protocol. Intrathecal methotrexate<br />
was given for central nervous system prophylaxis. The study<br />
group was composed <strong>of</strong> 27 (54%) female and 23 (46%) male<br />
participants. The age <strong>of</strong> the groups ranged between 13 and 18<br />
years, and the average age <strong>of</strong> the study group was 15.8±1.8<br />
years. The average age <strong>of</strong> the control group was 14.2±0.8 years.<br />
The control group was chosen from age- and sex-matched<br />
siblings because they shared similar social environmental and<br />
genetic features with the study group, apart from not having<br />
been diagnosed with ALL.<br />
If the family’s monthly income was under 2000 <strong>Turkish</strong> lira<br />
(TL), participants were considered as a lower income group. If it<br />
was between 2000 and 5000, they were considered as a middle<br />
income group, and if it was above 5000 TL, they were considered<br />
as a higher income group.<br />
The data <strong>of</strong> the study were gathered from 4 psychometrically<br />
validated self-report instruments. All <strong>of</strong> them were administered<br />
in one session to each participant separately.<br />
The Kovacs Children’s Depression Inventory (KCDI) is filled out<br />
by the adolescent. In this 27-item scale, there are three choices<br />
for each item. The patient is asked to choose the most relevant<br />
choice for considering the last 2 weeks. Reliability and validity<br />
study <strong>of</strong> the <strong>Turkish</strong> version <strong>of</strong> the KCDI was carried out by Öy<br />
[12] and a score <strong>of</strong> 19 was identified as the cut-<strong>of</strong>f level.<br />
The State-Trait Anxiety Inventory assesses the anxiety levels<br />
<strong>of</strong> the participants. It consists <strong>of</strong> two parts. The State Anxiety<br />
Inventory (SAI) requires the individual to describe how she/<br />
he feels at a given moment and under certain conditions and<br />
to respond to the items considering her/his feelings related to<br />
that specific condition. On the other hand, the Trait Anxiety<br />
Inventory (TAI) makes individuals express how they feel in<br />
general. The total score <strong>of</strong> each scale ranges between 20 and<br />
80. There are 4 choices for each item. High scores (more than 41<br />
points) indicate high anxiety levels. The reliability and validity<br />
<strong>of</strong> the <strong>Turkish</strong> version <strong>of</strong> the SAI and TAI were studied by Öner<br />
and Le Compte [13].<br />
The Offer Self-Image Questionnaire (OSIQ) was developed to<br />
identify the opinions <strong>of</strong> adolescents on self-esteem and sense <strong>of</strong><br />
identity. Developed by Offer, Ostrov, Howard, and Dolan in 1989,<br />
the OSIQ is a 6-point Likert-type scale (choosing the answer that<br />
the individual identifies with best) and measures individuals’<br />
adaptation in 11 different areas. The 99-item questionnaire<br />
form analyzes the self-image <strong>of</strong> adolescents in five dimensions<br />
(psychological, social, sexual, familial, and coping). Low scores<br />
(50 points and below) indicate low self-esteem. The reliability<br />
and validity <strong>of</strong> the <strong>Turkish</strong> version <strong>of</strong> the OSIQ were studied by<br />
Savaşır and Şahin [14].<br />
The Pediatric Quality <strong>of</strong> Life Inventory (PedsQL) examines<br />
individuals’ physical, psychological, and spiritual functioning,<br />
which are the characteristics <strong>of</strong> general well-being as defined<br />
by the World Health Organization. In addition to these, the scale<br />
also emphasizes school functioning. It consists <strong>of</strong> two subscales,<br />
which are the total physical health score (TPHS) and total score<br />
<strong>of</strong> psychosocial health (TSPH), and there is a total scale score,<br />
which is the combination <strong>of</strong> these two subscales. This scale<br />
does not include a cut-<strong>of</strong>f level but lower scores indicate poor<br />
quality <strong>of</strong> life. The reliability and validity <strong>of</strong> the <strong>Turkish</strong> version<br />
<strong>of</strong> the PedsQL was studied by Çakın Memik et al. [15].<br />
This research was approved by the Uludağ University Medical<br />
Ethics Committee and therefore the research was performed<br />
in accordance with the ethical standards <strong>of</strong> the Helsinki<br />
Declaration.<br />
SPSS 22.00 and ANOVA were used to determine if there were<br />
any significant differences between the groups.<br />
Results<br />
The results from patients’ and siblings’ reports are summarized<br />
in Table 1.<br />
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Baytan B, et al: Emotional Status and Health Quality in Childhood ALL<br />
Turk J Hematol 2016;<strong>33</strong>:326-<strong>33</strong>0<br />
Mean scores <strong>of</strong> the study and the control groups for self-report<br />
instruments are shown in Table 2.<br />
Quality <strong>of</strong> life and self-image scores <strong>of</strong> ALL survivors were lower<br />
and depression and anxiety scores were higher than in the<br />
siblings. Table 3 shows the comparison <strong>of</strong> the quality <strong>of</strong> life,<br />
depression, anxiety, and self-image scores in the groups.<br />
There were significant differences between groups. The study group<br />
Table 1. The demographic features <strong>of</strong> the study and control<br />
groups.<br />
Study Group<br />
n 50 50<br />
Sex<br />
Education<br />
Non-educated<br />
Primary school<br />
High school<br />
Undergraduate<br />
Graduate<br />
Income<br />
Low<br />
Medium<br />
High<br />
Employment status<br />
Employed<br />
Unemployed<br />
27 girls<br />
23 boys<br />
9<br />
5<br />
30<br />
5<br />
1<br />
9<br />
39<br />
2<br />
6<br />
44<br />
54%<br />
48%<br />
18%<br />
10%<br />
60%<br />
10%<br />
2%<br />
18%<br />
78%<br />
4%<br />
12%<br />
88%<br />
Control Group<br />
27 girls<br />
23 boys<br />
9<br />
9<br />
27<br />
4<br />
1<br />
9<br />
39<br />
2<br />
7<br />
43<br />
54%<br />
48%<br />
18%<br />
18%<br />
54%<br />
8%<br />
2%<br />
18%<br />
78%<br />
4%<br />
14%<br />
86%<br />
had more depression and anxiety symptoms and negative selfimage.<br />
Additionally, physical, psychological, and total qualities <strong>of</strong><br />
life were lower than in their siblings. Table 4 shows mean scores <strong>of</strong><br />
the depression, anxiety, quality <strong>of</strong> life, and self-image <strong>of</strong> survivors<br />
in different time periods after ALL treatment. Comparison <strong>of</strong> the<br />
depression, anxiety, quality <strong>of</strong> life, and self-image scores between<br />
ALL survivors and siblings is shown in Table 5.<br />
There were significant differences between the groups’ TvPHS,<br />
STS, TSPH, and KCDI scores according to time period after ALL<br />
treatment. Depression and quality <strong>of</strong> life scores were lower in<br />
the group <strong>of</strong> survivors 2-5 years after treatment.<br />
Discussion<br />
According to our study, the total quality <strong>of</strong> life score <strong>of</strong> the<br />
ALL survivors was significantly lower compared to their siblings<br />
and they had significantly lower self-concept (including the<br />
psychological, social, sexual, and familial self domains). Our<br />
study also showed that ALL survivors had significantly higher<br />
depression and anxiety symptoms than their siblings. Finally,<br />
our research revealed that the quality <strong>of</strong> life and depression<br />
scores were significantly lower among survivors 2-5 years after<br />
treatment when compared to 6-9 years and 10 years or more.<br />
Liew et al. [16] reported that adult long-term ALL survivors<br />
had a global HRQL score similar to the general population. van<br />
Litsenburg et al. [8] reported clinically important impaired HRQL<br />
scores <strong>of</strong> ALL survivors compared to the norms. ALL treatment<br />
impairs daily activities, family life, and school success, leading<br />
to low quality <strong>of</strong> life [17]. It is known that hospitalization for<br />
chemotherapy leads to problems such as social alienation and<br />
Table 2. Mean scores <strong>of</strong> the study and control groups for self-report instruments.<br />
Groups TPHS TSPH STS KCDI SAI TAI OSIQ<br />
Study (n=50) Mean 79.36 79.70 80.18 29.56 50.92 51.82 238.16<br />
Standard deviation 16.73 15.15 13.52 5.75 7.31 5.24 50.02<br />
Control (n=50) Mean 95.10 85.46 90.06 22.80 41.58 42.22 281.08<br />
Standard deviation 6.61 11.67 8.17 4.70 4.55 3.89 38.23<br />
TPHS: Total physical health score, TSPH: total score <strong>of</strong> psychosocial health, STS: scale total score, KCDI: Kovacs Children’s Depression Inventory, SAI: State Anxiety Inventory, TAI: Trait<br />
Anxiety Inventory, OSIQ: Offer Self-Image Questionnaire.<br />
Table 3. The comparison <strong>of</strong> groups’ quality <strong>of</strong> life, depression, anxiety, and self-image scores.<br />
Source Sum <strong>of</strong> Squares df Mean Squares F p<br />
TPHS between groups 6193.69 1 6193.693 38.25 0.00*<br />
2440.36 1 2440.36 19.54 0.00*<br />
TSPH between groups 829.44 1 829.44 4.53 0.00*<br />
KCDI between groups 1142.44 1 1142.40 41.34 0.00*<br />
SAI between groups 2180.89 1 2180.89 58.69 0.00*<br />
TAI between groups 2304 1 2304 107.83 0.00*<br />
OSIQ between groups 46,053.16 1 46,053.16 23.23 0.00*<br />
*: p≤0.05, F: F distribution, df: degrees <strong>of</strong> freedom, TPHS: total physical health score, TSPH: total score <strong>of</strong> psychosocial health, KCDI: Kovacs Children’s Depression Inventory, SAI: State<br />
Anxiety Inventory, TAI: Trait Anxiety Inventory, OSIQ: Offer Self-Image Questionnaire.<br />
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Baytan B, et al: Emotional Status and Health Quality in Childhood ALL<br />
Table 4. Mean scores <strong>of</strong> depression, anxiety, quality <strong>of</strong> life, and self-image regarding period after acute lymphocytic leukemia<br />
treatment.<br />
Period after ALL Treatment TPHS STS TSPH KCDI SAI TAI OSIQ<br />
Mean<br />
2-5 years SD<br />
n=12<br />
Mean<br />
6-9 years SD<br />
n=24<br />
Mean<br />
10 and more years SD<br />
n=14<br />
64.58<br />
15.10<br />
81.<strong>33</strong><br />
16.72<br />
87.78<br />
8.88<br />
67.<strong>33</strong><br />
14.74<br />
83.08<br />
11.34<br />
86.14<br />
8.31<br />
68.91<br />
4.63<br />
81.<strong>33</strong><br />
11.88<br />
86.07<br />
9.26<br />
36<br />
5.66<br />
28.75<br />
4.96<br />
51.50<br />
5.14<br />
52.08<br />
8.19<br />
52.500<br />
20.94<br />
52.54<br />
5.54<br />
232.25<br />
41.01<br />
234.79<br />
44.91<br />
ALL: Acute lymphocytic leukemia, SD: standard deviation, TPHS: total physical health score, TSPH: total score <strong>of</strong> psychosocial health, STS: scale total score, KCDI: Kovacs Children’s<br />
Depression Inventory, SAI: State Anxiety Inventory, TAI: Trait Anxiety Inventory, OSIQ: Offer Self-Image Questionnaire.<br />
25.42<br />
2.31<br />
48.43<br />
6.81<br />
50<br />
4.71<br />
249<br />
65.29<br />
Table 5. Comparison <strong>of</strong> the depression, anxiety, quality <strong>of</strong><br />
life, and self-image scores regarding period after acute<br />
lymphocytic leukemia treatment.<br />
Source<br />
TPHS between<br />
groups<br />
Sum <strong>of</strong><br />
Squares<br />
loneliness. For a child, quality <strong>of</strong> life is likely to be compromised<br />
by the pain <strong>of</strong> the illness and treatment, lack <strong>of</strong> energy to<br />
enjoy everyday activities, and fears about the future [18]. After<br />
cancer treatment, we usually observe that children do not<br />
want to attend to school again. Parents also usually have fears<br />
about their children contracting infections in school. The idea<br />
that their children are still vulnerable might be the reason for<br />
social isolation (according to our interviews with parents, ALL<br />
survivors are rarely allowed to join social activities outside the<br />
home), which might affect children’s quality <strong>of</strong> life negatively.<br />
Self-concept findings are similar to those <strong>of</strong> other studies, such<br />
as research on self-esteem among 578 pediatric ALL survivors<br />
compared to control groups [9]. According to some other<br />
studies, adult survivors <strong>of</strong> a variety <strong>of</strong> childhood cancers were<br />
found to have significantly lower self-esteem [18,19]. However,<br />
according to Maggiolini et al. [20], long-term adolescent ALL<br />
survivors had a more positive and mature self-image compared<br />
to a healthy student group. According to our study, self-image<br />
components such as coping capacity and individual values <strong>of</strong><br />
df<br />
Mean<br />
Squares<br />
3760.91 2 1880.45 8.87 0.00*<br />
STS between groups 2680.51 2 1340.25 10.08 0.00*<br />
TSPH between<br />
groups<br />
KCDI between<br />
groups<br />
2027.70 2 1013.85 5.19 0.01*<br />
752.39 2 376.19 20.28 0.00*<br />
SAI between groups 64.42 2 32.21 5.19 0.31<br />
TAI between groups 123.42 2 61.71 1.16 0.32<br />
OSI between groups 2<strong>33</strong>6.51 2 1168.27 0.46 0.64<br />
*: p≤0.05, F: F distribution, df: degrees <strong>of</strong> freedom, TPHS: total physical health score,<br />
TSPH: total score <strong>of</strong> psychosocial health, STS: scale total score, KCDI: Kovacs Children’s<br />
Depression Inventory, SAI: State Anxiety Inventory, TAI: Trait Anxiety Inventory.<br />
F<br />
p<br />
these children were stronger when compared to their siblings.<br />
These results indicate that patients undergoing a long and<br />
difficult treatment period, as in leukemia, may be damaged<br />
in some self-image domains, but at the same time that period<br />
may improve their capacity to cope with the problems that they<br />
encounter.<br />
Psychological problems among cancer patients are commonly<br />
reported. Acute stress symptoms, anxiety, depression, panic<br />
attacks, and post-traumatic stress symptoms might be observed<br />
among cancer patients [21,22]. Myers et al. [5] reported<br />
that anxiety was a significant problem in a subpopulation<br />
<strong>of</strong> patients with ALL immediately after diagnosis, whereas<br />
depression remained a significant problem for at least 1 year.<br />
Kanellopoulos et al. [23] reported that levels <strong>of</strong> anxiety and<br />
depression remained significantly associated with poor quality<br />
<strong>of</strong> life. Although major psychiatric disturbances are not common<br />
among survivors <strong>of</strong> ALL, a few earlier studies showed that this<br />
population has increased risk for mental health and adjustment<br />
problems [24,25,26]. Some studies indicate that the period<br />
after treatment is characterized by a higher risk <strong>of</strong> psychosocial<br />
problems compared with the actual treatment period. Children<br />
and adolescents who were <strong>of</strong>f treatment reported higher levels<br />
<strong>of</strong> depression and anxiety.<br />
The quality <strong>of</strong> life is worse at the time <strong>of</strong> diagnosis [7]. The period<br />
after treatment is characterized by a higher risk <strong>of</strong> psychosocial<br />
problems compared with the actual treatment period. Children<br />
and adolescents who were <strong>of</strong>f treatment reported higher levels<br />
<strong>of</strong> depression [27,28].<br />
There are some limitations <strong>of</strong> this research. First <strong>of</strong> all, besides<br />
the siblings who were our control group, a randomized peer<br />
group should have also participated in this research. Meanwhile,<br />
the ALL survivors who participated in this research came from<br />
the local area. A more widespread participant group would give<br />
more information about results.<br />
329
Baytan B, et al: Emotional Status and Health Quality in Childhood ALL<br />
Turk J Hematol 2016;<strong>33</strong>:326-<strong>33</strong>0<br />
Conclusion<br />
Despite the improved survival rates, cancer still remains a<br />
potentially life-threatening condition and a major challenge<br />
for both the child and the family. During and after the course<br />
<strong>of</strong> treatment, most children experience unpleasant physical<br />
and emotional side effects. The difficulties faced by children<br />
during and after treatment affect their quality <strong>of</strong> life, social<br />
life, and emotional status negatively. Continuous diagnostic and<br />
interventional mental health services might be necessary for<br />
possible emotional side effects during and after the treatment.<br />
Rehabilitation and follow-up programs should be implemented<br />
for these children both in the course <strong>of</strong> treatment and in the<br />
long-term follow-up period.<br />
Ethics<br />
Ethics Committee Approval: The study was approved by the<br />
Uludağ University Local Ethics Committee (protocol number:<br />
2014-2/15).<br />
Authorship Contributions<br />
Concept: Adalet Meral Güneş, Arzu Çırpan Kantarcıoğlu; Design:<br />
Birol Baytan, Arzu Çırpan Kantarcıoğlu; Data Collection or<br />
Processing: Çiğdem Aşut; Analysis or Interpretation: Arzu Çırpan<br />
Kantarcıoğlu; Literature Search: Çiğdem Aşut, Melike Sezgin<br />
Evim; Writing: Adalet Meral Güneş, Birol Baytan.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
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<strong>33</strong>0
BRIEF REPORT<br />
DOI: 10.4274/tjh.2016.0008<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>1-<strong>33</strong>4<br />
Clinical Courses <strong>of</strong> Two Pediatric Patients with Acute Megakaryoblastic<br />
Leukemia Harboring the CBFA2T3-GLIS2 Fusion Gene<br />
CBFA2T3-GLIS2 Füzyon Geni Taşıyan İki Pediatrik Akut Megakaryoblastik Lösemi Hastasının<br />
Klinik Seyri<br />
Mayu Ishibashi 1 , Tomoko Yokosuka 1,2 , Masakatsu D. Yanagimachi 1 , Fuminori Iwasaki 2 , Shin-ichi Tsujimoto 1 , Koji Sasaki 1 , Masanobu<br />
Takeuchi 1 , Reo Tanoshima 1 , Hiromi Kato 1 , Ryosuke Kajiwara 1 , Fumiko Tanaka 1 , Hiroaki Goto 1,2 , Shumpei Yokota 1<br />
1Yokohama City University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatrics, Yokohama, Japan<br />
2Kanagawa Children’s Medical Center, Clinic <strong>of</strong> <strong>Hematology</strong>/Oncology and Regenerative Medicine, Yokohama, Japan<br />
Abstract<br />
Acute megakaryoblastic leukemia (AMKL) in children without Down<br />
syndrome (DS) has an extremely poor outcome with 3-year survival<br />
<strong>of</strong> less than 40%, whereas AMKL in children with DS has an excellent<br />
survival rate. Recently, a novel recurrent translocation involving<br />
CBFA2T3 and GLIS2 was identified in about 30% <strong>of</strong> children with<br />
non-DS AMKL, and the fusion gene was reported as a strong poor<br />
prognostic factor in pediatric AMKL. We report the difficult clinical<br />
courses <strong>of</strong> pediatric patients with AMKL harboring the CBFA2T3-GLIS2<br />
fusion gene.<br />
Keywords: Acute megakaryoblastic leukemia without Down syndrome,<br />
CBFA2T3-GLIS2 fusion gene<br />
Öz<br />
Down sendromu (DS) olmayan çocuklarda akut megakaryoblastik<br />
löseminin (AMKL) prognozu çok kötü ve 3 yıllık sağkalım %40’ın altında<br />
iken, DS’li çocuklarda AMKL’nin sağkalım oranı mükemmeldir. Yakın<br />
zamanda, DS olmayan AMKL’li çocukların yaklaşık %30’unda CBFA2T3<br />
ve GLIS2’yi içeren yeni bir tekrarlayan translokasyon tanımlandı ve<br />
füzyon geninin pediatrik AMKL olgularında kötü prognoz ile ilişkili<br />
güçlü bir prognostik belirteç olduğu bildirildi. CBFA2T3-GLIS2 füzyon<br />
genini taşıyan AMKL tanılı pediatrik hastalarda sorunlu klinik seyri<br />
bildiriyoruz.<br />
Anahtar Sözcükler: Down sendromu olmayanlarda akut<br />
megakaryoblastik lösemi, CBFA2T3-GLIS2 füzyon geni<br />
Introduction<br />
Acute megakaryoblastic leukemia (AMKL) is classified as M7<br />
in the FAB (French-American-British) classification. AMKL<br />
accounts for approximately 10% <strong>of</strong> pediatric acute myeloid<br />
leukemia (AML) cases and 1% <strong>of</strong> adult AML cases [1,2,3].<br />
Pediatric AMKL is divided into two subgroups: AMKL arising in<br />
patients with Down syndrome (DS-AMKL), and AMKL arising in<br />
patients without DS (non-DS-AMKL). Although patients with<br />
DS-AMKL have an excellent survival rate, patients with non-<br />
DS-AMKL have an extremely poor outcome with 3-year survival<br />
<strong>of</strong> less than 40% [1,2,4]. Recently, two studies identified a<br />
novel recurrent translocation involving CBFA2T3 and GLIS2 in<br />
about 30% <strong>of</strong> children with non-DS-AMKL. The CBFA2T3-GLIS2<br />
fusion gene was reported as a strong poor prognostic factor in<br />
pediatric AMKL [5,6]. We report the difficult clinical courses <strong>of</strong><br />
two pediatric patients with AMKL harboring the CBFA2T3-GLIS2<br />
fusion gene.<br />
Case Presentation<br />
Between 2003 and 2012, six patients were diagnosed with<br />
AMKL at the Department <strong>of</strong> Pediatrics <strong>of</strong> Yokohama City<br />
University Hospital. We analyzed the fusion gene, CBFA2T3-<br />
GLIS2, in the six leukemic samples at the time <strong>of</strong> diagnosis by<br />
reverse transcription polymerase chain reaction (PCR) and direct<br />
sequencing, according to a previous report [5]. We compared<br />
characteristics between the patients who were diagnosed with<br />
AMKL with or without the CBFA2T3-GLIS2 fusion gene.<br />
Two patients had DS-AMKL harboring a GATA1 mutation and<br />
four had non-DS-AMKL. None <strong>of</strong> them had inv(16)/t(16;16)<br />
Address for Correspondence/Yazışma Adresi: Masakatsu D. YANAGIMACHI, M.D.,<br />
Yokohama City University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatrics, Yokohama, Japan<br />
Phone : +81-45-787-2800<br />
E-mail : m.yanagimachi@gmail.com<br />
Received/Geliş tarihi: January 07, 2016<br />
Accepted/Kabul tarihi: April 04, 2016<br />
<strong>33</strong>1
Ishibashi M, et al: CBFA2T3-GLIS2 Fusion Gene<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>1-<strong>33</strong>4<br />
chromosomal abnormalities upon G-band karyotyping. Two<br />
patients with non-DS-AMKL (Patient 1 and Patient 3) had the<br />
CBFA2T3-GLIS2 fusion gene (Table 1). Reverse transcription<br />
PCR and direct sequencing revealed that exon 11 <strong>of</strong> CBFA2T3<br />
was fused to exon 3 <strong>of</strong> GLIS2 in both cases (Figures 1A and<br />
1B). Neither <strong>of</strong> them achieved complete remission (CR) after<br />
induction therapies. They died from the primary disease after<br />
stem cell transplantation (SCT). The other 4 patients remain<br />
alive in CR (Table 1).<br />
Patient 1 with the CBFA2T3-GLIS2 fusion gene was treated<br />
under the AML05 protocol <strong>of</strong> the Japanese Pediatric Leukemia/<br />
Lymphoma Study Group [7] and could not achieve CR after<br />
induction 1 therapy (Figure 1C). After induction 2 therapy, Patient<br />
1 under non-CR conditions was treated with unrelated cord<br />
blood SCT (CBSCT) after a myeloablative conditioning regimen.<br />
Three months after CBSCT, her AMKL relapsed. She underwent<br />
two courses <strong>of</strong> chemotherapy. She received a haploidentical SCT<br />
Figure 1. Clinical courses <strong>of</strong> two Acute megakaryoblastic<br />
leukemia patients with the CBFA2T3-GLIS2 fusion gene. A)<br />
Reverse transcription polymerase chain reaction for the CBFA2T3-<br />
GLIS2 fusion gene in our patients. Two patients with non-Down<br />
syndrome-acute megakaryoblastic leukemia (patients 1 and 3)<br />
had the CBFA2T3-GLIS2 fusion gene. NC: Negative control. B)<br />
Direct sequencing for the polymerase chain reaction product<br />
<strong>of</strong> the CBFA2T3-GLIS2 fusion gene in patient 1 revealed that<br />
exon 11 <strong>of</strong> CBFA2T3 was fused to exon 3 <strong>of</strong> GLIS2. C) Clinical<br />
course <strong>of</strong> patient 1. FLAG: Fludarabine, cytarabine, G-CSF; FK506:<br />
tacrolimus. D) Magnetic resonance imaging <strong>of</strong> patient 1 revealed<br />
an extramedullary lesion at the thoracic spinal cord (Th9). E)<br />
Clinical course <strong>of</strong> patient 3. CAG: Cytarabine, aclarubicin, G-CSF;<br />
GO: gemtuzumab ozogamicin; IDA: idarubicin; VPL: vincristine,<br />
prednisolone, L-asparaginase.<br />
<strong>33</strong>2<br />
Table 1. Patient details.<br />
Outcome<br />
Karyotype CD56 (%) CBFA2T3-GLIS2 Sample Clinical<br />
Course<br />
Blasts<br />
(%, BM)<br />
Sex Blasts<br />
(%, PB)<br />
Age at<br />
Onset<br />
(Months)<br />
Patient<br />
No.<br />
Dead (30<br />
months)<br />
1 Non-DS 11 F 9 92 73,XXX,+X,+8,-12,+14,-15,+19,+20,+21 82.7 Positive BM CBSCTx2,<br />
R-BMTx2<br />
Alive (4 years)<br />
24.3 None PBMC UR-BMT, in<br />
1 st CR<br />
2 Non-DS 20 F 19.5 14.5 46XX,-7,add(11) (p11.2)<br />
,-7,21,22,+mar1,+mar2,+mar3,+mar4<br />
98.1 Positive BM UR-BMT Dead (23<br />
months)<br />
3 Non-DS 13 F 5.5 76 46,XX,add(3)(p21),add(4)(q11)14,add(17)<br />
(q25),add(19)(p13),20,+21,+der(?)t(?;14)<br />
(?;q1)/92,idem X2 46, idem, t(1;16)<br />
(q32;p13)<br />
0 None PBMC Chemotherapy Alive (7 years)<br />
4 Non-DS 20 F 42 Dry tap 46XXdel(7)(q?),del(11)(p?),t(12;14)<br />
(q13;p32),16,+mar1<br />
35.5 None PBMC Chemotherapy Alive (6 years)<br />
5 DS 20 M 21 15 47,XY,add(5)(p11),add(q11.2),+der(21)<br />
t(1;21)(q12;q22)ins(21;?)(q22;?)<br />
6 DS 21 M 42.5 70 47XY,+21 N/E None PBMC Chemotherapy Alive (5 years)<br />
BM: Bone marrow, PBMC: peripheral bone marrow cells, DS: Down syndrome, non-DS: patients without Down syndrome, F: female, M: male.
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>1-<strong>33</strong>4<br />
Ishibashi M, et al: CBFA2T3-GLIS2 Fusion Gene<br />
(haplo-SCT) from her mother under non-CR conditions. After<br />
the second transplant, she had leg paralysis and bladder and<br />
rectal disturbance from an extramedullary lesion at the thoracic<br />
spinal cord (Th9) (Figure 1D). Although she underwent radiation<br />
therapy for the Th9 mass, the mass did not disappear. While she<br />
received a second CBSCT and haplo-SCT, she failed to engraft<br />
and died 30 months after the fourth SCT.<br />
Patient 3 with the CBFA2T3-GLIS2 fusion gene was treated<br />
under the AML99 protocol [8] and could not achieve CR<br />
after induction A therapy (Figure 1E). She did not achieve<br />
CR even after several types <strong>of</strong> chemotherapy. Thereafter, she<br />
underwent chemotherapy with vincristine, prednisolone, and<br />
L-asparaginase (VPL), which is commonly used in therapy for<br />
acute lymphoblastic leukemia (ALL). After the VPL therapy,<br />
the percentage <strong>of</strong> blastic cells in the bone marrow decreased.<br />
She received unrelated bone marrow transplantation after<br />
a reduced-intensity conditioning regimen. She maintained<br />
remission for about 180 days and thereafter relapsed. Despite<br />
treatment with drugs including imatinib and L-asparaginase,<br />
she died 23 months after bone marrow transplantation.<br />
Discussion<br />
It was reported that CBFA2T3-GLIS2 fusion gene-positive cases<br />
account for about 30% <strong>of</strong> pediatric patients with AMKL [5,6,9].<br />
In addition, the overall survival rate and the event-free survival<br />
rate were lower in patients with the CBFA2T3-GLIS2 fusion<br />
gene than in those without this fusion gene [5,9,10,11]. There<br />
is little information about the clinical course <strong>of</strong> these patients.<br />
We encountered two AMKL patients with poor prognostics<br />
harboring the CBFA2T3-GLIS2 fusion gene, even though neither<br />
<strong>of</strong> them had inv(16)/t(16;16) chromosomal abnormalities upon<br />
G-band karyotyping. Therefore, evaluation <strong>of</strong> AMKL patients<br />
with this fusion gene without inv(16)/t(16;16) is needed.<br />
CD56 was expressed in leukemic blasts <strong>of</strong> the two CBFA2T3-<br />
GLIS2-positive patients with AMKL but not in the two CBFA2T3-<br />
GLIS2-negative patients among the non-DS-AMKL patients<br />
in our cohort (Table 1). It was reported that CD41 and CD56<br />
were positive and CD56 was drastically more highly expressed<br />
in patients with CBFA2T3-GLIS2-positive AMKL [6]. Higher<br />
expression <strong>of</strong> the CD56 antigen was reported as a poor prognostic<br />
marker [9,12,13,14,15,16,17]. Some investigators demonstrated<br />
that patients with CD56 positivity in blasts showed a higher<br />
incidence <strong>of</strong> extramedullary manifestations [12,13,14,18].<br />
Among our patients with AMKL, CD56 was also more highly<br />
expressed in the two CBFA2T3-GLIS2-positive patients with<br />
AMKL with poor outcomes, and Patient 1 had extramedullary<br />
manifestation that did not regress after irradiation. High CD56<br />
expression may be a surrogate marker <strong>of</strong> CBFA2T3-GLIS2<br />
positivity in AMKL.<br />
In Patient 3 with CBFA2T3-GLIS2-positive AMKL, chemotherapy<br />
regimens used to treat AML were not effective, but<br />
chemotherapy with VPL, commonly used to treat ALL, seemed<br />
to be more effective. When some <strong>of</strong> the treatment strategies<br />
commonly used to treat AML are not effective, the type<br />
<strong>of</strong> chemotherapy used to treat ALL might be effective in a<br />
subpopulation <strong>of</strong> patients with AMKL. There is a possibility that<br />
the conventional treatment commonly used to treat ALL may be<br />
effective for AMKL with this fusion gene. Eventually, the AMKL<br />
in both <strong>of</strong> the CBFA2T3-GLIS2-positive patients in our cohort<br />
became intractable to treatment, including SCT. Despite some<br />
chemotherapy regimens and SCT, the two patients with the<br />
CBFA2T3-GLIS2 fusion gene had poor prognosis. As previously<br />
reported, CBFA2T3-GLIS2 expression enhances BMP2/BMP4<br />
signaling [5]. The development <strong>of</strong> treatments including novel<br />
targeted therapy drugs is desired.<br />
Conclusion<br />
Clinical courses <strong>of</strong> pediatric patients with AMKL harboring<br />
the CBFA2T3-GLIS2 fusion gene are poor due to resistance to<br />
chemotherapies and SCT. New treatment strategies are necessary.<br />
Ethics<br />
Ethics Committee Approval: The protocol <strong>of</strong> this survey and<br />
research plan has been approved by the Clinical Ethics Committee<br />
<strong>of</strong> Yokohama City University (A130725002), Informed Consent:<br />
It was taken from patients and/or their parents.<br />
Authorship Contributions<br />
Concept: Masakatsu D.Yanagimachi; Design: Masakatsu D.<br />
Yanagimachi, Hiroaki Goto, Shumpei Yokota; Data Collection<br />
or Processing: Mayu Ishibashi, Tomoko Yokosuka, Masakatsu D.<br />
Yanagimachi, Fuminori Iwasaki, Shin-ichi Tsujimoto, Koji Sasaki,<br />
Masanobu Takeuchi, Reo Tanoshima, Hiromi Kato, Ryosuke<br />
Kajiwara, Fumiko Tanaka, Hiroaki Goto, Shumpei Yokota;<br />
Analysis or Interpretation: Mayu Ishibashi, Tomoko Yokosuka,<br />
Masakatsu D. Yanagimachi; Literature Search: Mayu Ishibashi,<br />
Tomoko Yokosuka, Masakatsu D. Yanagimachi, Fuminori Iwasaki,<br />
Shin-ichi Tsujimoto, Koji Sasaki, Masanobu Takeuchi, Reo<br />
Tanoshima, Hiromi Kato, Ryosuke Kajiwara, Fumiko Tanaka,<br />
Hiroaki Goto, Shumpei Yokota; Writing: Mayu Ishibashi, Tomoko<br />
Yokosuka, Masakatsu D. Yanagimachi, Fuminori Iwasaki, Shinichi<br />
Tsujimoto, Koji Sasaki, Masanobu Takeuchi, Reo Tanoshima,<br />
Hiromi Kato, Ryosuke Kajiwara, Fumiko Tanaka, Hiroaki Goto,<br />
Shumpei Yokota.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
<strong>33</strong>3
Ishibashi M, et al: CBFA2T3-GLIS2 Fusion Gene<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>1-<strong>33</strong>4<br />
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<strong>33</strong>4
BRIEF REPORT<br />
DOI: 10.4274/tjh.2016.0075<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>5-<strong>33</strong>8<br />
Evaluation <strong>of</strong> Insulin-like Growth Factor-1 and Insulin-like Growth<br />
Factor Binding Protein-3 Expression Levels in Patients with<br />
Chronic Lymphocytic Leukemia<br />
Kronik Lenfositik Lösemi Hastalarında İnsülin-benzeri Büyüme Faktörü-1 ve İnsülin-benzeri<br />
Büyüme Faktörü Bağlayıcı Protein-3 Düzeylerinin Değerlendirilmesi<br />
Mesut Ayer 1 , Abdullah Sakin 2 , Selim Ay 3 , Aylin Ayer 3 , Elif Gökçen Sazak 4 , Melih Aktan 4<br />
1Haseki Training and Research Hospital, Clinic <strong>of</strong> <strong>Hematology</strong>, İstanbul, Turkey<br />
2Okmeydanı Training and Research Hospital, Clinic <strong>of</strong> Internal Medicine, Oncology Unit, İstanbul, Turkey<br />
3Haseki Training and Research Hospital, Clinic <strong>of</strong> Internal Medicine, İstanbul, Turkey<br />
4İstanbul University İstanbul Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Internal Medicine, Division <strong>of</strong> <strong>Hematology</strong>, İstanbul, Turkey<br />
Abstract<br />
Objective: Chronic lymphocytic leukemia (CLL) is a disease <strong>of</strong><br />
nonproliferating and mature-appearing B lymphocytes. Insulin-like<br />
growth factor-1 (IGF-1) is a small peptide hormone and has mitogenic<br />
and antiapoptotic effects, and insulin-like growth factor binding<br />
protein-3 (IGFBP-3) has antiproliferative effects on cells. In this study, we<br />
investigated plasma levels <strong>of</strong> both IGF-1 and IGFBP-3 in patients with CLL<br />
compared with controls, and we compared these plasma levels according<br />
to prognostic factors.<br />
Materials and Methods: Patients with newly diagnosed CLL who were<br />
being followed at the Haseki Training and Research Hospital, İstanbul,<br />
Turkey, and volunteers were included in this study. Patients were stratified<br />
according to the Rai staging system. Statistical analysis was conducted<br />
using SPSS 17.0 for Windows.<br />
Results: Forty-three patients [16 women (37%) and 27 men (63%)] were<br />
enrolled in this study. Twenty-one volunteers (11 women, 10 men) were<br />
included in the control group. The median age <strong>of</strong> the patients was 65±9<br />
years (range: 18-63 years), and subjects in the control group were 68±8<br />
years old (range: 18-63 years). Even though the plasma levels <strong>of</strong> IGF-1 were<br />
higher and those <strong>of</strong> IGFBP-3 were lower and the ratio <strong>of</strong> IGF-I/IGFBP-3 was<br />
higher in comparison with the control group, these differences were not<br />
statistically significant (p>0.05). In the study group, IGF-1 levels appeared<br />
to be increased in parallel to more advanced Rai stages. There were no<br />
significant differences between the other groups (p=0.105).<br />
Conclusion: Plasma IGF-I levels were found higher in patients than in the<br />
control group and plasma IGFBP-3 levels were lower; however, neither<br />
result was statistically significant. Plasma IGF level increment was observed<br />
in concordance with Rai staging. These results prompted us to think that<br />
plasma IGF-1 levels in CLL patients are correlated with tumor burden and<br />
Rai staging and therefore could be a valuable prognostic factor. Further<br />
comprehensive studies are required to support our results.<br />
Keywords: Chronic lymphocytic leukemia, Insulin-like growth factor-1,<br />
Insulin-like growth factor binding protein-3<br />
Öz<br />
Amaç: Kronik lenfositik lösemi (KLL) olgun görünümlü B lenfositlerin<br />
hastalığıdır. İnsülin-benzeri büyüme faktörü-1 (IGF-1), mitojenik<br />
ve antiapoptotik etkili küçük peptid hormondur ve insülin-benzeri<br />
büyüme faktörü bağlayıcı protein-3 (IGFBP-3) ise hücre üzerinde<br />
antiproliferative etki gösterir. Çalışmamızda, KLL hasta grubu ve<br />
kontrol grubunda plazma IGF-1 ve IGFBP-3 düzeylerini ve prognostik<br />
faktörlerle ilişkisini karşılaştırdık.<br />
Gereç ve Yöntemler: Haseki Eğitim ve Araştırma Hastanesi,<br />
Hematoloji Bölümü’nde takip edilen yeni tanı almış KLL hastaları ile<br />
kontrol grubu çalışmaya dahil edilmiştir. Hastalar Rai sistemine göre<br />
evrelendirilmiştir. İstatistiksel analiz SPSS for Windows version 17.0<br />
kullanılarak yapılmıştır.<br />
Bulgular: Kırk üç hasta [16 kadın (%37) ve 27 erkek (%63)] çalışmaya<br />
alınmıştır. Kontrol grubu 21 kişiden (11 kadın, 10 erkek) oluşmuştur.<br />
Hasta grubunda ortanca yaş 65±9 (18-63), kontrol grubunda 68±8’dir<br />
(18-63). Kontrol grubu ile karşılaştırıldığında; çalışma grubunda<br />
plazma IGF-1 düzeyi yüksek; IGFBP-3 düzeyi düşük, IGF-I/IGFBP-3<br />
oranı ise yüksek olarak bulunmasına rağmen istatistiksel yönden<br />
anlamlı değildi (p>0,05). Çalışma grubunda plazma IGF-1 düzeyi<br />
yüksekliği ile Rai ileri evresi paralellik gösteriyordu. Diğer gruplarla<br />
istatistiksel yönden anlamlı farklılık yoktu (p=0,105).<br />
Sonuç: Çalışma grubunda, plazma IGF-1 düzeyi kontrol grubundan<br />
daha yüksek, IGFBP-3 düzeyi ise düşük bulundu, bununla beraber<br />
istatistiksel yönden anlamlı farklılık yoktu. Plazma IGF-1 düzeyi<br />
yüksekliği ile Rai ileri evresi uyumlu idi. Bu sonuçlar bize, IGF-1<br />
düzeyinin KLL hastalarında tümor yükü ve Rai evresi ile ilişkili olduğunu<br />
ve prognostik faktör olarak değerli olabileceğini düşündürmüştür.<br />
Bu sonuçları destekleyebilmek için daha geniş kapsamlı çalışmalara<br />
ihtiyaç vardır.<br />
Anahtar Sözcükler: Kronik lenfositik lösemi, İnsülin-benzeri büyüme<br />
faktörü-1, insülin benzeri büyüme faktörü bağlayıcı protein-3<br />
Address for Correspondence/Yazışma Adresi: Mesut AYER, M.D.,<br />
Haseki Training and Research Hospital, Clinic <strong>of</strong> <strong>Hematology</strong>, İstanbul, Turkey<br />
Phone : +90 212 529 44 00/2048<br />
E-mail : mesutayerdr@hotmail.com<br />
Received/Geliş tarihi: February 22, 2016<br />
Accepted/Kabul tarihi: April 08, 2016<br />
<strong>33</strong>5
Ayer M, et al: Evaluation <strong>of</strong> IGF-1 and IGFBP-3 Expression Levels in Patients with Chronic Lymphocytic Leukemia<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>5-<strong>33</strong>8<br />
Introduction<br />
Chronic lymphocytic leukemia (CLL) is a disease <strong>of</strong><br />
nonproliferating and mature-appearing B lymphocytes. Most<br />
patients with CLL are elderly; just 10% are aged less than<br />
50 years. In the evaluation <strong>of</strong> the prognosis <strong>of</strong> patients with<br />
CLL, mutations and cytogenetic abnormalities are crucial and<br />
independent markers in addition to clinical classifications [1,2].<br />
Insulin-like growth factor (IGF) has a pivotal role in the normal<br />
development <strong>of</strong> fetuses and children. In adulthood, this<br />
growth factor has a role in the inhibition <strong>of</strong> cell proliferation<br />
and apoptosis, in addition to its role in cellular metabolism.<br />
IGF-1 is a small peptide hormone that has mitogenic and<br />
antiapoptotic effects, but IGF-binding protein 3 (IGFBP-3) has<br />
an antiproliferative effect and negates the mitogenic effects <strong>of</strong><br />
IGF-1 by stimulating apoptosis. In several types <strong>of</strong> tumors, it has<br />
been shown that IGF-1 levels are increased and IGFBP-3 levels<br />
are decreased [3,4].<br />
In this study, we investigated plasma levels <strong>of</strong> both IGF-1 and<br />
IGFBP-3 in patients with CLL compared with controls and we<br />
compared these plasma levels according to prognostic factors.<br />
Materials and Methods<br />
Patients who were newly diagnosed with CLL at the Haseki<br />
Training and Research Hospital and healthy volunteers were<br />
included in this study. Patients with the following conditions<br />
were excluded from the study: chronic renal disease,<br />
decompensated heart failure, chronic hepatitis, coronary artery<br />
disease, diabetes mellitus with organ damage or uncontrolled<br />
plasma glucose levels, chronic inflammatory disease, and<br />
major trauma in the last the year. Twenty-one volunteers were<br />
included in the control group.<br />
Plasma samples were obtained after centrifugation at 3500<br />
rpm for 8 min and stored at -80 °C until analysis. Plasma IGF-I<br />
detection was performed using an ELISA kit (DRG International,<br />
USA) in accordance with the manufacturer’s protocol. The<br />
sensitivity <strong>of</strong> the kit was 0.15 ng/mL. IGFBP-3 levels were<br />
measured using a BioSource ELISA Kit with solid-phase enzyme<br />
immunoassay (BioSource, Belgium). The analytical sensitivity <strong>of</strong><br />
the kit was 10 μg/mL. Samples were measured using an ELISA<br />
microplate reader (DV-990 BV4, N.T. Laboratory, Italy).<br />
Statistical analysis was conducted using SPSS 17.0 for Windows<br />
(SPSS Inc., Chicago, IL, USA). The Kolmogorov-Smirnov test was<br />
used to determine whether the samples were from a population<br />
with normal distribution. In the comparison <strong>of</strong> values between<br />
two groups, Student’s t-test was used if the group was distributed<br />
normally. If the group was not normally distributed, the Mann-<br />
Whitney U test was used. In the analysis <strong>of</strong> proportional data,<br />
the chi-square test was used. Pearson and Spearman correlation<br />
tests were used to compare numerical parameters. One-way<br />
ANOVA testing was used to compare more than two groups;<br />
post hoc Bonferroni testing was used for multiple comparisons.<br />
In all statistical assessments, the cut-<strong>of</strong>f level <strong>of</strong> statistical<br />
significance was assumed as p0.05).<br />
Among the patients, 44% (n=19) had CLL <strong>of</strong> Rai stage 0, 11%<br />
(n=5) stage I, 20% (n=9) stage II, 16% (n=7) stage III, and 6%<br />
(n=3) stage IV.<br />
Compared with the control group, IGF-1 levels were found<br />
to be higher in the study group (531±246 ng/mL), and IGF-1<br />
levels were also detected to be subsequently higher in every<br />
Rai stage (Rai stage 0, 1… etc.). However, this difference was<br />
not statistically significant (p>0.05). IGFBP-3 levels were found<br />
lower in the study group (3890±324 ng/mL) and IGFBP-3 levels<br />
were also found lower in each sequential Rai stage (Rai stage 0,<br />
1… etc.), but this was not statistically significant (p>0.05). The<br />
IGF-I/IGFBP-3 ratio was higher in the study group (0.32±0.60<br />
ng/mL), although the difference was not statistically significant<br />
(p=0.5) (Table 1).<br />
In patients with CLL, we observed that IGF-1 levels had a<br />
positive correlation with Rai stages (Rs=0.411; p
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>5-<strong>33</strong>8<br />
Ayer M, et al: Evaluation <strong>of</strong> IGF-1 and IGFBP-3 Expression Levels in Patients with Chronic Lymphocytic Leukemia<br />
In our study, the mean plasma IGF-I levels <strong>of</strong> the patients<br />
were found higher than those <strong>of</strong> the control group, but the<br />
difference was not statistically significant. Plasma IGFBP-3<br />
level was lower than in the control group, but this was also not<br />
statistically significant. However, plasma IGF level increments<br />
were in parallel with Rai stages. A reverse correlation was not<br />
observed for IGFBP-3 levels.<br />
Figure 1. Mean insulin-like growth factor-1 values in Rai stages.<br />
Molica et al. measured serum levels <strong>of</strong> IGF-1 and IGFBP-3 in 77<br />
patients with CLL and found them to be statistically significantly<br />
lower than in the control group. However, no significant<br />
correlation was found between serum levels <strong>of</strong> either IGF-1 or<br />
IGFBP-3 and clinicohematologic variables including age, sex,<br />
Rai clinical stages, serum levels <strong>of</strong> lactate dehydrogenase and<br />
beta-2 microglobulin, peripheral blood lymphocyte count, and<br />
lymphocyte doubling time [11].<br />
In our study IGF-1 and IGFBP-3 levels were lower in patients<br />
with Rai stage 0 compared with the control group. Although<br />
IGF-1 levels were found lower in early stages, they increased<br />
significantly in parallel with more advanced Rai stages.<br />
In conclusion, plasma IGF-I levels in CLL patients were found<br />
higher than in the control group and plasma IGFBP-3 levels<br />
were lower. However, neither result was statistically significant.<br />
The increments <strong>of</strong> plasma IGF-1 level were in parallel with Rai<br />
staging.<br />
Figure 2. Insulin-like growth factor binding protein-3 values in<br />
Rai stages.<br />
Discussion<br />
The IGF system plays a pivotal role in normal growth throughout<br />
fetal and childhood development. In adult life, this system<br />
continues to function by regulating normal cellular metabolism,<br />
proliferation, and differentiation and it protects against<br />
apoptotic signals. However, aberrant stimulation can contribute<br />
to the development and progression <strong>of</strong> malignant growth<br />
[4,5,6].<br />
It has been shown in cell cultures that IGFBP-3 inhibits DNA<br />
synthesis without IGF. It has been claimed that IGFBP-3 may link<br />
p53 to potential novel autocrine/paracrine signaling pathways<br />
and to processes regulated by or dependent on IGF(s), such as<br />
cellular growth, transformation, and survival. It has also been<br />
asserted that induction <strong>of</strong> IGFBP-3 gene expression by wildtype,<br />
but not mutant, p53 was associated with enhanced<br />
secretion <strong>of</strong> an active form <strong>of</strong> IGFBP-3 capable <strong>of</strong> inhibiting<br />
mitogenic signaling by IGF-1 [7].<br />
Many studies have reported that high levels <strong>of</strong> IGF-I, low levels<br />
<strong>of</strong> IGFBP-3, or increments <strong>of</strong> the molar ratio <strong>of</strong> IGF-I/IGFBP-3<br />
were associated with various types <strong>of</strong> cancers [8,9,10,11].<br />
These results suggest that plasma IGF-1 levels in patients<br />
with CLL are correlated with tumor burden and Rai staging<br />
and therefore might be a valuable prognostic factor. Further<br />
comprehensive studies are required to support our results.<br />
Ethics<br />
Ethics Committee Approval: Study assessment and methods<br />
were approved by the local institutional ethics committee<br />
(21.01.2009/11); Informed Consent: Patient demographics<br />
and laboratory data were obtained from patient records upon<br />
obtaining oral informed consent from the patients and their<br />
information was recorded.<br />
Authorship Contributions<br />
Concept: Mesut Ayer; Design: Mesut Ayer; Data Collection or<br />
Processing: Mesut Ayer, Selim Ay, Abdullah Sakin, Aylin Ayer;<br />
Analysis or Interpretation: Mesut Ayer, Melih Aktan; Literature<br />
Search: Mesut Ayer, Abdullah Sakin, Selim Ay, Aylin Ayer, Elif<br />
Gökçen Sazak, Melih Aktan; Writing: Mesut Ayer, Abdullah<br />
Sakin, Selim Ay, Aylin Ayer, Elif Gökçen Sazak, Melih Aktan.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
<strong>33</strong>7
Ayer M, et al: Evaluation <strong>of</strong> IGF-1 and IGFBP-3 Expression Levels in Patients with Chronic Lymphocytic Leukemia<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>5-<strong>33</strong>8<br />
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10. Keleş M, Gündoğdu M, Erdem F, Türkeli M, Yıldız L, Turhan H. IGF-1 and<br />
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2006;11:98-102 (in <strong>Turkish</strong> with English abstract).<br />
11. Molica S, Vitelli G, Mirabelli R, Digiesu G, Giannarelli D, Cuneo A, Ribatti D,<br />
Vacca A. Serum insulin-like growth factor is not elevated in patients with<br />
early B-cell chronic lymphocytic leukemia but is still a prognostic factor for<br />
disease progression. Eur J Haematol 2006;76:51-57.<br />
<strong>33</strong>8
BRIEF REPORT<br />
DOI: 10.4274/tjh.2016.0102<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>9-345<br />
The Frequency <strong>of</strong> HLA-A, HLA-B, and HLA-DRB1 Alleles in<br />
Patients with Acute Lymphoblastic Leukemia in the <strong>Turkish</strong><br />
Population: A Case-Control Study<br />
Akut Lenfoblastik Lösemili Hastalarda HLA-A, HLA-B, ve HLA-DRB1 Alellerinin Türk<br />
Toplumundaki Sıklığı: Olgu-Kontrol Çalışması<br />
Türkan Patıroğlu 1,2 , H. Haluk Akar 1<br />
1Erciyes University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatric Immunology, Kayseri, Turkey<br />
2Erciyes University Faculty <strong>of</strong> Medicine, Human Leukocyte Antigen Tissue Typing Laboratory, Kayseri, Turkey<br />
Abstract<br />
We studied the frequencies <strong>of</strong> human leukocyte antigen alleles (A,<br />
B, and DRB1) in 90 patients with acute lymphoblastic leukemia (ALL)<br />
and then compared them with 126 controls in this study. Although<br />
the frequencies <strong>of</strong> the A*03 allele, the DRB1*03 allele, the DRB1*04<br />
allele, the A*02/B*35/DRB1*13 haplotype, and homozygosity <strong>of</strong> A*02<br />
were higher in patients (p=0.006, p=0.003, p=0.002, p=0.01, and<br />
p=0.02, respectively), the frequencies <strong>of</strong> the A*23, B*13, B*40, and<br />
DRB1*13 alleles were lower (p=0.002, p=0.07, p=0.002, and p=0.003,<br />
respectively) in patients than controls. The frequencies <strong>of</strong> the DRB1*04<br />
and DRB1*07 alleles were higher in patients in the high-risk group and<br />
standard-risk group, respectively (p=0.009 and p=0.007, respectively).<br />
This study indicated that the frequency <strong>of</strong> the A*03 allele, the DRB1*03<br />
allele, the DRB1*04 allele, the A*02/B*35/DRB1*13 haplotype, and A*02<br />
homozygosity may play a predisposing role in patients with ALL in the<br />
<strong>Turkish</strong> population. The frequency <strong>of</strong> the DRB1*04 and DRB1*07 alleles<br />
may also be associated with high risk and standard risk in patients<br />
with ALL, respectively.<br />
Keywords: Acute lymphoblastic leukemia, Human leukocyte antigen<br />
alleles, Risk groups<br />
Öz<br />
Bu çalışmada akut lenfoblastik lösemili (ALL) hastalarda insan lökosit<br />
antijeni alellerinin (A, B, ve DRB1) Türk toplumundaki dağılımını<br />
araştırdık. Çalışmaya 90 ALL hastası ve 126 sağlıklı kontrol dahil edildi.<br />
Kontrollerle karşılaştırdığımızda ALL hastalarında A*03, DRB1*03,<br />
DRB1*04 alellerinin, A*02/B*35/DRB1*13 haplotipinin ve homozigot<br />
olarak A*02 alelinin daha sık olarak (sırası ile p=0,006, p=0,003, p=0,002,<br />
p=0,01 ve p=0,02) dağıldığını gözlemledik. Aksine A*23, B*13, B*40<br />
ve DRB1*13 alelleri (sırası ile p=0,002, p=0,07, p=0,002 ve p=0,003)<br />
ise kontrol grubunda daha fazla olarak saptandı. Ayrıca DRB1*04 ve<br />
DRB1*07 alelleri (sırası ile p=0,009 ve p=0,007) risk gruplarına göre<br />
yapılan karşılaştırmada sırası ile yüksek ve standart riskli hastalarda<br />
daha fazla bulundu. Bu çalışma ile ALL hastalarında Türk toplumu<br />
için A*03, DRB1*03, DRB1*04 alelleri, A*02/B*35/DRB1*13 haplotipi<br />
ve homozigot formdaki A*02 alelinin bir risk faktörü olabileceği<br />
gözlemlendi. Ayrıca DRB1*04 ve DRB1*07 alellerinin risk gruplarının<br />
oluşmasında sırası ile yüksek ve standart risk gruplarında daha fazla<br />
bulunabileceği tespit edildi.<br />
Anahtar Sözcükler: Akut lenfoblastik lösemi, İnsan lökosit antijeni<br />
alelleri, Risk grupları<br />
Introduction<br />
Acute leukemia is an uncontrolled clonal disease due to the<br />
increasing <strong>of</strong> immature hematopoietic cells with a rate <strong>of</strong> at<br />
least 25% in the bone marrow [1]. Acute lymphoblastic leukemia<br />
(ALL) is the most common cancer in pediatric populations [2]. The<br />
incidence <strong>of</strong> ALL is about 30 cases per million persons younger<br />
than 20 years. It is also the most common cause <strong>of</strong> death among<br />
cancers in children [3,4]. Patients with ALL can be classified<br />
into 3 risk groups as follows: a standard-risk group (SRG), a<br />
moderate-risk group (MRG) with adequate early treatment<br />
response, and a high-risk group (HRG) with inadequate response<br />
to induction treatment or Philadelphia chromosome-positive<br />
ALL [4,5]. Human leukocyte antigen (HLA) genes encode cell<br />
surface glycoproteins associated with antigen presentation that<br />
selectively interact with short peptide fragments derived from<br />
Address for Correspondence/Yazışma Adresi: H. Haluk Akar, M.D.,<br />
Erciyes University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pediatric Immunology, Kayseri, Turkey<br />
Phone : +90 352 207 66 66/25300<br />
E-mail : himmetakar@gmail.com<br />
Received/Geliş tarihi: March 13, 2016<br />
Accepted/Kabul tarihi: April 20, 2016<br />
<strong>33</strong>9
Patıroğlu T and Akar HH; HLA (A, B, and DRB1) Alleles and Acute Lymphoblastic Leukemia<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>9-345<br />
non-self and self-proteins. The HLA class I molecules (A, B, and<br />
C) present intracellular antigens to CD8 + T cells, while class II<br />
molecules (DR, DQ, and DP) present extracellular antigens to<br />
CD4 + T cells, which activate macrophages and B cells. HLA has a<br />
major role in regulating host responses to infections. It has been<br />
hypothesized that the HLA alleles may have an important role in<br />
predisposal to ALL [6]. The HLA genes are the most polymorphic<br />
genes in the human genome [7]. An association between ALL and<br />
HLA alleles has been shown in the literature; however, the data<br />
are not conclusive so far [8,9,10,11,12,13]. There are no identified<br />
consistent leukemia-associated HLA class I genes to date, but<br />
investigations <strong>of</strong> HLA class II genes such as DRB3, DRB4, and<br />
DRB5 have demonstrated consistent associations in patients<br />
with leukemia [14]. Genome-wide association studies have<br />
also identified some other risk alleles in different genes such as<br />
CDKN2A, PIP4K2A, GATA3, ARID5B, and CEBPE in patients with<br />
ALL [15]. In this study, we aimed to evaluate the association <strong>of</strong><br />
HLA alleles, haplotypes, and homozygosity in patients with ALL.<br />
Materials and Methods<br />
Study Population<br />
This retrospective study was performed at the HLA Tissue Typing<br />
Laboratory <strong>of</strong> Erciyes University in Kayseri, Turkey. Ninety pediatric<br />
ALL patients (58 male patients and 32 female patients, 76 patients<br />
with B-cell and 14 patients with T-cell ALL, aged 7 months to 16<br />
years) and 126 age- and sex-matched unrelated healthy controls<br />
(72 males and 54 females, aged 1-18 years) were enrolled in this<br />
study, all <strong>of</strong> <strong>Turkish</strong> ethnic origin. Participants in the control<br />
group were selected from among unrelated healthy donors who<br />
were studied for HLA alleles for transplantation (for solid organ<br />
or hematological malignancies). In the 90 patients with ALL, risk<br />
groups were as follows: 29 patients in the SRG, 37 in the MRG,<br />
and 24 in the HRG.<br />
Human Leukocyte Antigen Typing<br />
Whole venous blood specimens were collected in 2KE tubes with<br />
EDTA for all participants. Genomic DNAs were obtained using<br />
the BioRobot EZ1 (QIAGEN, Hilden, Germany). Genotyping <strong>of</strong><br />
HLA alleles was done as low-resolution typing by the polymerase<br />
chain reaction with sequence-specific oligonucleotide probe<br />
(PCR-SSOP) method (Gen-Probe Lifecodes, Stanford, CA, USA).<br />
MATCH IT DNA s<strong>of</strong>tware version 1.2.0 was used for HLA allele<br />
interpretation.<br />
Statistical Analysis<br />
Statistical analyses were performed using SPSS 22. The association<br />
<strong>of</strong> alleles, haplotypes, and homozygosity was compared with the<br />
chi-square test (χ 2 ). Two groups were in accordance with Hardy-<br />
Weinberg equilibrium (p>0.005). The Bonferroni correction test<br />
was performed for multiple comparisons in risk groups. A value<br />
<strong>of</strong> p≤0.05 was accepted to be statistically significant.<br />
Results<br />
The frequencies <strong>of</strong> A, B, and DRB1 alleles are shown as 2n in Tables<br />
1, 2, and 3. Although the frequencies <strong>of</strong> the A*03, DRB1*03, and<br />
DRB1*04 alleles were observed to be higher (p=0.006, p=0.003,<br />
and p=0.002, respectively) in patients with ALL, the frequencies<br />
<strong>of</strong> A*23, B*13, B*40, and DRB1*13 (p=0.002, p=0.07, p=0.002,<br />
and p=0.003, respectively) were observed to be lower. In the<br />
second step, we evaluated the frequency <strong>of</strong> haplotypes (Table<br />
4). The A*02/B*35/DRB1*13 haplotype was found to be higher in<br />
Table 1. The frequency <strong>of</strong> HLA-A alleles.<br />
HLA-A ALL (2n=180) Controls (2n=252) p-value OR (95% CI)<br />
A*01<br />
A*02<br />
A*03<br />
A*11<br />
A*23<br />
A*24<br />
A*25<br />
A*26<br />
A*29<br />
A*30<br />
A*31<br />
A*32<br />
A*<strong>33</strong><br />
A*68<br />
n Frequency (%) n Frequency (%)<br />
18<br />
30<br />
<strong>33</strong><br />
13<br />
2<br />
30<br />
3<br />
6<br />
7<br />
4<br />
4<br />
12<br />
8<br />
10<br />
10<br />
16.7<br />
18.8<br />
7.2<br />
1.1<br />
16.7<br />
1.7<br />
3.3<br />
3.9<br />
2.2<br />
2.2<br />
6.7<br />
4.4<br />
5.6<br />
ALL: Acute lymphoblastic leukemia, CI: confidence interval, NS: nonsignificant, OR: odds ratio.<br />
29<br />
47<br />
23<br />
16<br />
18<br />
48<br />
1<br />
9<br />
9<br />
6<br />
4<br />
7<br />
10<br />
21<br />
11.5<br />
18.7<br />
9.1<br />
6.3<br />
7.1<br />
19<br />
0.4<br />
3.6<br />
3.6<br />
2.4<br />
1.6<br />
2.8<br />
4.0<br />
8.3<br />
NS<br />
NS<br />
0.006<br />
NS<br />
0.002<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
0.45 (0.25-0.79)<br />
NS<br />
6.84 (1.57-29.90)<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
340
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>9-345<br />
Patıroğlu T and Akar HH; HLA (A, B, and DRB1) Alleles and Acute Lymphoblastic Leukemia<br />
Table 2. The frequency <strong>of</strong> HLA-B alleles.<br />
HLA-B ALL (2n=180) Controls (2n=252) p-value OR (95% CI)<br />
B*07<br />
B*08<br />
B*13<br />
B*14<br />
B*15<br />
B*17<br />
B*18<br />
B*22<br />
B*27<br />
B*35<br />
B*38<br />
B*39<br />
B*40<br />
B*41<br />
B*44<br />
B*45<br />
B*49<br />
B*50<br />
B*51<br />
B*52<br />
B*55<br />
B*56<br />
B*57<br />
B*58<br />
n Frequency (%) n Frequency (%)<br />
10<br />
4<br />
4<br />
4<br />
5<br />
1<br />
16<br />
2<br />
7<br />
40<br />
2<br />
2<br />
2<br />
4<br />
10<br />
1<br />
7<br />
9<br />
29<br />
6<br />
4<br />
5<br />
2<br />
4<br />
5.6<br />
2.2<br />
2.2<br />
2.2<br />
2.8<br />
0.6<br />
8.9<br />
1.1<br />
3.9<br />
22.2<br />
1.1<br />
1.1<br />
1.1<br />
2.2<br />
5.6<br />
0.6<br />
3.9<br />
5<br />
16.1<br />
3.3<br />
2.2<br />
2.8<br />
1.1<br />
2.2<br />
ALL: Acute lymphoblastic leukemia, CI: confidence interval, NS: nonsignificant, OR: odds ratio.<br />
Table 3. The frequency <strong>of</strong> HLA-DRB1 alleles.<br />
11<br />
13<br />
21<br />
5<br />
6<br />
2<br />
13<br />
3<br />
6<br />
50<br />
2<br />
3<br />
18<br />
7<br />
10<br />
3<br />
11<br />
12<br />
28<br />
7<br />
6<br />
2<br />
4<br />
5<br />
4.4<br />
5.3<br />
8.3<br />
2.8<br />
3.3<br />
1.1<br />
5.2<br />
1.7<br />
2.4<br />
19.8<br />
0.8<br />
1.2<br />
7.1<br />
2.8<br />
5.6<br />
1.7<br />
4.4<br />
4.8<br />
11.1<br />
2.8<br />
2.4<br />
0.8<br />
1.6<br />
2.0<br />
NS<br />
NS<br />
0.007<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
0.002<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
4.0 (1.35-11.86)<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
6.8 (1.57-29.90)<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
HLA-DRB1 ALL (2n=180) Controls (2n=180) p-value OR (95% CI)<br />
DRB1*01<br />
DRB1*03<br />
DRB1*04<br />
DRB1*07<br />
DRB1*08<br />
DRB1*09<br />
DRB1*10<br />
DRB1*11<br />
DRB1*12<br />
DRB1*13<br />
DRB1*14<br />
DRB1*15<br />
DRB1*16<br />
n Frequency (%) n Frequency (%)<br />
16<br />
20<br />
60<br />
29<br />
7<br />
3<br />
8<br />
<strong>33</strong><br />
4<br />
6<br />
6<br />
12<br />
6<br />
8.9<br />
11.1<br />
<strong>33</strong>.3<br />
16.1<br />
3.9<br />
1.7<br />
4.4<br />
18.3<br />
2.2<br />
3.3<br />
3.3<br />
6.7<br />
3.3<br />
ALL: Acute lymphoblastic leukemia, CI: confidence interval, NS: nonsignificant, OR: odds ratio.<br />
19<br />
11<br />
50<br />
28<br />
7<br />
3<br />
5<br />
54<br />
3<br />
28<br />
14<br />
19<br />
11<br />
7.5<br />
4.4<br />
19.8<br />
11.1<br />
2.8<br />
1.2<br />
2.0<br />
21.4<br />
1.2<br />
11.1<br />
5.6<br />
7.5<br />
4.4<br />
NS<br />
0.003<br />
0.002<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
0.003<br />
NS<br />
NS<br />
NS<br />
NS<br />
0.36 (0.17-0.78)<br />
0.50 (0.32-0.77)<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
3.62 (1.47-8.95)<br />
NS<br />
NS<br />
NS<br />
frequency in patients with ALL (7.8% vs. 0.8%, p=0.01; Table 4).<br />
In the third step, we investigated the homozygosity <strong>of</strong> HLA alleles<br />
(Table 5). The most homozygous alleles were A*02 (6.7% vs. 0.8%,<br />
p=0.02) and DRB1*11 (6.7% vs. 4%). The frequency <strong>of</strong> HLA alleles<br />
was compared among patients according to risk groups in the<br />
last step (Table 6). Although DRB1*04 frequency was observed to<br />
be higher in patients in the HRG (p=0.009), DRB1*07 frequency<br />
was found to be higher in patients in the SRG (p=0.007).<br />
341
Patıroğlu T and Akar HH; HLA (A, B, and DRB1) Alleles and Acute Lymphoblastic Leukemia<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>9-345<br />
Table 4. The frequency <strong>of</strong> HLA-A, -B, and -DRB1 haplotypes.<br />
Haplotype ALL (n=90) Controls (n=126) p-value OR (95% CI)<br />
A*01/B*08/DRB1*03<br />
A*01/B*18/DRB1*11<br />
A*01/B*35/DRB1*11<br />
A*02/B*08/DRB1*03<br />
A*02/B*14/DRB1*01<br />
A*02/B*35/DRB1*04<br />
A*02/B*35/DRB1*13<br />
A*02/B*40/DRB1*04<br />
A*02/B*44/DRB1*07<br />
A*02/B*44/DRB1*11<br />
A*02/B*50/DRB1*07<br />
A*02/B*51/DRB1*04<br />
A*03/B*35/DRB1*11<br />
A*03/B*51/DRB1*04<br />
A*11/B*51/DRB1*14<br />
A*24/B*18/DRB1*11<br />
A*24/B*35/DRB1*11<br />
A*24/B*51/DRB1*04<br />
A*24/B*51/DRB1*11<br />
A*32/B*35/DRB1*11<br />
A*68/B*35/DRB1*11<br />
n Frequency (%) n Frequency (%)<br />
3<br />
3<br />
1<br />
2<br />
3<br />
2<br />
7<br />
1<br />
0<br />
1<br />
0<br />
1<br />
1<br />
2<br />
1<br />
3<br />
1<br />
1<br />
2<br />
2<br />
1<br />
3.3<br />
3.3<br />
1.1<br />
2.2<br />
3.3<br />
2.2<br />
7.8<br />
1.1<br />
0<br />
1.1<br />
0<br />
1.1<br />
1.1<br />
2.2<br />
1.1<br />
3.3<br />
1.1<br />
1.1<br />
2.2<br />
2.2<br />
1.1<br />
ALL: Acute lymphoblastic leukemia, CI: confidence interval, NS: nonsignificant, OR: odds ratio.<br />
Table 5. The homozygosity <strong>of</strong> HLA alleles.<br />
4<br />
1<br />
0<br />
3<br />
1<br />
2<br />
1<br />
2<br />
1<br />
2<br />
1<br />
1<br />
4<br />
2<br />
2<br />
0<br />
2<br />
0<br />
4<br />
2<br />
3<br />
3.2<br />
0.8<br />
0<br />
2.4<br />
0.8<br />
1.6<br />
0.8<br />
1.6<br />
0.8<br />
1.6<br />
0.8<br />
0.8<br />
3.2<br />
1.6<br />
1.6<br />
0<br />
1.6<br />
0<br />
3.2<br />
1.6<br />
2.4<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
0.01<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
0.095 (0.011-0.785) NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
Homozygosity ALL (n=90) Controls (n=126) p-value OR (95% CI)<br />
A*01/A*01<br />
A*02/A*02<br />
A*03/A*03<br />
A*11/A*11<br />
A*23/A*23<br />
A*24/A*24<br />
B*07/B*07<br />
B*18/B*18<br />
B*27/B*27<br />
B*35/B*35<br />
B*38/B*38<br />
B*39/B*39<br />
B*40/B*40<br />
B*44/B*44<br />
B*50/B*50<br />
B*51/B*51<br />
DRB1*03/DRB1*03<br />
DRB1*04/DRB1*04<br />
DRB1*07/DRB1*07<br />
DRB1*11/DRB1*11<br />
DRB1*13/DRB1*13<br />
DRB1*15/DRB1*15<br />
n Frequency (%) n Frequency (%)<br />
1<br />
6<br />
4<br />
0<br />
1<br />
4<br />
1<br />
1<br />
0<br />
4<br />
1<br />
0<br />
0<br />
1<br />
1<br />
4<br />
3<br />
2<br />
2<br />
6<br />
2<br />
0<br />
1.1<br />
6.7<br />
4.4<br />
0<br />
1.1<br />
4.4<br />
1.1<br />
1.1<br />
0<br />
4.4<br />
1.1<br />
0<br />
0<br />
1.1<br />
1.1<br />
4.4<br />
3.3<br />
2.2<br />
2.2<br />
6.7<br />
2.2<br />
0<br />
ALL: Acute lymphoblastic leukemia, CI: confidence interval, NS: nonsignificant, OR: odds ratio.<br />
0<br />
1<br />
2<br />
1<br />
0<br />
4<br />
0<br />
0<br />
1<br />
3<br />
0<br />
1<br />
1<br />
0<br />
0<br />
2<br />
2<br />
3<br />
0<br />
5<br />
0<br />
1<br />
0<br />
0.8<br />
1.6<br />
1.1<br />
0<br />
3.2<br />
0<br />
0<br />
0.8<br />
2.4<br />
0<br />
0.8<br />
0.8<br />
0<br />
0<br />
1.6<br />
1.6<br />
2.4<br />
0<br />
4<br />
0<br />
0.8<br />
NS<br />
0.02<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
0.112 (0.13-0.94)<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
NS<br />
342
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>9-345<br />
Patıroğlu T and Akar HH; HLA (A, B, and DRB1) Alleles and Acute Lymphoblastic Leukemia<br />
Table 6. The frequency <strong>of</strong> HLA alleles in risk groups.<br />
HLA<br />
ALL (2n=180)<br />
Allele frequencies<br />
in HRG (2n=48)<br />
Allele frequencies<br />
in MRG (2n=74)<br />
Allele frequencies<br />
in SRG (2n=58)<br />
A*01 4 (8.3%) 10 (13.5%) 4 (6.7%) NS<br />
A*02 12 (25%) 15 (20.2%) 13 (22.4%) NS<br />
A*03 7 (14.5%) 11 (14.9%) 10 (17.2%) NS<br />
A*11 5 (10.4%) 3 (4%) 5 (8.6%) NS<br />
A*23 1 (2%) 1 (1.3%) 1 (1.7%) NS<br />
A*24 7 (14.5%) 14 (18.9%) 9 (15.5%) NS<br />
A*25 1 (2%) 1 (1.3%) 1 (1.7%) NS<br />
A*26 1 (2%) 3 (4%) 3 (5.8%) NS<br />
A*29 1 (2%) 3 (4%) 3 (5.8%) NS<br />
A*30 1 (2%) 2 (2.7%) 1 (1.7%) NS<br />
A*31 0 2 (2.7%) 2 (3.4%) NS<br />
A*32 3 (6.25%) 6 (8.1%) 3 (5.8%) NS<br />
A*<strong>33</strong> 1 (2%) 1 (1.3%) 1 (1.7%) NS<br />
A*66 0 0 0 NS<br />
A*68 4 (8.3%) 2 (2.7%) 2 (3.4%) NS<br />
A*69 0 0 0 NS<br />
B*07 1 (2%) 2 (2.7%) 2 (3.4%) NS<br />
B*08 1 (2%) 2 (2.7%) 1 (1.7%) NS<br />
B*13 1 (2%) 2 (2.7%) 1 (1.7%) NS<br />
B*14 2 (4.1%) 2 (2.7%) 0 NS<br />
B*15 1 (2%) 2 (2.7%) 2 (3.4%) NS<br />
B*17 0 0 1 (1.7%) NS<br />
B*18 2 (4.1%) 9 (12.7%) 5 (8.6%) NS<br />
B*22 0 1 (1.3%) 0 NS<br />
B*27 2 (4.1%) 3 (4%) 2 (3.4%) NS<br />
B*35 10 (21%) 17 (22.3%) 13 (22.4%) NS<br />
B*38 4 (8.3%) 5 (6.8%) 4 (6.7%) NS<br />
B*39 1 (2%) 0 1 (1.7%) NS<br />
B*40 0 1 (1.3%) 1 (1.7%) NS<br />
B*41 1 (2%) 2 (2.7%) 1 (1.7%) NS<br />
B*44 2 (4.1%) 3 (4%) 5 (8.6%) NS<br />
B*45 1 (2%) 0 0 NS<br />
B*49 1 (2%) 2 (2.7%) 2 (3.4%) NS<br />
B*50 2 (4.1%) 2 (2.7%) 5 (8.6%) NS<br />
B*51 10 9 (12.7%) 10 (17.2%) NS<br />
B*52 3 (6.25%) 2 (2.7%) 1 (1.7%) NS<br />
B*55 0 1 (1.3%) 0 NS<br />
B*56 1 (2%) 3 (4%) 1 (1.7%) NS<br />
p-value<br />
343
Patıroğlu T and Akar HH; HLA (A, B, and DRB1) Alleles and Acute Lymphoblastic Leukemia<br />
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>9-345<br />
Table 6. Continuation<br />
B*57 0 1 (1.3%) 0 NS<br />
B*58 1 (2%) 1 (1.3%) 0 NS<br />
B*60 0 1 (1.3%) 0 NS<br />
B*62 1 (2%) 0 0 NS<br />
B*65 0 1 (1.3%) 0 NS<br />
DRB1*01 2 (4.1%) 5 (6.8%) 2 (3.4%) NS<br />
DRB1*03 5 (10.4%) 7 (9.5%) 6 (10.3%) NS<br />
DRB1*04 14 (29.2%) a 12 (16.2%) a,b 4 (6.7%) b 0.009<br />
DRB1*07 3 (6.25%) a 6 (8.1%) a 14 (24.1%) b 0.007<br />
DRB1*08 1 (2%) 2 (2.7%) 1 (1.7%) NS<br />
DRB1*09 1 (2%) 1 (1.3%) 2 (3.4%) NS<br />
DRB1*10 0 2 (2.7%) 2 (3.4%) NS<br />
DRB1*11 9 (18.8%) 14 (18.9%) 10 (17.2%) NS<br />
DRB1*12 0 2 (2.7%) 2 (3.4%) NS<br />
DRB1*13 5 (6.25%) 8 (10.8%) 5 (8.6%) NS<br />
DRB1*14 2 (4.1%) 5 (6.8%) 3 (5.8%) NS<br />
DRB1*15 4 (8.3%) 5 (6.8%) 4 (6.7%) NS<br />
DRB1*16 2 (4.1%) 5 (6.8%) 3 (5.8%) NS<br />
HLA: Human leukocyte antigen, ALL: acute lymphoblastic leukemia, HRG: high-risk group, MRG: moderate-risk group, SRG: standard-risk group, NS: nonsignificant; a, b: superscripted<br />
letters show statistical significance.<br />
Discussion<br />
The underlying mechanisms are not well defined in patients with<br />
ALL [1,16]. The presence <strong>of</strong> genetic effects on the development<br />
<strong>of</strong> leukemia was observed in monozygotic twins [16,17]. Some<br />
studies have shown that some HLA alleles may be involved in<br />
the development <strong>of</strong> leukemia [14,17]. The first HLA association<br />
was reported in 1967, with increased frequency <strong>of</strong> the A*02<br />
allele in patients with ALL [18]. On this topic, however, the data<br />
remain insufficient. Several associations have been reported<br />
between leukemia and HLA genes such as DRB3, DRB4, and<br />
DRB5 so far [14]. There are some inconsistencies among studies<br />
in the literature. The frequency <strong>of</strong> DRB1*13 as a protective allele<br />
was reported to be lower in some previously reported studies,<br />
as it was in our study [10,12]. This similarity for the DRB1*13<br />
allele among studies may be explained by geographic proximity<br />
and interactions between Iranian [10] and <strong>Turkish</strong> populations<br />
[12]. In another <strong>Turkish</strong> study, the frequency <strong>of</strong> DRB1*04 was<br />
reported to be higher and the frequency <strong>of</strong> A*23 was reported<br />
to be lower in patients with ALL, as in our study [11]. In that<br />
study, inconsistent with our data, B*07 frequency was observed<br />
to be lower in patients with ALL. In another <strong>Turkish</strong> study, a<br />
positive association was reported in some alleles such as A*11<br />
and DRB1*01, which is inconsistent with our results in patients<br />
with ALL [12]. These discrepancies among <strong>Turkish</strong> studies may<br />
result from the size <strong>of</strong> study populations. In this study, we<br />
also observed a positive association with A*03, DRB1*03, and<br />
DRB1*04 alleles in patients with ALL. In contrast to our study,<br />
Fernandes et al. [19] reported a negative association between<br />
ALL and DRB1*04 in an adult population. Our results contribute<br />
some new information to the literature about HLA associations<br />
in patients with ALL for the <strong>Turkish</strong> population. For example, the<br />
frequency <strong>of</strong> A*03, B*13, B*40, and DRB1*03 was inconsistent<br />
with the results <strong>of</strong> other reported <strong>Turkish</strong> studies [11,12]. In<br />
the literature, some HLA haplotypes have also been accepted<br />
as important risk factors for developing leukemia [10,19]. For<br />
example, a negative association with the A*02/B*35/DRB1*13<br />
haplotype was observed in patients with ALL [12]. On the<br />
contrary, A*02/B*35/DRB1*13 haplotype frequency was observed<br />
to be higher in our study as a predisposing factor. Homozygosity<br />
<strong>of</strong> DRB4*01 was also reported to be a risk factor in children<br />
with leukemia [20]. In this study, the homozygosity <strong>of</strong> A*02 was<br />
observed to be higher in patients as a predisposing factor. In the<br />
last step <strong>of</strong> our research, although the frequency <strong>of</strong> DRB1*04 was<br />
observed to be higher in patients with high risk, the frequency<br />
<strong>of</strong> the DRB1*07 allele was found to be higher in patients with<br />
standard risk. As a limitation, the number <strong>of</strong> participants in<br />
our study was not large enough to make conclusive decisions<br />
about HLA association, which may lead to some discrepancies<br />
from other <strong>Turkish</strong> studies <strong>of</strong> patients with ALL. Additionally,<br />
some odd ratios (OR) in this study were calculated as lower than<br />
zero (
Turk J Hematol 2016;<strong>33</strong>:<strong>33</strong>9-345<br />
Patıroğlu T and Akar HH; HLA (A, B, and DRB1) Alleles and Acute Lymphoblastic Leukemia<br />
(OR=0.50), the A*02/B*35/DRB1*13 haplotype (OR=0.09), and<br />
A*02/A*02 homozygosity (OR=0.11). The lower OR values can<br />
most likely be explained by the small importance <strong>of</strong> these data<br />
among the genetic factors predisposing to ALL.<br />
In conclusion, although A*03, DRB1*03, and DRB1*04 were<br />
observed to be susceptible alleles, A*23, B*13, B*40, and<br />
DRB1*13 were found to be protective alleles in patients with<br />
ALL. Although some results <strong>of</strong> our study support earlier findings,<br />
others are inconsistent. The increasing frequency <strong>of</strong> DRB1*04<br />
and the decreasing frequency <strong>of</strong> A*23 and DRB1*13 alleles<br />
support results <strong>of</strong> earlier <strong>Turkish</strong> studies [11,12]. As new data,<br />
the frequencies <strong>of</strong> the A*02/B*35/DRB1*13 haplotype and A*02<br />
homozygosity were observed to be higher as predisposing factors<br />
in patients with ALL. The frequency <strong>of</strong> DRB1*07 and DRB1*04<br />
was observed to higher in the SRG and HRG, respectively, as<br />
additional predisposing factors.<br />
Ethics<br />
Ethics Committee Approval: Retrospective study; Informed<br />
Consent: It was not required.<br />
Authorship Contributions<br />
Concept: Türkan Patıroğlu, H. Haluk Akar; Design: Türkan<br />
Patıroğlu, H. Haluk Akar; Data Collection or Processing: H. Haluk<br />
Akar; Analysis or Interpretation: Türkan Patıroğlu; Literature<br />
Search: H. Haluk Akar; Writing: Türkan Patıroğlu, H. Haluk Akar.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
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345
BRIEF REPORT<br />
DOI: 10.4274/tjh.2016.0046<br />
Turk J Hematol 2016;<strong>33</strong>:346-348<br />
Varicella-Zoster Virus Infections in Pediatric Malignancy Patients:<br />
A Seven-Year Analysis<br />
Pediatrik Malignite Hastalarında Varicella Zoster Virüs Enfeksiyonları: Yedi Yıllık Analiz<br />
Mine Düzgöl 1 , Gülcihan Özek 2 , Nuri Bayram 1 , Yeşim Oymak 2 , Ahu Kara 1 , Bengü Demirağ 2 , Tuba Hilkay Karapınar 2 , Yılmaz Ay 2 ,<br />
Canan Vergin 2 , İlker Devrim 1<br />
1Dr. Behçet Uz Children Training and Research Hospital, Clinic <strong>of</strong> Pediatric Infectious Diseases, İzmir, Turkey<br />
2Dr. Behçet Uz Children Training and Research Hospital, Clinic <strong>of</strong> Pediatric <strong>Hematology</strong> and Oncology, İzmir, Turkey<br />
Abstract<br />
Primary varicella-zoster virus (VZV) infection is a benign self-limited<br />
disease. In this study, we review our experience in focusing on the<br />
outcome and treatment <strong>of</strong> VZV infection in pediatric malignancy<br />
patients. During the study period, a total <strong>of</strong> 41 patients with pediatric<br />
malignancy had been hospitalized with the diagnosis <strong>of</strong> VZV infection.<br />
All the patients were treated with intravenous acyclovir for a median<br />
<strong>of</strong> 7 days (ranging from 5 to 21 days). The calculated attributable<br />
delay <strong>of</strong> chemotherapy due to VZV infections was 8 days (ranging<br />
from 2 to 60 days). VZV-related complications were observed in<br />
3 <strong>of</strong> 41 patients (7%) who suffered from acute respiratory distress<br />
syndrome, and one <strong>of</strong> them with hemophagocytic lymphohistiocytosis<br />
died due to respiratory failure despite acyclovir and broad-spectrum<br />
antimicrobial treatment plus supportive treatment. VZV infections<br />
are still important contagious diseases in pediatric cancer patients,<br />
because they cause not only significant mortality but also a delay in<br />
chemotherapy.<br />
Keywords: Varicella, Malignancy, Pediatric patient<br />
Öz<br />
Primer varisella zoster virüs (VZV) enfeksiyonu benign, kendi kendini<br />
sınırlayan bir hastalıktır. Bu çalışmada pediatrik malignitesi olan<br />
hastalarda VZV enfeksiyonu ve tedavisine odaklı tecrübelerimizi<br />
gözden geçirmeyi amaçladık. Çalışma süresi boyunca; VZV enfeksiyonu<br />
tanısı alan pediatrik maligniteli toplam 41 hasta hastaneye yatırıldı.<br />
Tüm hastalar ortalama 7 gün (5 ila 21 gün arasında değişen)<br />
intravenöz asiklovir ile tedavi edildi. VZV enfeksiyonlarına bağlı olarak<br />
hesaplanan atfedilebilir kemoterapi gecikmesi ortalama 8 gündü (2 ile<br />
60 gün arasında değişen). VZV enfeksiyonuna bağlı komplikasyonlar 41<br />
hastadan 3’ünde (%7) akut solunum distres sendromu olarak görüldü<br />
ve bu hastalardan hem<strong>of</strong>agositik lenfohistiyositozu olan bir tanesi<br />
asiklovir, geniş spektrumlu antibiyotik ve destekleyici tedaviye rağmen<br />
solunum yetmezliği nedeniyle kaybedildi. VZV enfeksiyonları, pediatrik<br />
malignite hastalarında hala önemli bulaşıcı hastalıklardan biridir,<br />
çünkü sadece ciddi mortaliteye sebep olmakla kalmayıp kemoterapi<br />
başlangıcını da geciktirmektedir.<br />
Anahtar Sözcükler: Varisella, Malignite, Çocuk hasta<br />
Introduction<br />
Immunocompromised children are at greater risk <strong>of</strong> suffering<br />
from severe, prolonged, and complicated varicella-zoster virus<br />
(VZV) infection [1]. Before introduction <strong>of</strong> antiviral therapy,<br />
the mortality rate <strong>of</strong> VZV infections in children with cancer<br />
was reported to be 7%, with numbers reaching up to 55%<br />
in cases with visceral involvement [2,3,4,5]. In this study, we<br />
aimed to review our experience in focusing on the outcome and<br />
treatment <strong>of</strong> VZV infections in pediatric malignancy patients.<br />
Materials and Methods<br />
A retrospective cohort study design was used to evaluate pediatric<br />
cancer patients with VZV infections who were hospitalized in the<br />
Pediatric <strong>Hematology</strong>-Oncology and Infectious Diseases Units<br />
<strong>of</strong> the Dr. Behçet Uz Children’s Hospital from December 2008<br />
to March 2015. In this study, the attending physician’s clinical<br />
diagnosis <strong>of</strong> VZV infection was based on case definitions set by<br />
the United States Centers for Disease Control and Prevention and<br />
the Council <strong>of</strong> State and Territorial Epidemiologists guidelines<br />
reported in 2009 [6,7]. Therapy with intravenous acyclovir (1500<br />
Address for Correspondence/Yazışma Adresi: Mine DÜZGÖL, M.D.,<br />
Dr. Behçet Uz Children Training and Research Hospital, Clinic <strong>of</strong> Pediatric Infectious Diseases, İzmir, Turkey<br />
Phone : +90 232 489 56 56<br />
E-mail : mineduzgol@gmail.com<br />
Received/Geliş tarihi: January 27, 2016<br />
Accepted/Kabul tarihi: March 28, 2016<br />
346
Turk J Hematol 2016;<strong>33</strong>:346-348<br />
Düzgöl M, et al: Varicella Infections in Pediatric Malignancy Patients<br />
mg/m 2 /day) in 3 divided doses was started on the first day <strong>of</strong> the<br />
onset <strong>of</strong> rash. VZV infection-related complications were defined<br />
as a condition or event occurring within 14 days <strong>of</strong> the onset <strong>of</strong><br />
VZV infection [2]. Statistical analysis was done using SPSS 16.0<br />
(SPSS Inc., Chicago, IL, USA).<br />
Results<br />
During the study period, a total <strong>of</strong> 41 patients with pediatric<br />
malignancy had been hospitalized with the diagnosis <strong>of</strong> VZV<br />
infection. Among them, 14 (34.1%) were female and 27 (65.9%)<br />
were male. The mean age was 58.8±32.4 months (within the<br />
range <strong>of</strong> 8 months to 12 years <strong>of</strong> age). Of the patients, 29 had<br />
acute lymphoblastic leukemia (ALL) (70.7%), followed by 2<br />
cases <strong>of</strong> acute myeloblastic leukemia (4.9%), 3 cases <strong>of</strong> Wilms<br />
tumor (7.3%), 2 cases <strong>of</strong> hemophagocytic lymphohistiocytosis<br />
(HLH) (4.9%), 2 cases <strong>of</strong> rhabdomyosarcoma (4.9%), 2 cases <strong>of</strong><br />
neuroblastoma (4.9%), and 1 case <strong>of</strong> hepatoblastoma (2.4%).<br />
Among the ALL patients, 8 (27.5%) <strong>of</strong> them were in the<br />
induction phase <strong>of</strong> chemotherapy (ALL REZ-Berlin-Frankfurt-<br />
Münster protocol), 19 (65.5%) <strong>of</strong> them were in a maintenance<br />
phase, and 2 patients (6.8%) had relapsed ALL. Only 2 children<br />
(4.9%) had a known exposure to siblings in the household who<br />
had developed chickenpox.<br />
Among the 41 patients, neutropenia was present in 18 patients<br />
(43.9%), lymphopenia was present in 27 (65.9%) patients,<br />
thrombocytopenia was present in 10 patients (24.4%), and<br />
anemia was present in 23 (56.1%) patients. Twenty-one patients<br />
had associated fever at the time <strong>of</strong> diagnosis <strong>of</strong> VZV infection.<br />
Active vesicular rashes were present in all <strong>of</strong> the patients at<br />
the time <strong>of</strong> diagnosis and the median duration <strong>of</strong> active VZV<br />
infection was 7 days (ranging from 5 to 21 days). All patients<br />
had been admitted to our hospital within the first day <strong>of</strong> the<br />
onset <strong>of</strong> rash.<br />
All the patients were treated with intravenous acyclovir for a<br />
median <strong>of</strong> 7 days (ranging from 5 to 21 days). During acyclovir<br />
treatment, no serious adverse effects including elevation in<br />
blood creatinine and urea levels or hematuria were observed,<br />
while 2 patients (4.8%) had nausea and vomiting that could not<br />
be explained with other reasons.<br />
The median hospital stay was 7 days (ranging from 3 to 35 days)<br />
and the calculated attributable delay <strong>of</strong> chemotherapy due to<br />
VZV infections was 8 days (ranging from 2 to 60 days). Thirtyeight<br />
patients (93%) showed no complications, but 3 patients<br />
(7%) suffered from Acute respiratory distress syndrome (ARDS).<br />
Two <strong>of</strong> them required mechanical ventilation and one required<br />
noninvasive ventilation; the patient with HLH (1%) died due<br />
to respiratory failure despite acyclovir and broad-spectrum<br />
antimicrobial treatment plus supportive treatment.<br />
Discussion<br />
Secondary attack rates among susceptible household contacts <strong>of</strong><br />
people with VZV are as high as 90%; i.e. 9 out <strong>of</strong> 10 susceptible<br />
household contacts will become infected [8]. In this study,<br />
only 2 children (4.9%) had a known exposure to siblings in the<br />
household who had developed chickenpox. The majority <strong>of</strong> the<br />
patients had no known exposure; it was reported that for half<br />
<strong>of</strong> the ALL cases with varicella infections, the source <strong>of</strong> infection<br />
was unknown [9]. Our findings suggest that, regarding the high<br />
secondary attack rates <strong>of</strong> VZV infection, precautions should be<br />
taken for preventing possible contact <strong>of</strong> malignancy patients<br />
with VZV patients, especially in outpatient clinics including<br />
elevators, playgrounds, etc.<br />
In our study, the most common underlying malignant disease<br />
was ALL (70.7%), supporting the findings <strong>of</strong> a previous report<br />
[10]. Patients with an underlying diagnosis <strong>of</strong> ALL and children<br />
less than 5 years <strong>of</strong> age were reported to develop complications<br />
more than any other age group, which was consistent with<br />
other studies [2]. In our study the ages <strong>of</strong> the most complicated<br />
cases were above 5 years, which showed that patients in every<br />
age group were at risk <strong>of</strong> serious VZV infection.<br />
Immunocompromised patients develop serious complications,<br />
such as secondary bacterial infection with invasive<br />
Streptococcus pyogenes [11]. However, in our study, we<br />
experienced Streptococcus pneumoniae sepsis only in one<br />
ALL patient who required noninvasive mechanical ventilation<br />
support. In our study, our patients who underwent intensive<br />
chemotherapy faced complications and even death. Previous<br />
reports showed higher mortality rates than our study, such as<br />
7% in 60 patients who were undergoing chemotherapy due to<br />
primary VZV pneumonitis, with or without acute encephalitis<br />
[11]. Before the introduction <strong>of</strong> specific antiviral therapy, the<br />
mortality rate <strong>of</strong> VZV infections in children with cancer was<br />
reported to be 7%-10%, with rates reaching up to 55% in<br />
cases with visceral involvement [2,3,4,5]. Children with acute<br />
leukemia who had VZV infections were reported to have a high<br />
risk for VZV pneumonia, which might occur in up to one-third<br />
<strong>of</strong> patients with a fatality rate <strong>of</strong> about 10% [12]. In our study,<br />
three patients (7%) with low absolute neutrophil count suffered<br />
from ARDS and one <strong>of</strong> them died because <strong>of</strong> respiratory failure.<br />
The fatality rate was about 2%.<br />
Our study showed that the complicated cases were not<br />
homogeneously distributed regarding their primary diseases. This<br />
visceral dissemination was thought not be related to the type or<br />
status <strong>of</strong> the malignancy or to the duration <strong>of</strong> specific anticancer<br />
therapy. VZV was more likely to disseminate in children with<br />
absolute lymphopenia, less than 500 cells per cubic millimeter,<br />
than in patients with higher lymphocyte counts. Patients with<br />
lymphopenia or poor cell-mediated immune responses during<br />
347
Düzgöl M, et al: Varicella Infections in Pediatric Malignancy Patients<br />
Turk J Hematol 2016;<strong>33</strong>:346-348<br />
VZV infection are said to be at risk for persistent, severe, or even<br />
fatal VZV [13]. Our patients with complicated clinical features<br />
had lymphopenia and neutropenia, suggesting a correlation<br />
between immune status and poor outcome.<br />
Immunocompromised children, particularly those with leukemia,<br />
have more numerous lesions, <strong>of</strong>ten with a hemorrhagic base,<br />
and healing takes nearly three times longer than in healthy<br />
children with VZV infections. These patients were reported to<br />
suffer from severe progressive VZV infections characterized by<br />
continuing eruption <strong>of</strong> lesions and high fever persisting into<br />
the second week <strong>of</strong> illness [14]. In our study, despite the median<br />
duration <strong>of</strong> the active chickenpox rash being 7 days, in some<br />
cases active hemorrhagic vesicular lesions were observed until<br />
21 days <strong>of</strong> disease. During our study the median hospital stay<br />
was 7 days, similar to a previous report <strong>of</strong> 7.96±3.57 days [13].<br />
Effective treatment with acyclovir is thought to be a significant<br />
factor in reducing the severity and mortality <strong>of</strong> infection [15];<br />
however, mortality is not the only problem with cancer patients.<br />
One <strong>of</strong> the most important findings in our study was that,<br />
regardless <strong>of</strong> the primary disease and chemotherapy protocol,<br />
chemotherapy was delayed for at least for 2 days with a median<br />
<strong>of</strong> 8 days, which could cause undesirable effects on the overall<br />
chemotherapy protocol in children.<br />
In conclusion, VZV infections are still important contagious<br />
diseases in pediatric cancer patients because they cause not only<br />
significant mortality but also a delay in chemotherapy. Thus,<br />
infection control preventions should be taken in hospitals and<br />
maximum efforts for preventing possible exposure <strong>of</strong> pediatric<br />
cancer patients to VZV-infected children should be made.<br />
Ethics<br />
Ethics Committee Approval: Retrospective study; Informed<br />
Consent: Retrospective study.<br />
Authorship Contributions<br />
Concept: Mine Düzgöl, Gülcihan Özek, Nuri Bayram, Yeşim<br />
Oymak, Ahu Kara, Bengü Demirağ, Tuba Hilkay Karapınar,<br />
Yılmaz Ay, Canan Vergin, İlker Devrim; Design: Mine Düzgöl,<br />
İlker Devrim; Data Collection or Processing: Mine Düzgöl, İlker<br />
Devrim; Analysis or Interpretation: Mine Düzgöl, İlker Devrim;<br />
Literature Search: Mine Düzgöl; Writing: Mine Düzgöl.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Gunawan S, Linardi P, Tawaluyan K, Mantik MF, Veerman AJ. Varicella<br />
outbreak in a pediatric oncology ward: the Manado experience. Asian Pac J<br />
Cancer Prev 2010;11:289-292.<br />
2. Feldman S, Hughes WT, Daniel CB. Varicella in children with cancer: seventyseven<br />
cases. Pediatrics 1975;56:388-397.<br />
3. Katsimpardi K, Papadakis V, Pangalis A, Parcharidou A, Panagiotou JP, Soutis<br />
M, Papandreou E, Polychronopoulou S, Haidas S. Infections in a pediatric<br />
patient cohort with acute lymphoblastic leukemia during the entire course<br />
<strong>of</strong> treatment. Support Care Cancer 2006;14:277-284.<br />
4. Matsuzaki A, Suminoe A, Koga Y, Kusuhara K, Hara T, Ogata R, Sata T, Hara<br />
T. Fatal visceral varicella-zoster virus infection without skin involvement<br />
in a child with acute lymphoblastic leukemia. Pediatr Hematol Oncol<br />
2008;25:237-242.<br />
5. Meir HM, Balawi IA, Meer HM, Nayel H, Al-Mobarak MF. Fever and<br />
granulocytopenia in children with acute lymphoblastic leukemia under<br />
induction therapy. Saudi Med J 2001;22:423-427.<br />
6. Centers for Disease Control and Prevention. Epidemiology and Prevention<br />
<strong>of</strong> Vaccine-Preventable Diseases, 10th ed. Washington DC, Public Health<br />
Foundation, 2008.<br />
7. Council <strong>of</strong> State and Territorial Epidemiologists. Public Health Reporting<br />
and National Notification for Varicella. Atlanta, Council <strong>of</strong> State and<br />
Territorial Epidemiologists, 2012.<br />
8. Centers for Disease Control and Prevention. Epidemiology and Prevention<br />
<strong>of</strong> Vaccine-Preventable Diseases, 13th ed. Washington DC, Public Health<br />
Foundation, 2015.<br />
9. Buda K, Tubergen DG, Levin MJ. The frequency and consequences <strong>of</strong> varicella<br />
exposure and varicella infection in children receiving maintenance therapy<br />
for acute lymphoblastic leukemia. J Pediatr Hematol Oncol 1996;18:106-112.<br />
10. Alam MM, Qamar FN, Khan ZW, Kumar V, Mushtaq N, Fadoo Z. Risk factors<br />
for complicated varicella infection in pediatric oncology patients at a<br />
tertiary health care facility in Pakistan. J Infect Dev Ctries 2014;8:215-220.<br />
11. Ben-Abraham R, Keller N, Vered R, Harel R, Barzilay Z, Paret G. Invasive<br />
group A streptococcal infections in a large tertiary center: epidemiology,<br />
characteristics and outcome. Infection 2002;30:81-85.<br />
12. Feldman S, Lott L. Varicella in children with cancer: impact <strong>of</strong> antiviral<br />
therapy and prophylaxis. Pediatrics 1987;80:465-472.<br />
13. Escaño-Gallardo ET, Bravo LC. Varicella in immunocompromised children at the<br />
Philippine general hospital: a six-year review. PIDSP <strong>Journal</strong> 2011;12:27-39.<br />
14. Cherry J. Feigin and Cherry’s Textbook <strong>of</strong> Pediatric Infectious Diseases, 5th<br />
ed. Philadelphia, W.B. Saunders, 2004.<br />
15. Carcao MD, Lau RC, Gupta A, Huerter H, Koren G, King SM. Sequential<br />
use <strong>of</strong> intravenous and oral acyclovir in the therapy <strong>of</strong> varicella in<br />
immunocompromised children. Pediatr Infect Dis J 1998;17:626-631.<br />
348
IMAGES IN HEMATOLOGY<br />
DOI: 10.4274/tjh.2015.0446<br />
Turk J Hematol 2016;<strong>33</strong>:349-350<br />
Chediak-Higashi Syndrome in Accelerated Phase Masquerading<br />
as Acute Leukemia<br />
Akut Lösemiyi Taklit Eden Akselere Fazda Chediak Higashi Sendromu<br />
Mili Jain, Ashutosh Kumar, Uma Shankar Singh, Rashmi Kushwaha<br />
King George’s Medical University, Department <strong>of</strong> Pathology, Uttar Pradesh, India<br />
Figure 1. Peripheral blood smear with Leishman stain at 400 x :<br />
giant granules in neutrophils and lymphocytes.<br />
Figure 2. Hair follicles at 400 x with irregularly sized melanosomes.<br />
We present a 3-year-old female born <strong>of</strong> a consanguineous<br />
marriage with the complaints <strong>of</strong> high-grade fever, petechial<br />
spots, abdominal distension, and lymphadenopathy for 20<br />
days. She had pallor, hypopigmented hairs, petechial rashes,<br />
and palpable lymph nodes (up to 1 cm) in the bilateral<br />
inguinal and cervical region. Systemic examination revealed<br />
hepatosplenomegaly. Her hematological pr<strong>of</strong>ile was as<br />
follows: hemoglobin <strong>of</strong> 8.4 g/dL, normocytic normochromic<br />
red cell indices, platelet count <strong>of</strong> 11x10 9 /L, total leukocyte<br />
count <strong>of</strong> 7x10 9 /L with increased lymphocytes (68.5%), and<br />
lactate dehydrogenase raised at 796 IU/L. The peripheral blood<br />
smear examination revealed giant granules in neutrophils,<br />
lymphocytes, and monocytes (Figure 1). Bone marrow<br />
examination revealed similar granules in myeloid precursors<br />
with moderate hemophagocytosis. Examination <strong>of</strong> the hair<br />
shafts showed large melanin granules (Figure 2). Her liver<br />
function tests, kidney function tests, and chest X-ray results<br />
were within reference ranges. She was diagnosed with Chediak-<br />
Higashi syndrome (CHS) in the accelerated phase.<br />
CHS is a rare autosomal recessive disorder (gene CHS1/LYST) [1].<br />
The clinical picture includes partial oculocutaneous albinism,<br />
abnormal bleeding time, peripheral neuropathy, and recurrent<br />
severe bacterial infection [2]. The giant lysosomal granules<br />
(formed as a result <strong>of</strong> cytoplasmic injury, phagocytosis, and<br />
fusion due to microtubular defects) in white blood cells are<br />
pathognomonic for diagnosis [3].<br />
Address for Correspondence/Yazışma Adresi: Mili JAIN, M.D.,<br />
King George’s Medical University, Department <strong>of</strong> Pathology, Uttar Pradesh, India<br />
Phone : 522 407 59 89<br />
E-mail : milijain786@gmail.com<br />
Received/Geliş tarihi: December 25, 2015<br />
Accepted/Kabul tarihi: January 20, 2016<br />
349
Jain M, et al. Chediak-Higashi Syndrome in Accelerated Phase Masquerading as Acute Leukemia Turk J Hematol 2016;<strong>33</strong>:349-350<br />
Keywords: Chediak Higashi syndrome, Giant granules,<br />
Immunodeficiency<br />
Anahtar Sözcükler: Chediak Higashi sendromu, Dev granüller,<br />
İmmün yetmezlik<br />
Authorship Contributions<br />
Concept: Mili Jain; Design: Mili Jain, Ashutosh Kumar, Uma Shankar<br />
Singh, Rashmi Kushwaha; Data Collection or Processing: Mili Jain,<br />
Ashutosh Kumar, Uma Shankar Singh, Rashmi Kushwaha; Analysis<br />
or Interpretation: Mili Jain, Ashutosh Kumar, Uma Shankar Singh,<br />
Rashmi Kushwaha; Literature Search: Mili Jain; Writing: Mili Jain.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts <strong>of</strong><br />
interest, including specific financial interests, relationships, and/or<br />
affiliations relevant to the subject matter or materials included.<br />
References<br />
1. Antunes H, Pereira A, Cunha I. Chediak-Higashi syndrome: pathognomonic<br />
feature. Lancet 2013;382:1514.<br />
2. Bharti S, Bhatia P, Bansal D, Varma N. The accelerated phase <strong>of</strong> Chediak-<br />
Higashi syndrome: the importance <strong>of</strong> hematological evaluation. Turk J<br />
Hematol 2013;30:85-87.<br />
3. Usha HN, Prabhu PD, Sridevi M, Baindur K, Balakrishnan CM. Chediak-<br />
Higashi syndrome. Indian Pediatr 1994;34:1115-1119.<br />
350
IMAGES IN HEMATOLOGY<br />
DOI: 10.4274/tjh.2015.0399<br />
Turk J Hematol 2016;<strong>33</strong>:351-352<br />
Auer Rod-Like Inclusions in Reactive Plasma Cells in a Case <strong>of</strong><br />
Acute Myeloid Leukemia<br />
Akut Miyeloid Lösemili Bir Olguda Reaktif Plazma Hücresinde Auer-Rod Benzeri İnklüzyonlar<br />
Sarita Pradhan<br />
Institute <strong>of</strong> Medical Sciences and Sum Hospital, Laboratory <strong>of</strong> <strong>Hematology</strong>, Bhubaneswar, India<br />
Figure 1. Myeloblasts and plasma cells containing Auer rod-like<br />
inclusions.<br />
Figure 2. Plasma cell showing Auer rod-like inclusions.<br />
Figure 3. A Mott cell.<br />
Address for Correspondence/Yazışma Adresi: Sarita PRADHAN, M.D.,<br />
Institute <strong>of</strong> Medical Sciences and Sum Hospital, Laboratory <strong>of</strong> <strong>Hematology</strong>, Bhubaneswar, India<br />
Phone : 9 776 243 866<br />
E-mail : dr.sarita26@gmail.com<br />
Received/Geliş tarihi: November 17, 2015<br />
Accepted/Kabul tarihi: February 23, 2016<br />
351
Pradhan S: Auer Rod-Like Inclusions in Plasma Cells Turk J Hematol 2016;<strong>33</strong>:351-352<br />
A 61-year-old female presented with decreasing hemoglobin for<br />
the past 6 months. She had a history <strong>of</strong> multiple transfusions in<br />
the recent past. Laboratory investigations showed hemoglobin<br />
<strong>of</strong> 8.6 g/dL, total blood leukocyte count <strong>of</strong> 1.13x10 9 /L, and<br />
platelets <strong>of</strong> 80x10 9 /L with the presence <strong>of</strong> occasional circulating<br />
blasts. Bone marrow examination revealed the presence <strong>of</strong><br />
63% myeloblasts with prominent Auer rods and mild reactive<br />
plasmacytosis (6%). Some <strong>of</strong> the plasma cells showed Auer<br />
rod-like thin slender inclusions (Figures 1, 2, and 3). She<br />
was diagnosed with acute myeloid leukemia. Serum protein<br />
electrophoresis was done, which showed a normal pattern.<br />
Presence <strong>of</strong> Auer rod-like inclusions has been described in rare<br />
cases <strong>of</strong> multiple myeloma [1,2], but Auer rod-like inclusions in<br />
reactive plasma cells in a case <strong>of</strong> acute myeloid leukemia have not<br />
been reported in the literature. The reported patients either had<br />
IgA kappa myeloma or IgG myeloma. Rare cases <strong>of</strong> Auer rod-like<br />
inclusions in aplastic anemia have been reported [3]. However,<br />
the exact nature <strong>of</strong> these inclusions needs to be studied further.<br />
Keywords: Auer rods, Acute myeloid leukemia, Plasma cells<br />
Anahtar Sözcükler: Auer cismi, Akut miyeloid lösemi, Plazma<br />
hücreleri<br />
Conflict <strong>of</strong> Interest: The author <strong>of</strong> this paper has no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Parmentier S, Radke J. Pseudo Auer rods in a patient with newly diagnosed<br />
IgG myeloma. Blood 2012;119:650.<br />
2. Hütter G, Nowak D, Blau IW, Thiel E. Auer rod like intracytoplasmic<br />
inclusions in multiple myeloma. A case report and review <strong>of</strong> literature. Int J<br />
Lab Hematol 2009;31:236-240.<br />
3. Lemez P. Auer rod-like inclusions in cells <strong>of</strong> B-lymphocytic lineage. Acta<br />
Haematol 1988;80:177-178.<br />
352
IMAGES IN HEMATOLOGY<br />
DOI: 10.4274/tjh.2016.0106<br />
Turk J Hematol 2016;<strong>33</strong>:353-354<br />
Coexistence <strong>of</strong> Chronic Lymphocytic Leukemia and Acute<br />
Myeloid Leukemia<br />
Kronik Lenfositik Lösemi ile Akut Myeloid Lösemi Birlikteliği<br />
Ivana Milosevic<br />
University <strong>of</strong> Novi Sad Faculty <strong>of</strong> Medicine, Clinical Center <strong>of</strong> Vojvodina, Novi Sad, Serbia<br />
Figure 1. Chronic lymphocytic leukemia cells and acute myeloid<br />
leukemia cells in the peripheral blood smear.<br />
A 76-year-old man presented with leukocytosis (86x10 9 /L),<br />
fever, pneumonia, and significant weight loss. He had a history<br />
<strong>of</strong> chronic lymphocytic leukemia diagnosed 5 years earlier<br />
and he responded with partial remission to treatment with<br />
continuous low doses <strong>of</strong> chlorambucil.<br />
Analysis <strong>of</strong> the blood smear, bone marrow aspiration, and<br />
bone marrow biopsy revealed the predomination <strong>of</strong> small<br />
lymphocytes, but 22% <strong>of</strong> the cells were blasts negative with<br />
cytochemical staining (Figure 1). Flow cytometric analysis<br />
showed two distinct populations: 65% <strong>of</strong> cells were small to<br />
moderate in size and CD19+, CD45+, CD5+, and CD20+/-, while<br />
30% <strong>of</strong> cells were large, CD34+, CD13+, HLA DR+, CD65+,<br />
CD45+, and MPO weakly positive and CD<strong>33</strong>, CD14, CD15, and<br />
CD16 negative. Immunophenotyping confirmed the coexistence<br />
<strong>of</strong> chronic lymphocytic leukemia and poorly differentiated<br />
acute myeloid leukemia. Conventional cytogenetic testing did<br />
not show any chromosomal abnormalities.<br />
The patient was treated with intensive antibiotherapy and<br />
received one course <strong>of</strong> chemotherapy, but he did not achieve<br />
remission and died 2 months later.<br />
The coexistence <strong>of</strong> chronic lymphocytic leukemia and acute<br />
myeloid leukemia is rare [1]. Therapy-related acute myeloid<br />
leukemia can develop after treatment <strong>of</strong> chronic lymphocytic<br />
leukemia with alkylating agents, nucleoside analogs, or<br />
combination chemotherapy, but the two leukemias can also<br />
originate independently [2,3].<br />
Keywords: Chronic lymphocytic leukemia, Acute myeloid<br />
leukemia, Therapy<br />
Address for Correspondence/Yazışma Adresi: Ivana MILOSEVIC, M.D.,<br />
University <strong>of</strong> Novi Sad Faculty <strong>of</strong> Medicine, Clinical Center <strong>of</strong> Vojvodina, Novi Sad, Serbia<br />
E-mail : ivana.milosevic@mf.uns.ac.rs<br />
ivana.ml@mts.rs<br />
Received/Geliş tarihi: March 16, 2016<br />
Accepted/Kabul tarihi: March 23, 2016<br />
353
Milosevic I: Coexistence <strong>of</strong> Chronic Lymphocytic Leukemia and Acute Myeloid Leukemia Turk J Hematol 2016;<strong>33</strong>:353-354<br />
Anahtar Sözcükler: Kronik lenfositik lösemi, Akut miyeloid<br />
lösemi, Tedavi<br />
Conflict <strong>of</strong> Interest: The author <strong>of</strong> this paper has no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Tambaro FP, Garcia-Manero G, O’Brien SM, Faderl SH, Ferrajoli A,<br />
Burger JA, Pierce S, Wang X, Do KA, Kantarjian HM, Keating MJ, Wierda<br />
WG. Outcomes for patients with chronic lymphocytic leukemia and<br />
acute leukemia or myelodysplastic syndrome. Leukemia 2016;30:325-<br />
<strong>33</strong>0.<br />
2. Morrison VA, Rai KR, Peterson BL, Kolitz JE, Elias L, Appelbaum FR, Hines<br />
JD, Shepherd L, Larson RA, Schiffer CA. Therapy-related myeloid leukemias<br />
as are observed in patients with chronic lymphocytic leukemia after<br />
treatment with fludarabine and chlorambucil: results <strong>of</strong> an intergroup<br />
study, Cancer and Leukemia Group B 9011. J Clin Oncol 2002;15:3878-<br />
3884.<br />
3. Leone G, Pagano L, Ben-Yehuda D, Voso MT. Therapy-related leukemia and<br />
myelodysplasia: susceptibility and incidence. Haematologica 2007;92:1389-<br />
1398.<br />
354
LETTERS TO THE EDITOR<br />
Turk J Hematol 2016;<strong>33</strong>:355-370<br />
Evaluation <strong>of</strong> Knowledge <strong>of</strong> Patients with Hemophilia Regarding<br />
Their Diseases and Treatment in Iran<br />
İran’daki Hem<strong>of</strong>ili Hastalarının Hastalıkları ve Tedavileri Hakkında Bilgilerinin<br />
Değerlendirilmesi<br />
Mehran Karimi, Tahereh Zarei, Sezaneh Haghpanah, Zohreh Zahedi<br />
Shiraz University <strong>of</strong> Medical Sciences, <strong>Hematology</strong> Research Center, Shiraz, Iran<br />
To the Editor,<br />
Hemophilia A and B are hereditary X-chromosomal recessive<br />
disorders affecting 1 in 5000 male births [1,2]. Hemophilia is<br />
classified as severe at F VIII / F IX 5-25 kIU L -1 [3].<br />
During the mid-1970s hemophilia care underwent substantial<br />
improvement to provide more optimal disease management for<br />
bleeding prevention strategies and education programs. This<br />
led to better educational strategies for disease management<br />
[4,5].<br />
Home therapy can be used to manage mild and moderate<br />
bleeding episodes and can help to achieve optimal treatment,<br />
resulting in decreased pain and hospital admissions for<br />
complications [6].<br />
In this cross-sectional study, 30 patients with hemophilia<br />
A and B who were registered at the Hemophilia Center<br />
<strong>of</strong> Shiraz, Fars Province, southern Iran, were investigated<br />
between March and October <strong>of</strong> 2013. The data collection<br />
form consisted <strong>of</strong> two parts including demographic data and<br />
22 specific questions regarding assessment <strong>of</strong> knowledge<br />
<strong>of</strong> the patients regarding the disease and treatment. In<br />
this latter section specific topics included appropriate<br />
treatment, disease transmission, physiotherapy application,<br />
management <strong>of</strong> bleeding, and the most common symptoms<br />
<strong>of</strong> bleeding.<br />
The correct answer to questions had a sum <strong>of</strong> 1 to 4 points.<br />
Some <strong>of</strong> the questions had more than one correct answer.<br />
Total knowledge scores were categorized into three grades:<br />
scores <strong>of</strong> 1-14 (poor knowledge), 15-29 (fair knowledge), and<br />
30-41 (good knowledge).<br />
This study was approved by the Ethics Committee <strong>of</strong> Shiraz<br />
University <strong>of</strong> Medical Sciences.<br />
Data were analyzed by SPSS 17 using the Mann-Whitney U test<br />
and the Pearson correlation test, and p0.999<br />
355
LETTERS TO THE EDITOR Turk J Hematol 2016;<strong>33</strong>:355-370<br />
Hemophilia associations should be recommended for educational<br />
programs for patients and caregivers. Hematologists and<br />
nongovernmental organizations can work together for lifelong<br />
educational programs. Finally, we recommend holding patient<br />
workshops twice a year as well as publishing simple books or<br />
brochures in each local language to improve the knowledge and<br />
therefore the quality <strong>of</strong> life <strong>of</strong> these patients.<br />
Keywords: Knowledge, Hemophilia, Treatment, Disease<br />
Anahtar Sözcükler: Bilgi, Hem<strong>of</strong>ili, Tedavi, Hastalık<br />
Ethics<br />
Ethics Committee Approval: This study was approved by the<br />
Ethics Committee <strong>of</strong> Shiraz University <strong>of</strong> Medical Sciences.<br />
Authorship Contributions<br />
Concept: Mehran Karimi; Design: Mehran Karimi; Editing the<br />
Manuscript: Mehran Karimi; Data Collection or Processing:<br />
Zohreh Zahedi; Analysis or Interpretation: Sezaneh Haghpanah;<br />
Literature Search: Tahereh Zarei; Writing: Tahereh Zarei.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Stachnik J. Hemophilia: etiology, complications, and current options in<br />
management. Formulary 2010;45:218.<br />
2. Lee CA, Berntorp EE, Hoots WK. Textbook <strong>of</strong> Hemophilia. New York, John<br />
Wiley & Sons, 2011.<br />
3. White GC 2nd, Rosendaal F, Aledort LM, Lusher JM, Rothschild C,<br />
Ingerslev J; Factor VIII and Factor IX Subcommittee. Definitions in<br />
hemophilia. Recommendation <strong>of</strong> the Scientific Subcommittee on Factor<br />
VIII and Factor IX <strong>of</strong> the Scientific and Standardization Committee <strong>of</strong> the<br />
International Society on Thrombosis and Haemostasis. Thromb Haemost<br />
2001;85:560.<br />
4. Smith PS, Levine PH. The benefits <strong>of</strong> comprehensive care <strong>of</strong> hemophilia: a<br />
five-year study <strong>of</strong> outcomes. Am J Public Health 1984;74:616-617.<br />
5. Soucie JM, Nuss R, Evatt B, Abdelhak A, Cowan L, Hill H, Kolakoski M,<br />
Wilber N. Mortality among males with hemophilia: relations with source <strong>of</strong><br />
medical care. Blood 2000;96:437-442.<br />
6. Teitel J, Barnard D, Israels S, Lillicrap D, Poon MC, Sek J. Home management<br />
<strong>of</strong> haemophilia. Haemophilia 2004;10:118-1<strong>33</strong>.<br />
7. Lindvall K, Colstrup L, Wollter IM, Klemenz G, Loogna K, Grönhaug S,<br />
Thykjaer H. Compliance with treatment and understanding <strong>of</strong> own disease in<br />
patients with severe and moderate haemophilia. Haemophilia 2006;12:47-<br />
51.<br />
8. Nazzaro AM, Owens S, Hoots WK, Larson KL. Knowledge, attitudes, and<br />
behaviors <strong>of</strong> youths in the US hemophilia population: results <strong>of</strong> a national<br />
survey. Am J Public Health 2006;96:1618-1622.<br />
9. Miller K, Guelcher C, Taylor A. Haemophilia A: patients’ knowledge level<br />
<strong>of</strong> treatment and sources <strong>of</strong> treatment‐related information. Haemophilia<br />
2009;15:73-77.<br />
Address for Correspondence/Yazışma Adresi: Mehran KARIMI, M.D.,<br />
Shiraz University <strong>of</strong> Medical Sciences, <strong>Hematology</strong> Research Center, Shiraz, Iran<br />
Phone : 00987136473239<br />
E-mail : karimim@suns.ac.ir<br />
Received/Geliş tarihi: January 24, 2016<br />
Accepted/Kabul tarihi: June 02, 2016<br />
DOI: 10.4274/tjh.2016.0041<br />
Therapeutic Plasma Exchange Ameliorates Incompatible<br />
Crossmatches<br />
Çapraz Karşılaştırma Uyumsuzluklarını Ortadan Kaldıran Tedavi Edici Plazma Değişimi<br />
Mehmet Özen 1 , Sinan Erkul 2 , Gülen Sezer Alptekin Erkul 2 , Özlem Genç 3 , Engin Akgül 2 , Ahmet Hakan Vural 2<br />
1Dumlupınar University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Kütahya, Turkey<br />
2Dumlupınar University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Cardiac Surgery, Kütahya, Turkey<br />
3Dumlupınar University Faculty <strong>of</strong> Medicine, Blood Bank Unit, Kütahya, Turkey<br />
To the Editor,<br />
Red blood cell (RBC) transfusion is a risk factor for mortality and<br />
morbidity in coronary artery bypass graft (CABG) surgery, and<br />
transfusion-related adverse effects may be catastrophic in these<br />
patients [1,2,3,4]. Unfortunately, there are no recommendations<br />
for these patients regarding how to proceed in the case <strong>of</strong><br />
incompatible crossmatch tests against donors’ blood. To our<br />
knowledge, there is no report about the role <strong>of</strong> therapeutic<br />
plasma exchange (TPE) in resolving incompatible crossmatches.<br />
A 73-year-old man was admitted to our hospital because <strong>of</strong><br />
chest pain. He had no previous medical history <strong>of</strong> coronary<br />
artery disease or any other diseases, including hemolytic disease<br />
and recent infection. In addition, he used no medication and had<br />
not received blood transfusions. After coronary angiography, a<br />
356
Turk J Hematol 2016;<strong>33</strong>:355-370<br />
LETTERS TO THE EDITOR<br />
CABG was planned for the patient. Because <strong>of</strong> critical coronary<br />
artery lesions, he had to undergo the operation as soon as<br />
possible. His laboratory tests revealed mild normocytic anemia<br />
with hemoglobin <strong>of</strong> 12.8 g/dL, mean corpuscular volume <strong>of</strong><br />
82.2 fL, white blood cell count <strong>of</strong> 9200/µL, and platelet count <strong>of</strong><br />
281,000/µL. His biochemical results were normal for renal and<br />
liver function tests. The patient’s blood group was B Rh D positive<br />
based on forward and reverse grouping. Whole blood transfusion<br />
was planned for the CABG procedure by the surgeons as a part<br />
<strong>of</strong> their conventional approach. However, cross match results<br />
revealed 3+ reactions against B Rh D positive donors’ whole<br />
blood and other B Rh D positive RBCs in the blood bank (Figure<br />
1A). Direct Coombs test results were 2+ AHG and IgG (Figure<br />
1B). Due to the urgency <strong>of</strong> the planned CABG, we did not wait<br />
for detailed antibody screening test results, and TPE (Infomed,<br />
Geneva, Switzerland) was performed. Total body plasma was<br />
exchanged with fresh frozen plasma within 2 h. After one TPE<br />
procedure, the cross-reaction to donors’ whole blood was 2+.<br />
TPE was performed again 1 day later, and after the second TPE,<br />
the crossmatches were compatible (Figures 1C and 1D). There<br />
was no adverse effect due to TPE. We operated after the second<br />
TPE, used a regular erythrocyte suspension and whole blood,<br />
administered 40 mg/day intravenous methylprednisolone for 4<br />
days, and discharged the patient 1 week after the operation.<br />
Two weeks after the operation, he had no hematological or<br />
antibody-related disease and he had a normal complete blood<br />
count with compatible crossmatches. He also had no antibodies<br />
related to incompatible crossmatches.<br />
Figure 1. A) Crossmatch before therapeutic plasma exchange<br />
(TPE), B) direct Coombs test before TPE, C) crossmatch after one<br />
TPE, D) crossmatch after two TPEs. All tests were performed with<br />
DG gel cards (Grifols) and used the Wadiana automated blood<br />
bank (Grifols, SantCugat del Valles, Barcelona, Spain).<br />
In a patient undergoing CABG, an incompatible blood<br />
transfusion can lead to perioperative hemolysis and increased<br />
mortality [5,6]. Defining the antibodies and finding compatible<br />
blood for a patient with incompatible crossmatches can be a<br />
challenging and time-consuming problem [5,7].<br />
TPE is an important treatment modality for many autoimmune<br />
conditions and helps by removing autoantibodies [8]. Our patient<br />
did not have time to wait and needed CABG urgently. Therefore,<br />
we assumed that the patient had antibody-related autoimmune<br />
hemolytic anemia and treated him with TPE. We report that<br />
this approach may be efficient for patients with incompatible<br />
crossmatch results even if they do not have autoimmune<br />
hemolytic anemia. Therefore, TPE might be reserved for urgent<br />
conditions or when identification <strong>of</strong> antibodies is inconclusive.<br />
Keywords: Cardiac surgery, Apheresis, Crossmatch, Transfusion<br />
medicine<br />
Anahtar Sözcükler: Kalp cerrahisi, Aferez, Çapraz karşılaştırma,<br />
Transfüzyon tıbbı<br />
Authorship Contributions<br />
Concept: Mehmet Özen, Sinan Erkul; Design: Mehmet Özen,<br />
Ahmet Hakan Vural; Data Collection or Processing: Özlem Genç,<br />
Sinan Erkul, Gülen Sezer Alptekin Erkul, Engin Akgül; Analysis<br />
or Interpretation: Mehmet Özen, Ahmet Hakan Vural; Writing:<br />
Mehmet Özen.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Evanovitch D. A primer in pretransfusion testing. Transfus Apher Sci<br />
2012;46:281-286.<br />
2. Santos AA, Silva JP, Silva Lda F, Sousa AG, Piotto RF, Baumgratz JF.<br />
Therapeutic options to minimize allogeneic blood transfusions and their<br />
adverse effects in cardiac surgery: a systematic review. Rev Bras Cir<br />
Cardiovasc 2014;29:606-621.<br />
3. Senay S, Toraman F, Karabulut H, Alhan C. Is it the patient or the physician<br />
who cannot tolerate anemia? A prospective analysis in 1854 non-transfused<br />
coronary artery surgery patients. Perfusion 2009;24:373-380.<br />
4. Society <strong>of</strong> Thoracic Surgeons Blood Conservation Guideline Task Force,<br />
Ferraris VA, Ferraris SP, Saha SP, Hessel EA 2nd, Haan CK, Royston BD,<br />
Bridges CR, Higgins RS, Despotis G, Brown JR; Society <strong>of</strong> Cardiovascular<br />
Anesthesiologists Special Task Force on Blood Transfusion, Spiess BD, Shore-<br />
Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE,<br />
Body S. Perioperative blood transfusion and blood conservation in cardiac<br />
surgery: the Society <strong>of</strong> Thoracic Surgeons and the Society <strong>of</strong> Cardiovascular<br />
Anesthesiologists clinical practice guidelines. Ann Thorac Surg 2007;83(5<br />
Suppl):27-86.<br />
357
LETTERS TO THE EDITOR Turk J Hematol 2016;<strong>33</strong>:355-370<br />
5. White MJ, Hazard SW 3rd, Frank SM, Boyd JS, Wick EC, Ness PM, Tobian<br />
AA. The evolution <strong>of</strong> perioperative transfusion testing and blood ordering.<br />
Anesth Analg 2015;120:1196-1203.<br />
6. Rakic S, Belic B, Erceg S, Jovanovic R, Kulic Z, Stefanovic N, Belic A,<br />
Uzurov V, Spasojevic J. Complications in the use <strong>of</strong> blood transfusions-<br />
-alloimmunization in polytransfused patients. Med Pregl 1999;52:375-<br />
378.<br />
7. Sanz C, Nomdedeu M, Belkaid M, Martinez I, Nomdedeu B, Pereira A. Red<br />
blood cell alloimmunization in transfused patients with myelodysplastic<br />
syndrome or chronic myelomonocytic leukemia. Transfusion 2013;53:710-715.<br />
8. Sengul Samanci N, Ayer M, Gursu M, Ar MC, Yel K, Ergen A, Dogan EE,<br />
Karadag S, Cebeci E, Toptas M, Kazancioglu R, Ozturk S. Patients treated<br />
with therapeutic plasma exchange: a single center experience. Transfus<br />
Apher Sci 2014;51:83-89.<br />
Address for Correspondence/Yazışma Adresi: Mehmet ÖZEN, M.D.,<br />
Dumlupınar University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Kütahya, Turkey<br />
Phone : +90 274 231 66 60<br />
E-mail : kanbilimci@gmail.com<br />
Received/Geliş tarihi: February 06, 2016<br />
Accepted/Kabul tarihi: June 06, 2016<br />
DOI: 10.4274/tjh.2016.0056<br />
Megaloblastic Anemia with Ring Sideroblasts is not Always<br />
Myelodysplastic Syndrome<br />
Halka Sideroblastlı Megaloblastik Anemi Her Zaman Miyelodisplastik Sendrom Olmayabilir<br />
Neha Chopra Narang 1 , Mrinalini Kotru 2 , Kavana Rao 1 , Meera Sikka 1<br />
1University College <strong>of</strong> Medical Sciences, Department <strong>of</strong> Pathology, Delhi, India<br />
2University College <strong>of</strong> Medical Sciences, Department <strong>of</strong> Hematopathology, Delhi, India<br />
To the Editor,<br />
Ring sideroblasts are morphological hallmarks <strong>of</strong> hereditary and<br />
acquired sideroblastic anemias [1]. The International Working<br />
Group on Morphology <strong>of</strong> Myelodysplastic syndrome (MDS)<br />
defined ring sideroblasts as erythroblasts in which a minimum<br />
<strong>of</strong> five siderotic granules cover at least one-third <strong>of</strong> the<br />
circumference <strong>of</strong> the nucleus.<br />
We present the case <strong>of</strong> an 18-year-old female who had lowgrade<br />
fever, jaundice, nausea, vomiting, and shortness <strong>of</strong><br />
breath for 25 days. The patient was not an alcoholic and not<br />
on any drugs. On examination she appeared pale and icteric;<br />
however, no hepatosplenomegaly was noted. A complete blood<br />
count (CBC) and bone marrow examination were performed.<br />
The CBC revealed Hb: 75 g/L, PCV: 0.232%, RBC: 2.15x10 12 /L,<br />
MCV: 108 fL, MCH: 34.8 pg, MCHC: 32.2 g/dL, total leukocyte<br />
count: 2.6x10 9 /L, platelet count: 87x10 9 /L, reticulocyte count:<br />
0.8%, and differential leukocyte count: N74 L26. A peripheral<br />
smear revealed pancytopenia with dimorphic anemia. No coarse<br />
basophilic stippling was noted (as seen in lead poisoning). Bone<br />
marrow aspirate was particulate and hypercellular for age<br />
with erythroid hyperplasia, showing megaloblastic maturation<br />
and dyserythropoiesis (Figure 1). Giant myeloid forms were<br />
seen. Megakaryocytes appeared adequate and were normal in<br />
morphology. Bone marrow iron was increased (grade 3) and<br />
showed 6%-7% ring sideroblasts (Figure 2). A final diagnosis<br />
<strong>of</strong> megaloblastic anemia with ring sideroblasts was made after<br />
excluding various other causes <strong>of</strong> the same symptoms. The<br />
patient was put on a therapeutic trial <strong>of</strong> hematinics (vitamin<br />
B12, folic acid, and pyridoxine) and showed improvement.<br />
After therapy, a CBC revealed Hb: 122 g/L, PCV: 0.432%, RBC:<br />
4.15x10 12 /L, MCV: 85 fL, MCH: 30.8 pg, MCHC: 31.2 g/dL, total<br />
leukocyte count: 5.6x10 9 /L, and platelet count: 177x10 9 /L.<br />
However, a repeat bone marrow examination could not be<br />
performed as the patient did not comply.<br />
Figure 1. Bone marrow aspiration: megaloblastic maturation with<br />
dyserythropoiesis and giant myelocyte (1000 x ).<br />
358
Turk J Hematol 2016;<strong>33</strong>:355-370<br />
LETTERS TO THE EDITOR<br />
vitamin B12 and folic acid [8]. The presence <strong>of</strong> ring sideroblasts<br />
does not always point towards impending MDS.<br />
The development <strong>of</strong> ring sideroblasts in the above case was<br />
related to an absolute or relative deficiency <strong>of</strong> pyridoxine<br />
associated with vitamin B12 and folate deficiency.<br />
Keywords: Ring sideroblasts, Megaloblastic anemia,<br />
Myelodysplastic syndrome<br />
Anahtar Sözcükler: Halka sideroblastlar, Megaloblastik anemi,<br />
Miyelodisplastik sendrom<br />
Authorship Contributions<br />
Figure 2. Ring sideroblasts; Perl’s stain on bone marrow aspirate<br />
(1000 x ).<br />
Ring sideroblasts are found exclusively in pathological conditions<br />
and should not be confused with ferritin sideroblasts, which are<br />
present in normal bone marrow. The latter are normal erythroblasts<br />
that, upon Prussian blue staining, show a few blue granules<br />
scattered in the cytoplasm, representing endosomes filled with<br />
excess iron not utilized for heme synthesis (siderosomes). While<br />
the iron <strong>of</strong> ferritin sideroblasts is stored in cytosolic ferritin,<br />
whose subunits are encoded by the FTH1 and FTL genes, the iron<br />
<strong>of</strong> ring sideroblasts is stored in mitochondrial ferritin, encoded by<br />
the FTMT gene [2]. There are two forms <strong>of</strong> sideroblastic anemia:<br />
congenital sideroblastic anemia and acquired sideroblastic<br />
anemia. Most acquired sideroblastic anemia cases were included<br />
within MDS. Acquired sideroblastic anemia in MDS is categorized<br />
either as refractory cytopenia with multilineage dysplasia or<br />
refractory anemia with ring sideroblasts, depending on the level<br />
<strong>of</strong> dysplasia [3]. Causes <strong>of</strong> acquired reversible sideroblastic anemia<br />
include alcohol use (most common), pyridoxine deficiency, lead<br />
poisoning, copper deficiency, excess zinc that can indirectly<br />
cause sideroblastic anemia by decreasing absorption and<br />
increasing excretion <strong>of</strong> copper, and antimicrobials like isoniazid,<br />
chloramphenicol, linezolid, and cycloserine [1,4].<br />
Impaired heme synthesis in sideroblastic anemias is associated<br />
with abnormal vitamin B6 metabolism at the level <strong>of</strong> the<br />
mitochondrion. Megaloblastic anemia due to folic acid deficiency<br />
and ringed sideroblastic anemia have been reported in alcohol<br />
abusers [1,5,6,7]. Vitamin B6 deficiency is associated with the<br />
development <strong>of</strong> ring sideroblasts in these patients. Patients with<br />
megaloblastic anemia showing the presence <strong>of</strong> ring sideroblasts<br />
should therefore be supplemented with pyridoxine in addition to<br />
Concept: Neha Chopra Narang, Mrinalini Kotru; Design: Neha<br />
Chopra Narang, Mrinalini Kotru, Kavana Rao, Meera Sikka;<br />
Data Collection or Processing: Neha Chopra Narang, Kavana<br />
Rao; Analysis or Interpretation: Neha Chopra Narang, Mrinalini<br />
Kotru, Kavana Rao, Meera Sikka; Literature Search: Neha Chopra<br />
Narang, Mrinalini Kotru, Kavana Rao, Meera Sikka; Writing:<br />
Neha Chopra Narang, Mrinalini Kotru, Kavana Rao, Meera Sikka.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Hines JD. Reversible megaloblastic and sideroblastic marrow abnormalities<br />
in alcoholic patients. Br J Haematol 1969;16:87-101.<br />
2. Cazzola M, Invernizzi R. Ring sideroblasts and sideroblastic anemia.<br />
Haematologica 2011;96:789-792.<br />
3. Ohba R, Furuyama K, Yoshida K, Fujiwara T, Fukuhara N, Onishi Y, Manabe<br />
A, Ito E, Ozawa K, Kojima S, Ogawa S, Harigae H. Clinical and genetic<br />
characteristics <strong>of</strong> congenital sideroblastic anemia: comparison with<br />
myelodysplastic syndrome with ring sideroblast (MDS-RS). Ann Hematol<br />
2013;92:1-9.<br />
4. Willekens C, Dumezy F, Boyer T, Renneville A, Rossignol J, Berthon C,<br />
Cotteau-Leroy A, Mehiaoui L, Quesnel B, Preudhomme C. Linezolid induces<br />
ring sideroblasts. Haematologica 2013;98:e138-140.<br />
5. Iwama H, Iwase O, Hayashi S, Nakano M, Toyama K. Macrocytic anemia<br />
with anisocytosis due to alcohol abuse and vitamin B6 deficiency. Rinsho<br />
Ketsueki 1998;39:1127-1130.<br />
6. Solomon LR, Hillman RS. Vitamin B6 metabolism in idiopathic sideroblastic<br />
anaemia and related disorders. Br J Haematol 1979;42:239-253.<br />
7. Lindenbaum J, Roman MJ. Nutritional anemia in alcoholism. Am J Clin Nutr<br />
1980;<strong>33</strong>:2727-2735.<br />
8. Dawson AM, Holdsworth CD, Pitcher CS. Sideroblastic anaemia in adult<br />
coeliac disease. Gut 1964;5:304-308.<br />
Address for Correspondence/Yazışma Adresi: Mrinalini KOTRU, M.D.,<br />
University College <strong>of</strong> Medical Sciences, Department <strong>of</strong> Pathology, Delhi, India<br />
Phone : +91 981 034 52 36<br />
E-mail : mrinalinikotru@gmail.com<br />
Received/Geliş tarihi: March 05, 2016<br />
Accepted/Kabul tarihi: July 28, 2016<br />
DOI: 10.4274/tjh.2016.0090<br />
359
LETTERS TO THE EDITOR Turk J Hematol 2016;<strong>33</strong>:355-370<br />
Annular Erythematous Patches as the Presenting Sign <strong>of</strong><br />
Extranodal Natural Killer/T-Cell Lymphoma<br />
Ekstranodal Doğal Öldürücü/T-Hücreli Lenfomanın Bulgusu Olarak Anüler Eritematöz Yamalar<br />
Can Baykal 1 , Algün Polat Ekinci 1 , Şule Öztürk Sarı 2 , Zeynep Topkarcı 3 , Özgür Demir 1 , Nesimi Büyükbabani 2<br />
1İstanbul University İstanbul Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Dermatology and Venereology, İstanbul, Turkey<br />
2İstanbul University İstanbul Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Pathology, İstanbul, Turkey<br />
3Bakırköy Dr. Sadi Konuk Training and Research Hospital, Clinic <strong>of</strong> Dermatology, İstanbul, Turkey<br />
To the Editor,<br />
Extranodal natural killer/T-cell lymphoma (ENKTL) is a distinct<br />
type <strong>of</strong> lymphoma strongly associated with Epstein-Barr virus<br />
(EBV) infection and showing an aggressive course [1]. It usually<br />
presents as a localized disease in the upper aerodigestive tract,<br />
from the nasal cavity to the hypopharynx [2,3], but it may rapidly<br />
extend to the neighboring tissues and disseminate to various<br />
organs such as the small intestine, epiglottis, testes, adrenal<br />
gland, kidneys, and breasts [4,5]. As nasal/upper aerodigestive<br />
tract involvement may only cause nonspecific symptoms in the<br />
early period, diagnosis may be initially established based upon<br />
skin lesions [6]. We present two ENKTL patients with unusual<br />
dermatological findings.<br />
Patient 1, a 44-year-old male, presented with a widespread<br />
eruption on the trunk, scalp, and arms consisting <strong>of</strong> annular<br />
erythematous patches (Figure 1a) and hyperpigmented/purpuric<br />
patches circumscribed with erythematous rings (Figure 1b). A<br />
biopsy revealed neoplastic infiltration <strong>of</strong> atypical lymphocytes<br />
expressing CD56 and granzyme-B but negative for CD2, CD3,<br />
CD8, and CD20. Nasopharyngeal involvement was suspected with<br />
radiologic imaging (magnetic resonance imaging) and ENKTL<br />
was diagnosed after a nasopharyngeal biopsy. Bone marrow<br />
biopsy was normal. Following CHOP chemotherapy, most <strong>of</strong><br />
the cutaneous lesions resolved with slight hyperpigmentation,<br />
but complete clearance was not achieved during the 3-month<br />
follow-up period.<br />
Patient 2, a 39-year-old male having a history <strong>of</strong> infectious<br />
mononucleosis 5 months earlier, presented with widespread<br />
infiltrated plaques on the nose, cheeks, (Figure 1c), forehead,<br />
scalp, trunk, and arms and a deep nodule on the hard palate for 2<br />
months. Annular erythema and purpuric patches circumscribed<br />
with annular rims were remarkable on the back (Figure 1d).<br />
Serum EBV-PCR and EBV VCA-IgG tests revealed positive results.<br />
Punch biopsies performed from both erythematous patches on<br />
the back and infiltrated plaques showed neoplastic lymphocytic<br />
infiltration with EBV-encoded RNA (EBER) positivity by in situ<br />
hybridization, which confirmed the diagnosis <strong>of</strong> ENKTL (Figures<br />
1e and 1f). A PET-CT examination revealed nasopharynx, palate,<br />
and tonsil involvements and metastatic parenchymatous<br />
nodules in both lungs.<br />
A broad spectrum <strong>of</strong> skin lesions such as erythematous<br />
indurated plaques, painful subcutaneous nodules, persistent<br />
cellulitis-like or abscess-like swellings, panniculitis-like<br />
lesions, mycosis fungoides-like lesions, and nonhealing<br />
ulcers can be seen in patients with ENKTL [7,8,9]. Three<br />
ENKTL cases were reported in which patients presented<br />
with skin lesions on the trunk and extremities described<br />
as infiltrated erythema, edematous erythema, and dark red<br />
erythema, one <strong>of</strong> them showing an annular configuration<br />
[8]. An ENKTL case also involving erythematous patches that<br />
developed and regressed over the course <strong>of</strong> chemotherapy<br />
was reported [10]. However, this was considered as a possible<br />
paraneoplastic sign.<br />
Both <strong>of</strong> our patients had unusual lesions for cutaneous<br />
lymphoma, namely erythematous patches mostly showing<br />
annular configurations besides the more typical infiltrated<br />
plaques <strong>of</strong> Patient 2. From a clinical standpoint, the appearance<br />
<strong>of</strong> these erythematous lesions is like an inflammatory disease<br />
and may be a paraneoplastic sign. However, the lesions were<br />
Figure 1. a, b) Widespread eruption on the trunk consisting <strong>of</strong><br />
annular erythematous patches (Patient 1). c) Infiltrated plaque<br />
on the forehead extending to the scalp (Patient 2). d) Annular<br />
erythematous patches and purpuric patches circumscribed with a<br />
thin erythematous ring (Patient 2). e) Dense neoplastic infiltration<br />
<strong>of</strong> atypical lymphocytes on the mid-deep dermis (hematoxylin<br />
and eosin, 200 x ). f) In situ hybridization for EBER shows positive<br />
signals (EBER, 100 x ) (Patient 2).<br />
360
Turk J Hematol 2016;<strong>33</strong>:355-370<br />
LETTERS TO THE EDITOR<br />
nonmigratory and had persisted for a long time, in contrast to the<br />
expected course <strong>of</strong> possible reactive inflammatory dermatoses.<br />
Moreover, in both cases histopathologic examination showed<br />
neoplastic infiltration <strong>of</strong> ENKTL.<br />
In conclusion, persistent erythematous patches with annular<br />
shape may be among the skin involvement patterns <strong>of</strong> ENKTL<br />
and awareness <strong>of</strong> this peculiar finding may avoid delay in its<br />
diagnosis.<br />
Keywords: Extranodal natural killer/T cell lymphoma,<br />
Erythematous indurated plaques, Annular erythematous patch,<br />
Annular erythema<br />
Anahtar Sözcükler: Ekstranodal doğal öldürücü/T hücreli<br />
lenfoma, Eritemli indüre plaklar, Anuler eritemli yama, Anuler<br />
eritem<br />
Authorship Contributions<br />
Concept: Can Baykal, Algün Polat Ekinci, Şule Öztürk Sarı,<br />
Zeynep Topkarcı, Özgür Demir, Nesimi Büyükbabani; Design:<br />
Can Baykal, Algün Polat Ekinci, Şule Öztürk Sarı, Zeynep<br />
Topkarcı, Özgür Demir, Nesimi Büyükbabani; Data Collection<br />
or Processing: Can Baykal, Algün Polat Ekinci, Şule Öztürk Sarı,<br />
Zeynep Topkarcı, Özgür Demir, Nesimi Büyükbabani; Analysis or<br />
Interpretation: Can Baykal, Algün Polat Ekinci, Şule Öztürk Sarı,<br />
Zeynep Topkarcı, Özgür Demir, Nesimi Büyükbabani; Literature<br />
Search: Can Baykal, Algün Polat Ekinci, Şule Öztürk Sarı, Zeynep<br />
Topkarcı, Özgür Demir, Nesimi Büyükbabani; Writing: Can<br />
Baykal, Algün Polat Ekinci, Şule Öztürk Sarı, Zeynep Topkarcı,<br />
Özgür Demir, Nesimi Büyükbabani.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Chan JK, Sin VC, Wong KF, Ng CS, Tsang WY, Chan CH, Cheung MM, Lau<br />
WH. Nonnasal lymphoma expressing the natural killer cell marker CD56: a<br />
clinicopathologic study <strong>of</strong> 49 cases <strong>of</strong> an uncommon aggressive neoplasm.<br />
Blood 1997;89:4501-4513.<br />
2. Miyazato H, Nakatsuka S, Dong Z, Takakuwa T, Oka K, Hanamoto H, Tatsumi<br />
Y, Kanamaru A, Aozasa K; Osaka Lymphoma Study Group. NK-cell related<br />
neoplasms in Osaka, Japan. Am J Hematol 2004;76:230-235.<br />
3. Oshimi K, Kawa K, Nakamura S, Suzuki R, Suzumiya J, Yamaguchi M,<br />
Kameoka J, Tagawa S, Imamura N, Ohshima K, Kojya S, Iwatsuki K, Tokura<br />
Y, Sato E, Sugimori H; NK-cell Tumor Study Group. NK-cell neoplasms in<br />
Japan. <strong>Hematology</strong> 2005;10:237-245.<br />
4. Lim ST, Hee SW, Quek R, Lim LC, Yap SP, Loong EL, Sng I, Tan LH, Ang MK,<br />
Ngeow J, Tham CK, Ngo L, Tan MH, Tao M. Comparative analysis <strong>of</strong> extranodal<br />
NK/T-cell lymphoma and peripheral T-cell lymphoma: significant<br />
differences in clinical characteristics and prognosis. Eur J Haematol<br />
2008;80:55-60.<br />
5. Li S, Feng X, Li T, Zhang S, Zuo Z, Lin P, Konoplev S, Bueso-Ramos CE, Vega F,<br />
Medeiros LJ, Yin CC. Extranodal NK/T-cell lymphoma, nasal type: a report <strong>of</strong><br />
73 cases at MD Anderson Cancer Center. Am J Surg Pathol 2013;37:14-23.<br />
6. Zheng Y, Jia J, Li W, Wang J, Tian Q, Li Z, Yang J, Dong X, Pan P, Xiao S.<br />
Extranodal natural killer/T-cell lymphoma, nasal type, involving the skin,<br />
misdiagnosed as nasosinusitis and a fungal infection: a case report and<br />
literature review. Oncol Lett 2014;8:2253-2262.<br />
7. Lee WJ, Jung JM, Won CH, Chang SE, Choi JH, Chan Moon K, Park CS,<br />
Huh J, Lee MW. Cutaneous extranodal natural killer/T-cell lymphoma:<br />
a comparative clinicohistopathologic and survival outcome analysis<br />
<strong>of</strong> 45 cases according to the primary tumor site. J Am Acad Dermatol<br />
2014;70:1002-1009.<br />
8. Miyamoto T, Yoshino T, Takehisa T, Hagari Y, Mihara M. Cutaneous<br />
presentation <strong>of</strong> nasal/nasal type T/NK cell lymphoma: clinicopathological<br />
findings <strong>of</strong> four cases. Br J Dermatol 1998;139:481-487.<br />
9. Cerroni L. Skin Lymphoma: The Illustrated Guide, Fourth Edition. Singapore,<br />
Blackwell, 2014.<br />
10. Türker B, Uz B, Işık M, Bektaş O, Demiroğlu H, Sayınalp N, Uner A, Ozcebe<br />
Oİ. Nasal natural killer/T-cell lymphoma with skin, eye, and peroneal nerve<br />
involvement. Turk J Hematol 2012;29:413-419.<br />
Address for Correspondence/Yazışma Adresi: Algün POLAT EKİNCİ, M.D.,<br />
İstanbul University İstanbul Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Dermatology and Venereology, İstanbul, Turkey<br />
Phone : +90 212 635 29 39<br />
E-mail : algunekinci@yahoo.com<br />
Received/Geliş tarihi: February 19, 2016<br />
Accepted/Kabul tarihi: July 20, 2016<br />
DOI: 10.4274/tjh.2016.0071<br />
361
LETTERS TO THE EDITOR Turk J Hematol 2016;<strong>33</strong>:355-370<br />
Presentation <strong>of</strong> Diffuse Large B-Cell Lymphoma Relapse as a<br />
Penile Mass<br />
Penil Kitle ile Başvuran Diffüz Büyük B Hücreli Lenfoma Nüksü<br />
Birgül Öneç 1 , Kürşad Öneç 2 , Ali Ümit Esbah 3 , Onur Esbah 4<br />
1Düzce University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Düzce, Turkey<br />
2Düzce University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Nephrology, Düzce, Turkey<br />
3Düzce University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Anesthesia and Intensive Care, Düzce, Turkey<br />
4Düzce University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Medical Oncology, Düzce, Turkey<br />
To the Editor,<br />
Penile malignant tumors constitute less than 1% <strong>of</strong> all<br />
malignancies in men but penile lymphoma is even rarer in<br />
this population [1]. Presentation with a primary penile mass is<br />
extremely rare for lymphomas, as reported only in case reports<br />
in the literature [2,3,4,5,6,7]. Here we report a case <strong>of</strong> recurrent<br />
lymphoma presenting with a penile mass lesion.<br />
A 51-year-old man was admitted with the appearance <strong>of</strong> swelling<br />
and ulcerations <strong>of</strong> the penis that had started 2 weeks earlier. His<br />
history revealed that he was diagnosed with stage IIIB diffuse<br />
large B-cell lymphoma (DLBCL) 7 years ago, received 6 courses <strong>of</strong><br />
R-CHOP, and was assumed to be cured after 5 uneventful years <strong>of</strong><br />
follow-up. Swelling at the penis increased within 2 weeks with the<br />
addition <strong>of</strong> continuous pain, superficial ulcerations, and frequent<br />
and painful urination. Physical examination revealed a diffuse<br />
and indurated swelling at the shaft <strong>of</strong> the penis with an ulcer. An<br />
enlarged left inguinal lymph node was also palpable. Magnetic<br />
resonance imaging revealed a solid lesion <strong>of</strong> 55x37 mm in size,<br />
almost completely filling the penile corpus and significantly<br />
narrowing the penile urethra, extending to the glans penis. Tru-<br />
Cut biopsy <strong>of</strong> the penile lesion was consistent with DLBCL. He<br />
was staged as Ann Arbor IIIE with positron emission tomographycomputed<br />
tomography revealing F-18 fluorodeoxyglucose<br />
involvement in the deep cervical left inguinal lymph nodes and a<br />
solid mass in the corpus penis (Figure 1). Treatment with R-CHOP<br />
started immediately and his complaints rapidly reduced after the<br />
first course. The patient is still having chemotherapy without<br />
complications and autologous stem cell transplantation will be<br />
considered for consolidation after complete remission.<br />
Although most DLBCL patients have nodal presentation at<br />
admission, extranodal involvements are also common. The<br />
classical extranodal involvements sites are the breast, central<br />
nervous system, and testes. Penile involvement is a rare entity<br />
reported in case reports [2,5,7,8,9,10]. Chu et al. reviewed<br />
penile lymphomas and reported only 48 cases, among which<br />
DLBCL was the most frequent subtype with 14 cases [5]. The<br />
most common symptom <strong>of</strong> penile lymphoma was a painless<br />
mass lesion or nodule in the penis followed by ulcerations<br />
[5,7].<br />
Surgery remains the best approach for penile cancers, whereas<br />
no standard treatment modality has been established for<br />
penile lymphomas. Systemic chemotherapy according to the<br />
subtype is a good treatment option because it preserves penile<br />
functions [2]. In our patient, R-CHOP therapy was initiated<br />
within 2 weeks after admission and obstructive symptoms were<br />
relieved immediately after the first course. Disease-free survival<br />
was reported to be between 6 and 48 months in previous case<br />
series [5], clearly indicating better outcomes than in cases <strong>of</strong><br />
metastatic carcinomas.<br />
In conclusion, the possibility <strong>of</strong> lymphoma involvement<br />
should be kept in mind in patients admitting with penile mass<br />
lesions, especially in patients who have a history <strong>of</strong> aggressive<br />
lymphomas, in order to avoid aggressive surgical interventions.<br />
It is important to initiate systemic chemotherapy immediately<br />
in order to prevent complications related to urethra obstruction<br />
and to preserve erectile functions.<br />
Keywords: Penis, Lymphoma, Non-Hodgkin lymphoma, Diffuse<br />
large B-cell lymphoma, Penile mass<br />
Anahtar Sözcükler: Penis, Lenfoma, Non-Hodgkin lenfoma,<br />
Diffüz büyük B hücreli lenfoma, Penil kitle<br />
Figure 1. Transaxial fused positron emission tomographycomputed<br />
tomography (A) and computed tomography (B)<br />
images showing the penile s<strong>of</strong>t tissue mass with intense F-18<br />
fluorodeoxyglucose uptake (arrows).<br />
Authorship Contributions<br />
Concept: Birgül Öneç, Kürşad Öneç, Ali Ümit Esbah, Onur Esbah;<br />
Design: Birgül Öneç, Kürşad Öneç; Data Collection or Processing:<br />
Birgül Öneç, Kürşad Öneç; Analysis or Interpretation: Birgül<br />
362
Turk J Hematol 2016;<strong>33</strong>:355-370<br />
LETTERS TO THE EDITOR<br />
Öneç, Onur Esbah; Literature Search: Birgül Öneç, Ali Ümit<br />
Esbah; Writing: Birgül Öneç, Ali Ümit Esbah.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Schniederjan SD, Osunkoya AO. Lymphoid neoplasms <strong>of</strong> the urinary tract<br />
and male genital organs: a clinicopathological study <strong>of</strong> 40 cases. Mod<br />
Pathol 2009;22:1057-1065.<br />
2. Stamatiou K, Pierris N. Lymphoma presenting as cancer <strong>of</strong> the glans penis:<br />
a case report. Case Rep Pathol 2012;2012:948352.<br />
3. Gentile G, Broccoli A, Brunocilla E, Schiavina R, Borghesi M, Romagnoli D,<br />
Bianchi L, Derenzini E, Agostinelli C, Franceschelli A, Colombo F, Zinzani<br />
PL. An isolated penile mass in a young adult turned out to be a primary<br />
marginal zone lymphoma <strong>of</strong> the penis. A case report and a review <strong>of</strong><br />
literature. Anticancer Res 2013;<strong>33</strong>:2639-2642.<br />
4. Gong Z, Zhang Y, Chu H, Lian P, Zhang L, Sun P, Chen J. Priapism as the<br />
initial symptom <strong>of</strong> primary penile lymphoma: a case report. Oncol Lett<br />
2014;8:1929-1932.<br />
5. Chu L, Mao W, Curran Vikramsingh K, Liu X, Qiu HM, Zheng JH, Wang Y,<br />
Yu GP, Xu Q. Primary malignant lymphoma <strong>of</strong> the glans penis: a rare case<br />
report and review <strong>of</strong> the literature. Asian J Androl 2013;15:571-572.<br />
6. Karki K, Mohsin R, Mubarak M, Hashmi A. Primary Non-Hodgkin’s<br />
lymphoma <strong>of</strong> penis masquerading as a non-healing ulcer in the penile<br />
shaft. Nephrourol Mon 2013;5:840-842.<br />
7. Wang GC, Peng B, Zheng JH. Primary penile malignant lymphoma: report <strong>of</strong><br />
a rare case. Can Urol Assoc J 2012;6:E277-279.<br />
8. Marks D, Crosthwaite A, Varigos G, Ellis D, Morstyn G. Therapy <strong>of</strong> primary<br />
diffuse large cell lymphoma <strong>of</strong> the penis with preservation <strong>of</strong> function. J<br />
Urol 1988;139:1057-1058.<br />
9. Kim HY, Oh SY, Lee S, Lee DM, Kim SH, Kwon HC, Hong SH, Yoon JH,<br />
Kim HJ. Primary penile diffuse large B cell lymphoma treated by local<br />
excision followed by rituximab-containing chemotherapy. Acta Haematol<br />
2008;120:150-152.<br />
10. Jabr FI. Recurrent lymphoma presenting as a penile ulcer in a patient with<br />
AIDS. Dermatol Online J 2005;11:29.<br />
Address for Correspondence/Yazışma Adresi: Birgül ÖNEÇ, M.D.,<br />
Düzce University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, Düzce, Turkey<br />
Phone : +90 505 242 81 83<br />
E-mail : birgulonec@gmail.com<br />
Received/Geliş tarihi: March 29, 2016<br />
Accepted/Kabul tarihi: April 13, 2016<br />
DOI: 10.4274/tjh.2016.0132<br />
Successful Treatment <strong>of</strong> Disseminated Fusariosis with the<br />
Combination <strong>of</strong> Voriconazole and Liposomal Amphotericin B<br />
Vorikonazol ve Lipozomal Amphoterisin B ile Başarıyla Tedavi Edilen Dissemine<br />
Fusariosis Olgusu<br />
Nur Efe İris 1 , Serkan Güvenç 2 , Tülay Özçelik 2 , Aslıhan Demirel 1 , Safiye Koçulu 1 , Esin Çevik 1 , Mutlu Arat 2<br />
1İstanbul Bilim University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Infectious Diseases and Clinical Microbiology, İstanbul, Turkey<br />
2İstanbul Bilim University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> <strong>Hematology</strong>, İstanbul, Turkey<br />
To the Editor,<br />
Fusarium species are important causes <strong>of</strong> disseminated<br />
infections in patients with prolonged, severe neutropenia.<br />
Clinical presentation includes refractory fever, skin lesions,<br />
and sinopulmonary infections [1,2]. Disseminated Fusarium<br />
infection (DFI) carries a poor prognosis, which is related to the<br />
angiotropism <strong>of</strong> Fusarium and its capacity for adventitious<br />
sporulation in tissues [3] and resistance to many antifungal<br />
agents [4].<br />
Here we report a hematopoietic stem cell transplant (HSCT)<br />
recipient with acute myeloid leukemia (AML) and disseminated<br />
fusariosis who was successfully treated using both liposomal<br />
amphotericin B and voriconazole.<br />
A 24-year-old male patient underwent allogeneic HSCT from<br />
his HLA-matched brother for AML in the first remission. At 21<br />
months after HSCT he had extramedullary relapse with a mass<br />
over his humerus. He received radiotherapy plus the FLAG-IDA<br />
salvage regimen. After 4 months, medullary relapse occurred.<br />
When he was hospitalized for the medullary relapse, he received<br />
cl<strong>of</strong>arabine with ARA-C, which caused severe neutropenia<br />
and fever. According to in-house protocol for neutropenia,<br />
piperacillin-tazobactam was initiated. However, on the third<br />
day, he was still febrile and neutropenic, so treatment was<br />
changed to meropenem and 2 days later amikacin was added.<br />
Because <strong>of</strong> hypotension, we broadened the spectrum with<br />
vancomycin. He was still febrile and he had rectal carbapenemresistant<br />
Klebsiella pneumoniae colonization. Antibiotherapy<br />
was reordered with colistin plus meropenem and vancomycin.<br />
363
LETTERS TO THE EDITOR Turk J Hematol 2016;<strong>33</strong>:355-370<br />
According to thorax computed tomography findings that showed<br />
a nodule on the base <strong>of</strong> the left lung and sphenoidal sinusitis,<br />
3 mg/kg liposomal amphotericin B was added empirically to his<br />
treatment. On follow-up, new papular and nodular skin lesions<br />
appeared on his face, head, arms, legs, feet, and anteriorposterior<br />
trunk. Some <strong>of</strong> these papules had central necrosis<br />
and eschar formations on his feet (Figure 1). These papules and<br />
especially the nodules were extremely painful, and he also had<br />
myalgia. Blood cultures revealed Fusarium solani by the VITEK<br />
system and MALDI-TOF. The diagnosis <strong>of</strong> DFI was established<br />
and we decided to augment the antifungal therapy on the<br />
seventh day by adding intravenous voriconazole as Fusarium<br />
is a resistant pathogen and the prognosis is especially poor in<br />
neutropenic patients. There were no antifungal susceptibility<br />
test results for amphotericin B or voriconazole. The skin lesions<br />
were not biopsied or cultured. Five days later his skin lesions<br />
began to resolve and on the sixth day <strong>of</strong> combined antifungal<br />
therapy his fever subsided. He was neutropenic at the time and<br />
neutrophil levels resolved 5 days later when he was afebrile.<br />
Clinical improvement was evident 5 days before the resolution<br />
<strong>of</strong> neutropenia. Parenteral antifungal treatment was continued<br />
for 21 days and the patient was discharged on oral voriconazole<br />
treatment. After combined antifungal therapy, blood cultures<br />
obtained on the fifth day were negative.<br />
We added voriconazole to the antifungal treatment <strong>of</strong> this<br />
patient because disseminated fusariosis has a very poor prognosis.<br />
Some investigators have stated that antifungal therapy is rarely<br />
effective and recovery depends on neutrophil recovery, but we<br />
achieved effective control <strong>of</strong> fusariosis with combined antifungal<br />
therapy before neutrophil recovery [5,6,7,8,9,10].<br />
In conclusion, using combination therapy such as amphotericin<br />
B and voriconazole may be considered as early as possible in<br />
patients who are not responding to antifungal monotherapy.<br />
Figure 1. Eschar formation on the foot and papules over the leg.<br />
Keywords: Invasive fungal infection, Fusariosis, Combined<br />
antifungal treatment, Lyposomal amphotericin B, Voriconazole,<br />
Acute myeloid leukemia<br />
Anahtar Sözcükler: İnvazif mantar enfeksiyonu, Fusariosis,<br />
Kombine antifungal tedavi, Lipozomal amfoterisin B,<br />
Vorikonazol, Akut myeloid lösemi<br />
Authorship Contributions<br />
Concept: Nur Efe İris; Design: Nur Efe İris, Mutlu Arat; Data<br />
Collection or Processing: Nur Efe İris, Serkan Güvenç; Analysis or<br />
Interpretation: Nur Efe İris, Tülay Özçelik, Safiye Koçulu, Aslıhan<br />
Demirel, Esin Çevik; Literature Search: Nur Efe İris; Writing: Nur<br />
Efe İris, Serkan Güvenç.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Nelson PE, Dignani MC, Anaissie EJ. Taxonomy, biology and clinical aspects<br />
<strong>of</strong> Fusarium species. Clin Microbiol Rev 1994;7:479-504.<br />
2. Dignani MC, Anaissie E. Human fusariosis. Clin Microbiol Infect<br />
2004;10(Suppl 1):67-75.<br />
3. Liu K, Howell DN, Perfect JR, Schnell WA. Morphologic criteria for the<br />
preliminary identification <strong>of</strong> Fusarium, Paecilomyces, and Acremonium<br />
species by histopathology. Am J Clin Pathol 1998;109:45-54.<br />
4. Jossi M, Ambrossioni J, Macedo-Vinas Garbino J. Invasive fusariosis with<br />
prolonged fungemia in a patient with acute lymphoblastic leukemia; case<br />
report and review <strong>of</strong> the literature. Int J Inf Dis 2010;14:e394-e356.<br />
5. Consigny S, Dhedin N, Datry A, Choquet S, Leblond V, Chosidow O.<br />
Successful voriconazole treatment <strong>of</strong> disseminated Fusarium infection in<br />
an immunocompromised patient. Clin Infect Dis 2003;37:311-313.<br />
6. Bodey G, Boutati EL, Anaissie E. Fusarium, a significant emerging pathogen<br />
in patients with hematologic malignancy: ten years <strong>of</strong> experience at a<br />
cancer center and implications for management. Blood 1997;3:999-1008.<br />
7. Velasso E, Martis C, Nucci M. Successful treatment <strong>of</strong> catheter related<br />
fusarial infection in immunocompromised children. Eur J Clin Microbiol<br />
Infect Dis 1995;14:697-699.<br />
8. Dobougogne A, de Hoog S, Lozniewski A, Machounant M. Amphotericin<br />
B and voriconazole susceptibility pr<strong>of</strong>iles for the Fusarium solani species<br />
complex: comparison between the E-test and CLSIM38A2 microdilution<br />
methodology. Eur J Clin Microbiol Infect Dis 2012;31:615-618.<br />
9. Compo M, Lewis RE, Kontoyiannis DP. Invasive fusariosis in patients<br />
with hematologic malignancies at a cancer center: 1998-2009. J Infect<br />
2010;60:<strong>33</strong>1-<strong>33</strong>7.<br />
10. Avelino-Silva VI, Ramos JF, Leal FE, Tastograssa L, Novis YS. Disseminated<br />
Fusarium infection in autologous stem cell transplant recipient. Braz J<br />
Infect Dis 2015;19:90-93.<br />
Address for Correspondence/Yazışma Adresi: Nur EFE İRİS, M.D.,<br />
Istanbul Bilim University Faculty <strong>of</strong> Medicine, Department <strong>of</strong> Infectious<br />
Diseases and Clinical Microbiology, Istanbul, Turkey<br />
Phone : +90 212 361 88 00<br />
E-mail : nurefeiris@yahoo.com<br />
Received/Geliş tarihi: March 25, 2016<br />
Accepted/Kabul tarihi: June 17, 2016<br />
DOI: 10.4274/tjh.2016.0128<br />
364
Turk J Hematol 2016;<strong>33</strong>:355-370<br />
LETTERS TO THE EDITOR<br />
NOS3 27-bp and IL4 70-bp VNTR Polymorphisms Do Not<br />
Contribute to the Risk <strong>of</strong> Sickle Cell Crisis<br />
NOS3 27-bp ve IL4 70-bp VNTR Polimorfizmleri Orak Hücreli Anemide Kriz Riskine<br />
Katkıda Bulunmaz<br />
Henu Verma 1 , Hrishikesh Mishra 1 , P. K. Khodiar 2 , P. K. Patra 1,2 , L. V. K. S. Bhaskar 1<br />
1Sickle Cell Institute Chhattisgarh, Division <strong>of</strong> Research, Raipur, India<br />
2Pt. JNM Medical College, Department <strong>of</strong> Biochemistry, Raipur, India<br />
To the Editor,<br />
A great deal <strong>of</strong> data support the direct involvement <strong>of</strong> the<br />
vascular endothelium, complex cellular interactions, and global<br />
inflammation-mediated cell activation in triggering vasoocclusive<br />
crisis (VOC) in sickle cell disease (SCD) [1]. In the<br />
transgenic mice model for SCD, it has been shown that nitric<br />
oxide (NO) protects the mice from VOC [2]. Elevated plasma<br />
levels <strong>of</strong> certain proinflammatory cytokines support a role for<br />
cytokine-driven inflammation in SCD. The aim <strong>of</strong> the present<br />
study was to evaluate the role <strong>of</strong> the NOS3 27-bp variable<br />
number tandem repeat (VNTR) and IL4 intron-3 VNTR functional<br />
polymorphisms in the development <strong>of</strong> crisis in Indian SCD<br />
patients. The study protocol was approved by the Institutional<br />
Ethics Committee <strong>of</strong> the Sickle Cell Institute Chhattisgarh,<br />
Raipur, India. Written informed consent was obtained from the<br />
study participants. A total <strong>of</strong> 256 individuals with SCD (55.5%<br />
men) were divided into two groups based on the history <strong>of</strong> VOC.<br />
The patients hospitalized with recurrent VOC were considered<br />
as the frequent crisis (FC) group (n=140; 54.7%) and patients<br />
who had not experienced any VOC during the past 1 year were<br />
considered as the infrequent crisis (IFC) group (n=116; 45.3%).<br />
Genotyping <strong>of</strong> the NOS3 27-bp VNTR [3] and IL4 intron-3 VNTR<br />
[4] functional polymorphisms was performed and results were<br />
compared between the FC and IFC groups.<br />
The genotype frequencies were in agreement with Hardy-<br />
Weinberg equilibrium for both the NOS3 27-bp (p=0.063) and<br />
the IL4 70-bp (p=0.614) VNTR. The genotype frequencies were<br />
not significantly different between the FC and IFC groups<br />
(Table 1). Similarly, the risk <strong>of</strong> frequent crisis was not found<br />
to be different between male and female SCD patients or<br />
between SCD patients with different HbF levels or different<br />
age groups (Table 1). Several lines <strong>of</strong> evidence suggest that<br />
there is vascular dysfunction and impaired NO bioactivity in<br />
SCD. Although no significant differences were observed in<br />
plasma NO metabolites between controls and SCD patients in<br />
the steady state, a significant reduction was noticed during<br />
VOC or acute chest syndrome [5]. Analysis <strong>of</strong> three NOS3 gene<br />
polymorphisms did not reveal a significant association with<br />
severe clinical manifestations in Brazilian SCD patients [6].<br />
In contrast to this, in another study a significant association<br />
<strong>of</strong> NOS3 variants with VOC in SCD patients was reported [7].<br />
However, our results indicate that the NOS3 27-bp VNTR<br />
polymorphism is not associated with the risk <strong>of</strong> frequent<br />
crises. Although the role <strong>of</strong> IL4 in SCD is controversial,<br />
increased serum IL4 levels were found in steady-state SCD<br />
patients compared to normal healthy controls [8]. Remarkably<br />
elevated levels <strong>of</strong> IL4 were noted in a VOC group compared to<br />
steady-state SCD patients and healthy controls [9]. IL4 levels<br />
correlated well with SCD status in Jamaicans, while exhibiting<br />
an ethnic difference between British and Jamaican children<br />
[10]. So far there are no published studies concerning IL4<br />
SNPs and SCD or its complications. As these results conflict<br />
with the biological plausibility that NO and interleukin levels<br />
modulate SCD, they deserve careful interpretation and further<br />
exploration.<br />
Keywords: Sickle cell disease, Crisis, NOS3, IL4<br />
Anahtar Sözcükler: Orak hücre hastalığı, Kriz, NOS3, IL4<br />
Ethics<br />
Ethics Committee Approval: The study protocol was approved<br />
by the Institutional Ethics Committee <strong>of</strong> the Sickle Cell Institute<br />
Chhattisgarh, Raipur, India, Informed Consent: Written informed<br />
consent was obtained from the study participants.<br />
Authorship Contributions<br />
Concept: L. V. K. S. Bhaskar, P. K. Patra; Design: L. V. K. S. Bhaskar,<br />
P. K. Patra; Data Collection or Processing: Henu Verma, L. V. K. S.<br />
Bhaskar; Analysis or Interpretation: L. V. K. S. Bhaskar; Literature<br />
Search: P. K. Khodiar, Henu Verma, Hrishikesh Mishra; Writing:<br />
Henu Verma, L. V. K. S. Bhaskar.<br />
Conflict <strong>of</strong> Interest: No conflict <strong>of</strong> interest was declared by the<br />
authors.<br />
365
LETTERS TO THE EDITOR Turk J Hematol 2016;<strong>33</strong>:355-370<br />
Table 1. Association between NOS3 27-bp and IL4 70-bp VNTR polymorphisms and development <strong>of</strong> vaso-occlusive crisis in sickle<br />
cell disease.<br />
Vaso-Occlusive Crisis Unadjusted Adjusted for Age and Sex<br />
Genotype FC IFC OR (95% CI) p-value OR (95% CI) p-value<br />
NOS3 27-bp VNTR<br />
4bb 101 (72.1) 89 (76.7) Reference<br />
4ab 39 (27.9) 26 (22.4) 1.32 (0.75-2.34) 0.<strong>33</strong>9 1.32 (0.75-2.35) 0.<strong>33</strong>8<br />
4aa 0 (0) 1 (0.9) - - - -<br />
IL4 70-bp VNTR<br />
3R3R 83 (59.3) 67 (57.8) Reference<br />
2R3R 51 (36.4) 39 (<strong>33</strong>.6) 1.06 (0.62-1.79) 0.840 1.04 (0.61-1.76) 0.897<br />
2R2R 6 (4.3) 10 (8.6) 0.48 (0.17-1.40) 0.181 0.49 (0.17-1.41) 0.184<br />
Sex<br />
Male 78 (55.7) 64 (55.2) Reference<br />
Female 62 (44.3) 52 (44.8) 0.98 (0.60-1.61) 0.931 0.97 (0.59-1.59) 0.896<br />
HbF<br />
>20.1% 66 (47.1) 60 (51.7) Reference<br />
10.1%-20% 59 (42.1) 43 (37.1) 1.25 (0.74-2.11) 0.140 1.27 (0.75-2.16) 0.374<br />
Turk J Hematol 2016;<strong>33</strong>:355-370<br />
LETTERS TO THE EDITOR<br />
Comment: In Response to “Auer Rod-Like Inclusions in Reactive<br />
Plasma Cells in a Case <strong>of</strong> Acute Myeloid Leukemia”<br />
“Akut Miyeloid Lösemili Olguda Reaktif Plazma Hücrelerinde Auer-Rod Benzeri<br />
İnkülüzyonlar” Adlı Makale ile İlgili Yorum<br />
Smeeta Gajendra<br />
Medanta-The Medicity, Department <strong>of</strong> Pathology and Laboratory Medicine, Gurgaon, India<br />
To the Editor,<br />
I read the article “Auer Rod-Like Inclusions in Reactive Plasma<br />
Cells in a Case <strong>of</strong> Acute Myeloid Leukemia” by Pradhan when<br />
it was first published online (http://www.journalagent.com/tjh/<br />
pdfs/TJH-09216-IMAGES_IN_HEMATOLOGY-PRADHAN.pdf).<br />
The manuscript is well written with the description <strong>of</strong> a rare<br />
presence <strong>of</strong> Auer rod-like inclusions in reactive plasma cells<br />
in a case <strong>of</strong> acute myeloid leukemia (AML). However, it is not<br />
the first case <strong>of</strong> Auer rod-like inclusions in reactive plasma<br />
cells in a case <strong>of</strong> AML in the literature as was claimed by the<br />
author in the article. Sharma et al. had already described a<br />
case <strong>of</strong> the presence <strong>of</strong> this type <strong>of</strong> plasma cell inclusion in<br />
a case <strong>of</strong> therapy-related AML. Needle-like or Auer rod-like<br />
intracytoplasmic inclusions in plasma cells were first described<br />
by Steinmann in 1940. A few cases <strong>of</strong> multiple myeloma<br />
with intracytoplasmic plasma cell inclusions are described<br />
in the literature [1]. Other conditions associated with these<br />
crystalline intracytoplasmic inclusions are plasmacytoma,<br />
chronic lymphocytic leukemia, lymphoplasmacytic lymphoma,<br />
mucosa-associated lymphoid tissue lymphomas, and, rarely,<br />
high-grade lymphomas [2]. Lemez reported a very rare case <strong>of</strong><br />
Auer rod-like inclusions in reactive plasma cells in a patient<br />
with aplastic anemia [3]. Some postulations were described<br />
in the literature that these inclusions are related to abnormal<br />
synthesis, trafficking, or excretion <strong>of</strong> the immunoglobulin or<br />
immunoglobulin light chains that accumulate in excess within<br />
the cytoplasm [4], but immunocytochemical examinations<br />
revealed no reaction with antibodies against immunoglobulins,<br />
light chains, or amyloid A antibodies inside the inclusions [5].<br />
These are positive for α-naphthyl acetate esterase (sensitive to<br />
sodium fluoride treatment) and β-glucuronidase, suggesting<br />
a lysosomal origin [1]. Plasmacytosis in AML occurs in about<br />
7% <strong>of</strong> cases and the number <strong>of</strong> plasma cells may vary from<br />
5% to 16%. This plasmacytosis is due to increased production<br />
<strong>of</strong> IL-6 by leukemic blasts, causing stimulation <strong>of</strong> plasma cells<br />
resulting in marrow plasmacytosis [6]. A rare case <strong>of</strong> Auer rodlike<br />
inclusions in reactive plasma cells in a case <strong>of</strong> AML was<br />
reported by Sharma et al. [7]. This should be diagnosed with<br />
caution to exclude the coexistence <strong>of</strong> multiple myeloma with<br />
AML. Not only serum and urine protein electrophoresis with<br />
immun<strong>of</strong>ixation but also serum free light-chain assay should be<br />
performed to exclude associated nonsecretory myeloma.<br />
Keywords: Plasma cell, Inclusion, Reactive plasmacytosis<br />
Anahtar Sözcükler: Plazma hücre, İnkülüzyon, Reaktif<br />
plazmositoz<br />
Conflict <strong>of</strong> Interest: The author <strong>of</strong> this paper has no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Hütter G, Nowak D, Blau IW, Thiel E. Auer rod-like intracytoplasmic<br />
inclusions in multiple myeloma. A case report and review <strong>of</strong> the literature.<br />
Int J Lab Hematol 2009;31:236-240.<br />
2. Gupta A, Gupta M, Handoo A, Vaid A. Crystalline inclusions in plasma cells.<br />
Indian J Pathol Microbiol 2011;54:836-837.<br />
3. Lemez P. Auer-rod-like inclusions in cells <strong>of</strong> B-lymphocytic lineage. Acta<br />
Haematol 1988;80:177-178.<br />
4. Jennette JC, Wilkman AS, Benson JD. IgD myeloma with intracytoplasmic<br />
crystalline inclusions. Am J Clin Pathol 1981;75:231-235.<br />
5. Metzgeroth G, Back W, Maywald O, Schatz M, Willer A, Hehlmann R, Hastka<br />
J. Auer rod-like inclusions in multiple myeloma. Ann Hematol 2003;82:57-<br />
60.<br />
6. Rosenthal NS, Farhi DC. Reactive plasmacytosis and lymphocytosis in acute<br />
myeloid leukemia. Hematol Pathol 1994;8:43-51.<br />
7. Sharma S, Malhan P, Pujani M, Pujani M. Auer rod-like inclusions in<br />
reactive plasmacytosis seen with acute myeloid leukemia. J Postgrad Med<br />
2009;55:197.<br />
Address for Correspondence/Yazışma Adresi: Smeeta GAJENDRA, M.D.,<br />
Medanta-The Medicity, Department <strong>of</strong> Pathology and Laboratory Medicine, Gurgaon, India<br />
Phone : 0901 359 08 75<br />
E-mail : drsmeeta@gmail.com<br />
Received/Geliş tarihi: March 31, 2016<br />
Accepted/Kabul tarihi: April 05, 2016<br />
DOI: 10.4274/tjh.2016.0139<br />
367
LETTERS TO EDITOR Turk J Hematol 2016;<strong>33</strong>:355-370<br />
Reply: “Auer Rod-Like Inclusions in Reactive Plasma Cells in a<br />
Case <strong>of</strong> Acute Myeloid Leukemia”<br />
Cevap: “Akut Myeloid Lösemi Tanılı Bir Olguda Reaktif Plazma Hücrelerinde Auer Rod<br />
Benzeri İnklüzyonlar”<br />
Sarita Pradhan<br />
Institute <strong>of</strong> Medical Sciences and Sum Hospital, Laboratory <strong>of</strong> <strong>Hematology</strong>, Bhubaneswar, India<br />
To the Editor,<br />
First I would like to thank Smeeta Gajendra for scrutinizing<br />
my article in her ‘Comment: In Response to “Auer Rod-Like<br />
Inclusions in Reactive Plasma Cells in a Case <strong>of</strong> Acute Myeloid<br />
Leukemia”’ published online and for bringing to light the missing<br />
reference <strong>of</strong> Sharma et al. [1], who reported a case <strong>of</strong> Auer rodlike<br />
inclusions in plasma cells in a case <strong>of</strong> therapy-related AML.<br />
I sincerely regret missing that article in my literature search but<br />
I would also like to clarify a few points.<br />
My presented case was not secondary AML and the patient had<br />
no prior history <strong>of</strong> chemotherapy, unlike the case reported by<br />
Sharma et al. [1]. The aim <strong>of</strong> my publication was to highlight a<br />
rare and interesting morphological finding, but within a limit <strong>of</strong><br />
200 words it was not possible to acknowledge all hematological<br />
malignancies showing similar inclusions in plasma cells.<br />
In conclusion, I would like to again thank Dr. Gajendra for the<br />
elaborate and informative additions made in the commentary.<br />
Conflict <strong>of</strong> Interest: The author <strong>of</strong> this paper has no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
Reference<br />
1. Sharma S, Malhan P, Pujani M, Pujani M. Auer rod-like inclusions in<br />
reactive plasmacytosis seen with acute myeloid leukemia. J Postgrad Med<br />
2009;55:197.<br />
Address for Correspondence/Yazışma Adresi: Sarita PRADHAN, M.D.,<br />
Institute <strong>of</strong> Medical Sciences and Sum Hospital, Laboratory <strong>of</strong> <strong>Hematology</strong>, Bhubaneswar, India<br />
Phone : 9 776 243 866<br />
E-mail : dr.sarita26@gmail.com<br />
Received/Geliş tarihi: May 12, 2016<br />
Accepted/Kabul tarihi: May 24, 2016<br />
DOI: 10.4274/tjh.2016.0172<br />
Auer Rods Are Not Seen in Non-Neoplastic Cells<br />
Auer Cismi Neoplastik Olmayan Hücrelerde Görülmez<br />
İrfan Yavaşoğlu, Zahit Bolaman<br />
Adnan Menderes University Faculty <strong>of</strong> Medicine, Division <strong>of</strong> <strong>Hematology</strong>, Aydın, Turkey<br />
To the Editor,<br />
The article entitled “Auer Rod in a Neutrophil in a<br />
Nonmalignant Condition”, written by Chandra et al. [1]<br />
and published in a recent issue <strong>of</strong> your journal, was quite<br />
interesting. Here we would like to emphasize some relevant<br />
points.<br />
This article demonstrates why peripheral smears, bone marrow<br />
examination, and genetic tests are mandatory. Acute myeloid<br />
leukemia must be excluded. Electron microscopic analyses<br />
would be helpful. The title is overly assertive. It may be called an<br />
Auer rod-like image.<br />
It is not known why Auer rods are not seen in non-neoplastic<br />
cells. However, there have been some hypotheses on the genesis<br />
<strong>of</strong> Auer rods, including infectious microorganisms, abnormal<br />
nucleoplasm segregation, pathologic forms <strong>of</strong> azurophilic<br />
granules, and cytoplasmic pH alteration. Unsuccessful results<br />
in Auer body inoculation experiments led to the elimination <strong>of</strong><br />
the infectious microorganism theory. Although the conditions<br />
368
Turk J Hematol 2016;<strong>33</strong>:355-370<br />
LETTERS TO EDITOR<br />
for pH alteration are not known, Ackerman [2] suggested that<br />
cytoplasmic pH alteration occurred in specific leukemia cells,<br />
which allowed the granules to unite into crystal-like rods [3].<br />
Additionally, a titration rate <strong>of</strong> 1/200 or higher in O antigen<br />
should be considered positive for acute infection diagnosis.<br />
Salmonella Typhi isolation in culture is the gold standard for<br />
diagnosis [4].<br />
Keywords: Auer rods, Non-neoplastic cells<br />
Anahtar Sözcükler: Auer cismi, Neoplastik olmayan hücreler<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts<br />
<strong>of</strong> interest, including specific financial interests, relationships,<br />
and/or affiliations relevant to the subject matter or materials<br />
included.<br />
References<br />
1. Chandra H, Chandra S, Gupta V, Mahajan D. Auer rod in a neutrophil in a<br />
nonmalignant condition. Turk J Hematol 2016;<strong>33</strong>:167.<br />
2. Ackerman GA. Microscopic and histochemical studies on the Auer bodies in<br />
leukemic cells. Blood 1950;5:847-863.<br />
3. Yoshida Y, Oguma S, Ohno H. John Auer and Auer rods; controversies<br />
revisited. Leuk Res 2009;<strong>33</strong>:614-616.<br />
4. Mogasale V, Ramani E, Mogasale VV, Park J. What proportion <strong>of</strong> Salmonella<br />
Typhi cases are detected by blood culture? A systematic literature review.<br />
Ann Clin Microbiol Antimicrob 2016;15:32.<br />
Reply<br />
Dear Sir,<br />
The authors are thankful for considering their manuscript<br />
entitled “Auer Rod in a Neutrophil in a Nonmalignant Condition”<br />
interesting enough for critical analysis. However, the authors<br />
would like to clarify few points:<br />
1. The authors have clearly stated in the manuscript the presence<br />
<strong>of</strong> Auer rod-like inclusions on peripheral examination.<br />
2. In view <strong>of</strong> the presence <strong>of</strong> Auer rods bone marrow examination<br />
was done and which showed only unremarkable features <strong>of</strong><br />
normoblastic maturation. There was presence <strong>of</strong> no leukemia<br />
cells. This clearly excluded the possibility <strong>of</strong> malignant condition<br />
and nonmalignant diagnosis was considered. Moreover the<br />
patient also responded well to an antibiotic course after<br />
diagnosis <strong>of</strong> typhoid.<br />
3. Genetic studies were however not done as firstly it was not<br />
considered necessary in view <strong>of</strong> absolutely normal bone marrow<br />
and secondly also due to financial constraints.<br />
4. The Salmonella Typhi O antigen titre <strong>of</strong> 1: 160 dilution was<br />
considered positive and patient responded very well to course<br />
<strong>of</strong> antibiotics. Her clinical follow up was unremarkable and thus<br />
chance <strong>of</strong> any leukemic process was completely eliminated.<br />
5. The authors agree with the various hypotheses that have<br />
been enlisted by Yavaşoğlu and Bolaman for genesis <strong>of</strong> Auer rod<br />
in infectious conditions. In the background <strong>of</strong> these theories<br />
and findings, the presence <strong>of</strong> clear rod-like structure due to<br />
condensation <strong>of</strong> azurophilic granules in neutrophil in typhoid<br />
infection led to the consideration <strong>of</strong> Auer rod in nonmalignant<br />
condition.<br />
Thanking you,<br />
Harish Chandra, Smita Chandra, Vibha Gupta, Divyaa Mahajan<br />
Address for Correspondence/Yazışma Adresi: İrfan YAVAŞOĞLU, M.D.,<br />
Adnan Menderes University Faculty <strong>of</strong> Medicine, Division <strong>of</strong> <strong>Hematology</strong>, Aydın, Turkey<br />
Phone : +90 256 212 00 20<br />
E-mail : dr_yavas@yahoo.com<br />
Received/Geliş tarihi: May 19, 2016<br />
Accepted/Kabul tarihi: May 24, 2016<br />
DOI: 10.4274/tjh.2016.0179<br />
369
LETTERS TO EDITOR Turk J Hematol 2016;<strong>33</strong>:355-370<br />
Iron and Zinc Treatment in Iron Deficiency<br />
Demir Eksikliğinde Demir ve Çinko Tedavisi<br />
Beuy Joob 1 , Viroj Wiwanitkit 2<br />
1Sanitation 1 Medical Academic Center, Bangkok, Thailand<br />
2Hainan Medical University, Hainan, China<br />
To the Editor,<br />
The recent report by Özhan et al. was very interesting [1]. Özhan<br />
et al. concluded that “iron and zinc treatment instead <strong>of</strong> only<br />
iron replacement may be considered in cases <strong>of</strong> iron deficiency”<br />
[1]. The results from their study might support this suggestion.<br />
Nevertheless, we would like to add some comments. First, there<br />
was no complete nutritional evaluation in the patient and<br />
control groups, and there might have been some effects due<br />
to differences <strong>of</strong> intake among the subjects. In addition, it is<br />
not doubted that the patients had iron deficiency, but there<br />
is still the chance <strong>of</strong> the coexistence <strong>of</strong> other hemoglobin<br />
disorders. In Southeast Asia, concurrent iron deficiency and<br />
hemoglobinopathy are very common and can be misdiagnosed<br />
and incorrectly managed [2]. Iron supplementation in the case<br />
<strong>of</strong> combined iron deficiency and hemoglobinopathy has to be<br />
carefully considered [2,3]. Focusing on the serum zinc level,<br />
there is still no pathogenesis to explain the problem in the case<br />
<strong>of</strong> iron deficiency, but there is already a report confirming that<br />
hemoglobinopathy can result in low serum zinc levels [4]. Hence,<br />
to apply the recommendation <strong>of</strong> Özhan et al., further studies are<br />
required for validation, and attention to possible concomitant<br />
hemoglobinopathy is necessary [1].<br />
Keywords: Iron, Zinc, Treatment, Deficiency<br />
Anahtar Sözcükler: Demir, Çinko, Tedavi, Eksiklik<br />
Authorship Contributions<br />
Concept: Beuy Joob, Viroj Wiwanitkit; Design: Beuy Joob,<br />
Viroj Wiwanitkit; Data Collection or Processing: Beuy Joob,<br />
Viroj Wiwanitkit; Analysis or Interpretation: Beuy Joob, Viroj<br />
Wiwanitkit; Literature Search: Beuy Joob, Viroj Wiwanitkit;<br />
Writing: Beuy Joob, Viroj Wiwanitkit.<br />
Conflict <strong>of</strong> Interest: The authors <strong>of</strong> this paper have no conflicts <strong>of</strong><br />
interest, including specific financial interests, relationships, and/<br />
or affiliations relevant to the subject matter or materials included.<br />
References<br />
1. Özhan O, Erdem N, Aydoğdu İ, Erkurt A, Kuku İ. Serum zinc levels in iron<br />
deficient women: a case-control study. Turk J Hematol 2016;<strong>33</strong>:156-158.<br />
2. Pansuwan A, Fucharoen G, Fucharoen S, Himakhun B, Dangwiboon S. Anemia,<br />
iron deficiency and thalassemia among adolescents in Northeast Thailand:<br />
results from two independent surveys. Acta Haematol 2011;125:186-192.<br />
3. Burdick C. Combined iron deficiency and thalassemia minor. Am J Clin<br />
Pathol 2013;139:260.<br />
4. Fung EB, Gildengorin G, Talwar S, Hagar L, Lal A. Zinc status affects glucose<br />
homeostasis and insulin secretion in patients with thalassemia. Nutrients<br />
2015;7:4296-4307.<br />
Reply<br />
Dear Dr Joob,<br />
Thank you for your comments and recommendations. We had<br />
evaluated the zinc deficiency in iron deficiency anemia, not in all<br />
anemia types. Serum iron, ferritin, and transferrin saturation levels<br />
were used in diagnosis and whether or not hemoglobinopathy<br />
exists, these patients were diagnosed iron deficiency anemia. And<br />
for possible mechanisms, there are some theories mentioned in the<br />
article. One <strong>of</strong> them is increase in production <strong>of</strong> Zn-protoporphyrin<br />
and usage <strong>of</strong> zinc instead <strong>of</strong> iron in the protoporphyrin structure<br />
[1], which can explain zinc deficiency in iron deficiency. And in<br />
another study, histopathological changes causing iron and zinc<br />
deficiency in intestinal mucosa were reversed with zinc treatment<br />
and the absorption <strong>of</strong> zinc and iron was improved [2]. But still as<br />
you mentioned and as we mentioned in our article, further studies<br />
are needed.<br />
References<br />
1. Hastka J, Lassere JJ, Schwarzbeck, Hehlmann R. Central role <strong>of</strong> zinc<br />
protoporphyrin in staging iron deficiency. Clin Chem 1994;40:768-773.<br />
2. Arcasoy A. İnsan sağlığında çinkonun önemi. TÜBİTAK Bilim ve Teknik<br />
Dergisi 1996;12:56 (in <strong>Turkish</strong>).<br />
Address for Correspondence/Yazışma Adresi: Beuy JOOB, M.D.,<br />
Sanitation 1 Medical Academic Center, Bangkok, Thailand<br />
E-mail : beuyjoob@hotmail.com<br />
Received/Geliş tarihi: June 27, 2016<br />
Accepted/Kabul tarihi: June 27, 2016<br />
DOI: 10.4274/tjh.2016.0249<br />
370
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
SUBJECT INDEX - KONU DİZİNİ 2016<br />
Acute Leukemia<br />
Chronic lymphocytic leukemia / Kronik lenfositik lösemi, 8, 202, 248,<br />
<strong>33</strong>5, 353<br />
Non-Hodgkin’s lymphoma / Non-Hodgkin lenfoma, 8<br />
Cancer / Kanser, 8, 311<br />
Thrombosis / Tromboz, 8, 84<br />
T-cell neoplasms / T-hücreli neoplaziler, 8<br />
B-cell neoplasms / B-hücreli neoplaziler, 8<br />
Acute leukemia / Akut lösemi, 8, 84, 170<br />
Myelodysplastic syndromes / Myelodisplastik sendromlar, 8, 81, 119,<br />
359<br />
Chronic leukemia / Kronik lösemi, 8<br />
HEPA filter / YEPE filtre, 41<br />
Infection / Enfeksiyon, 41, 244, 304<br />
Invasive fungal infection / İnvaziv fungal enfeksiyon, 41, 364<br />
Thiamine / Tiamin, 78<br />
Wernicke’s encephalopathy / Wernicke ensefalopatisi, 78<br />
Acute myeloid leukemia / Akut miyeloid lösemi, 78, 135, 273, 351, 364, 369<br />
Sepsis / Sepsis, 84<br />
Acute lymphoblastic leukemia / Akut lenfoblastik lösemi, 131, <strong>33</strong>9<br />
Lymphoid cell neoplasm / Lenfoid hücreli neoplazi, 131<br />
Hematopoiesis / Hematopoiez, 131<br />
Chemotherapy / Kemoterapi, 131<br />
Soluble urokinase plasminogen activator receptor / Solubl ürokinaz<br />
plazminojen aktivatör reseptörü, 135<br />
Prognosis / Prognoz, 135, 281<br />
B-cell lymphoblastic lymphoma / B-hücreli lenfoblastik lenfoma, 168<br />
Thoracic spine / Torasik vertebra, 168<br />
Spinal cord compression / Spinal kord basısı, 168<br />
Hepatitis B / Hepatit B, 231<br />
Vaccine / Aşılama, 231<br />
Hematological malignancies / Hematolojik malignite, 231<br />
Azacitidine / Azasitidin, 273<br />
Elderly / Yaşlı, 273<br />
Bone marrow blasts / Kemik iliği blastları, 273<br />
Prognostic factors / Prognostik faktörler, 273<br />
Overall survival / Genel sağkalım, 273<br />
Burkitt’s cell leukemia / Burkitt hücreli lösemi, 281<br />
Childhood leukemia / Çocukluk çağı lösemisi, 326<br />
Depression / Depresyon, 326<br />
Anxiety / Anksiyete, 326<br />
Self-image / Benlik imajı, 326<br />
Health-related quality <strong>of</strong> life / Sağlıkla ilişkili yaşam kalitesi, 326<br />
Acute megakaryoblastic leukemia without Down syndrome / Down<br />
sendromu olmayanlarda akut megakaryoblastik lösemi, <strong>33</strong>1<br />
CBFA2T3-GLIS2 fusion gene / CBFA2T3-GLIS2 füzyon geni, <strong>33</strong>1<br />
Insulin-like growth factor-1 / İnsülin-benzeri büyüme faktörü-1, <strong>33</strong>5<br />
Insulin-like growth factor binding protein-3 / İnsülin benzeri büyüme<br />
faktörü bağlayıcı protein-3, <strong>33</strong>5<br />
Human leukocyte antigen alleles / İnsan lökosit antijeni alelleri, <strong>33</strong>9<br />
Risk groups / Risk grupları, <strong>33</strong>9<br />
Chediak Higashi syndrome / Chediak Higashi sendromu, 349<br />
Giant granules / Dev granüller, 349<br />
Immunodeficiency / İmmün yetmezlik, 349<br />
Auer rods / Auer cismi, 167, 351, 369<br />
Plasma cells / Plazma hücreleri, 367<br />
Therapy / Tedavi, 353<br />
Ring sideroblasts / Halka sideroblastlar, 359<br />
Megaloblastic anemia / Megaloblastik anemi, 359<br />
Myelodysplastic syndrome / Miyelodisplastik sendrom, 8, 81, 119, 359<br />
Non-neoplastic cells / Neoplastik olmayan hücreler, 369<br />
Anemia<br />
Anemia / Anemi, 86, 156, 263<br />
Elliptocytosis / Eliptositoz, 86<br />
Pyropoikilocytosis / Piropoikilositoz, 86<br />
Iron / Demir, 156, 370<br />
Zinc / Çinko, 156, 370<br />
Women / Kadın, 156<br />
Iron deficiency / Demir eksikliği, 156<br />
Iron deficiency anemia / Demir eksikliği anemisi, 257<br />
Unicentric plasma-cell type / Unisentrik plazma hücreli tip, 257<br />
Castleman’s disease / Castleman hastalığı, 257<br />
Fanconi / Fanconi, 263<br />
Congenital lobar emphysema / Konjenital lober amfizem, 263<br />
Ring sideroblasts / Halka sideroblastlar, 359<br />
Megaloblastic anemia / Megaloblastik anemi, 359<br />
Myelodysplastic syndrome / Miyelodisplastik sendrom, 8, 81, 119, 359<br />
Sickle cell disease / Orak hücre hastalığı, 365<br />
Crisis / Kriz, 365<br />
NOS3 / NOS3, 365<br />
IL4 / IL4, 365<br />
Bleeding Disorders<br />
Bleeding / Kanama, 48<br />
Ankaferd / Ankaferd, 48<br />
Chitosan / Chitosan, 48<br />
Hemostasis / Hemostaz, 48<br />
Platelet aggregation / Trombosit agregasyonu, 127<br />
Chronic myeloid leukemia / Kronik miyelositer lösemi, 127<br />
Imatinib mesylate / İmatinib mesilat, 127<br />
Hyperparathyroidism / Hiperparatiroidism, 293<br />
Platelet function / Trombosit fonksiyonları, 293<br />
P selectin / P selektin, 293<br />
Calcium / Kalsiyum, 293<br />
Bone loss / Kemik kaybı, 293<br />
Chronic Leukemia<br />
Platelet aggregation / Trombosit agregasyonu, 127<br />
Chronic myeloid leukemia / Kronik miyelositer lösemi, 127<br />
Imatinib mesylate / İmatinib mesilat, 127<br />
ZAP70 / ZAP70, 202<br />
Interleukin-4 / İnterlökin-4, 202<br />
Interferon gamma / İnterferon gama, 202<br />
T cells / T hücreleri, 202<br />
B cells / B hücreleri, 202<br />
Chronic lymphocytic leukemia / Kronik lenfositik lösemi, 8, 202, 248,<br />
<strong>33</strong>5, 353<br />
Radiation / Radyasyon, 248<br />
Tumor lysis syndrome / Tümör lizis sendromu, 248<br />
Acute myeloid leukemia / Akut miyeloid lösemi, 78, 135, 273, 351, 364, 369<br />
Therapy / Tedavi, 353
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
SUBJECT INDEX - KONU DİZİNİ 2016<br />
Coagulation<br />
Angiogenesis / Anjiyogenez, 88<br />
Haemophilic arthropathy / Hem<strong>of</strong>ilik artropati, 88<br />
Vascular endothelial growth factor / Vasküler endoteliyal büyüme<br />
faktörü, 88<br />
Haemophilia / Hem<strong>of</strong>ili, 88<br />
Infant / Süt çocuğu, 163<br />
Adult / Erişkin, 163<br />
Microparticle / Mikropartikül, 163<br />
Thrombin / Trombin, 163<br />
Superwarfarin / Süpervarfarin, 251<br />
Acquired coagulopathies / Kazanılmış koagülopatiler, 251<br />
Vitamin K / K vitamin, 251<br />
Endothelium / Endotel, 261<br />
Ankaferd / Ankaferd, 261<br />
Estradiol / Estradiol, 261<br />
International normalized ratio / Uluslararası düzeltme oranı, 299<br />
Warfarin / Warfarin, 299<br />
Hypercoagulable conditions / Hiperkoagülabilite durumları, 299<br />
Venous thromboembolism / Venöz tromboembolizm, 299<br />
Knowledge / Bilgi, 356<br />
Hemophilia / Hem<strong>of</strong>ili, 356<br />
Treatment / Tedavi, 187, 356, 370<br />
Disease / Hastalık, 356<br />
Hematological Malignancies<br />
Colonization / Kolonizasyon, 244<br />
Infection / Enfeksiyon, 41, 244, 304<br />
Pediatric malignancy / Pediatrik malignite, 244<br />
Vancomycinresistant enterococci / Vankomisine dirençli enterokok, 244<br />
Immunohematology<br />
Antiphospholipid syndrome / Antifosfolipid sendromu, 1<br />
Complement inhibition / Komplaman inhibisyonu, 1<br />
Eculizumab / Eculizumab, 1<br />
Thrombotic angiopathy / Trombotik anjiyopati, 1<br />
Cardiac surgery / Kalp cerrahisi, 357<br />
Apheresis / Aferez, 357<br />
Crossmatch / Çapraz karşılaştırma, 357<br />
Transfusion medicine / Transfüzyon tıbbı, 148, 357<br />
Iron Disorder<br />
Iron overload / Demir birikimi, 21, 320<br />
Liver / Karaciğer, 21<br />
Pancreas / Pankreas, 21<br />
R2* / R2*, 21<br />
Magnetic resonance imaging-proton density fat fraction / Manyetik<br />
rezonans görüntüleme-proton dansite yağ oranı, 21<br />
Hemochromatosis / Hemokromatozis, 320<br />
HFE gene / HFE geni, 320<br />
p.C282Y / p.C282Y, 320<br />
p.H63D / p.H63D, 320<br />
Sickle cell anemia / Orak hücreli anemi, 320<br />
Iron / Demir, 156, 370<br />
Zinc / Çinko, 156, 370<br />
Treatment / Tedavi, 187, 356, 370<br />
Deficiency / Eksiklik, 370<br />
Infection Disorders<br />
HEPA filter / YEPE filtre, 41<br />
Infection / Enfeksiyon, 41, 244, 304<br />
Invasive fungal infection / İnvaziv fungal enfeksiyon, 41, 364<br />
Antifungal treatment / Antifungal tedavi, 53<br />
Diagnosis / Teşhis, 53<br />
Stem cell transplantation / Kemik iliği transplantasyonu, 53<br />
Neutropenia / Nötropeni, 102<br />
D-index / D-indeks, 102<br />
Cumulative-D-index / Kümülatif-D-indeks, 102<br />
Hematological malignancies / Hematolojik malignite, 102<br />
Invasive fungal infections / İnvaziv fungal enfeksiyon, 102<br />
Coagulation / Koagülasyon, 112<br />
Sepsis / Sepsis, 112<br />
Enoxaparin / Enoksaparin, 112<br />
Acute leukemia / Akut lösemi, 8, 84, 170<br />
Stevens-Johnson syndrome / Stevens-Johnson sendromu, 170<br />
Toxic epidermal necrolysis / Toksik epidermal nekrolizis, 170<br />
Hematopoietic stem cell transplantation / Hematopoetik kök hücre<br />
nakli, 216<br />
Bloodstream infection / Kan akımı enfeksiyonu, 216<br />
Epidemiology / Epidemiyoloji, 216<br />
Resistance / Direnç, 216<br />
Central venous catheter / Santral venöz kateter, 216<br />
BK virus / BK virüs, 223<br />
Hemorrhagic cystitis / Hemorajik sistit, 223<br />
Allogeneic stem cell transplantation/ Allojenik kök hücre<br />
transplantasyonu, 223<br />
Leflunomide / Leflunomid, 223<br />
Hepatitis B / Hepatit B, 231<br />
Vaccine / Aşılama, 231<br />
Hematological malignancies / Hematolojik malignite, 231<br />
Colonization / Kolonizasyon, 244<br />
Infection / Enfeksiyon, 41, 244, 304<br />
Pediatric malignancy / Pediatrik malignite, 244<br />
Vancomycinresistant enterococci / Vankomisine dirençli enterokok, 244<br />
Febrile neutropenia/ Febril nötropeni, 304<br />
Infection/ Enfeksiyon, 41, 244, 304<br />
Mannose-binding lectin/ Mannoz-bağlayıcı lektin, 304<br />
H-ficolin/ H-fikolin, 304<br />
Procalcitonin/ Prokalsitonin, 304<br />
C-reactive protein / C-reaktif protein, 304<br />
Febrile neutropenia / Febril nötropeni, 311<br />
Cancer / Kanser, 8, 311<br />
Mortality / Mortalite, 311<br />
Risk factors / Risk faktörleri, 311<br />
Varicella / Varisella, 346<br />
Malignancy / Malignite, 346<br />
Pediatric patient / Çocuk hasta, 346<br />
Invasive Fungal Infection / İnvazif mantar enfeksiyonu, 41, 364<br />
Fusariosis / Fusariosis, 364<br />
Combined antifungal treatment / Kombine antifungal tedavi, 364<br />
Lyposomal amphotericin B / Lipozomal amfoterisin B, 364<br />
Voriconazole / Vorikonazol, 364<br />
Acute myeloid leukemia / Akut myeloid lösemi, 78, 135, 273, 351, 364, 369
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
SUBJECT INDEX - KONU DİZİNİ 2016<br />
Lymphoma<br />
Chronic lymphocytic leukemia / Kronik lenfositik lösemi, 8, 202, 248,<br />
<strong>33</strong>5, 353<br />
Non-Hodgkin’s lymphoma / Non-Hodgkin lenfoma, 8<br />
Cancer / Kanser, 8, 311<br />
Thrombosis / Tromboz, 8<br />
T-cell neoplasms / T-hücreli neoplaziler, 8<br />
B-cell neoplasms / B-hücreli neoplaziler, 8<br />
Acute leukemia / Akut lösemi, 8, 84<br />
Myelodysplastic syndromes / Myelodisplastik sendromlar, 8, 81, 119, 359<br />
Chronic leukemia / Kronik lösemi, 8<br />
Secondary neoplasms / İkincil neoplaziler, 66<br />
Chemoradiotherapy / Kemoradyoterapi, 66<br />
Hodgkin’s lymphoma / Hodgkin lenfoması, 66<br />
Extranodal natural killer/T-cell lymphoma / Ekstranodal natural killer/Thücreli<br />
lenfoma, 74, 361<br />
Non-Hodgkin lymphoma / Hodgkin dışı lenfoma, 74<br />
Parotid gland / Parotis bezi, 75<br />
T-Cell lymphoma / T-Hücreli lenfoma, 75<br />
Auricula / Aurikula, 75<br />
Lymphoma / Lenfoma, 141, 159, 362<br />
Expression / Ekspresyon, 141<br />
Polymorphism / Polimorfizm, 141<br />
Rho-kinase / Rho-kinaz, 141<br />
Acute kidney injury / Akut böbrek hasarı, 159<br />
Hematuria / Hematüri, 159<br />
Renal biopsy / Renal biyopsi, 159<br />
Renal masses / Renal kitle, 159<br />
Diffuse large B-cell lymphoma/ Diffüz büyük B-hücreli lenfoma, 164<br />
Downgraded lymphoma / Geriletilmiş lenfoma, 164<br />
Relapsed/refractory lymphoma / Nüks/dirençli lenfoma, 209<br />
Hematopoietic stem cell transplantation / Hematopoetik kök hücre<br />
nakli, 209<br />
Conditioning regimen / Hazırlama rejimi, 209<br />
bone lymphoma / Primer kemik lenfoma, 254<br />
Ocular adnexal lymphoma / Oküler adneks lenfoma, 254<br />
Diffuse large B-cell lymphoma / Diffüz büyük B hücreli lenfoma, 254<br />
Non-Hodgkin’s lymphoma / Hodgkin dışı lenfoma, 259<br />
Vaginal B-cell lymphoma / Vajinal B-hücreli lenfoma, 259<br />
Postmenopausal bleeding / Postmenopozal kanama, 259<br />
Vaginal discharge / Vajinal akıntı, 259<br />
Childhood Hodgkin’s lymphoma / Çocukluk çağı Hodgkin lenfoma, 265<br />
Prognosis / Prognoz, 265<br />
Autologous hematopoietic stem cell transplantation / Otolog<br />
hematopoetik kök hücre nakli, 265<br />
Prognostic index / Prognostik indeks, 265<br />
Extranodal natural killer/T cell lymphoma / Ekstranodal doğal<br />
öldürücü/T hücreli lenfoma, 74, 361<br />
Erythematous indurated plaques/ Eritemli indüre plaklar, 361<br />
Annular erythematous patch / Anuler eritemli yama, 361<br />
Annular erythema / Anuler eritem, 361<br />
Penis / Penis, 362<br />
Non-Hodgkin lymphoma / Hodgkin dışı lenfoma, 362<br />
Diffuse large B-cell lymphoma / Diffüz büyük B hücreli lenfoma, 362<br />
Penile mass / Penil kitle, 362<br />
Molecular <strong>Hematology</strong><br />
Chronic lymphocytic leukemia / Kronik lenfositik lösemi, 8, 202, 248,<br />
<strong>33</strong>5, 353<br />
Non-Hodgkin’s lymphoma / Non-Hodgkin lenfoma, 8<br />
Cancer / Kanser, 8, 311<br />
Thrombosis / Tromboz, 8<br />
T-cell neoplasms / T-hücreli neoplaziler, 8<br />
B-cell neoplasms / B-hücreli neoplaziler, 8<br />
Acute leukemia / Akut lösemi, 8, 84<br />
Myelodysplastic syndromes / Myelodisplastik sendromlar, 8, 81, 119, 359<br />
Chronic leukemia / Kronik lösemi, 8<br />
BACH1 / BACH1, 15<br />
Gene expression / Gen sunumu, 15<br />
Hemoglobin E/β-thalassemia / Hemoglobin E/β-talasemi, 15<br />
Oxidative stress / Oksidatif stres, 15<br />
Red blood cell parameters / Eritrosit değişkenleri, 15<br />
Chronic myeloid leukemia / Kronik myeloid lösemi, 60<br />
Variant Philadelphia / Varyant Philadelphia, 60<br />
Tyrosine kinase inhibitors / Tirozin kinaz inhibitörleri, 60<br />
Prognosis / Prognoz, 60<br />
JAK2V617F mutation / JAK2V617F mutasyonu, 94<br />
Essential thrombocythemia / Esansiyel trombositemi, 94<br />
Primary myel<strong>of</strong>ibrosis / Primer miyel<strong>of</strong>ibrozis, 94<br />
Acute leukemia / Akut lösemi, 8, 84, 170<br />
Stevens-Johnson syndrome / Stevens-Johnson sendromu, 170<br />
Toxic epidermal necrolysis / Toksik epidermal nekrolizis, 170<br />
Genetic variation / Genetik varyasyon, 172<br />
Sequencing / Dizileme, 172<br />
Genomic data / Genomik data, 172<br />
Clinical interpretation / Klinik yorum, 172<br />
ZAP70 / ZAP70, 202<br />
Interleukin-4 / İnterlökin-4, 202<br />
Interferon gamma / İnterferon gama, 202<br />
T cells / T hücreleri, 202<br />
B cells / B hücreleri, 202<br />
Hemochromatosis / Hemokromatozis, 320<br />
HFE gene / HFE geni, 320<br />
Iron overload / Demir birikimi, 320<br />
p.C282Y / p.C282Y, 320<br />
p.H63D / p.H63D, 320<br />
Sickle cell anemia / Orak hücreli anemi, 320<br />
Acute megakaryoblastic leukemia without Down syndrome / Down<br />
sendromu olmayanlarda akut megakaryoblastik lösemi, <strong>33</strong>1<br />
CBFA2T3-GLIS2 fusion gene / CBFA2T3-GLIS2 füzyon geni, <strong>33</strong>1<br />
Chronic lymphocytic leukemia / Kronik lenfositik lösemi, 8, 202, 248,<br />
<strong>33</strong>5, 353<br />
Insulin-like growth factor-1 / İnsülin-benzeri büyüme faktörü-1, <strong>33</strong>5<br />
Insulin-like growth factor binding protein-3 / İnsülin benzeri büyüme<br />
faktörü bağlayıcı protein-3, <strong>33</strong>5<br />
Acute lymphoblastic leukemia / Akut lenfoblastik lösemi, 131, <strong>33</strong>9<br />
Human leukocyte antigen alleles / İnsan lökosit antijeni alelleri, <strong>33</strong>9<br />
Risk groups / Risk grupları, <strong>33</strong>9<br />
Sickle cell disease / Orak hücre hastalığı, 365<br />
Crisis / Kriz, 365<br />
NOS3 / NOS3, 365
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
SUBJECT INDEX - KONU DİZİNİ 2016<br />
IL4 / IL4, 365<br />
Multiple Myeloma<br />
Myeloma and other plasma cell dyscrasias / Miyelom ve diğer plazma<br />
hücre diskrazileri, 286<br />
Neoplasia / Neoplazi, 286<br />
Cytogenetics / Sitogenetik, 286<br />
Gene therapy / Gen terapisi, 286<br />
Molecular hematology / Moleküler hematoloji, 286<br />
Myelodysplastic Syndromes<br />
Erythema annulare centrifugum / Eritem annuler santrifuj, 81<br />
Azacitidine / Azasitidin, 81<br />
Myelodysplastic syndrome / Miyelodisplastik sendrom, 8, 81, 119, 359<br />
International Prognostic Scoring System / Uluslararası Prognostik Skorlama<br />
Sistemi, 119<br />
MD Anderson Prognostic Scoring System / MD Anderson Prognostik<br />
Skorlama Sistemi, 119<br />
World Health Organization Classification-Based Prognostic Scoring<br />
System / Dünya Sağlık Örgütü Sınıflandırması Bazlı Prognostik Skorlama<br />
Sistemi, 119<br />
Revised International Prognostic Scoring System / Yeniden Düzenlenmiş<br />
Uluslararası Prognostik Skorlama Sistemi, 119<br />
Myeloproliferative Disorders<br />
JAK2V617F mutation / JAK2V617F mutasyonu, 94<br />
Essential thrombocythemia / Esansiyel trombositemi, 94<br />
Primary myel<strong>of</strong>ibrosis / Primer miyel<strong>of</strong>ibrozis, 94<br />
Calreticulin mutation / Kalretikülin mutasyonu, 180<br />
Myeloproliferative neoplasms / Miyeloproliferatif neoplazi, 180<br />
Leukemia / Lösemi, 180<br />
Myeloproliferative neoplasms / Miyeloproliferatif hastalıklar, 187<br />
Survival / Sağkalım, 187<br />
Thrombosis / Tromboz, 187<br />
Treatment / Tedavi, 187, 356, 370<br />
Neutropenia<br />
Febrile neutropenia / Febril nötropeni, 304<br />
Infection / Enfeksiyon, 41, 244, 304<br />
Mannose-binding lectin / Mannoz-bağlayıcı lektin, 304<br />
H-ficolin / H-fikolin, 304<br />
Procalcitonin / Prokalsitonin, 304<br />
C-reactive protein / C-reaktif protein, 304<br />
Stem Cell Transplantation<br />
Hematopoietic stem cell transplantation / Hematopoetik kök hücre nakli, 34<br />
Exhaled nitric oxide / Ekshale nitrik oksit, 34<br />
Pulmonary complications / Pulmoner komplikasyonlar, 34<br />
Mortality / Mortalite, 34<br />
Antifungal treatment / Antifungal tedavi, 53<br />
Diagnosis / Teşhis, 53<br />
Stem cell transplantation / Kemik iliği transplantasyonu, 53<br />
Eosinophilia/ Eozin<strong>of</strong>ili,196<br />
Allogeneic hematopoietic stem cell transplantation/ Allojenik<br />
hematopoetik kök hücre nakli, 196<br />
Corticosteroid therapy/ Kortikosteroid tedavisi, 196<br />
Prognostic factor/ Prognostik faktör, 196<br />
Graft versus-host disease/ Graft versus-host hastalığı, 196<br />
Relapsed/refractory lymphoma / Nüks/dirençli lenfoma, 209<br />
Hematopoietic stem cell transplantation / Hematopoetik kök hücre<br />
nakli, 209<br />
Conditioning regimen / Hazırlama rejimi, 209<br />
Hematopoietic stem cell transplantation / Hematopoetik kök hücre<br />
nakli, 216<br />
Bloodstream infection / Kan akımı enfeksiyonu, 216<br />
Epidemiology / Epidemiyoloji, 216<br />
Resistance / Direnç, 216<br />
Central venous catheter / Santral venöz kateter, 216<br />
BK virus / BK virüs, 223<br />
Hemorrhagic cystitis / Hemorajik sistit, 223<br />
Allogeneic stem cell transplantation/ Allojenik kök hücre<br />
transplantasyonu, 223<br />
Leflunomide / Leflunomid, 223<br />
Childhood Hodgkin’s lymphoma / Çocukluk çağı Hodgkin lenfoma, 265<br />
Prognosis / Prognoz, 265<br />
Autologous hematopoietic stem cell transplantation / Otolog<br />
hematopoetik kök hücre nakli, 265<br />
Prognostic index / Prognostik indeks, 265<br />
Thalassemia<br />
BACH1 / BACH1, 15<br />
Gene expression / Gen sunumu, 15<br />
Hemoglobin E/β-thalassemia / Hemoglobin E/β-talasemi, 15<br />
Oxidative stress / Oksidatif stres, 15<br />
Red blood cell parameters / Eritrosit değişkenleri, 15<br />
Thalassemia / Talasemi,56<br />
Hemoglobinopathy / Hemoglobinopati, 56<br />
Hemoglobin H disease / Hemoglobin H hastalığı, 56<br />
Abnormal hemoglobins / Anormal hemoglobinler, 71<br />
Hemoglobin G-Waimanalo / Hemoglobin G-Waimanalo, 71<br />
Hemoglobin Fontainebleau / Hemoglobin Fontainebleau, 71<br />
Thalassemia major / Talasemi majör, 72<br />
Thalassemia minor / Talasemi minör, 72<br />
Serum lipids / Serum lipidleri, 72<br />
Deletional mutations/ Delesyonel mutasyonlar, 107<br />
<strong>Turkish</strong> inversion/deletion (δβ)0 mutation/ Türk tipi inversiyon/<br />
delesyon (δβ)0 mutasyonu, 107<br />
Gap-PCR, β-Globin gene cluster / Gap-PCR, Beta-globin gen kümesi, 107<br />
Thrombosis<br />
Antiphospholipid syndrome / Antifosfolipid sendromu, 1<br />
Complement inhibition / Komplaman inhibisyonu, 1<br />
Eculizumab / Eculizumab, 1<br />
Thrombotic angiopathy / Trombotik anjiyopati, 1<br />
Microangiopathy / Mikroanjiopati, 83<br />
Kidney functions / Böbrek fonksiyonları, 83<br />
Hemolytic anemia / Hemolitik anemi, 83<br />
Acute leukemia / Akut lösemi, 8, 84<br />
Sepsis / Sepsis, 84<br />
Thrombosis / Tromboz, 84<br />
Intracranial mass / İntrakranial kitle, 255<br />
Cerebral sinovenous thrombosis / Serebral sinovenöz tromboz, 255<br />
Increased intracranial pressure / Artmış intrakranial basınç, 255<br />
Thrombocytopenia
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
SUBJECT INDEX - KONU DİZİNİ 2016<br />
Idiopathic thrombocytopenic purpura / İdiyopatik immün<br />
trombositopeni, 77<br />
Glucose-6-phosphate dehydrogenase deficiency / Glukoz-6-fosfat<br />
dehidrogenaz eksikliği, 77<br />
Thrombopoietin mimetic peptide / Trombopoetin uyarıcı peptit, 77<br />
TMP mimetic peptide / TPO uyarıcı peptit, 77<br />
Idiopathic thrombocytopenic purpura/ İdiyopatik trombositopenik<br />
purpura, 153<br />
Regulatory T cells/ Düzenleyici T hücreleri, 153<br />
Chediak Higashi syndrome / Chediak Higashi sendromu, 349<br />
Giant granules / Dev granüller, 349<br />
Immunodeficiency / İmmün yetmezlik, 349<br />
Other<br />
Oxalosis / Oksalozis, 79<br />
Hyperoxaluria / Hiperoksalüri, 79<br />
Bone marrow / Kemik iliği, 79<br />
Thalassemia / Talasemi, 166<br />
Tumor necrosis factor / Tümör nekrozis faktör, 166<br />
Splenectomy / Splenektomi, 166<br />
Pediatric Quality <strong>of</strong> Life Inventory/ Çocuklar için Yaşam Kalitesi<br />
Ölçeği, 236<br />
Validity / Geçerlilik, 236<br />
Reliability / Güvenirlik, 236<br />
Children / Çocuk, 236<br />
Cancer / Kanser, 236<br />
Pathology<br />
Oxalosis / Oksalozis, 79<br />
Hyperoxaluria / Hiperoksalüri, 79<br />
Bone marrow / Kemik iliği, 79<br />
Auer rods / Auer cismi, 167, 351, 369<br />
Neutrophil / Nötr<strong>of</strong>il, 167<br />
Typhoid fever / Tifo, 167<br />
Iron deficiency anemia / Demir eksikliği anemisi, 257<br />
Unicentric plasma-cell type / Unisentrik plazma hücreli tip, 257<br />
Castleman’s disease / Castleman hastalığı, 257<br />
Non-neoplastic cells / Neoplastik olmayan hücreler, 369<br />
Acute myeloid leukemia / Akut miyeloid lösemi, 78, 135, 273, 351, 364, 369<br />
Plasma cells / Plazma hücreleri, 367<br />
Inclusion / İnkülüzyon, 367<br />
Reactive plasmacytosis / Reaktif plazmositoz, 367<br />
Autoimmune Disorders<br />
Antiphospholipid syndrome / Antifosfolipid sendromu, 1<br />
Complement inhibition / Komplaman inhibisyonu, 1<br />
Eculizumab / Eculizumab, 1<br />
Thrombotic angiopathy / Trombotik anjiyopati, 1<br />
Idiopathic thrombocytopenic purpura / İdiyopatik immün<br />
trombositopeni, 77<br />
Glucose-6-phosphate dehydrogenase deficiency / Glukoz-6-fosfat<br />
dehidrogenaz eksikliği, 77<br />
Thrombopoietin mimetic peptide / Trombopoetin uyarıcı peptit, 77<br />
TMP mimetic peptide / TPO uyarıcı peptit, 77<br />
Idiopathic thrombocytopenic purpura/ İdiyopatik trombositopenik<br />
purpura, 153<br />
Regulatory T cells/ Düzenleyici T hücreleri, 153<br />
Transfusion<br />
Frozen platelets / Dondurulmuş trombositler, 28<br />
Flow-cytometric analysis / Akım-sitometri testi, 28<br />
In vivo thrombin generation test / İn vivo thrombin jenerasyon testi, 28<br />
Medical audit / Tıbbi denetleme, 148<br />
Transfusion medicine / Transfüzyon tıbbı, 148, 357<br />
Donor selection / Donör seçimi, 148
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
AUTHOR INDEX - YAZAR DİZİNİ 2016<br />
Abdel Galil M. Abdel Gader........................ 112<br />
Abdul Kareem Al Momen........................... 112<br />
Abdulaziz H. Alzeer..................................... 112<br />
Abdullah Sakin............................................ <strong>33</strong>5<br />
Abdullah T. Demiryürek............................. 141<br />
Absia Jabbar................................................. 299<br />
Adalet Meral Güneş..................................... 326<br />
Adeel Arshad............................................... 299<br />
Afak Durur Karakaya.................................. 263<br />
Ahmet Emre Eşkazan.................................. 216<br />
Ahmet Hakan Vural..................................... 356<br />
Ahmet Menteşe............................................ 135<br />
Ahmet Pekoğlu ..............................................28<br />
Ahu Kara..................................................... 346<br />
Akif Selim Yavuz............................................94<br />
Albane Ledoux-Pilon.................................. 259<br />
Alev Akyol Erikçi........................................ 153<br />
Alexandra Agapidou.......................................88<br />
Algün Polat Ekinci....................................... 360<br />
Ali Alkan..................................................... 248<br />
Ali Bay............................................................56<br />
Ali Erkurt.................................................... 156<br />
Ali Fettah..................................................... 263<br />
Ali Haythem................................................ 299<br />
Ali Kaya....................................................... 209<br />
Ali Mert............................................... 216, 304<br />
Ali Pamir.........................................................66<br />
Ali Ümit Esbah............................................ 362<br />
Ali Zahit Bolaman........................................ 187<br />
Alpay Azap.................................................. 102<br />
Alper Koç........................................................75<br />
Alphan Küpesiz........................................... 265<br />
Ammara Arslan........................................... 131<br />
Andrea Tendas................................................77<br />
Anıl Tombak................................................ 273<br />
Arzu Çırpan Kantarcıoğlu........................... 326<br />
Arzu Yaşar................................................... 248<br />
Ashutosh Kumar......................................... 349<br />
Asım Örem.................................................. 135<br />
Aslı Özdemir............................................... 244<br />
Aslıhan Demirel........................................... 363<br />
Atilla Çayır.................................................. 263<br />
Atilla Elhan.................................................. 102<br />
Atsuo Maruta............................................... 196<br />
Aydan Akdeniz............................................ 273<br />
Ayhan Çavdar.................................................66<br />
Ayhan Dağdemir.......................................... 265<br />
Aylin Ayer.................................................... <strong>33</strong>5<br />
Aynur Dağlar-Aday.........................................94<br />
Ayper Somer................................................ 244<br />
Aysel Pekel......................................................28<br />
Aysen Akalın................................................ 293<br />
Ayşe Hiçsönmez.......................................... 248<br />
Ayşe Işık....................................................... 119<br />
Ayşe Salihoğlu............................................. 216<br />
Ayşe Uysal................................................... 273<br />
Ayşegül Sümer............................................. 135<br />
Ayşegül Tetik............................................... 209<br />
Ayşegül Üner............................................... 119<br />
Ayşegül Ünüvar........................................... 244<br />
Aytekin Ünlü .................................................28<br />
Bahattin Işık...................................................48<br />
Barış Malbora..................................................56<br />
Başak Akadam-Teker......................................94<br />
Başak Doğanavşargil.......................................79<br />
Belgin Coşkun....................................... 41, 102<br />
Bengi Öztürk..................................................41<br />
Bengü Demirağ............................................ 346<br />
Berna Ateşağaoğlu....................................... 251<br />
Betül Ulukol................................................ 163<br />
Beuy Joob..................................................... 370<br />
Bilgül Mete.......................................... 216, 304<br />
Birgül Erkmen................................................28<br />
Birgül Öneç........................................... 75, 362<br />
Birol Baytan................................................. 326<br />
Burak Uz.............................................. 119, 164<br />
Burak Yılmaz............................................... 286<br />
Burhan Ferhanoğlu............................. 216, 304<br />
Bülent Karagöz............................................ 153<br />
Can Acıpayam................................................56<br />
Can Baykal................................................... 360<br />
Can Boğa..................................................... 320<br />
Can Polat Eyigün............................................28<br />
Canan Vergin............................................... 346<br />
Cécile Moluçon-Chabrot............................. 259<br />
Cem Kis....................................................... 273<br />
Cengiz Bal.................................................... 293<br />
Ceyda Aslan................................................. 254<br />
Ceylan Yılmaz................................................94<br />
Chul Soo Kim.............................................. 223<br />
Chunyan Ji.................................................. 180<br />
Cihan Gündoğan......................................... 254<br />
Çiğdem Aşut................................................ 326<br />
Çiğdem Tokyol............................................ 168<br />
Damla Eyüpoğlu.............................................60<br />
Daniil F. Gluzman.............................................8<br />
Daoxin Ma................................................... 180<br />
Deniz Gören Şahin...................................... 273<br />
Deniz Güven...................................................60<br />
Deniz Sünnetçi.................................................8<br />
Derya Aydın................................................. 244<br />
Derya Özyörük.............................................255<br />
Didar Yanardağ Açık................................... 141<br />
Didem Atay.................................................. 265<br />
Divyaa Mahajan........................................... 167<br />
Doruk Erkan.....................................................1
Turk J Hematol 2016;<strong>33</strong>:323-328<br />
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
AUTHOR INDEX - YAZAR DİZİNİ 2016<br />
Füsun Özdemirkıran et al. IL-18 Polymorphisms in CML and CLL Patients<br />
Duran Canatan...............................................71<br />
Durdu Mehmet Köş........................................75<br />
Ebru Karcı................................................... 248<br />
Eda Ataseven......................................... 84, 170<br />
Edip Gali........................................................56<br />
Efthymia Vlachaki..........................................88<br />
Ekrem Ünal................................................. 265<br />
Elif Gökçen Sazak........................................<strong>33</strong>5<br />
Elif Nisa Ünlü.................................................75<br />
Elif Suyanı..................................... 34, 231, 254<br />
Elizabeth George............................................15<br />
Emel Gürkan............................................... 273<br />
Emel Ünal.............................................. 66, 265<br />
Emin Kürekçi.................................................28<br />
Emre Tekgündüz......................................... 209<br />
Engin Akgül................................................ 356<br />
Ercüment Ünlü...............................................78<br />
Erden Atilla............................................. 41, 53<br />
Erdoğan Işıkman............................................66<br />
Erdoğan Nohuz........................................... 259<br />
Eren Yağcı.................................................... 187<br />
Ergun Karaağaoğlu...................................... 311<br />
Eriko Ogusa................................................. 196<br />
Erman Ataş.................................................. 265<br />
Esin Aktaş Çetin.......................................... 202<br />
Esin Çevik................................................... 363<br />
Esra Sarıbacak Can.........................................74<br />
Esra Turan Erkek...........................................81<br />
Esra Yıldızhan............................................. 273<br />
Evren Üstüner............................................. 159<br />
Eylem Eliaçık...................................... 119, 281<br />
Eyüp Naci Tiftik.......................................... 273<br />
Fahri Şahin.................................................. 273<br />
Farja Al Gahtani.......................................... 112<br />
Fatih Beşışık................................................ 257<br />
Fatih Büyükcam.............................................48<br />
Fatih Erbey.................................................. 265<br />
Fatma Deniz Sargın........................................94<br />
Fatma Gümrük ................................. 21, 72, 86<br />
Fatma Yıldırım................................................34<br />
Fehmi Hindilerden...................................... 257<br />
Fehmi Tabak........................................ 216, 304<br />
Feride İffet Şahin......................................... 320<br />
Ferit Avcu.......................................................28<br />
Fevzi Altuntaş.............................................. 209<br />
Feyzullah Akyüz.......................................... 168<br />
Fezan Mutlu................................................ 127<br />
Filiz Şimşek Orhon..................................... 163<br />
Fumiko Tanaka........................................... <strong>33</strong>1<br />
Fuminori Iwasaki........................................ <strong>33</strong>1<br />
Gamze Durgun............................................ 209<br />
Garip Şahin.................................................. 293<br />
Gökçe Pınar Reis......................................... 263<br />
Göknur Yorulmaz........................................ 293<br />
Gönül Oktay...................................................56<br />
Gül İlhan........................................................56<br />
Gülcihan Özek............................................ 346<br />
Gülden Yılmaz....................................... 41, 102<br />
Gülen Sezer Alptekin Erkul........................ 356<br />
Gülsan Türköz Sucak.....................................34<br />
Gülsan Yavuz..................................................66<br />
Gülsüm Pamuk...............................................78<br />
Gülsüm Yazıcı................................................71<br />
Gülsün Karasu............................................. 265<br />
Gülşah Kaygusuz......................................... 159<br />
Gülşen Hasçelik........................................... 311<br />
Gülyüz Öztürk............................................ 265<br />
Güngör Utkan............................................. 248<br />
Günhan Gürman............................................41<br />
Günnur Deniz............................................. 202<br />
Gürsel Güneş....................................... 281, 286<br />
H. Haluk Akar............................................. <strong>33</strong>9<br />
Hacer Aktürk............................................... 244<br />
Hadil A. Al Otair......................................... 112<br />
Hakan Göker............................... 119, 281, 286<br />
Hakan Özdoğu............................................ 320<br />
Hakan Savlı.......................................................8<br />
Haldun Öniz................................................ 265<br />
Hale Ören...................................... 84, 170, 265<br />
Haluk Deda.....................................................66<br />
Haluk Demiroğlu......................... 119, 281, 286<br />
Hamdi Akan.................................... 41, 53, 102<br />
Handan Güleryüz...........................................84<br />
Harika Okutan................................................74<br />
Harish Chandra........................................... 167<br />
Hasan Mücahit Özbaş.................................. 135<br />
Heiwa Kanamori.......................................... 196<br />
Henu Verma................................................. 365<br />
Hiroaki Goto............................................... <strong>33</strong>1<br />
Hiromi Kato................................................. <strong>33</strong>1<br />
Hossam A.H. Abdelrazik............................. 112<br />
Hrishikesh Mishra....................................... 365<br />
Hüseyin Yaman..............................................75<br />
Hyeon Gyu Yi.............................................. 223<br />
Itır Şirinoğlu Demiriz.................................. 209<br />
Ivana Milosevic............................................ 353<br />
İbrahim Celalettin Haznedaroğlu......... 60, 119,<br />
..................................................... 261, 281, 286<br />
İbrahim Eker .................................................28<br />
İbrahim Keser........................................ 71, 107<br />
İbrahim Öner Doğan................................... 257<br />
İbrahim Sarı................................................. 141<br />
İlhami Berber............................................... 273<br />
İlhan Ünlü......................................................75<br />
İlkay S. İdilman .............................................21<br />
İlker Devrim................................................ 346
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
AUTHOR INDEX - YAZAR DİZİNİ 2016<br />
İlker İnanç Balkan............................... 216, 304<br />
İpek Kıvılcım Oğuzülgen...............................34<br />
İpek Yönal Hindilerden......................... 94, 257<br />
İrfan Kuku................................................... 156<br />
İrfan Yavaşoğlu.................... 166, 187, 273, 368<br />
İsmail Balık.....................................................41<br />
İsmail Haluk Gökçora....................................66<br />
İsmail Sarı.................................................... 273<br />
İsmail Yaşar Avcı ...........................................28<br />
İsmet Aydoğdu............................................ 156<br />
Jameela Sathar................................................15<br />
Jane E. Salmon..................................................1<br />
Jianguo Hao................................................. 180<br />
Jingyi Wang................................................. 180<br />
Joo Han Lim................................................ 223<br />
Kadir Acar........................................... 164, 281<br />
Kavana Rao.................................................. 358<br />
Kemal Aydın...................................................48<br />
Kenan Keven............................................... 159<br />
Kenji Matsumoto......................................... 196<br />
Koji Sasaki................................................... <strong>33</strong>1<br />
Koray Ceyhan.................................................66<br />
Kutay Sarsar................................................ 244<br />
Kürşad Öneç................................................ 362<br />
L. V. K. S. Bhaskar........................................ 365<br />
Lai Kuan Teh..................................................15<br />
Laura Scaramucci...........................................77<br />
Leylagül Kaynar........................................... 273<br />
Lilia M. Sklyarenko..........................................8<br />
Logeswaran Muniandy...................................15<br />
Luisa De Simone.......................................... 259<br />
M. Akif Yeşilipek................................. 107, 265<br />
M. Cem Ar................................................... 216<br />
Maël Albaut................................................. 259<br />
Maha Abdullah...............................................15<br />
Mahmut Subaşı............................................ 263<br />
Manolya Acar.............................................. 244<br />
Marco Giovannini..........................................77<br />
Maria Haroon.............................................. 131<br />
Masakatsu D. Yanagimachi.......................... <strong>33</strong>1<br />
Masanobu Takeuchi.................................... <strong>33</strong>1<br />
Mashael Al Shaikh....................................... 112<br />
Massimiliano Palombi....................................77<br />
Mayu Ishibashi............................................ <strong>33</strong>1<br />
Meera Sikka................................................. 358<br />
Mehdi Ghasemi........................................... 286<br />
Mehmet Ali Erkurt...................................... 273<br />
Mehmet Ali Özcan...................................... 273<br />
Mehmet Ali Sungur..................................... 273<br />
Mehmet Ali Uçar......................................... 273<br />
Mehmet Gündüz........................... 41, 251, 286<br />
Mehmet Hilmi Doğu........................... 254, 273<br />
Mehmet Özen........................................ 41, 356<br />
Mehmet Sezgin Pepeler............................... 168<br />
Mehmet Sönmez.......................................... 135<br />
Mehmet Yılmaz........................................... 141<br />
Mehran Karimi............................................ 355<br />
Mei I Lai.........................................................15<br />
Melih Aktan......................................... 202, <strong>33</strong>5<br />
Meliha Nalçacı................................................94<br />
Melike Sezgin Evim..................................... 326<br />
Meral Beksaç................................................ 251<br />
Mesut Ayer.................................................. <strong>33</strong>5<br />
Metin Uyanık .................................................28<br />
Michael P. Zavelevich ......................................8<br />
Mili Jain....................................................... 349<br />
Mine Durusu Tanrıöver............................... 311<br />
Mine Düzgöl................................................ 346<br />
Mine Hekimgil................................................79<br />
Mithat Haliloğlu ............................................21<br />
Moon Hee Lee............................................. 223<br />
Mrinalini Kotru........................................... 358<br />
Mualla Çetin................................................ 236<br />
Muhammed Evvah Karakılıç..........................48<br />
Muhammet Maden.........................................78<br />
Muhit Özcan.......................................... 41, 273<br />
Murat Akova................................................ 311<br />
Murat Albayrak..............................................74<br />
Murat Duman.................................................84<br />
Murat Elli.................................................... 265<br />
Murat Sezak....................................................79<br />
Murat Sütçü................................................. 244<br />
Murat Yıldırım............................................. 273<br />
Musa Karakükcü......................................... 265<br />
Mustafa Merter.................................... 251, 273<br />
Mustafa Ünübol........................................... 187<br />
Muşturay Karçaaltıncaba ...............................21<br />
Mutlu Arat................................................... 363<br />
Mücahit Yemişen................................. 216, 304<br />
Müge Aydoğdu...............................................34<br />
Müge Sayitoğlu............................................ 172<br />
Mümtaz Yılmaz..............................................79<br />
Münci Yağcı................................................. 231<br />
Na He........................................................... 180<br />
Nabeel Khan Afridi...................................... 131<br />
Naci Çine..........................................................8<br />
Nadir Ali...................................................... 131<br />
Nahide Konuk................................................41<br />
Naila Raza.................................................... 148<br />
Namık Kemal Altınbaş................................ 159<br />
Nazan Özsan..................................................79<br />
Neha Chopra Narang.................................. 358<br />
Nejat Akar..................................... 56, 163, 261<br />
Nergiz Erkut................................................ 135<br />
Nesimi Büyükbabani................................... 360<br />
Neslihan Andıç............................................ 187
Turk J Hematol 2016;<strong>33</strong>:323-328<br />
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
AUTHOR INDEX - YAZAR DİZİNİ 2016<br />
Füsun Özdemirkıran et al. IL-18 Polymorphisms in CML and CLL Patients<br />
Neslihan Erdem........................................... 156<br />
Neşe Saltoğlu....................................... 216, 304<br />
Nilay Ermantaş............................................ 135<br />
Nilgün Işıksaçan.......................................... 202<br />
Nilgün Sayınalp........................... 119, 281, 286<br />
Nur Efe İris.................................................. 363<br />
Nuran Ahu Baysal....................................... 168<br />
Nuran Salman.............................................. 244<br />
Nurdan Köktürk.............................................34<br />
Nurdan Taçyıldız................................... 66, 265<br />
Nuri Bayram................................................ 346<br />
Nursel Çalık Başaran................................... 311<br />
Oğuz Bilgi.................................................... 153<br />
Oğuzhan Erol.............................................. 168<br />
Olga Meltem Akay............... 127, 187, 273, 293<br />
Onur Esbah......................................... 209, 362<br />
Onur Özhan................................................ 156<br />
Oral Nevruz................................................. 273<br />
Osman İlhami Özcebe................. 119, 281, 286<br />
Osman İlhan...................................................41<br />
Osman Yokuş............................................... 254<br />
Ozan Salim.................................................. 273<br />
Ömer Özden...................................................84<br />
Ömer Uluoğlu................................................66<br />
Ömür Kayıkçı.............................................. 209<br />
Önder Arslan..................................................41<br />
Özden Altıok Clark..................................... 107<br />
Özgür Demir............................................... 360<br />
Özgür Mehtap............................................. 273<br />
Özlem Genç................................................. 356<br />
Özlen Bektaş................................................ 119<br />
P. K. Khodiar................................................ 365<br />
P. K. Patra..................................................... 365<br />
Panagiotis Anagnostis....................................88<br />
Paolo de Fabritiis............................................77<br />
Pasquale Niscola.............................................77<br />
Pervin Topçuoğlu...........................................41<br />
Pınar Tarkun............................................... 273<br />
Pushpinderdeep Kahlon.............................. 299<br />
Rafet Eren.................................................... 254<br />
Rahşan Yıldırım........................................... 273<br />
Ramis Ufuk Akkoyunlu....................................8<br />
Rashmi Kushwaha....................................... 349<br />
Rauf Haznedar............................................. 231<br />
Recep Öztürk....................................... 216, 304<br />
Reo Tanoshima............................................ <strong>33</strong>1<br />
Reşat Özaras........................................ 216, 304<br />
Rıza Aytaç Çetinkaya .....................................28<br />
Ryosuke Kajiwara........................................ <strong>33</strong>1<br />
Saba Kiremitçi............................................. 159<br />
Safiye Koçulu............................................... 363<br />
Saleem Ahmed Khan................................... 131<br />
Salih Aksu.................................... 119, 281, 286<br />
Salih Subari.................................................. 141<br />
Sarita Pradhan..................................... 351, 368<br />
Savaş Kansoy............................................... 265<br />
Sebahattin Yılmaz ..........................................28<br />
Seda Aydın................................................... 286<br />
Seda Balaban................................................ 281<br />
Selim Ay....................................................... <strong>33</strong>5<br />
Selma Ünal.....................................................56<br />
Sema Anak................................................... 244<br />
Sema Karakuş.............................................. 320<br />
Semih Alpsoy............................................... 286<br />
Seniz Öngören............................................. 304<br />
Serap Aksoylar............................................. 265<br />
Serap Karaman............................................ 244<br />
Serdar Öztuzcu............................................ 141<br />
Serkan Abacıoğlu............................................48<br />
Serkan Aktürk............................................. 159<br />
Serkan Güvenç............................................ 363<br />
Serkan Tapan .................................................28<br />
Serpil Delibaş..................................................71<br />
Sevgi Başkan................................................ 163<br />
Sevgi Gözdaşoğlu...........................................66<br />
Sevgi Kalayoğlu Beşışık......................... 81, 257<br />
Seyhan Türk................................................ 286<br />
Sezaneh Haghpanah.................................... 355<br />
Sezgin Etgül................................. 119, 281, 286<br />
Shahzaib Nabi.............................................. 299<br />
Shan E. Rauf................................................ 131<br />
Sharif Kullab................................................ 259<br />
Shin-ichi Tsujimoto.................................... <strong>33</strong>1<br />
Shumpei Yokota.......................................... <strong>33</strong>1<br />
Sibel Işlak Mutcalı....................................... 304<br />
Simge Erbil.....................................................79<br />
Sinan Erkul.................................................. 356<br />
Sinem Civriz Bozdağ................................... 209<br />
Smeeta Gajendra......................................... 367<br />
Smita Chandra............................................. 167<br />
Soner Sertan Kara........................................ 263<br />
Soner Yılmaz .................................................28<br />
Sophia Vakalopoulou.....................................88<br />
Stella V. Koval...................................................8<br />
Suzan Çınar................................................. 202<br />
Süreyya Bozkurt.................................... 60, 119<br />
Syed M. Khurshid........................................ 112<br />
Şahika Zeynep Akı.........................................34<br />
Şebnem Yılmaz Bengoa................. 84, 170, 265<br />
Şeniz Öngören............................................. 216<br />
Şerife Kocubaba........................................... 209<br />
Şerife Medeni Solmaz.................................. 273<br />
Şinasi Özsoylu................................................83<br />
Şiyar Erdoğmuş........................................... 159<br />
Şule Öztürk Sarı.......................................... 360<br />
Şule Ünal................................................. 72, 86
<strong>33</strong> rd <strong>Volume</strong> Index / <strong>33</strong>. Cilt Dizini<br />
AUTHOR INDEX - YAZAR DİZİNİ 2016<br />
Şükrü Atakan................................................286<br />
Tahereh Zarei.............................................. 355<br />
Taner Demirer................................................41<br />
Tayfur Toptaş..................................................56<br />
Tekin Aksu.................................................. 263<br />
Teoman Soysal..................................... 216, 304<br />
Thomas Stavrakis...........................................88<br />
Tiraje Celkan..................................................56<br />
Tomoko Yokosuka....................................... <strong>33</strong>1<br />
Tuba Hilkay Karapınar................................ 346<br />
Tuğçe Bulakbaşı Balcı.................................. 320<br />
Tuğçe Kütük................................................ 248<br />
Tuncay Aslan....................................... 281, 286<br />
Turan Bayhan.................................................86<br />
Tülay Özçelik.............................................. 363<br />
Tülin Düger................................................. 236<br />
Tülin Fıratlı Tuğlular.................................. 273<br />
Türkan Patıroğlu......................................... <strong>33</strong>9<br />
Türker Bilgen........................................ 71, 107<br />
Tze Yan Lee....................................................15<br />
Uğur Muşabak................................................28<br />
Uğur Şahin................................................... 251<br />
Uma Shankar Singh..................................... 349<br />
Ural Kaya........................................................48<br />
Ülker Koçak................................................ 265<br />
Ümit Yavuz Malkan............................. 281, 286<br />
Ünsal Han.......................................................74<br />
Vefki Gürhan Kadıköylü............................. 187<br />
Vesile Yıldız Kabak...................................... 236<br />
Vibha Gupta................................................ 167<br />
Vildan Çiftçi...................................................71<br />
Viroj Wiwanitkit......................................... 370<br />
Volkan Hazar............................................... 265<br />
Vural Kesik.................................................. 265<br />
Wataru Yamamoto....................................... 196<br />
Xavier Durando........................................... 259<br />
Yahya Büyükaşık................... 60, 119, 281, 286<br />
Yahya Çelik.....................................................78<br />
Yasemin Ardıçoğlu...................................... 261<br />
Yasemin Işık Balcı...........................................72<br />
Yavuz Yakut................................................. 236<br />
Yelda Dere......................................................79<br />
Yeşim Oymak......................................... 56, 346<br />
Yıldız Aydın................................................. 304<br />
Yılmaz Ay..................................................... 346<br />
Yonca Eğin................................................... 163<br />
Yoshiaki Ishigatsubo.................................... 196<br />
Young Hoon Park........................................ 223<br />
Yunus Kasım Terzi...................................... 320<br />
Zafer Başlar.......................................... 216, 304<br />
Zafer Gülbaş................................................ 127<br />
Zafer Koç..................................................... 320<br />
Zahit Bolaman............................................. 368<br />
Zehra Narlı Özdemir................................... 251<br />
Zerrin Yılmaz Çelik..................................... 320<br />
Zeynel A. Sayıner........................................ 141<br />
Zeynep Arzu Yeğin.........................................34<br />
Zeynep Karakaş........................................... 244<br />
Zeynep Kendi Çelebi................................... 159<br />
Zeynep Öztürk............................................ 107<br />
Zeynep Topkarcı.......................................... 360<br />
Zohair A. Al Aseri........................................ 112<br />
Zohreh Zahedi............................................. 355<br />
Zübeyde Nur Özkurt............................. 34, 231<br />
Zühre Kaya.................................................. 265
Füsun Özdemirkıran et al. IL-18 Polymorphisms in CML and CLL Patients Turk J Hematol 2016;<strong>33</strong>:323-328<br />
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