Elevated Beta-2 Microglobulin Levels Research Articles

Single-cell transcriptomics following ischemic injury identifies a role for B2M in cardiac repair

The efficiency of the repair process following ischemic cardiac injury is a crucial determinant for the progression into heart failure and is controlled by both intra- and intercellular signaling within the heart. An enhanced understanding of this complex interplay will enable better exploitation of these mechanisms for therapeutic use. We used single-cell transcriptomics to collect gene expression data of all main cardiac cell types at different time-points after ischemic injury. These data unveiled cellular and transcriptional heterogeneity and changes in cellular function during cardiac remodeling. Furthermore, we established potential intercellular communication networks after ischemic injury. Follow up experiments confirmed that cardiomyocytes express and secrete elevated levels of beta-2 microglobulin in response to ischemic damage, which can activate fibroblasts in a paracrine manner. Collectively, our data indicate phase-specific changes in cellular heterogeneity during different stages of cardiac remodeling and allow for the identification of therapeutic targets relevant for cardiac repair.

Bone Marrow Infiltration at Diffuse Large B-Cell Lymphoma NOS Diagnosis: Comparative Study between PET, Histology and Flow Cytometry

Introduction Bone marrow (BM) examination at diffuse large B-cell lymphoma (DLBCL) diagnosis is essential in staging and has prognostic implication. According to the last recommendations (Cheson, et al. JCO 2014) BM biopsy (BMB) is only needed for those patients with a negative BM infiltration by positron emission tomography (PET) for whom identification of occult discordant histology - whose biological and prognostic implications are unknown - is clinically important. Despite its greater sensitivity, flow cytometry (FC) is secondary in BM assessment. Our aim was to compare PET, BMB and FC in the study of BM infiltration at DLBCL diagnosis. Methods Retrospective study in two hospitals in Madrid of patients diagnosed with DLBCL NOS from January 2014 to January 2020. A complete BM assessment including PET, BMB and FC was performed in all included patients. The hole series (n=102) was analysed separately according with BM infiltration by each technique, differences between biological, clinical and laboratory variables were studied applying descriptive statistics tests when appropriate (Fisher's exact test, chi-square test, Student's T test and Mann-Witney U test). Event-free survival (EFS) and overall survival (OS) were analysed with Kaplan-Meier estimator according to BM infiltration positive vs negative for each technique, using Cox proportional-hazard model for comparisons. Results BM infiltration was not assessed in 2 patients by BMB and in 4 patients by FC due to technical reasons. Analysing separately the series according to BM infiltration by each technique (PET+ 25 vs PET- 77, BMB+ 15 vs BMB- 85 and FC+ 16 vs FC- 82) the basal characteristics were comparable between groups, except from extranodal sites ≥2, Ann Arbor III-IV and elevated LDH level in groups with positive BM infiltration. The variables associated with worsen EFS in univariate analysis were age ≥80 years (HR 2.31; CI 95% 1.1-5.1), cell-of-origin (COO) non-GCB (HR 2.33; CI 95% 1.1-4.9), extranodal sites ≥2 (HR 2.39; CI 95% 1.2-4.7), Ann Arbor III-IV (HR 4.55; CI 95% 2.0-10.5), and elevated LDH level (HR 2.32; CI 95% 1.1-4.7). The variables statistically related with worsen OS were COO non-GCB (HR 2.91; CI 95% 1.2-6.8), extranodal sites ≥2 (HR 2.61; CI 95% 1.2-5.5), Ann Arbor III-IV (HR 5.97; CI 95% 2.1-17.3), elevated LDH level (HR 2.36; CI 95% 1.1-5.4), and elevated beta-2 microglobulin level (HR 3.82; CI 95% 1.1-12.9). Double-expressor phenotype did not demonstrated association with EFS or OS. Median infiltration by FC analysis was 0.9% (0.05-27). The series distribution among BM infiltration is presented in Figure 1. Median follow-up was 25 months (0.3-90). Survival curves according to BM infiltration by PET, BMB and FC are presented in Figure 2. Univariate analysis among the type of infiltration by each technique are presented in Table 1. Multivariate analysis included age ≥80 years, COO non-GCB, BM FC+ and IPI score 3-5; BM infiltration by FC demonstrated no association with EFS (HR 2.2; CI 95% 0.9-5.3) or OS (HR 2.5; CI 95% 0.9-6.5). Conclusions BM infiltration by PET at DLBCL NOS diagnosis has not survival implication, contrary to infiltration demonstrated by BMB or FC. Cases with positive infiltration by PET but negative by BMB and FC could be false positive in PET or false negative in BMB/FC. According to our results the patients with discordant lymphoproliferative disorder BM infiltration presented worse prognosis and FC is probably the most important technique in this regard. Disclosures No relevant conflicts of interest to declare.

A prognostic score for survival in patients older than 65 years with Diffuse Large B-Cell Lymphoma.

Available prognosis scores for patients with diffuse large B-cell lymphoma (DLBCL) included a limited number of patients ≥ 65 years of age, and most of them did not include comorbidities. Here, we propose a prognostic score for overall survival (OS) for this group of patients. Patients ≥ 65 years with DLBCL treated at a single national reference center were included. Clinical features including comorbidities and biochemical parameters were analyzed. We included 141 patients. Response rate in the whole group was 77%. Based on multivariate analysis, the presence of the European Cooperative Oncology Group (ECOG) > 2, elevated levels of beta-2 microglobulin, bulky disease, and anemia (hemoglobin < 10 g/dL) had a significant effect on OS. These parameters were considered when computing the prognostic score, which identified three groups with differential survival: Low, intermediate, and high risk of death, with a probability of survival at 60 months of 80.05%, 55.5%, and 29.84%, respectively. This score may select patients to optimize treatment. The presence of high levels of beta-2 microglobulin, bulky disease, and hemoglobin < 10 g/dL, and ECOG > 2 was associated with poor OS in elderly patients with DLBCL.

A Prognostic Index for Extranodal Natural Killer/T Cell Lymphoma after Non-Anthracycline-Based Treatment (PINK-B): Prognostic Index of Natural Killer Cell Lymphoma (PINK) Combined with Serum Beta-2 Microglobulin

BackgroundNovel treatment strategies, such as non-anthracycline-based chemotherapy and upfront use of concurrent chemoradiotherapy or radiotherapy have markedly improved the survival outcome of extranodal natural killer/T cell lymphoma (ENKTL). Recently, a new prognostic model, Prognostic Index of Natural killer cell lymphoma (PINK) was proposed for predicting clinical outcomes of ENKTL patients treated with non-anthracycline-based strategies. Elevated serum beta-2 microglobulin (B2M) had been suggested as a potential prognostic predictor for patients with ENKTL, but there was no prognostic model including serum B2M level. We investigated the prognostic role of serum B2M level and suggested a new prognostic index by incorporating serum B2M level into PINK in patients with ENKTL.MethodsWe retrospectively identified 98 patients who received non-anthracycline-based treatment for newly diagnosed ENKTL in Asan Medical Center between January 2005 to December 2014. Serum beta-2 microglobulin level was measured using a radioimmunoassay kit (Immunotech, Inc., Prague, Czech Republic). The optimal cutoff point of serum beta-2 microglobulin level was estimated using ROC curve analysis. We developed a new prognostic model (PINK-B) with 4 elements of PINK (Age>60 years, Ann arabor Stage ¥²-¥³, distant lymph node involvement, and non-nasal type disease) plus serum B2MG level. We performed a validation analysis of a new prognostic model (PINK-B) in an independent cohort.ResultBaseline characteristic were summarized in Table 1. Median B2M value was 2.35 mg/L (range, 1.0-22.0) and the optimal cutoff value of serum B2M level for predicting 3-year overall survival (OS) was ¡Ã2.8 mg/L. Baseline serum B2M elevation (¡Ã2.8 mg/L) was observed in 39 patients (39.8%). In univariate analysis, elevated B2M level (¡Ã2.8 mg/L) was significantly associated with poorer OS (HR=3.83 ;95% CI: 2.06-7.09; p<0.001). We performed multivariate analysis including 4 factors of PINK and elevated serum B2M level. In the multivariate analysis, elevated serum B2M level retained its significant poor prognostic impact for OS (HR=2.13 ;95% CI: 1.09-4.17; p=0.028). Three risk groups in PINK-B were composed as followings: low risk (0-1 points), intermediate risk (2-3 points), and high risk (4 or more points). PINK-B showed better discriminative power compared with PINK for predicting 3-year OS of low-, intermediate-, and high-risk group: 79.5%, 70.0%, and 18.6% for PINK, 78.3%, 40.9%, and 13.5% for PINK-B, respectively. (Figure 1.) The C-indices for PINK and PINK-B were 0.72 (95% CI: 0.62-0.82) and 0.74 (95% CI: 0.64-0.84). We applied PINK and PINK-B to an independent cohort of 90 newly diagnosed ENKTL patients. The performance of PINK and PINK-B for predicting probabilities was validated and 3-years OS of low-, intermediate-, and high-risk groups were 80.2%, 68.7%, and 9.4% for PINK and 80.3%, 31.3%, and 9.5% for PINK-B, respectively (Figure 2.)ConclusionWe suggest a new version of prognostic index (PINK-B : PINK combined with elevated serum B2M) for ENKTL patients treated with non-anthracycline-based strategies. [Display omitted] [Display omitted] [Display omitted] DisclosuresKim:Celltrion, Inc.: Consultancy, Honoraria.

Prognostic significance of serum beta-2 microglobulin in patients with diffuse large B-cell lymphoma in the rituximab era.

The prognostic value of serum beta-2 microglobulin for diffuse large B-cell lymphoma (DLBCL) is not well known in the rituximab era. A retrospective registry data analysis of 833 patients with de novo DLBCL treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) was conducted to establish the prognostic significance of serum beta-2 microglobulin at a ≥2.5 mg/L cutoff. Five-year progression-free survival (PFS, 76.1% vs. 41.0%; p < 0.001) and overall survival (OS, 83.8% vs. 49.2%; p < 0.001) were significantly worse in patients with elevated serum beta-2 microglobulin (n = 290, 34.8%). Furthermore, the five parameters of the International Prognostic Index, accompanying B symptoms, bone marrow involvement and impaired renal function were associated with worse PFS and OS. In multivariate analysis, elevated beta-2 microglobulin was a significant poor prognostic factor for PFS (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.29–2.24; p < 0.001) and OS (HR, 2.0; 95% CI, 1.47–2.75; p < 0.001). In an independent validation cohort of 258 R-CHOP treated patients with de novo DLBCL, elevated beta-2 microglobulin levels remained a significant poor prognostic factor for PFS (HR, 2.03; 95% CI, 1.23–3.32; p = 0.005) and exhibited a strong trend of association with worse OS (HR, 1.64; 95% CI, 0.98–2.75; p = 0.062). The significance of serum beta-2 microglobulin levels as an independent prognostic factor for patients with DLBCL receiving R-CHOP is confirmed.

Clinical features and survival of 338 multiple myeloma patients treated with hematopoietic stem cell transplantation or conventional chemotherapy.

Therapeutic approaches against multiple myeloma (MM) have largely changed during the past decade. Hematopoietic stem cell transplantation (HSCT) and licensing of immunomodulators and proteasome inhibitors have resulted in better response and increased overall survival rates compared to previous conventional therapies. To assess the impact that these new strategies have had on outcome of patients with symptomatic MM in Spain, we conducted an epidemiological retrospective analysis of 338 newly diagnosed patients with stage II-III MM who started first-line treatment over a 2-yr period (2003-2005) by collecting data from their medical records. Most patients had been diagnosed with secretory MM (94.4%), 41.7% stage II and 58.3% stage III. The presence of bone lesions (72.2%), as well as anemia (79.8%) and elevated beta2-microglobulin levels (62.3%), was a common finding; in contrast, hypercalcemia and elevated serum creatinine were less frequent (25% each). First-line treatment had consisted of either conventional chemotherapy (62%) or induction treatment plus autologous HSCT (38%), as per standard clinical practice. HSCT not only resulted in greater objective response rates (93% vs. 50%), but also contributed to a significant increase in 3-yr survival (85% vs. 49.7%; 95% CI, range 77-91 vs. 41-58; P < 0.001). Overall, 55% of patients presented treatment-related adverse events, mainly hematological. Toxicity rates were higher among patients treated with alkylating-based regimens and in those undergoing transplantation. In conclusion, data analysis shows an adequate balance between increased response rates and safety that supports the use of up-front high-dose HSCT therapy in younger patients. Most importantly, this study provides further confirmation that the introduction of HSCT has significantly prolonged survival of patients with MM.

Chlorambucil-rituximab as first-line therapy in patients affected by follicular non-Hodgkin's lymphoma: a retrospective single-centre study.

Rituximab, a chimeric monoclonal antibody directed against the CD20 antigen, has been shown to be active in newly diagnosed and relapsed patients with follicular lymphoma (FL), both as monotherapy and in combination with chemotherapy. Many studies suggest that the prognosis of patients with FL may improve when it is used in combination with chemotherapy. Despite these advances, the disease remains essentially incurable with standard therapy, and novel approaches to treatment are needed because optimal therapy is not defined. The combination of chlorambucil-rituximab is one of several standard treatment options for FL. Here, we considered data arising from 75 patients with newly diagnosed FL at the European Institute of Oncology treated with the combination of rituximab plus chlorambucil. The aim of this study was to evaluate the efficacy and safety of chlorambucil and rituximab, delivered 6 mg/m(2) /day orally for 6 weeks and 375 mg/m(2) in a standard 4-weekly schedule, respectively. Patients responding to the induction therapy received a prolonged therapy with four additional cycles of chlorambucil plus rituximab. Seventy-one patients (94.6%) completed the treatment; four patients discontinued treatment because of grade 3-4 hematological toxicity. The overall response rate was 97.3% including 74.7% of complete responses. Only two patients had a stable disease at revaluation after treatment. With a median follow-up of 57 months, 72 patients (96%) are alive. Median event-free survival (EFS) and median overall survival (OS) were not reached; 5-year OS rate was 98.4%. The 5-year EFS was 71.3%. By univariate and multivariate analyses, elevated beta-2 microglobulin levels and partial responses to therapy were correlated with worse EFS. These results suggest that the combination of chlorambucil and rituximab is an active and safe regimen in patients with newly diagnosed FL, principally in those with low tumour burden and favourable prognostic factors.

Elevated Beta2-microglobulin Level is an Adverse Prognostic Factor for Patients With Extranodal Nasal-type NK/T-cell Lymphoma

Elevated Beta2-microglobulin Level is an Adverse Prognostic Factor for Patients With Extranodal Nasal-type NK/T-cell Lymphoma

A model of experimental acute hematogenous pyelonephritis in the rat

The OBJECTIVE of the study was to create a model of acute hematogenous pyelonephritis in the rat without causing urinary retention by ligation of the ureter. Mixed bacterial suspension containing 1.5 x 10(6) colony-forming units (CFU) of S. aureus and 3.0 x 10(6) CFU of E. coli was inoculated in the caudal vein at a dose of 0.5 ml/kg. Control animals received the same amount of saline solution. Pyelonephritis was confirmed by lab urine tests and histopathological study of the kidneys. Infected animals initially developed sepsis with a significant increase of leukocytes and C-reactive protein in the blood. Originally only bacteriuria was found in the urine of experimental animals, but later, in the course of the development of pyelonephritis (12-18 days), leucocyturia and active leukocytes (glitter cells) were also available in urine. The levels of beta-2 microglobulin in the urine of infected animals (4.02 +/- 0.04 mmol/l on day 16 and 4.18 + 0.07 mmol/l on day 18) were significantly highly increased (p <0.0001) in comparison with the value of the control group (0.088 +/- 0.005 mmol/l). In the early days the histopathological examination of the kidneys established erythrocyte stasis. Later leukocyte infiltrates were observed in the interstitial tissue around the kidney tubules, glomeruli and vascular walls, and inflammatory cell infiltration and degenerative changes were present in the epithelium of the canaliculi. Combined hematogenous infection with S. aureus and E. coli led to the development of pyelonephritis in rats. The pathology in the kidney tubules was confirmed by histopathological study and by the elevated levels of beta-2 microglobulin and the presence of active leukocytes in urine.

Upfront Treatment with Novel Agents Improves the Survival of Symptomatic Patients with Multiple Myeloma Who Are Older Than 65 Years

AbstractAbstract 1947The introduction of novel agents and improvements in supportive care over the last years resulted in a significant improvement of the overall survival (OS) of myeloma patients (Brenner et al Blood 2008, Kumar et al Blood 2008, Kastritis et al Leukemia 2009). However, these retrospective studies indicated that this survival benefit was more pronounced in younger patients while in older patients there was only a marginal improvement in outcome. Randomized studies have shown that upfront use of thalidomide with melphalan and prednisone (MPT) offers superior progression free survival (PFS) than MP alone, and in some of these studies there was also a survival advantage. Bortezomib with MP was also superior to MP in a randomized study, both in terms of PFS and OS. However, these studies included selected patients that may not be representative of the general population of elderly patients with myeloma. Thus, we analyzed our database in order to assess the effect of the upfront use of novel agents (thalidomide, bortezomib, lenalidomide) in consecutive patients older than 65 who were treated in a single center, in Athens, Greece. Many of these patients had been included in clinical trials; however, several patients who were ineligible because of poor performance status, significant renal impairment or comorbidities were also treated with novel agent-based regimens. Thus, these patients are more representative of the general myeloma population. We included patients who started treatment from January 1995 to January 2010, i.e patients who received similar supportive care. All patients were included in the analysis, regardless of performance status, infections, comorbidities etc. Patients were divided in two groups: those who were treated upfront with conventional regimens (group A, N=76) and those who were treated upfront with novel agent-based regimens (group B, N=115). Demographics of the two groups of patients, including gender and age were similar. Performance status at presentation was also similar among the two groups: 56% of those treated upfront with conventional agents and 57% of those treated upfront with novel agents had an ECOG performance status of 2 or higher. Thirty per cent of patients in group A and 44% of patients in group B were older than 75 years, respectively (p=0.07). The presence of osteolytic bone disease (p=0.313), anemia (Hb <10 g/dl, p=0.139), low platelets (<130,000/ml, p=0.949), albumin <3.5 g/dl (p=0.661), elevated LDH ≥300 IU/L (p=0.412), levels of Bence Jones proteinuria (p=0123), heavy (p=0.220) and light chain isotype (p=0.837) were similar among the two groups. However, patients treated upfront with novel agents presented more often with renal impairment (creatinine ≥2 mg/dl in 29% vs. 16%, p=0.044) and had more often elevated beta2-microglobulin levels (p=0.046) and ISS-3 disease (49% vs. 32%, p=0.1). Response to first line treatment was similar for the two groups: 73% for patients treated with novel agents vs. 67% for patients treated with conventional regimens (p=0.371). The median survival of the patients who were treated with novel agent-based regimens was 47 months while it was 34 months for those who received conventional regimens, but this was not statistically significant (p=0.271). Early death rates (<3 months from the initiation of treatment) were 8% for those treated upfront with novel agents and 11% for those treated with conventional regimens. After adjustment for adverse prognostic factors, such as elevated beta2-microglobulin, renal impairment and advanced age, upfront use of novel agents was associated with a significant reduction in the risk of death (HR=0.621, p=0.029). Subsequently, we performed a multivariate analysis which included established adverse prognostic factors and the upfront use of novel drugs. In this analysis, upfront treatment with novel agents was independently associated with superior outcome and a reduced risk of death (HR=0.626, p=0.033). Other factors independently associated with adverse outcome were ISS stage (ISS-3: HR=2.64, ISS-2: HR=1.25, p=0.032), elevated LDH ≥300 IU/L (HR=3.5, p=0.002) and low platelet counts <130,000/ml (HR=1.68, p=0.038) and age >75 years (HR=2, p=0.002). We conclude that in the general population of elderly patients with MM the upfront use of novel agents is associated with improved survival. Disclosures:Dimopoulos:Ortho-Biotech: Honoraria; Celgene: Honoraria; Millennium: Honoraria.

Diffuse large B‐cell lymphoma

: The objective of this study was to compare the clinical features and prognosis of patients with diffuse large B-cell lymphoma (DLBCL) of Waldeyer ring (WR-DLBCL) and patients with lymph node DLBCL (N-DLBCL). : One hundred eighty-one patients with WR-DLBCL and N-DLBCL were reviewed. There were 57 patients with stage I disease, 83 patients with stage II disease, 26 patients with stage III disease, and 15 patients with stage IV disease. Among them, 101 patients had primary N-DLBCL, and 80 patients had primary WR-DLBCL. : Patients with WR-DLBCL and N-DLBCL usually presented at an older age and had localized disease, a low frequency of B symptoms, a good performance status, and a low-risk International Prognostic Index (IPI) score. Compared with patients who had N-DLBCL, patients who had WR-DLBCL presented with more stage II disease and lower tumor burdens. The overall response rate after treatment was similar in both groups. The 5-year overall survival (OS) and progression-free survival (PFS) rates were 76% and 61% in patients with WR-DLBCL, respectively, and 56% and 50% in patients with N-DLBCL, respectively (P = .119 for OS; P = .052 for PFS). IPI scores and elevated beta2-microglobulin and LDH levels were associated with a poor prognosis for patients who had WR-DLBCL; whereas bulky tumor, elevated beta2-microglobulin levels, and IPI scores were associated with poor OS for patients who had N-DLBCL. : The current results supported the continued inclusion of WR-DLBCL as a lymph node group in the staging of DLBCL. Patients with WR-DLBCL had clinical features and prognosis similar to those of patients with N-DLBCL. Cancer 2009. (c) 2009 American Cancer Society.

Cyclophosphamide Remains An Important Component of Treatment in CLL Patients Receiving Pentostatin and Rituximab Based Chemoimmunotherapy

BACKGROUND: We have previously studied and reported that the combination of pentostatin (P, 2 mg/m2), cyclophosphamide (C 600 mg/m2) and rituximab (R 375 mg/m2) in previously untreated CLL is highly effective with an overall response (OR) rate of over 90% and a complete response rate (CR) of 41% (Blood 109:405–411, 2007). We also found that this regimen can be effective even in older patients (>70 y), those with elevated beta-2 microglobulin levels, and patients with mildly reduced creatinine clearances (Cancer . 109:2291–2298, 2007). To determine whether similar benefit could be achieved without inclusion of an alkylating agent, we conducted a follow-up trial testing pentostatin and rituximab without cyclophosphamide and employing a higher pentostatin dose (4 mg/m2).METHODS: Eligible pts had documentation of active CLL by standard NCI-WG criteria, and were previously untreated. Treatment schema consisted of 6 cycles of pentostatin (4 mg/m2) and rituximab given every 21 days. Pentostatin was given on the first day of each cycle following infusion of rituximab. Rituximab was given at 100mg/m2 IV at day 1, then 375 mg/m2 IV on days 3 and 5 of the first treatment cycle. During cycles 2 to 6, Rituximab was given at 375 mg/m2 as a single IV infusion day 1 of week 4, 7, 10, 13 and 16. All patients were staged two months after completion of the 6 cycles of PR using the NCI-WG criteria.PATIENT CHARACTERISTICS: Overall, 33 patients were enrolled at Mayo Clinic and Ohio State University between July 2005 and February 2008. All 33 were eligible: 82% male, median age 65 (range: 45–81), with 9 (27%) being 70 years or older. 76% had a baseline ECOG PS of 0, and the rest were ECOG PS 1. Overall, 36% of patients had intermediate Rai risk (stage I–II) and 63% high Rai risk (stage 3–4) disease. Prognostic testing revealed that 36% were CD38+, 50% were Zap-70 +, and 39% had an unmutated IgVh status. Chromosome analysis by FISH found that 99% had detectable FISH panel defect, including 61%, 27% and 3% of patients with 1, 2, or 3 FISH detects, respectively.RESULTS: 28 of 33 patients (85%) completed therapy. While on treatment, 6 pts (18%) had a dose held or modified with 4 of these delays due to hematologic AE. For adverse events deemed at least possibly related to treatment, 4 (12%) pts experienced grade 3+ hematologic toxicity and 5 (15%) experienced grade 3+ non-hematologic toxicity. Out of all 33 enrolled patients, the overall response rate was 79% with 10 CR, 6 nPR, and 10 PR. At the time of this analysis, 29/33 patients are still alive with a median follow-up time of 14 months on surviving patients. To date 17/33 (52%) of patients have progressed with an estimated median time to progression of 12 months (95% CI: 8.5–21 months). 13/26 responders have progressed. Median duration of response is 12.5 months ((95% CI: 11–21 months).Finally, since eligibility were nearly identical and enrollment accrued at the same two academic centers, we compared the patient characteristics, response rates, and PFS of the 33 patients treated with PR to the 64 patients previously treated on our PCR trial. Patients in the two studies were generally similar with respect to demographic and prognostic characteristics, although patients in the PR trial had higher WBC and were less likely to be IgVH unmutated (Table). Although the differences in ORR and CR rate were not significantly different, the PFS appeared to be inferior in patients treated with PR as compared to PCR (12 months vs. 31 months; p=0.003).CONCLUSION: Although the PR regimen achieves a high OR response rate, the PFS appears inferior to PCR therapy. These findings suggest that increasing the purine nucleoside analogue dose does not eliminate the need to include cyclophosphamide in chemoimmunotherapy for patients with CLL.PCR Trial N=64PR Trial N=33P valueAge, median(range)63 years (38–80)65 years (45–81)0.34≥70 years(%)28%27%Male77%82%0.61Rai stage 05%00.46Rai stage I–II42%36%Rai stage III–IV53%64%White Cell Count, median(range)79 × 109/L (11–519)127 × 109/L (8–430)0.04<50 × 109/L36%28%50–149 × 109/L44%25%>150 × 109/L20%47%Serum B2-microglobulin, median(range)3.97 (1.8–13.5)3.80 (2.0–8.2)0.81>2 × Upper Limit Normal(%)57%58%CD38 Positive34%36%1.00ZAP-70 Positive36%50%0.26IgVH Unmutated71%39%0.004FISHNormal,11%9%13q-35%42%+1221%24%6q-2%011q-22%18%17p-6%3%other3%3%Overall Response Rate91%79%0.12Complete Response Rate41%30%0.38Median PFS31 months12 months0.003

Enzymatic activity of circulating proteasomes correlates with clinical behavior in patients with chronic lymphocytic leukemia

The ubiquitin-proteasome pathway has been implicated in the pathogenesis of many hematologic malignancies. The authors measured proteasome peptidase activity levels in plasma samples from 225 patients with chronic lymphocytic leukemia (CLL) and correlated the results with clinical behavior. By using fluorogenic kinetic assays, the enzymatic activity levels of 3 proteasomes were measured: chymotrypsin-like (Ch-L), trypsin-like (Tr-L), and caspase-like (Cas-L). All activity levels were significantly higher in patients who had CLL compared with the levels in a control group of healthy volunteers (P<.001). Rai stage was correlated with Ch-L activity (P<.001) but not with Cas-L or Tr-L activity. Levels of beta2 microglobulin (B2M) were correlated with Ch-L activity (correlation coefficient [R]=0.4; P<.001) and with Cas-L activity (R=0.25; P=.001) but not with Tr-L activity. Cas-L activity as a continuous variable was a strong predictor of survival. Ch-L and Cas-L activity levels as categorical variables both were strong predictors of survival; Cas-L activity was independent of B2M level but not of immunoglobulin variable heavy chain gene (IgVH) mutation status. However, the combination of elevated B2M levels (>3.2 mg/L) and Cas-L activity (>1.32 pmoL/second/mL plasma) was associated with significantly shorter survival independent of IgVH mutation status. The current results indicated that measuring plasma proteasome activity has prognostic value in CLL that, when combined with B2M, can be independent of IgVH mutation status.

Characterization of a highly glycosylated form of the human cytomegalovirus HLA class I homologue gpUL18.

Human cytomegalovirus (HCMV) gpUL18 is a HLA class I (HLA-I) homologue with high affinity for the inhibitory receptor LIR-1/ILT2. The previously described 67 kDa form of gpUL18 is shown here to be sensitive to endoglycosidase-H (EndoH). A novel form of gpUL18 with a molecular mass of approximately 160 kDa and resistance to EndoH was identified in cells infected with HCMV strain AD169 or the low passage HCMV isolates Merlin and Toledo. The 67 kDa EndoH-sensitive gpUL18 glycoform was detected earlier in a productive infection (from 24 h post-infection) than the slower-migrating EndoH-resistant glycoform (from 72 h post-infection). Deletion of the US2-US11 region from the HCMV genome was associated with a substantial up-regulation of endogenous HLA-I in infected cells, but had no obvious effect on the gpUL18 expression pattern. Vaccinia virus and adenovirus vectors were used to further analyse gpUL18 expression. Depending on the delivery vector system, differences in the electrophoretic motility of the EndoH-resistant >105 kDa form of gpUL18, but not the EndoH-sensitive 67 kDa form, were observed; post-translational modification of the higher molecular mass glycoform appears to be influenced by active virus infection and vector delivery. The EndoH-sensitive 67 kDa gpUL18 had a rapid turnover, while the maturation to the EndoH-resistant >105 kDa form was relatively slow and inefficient. However, synthesis of the EndoH-resistant >105 kDa form was enhanced with elevated levels of beta2-microglobulin. When expressed by using an adenovirus vector, both the EndoH-sensitive 67 kDa and the EndoH-resistant >105 kDa gpUL18 forms could be detected on the cell surface.

CD56 as Prognostic Factor in Patients with Multiple Myeloma Treated by High-Dose Chemotherapy and Autologous Stem Cell Transplantation.

Neuronal cell adhesion molecule (NCAM, CD56) is expressed by approximately 75% of multiple myeloma (MM) clones. The lack of CD56 expression on MM cells is described to be associated with a higher frequency of extramedullary involvement (Pellat-Deceunynck et al. 1998) and a lower overall survival in patients treated by conventional chemotherapy (Sahara et al. 2002). We analyzed the CD56 expression of myeloma cells by flowcytometry in 52 newly diagnosed patients to determine its prognostic and clinical relevance. Seventeen of 52 patients were NCAM-negative and 35 patients NCAM positive. The CD56 expression did not correlate with elevated beta2-microglobulin levels or deletions of chromosome 13q14 as investigated by interphase FISH. All patients were scheduled for treatment according to the GMMG-HD3 protocol and received 3 cycles of VAD or TAD induction chemotherapy, followed by CAD chemotherapy, stem cell collection and high dose chemotherapy with melphalan and autologous stem cell transplantation (ASCT). We analyzed the response rate (EBMT/IBMTR criteria) 3 months after the first ASCT and the event free survival (EFS) (median 479 days, range 29–911 days). Three months after the first ASCT, 6/17 of the CD56 negative patients were in CR, 7/17 in PR, 1/17 in MR and 3/17 had PD. Of the CD56 positive patients evaluated for clinical outcome 5/35 showed CR, 20/35 a PR and 10/35 a PD. In an intention-to-treat analysis, EFS showed no significant difference between these two groups. With only 13 events out of 52 cases, a longer follow up in terms of EFS and OS is required. We conclude that in patients treated by high-dose melphalan and autologous stem cell transplantation, the lack of CD56 did not correlate with a poor response rate 3 month after transplantation. Our preliminary results indicate that high-dose therapy followed by ABSCT is able to overcome the poor prognosis of CD56 negative patients treated with conventional chemotherapy.

Impact of renal cryoablation on urine composition

Objectives. To examine prospectively serial urine biochemical parameters in 14 patients (9 men, 5 women) undergoing laparoscopic cryoablation of a small, exophytic solid renal mass. Prior studies have shown that various types of renal injury may predispose to the formation of urinary calculi. The metabolic effects of cryoenergy on the surrounding normal renal parenchyma are unknown. Methods. Timed 24-hour urine collections were obtained preoperatively and postoperatively on days 1, 30, and 60 to evaluate the following parameters: light microscopic findings, volume, pH, creatinine, protein, beta 2-microglobulin, calcium, citrate, oxalate, phosphate, uric acid, sodium, and potassium. Results. Urinary beta 2-microglobulin excretion increased from a preoperative baseline value of 114.8 to 1931.2 μg/L on postoperative day 1, an increase of more than 15-fold ( P = 0.05), thus confirming major renal injury. These values sharply decreased at 30 days and returned to near-baseline levels at 60 days postoperatively ( P = 0.76). Nevertheless, all lithogenic parameters remained within the normal range throughout the follow-up period, with no significant change in any value. Conclusions. Our findings suggest that renal cryoablation does not adversely alter urine composition with respect to lithogenic parameters for up to 2 months after surgery. Elevated beta 2-microglobulin levels indicating significant renal injury immediately postoperatively spontaneously revert to baseline levels within 2 months.

IgM paraproteinaemia: disease associations and laboratory features

To review the disease associations and laboratory features occurring in IgM paraproteinaemia. Systematic review of all new serum IgM paraproteins detected over a 6-year period in an immunodiagnostic laboratory serving a population of 400,000 people. Clinical diagnoses were ascertained from a computerised laboratory database or clinical notes, whilst associated laboratory features were obtained from the same sources. The 125 IgM paraproteins detected constitute 19.7% of all new paraproteins observed over the period of study. IgM paraproteinaemia occurred more commonly in males and its frequency increased with age. Approximately 30% were associated with B cell lymphoproliferative disorders (Waldenstrom's macroglobulinaemia, non-Hodgkin's lymphoma, chronic lymphocytic leukaemia, amyloid, etc.) with the remainder being labelled as monoclonal IgM gammopathies of uncertain significance (four having a peripheral neuropathy). At clinical presentation, patients with lymphoproliferative disorders tended to have higher levels of IgM, beta2-microglobulin, the presence of free urinary light chains and demonstrated molecular size heterogenicity of the paraprotein (presence of decamers, oligomers and monomers in addition to the pentamer) but there was considerable overlap. A good correlation was noted between paraprotein concentration and viscosity in most patients. IgM paraproteinaemia was most frequently encountered in the context of a gammopathy of uncertain significance. Features which suggested lymphoproliferative disorders included higher levels of paraprotein (>15 g/l) elevated levels of beta2-microglobulin and the presence of urinary free high chain. However, as much overlap was seen, regular monitoring of paraprotein levels is considered mandatory in the management of these patients.

High response rates with short infusional 2-chlorodeoxyadenosine in de novo and relapsed low-grade lymphoma. Australian and New Zealand Lymphoma Study Group.

Thirty-five patients (eight de novo, 27 relapsed disease) with low-grade non-Hodgkin's lymphoma (diffuse small lymphocytic, follicular small cleaved cell, follicular mixed cell, and lymphoplasmacytoid) were treated with 2-chlorodeoxyadenosine (2CdA) at a daily dose of 0.14 mg/kg for 5d (2 h infusion) for an average of three cycles. Minor treatment delays, generally due to haematological toxicities, occurred in nine of 105 cycles. Major toxicities were lymphopenia, neutropenia and thrombocytopenia. Opportunistic infections occurred in seven patients. Overall response rate was 69% (five complete, 19 partial) reaching 88% for de novo patients (two complete, five partial). Elevated beta 2-microglobulin level was negatively predictive of response (P = 0.0014). Eight of 24 responders relapsed, with a median follow-up of 13 months. 2CdA administered as an intermittent infusion shows considerable single-agent activity in low-grade lymphomas achieving high response rates of prolonged duration. Consideration of schedules where 2CdA is alternatively administered with combination chemotherapy appears warranted.

Poor Prognosis in Multiple Myeloma Is Associated Only With Partial or Complete Deletions of Chromosome 13 or Abnormalities Involving 11q and Not With Other Karyotype Abnormalities

Chromosomal abnormalities have major biologic and prognostic implications in leukemias. Cytogenetic information in typically hypoproliferative multiple myeloma (MM) is limited because of difficulties in obtaining analyzable metaphases. In this study, karyotypes and other known prognostic factors were analyzed in 155 newly diagnosed MM patients, entered on an intensive treatment program with two autotransplants. Complete remission (CR), event-free (EFS) and overall survival (OS) were analyzed using standard statistical methods. Abnormal cytogenetics were found in 39% of patients and were associated with a significantly lower CR rate (27% v 48%; P = .008). EFS and OS were inferior in patients with either partial or complete deletion of chromosome 13 or 11q abnormalities ("unfavorable" karyotype) when compared with the remaining patients (P < .001) who, as a group, had a similar prognosis irrespective of cytogenetic findings, ie, inevaluable, normal, or abnormal but without an "unfavorable" karyotype. The patients with abnormalities of both chromosomes 11 and 13 had a dismal prognosis with median EFS and OS of only 11 and 12 months, respectively. Significant associations were noted between an "unfavorable" karyotype and IgA isotype, elevated levels of beta-2 microglobulin (B2M, > or = 3 mg/L) and age > 60 years. On multivariate regression analysis, the absence of an "unfavorable" karyotype was the most significant variable associated with prolonged EFS and OS (P = .0001 and .0002, respectively). Other independent favorable variables were age less than 60 years, C-reactive protein (CRP) < or = 0.4 mg/dL and bone marrow plasmacytosis < or = 50% before treatment. On a multivariate analysis without cytogenetics, these same three standard parameters were identified as the only favorable variables. Patients not having all three standard favorable variables had a significantly lower CR rate (P = .03), EFS (P = .0001), and OS (P = .002) if an unfavorable karyotype was detected. We conclude that, in this program of uniformly treated MM patients, a poor prognosis was associated predominantly with abnormalities of chromosomes 11 and 13.

Serum interleukin-6 levels correlate with prognosis in diffuse large-cell lymphoma.

Interleukin-6 (IL-6) is a potent immunomodulatory cytokine that may have pathogenetic and prognostic significance in a number of disorders. The objective of this study was to examine the correlation between serum IL-6 levels and phenotypic characteristics, as well as outcome of patients with diffuse large-cell lymphoma (DLCL). Using an enzyme-linked immunosorbent assay (ELISA; lower limit of sensitivity, 0.35 pg/mL), we measured IL-6 levels in frozen sera from 33 healthy controls and 58 untreated patients with DLCL who were enrolled onto a single combination chemotherapy protocol. Serum IL-6 levels were correlated with clinical and laboratory features at diagnosis and with failure-free and overall survival. Serum IL-6 levels in the lymphoma patients (median, 4.37 pg/mL; range, < 0.35 to 110 pg/mL) were significantly higher than in the control group (median, < 0.35 pg/mL; range, < 0.35 to 1.87 pg/mL) (P < .0001). Serum IL-6 levels were higher in patients with B symptoms (P = .012), an elevated beta 2-microglobulin level (> or = 3.0 mg/L) (P = .017), and a poor performance status (P = .02). Direct linear correlations with the erythrocyte sedimentation rate (ESR), platelet count, and total WBC count, and an inverse linear correlation with the serum albumin level, were observed (all P < .02). Patients with elevated serum IL-6 levels had inferior failure-free (P = .042) and overall survival (P = .05) compared with those with normal serum IL-6 levels. In patients with DLCL, elevated serum levels of IL-6 at diagnosis are frequent, strongly associated with many adverse disease features, and predictive of a poor failure-free and overall survival.