clinicopathological correlation, p16-p15 methylation status and outcome predictors in anaplastic...

Correspondence

SPONTANEOUS REMISSION OF B-CHRONIC LYMPHOCYTIC LEUKAEMIA

We read with interest the recent report by Thomas et al(2002) regarding the spontaneous clinical regression ofchronic lymphocytic leukaemia (CLL), as we have experi-enced a spontaneous and continuous regression, leading toa complete remission, in a patient with B-CLL.

As Thomas et al (2002) point out, true clinico-haemato-logical remission, as defined by Cheson et al (1988) is veryrare. Unfortunately, a precise estimation of the status or thedegree of remission in their patients is not possible as a bonemarrow (BM) aspirate was performed in only three of theten cases during follow-up. In addition, for a properassessment of clinico-haematological remission, only twoof their cases and three additional patients from theliterature (reviewed in Thomas et al, 2002) were sufficientlydocumented for evaluation.

We report a 64-year-old man diagnosed with B-CLLstages Rai 1 and Binet A in October 1998, after alymphocytosis (absolute lymphocyte count of 21Æ6 ·109 ⁄ l) was observed during a routine blood analysis. Onlytwo axillary lymph nodes (of 1Æ5 and 1 cm diameterapproximately) were palpable by physical examination.The haemoglobin concentration (15Æ3 g ⁄ dl) and the plateletcount (214 · 109 ⁄ l) were normal. BM aspirate revealed61Æ6% lymphocytes. Immunophenotypic analysis revealed amonoclonal (SmIg j) B-cell population with an immuno-phenotype compatible with B-CLL, CD19+ ⁄CD20dim ⁄CD22dim ⁄CD23dim ⁄CD5+ ⁄CD6+ ⁄CD38) ⁄ FMC7, which rep-

resented 85% and 78% of the leucocytes in blood and BMrespectively. The patient received no treatment for B-CLL, orany other treatment except for omeprazol for a hiatushernia and an angiotensin-converting enzyme inhibitor fora mild chronic cardiac insufficiency. Figure 1 shows anoverview of the peripheral leucocyte count and percentageof B-CLL cells analysed by flow cytometry during follow-up.The disease was initially stable, but from June 2000(20 months after diagnosis) we observed a continuousdecrease of the absolute lymphocyte count until a normalcount was achieved and thereafter a progressive decrease inthe percentage of immunologically positive B-CLL cells toonly 0Æ5% of the leucocytes. At the last follow-up, apartfrom a normal physical examination, BM examinationrevealed only 0Æ6% of leucocytes with B-CLL immunophe-notype.

Just as �smouldering� B-CLL has certain distinct features(Montserrat et al, 1988), we wondered whether those caseswith spontaneous regression can also be identified a priori.Cytogenetic analysis at diagnosis of our patient showed a13q14 deletion as the only cytogenetic abnormality, whichhas been associated with a long treatment-free interval(Dohner et al, 2000). The absence of CD38 expression in thispatient also indicates a good prognosis (Damle et al, 1999).

In summary, this patient provided well-documented evi-dence that spontaneous regression and even clinico-haem-atological remission of B-CLL is possible, and can be easily

Fig 1. Distribution of the leucocyte popula-

tion during follow-up of the patient. Within

each column the upper portion represents the

lymphocyte population and the lowest part

the remaining normal white cell population.

Please note that whenever immunopheno-

typic analysis was done (at diagnosis, and at

32, 34 and 42 months follow-up interval), the

lymphocyte portion is further subdivided into

B-CLL cells and normal lymphocytes. At these

time intervals, the percentage of malignant B

cells was: 68%, 5%, 3% and 0Æ5% of the

leucocytes respectively.

British Journal of Haematology, 2002, 119, 874–884

874 � 2002 Blackwell Publishing Ltd

monitored by immunophenotyping. Further, it confirms theprinciple that early stages of B-CLL should not be treated.

Encarnacion B. Gomez Garcıa1

Ellen G. van Lochem2

Kirsten van Lom1

Herbert Hooijkaas2

1Haematology and2ImmunologyDepartments,Erasmus MC,Rotterdam,The Netherlands.E-mail:[email protected]

REFERENCES

Cheson, B.D., Bennett, J.M., Rai, K.R., Grever, M.R., Kay, N.E.,

Schiffer, C.A., Oken, M.M., Keating, M.J., Boldt, D.H., Kempin,

S.J. & Foon, K. (1988) Guidelines for clinical protocols for chronic

lymphocytic leukemia: recommendations of the NCI sponsored

working group. American Journal of Hematology, 29, 152–163.

Damle, R.N., Wasil, T., Fais, F., Ghiotto, F., Valetto, A., Allen, S.L.,

Buchbinder, A., Budman, D., Dittmar, K., Kolitz, J., Lichtman,

S.M., Schulman, P., Vinciguerra, V.P., Rai, K.R., Ferrarini, M. &

Chiorazzi, N. (1999) Ig V gene mutation status and CD38 ex-

pression as novel prognostic indicators in chronic lymphocytic

leukemia. Blood, 94, 1840–1847.

Dohner, H., Stllgenbauer, S., Benner, A., Leupolt, E., Krober, A.,

Bullinger, L., Dohner, K., Bentz, M. & Lichter, P. (2000) Genomic

aberrations and survival in chronic lymphocytic leukemia. The

New England Journal of Medicine, 343, 1910–1916.

Montserrat, E., Vinolas, N., Reverter, J.C. & Rozman, C. (1988)

Natural history of chronic lymphocytic leukemia: on the pro-

gression and prognosis of early clinical stages. Nouvelle Revue

Francaise de Hematologie, 30, 359–367.

Thomas, R., Ribeiro, I., Sheperd, P., Johnson, P., Cook, M., Lakhani,

A., Kaczmarski, R., Carrington, P. & Catovsky, D. (2002) Spon-

taneous clinical regression in chronic lymphocytic leukaemia.

British Journal of Haematology, 116, 341–345.

Keywords: B-CLL, spontaneous remission.

ANTI-PHOSPHOLIPID ⁄ COFACTOR ANTIBODIES IN THREE CASES OF PERSISTENT

POLYCLONAL B LYMPHOCYTOSIS

We report three patients with persistent polyclonal lympho-cytosis of B-cell lymphocytes (PBL) and anti-phospho-lipid ⁄ cofactor (aPA ⁄ cofactor) antibodies of immunogloblin(Ig)M isotype or lupus anticoagulant (LA).

CASE REPORTS

Patient 1A 42-year-old female smoker (30 cigarettes ⁄ d for 28 years)had presented one fetal loss and three normal pregnancies.She complained of frequent migraine and had presented atransient left eye amaurosis with normal cerebral resonancemagnetic imaging. Physical examination was normal andhigh polyclonal IgM was noted (Table I). A thoracic andabdominal computerized tomography scan was normal.

Patient 2This 43-year-old woman presented with fibromyalgia andRaynaud’s phenomenon from the age of 10 years. She wasa regular smoker (30 cigarettes ⁄ d). She had never had afetal abortion or thrombosis. Physical examination wasnormal. Biological evaluation revealed a polyclonal hyper-IgM (Table I).

Patient 3A 44-year-old woman was referred because of chronicthrombocytopenia (platelet count of 75 · 109 ⁄ l since1994). She was a smoker (20 cigarettes ⁄ d for 10 years).She had not suffered from fetal loss or vascular thrombosis.Physical examination was normal. Biological evaluationshowed a polyclonal hyper-IgM (Table I).

Table I. Principal biological findings of the three cases.

Biological findings Patient 1 Patient 2 Patient 3

Full blood count

Platelets (·109 ⁄ l) 220 296 96

Lymphocytes (·109 ⁄ l) 4Æ6 4Æ41 4

Peripheral blood lymphocytes analysis 11% bi-lobed lymphocytes 6% bi-lobed lymphocytes 6% bi-lobed lymphocytes

Peripheral blood lymphocytes 41% CD19+ 33% CD19+ 41% CD19+

Immunophenotyping (2 · 109 ⁄ l) CD5–

CD23– with j and klight chains

(1Æ5 · 109 ⁄ l) CD5–


(1Æ5 · 109 ⁄ l) CD5–


IgM level (g ⁄ l) (0Æ4–2Æ4) 13 8Æ89 6Æ12

LA: Rosner index (positive: > 12) 17 Negative 17

LA: Schleider index (positive: > 1Æ2) 1Æ6 Negative Negative

aCL of IgM isotype (positive > 10) 16 Negative Negative

aß2GP1 of IgM isotype (positive: > 0Æ25) 0Æ30 0Æ55 0Æ75

aPE of IgM isotype (positive: > 0Æ55) 2 1Æ66 1Æ40

Correspondence 875

� 2002 Blackwell Publishing Ltd, British Journal of Haematology 119: 874–884

MATERIALS AND METHODS

LA was determined using the activated partial thrombo-plastin time and diluted thromboplastin time. The resultswere, respectively, expressed as the Rosner and Schleiderindex (Working Group on Hemostasis of the SocieteFrancaise de Biologie Clinique, 1993).

Sera were assayed for IgG and IgM isotypes, and anti-cardiolipin (aCL) using an in-house enzyme-linkedimmunosorbent assay (ELISA) (SanMarco et al, 1997).Values higher than 22 IgG phospholipid units (GPL) and10 IgM phospholipid units (MPL) were considered posit-ive.

Sera were tested for anti-b2-glycoprotein 1 (aß2GP1) ofthe IgG and IgM isotypes using an in-house ELISA(SanMarco et al, 1997). The cut-off values for positivitywere set at 0Æ16 for the IgG isotype and 0Æ25 for the IgMisotype.

Sera were tested for anti-phosphatidylethanolamine(aPE) of the IgG and IgM isotypes, using a modifiedversion of the ELISA method (Berard et al, 1996). Valueshigher than 0Æ12 for IgG and 0Æ55 for IgM were consideredpositive.

RESULTS

As shown in Table I, ab2GP1 and aPE of IgM isotype werepositive in all three cases, aCL of IgM isotype was positive inone case and LA was positive in two cases. The search foraCL, ab2GP1 and aPE of IgG isotype was negative. Thesedata remained the same after 3 months (one patient) and1 year (two patients). Blood karyotype analysis was normaland HLA-DR7 was not found. Anti-nuclear and anti-mitochondria antibodies, and rheumatoid factor were allnegatives.

DISCUSSION

Our three patients fulfilled the criteria for PBL:1. persistent peripheral blood lymphocytosis with binucle-

ated nuclei;2. polyclonal nature of the B-cell proliferation;3. serum polyclonal hyper-IgM;4. female and regular smoker.

The first patient had suffered from migraine and hadpresented one fetal loss; the second had suffered from aRaynaud’s phenomenon and the third had a chronicthrombocytopenia. Such manifestations are frequentlyobserved in the field of the anti-phospholipid syndrome,but none of our patients fulfilled the new classificationcriteria (Wilson et al, 1999) and none of them suffered froma characterized autoimmune disease.

In PBL, HLA-DR7 has been reported in about 90% ofcases and i(3q) in 77% of cases (Mossafa et al, 1999), butwe did not find either in our series. This may be due tothe low number of mitosis in our analysis (under 50), butmay also suggest a variant form of the classic PBL in ourpatients.

To our knowledge, an association between PBL andaPA ⁄ cofactor has not been reported, probably because thesearch for anti-phospholipid antibodies is not carried out.We have already reported an association between poly-clonal hyper-IgM and aPE of IgM isotype (Granel et al,2000). Thus, IgM in PBL could recognize some aPL ⁄ cofactorwithout being pathogenic.

Brigitte Granel1

Jacques Serratrice1

Patrick Disdier1

Marielle SanMarco2

Marie Michele Hubert2

Marie-Christine Alessi3

Helene Cannoni4

Laurence Camoin5

Reda Bouabdallah6

Irene Juhan-Vague3

Pierre-Jean Weiller1

1Service de Medecine Interne,Hopital de la Timone,2Laboratoire d’Immunologie,Hopital de la Conception,3Laboratoire d’Hematologie,and 4Laboratoire deCytogenetique Oncologique,Hopital de la Timone,5Laboratoire d’Hematologie,Hopital de la Conception,and 6Service d’Hematologie,Institut Paoli-Calmettes,Marseille, France. E-mail:[email protected]

REFERENCES

Berard, M., Chantome, R., Marcelli, A. & Boffa, M.C. (1996) Anti-

phosphatidylethanolamine antibodies as the only antiphos-

pholipid antibodies. Association with thrombosis and vascular

cutaneous diseases. Journal of Rheumatology, 23, 1369–1374.

Granel, B., Serratrice, J., Hubert, A.M., Volot, F., Pach, X., Swiader,

L., Ross, P., Disdier, P. & Weiller, P.J. (2000) Hyper-

immunoglobulinemie M et anticorps anti-phosphatidylethanola-

mine d’isotype IgM: a propos de 72 patients. Revue de Medecine

Interne, 21, 595–598.

Mossafa, H., Malaure, H., Maynadie, M., Valensi, F., Schillinger, F.,

Garand, R., Jung, G., Flandrin, G. & Troussard, X. (1999) Per-

sistent polyclonal B lymphocytosis with binucleated lympho-

cytes: a study of 25 cases. British Journal of Haematology, 104,

486–493.

SanMarco, M., Soler, C., Christides, C., Raoult, D., Weiller, P.J.,

Gerolami, V. & Bernard, D. (1997) Prevalence and clinical sig-

nificance of IgG isotype anti-b2-glycoprotein 1 antibodies in

antiphospholipid syndrome: a comparative study with anticard-

iolipin antibodies. Journal of Laboratory and Clinical Medicine,

129, 499–506.

Wilson, W.A., Gharavi, A.E., Koike, T., Lockshi, N.M.D., Branch,

D.W., Piette, J.C., Brey, R., Derksen, R., Harris, E.N., Hughes,

G.R.V., Triplett, D.A. & Khamashta, M.A. (1999) International

consensus statement on preliminary classification criteria for

definite antiphospholipid syndrome. Report of an international

workshop. Arthritis and Rheumatism, 42, 1309–1311.

Working Group on Hemostasis of the Societe Francaise de Biologie

Clinique (1993) Comparison of the standardized procedure

with current laboratory practices for the detection of lupus

anticoagulant in France. Thrombosis and Haemostasis, 70, 781–

786.

Keywords: persistent polyclonal lymphocytosis of B cell,anti-phospholipid antibodies, hyper-immunoglobulin M,

anti-phosphatydylethanolamine, tobacco.

876 Correspondence


CLINICOPATHOLOGICAL CORRELATION, p16-p15 METHYLATION STATUS AND OUTCOME

PREDICTORS IN ANAPLASTIC LARGE CELL LYMPHOMA

There is general agreement on considering t(2;5)(p23;5q35)as a distinctive marker for anaplastic large cell lymphoma(ALCL), but it has also been described in other non-Hodgkin’slymphomas (NHL), Hodgkin’s lymphomas (HL) and evenin reactive lesions (Orscheschek et al, 1995; Beylot-Barryet al, 1998; Gascoyne et al, 1999). This translocationproduces the fusion of the anaplastic lymphoma kinase(ALK) gene on chromosome 2 to the nucleophosmine (NPM)gene on chromosome 5, although different rearrangementsinvolving ALK gene have also been described.

ALK-positive ALCL cases seem to present better prognosisthan negative cases (Falini et al, 1999). Another feature,whose implication in haematological neoplasms has beenrecently highlighted, is the methylation status of thep16INK4a and ⁄ or p15INK4b suppressor genes, but fewALCL have been analysed.

We have studied ALK staining in 80 CD30-positivelymphomas [27 T-null ALCL, 14 anaplastic diffuse largeB-cell lymphomas (DLBCL), 13 peripheral T-cell lymphomas(PTCL) and 26 HL] and correlated this marker with clinical

Table I. Clinical findings, TIA expression, p16 ⁄ p15 methylation and response to treatment data for ALK-positive and

ALK-negative ALCL.

Factor

ALK+ (n ¼ 11)*

n (%)

ALK– (n ¼ 16)*

n (%) P-value

Mean age (years) ± SD 19Æ5 ± 14Æ6 38Æ2 ± 20Æ3 0Æ007

Age range (years) 2–57 5–74 –

Sex

M 8 9 0Æ448 NS

F 3 7

B symptoms 8 (73) 12 (75) 1Æ000 NS

Bulky disease 9 (82) 2 (12) 0Æ001

Extranodal sites 4 (36) 3 (19) 0Æ391 NS

< 2 2 (18) 3 (19) 0Æ428 NS

‡ 2 2 (18) 0

Haematopoietic organs involvement ‡1 n ¼ 10

6 (60) 4 (25) 0Æ109 NS

Increased LDH n ¼ 9 n ¼ 15

6 (67) 5 (33) 0Æ206 NS

Paraproteinaemia n ¼ 9 n ¼ 15

1 (11) 0 0Æ360 NS

Ann Arbor stage

I–II 6 (55) 10 (63) 0Æ710 NS

II–IV 5 (45) 6 (37)

IPI

0–2 8 (73) 15 (94) 0Æ273 NS

3–4 3 (27) 1 (6)

Mean evolution time prior to diagnosis (d) 37 109 0Æ009

TIA-1 expression n ¼ 14

10 (91) 7 (50) 0Æ042

p16 methylation n ¼ 6 n ¼ 12

1 (17) 4 (33) 0Æ615 NS

p15 methylation n ¼ 6 n ¼ 12

3 (50) 9 (75) 0Æ344 NS

Response to treatment n ¼ 10 n ¼ 15

NR 1 (10) 1 (7) 0Æ560 NS

PR 2 (20) 1 (7)

CR 7 (70) 13 (87)

Relapses n ¼ 8 n ¼ 15

1 (12) 6 (40) 0Æ345 NS

*n, number of cases except for those parameters in which other n is indicated.

d, days; SD, standard deviation; M, male; F, female; LDH, lactate dehydrogenase; IPI, International Prognostic Index;

NR, no response; PR, partial response; CR, complete response; NS, not significant. Haematopoietic organ involvement

includes bone marrow, spleen or liver. Significant differences in the clinical prognostic factors between the ALK+ and

ALK– ALCL were determined by the Exact Fisher test. Age distribution and time of evolution previous to diagnosis were

analysed by the Mann–Whitney U test.

Correspondence 877


features, T-cell intracellular antigen (TIA) expression andp16 and ⁄ or p15 methylation status. ALK, TIA and theInternational Prognostic Index (IPI) were also evaluated asoutcome predictors in the ALCL patients.

ALK-1, and anti-NPM antibodies were used for theimmunohistological study. RNA was isolated from 21 caseswith available frozen material (six ALCL, two DLBCL, onePTCL and 12 HL) and NPM-ALK chimaeric transcripts weredetected by nested reverse-transcription polymerase chainreaction (RT-PCR). The methylation status of p15INK4band p16INK4a genes was determined in 27 ALCL bymethylation-specific PCR (MSP) (Herman et al, 1996). Themethod of Kaplan and Meier, and the log-rank test wereused for the survival curves. A multivariate survival modelwas performed using logistic regression analysis.

Only ALCL patients expressed ALK protein (41%) or werepositive in the molecular study. Interestingly, one positivesample in the nested-PCR second round of amplification didnot show ALK staining. As shown in Table I, ALK+ ALCLpatients were significantly younger, had shorter evolutiontime prior to diagnosis, presented a higher incidence ofbulky disease and more frequently showed TIA-1 expressionthan the ALK– ALCL patients. p16 ⁄ p15 hypermethylationwas less frequently observed in the ALK+ ALCL than in theALK– ALCL. The 5-year overall survivals of ALK+ and ALK–

patients were comparable, the Kaplan–Meier survivalcurves being similar (P ¼ 0Æ778). Cytotoxic phenotypewas not associated with prognosis, but IPI was found tobe prognostically important. In the multivariate analysis,including sex, age, ALK expression and IPI, only IPI scorewas significantly associated with mortality [adjusted OddsRatio (OR) ¼ 4Æ7].

Our results support that ALK rearrangements are specificmarkers for T-null ALCL. Many of the �unspecific� findingsreported in the literature may be due to misdiagnosis or tothe use of very sensitive techniques that yield false-positiveresults, which seemed to be the case in our sample thatshowed discrepancies between the immunohistochemicaland molecular analyses. A high percentage of ALCL patientsexpressed TIA protein (68%), adding force to the hypothesisthat a cytotoxic-activated cell is the normal counterpart fornearly all these lymphomas.

Differences were not found in the 5-year overall survivalof the ALK+ and the ALK– ALCL, probably as a result of thesmall size of this series, but our data provide evidence thatIPI is able to predict outcome in ALCL. Both p16 and p15

methylation frequencies were lower in the ALK+ than in theALK– cases; this may contribute to the better outcomereported for the ALK+ patients. More studies are needed toassess whether these epigenetic anomalies are prognosticmarkers independent of ALK expression in ALCL.

Marıa J. Garcıa1

Jose M. Castrillo2

Juan J. Granizo3

Alicia Cazorla1

Carmen Rivas1

1Department of Pathology,2Department of Internal Medicine,and 3Department of EpidemiologyFundacion Jimenez Dıaz,Universidad Autonoma (UAM),Madrid, Spain. E-mail:[email protected]

ACKNOWLEDGMENTS

The authors wish to thank Professors Mason and Falini forkindly providing NMP antibodies.

REFERENCES

Beylot-Barry, M., Groppi, A., Vergier, B., Pulford, K. & Merlio, J.P.

(1998) Characterization of t(2;5) reciprocal transcripts and

genomic breakpoints in CD30+ cutaneous lymphoproliferations.

Blood, 91, 4668–4676.

Falini, B., Pileri, S., Zinzani, P.L., Carbone, A., Zagonel, V., Wolf

Peeters, C., Verhoer, G., Menestrina, F., Todeschini, G., Paulli, M.,

Lazzarino, M., Giardini, R., Aiello, A., Foss, H.D., Araujo, I.,

Fizzotti, M., Pelicci, P.G., Flenghi, L., Martelli, M.F. & Santucci, A.

(1999) ALK+ lymphoma: Clinico-pathological findings and out-

come. Blood, 93, 2697–2706.

Gascoyne, R.D., Aoun, P., Wu, D., Chhanabhai, M., Skinnider, B.F.,

Greiner, T.C., Morris, S.W., Connors, J.M., Vose, J.M., Viswana-

tha, D.S., Coldman, A. & Weisenburger, D. (1999) Prognostic

significance of anaplastic lymphoma kinase (ALK) protein

expression in adults with anaplastic large cell lymphoma. Blood,

93, 3913–3921.

Herman, J.G., Graff, J.R., Myohanen, S., Nelkin, B.D. & Baylin, S.

(1996) Methylation-specific PCR: a novel assay for methylation

status of CpG islands. Proceedings of the National Academy of Sci-

ences of the United States of America, 93, 9821–9826.

Orscheschek, K., Merz, H., Hell, J., Binder, T., Bartels, H. & Feller,

A.C. (1995) Large-cell anaplastic lymphoma-specific transloca-

tion [t(2;5)(p23;q35)] in Hodgkin’s disease: indication of a

common pathogenesis? Lancet, 345, 87–90.

Keywords: ALCL, ALK, p16INK4a ⁄ p15INK4b methyla-tion, TIA, outcome.

THE SUCCESSFUL USE OF PLASMA EXCHANGE AND IMMUNOSUPPRESSION

IN THE MANAGEMENT OF ACQUIRED GLANZMANN’S THROMBASTHENIA

We describe a patient with acquired Glanzmann’s throm-basthenia who developed a life-threatening gastrointestinalhaemorrhage. A combination of corticosteroids, azathio-prine and plasma exchanges led to normalization of plateletfunction and cessation of gastrointestinal bleeding. Themanagement was further complicated by the development

of heparin-induced thrombocytopenia associated with ileo-femoral thrombosis. This was successfully treated bymechanical embolectomy followed by anticoagulation withhirudin.

A 60-year-old woman presented with a 2 month historyof easy bruising. There was no past or family history of

878 Correspondence


bleeding. Clinical examination was normal. Investigationrevealed a near normal full blood count (haemoglobin10Æ6 g ⁄ dl, white cell count 6 · 109 ⁄ l with normal differ-ential counts, platelet count 321 · 109 ⁄ l), and normalrenal and liver function tests. Salicyclates were not detectedin urine. The activated partial thromboplastin time (APTT),prothrombin time, fibrinogen, individual coagulation factorsand von Willebrand factor were normal. Her bleeding timewas prolonged at > 15 min.

Platelet aggregation tests revealed no aggregation with2 lmol ⁄ l and 5 lmol ⁄ l ADP, 2 lmol ⁄ l and 5 lmol ⁄ ladrenaline, or with arachidonic acid, minimal aggregationto collagen (8%), weak responses to U46619 0Æ3 lmol ⁄ land 1Æ0 lmol ⁄ l (25% and 21%), and normal response toristocetin (85%) (PAP 4D; Alpha Laboratories, UK). Plateletnucleotides and 5-HT release were normal.

The patient’s platelets demonstrated normal levels ofglycoprotein (GP)IIb ⁄ IIIa and GPIb ⁄ IX expression by flowcytometry. The direct platelet immunofluorescence test waspositive. Her serum contained anti-GPIIb ⁄ IIIa. The plateleteluate contained auto anti-GPIIb ⁄ IIIa, GPIb ⁄ IX andGPIa ⁄ IIa [GTI PAK 12 enzyme-linked immunosorbentassay (ELISA); Quest, UK]. In mixing experiments, controlplatelets failed to aggregate to the agonists mentioned abovewhen exposed to the patient’s plasma. Flow cytometrystudies on activated platelets incubated with normal andpatient’s plasma were conducted using fluorescein isothio-cyanate-conjugated anti-PAC I (activated GPIIb ⁄ IIIa),phycoerythrin (PE)-conjugated anti-P selectin and PE-con-jugated anti-CD4 1 (non-activated GPIIb ⁄ IIIa) (BectonDickinson, UK). Analysis of gated platelets showed that thepatient’s antibody bound to both activated and non-activa-ted GPIIb ⁄ IIIa.

A diagnosis of acquired Glanzmann’s thrombastheniawas made. A month after her initial presentation, shewas admitted with severe gastrointestinal bleeding. Nofocal point was obvious despite extensive investigation.Prednisolone was commenced at 60 mg ⁄ d and sub-sequently azathioprine 100 mg ⁄ d was added. Despite this,gastrointestinal blood loss continued. Mixing experimentssuggested probable improvement in platelet function with

dilution of her plasma (Fig 1) and, therefore, plasmaexchanges were commenced. Twelve plasma exchanges(latterly through a femoral catheter kept patent withintraluminal heparin) resulted in normalization of herplatelet function and bleeding time with cessation ofgastrointestinal bleeding.

A week after insertion of the femoral line, her plate-let count fell to 50 · 109 ⁄ l and she developed a largefemoral deep venous thrombosis, extending into theright iliac vein. An ELISA demonstrated a heparin-plateletfactor 4 antibody with complete blockade by excessheparin and a diagnosis of heparin-induced thrombo-cytopenia with thrombosis was made. Anticoagulationwas commenced with hirudin after removal of the catheterand a mechanical right iliac vein thrombectomy wasperformed successfully. Hirudin was continued keeping anAPTT ratio of 2 for 2 weeks. Warfarin therapy was notinitiated.

Her gastrointestinal bleeding has not recurred. She isnow well 18 months after her presentation, and herimmunosuppressive treatment was tapered and stoppedover 1 year. Her recent platelet function was nor-mal and the platelet immunofluorescence tests werenegative.

Review of literature has revealed eight cases of acquiredGlanzmann’s thrombasthenia, most of them being associ-ated with lymphoproliferative disorders (reviewed by Maliket al, 1998). The successful outcome in this case wasprobably related to instituting plasma exchanges whileawaiting the effects of immunosuppressant therapy.Recombinant VIIa has also been used to treat bleeding inGlanzmann’s thrombasthenia (d’Orion et al, 2000; Patelet al, 2001).

R. V. Thomas1

H. Bessos2

M. L. Turner2

E. H. Horn1

C. A. Ludlam1

1Department of Haematology, RoyalInfirmary of Edinburgh, and2South-east Scotland BloodTransfusion Service, Edinburgh.E-mail: [email protected]

ACKNOWLEDGMENTS

We acknowledge Mr R. Wallace and Mr E. B. Thomson(Department of Haematology, Royal Infirmary of Edin-burgh, Edinburgh) for expert technical assistance. We arealso grateful to Sr. A. Stewart at the Cell Separator Unit,Royal Infirmary of Edinburgh, Edinburgh.

REFERENCES

Malik, U., Dutcher, J.P. & Oleksowicz, L. (1998) Acquired Glanz-

mann’s thrombasthenia associated with Hodgkin’s lymphoma:

a case report and review of the literature. Cancer, 82, 1764–

1768.

d’Orion, R., Menart, C., Trzeciak, M.C., Nurden, P., Fressinaud, E.,

Dreyfus, M., Laurian, Y. & Negrier, C. (2000) Use of recombinant

factor VIIa in 3 patients with inherited type I Glanzmann’s

thrombasthenia undergoing invasive procedures. Thrombosis and

Haemostasis, 83, 644–647.

Fig 1. Progressive improvement in aggregation of normal platelets

with increasing dilutions of patient’s plasma. Platelet-rich

plasma ¼ 150 · 109 ⁄ l. Incubation for 15 min. Ristocetin

1Æ5 lmol ⁄ l, ; collagen, ; ADP 2 lmol ⁄ l, m.

Correspondence 879


Patel, R.K., Savidge, G.F. & Rangarajan, S. (2000) Use of recombinant

factor VIIa for post-operative haemorrhage in a patient with

Glanzmann’s thrombasthenia and human leucocyte antigen

antibodies. British Journal of Haematology, 114, 245–246.

Keywords: acquired Glanzmann’s thrombasthenia, plasmaexchange, heparin-induced thrombocytopenia, mechanicalthrombectomy.

MANAGEMENT DILEMMA OF CARDIOPULMONARY BYPASS IN PATIENTS WITH TYPE II

HEPARIN-INDUCED THROMBOCYTOPENIA

We would like to share our most recent experience incarrying out cardiopulmonary bypass (CPB) in a patientwith type II heparin-induced thrombocytopenia (HIT II).

A 77-year-old woman was referred to our cardiothoracicunit with right axillary vein thrombosis secondary to rightatrial myxoma, an unusual presentation of a rare tumour.The patient was started on low molecular subcutaneousheparin (tinzeparin; innohep; Leo Laboratory, UK) at175 IU ⁄ kg once daily, which caused the platelet count tofall from 261 to 51 · 109 ⁄ l over 10 d. The subsequentenhanced enzyme-linked immunosorbent assay (GTI,Brookfield, USA), for detection of antibodies directed againstcomplexes of platelet factor-4 and polyvinyl sulphonate, waspositive. Heparin was stopped and the operation waspostponed. Fortunately, in this case, there was no associatedthrombosis as part of the HIT type II syndrome.

For the management of CPB, this case posed someclinical dilemmas. We considered three different strategiesin the management of this patient. The first was toproceed with the surgical resection under conventionalCPB with concomitant administration of a potent anti-platelet aggregation agent such as iloprost (Addonizio et al,1987), but this was deemed a dangerous option as iloprostcan disturb the haemodynamics owing to its vasodilatoryaction. The second option was to allow the HIT antibodiesto reach an undetectable level, which usually takes about100 d, before undergoing CPB with heparin re-exposure(Warkentin & Kelton, 1998). This option entailed aconsiderable delay with a significant risk of recurrentthromboembolic complications during the long serocon-version period. The third strategy was the avoidance ofa secondary immune response by performing CPButilizing a heparin substitute such as recombinant hirudin(r-hirudin) as the anti-coagulant agent for the CPB (Riesset al, 1996).

On the balance of risks and benefits of each strategy, thethird option seemed the most clinically attractive but thereis currently no available agent to reverse the anti-coagulanteffect of r-hirudin at the end of CPB, raising the risk of intra-and postoperative haemorrhage.

The operation was carried after a 12 d delay. Thepreoperative platelet count was 224 · 109 ⁄ l. A heparin-free CPB circuit was used; non-heparin-coated vascularcatheters were used in this patient. All catheter rinsingfluids were heparin-free. r-Hirudin (lepirudin; refludan;Hoechst, France) was used as the anti-coagulant for theCPB with the Ecarin Clotting Time (ECT) measured every15 min and the corresponding concentration of r-hirudincalculated; 0Æ25 mg ⁄ kg of body weight was used to primethe CPB circuit and 0Æ2 mg ⁄ kg body weight was given

followed by 0Æ5 mg ⁄min as a continuous infusion. Ther-hirudin concentration was maintained in the range of3Æ5–4Æ5 lg ⁄ml. The resection was carried out successfully.Because of its short half-life (approximately 1 h), r-hirudininfusion was stopped at the end of the procedure, allowingthe plasma level to decline rapidly and its anticoagulanteffect to be reversed before chest closure. The intraoperativeblood loss was 290 ml. There was no abnormal bleeding orfibrin formation in the extracorpeal circuit during the CPB.The postoperative course was unremarkable with nobleeding or thrombotic complications. The patient wasextubated and chest drains were removed at 6 and 23postoperative hours, respectively, with a total blood loss of320 ml. The patient was discharged to the referring hospitalon postoperative d 6 for cardiac rehabilitation.

Type II heparin-induced thrombocytopenia poses severalproblems for the conduct of CPB but, from our limitedexperience and the available data, r-hirudin could play arole in the management of CPB if strict control of the ECT isexercised. More research and clinical trials will hopefullylead to better insight and clinical practice.

R. A. G. Saad1

L. Horn2

P. S. Mankad3

1Department of PaediatricCardiothoracic Surgery, YorkhillHospital, Glasgow, 2Departmentof Haematology, Royal Infirmary ofEdinburgh, and 3Department ofCardiothoracic Surgery, RoyalInfirmary of Edinburgh, Edinburgh,UK. E-mail: [email protected]

REFERENCES

Addonizio, Jr, V.P. Fisher, C.A. & Kappa, J.R. & Ellison, X.X. (1987)

Prevention of heparin- induced thrombocytopenia during

open heart surgery with iloprost (ZK36374). Surgery, 102, 796–

807.

Riess, F.C., Potzsch, B., Bader, R., Bleese, N., Greinacher, A., Lower,

C., Madlener, K. & Muller-Berghaus, G. (1996) A case report on

the use of recombinant hirudin as an anticoagulant for cardio-

pulmonary bypass in open heart surgery. European Journal of

Cardiothoracic Surgery, 10, 386–388.

Warkentin, T.E. & Kelton, J.G. (1998) Timing of heparin-induced

thrombocytopenia (HIT) in relation to previous heparin use:

absence of an anamnestic immune response, and implications for

repeat heparin use in patients with a history of HIT. Blood, 92,

182a (Abstract).

Keywords: heparin, heparin-induced thrombocytopenia,cardiopulmonary bypass, hirudin, cardiac surgery.

880 Correspondence


EPCR 23 bp INSERTION IN A PATIENT WITH SEVERE PROGRESSIVE ARTERIAL DISEASE:

A DOMINANT LOSS OF FUNCTION MUTANT IN CONDITIONS OF INCREASED APC REQUEST?

Endothelial protein C receptor (EPCR) is a type I transmem-brane protein expressed in the endothelium of large vesselsthat accelerates the formation of activated protein C (APC)and seems to be involved in the regulation of inflammatoryresponse (Esmon et al, 1997).

We report the case of a previously healthy 33-year-oldwoman who developed a severe progressive, plurisegmen-tal arterial disease. The patient was a heavy smoker; shehad no family history of thrombophilia or other risk factorsfor vascular disease. In February 1998, she experiencedthe first thrombotic occlusion of the anterior and posteriorleft tibial arteries that led to left foot gangrene andsubsequent amputation. Since presentation, vessel involve-

ment has been associated with symptoms and signs ofsystemic disease, such as fever, malaise and weight loss.On admission to our department in March 1999, physicalexamination showed amputation of the left foot, adistrophic lesion of the right leg and absence of the rightradial pulse. Laboratory tests showed: elevated leucocytecount (19 · 109 ⁄ l) with neutrophilia (76%), mild thromb-ocytosis (500 · 109 ⁄ l), anaemia of chronic disease (Hb9Æ5 g ⁄ dl, ferritin 8Æ17 lg ⁄ l with normal transferrin andserum iron), and strikingly elevated erythrocyte sedimen-tation rate (ESR, 131 mm ⁄h), fibrinogen (7Æ65 g ⁄ l), a1, a2and a-globulins (10%, 22% and 18% respectively). Pro-thrombin time, partial thromboplastin time, anti-thrombin

A

B

C

Fig 1. (A) Schematic representation of the genomic structure of the EPCR gene. Coding exons are in black. (B) Results of the PCR amplification

of EPCR gene exon III in four control DNA samples (lanes 1–4) and in genomic DNA of the proband (lane 5). (C) Sequencing chromatograph of

the separated abnormal band in the region of the insertion. The 23 bp insertion is shown with the five predicted amino acids. The number

4024 refers to the position of the first G shown in the chromatograph.

Correspondence 881


III, protein C, protein S, homocysteine, folates, vitaminB12, lipid serum levels, complements C3 and C4, hepatitisC virus, hepatitis B virus, anti-cardiolipin antibodies, lupusanticoagulant, rheumatoid factor, Waaler–Rose, anti-neu-trophil cytoplasmic antibodies, anti-DNA and anti-extract-able nuclear antigen antibodies, and tumour serologicalmarkers were normal. Blood cultures were persistentlynegative. Trans-thoracic echocardiography, total-bodycomputerized tomography, esophagogastroscopy andcolonscopy were normal.

The patient never stopped smoking. She was treatedwith prednisone (1 mg ⁄ kg ⁄ d for 1 month), vasodilators,oral anticoagulation, wide-spectrum antibiotics andreceived a short course of cyclophosphamide (2 mg ⁄ kgdaily).

The disease underwent a catastrophic progression with apartial occlusion of the right tibial and the left humeralarteries (documented by arteriography), and the occlusionof the right humeral artery, leading to hand gangrene andamputation. After surgery, a ventilation-perfusion lungscan showed diffuse pulmonary thromboembolism and anultrasonographic Doppler examination, performed becauseof increased liver-enzyme values, showed a partial occlusionof the celiac-trunk arteries.

Finally, 2 months from admission, she developed bacterialendocarditis of the mitral valve and died from heart failure.

Factor V Leiden, prothrombin G20210A, I278T andA114V mutations of cystathionine-b-sinthase were negat-ive. Homozygosity for the thermolabile variant of themethylene-tetrahydrofolate-reductase was found, but homo-cysteine levels were normal. Polymerase chain reaction(PCR) amplification of EPCR-gene exon 3 (forward primer5¢-CATAGTTCCCTGACCTAAAC-3¢, reverse 5¢-CCGGAAAC-TCACAAAGGAGC-3¢) (Simmonds & Lane, 1999) revealed alarger size band (Fig 1A and B) due to a 23 bp insertionidentical to that previously reported (Merati et al, 1999)(Fig 1C), leading to a 5-amino-acid insertion and a prema-ture stop.

This rare mutation predicts a truncated protein retainedinside the cell and an inability to sustain protein C (PC)activation (Biguzzi et al, 2001). It has been reported inarterial and venous thrombosis (Biguzzi et al, 2001), and inassociation with fetal loss (Franchi et al, 2001). In ourseries, this is the only positive case among six patients withperipheral artery occlusive disease studied.

Although this loss of function mutation is well toleratedin basal conditions, the reduced PC activation capacityprobably becomes critical in conditions requiring increasedAPC production, such as thrombosis, sepsis and inflamma-tion. A marked cytokine production associated with theseconditions might downregulate the normal EPCR allele, as

shown in an in vitro model where tumour necrosis factor-adownregulated EPCR expression in cell cultures (Fukudome& Esmon, 1994), and further reduce APC synthesis.

This hypothetical model of relative haploinsufficiencymight explain the catastrophic progression of the disease inour patient, once an environmental trigger has initiated thefirst thrombotic occlusion.

Gabriella Zecchina

Sandra Bosio

Elena Brusa

Giovanna Rege-Cambrin

Clara Camaschella

Dipartimento di ScienzeCliniche e Biologiche,Universita di Torino, AziendaOspedaliera San Luigi,Orbassano, Torino, Italy.E-mail: [email protected]

ACKNOWLEDGMENT

This work was partially supported by MURTS 40% to C.C.

REFERENCES

Biguzzi, E., Merati, G., Liaw, P.C.Y., Bucciarelli, P., Oganesyan, N.,

Dongfeng, Q., Gu, J.M., Fetiveau, R., Esmon, C.T., Mannucci,

P.M. & Faioni, E. (2001) A 23bp insertion in the Endothelial

Protein C Receptor (EPCR) gene impairs EPCR function. Throm-

bosis and Haemostasis, 86, 945–948.

Esmon, C.T., Ding, W., Yasuhiro, K., Gu, J.M., Ferrell, G., Regan,

L.M., Stearns-Kurosawa, D.J., Kurosawa, S., Mather, T., Laszik, Z.

& Esmon, N.L. (1997) The protein C pathway: new insights.

Thrombosis and Haemostasis, 78, 70–74.

Franchi, F., Biguzzi, E., Cetin, I., Facchetti, F., Radaelli, T., Bozzo,

M., Pardi, G. & Faioni, E.M. (2001) Mutations in the thrombo-

modulin and endothelial protein C receptor genes in women with

late fetal loss. British Journal of Haematology, 114, 641–646.

Fukudome, K. & Esmon, C.T. (1994) Identification, cloning and

regulation of a novel endothelial cell protein C ⁄ activated

protein C receptor. Journal of Biological Chemistry, 269, 26486–

26491.

Merati, G., Biguzzi, E., Oganesyan, N., Fetivau, R., Qu, D., Buc-

ciarelli, P., Stearns-Kurosawa, D.J., Mannucci, P.M., Esmon,

C.T. & Faioni, E.M. (1999) A 23bp insertion in the Endothelial

Protein C Receptor (EPCR) Gene in patients with myocardial

infarction and deep vein thrombosis. Thrombosis and Haemos-

tasis, 82, 507.

Simmonds, R.E. & Lane, D. (1999) Structural and functional

implications of the intron ⁄ exon organization of the human

Endothelial cell Protein C ⁄Activated protein C Receptor (EPCR)

gene: comparison with the structure of CD1 ⁄Major Histocom-

patibility Complex a1 and a2 domains. Blood, 94, 632–641.

Keywords: arterial thrombosis, protein C activation,

thrombophilia, inflammation.

B1 2 DEFICIENCY: NOT AN UNCOMMON GENETIC-RELATED DISORDER

We read with interest the recent article of Gielchinsky et al(2001a). Following their initial finding of a high prevalenceof decreased serum B12 levels among adult Ashkenazi

Jewish patients with type I Gaucher (Gielchinsky et al,1997), they also observed similar findings among untreatedpatients, as well as in their neighbour control subjects

882 Correspondence


(43Æ8%, 40Æ0% and 31Æ0% respectively) (Gielchinsky et al,2001a). Furthermore, the authors noted a high incidence ofdiminished B12 levels in healthy blood donors, eitherAshkenazi (22%) or of Tunisian, Yemenite, or Iraqi origin(37Æ5%, 21Æ1% and 18Æ6% respectively) (Gielchinsky et al,2001a). Subsequently they suggested that inherited trans-cobalamin (TCB) deficiency, besides a possible environmen-tal impact, might have a role in the wide spectrum of B12

deficiency states (Gielchinsky et al, 2001b). However, thisleads us to add the following comments.

The authors did not mention whether or not theirfindings of decreased levels of serum B12 were correlatedwith the frequency and number of blood donations ineach ethnic group. In four Ashkenazi, non-vegan males,we previously reported low B12 levels (142, 107, 91 and94 pmol ⁄ l respectively; mean level 108 pmol ⁄ l; normalrange 130–660 pmol ⁄ l) (Delpre & Niv, 1999). All hadbeen regular blood donors, making 2–3 donations yearly,for periods of as long as 30 years, i.e. as many as 60–90donations per person. Indeed, the sole laboratory abnor-malities were slightly low levels of TCB-I and normal butlow levels of TCB-III. We suggest that repeated blood dona-tions over a period of many years might result in B12

deficiency, due to chronic loss of serum B12 and furtherdepletion of hepatic stores. Decrease in TCB may be bothprimary (genetically predisposed) and secondary (chronicdepletion). Therefore, regular screening for B12 deficiencyshould be advised in cases of multiple blood donations andin patients on chronic intermittent plasmapheresis.

It is of notable interest that subnormal TCB-I levels havebeen previously observed among as many as 20 out of 106(18Æ9%) patients with low B12 levels (< 190 ng ⁄ l) (Carmelet al, 1996), raising the possibility of a heterozygous statewith milder form of TCB-I deficiency.

Moreover, the importance of racial and ethnic factors inB12 metabolism and its disorders is well recognized, asrecently reviewed by Carmel (1999), who reported signifi-cantly higher levels of cobalamin as well as TCB (mainlyTCB-II), among blacks.

Furthermore, there is a great deal of concern aboutcobalamin measurements, definition of the normal reference

range of cobalamin and the interpretation of borderlinelevels in a given population devoid of any manifestation ofB12 deficiency, not least in the ageing population of manycountries. Thus, genetic aspects, as part of the complexity ofthe B12 deficiency spectrum, merit further investigation.This will provide a better understanding, enabling earlierrecognition and an effective therapeutic approach.

Georges Delpre1

Pinhas Stark2

Yaron Niv1

1Department of Gastroenterology,and 2Institute of Haematology,Rabin Medical Centre, and SacklerFaculty of Medicine, Tel AvivUniversity, Tel Aviv,Israel. E-mail: [email protected]

REFERENCES

Carmel, R. (1999) Ethnic and racial factors in cobalamin metabo-

lism and its disorders. Seminars in Hematology, 36, 88–100.

Carmel, R., Montes-Garces, R., Wardinsky, T. & Liebman, H. (1996)

Mild transcobalamin (TC) I deficiency is common and may be

responsible for many low serum cobalamin levels: Observation in

a family and survey of 106 patients with low serum cobalamin

levels not explained by malabsoption. Blood, 88, 646a.

Delpre, G. & Niv, Y. (1999) Significance of B12 deficiency in long-

term blood donors. Gastroenterology, 116, 55a.

Gielchinsky, Y., Elstein, D., Algur, N., Abrahamov, A., Shinar, E.,

Green, R. & Zimran, A. (1997) Study of B12 levels in patients

with type I gaucher disease uncovers high prevalence of vitamin

B12 deficiency in non-aged, multi-ethnic Israeli population.

Blood, 90, 14b.

Gielchinsky, Y., Elstein, D., Abrahamov, A., Green, R., Miller, J.W.,

Elstein, Y., Algur, N., Lahad, A., Shinar, E. & Zimran, A. (2001a)

High prevalence of low serum B12 in multi-ethnic Israeli popu-

lation. British Journal of Haematology, 115, 707–709.

Gielchinsky, Y., Elstein, D., Abrahamov, A. & Zimran, A. (2001b)

How B12 deficiency can impact on the individual and how society

can impact on B12 deficiency. Israel Medical Association Journal, 3,

672–674.

Keywords: B12 deficiency, transcobalamin deficiency,

blood donation, racial and ethnic factors.

THALIDOMIDE IN COMBINATION WITH CYCLOPHOSPHAMIDE AND DEXAMETHASONE

(THACYDEX) IS EFFECTIVE IN SOFT-TISSUE PLASMACYTOMAS

Blade et al (2001) have reported on the use of thalido-mide in 17 patients with heavily pretreated, resistantmultiple myeloma (MM), including five patients withextramedullary plasmacytomas. Nine patients (53%) re-sponded to thalidomide. Three of them achieved a partialresponse and six a minimal response (35%). However,none of the five patients with extramedullary plasmacy-tomas responded to thalidomide, which the authorssuggest indicates the limited efficacy of thalidomide insoft-tissue plasmacytomas. There is increasing evidencethat thalidomide is active as a single agent in refractoryMM, where it leads to 35–50% of responses. However, the

response results in extramedullary disease are debatable.In line with the experience of Blade et al (2001), Myerset al (2001) have recently reported a lack of response tothalidomide in three patients with plasmacytomas. Incontrast, Biagi et al (2001) highlighted three cases ofrelapsed extramedullary MM, following allogeneic bonemarrow transplantation, who had responded to thalido-mide. Thus, according to these reports, no definitiveconclusion can be established.

We have been using thalidomide in combination withcyclophosphamide and dexamethasone (ThaCyDex) forrelapsed ⁄ refractory MM (Garcia-Sanz et al, 2002). Patients

Correspondence 883


received thalidomide at escalating doses (200–800 mg ⁄ d),daily oral cyclophosphamide (50 mg ⁄ d) and pulsed dexa-methasone (40 mg ⁄ d, 4 d every 3 weeks). Most patientstolerated the treatment well and the overall response was76%. Here, we specifically report on five patients withrelapsed ⁄ refractory extramedullary MM. Three of the fivepatients responded to ThaCyDex treatment. The firstpatient, aged 65 years, had an abdominal plasmacytomarefractory to chemo ⁄ radiotherapy, with multiple skin nod-ules when ThaCyDex was started. He achieved completeresponse with disappearance of all plasmacytomas. Thesecond patient, aged 58 years, had a Bence–Jones MM withplasmacytomas localized in the sacrum and spine thatrelapsed with multiple cutaneous plasmacytomas after8 years. With the first cycle, a reduction in the urineM-protein was noted (from 10Æ5 to 3Æ5 g ⁄24 h) and allcutaneous plasmacytomas disappeared. The third patient,aged 60 years, had an IgA-k MM that progressed afterautologous stem cell with a small M-component and soft-tissue clavicular plasmacytoma that was refractory toradiotherapy and vinorelbine. With ThaCyDex, he achievedpartial response, demonstrated by a decrease in the size ofthe tumour though the IgA M-component persisted. In thetwo remaining patients, the plasmacytomas progressed after6 months of ThaCyDex, although both cases displayed aninitial reduction in the M-component that was sustained foronly 2 and 5 months.

Thalidomide has immunomodulatory and antiangiogenicproperties responsible for activity in MM and other types ofcancer. Its efficacy as a single agent in soft-tissue plasma-cytomas is debatable. Thalidomide could act synergisticallywith corticosteroids and chemotherapy (Singhal & Mehta,2002). It has been reported that thalidomide enhances theanti-MM activity of dexamethasone (Hideshima et al, 2000)and it is probable that thalidomide and dexamethasoneinfluence separate pathways involved in cytokine generegulation (Rowland et al, 1998; Hideshima et al, 2000). Inthree of the five cases reported here, the combination waseffective, suggesting that given the possible synergistic effectof thalidomide with other drugs, it should not be excluded,

at least in combination protocols, in MM patients withplasmacytomas.

J. R. Gonzalez-Porras

M. Gonzalez

R. Garcıa-Sanz

J. F. San Miguel

Servicio de Hematologia,Hospital Clinico Universitario,Salamanca, Spain.E-mail: [email protected]

REFERENCES

Biagi, J.J., Mileshkin, L., Grigg, A.P., Westerman, D.W. & Prince,

H.M. (2001) Efficacy of thalidomide therapy for extramedullary

relapse of myeloma following allogeneic transplantation. Bone

Marrow Transplantation, 28, 1145–1150.

Blade, J., Perales, M., Rosinol, L., Tuset, M., Montoto, S., Esteve, J.,

Cobo, F., Villela, L., Rafel, M., Nomdedeu, B. & Montserrat, E.

(2001) Thalidomide in multiple myeloma: lack of response of

soft-tissue plasmacytomas. British Journal of Haematology, 113,

422–424.

Garcia-Sanz, R., Gonzalez-Fraile, M.I., Sierra, M., Lopez, C.,

Gonzalez, M. & San Miguel, J.F. (2002) The combination of

thalidomide, cyclophosphamide and dexamethasone (ThaCyDex)

is feasible and can be an option for relapsed ⁄ refractory multiple

myeloma. Hematological Journal, 3, 43–48.

Hideshima, T., Chauhan, D., Shima, Y., Raje, N., Davies, F.E., Tai,

Y.T., Treon, S.P., Lin, B., Schlossman, R.L., Richardson, P.,

Muller, G., Stirling, D.I. & Anderson, K.C. (2000) Thalidomide

and its analogs overcome drug resistance of human multiple

myeloma cells to conventional therapy. Blood, 96, 2943–2950.

Myers, B., Grimley, C., Crouch, D. & Dolan, G. (2001) Lack of

response to thalidomide in plasmacytomas. British Journal of

Haematology, 115, 234.

Rowland, T.L., McHugh, S.M., Deighton, J., Dearman, R.J.,

Ewan, P.W. & Kimber, I. (1998) Differential regulation by tha-

lidomide and dexamethasone of cytokine expression in human

peripheral blood mononuclear cells. Immunopharmacology, 40,

11–20.

Singhal, S. & Mehta, J. (2002) Thalidomide in cancer. Biomedical

Pharmacotherapy, 56, 4–12.

Keywords: thalidomide, soft-tissue plasmacytoma, multiplemyeloma, ThaCyDex.

884 Correspondence


clinicopathological correlation, p16-p15 methylation status and outcome predictors in anaplastic...

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