The effect of DNR and MIT on erythrocyte membrane structure was examined using Electron Spin Resonance spectroscopy and the fluorimetric technique. The results suggest that the in vivo interaction of the drugs with the RBCs of AML patients led to a perturbation in the structure of plasma membrane components. Differences between DNR and MIT were only noted in the interaction of the drugs with deeper regions of the lipid bilayer

We report the case of a 23-year-old female with severe neurologic dysfunction without a clear cause at the time of initial presentation. The search for an underlying malignancy revealed a slightly enlarged cervical lymph node with Hodgkin's disease (HD). There was no evidence of a brain tumor despite nonspecific bright changes in proton density in the basal ganglia of the right hemisphere of the cerebellum, right cerebellar tonsil, posterior limb of the internal capsule, and the right side of the medulla spinae as shown by magnetic resonance imaging (MRI) as well as reactive lymphocytosis with slightly elevated protein levels in the cerebrospinal fluid (CSF). The findings suggested a cerebellar disorder, with main differential diagnosis between neurologic paraneoplastic syndrome (NPS) and HD involving the CNS. Based on limited experience with NPS and HD in the CNS, possible diagnostic and therapeutic options are discussed.

Cutaneous presentation of B-cell chronic lymphocytic leukaemia (B-CLL) is uncommon, and the influence of skin changes on B-CLL prognosis is unclear. We report a patient with B-CLL Rai II, with multiple nodular skin infiltrations on the trunk, upper arms and thighs as well as constitutional symptoms, who was successfully treated with cladribine. The peripheral blood (PB) lymphocytes were CD19, CD20, CD23 and CD5 positive, which confirmed the diagnosis of B-CLL. Skin biopsy of one of the lesions showed an intense infiltrate composed of small lymphocytes with no epidermotropism. These cells also showed the expression of CD19, CD20, CD23 and CD5 antigens similar to those presented on PB lymphocytes. Polymerase chain reaction perfomed on bone marrow lymphocytes and a lesional skin biopsy using consensus primers for immunoglobulin heavy-chain genes also showed the same monoclonal population of B lymphocytes both in the bone marrow and in the skin. The patient received four courses of cladribine 0.12 mg kg(-1) daily as a 2-h infusion for five consecutive days. The courses were repeated at monthly intervals. The lymphocytosis gradually decreased and the PB count normalized after three courses. At the same time, a significant decrease in the cutaneous symptoms was observed. The patient became free of skin tumours after the fourth course of cladribine; only slight discoloration at the previous sites of cutaneous infiltration remained. There was no relapse of leukaemia cutis during a further 7 months of observation.

Abstract: Patients with chronic lymphocytic leukemia (CLL) may develop a large‐cell transformation known as Richter's syndrome (RS). RS usually presents as diffuse large‐cell lymphoma (DLCL) or its immunoblastic variant, and it can be recognized simultaneously with CLL or even 23 yr after its diagnosis. We describe an unusual case of CLL treated with cladribine (2‐CdA) in whom DLCL of the plasmablastic type (PBL) developed 4 yr after CLL (Rai IV) diagnosis and 1.5 yr after the 10th course of 2‐CdA treatment. Immmunologic, cytogenetic, and molecular studies performed at the time of CLL and PBL coappearence indicated that both tumors originated from different B‐cell progenitors. Both malignancies were refractory to VAD (vincristine, doxorubicin, dexamethasone)‐based chemotherapy, and only partial response was achieved with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) salvage treatment. However, the patient died 6 months after the occurrence of RS due to rapid progression of PBL. This is the first description of a CLL patient who developed an unusual plasmablastic variant of RS. Recently, the PBL entity has been identified among DLCL associated with the human immunodeficiency virus (HIV) infection. We suggest that in our CLL patient heavily pretreated with 2‐CdA, PBL arose as a second clone due to the prolonged and severe state of the host's immunosuppression. Overall survival with current strategies is poor, and further insight into the natural history, biology, and treatment of PBL are needed.

On the basis of a retrospective study of 327 patients with Hodgkin's disease (HD), the prognostic significance of several factors, accepted previously and recently proposed, has been analyzed with regard to response to treatment and the survival time. Multivariate regression analysis strongly decreased the number of potentially prognostic parameters. The only independent, pretreatment factors negatively influenced by either time of survival or response to treatment were the following: age at diagnosis of more than 45 years, advanced (IIIB/IV) clinical stage, poor clinical status according to Karnofsky's scale (score less than 70), presence of systemic symptoms, mixed cellularity/lymphocyte depletion histological type, multisite peripheral nodal localization of the disease, abdominal lymphadenopathy, and large primary tumor mass (bulky disease), Short time to achieve complete remission (during the first four courses of chemo therapy) has proven to be significantly positive predictive factor. Cumulative dose of cytostatics lower than programmed was a significantly negative prognostic factor that correlated with a shorter time of survival, Lack of or a too-low dose of radiotherapy had the same predictive value, High activity of serum lactate dehydrogenase correlated moderately with poor response to the first-line treatment but did not influence the survival time. Other clinical, morphological, and biochemical parameters influenced neither the prognosis nor the response to treatment, Additionally, immunohistochemical examinations for proliferating cell nuclear antigen and the protein products of the p53 and bcl-2 genes were performed on the lymph nodes obtained from the patients with HD, High expression of proliferating cell nuclear antigen, p53, and BCL-2 correlated with poor response to the treatment and/or short time of survival. Statistical analysis has led us to the conclusion that the pretreatment expression of these oncoproteins can be taken into consideration as a new prognostic factor in HD.

The efficacy and toxicity of cladribine (2-CdA) + prednisone (P) versus chlorambucil (Chl) + P were compared in previously untreated patients with progressive or symptomatic chronic lymphocytic leukemia (CLL) in a randomized, multicenter prospective trial. Eligible patients were assigned to either 2-CdA 0.12 mg/kg per day in 2-hour infusions and P 30 mg/m(2) per day for 5 consecutive days or Chl 12 mg/m(2) per day and P 30 mg/m(2) per day for 7 consecutive days. Three courses were administered at 28-day intervals or longer if myelosuppression developed. The therapy was finished if complete response (CR) was achieved. Of 229 available patients 126 received 2-CdA+P and 103 received Chl+P as a first-line treatment. CR and overall response rates were significantly higher in the patients treated with 2-CdA+P (47% and 87%, respectively) than in the patients treated with Chl+P (12% and 57%, respectively) (P = .001). Progression-free survival was significantly longer in the 2-CdA-treated group (P = .01), but event-free survival was not statistically different. Thirteen percent of patients were refractory to 2-CdA+P and 43% to Chl+P (P = .001). Drug-induced neutropenia was more frequently observed during 2-CdA+P (23%) than Chl+P therapy (11%) (P = .02), but thrombocytopenia occurred with similar frequency in both groups (36% and 27%, respectively). Infections were seen more frequently in the 2-CdA+P-treated group (56%) than in the Chl+P-treated group (40%; P = .02). Death rates have so far been similar in patients treated with 2-CdA (20%) and with Chl (17%). The probability of overall survival calculated from Kaplan-Meier curves at 24 months was also similar for both groups (78% and 82%, respectively). (Blood. 2000;96:2723-2729)

The aim of our phase II study was to determine the effectiveness of combined chemotherapy consisting of 2-hour intravenous infusion of 2-CdA, mitoxantrone and dexamethasone (CMD) regimen in the treatment of heavily previously treated patients with refractory or relapsed low grade non-Hodgkin's lymphoma (LGNHL). All of the 14 patients had clinical stage IV disease, most of them had B symptoms and elevated LDH levels. All cases were refractory to standard chemotherapy or had recurrent relapses having received at least 5 courses of prior chemotherapy. All patients received at least one cycle of CMD (range, 14). A total of 35 courses of CMD were given to the entire group. Complete response (CR) was obtained only in one patient (7.1%) and partial response (PR) in 3 (21.4%) with an overall response rate of 28.5%. The major toxicity was myelosuppression and 35% of the patients had infection. One patient died of sepsis. These results suggest that the addition of other drugs to 2-CdA in heavily treated patients with refractory or relapsing disease may not be more advantageous when composed to giving 2-CdA alone.

Expression of proliferating cell nuclear antigen (PCNA) as well as p53, bcl-2 and C-erb B-2 genes protein products on Reed-Sternberg/Hodgkin's (R-S/H) cells was analyzed by immunohistochemistry in 65 patients with Hodgkin's disease (HD). Their significance as markers of clinical malignancy and prognostic factors was evaluated. Positive reaction for PCNA was present in 57 cases (87.7%), for p53 in 42 (64.6%), for bcl-2 in 41 (63.1%), and for C-erb B-2 in 38 cases (58.5%) of HD. The high proliferate PCNA index and high expression of p53 and bcl-2 correlated with poor response to the treatment. Expression of both p53 and bcl-2 oncoproteins negatively influenced overall survival and disease free survival. Indexes of PCNA, p53 and bcl-2 were significantly higher in patients with advanced disease then in early clinical stages. In LP type of HD the lowest indexes of PCNA or bcl-2, and even lack of bcl-2 expression on R-S/H cells were observed. There was no correlation between expression of C-erb B-2 and response to the treatment, time of survival, clinical stage or histopathological types of HD. Statistical analysis let us to the conclusion, that indexes of PCNA, p53 and bcl-2 expression can be taken into consideration as a new prognostic factors in Hodgkin's disease. C-erb B-2 protein expression seems to be of no value for prognosis in HD.

Acute promyelocytic leukemia (APL) is a distinct subtype of acute myeloid leukemia (AML). It is characterized by an arrest of differentiation at the promyelocytic stage. APL is consistently associated with translo cation between the long arms of chromosomes 15 and 17 - t(15;17). The translocation leads to fusion of the genes for PML (promyelocytic leukemia) on chromosome 15 with the gene encoding the retinoic acid receptor a (RARa). The fusion protein PML/RARa is believed to cause APL. At initial presentation the coagulopathy associated with APL is often present. Standard chemotherapy (Daunorubicine + ARA-C) increases the risk of early fatal hemorrhage by exacerbating coagulopathy and due to decreases of the platelet count.

Autoimmune haemolytic anaemia (AIHA) is one of the major complications in chronic lymphocytic leukaemia (CLL). Treatment with alkylating agents and the adenosine analogue, fludarabine, might trigger the development of AIHA in CLL patients despite the reduction of leukaemic clone. The influence of 2-chlorodeoxyadenosine (2-CdA) on AIHA in patients with CLL is undefined so far. In a group of 114 patients treated at our clinics with this agent, AIHA with direct antiglobulin test (DAT) positively was observed in 25 (21.9%) patients. In 23 patients AIHA was noticed before the starting of 2-CdA and in 2 patients DAT became positive after 2-CdA treatment. In 6 patients the drug caused complete resolution of haemolysis and DAT became negative. Eight patients exhibited partial resolution of haemolysis with significant improvement in haemoglobin level but DAT test remained positive. In 11 patients there was no response to 2-CdA in relation to autoimmune haemolysis. Two patients with no previous history of haemolysis developed AIHA after 5 and 6 courses of 2-CdA therapy and their DAT became positive 1-2 months after the last course of the drug. One of them entered severe haemolytic crisis and severe thrombocytopenia and died because of haemorrhagy to the central nervous system. In the other patient AIHA was controlled by steroids and chlorambucil treatment. Our study indicates that 2-CdA may suppress autoimmunohaemolytic process in some patients with CLL and trigger the development of AIHA in others.

Abstract: Eosinophilia and allergic skin reactions are uncommon events after 2‐chlorodoxyadenosine (2‐CdA, cladribine) administration. A multicentre retrospective analysis of eosinophilia in 360 patients treated with 2‐CdA for lymphoid malignancies has been made. B‐cell chronic lymphocytic leukaemia (B‐CLL) was diagnosed in 153, hairy cell leukaemia (HCL) in 68, low‐grade non‐Hodgkin's lymphoma (LGNHL) in 119, high‐grade NHL in 2 and Waldenström's macroglobulinaemia (WM) in 18 patients. 2‐CdA was administered at a dose 0.12 mg/kg/d in 2‐h intravenous infusion for 5 consecutive d. The courses were repeated monthly. Patients with HCL received 1 cycle of 2‐CdA, with NHL 2 – 6 (mean 3.5) cycles and with B‐CLL 3 – 6 (mean 5) cycles. Twenty patients (5.5%), including 5 with HCL, 6 with LGNHL, 7 with B‐CLL and 2 with WM, developed peripheral blood eosinophilia. The mean values of absolute eosinophil count were 0.78×109/l (0.58 – 1.06×109/l), 0.71×109/l (0.52 – 1.3×109/l), 85 (0.56 – 1.82×109/l) and 0.75 (0.74 – 0.76×109/l), respectively. Eosinophilia occurred in 13 patients after 1 course, in 4 after 2 courses, and in 5 after ≥3 courses of the therapy. In 17 cases it resolved spontaneously. Allergic skin lesions with pruritus were noticed in 3 patients simultaneously with an increase in eosinophil count. All of them required antihistaminic drugs and/or corticosteroids. One patient with B‐CLL experienced repeated episodes of eosinophilia. The highest incidence of 2‐CdA‐induced eosinophilia was noticed in patients with MW (11.1%) and HCL (7.4%) who received only 1 cycle of this drug and entered a complete remission. This side effect was less frequently observed in LGNHL and B‐CLL, i.e. in 5.0% and 4.6% of cases, respectively. The mechanism of 2‐CdA‐induced eosinophilia is not clear. It has been postulated that massive tumour cell lysis may trigger a release of IL‐5 and probably other cytokines. The allergic mechanism of 2‐CdA‐induced eosinophilia is also possible, especially in patients with simultaneous skin reactions.

2-Chlorodeoxyadenosine (2-CdA) is a new antimetabolite chemotherapeutic agent active in indolent lymphoid malignancies. In this retrospective study, 69 previously untreated patients with B-cell chronic lymphocytic leukaemia (B-CLL) were treated with 2-CdA administered at a dose of 0.12mg/kg daily in 2-h intravenous infusion for 5 consecutive days. 45 patients also received prednisone 30mg/m2 orally each day for 5 days starting with 2-CdA courses. Patients were given 2–6 courses (mean 4.6) of 2-CdA repeated usually at monthly intervals. If a complete response was achieved, no further 2-CdA courses were administered. Guidelines for response were those developed by the NCI Sponsored Working Group. Complete response (CR) was achieved in 26 (38%) and partial response (PR) in 27 (39%) cases, giving an overall response rate of 77%. 16 patients (23%) did not respond to 2-CdA. In the subgroup of 45 patients receiving 2-CdA with prednisone, CR was obtained in 15 (33%) and PR in 20 (44%) patients giving an overall response rate of 78%. CR was achieved in 11 (46%) out of 24 patients treated only with 2-CdA and in 7 cases (29%) PR was observed, giving an objective response rate of 75%. The differences between both subgroups were not statistically significant. However, we observed a relationship between the response and the number of courses of 2-CdA given in patients receiving and those not receiving prednisone. In the subgroup receiving 2-CdA with prednisone, an earlier response to 2-CdA was observed. In this group a response was achieved in 9 (20%) patients after two courses of 2-CdA and in 18 (40%) after four courses. In the subgroup receiving only 2-CdA, 17 (71%) responses were obtained after six cycles.

In 1982, the French–American–British (FAB) cooperative group proposed a classification of myelodysplastic syndromes (MDS) based on morphological features in blood and bone marrow, namely on medullary and peripheral blast count, Auer rods, ring sideroblasts and the number of monocytes in the peripheral blood. This classification has been used for numerous studies regarding morphology, prognosis and treatment of MDS. Some details of this morphological classification remained unclear, and some patients were unclassifiable. A working group of the World Health Organization (WHO) recently proposed a new classification of MDS, based on a significant modification of the original FAB proposals. CMML and RAEB-T were removed from the MDS classification and RAEB was split into two groups with medullary blast counts below and above 10%. In addition, a group of patients with less than 5% medullary blasts but evidence of multilineage dysplasia was defined. MDS patients with 5q− as the sole chromosomal anomaly were also considered a separate group. The aim of the present study was to validate the new classification with respect to prognostic importance, and to correlate it with cytogenetic and hematological features in a large series of patients (n=1600) with a long-term follow up. We were able to confirm a significant difference in prognosis between RAEB I and RAEB II, as well as a difference between refractory anemia and multilineage dysplasia. Furthermore, patients with 5q− anomaly had a much better prognosis than other WHO subtypes, but this was only true for patients with a medullary blast count below 5%. In summary, the WHO classification appears to define morphological subgroups that are more homogeneous with respect to prognosis than the FAB subtypes.