Quercetin, Menadione, Doxorubicin combination as a potential alternative to Doxorubicin monotherapy of acute lymphoblastic leukemia

Doxorubicin is a widely used chemotherapeutic drug, effective on patients with acute lymphoblastic leukemia but associated with significant long term cardio-toxicity. Menadione (vitamine K3) and the flavonoid quercetin are known as strong apoptogens in human leukemia Jurkat T cells. We explored the potential synergic cytotoxic effects of doxorubicin in association with quercetin and Menadione in this cellular model for acute lymphoblastic leukemia. Cellular viability, apoptosis, necrosis oxidative stress and cellular cycle were determined by flow cytometry utilizing Jurkat lymphoblasts labeled with Annexin V-FITC/7-AAD, CM-H2DCFDA/7-AAD and propidium iodide respectively. Results indicate a dose-dependent oxidative-stress generation, cell cycle arrest and apoptosis induction by doxorubicin alone, correlated with a decrease of the required doses when the anticancer drug was associated with quercetin and menadione, hence supporting the theory of an additive cytotoxic effect on leukemia cells. Introducing QC-MD combinations in leukemia doxorubicin-based treatment could significantly increase the treatment’s efficacy. The main mechanism responsible for this effect appears to be the increase in DOX affinity for DNA, which enables lowering of the therapeutic dose.

Clonal evolution in a patient with aplastic anemia – case report

Background: Aplastic anemia (AA) is a rare and serious disease characterized by pancytopenia and hypoplastic bone marrow in the absence of infiltrates/fibrosis. It occurs more frequently in childhood and young adulthood (10-30 years) and with older age (>60 years), with equal distribution among men and women. As hypoplastic myelodysplastic syndromes (hMDS) are also associated with cytopenia and hypocellular marrow,they may be difficult to differentiate from AA. The presence of dysplastic features (others than erythroid) and/or blast cells >5% is essential to distinguish hMDS from AA. Cytogenetic tests may reveal clonal evolution in hMDS. As the two disorders differ greatly in means of management and prognosis, the correct diagnostic is very important. Case presentation: We report the case of a 39 years old female diagnosed in 2005 (at age 29) with aplastic anemia. She received treatment with corticosteroids, Cyclosporine, blood transfusions and growth factors with partial response and no transfusion independency. After 8 years of evolution she developed dysplastic features within the megakaryocytic and granulocytic lineages and an increase in the blast population. The bone marrow slowly became hypercellular. The treatment with cyclosporine and growth factors was stopped.

Clinical Case of Aplastic Crisis Associated with Extramedullary Hematopoiesis in an Adult With Hereditary Spherocytosis and Parvovirus B19 Infection

Hereditary spherocytosis is an inherited hemolytic anemia due to red cell membrane defects, characterised by chronic hemolysis with different severity degrees, splenomegaly and microspherocytosis on the peripheral blood film. Among the possible complications in these patients are aplastic crisis and extramedullary hematopoiesis. In this article we present the case of a 42 years old man with hereditary spherocytosis diagnosed during childhood (average haemoglobin (Hb) value of 11-12 g/dl), which presented with worsening anemia, fever, chills, bone and muscle pain. The evolution was with accentuation of anemia (Hb 4.2 g/dl), decease of reticulocyte number (Ret 0,8%) and bilirubin (indirect bilirubin 2.7 g/dl). ParvovirusB19 DNA was 100.000.000 copies/ml. A computer tomography (CT)scan was performed and showed extramedullary hematopoiesis areas situated paravertebraly in the inferior thorax and hepatosplenomegaly. The infectious episode was self-limited and improved with substitution treatment.

Updates in acquired aplastic anemia: Can we do more for our patients?

The purpose of this work is to present the results of allogeneic stem cell transplantation as therapy for patients diagnosed with acquired aplastic anemia in the Department of Bone Marrow Transplantation of Fundeni Clinical Institute and to elaborate an algorithm of treatment in aplastic anemia starting with the observations obtained from our clinical practice and following the European treatment guidelines in this group of patients. Aplastic Anemia (AA) is a rare hematological disease characterized by pancytopenia and a hypocellular bone marrow. The paradigm of bone marrow failure syndromes, aplastic anemia is a diagnosis of exclusion despite the precision of its diagnosis criteria. Although AA is not a malignant disease, but an autoimmune disorder, the grave consequences of pancytopenia and clonal transformation into acute leukemia make it a potentially fatal condition. The management of AA patients is challenging and necessitates a very well established treatment plan from the diagnosis. We present the treatment algorithm for AA patients with recommendations based on both recent guidelines in the field and on our experience treating AA patients with allogeneic stem cell transplant. Therapeutic procedure algorithm comprises different approaches for different patient populations, age categories and availability of immunosuppression therapy or different types of donors. According to the recent EBMT recommendations the treatment of choice for young patients (younger than 40 years) who have a matched sibling donor is hematopoietic stem cell transplantation (HSCT). For those patients who don’t have a matched sibling donor or are not candidates for HSCT due to older age, the immunosuppression with ATG and cyclosporine is an efficient treatment. The supportive care has an important role and the patients with aplastic anemia should be managed by a multidisciplinary team. For patients older than 40 years, the choice between immunosuppressive therapy (IST) and upfront transplant with HLA identical sibling donor remains a key question. However, the standard approaches for this category of patients is front line immunosuppression with ATG and cyclosporine and if they become refractory to at least one course of IST the allogeneic stem cell transplant using fludarabine-based conditioning is the second-line treatment option. In our institution there were eleven AA patients treated with allogeneic stem cell transplantation from 2009 till 2015. They were all young patients with age between 19 and 42 years old and all had severe acquired aplastic anemia with transfusion dependence. Six cases were transplanted from a matched sibling donor and five patients had undergone an unrelated matched donor transplant. The allogeneic HSCT procedure was done both as front line therapy in the case of three patients and as second treatment choice in the rest of eight patients. Four patients died, three of them due to transplant related toxicity and one patient experienced severe autoimmune reaction with transfusion inefficacy complicated with intracerebral haemorrhage at four months from transplant. In our opinion the most challenging aspect in treating AA patients is choosing the best treatment option taking into account the patient age and performance status, the severity of the disease and the availability of a donor for allogeneic HSCT. Although the treatment strategy must be individualized in every patient case, it is necessary to make a standardization of treatment procedures in AA and to follow the evidence based recommendations available in the management of this rare disease.

Haplo-Identical Bone Marrow Transplant Protocol using Reduced Intensity Conditioning for Fundeni Clinical Institute

Purpose: Even if the romanian population is ethnically compact caucasian-type population, many of the patients referred for bone marrow transplantation lack a suitable donor. In order to expand the donor pool and the accesibility to transplant for those who have indications it is necessary to perform haplo-identical bone marrow transplant procedure in Fundeni Clinical Institute. Since 2009 Romania established a National Volunteer Stem Cell Donor Registry (RNDVCSH), the goal was to enlarge the possibility to find HLA-matched unrelated donors (MUD) for patients. This approach offered transplant for only up to 60%patients referred for transplantation in 2014, even we chose one HLA-mismatch donors. The haploidentical transplant protocol proposed for our institution is based on Sidney Kimmel Comprehensive Cancer Center protocol from Johns Hopkins University School of Medicine. The major milestones of this protocol include: patient eligibility, donor selection criterias, evaluation of the haplo donor, the conditioning regimen plan and additional supportive care, the bone marrow harvest, prophylaxis of graft versus host disease, assessment during and after the transplant. Donor must be HLA-haploidentical first-degree relatives of the patient with signed consent. The patient, parents and children are typed at the allelic level for HLA-A, -B,-C,-DRB1 and -DQB1. They will perform also de HLA-antibody search using cross-match test in complement-dependent cytotoxicity. The conditioning regimen is composed by Fludarabine 30 mg/m2/day (from day -6 to day -2) combined with Cyclophosphamide 14,5 mg/kgIBW/day (from day -6 to day-5) and TBI at 2 Gyîn day -1. In case of lacking TBI procedure at 2 Gy dose in day -1, it could be replaced by two dose of Busulfan iv in day -3 and day-2 (dose=3,2 mg/kgIBW/day) for those with acute and chronic leukemias. The donor will have general anesthesia,the target yield of marrow is 4 x 10^8 total nucleated cells/kg recipient using his IBW. The GVHD prophylaxis consisted of post-transplant Cyclophosphamide (PTCy) of 50mg/kgIBW/day in IV administration in day +3 and +4, followed by tacrolimus and mycophenolatemofetil (MMF) beginning day +5. The MMF will be stopped at day+35, the tacrolimus will continue till 6 months after the transplantation. Conclusion: One of the most important factors affecting transplantation outcome is proper timing.Therefore, donor availability is an crucial issue. Haploidentical related donors are available for almost all patients, so the use of those donors is a viable alternative.