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Background Thalassemias are genetic disorders of globin chain synthesis. In Iraq, β-thalassemia is more prevalent than α-thalassemia. This study identifies two unpredicted globin gene mutations, a rare α-globin gene mutation (Hb SKMC) and a novel γδβ-thalassemia deletion.Methods Over 2 years, the Genetics unit at PAR hospital in Erbil, northern Iraq processed 137 β-thalassemia and 97 α-thalassemia genetic testing requests. Three symptomatic thalassemia cases with unreported genotypes were identified. Proband-1α and proband-2α had Hb H disease, while proband-1β had severe transfusion-dependent β-thalassemia (TDT). Molecular studies included multiplex PCR, reverse hybridization, multiplex ligation-dependent probe amplification (MLPA), and globin gene sequencing.Results The α-thalassemia probands exhibited moderate microcytic hypochromic anemia with irregular transfusions and splenomegaly. Hb H disease was confirmed by positive Hb H tests and high-performance liquid chromatography (HPLC). Molecular analysis revealed heterozygous –MED deletion in proband-1α and α2Poly-A2 mutation in proband-2α. Sequencing identified the Hb SKMC (HBA1:c.283_300+3dup) mutation in both probands. The β-thalassemia proband showed anemia and regular transfusions. Molecular studies detected the IVS1.110 G>A mutation and a novel γδβ-thalassemia deletion in compound heterozygous form. The maternal sample showed the IVS1.110 G>A mutation, and MLPA confirmed the γδβ-thalassemia deletion in the paternal sample.Conclusion These findings highlight the genetic diversity of thalassemias in the region and emphasize the importance of advanced molecular diagnostics in detecting rare mutations.

Background and objective: β-Thalassemia is a common inherited disease in this region. A considerable number of transfusion-dependent β-thalassemia (TDT) patients suffer bone problems. The objective of this study was to evaluate bone mineral density in TDT patients using dual-energy X-ray absorptiometry (DEXA) scan. Methods: In this study, 53 TDT patients aged ≥10 years, together with 25 normal healthy individuals were enrolled. Their bone status was assessed using DEXA scan at lumber spine (L1-L4) and femoral neck. The effect of physical, biochemical, and hormonal characteristics on the bone mineral density (BMD) parameters were evaluated. BMD-Z score was used to assess the magnitude of bone disease. Results: The mean age of the patients was 21.3±7.8 years with male to female ratio 1.4:1. The values BMD parameters were significantly lower in the patients compared to the normal group. The mean values of BMD Z-core among the patients at lumber spine and femoral neck were -2.95±1.07 and -1.51±1.02 respectively. Among the patients, osteoporosis was detected in 69.8% and 13.2% in lumber spine and femoral neck respectively. None of the normal individuals had osteoporosis. Patients’ age. body mass index (BMI) and parathyroid hormone level had a significant association with BMD Z-score (P

Background and objective: Bleeding and thrombosis are major causes of morbidity and mortality in patients with acute leukemia (AL); they are attributed to hemostatic derangement and coagulation defects that are associated with leukemia. There is a paucity of information regarding coagulopathy in AL patients in our locality; this study, therefore, was employed to evaluate hemostatic parameters in patients with AL at the time of presentation. Methods: This prospective cross-sectional study included 84 newly diagnosed patients with AL. The study was carried out at Nanakali hemato-oncology center from September 2021 to May 2022. Patients were assessed for coagulation parameters including prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen level (FBG), D-dimer (D-Di), antithrombin (AT), protein C (PC), and protein S (PS). Results: The median age of the studied patients was 26 years with a male to female ratio of 1.1:1. Acute myeloid leukemia (AML) patients constitutes 51.2% (43 patients), and the remaining 41 (48.8%) patients had acute lymphoblastic leukemia (ALL). PT was significantly prolonged, D-Di was significantly higher and AT, and PC were significantly decreased in AML compared to control groups. Only D-Di level was significantly higher in ALL compared to control groups. Bleeding manifestations were encountered in 40 (47.6%) patients with a higher incidence among the AML group (28 patients, 70%). Thrombosis occurred in 2 (2.4%) patients. Conclusion: Defects of coagulation were common in AL. Hemostatic derangement and bleeding at the time of presentation were more noticeable in patients with AML.

Abstract Background HbH disease results from dysfunction of three, less commonly two, α-globin genes through various combinations of deletion and non-deletion mutations. Characterization of the mutations and the underlying genotypes is fundamental for proper screening and prevention of thalassaemia in any region. The aim of this study was to explore the genetic arrangements of HbH disease and to correlate the genotypes with the clinical phenotypes. Methods A total of 44 HbH disease patients were enrolled in this study. They were clinically and haematologically assessed. The patients were tested for 21 common α-globin gene mutations using multiplex PCR and reverse hybridization. According to the genotype, the patients were categorized into two separate sub-groups, deletion and non-deletion types HbH disease. Results Within the studied HbH disease patients, eight different α-globin gene mutations were detected in nine different genetic arrangements. The --MED and -α3.7 deletions were the two most frequently encountered mutations (37.5 and 35.2% respectively). Patients with deletion genotypes constituted 70.4%. The most common detected genotype was --MED/−α3.7 (59.1%), followed by αpoly-A1α/αpoly-A1α (13.6%). For the first time, coinheritance of two relatively mild mutations (−α3.7/ααAdana) was unpredictably detected in a 1.5 year-old child with Hb of 7.1 g/dL. Conclusion The HbH disease patients’ clinical characteristics were variable with no ample difference between the deletion and non-deletion types. These results can be of benefit for the screening and management of thalassaemia in this region.

BACKGROUND: Chronic lymphocytic leukemia is an uncommon type of leukemia in Iraq, although many reported cases of chronic lymphocytic leukemia in the Iraqi Kurdistan region are of high risk stage. Staging of chronic lymphocytic leukemia is essential in treatment planning and for disease prognosis. the aims of this study were to find out the difference in patients' survival with early and late clinical stages, and to evaluate CLL outcome in relation to the Rai and Binet staging. PATIENTS AND METHODS: This retrospective cross-sectional analysis studied 250 patients, 170 male and 80 female, with chronic lymphocytic leukemia who were registered in three hemato-oncology centers in Iraqi Kurdistan for the last 10 years. The diagnosis of the disease was made according to the guideline of the International Workshop Chronic Lymphocytic Leukemia update of the National Cancer Institute. The patients' clinical staging was determined by a senior hematologist based on the clinical and laboratory findings. RESULTS: The mean age of the patients was 63(±11.8) years, 40% were >65 years. The median survival was 27 months. Elderly patients >65 years had significantly lower mean survival. The Rai staging was distributed as follows: stage 0 (24.8%), stage I (12.8%), stage II (30.8%), stage III (9.6%) and stage IV (22%). The median survival was significantly higher among patients with Rai stage 0 comparing to patients with advanced stages (P

OBJECTIVES : There are the variable degrees of bone marrow (BM) infiltration patterns in chronic lymphocytic leukemia (CLL). Four BM patterns: Interstitial, nodular, mixed, and diffuse patterns were identified. The aim of this study is to assess the effects of BM infiltration patterns on the disease outcome among CLL patients in Kurdistan Region of Iraq. METHODS: This study is a cross-sectional, descriptive, retrospective involved 106 patients with CLL disease. The data are collected in the Kurdistan region of Iraq (including Erbil, Sulaymaniyah, and Duhok) cancer centers. Through the period from January 1, 2010 to December 31, 2019. BM histopathology study of all patients was assessed and correlated with the disease outcome. RESULTS: Fifty-three (50.0%) patients had interstitial BM patterns, 17 (16.0%) had nodular BM pattern, 14 (13.2%) had mixed BM patterns, and 22 (20.8%) had diffuse BM pattern. The results showed that patients with interstitial, nodular, and mixed BM patterns had a superior overall survival (OS) and progression-free survival (PFS) rate than diffuse BM pattern. Kaplan–Meier curve illustrates that our CLL patients with interstitial BM patterns had a better mean OS rate (44.0 months) than diffuse BM pattern with a mean of (23.2 months). As well as for PFS, the mean was (35.7 months) for the interstitial BM patterns and (17.6 months) for diffuse BM pattern. CONCLUSIONS: We demonstrate that the BM involvement patterns have a prognostic value in our CLL patients and provide more reliable information regarding the clinical outcome.

BACKGROUND: The clinical course of patients with chronic lymphocytic leukemia (CLL) is heterogeneous. Certain patients go through a brisk illness progression, and others stay alive for quite a long time without requiring treatment. OBJECTIVE: This study was conducted to evaluate the impact of clinical staging, age, gender, and treatment initiation on the survival of CLL patients in Kurdistan-Iraq. MATERIALS AND METHODS: A total of 239 CLL patients from Oncology Centers from Kurdistan-Iraq were enrolled in a retrospective study from January 1, 2010, to December 31, 2020. A standardized questionnaire was used to obtain demographics data, presenting features, blood investigations, and imaging results. The diagnosis and treatment assessment was based on the International Workshop of CLL, and clinical staging was performed using both Rai and Binet classifications. There were two groups of patients (watch and wait) and (treated) groups. RESULTS: The median age at the diagnosis was 64 years old with a male: female ratio of 2.3:1. Eighty-three patients (34.7%) were diagnosed incidentally and about one-third of the patients presented with advanced stage, and also, 62.3% of the patients received therapy throughout the study period. The 3-year overall survival was (81.1%) (95% confidence interval 74.3%–87.9%). Of particular interest to report that advanced age, Binet Stage C, and hemoglobin

BACKGROUND: Chronic lymphocytic leukemia (CLL) is characterized by a lower incidence rate in Iraq and Kurdistan as compared to Western countries. However, a good prognosis of CLL is dependable on diagnosis, risk stratification, and a better choice of an appropriate treatment regimen. AIM OF THE STUDY: To evaluate the effectiveness of fludarabine, cyclophosphamide, and rituximab (FCR) regimen in comparison to other chemotherapy regimens in the management of patients with CLL in Kurdistan region/Iraq. PATIENTS AND METHODS: A retrospective review study carried out in three cancer centers in the Kurdistan region of Iraq for the duration of 10 years through the period from January 1, 2010 to December 31, 2019, on 152 CLL patients. CLL was diagnosed according to the International Workshop on CLL. The treatment of CLL patients was either by FCR chemo-immunotherapy regimen or other chemotherapies. RESULTS: The FCR chemo-immunotherapy was the treatment of 38.8% of CLL patients, while 61.2% of CLL patients were treated by other chemotherapies. There was a significant association between younger age patients and the use FCR chemo-immunotherapy (P = 0.001). There was a significant association between a complete response and treatment by FCR chemo-immunotherapy (P = 0.02). The mean overall survival duration and progression-free survival of CLL patients treated by FCR chemo-immunotherapy were significantly longer than the mean survival time of CLL patients treated by other chemotherapies (P = 0.01). CONCLUSIONS: Complete response and survival of CLL patients treated by FCR chemo-immunotherapy were better than the complete response and survival of CLL patients treated by other chemotherapies.

BACKGROUND: Cardiac complications are still the primary cause of mortality and a major cause of morbidity in thalassemia patients. OBJECTIVES: The aims of this study were to assess the prevalence of cardiac involvement in TDT and NTDT beta thalassemia patients and compare between the different forms and severity in both groups. MATERIALS AND METHODS: In this prospective study, 70 TDT and 50 NTDT β-thalassemia patients were recruited; their cardiac status was evaluated by transthoracic echocardiography as per the standard recommendations. Patients' cardiac status was evaluated against the causal risk factors. RESULTS: The mean serum ferritin level was significantly (P < 0.001) higher in the TDT patients (4940 ± 3643 ng/mL) compared to the NTDT patients (634 ± 520 ng/mL). The mean hemoglobin was significantly (P = 0.004) higher in the TDT group (9.2 ± 0.8 vs. 8.7 ± 1.0 g/dL). The prevalence of dilated cardiomyopathy and left cardiac dysfunction in TDT was 18.6%, whereas pulmonary hypertension (PHT) was found in 30% of NTDT patients. CONCLUSION: Dilated cardiomyopathy was prevailing in the adult TDT patients, whereas PHT was the main cardiac complication in NTDT patients.

BACKGROUND: Health-related quality of life (HRQoL) in multiple myeloma (MM) gained increasing importance to ensure that the improved survival is associated with improved life quality. OBJECTIVES: The aim of this study was to assess the HRQoL in a cohort of myeloma patients from Kurdistan region in Iraq. MATERIALS AND METHODS: This observational, cross-sectional, multi-center study enrolled 138 patients with symptomatic MM patients. The patients' records were retrieved and they were also clinically assessed and appropriately investigated at the time of enrolment. HRQoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Multiple Myeloma module (EROTC QLQ-MY20. RESULTS: The 138 patients included had a mean age of 60.4 years and included 83 males and 55 females. Significant predictors of worse HRQoL disease symptoms and side effects of treatment domains included increasing age, female sex, and increase number of treatment courses. Other predictors associated with worse disease symptom domain include presence of bone lesions and nonsecretory myeloma versus light chain myeloma. Basic parameters including the concentration of monoclonal band, hemoglobin, serum creatinine, calcium, and albumin were not significant associated with scores in any of the domain while serum LDH was associated with worse side effects of treatment scores. Furthermore, it was noted that patients who had underwent autologous stem cell transplants had better HRQoL in all domains compared to other modalities of therapy, though this did not reach significance. CONCLUSIONS: HRQoL in MM treated in Iraqi Kurdistan is not much different from their Western counterparts and several predictors of worse QoL were identified in this cohort of patients.

Background: Multiple myeloma (MM) is defined as a clonal B-cell malignancy of the bone marrow. Hypercalcemia is associated with cancers in general and in MM specifically becomes more obvious with frequent adverse outcomes. Objectives: The objective is to determine the frequency of hypercalcemia in MM patients and survival rate after 3 years of diagnosis with the assessment of relationship between MM prognosis and hypercalcemia. Materials and Methods: Retrospective data were reviewed from the Hematology and Cancer Centers of Kurdistan Region of Iraq (KRI, Erbil, Sulaymaniyah, and Duhok) from January 2012 to December 2017 on a sample of 130 patients with MM. The diagnosis of MM and hypercalcemia was done according to the International Myeloma Working Group definition of MM and serum calcium of ≥11 mg/dl. Results: The prevalence of hypercalcemia among MM patients after calcium correction was 17.7%. Serum creatinine level is significantly higher among MM patients with hypercalcemia. There was a significant association between high death rates and MM patients with hypercalcemia. The mean survival of MM patients was 4.5 years and 72% of the MM patients had 3-year survival, which decreased to

Background: Nowadays, the therapy of multiple myeloma (MM) has successful and hopeful outcomes. Worldwide, various treatment regimens are prescribed by clinical hematologists. Objectives: The objective was to evaluate response to induction treatment and survival of MM patients treated with various treatment regimens in the Kurdistan Region of Iraq (KRI). Materials and Methods: A total of 114 patients in the KRI were included in a retrospective study through the period of January 1, 2010, to September 31, 2019. The diagnosis of MM was confirmed using the International Myeloma Working Group (IMWG) guidelines. The treatment responses were assessed according to the IMWG response criteria. Results: Complete response among the MM patients was 35.7%, very good partial response (VGPR) was 28.7%, partial response reached 9.1%, and stable disease reached 16.5%. The Kaplan–Meier curve showed those with VGPR had better survival than the rest of the response categories. Meanwhile, there was a significant association between MM patients on bortezomib and dexamethasone treatment regimen and complete remission was noticed (P = 0.02). Conclusions: The combination therapy of bortezomib and dexamethasone is effective in achieving a better response to treatment and good survival than other therapy regimens.

Hodgkin's Lymphoma (HL) reveals variable epidemiological and clinico-pathological features in different geographical locations. In this retrospective study, we aimed to assess the epidemiological and clinic-pathological features, and outcome of HL patients treated at one hemato-oncology centre in Erbil, northern Iraq. Medical records of 103 HL patients treated over more than six years were reviewed. Treatment outcome was evaluated by measuring the 5-year overall and progression-free survival rates. The median age of patients was 23 years, children up to 17 years constituted 31.1%, and male to female ratio was 1:1.05. The majority (96.1%) of patients presented with lymphadenopathy. Nodular sclerosis subtype was the mostly encountered histologic type (48.5%); about half of the patients (49.5%) had stage II disease. Relapse occurred in 20 patients; the 5-year overall survival for children was better (89%) compared to adult patients (79%). The associated risk features found to have adverse effects on the survival, however, only high LDH level and presence of B-symptoms at presentation showed significant correlation. The epidemiological and clinical characteristics of HL in our locality followed the pattern in the western world. The 5-year overall and progression-free survivals were far below the international rates, a matter which may necessitate a revision to HL treatment strategy at our centre.