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Samples from 34 adult patients newly diagnosed with core binding factor leukemia (CBFL) were collected both at the time of diagnosis and at relapse and were centrally analyzed. Eligible patients received either standard induction CT known as "3 + 7" or an equivalent regimen, according to the recruiting center's policy. Patients who achieved CR or CRi received 3 courses of high-dose ARA-C (Cytarabine) 3000 mg/m 2 every 12 h on days 1, 3, and 5, along with midostaurin at the dose of 50 mg b.i.d from Day 8 to Day 21 as part of consolidation therapy. Following the completion of the consolidation phase, patients received midostaurin as a monotherapy at the dose of 50 mg b.i.d. for 1 year as continuation therapy. The CR rate was 97%; we recorded an OS rate of 73.52% and a DFS rate of 48.4% for the entire cohort. The RI was 38.8% in the CBFB::MYH11 and 66.6% in the RUNX1::RUNX1T1 group. MRD (Measurable Residual Disease) was assessed by RQ-PCR at 10 time points throughout the study, as indicated by arrows., (© 2024 Wiley Periodicals LLC.)

A 75-year-old woman with a history of lobular breast adenocarcinoma treated with mastectomy and radiotherapy in 2021 and on maintenance hormone therapy, presented with asthenia and tremors. Laboratory tests showed leucocytosis, anemia and low platelet count, with increased serum calcium, lactate dehydrogenase and indirect bilirubin levels. Haptoglobin was decreased and renal function was normal. Peripheral blood smear showed red cell anisocytosis, many schistocytes and immature granulocytes. Furthermore, 15% of white cells displayed large size and atypical morphology. A macroangiopathic hemolytic anemia (MAHA) related to a de novo or recurring cancer was hypothesized, and total body computed tomography (CT) and 18 F-FDG positron emission tomography (PET)/CT were undertaken. Only a slight FDG uptake was demonstrated in the spine, attributable to a reactive bone marrow due to MAHA. Then, to rule out a MAHA related to acute leukemia, a bone marrow aspirate and trephine biopsy were performed, with an extensive cell immunophenotyping. The first myeloid flow cytometry (FC) panel evidenced a large volume population of about 20%, expressing CD117 but negative for CD45 and CD34. All myeloid markers were negative. A more extensive panel was then used, including plasma cell and erythroid markers. Interestingly, the abnormal population resulted positive for CD138 and CD71 with negativity for CD38. A recent study reported that besides CD45 negativity, non-hematological neoplasms frequently express CD56, CD117, or CD138. Therefore, a panel for non-hematological markers including epithelial cell adhesion molecule (EpCAM) was carried out. This population resulted EpCAM positive and also expressed CD9, a breast cancer prognostic marker. Bone marrow smears revealed the presence of the same cells, and the immunohistochemistry analysis of bone marrow biopsy demonstrated the massive infiltration of breast cancer cells, expressing all epithelial markers identified at diagnosis. The FC analysis of the peripheral blood allowed the rapid characterization of a non-hematological neoplastic cell population, circulating at unusually high frequency and mimicking an acute myeloid leukemia. The FC detection of CD45-negative cell populations in peripheral blood, bone marrow or lymph node aspirate should prompt the setup of an immunophenotyping panel including EpCAM, CD9, CD56 and CD117, to allow for a rapid and accurate identification of ectopic malignant epithelial cells., Competing Interests: The authors declare no potential conflict of interest., (Copyright 2024, Gatti et al.)

Background: Anaemia is a common finding in the preoperative setting, affecting around one-third of patients for whom major surgery is programmed. Moreover, preoperative anaemia has been shown to worsen patient outcome and increase length of hospital stay and costs. In the field of preoperative anaemia correction, a recent Consensus statement suggested reviewing the classic World Health Organization (WHO) criteria in adults by aligning the haemoglobin cut-off to 13 g/dL for both genders. The aim of our study was to assess the differences in terms of prevalence, transfusion rate, transfusion trigger, and blood losses according to gender in a mixed population of surgical patients., Material and Methods: We reviewed data of 610 consecutive patients undergoing elective major surgery at a tertiary care hospital during a 9-month period. Transfusion rate and transfusion triggers were recorded, analysed and stratified by haemoglobin class, with a particular focus on the 12.0-12.9 g/dL range., Results: Since the anaemia threshold was redefined at 13 g/dL for both genders, its prevalence rose from 26.4 to 39.5% (161/610 vs 241/610; p<0.001) in the overall population and from 22.7 to 49.3% (68/300 vs 148/300; p<0.001) in women. Eighty women (26.7%) fell in the haemoglobin 12.0-12.9 g/dL range, and this category was the most represented among transfused women (34.0%). There was no statistical difference in transfusion triggers or overall transfusion rate between genders. Subjects of both genders were transfused at the same haemoglobin level (8.1 g/dL), but women reached the transfusion trigger after less red cell mass loss than men, i.e. 377 mL (249-472 mL) vs 528 mL (356-717 mL), respectively (p<0.001)., Discussion: Treatment of pre-surgical anaemia is one of the core principles of Patient Blood Management. Aligning the haemoglobin threshold between genders in the management of pre-surgical anaemia may result in a lower transfusion rate, but in an increased workload for medical staff in the preoperative phase.

Background: Moderate to severe iron deficiency anaemia is a common finding in patients admitted to the Emergency Department (ED). According to Patient Blood Management principles, intravenous iron should be the therapy of choice instead of blood transfusion for selected cases affected by chronic iron deficiency anaemia. However, this option is only rarely taken into account by physicians in the ED. As a result, in many circumstances, treatment of iron deficiency anaemia in the ED can differ from that of the Anaemia Clinic. With the aim of reducing inappropriate transfusions, and to implement intravenous iron usage, we shared a specific protocol with the ED., Material and Methods: We reviewed the medical records of all subjects admitted to the ED (n=267, Post-protocol group) with hemoglobin ≤9.0 g/dL and mean corpuscular volume <80 fL in a 13-month period, except if the massive transfusion protocol was activated, and results were compared with an equivalent Pre-protocol historical cohort (n=226)., Results: In comparison with the Pre-protocol series, the number of patients transfused did not change, but the appropriateness in terms of transfusion and red blood cell volume transfused improved sharply (87.0 vs 13.3%; p<0.001) with a significant increase in intravenous iron administration (50.2 vs 4.4% of cases; p<0.001). As a positive consequence, both the time spent in the ED by patients who were then directly discharged and costs per subject treated dropped by 37.9% and 59.0%, respectively. Treatment with infusion only in comparison with transfusion only led to a statistically significant Relative Risk reduction in transfusion on the ward and post-discharge transfusion of 55.6% and 44.4%, respectively., Discussion: The implementation of Patient Blood Management principles and early intravenous iron therapy in the Emergency Department have proved to be effective tools to optimise resources both in terms of units transfused and costs.

Paroxysmal Nocturnal Hemoglobinuria (PNH) is a rare blood disorder characterized by chronic intravascular hemolysis, thromboses in unusual sites and cytopenias related to bone marrow failure. The diagnosis is based on the Flow Cytometric (FCM) detection of peripheral blood cell clones lacking the surface molecules linked to the GPI anchor, which is altered by mutations. Consensus studies have developed standardized and robust multicolor FCM assays to disclose PNH clones among red cells, neutrophils and monocytes at a high level of sensitivity and accuracy. High-resolution procedures have been also established to detect small PNH clones at a sensitivity level of around 0.01% in red cells and neutrophils. Cell clone type and size have been put into correlation with the clinical presentations of the associated diseases, and recommendations for the clinical follow-up have been established. The recent advent of the therapeutic monoclonal antibody Eculizumab has dramatically improved both the quality of life and the life expectancy of the affected patients, further increasing the importance of an accurate FCM detection and monitoring of the clones. The technical features of the FCM diagnostic workup and the many critical aspects of the analytical process are discussed here., Competing Interests: Disclosures: The authors declare no potential conflicts of interest. The study was not funded., (Copyright © 2019 International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). All rights reserved.)

Competing Interests: The Authors declare no conflicts of interest.

Objective: To determine distribution of T cells and activation degree of Th CD4+ cells in peripheral blood of patients with osteoarthritis (OA), rheumatoid arthritis (RA), and healthy donors., Methods: Patients with established diagnosis of RA according to American College of Rheumatology/European League Against Rheumatism 2010 criteria, knee or hip OA according to American College of Rheumatology criteria, and healthy blood donor volunteers were eligible. Multi-channel flow cytometry and monoclonal antibodies against CD3, CD4, CD8, CCR6, CD38, CXCR3, and HLA DR were used to distinguish and evaluate T cells' subpopulation., Results: We analyzed blood samples of 15 patients with well-defined RA, 56 with hip or knee OA, and 20 healthy age matched controls. Blood samples from RA patients showed significantly higher counts of CD4+ CD38+ DR+ (activated CD4 T cells) and Th17 (CCR6+ CXCR3-) cells as compared to OA patients and control group ( P <0.01). Furthermore the samples from the OA patients showed a higher percentage of activated CD4 T cells and Th17 cells as compared to control group ( P <0.05). Interestingly there was no difference between Th1 (CD4+ CXCR3+ CCR6-) and Th2 (CD4+ CXCR3- CCR6-) between the three groups ( P >0.1)., Conclusion: According to the latest view of OA disease pathogenesis, our preliminary results support the hypothesis that OA may also be a disease with an immunological/inflammatory involvement like RA. It seems that there is a quantitative but non-qualitative difference in Th17 cells' profile, including the expression of activation markers, between RA and OA.

Background: The implementation of mass vaccinations against hepatitis B virus (HBV) has significantly reduced the prevalence of HBsAg-positive subjects. At the same time, the prevalence of the other markers of infection has decreased, but there has been an increase in the percentage of subjects with markers of a successful vaccination. It has been suggested that increasing immigration from countries in which this virus is highly endemic is changing the epidemiology of HBV infection. The aim of this study was to assess the prevalence of the serological markers of HBV in Italian and non-Italian HBsAg-negative subjects., Materials and Methods: In the years 2007-2008, 8,018 samples from HBsAg-negative subjects (7,521 Italians and 497 non-Italians) were received for detection of anti-HBs and/or anti-HBc. The findings in the 1,358 samples from candidate blood donors were compared with those obtained in 1991 and 1999., Results: The rate of anti-HBc positivity was 18.3% in the Italian samples and 32.8% in the non-Italian samples; the corresponding percentages of anti-HBs/anti-HBc positive samples (indicating past infection), anti-HBs positive only samples (vaccination) and anti-HBc positive only were, 11.3% vs. 22.5%, 25.8% vs. 17.2%, and 6.9% vs. 9.9% in Italians and non-Italians, respectively. The differences were more marked when stratified by age. In relation to candidate blood donors, simultaneous positivity for anti-HBs and anti-HBc decreased from 11.0% in 1991 to 8.1% in 1999 and 3.9% in 2007-2008, whereas isolated anti-HBs positivity increased from 2.2% in 1991 to 21.4% in 1999 and 42.9% in 2007-2008., Conclusions: The frequency of markers of past infection among Italians has decreased over time as a result of mass vaccination and is significantly lower than that observed in non-Italians. The increasing number of immigrants from countries in which HBV is highly endemic is changing the epidemiology of HBV infection in Italy.

Background: In order to identify neuroblastoma cells infiltrating the bone marrow, a triple-color flow-cytometric assay was developed combining CD56 and CD45 with the intracellular anti-NB84 specific antibody., Materials and Methods: The bilateral aspirates obtained from 27 consecutive children over the age of one year with stage 4 neuroblastoma were evaluated., Results: Neuroblastoma cells were detected in the bone marrow of 17/27 (63%) and 19/27 (70%) cases using cytomorphology and triple-color flow-cytometry, respectively. Using cytometry, the percentage of CD56+/NB84+/CD45-cells infiltrating the bone marrow ranged from 0.02% to 65%. Five out of eight patients without bone marrow involvement according to cytometry are in continuous complete remission, while only 3 out of 19 patients whose bone marrow gave positive results are still alive., Conclusion: By combining CD45 and CD56 with the specific antibody, NB84, directed against neuroblastoma cells, we developed a rapid and reliable cytometric assay that can be associated with conventional cytomorphological bone marrow evaluation to detect infiltrating neuroblastoma cells, especially in cases of dubious positivity.

Although flow cytometry is increasingly used as a tool to diagnose hematologic malignancies, the reporting format of acute leukemia immunodiagnosis is still imprecise and sometimes vague, often reflecting old guidelines. Thus, the purpose of the present work was to make the reporting format for the immunological diagnosis of acute leukaemia easy and clear to understand. This work represents part of a more articulated series of technical guidelines that the Italian Society for Cytometry (GIC) is currently processing. Thirteen separate recommendations, covering all aspects of an acute leukemia cytometry report, are listed. According to our suggestions, the report must contain clear statements about: 1. demographic identification of patient; 2. identification of the hospital or division sending the sample; 3. type of specimen (bone marrow aspirate, peripheral blood, other biological fluids); 4. timing of observation (first diagnosis or follow-up); 5. diagnostic hypothesis made by the sender; 6. list of antigens and type of immunofluorescence analysis carried out; 7. absolute number of cells in the sample; 8. quality of the sample, in terms of viability; 9. general description of the gating procedure; 10. immunophenotype of blast cells; 11. description of cells surrounding blasts; 12. diagnostic conclusions; 13. definition of an antigen panel (when applicable) for the detection of minimal residual disease. As an example of a final report we present a case of acute myeloid leukaemia with t(8;21) translocation; in filling this report, we followed all the 13 points of the checklist described in the paper.

Background and Objectives: Recent observations suggested that targeted monoclonal antibodies might be best employed in lymphoid malignancies under conditions of minimal residual disease. This prompted us to investigate the role of Campath-1H as treatment for patients with chronic lymphocytic leukemia (CLL) in whom fludarabine (FAMP) had produced a marked disease debulking with persistence of bone marrow (BM) infiltration or a complete remission (CR) without the disappearance of the molecular aberration (IgH monoclonal expression). As intravenous Campath-1H is almost invariably associated with reactions, sometimes of WHO grade 3-4, we adopted the subcutaneous route of administration, which proved to induce rare and mild adverse reactions but had comparable efficacy. DESIGN AND METHODS. Nine patients (7 males, 2 females) with a median age of 55 years (range 41-61) who responded to FAMP (1 had a CR, 5 a nodular partial remission [PRN], and 3 a partial remission [PR]), according to NCI Working Group Criteria, received subcutaneous Campath-1H, three times a week for 6 weeks in escalating doses up to 10 mg. Monoclonal rearrangement of IgH was present in all patients before immunotherapy. Patients received acyclovir and cotrimoxazole as infection prophylaxis. Granulocyte colony-stimulating factor (G-CSF), at the dosage of 5-10 microg/kg/die, or intermediate-dose Ara-C (800 mg/m(2)/q 12h x 6 doses), was administered to obtain peripheral blood stem cell (PBSC) mobilization., Results: All patients were evaluable for response. Five patients, 2 in PR and 3 in PRN after FAMP treatment, reached a CR. Three patients, one in PR, one in PRN and one in CR, converted to a molecular remission. In four out of seven patients PBSC harvesting was successful; more than 2.5 x 10(6) cells/kg were collected from all these patients. Collection was polyclonal for IgH gene rearrangement in three cases. One patient has been transplanted after cyclophosphamide and total body irradiation as conditioning regimen, without complications and with rapid hemopoietic engraftment. All patients were evaluable for toxicity. A WHO grade 1-2 skin reaction was observed in 5 patients at the site of injection. No infectious episodes were recorded. Two out of three patients presenting cytomegalovirus reactivation, without pneumonia, were successfully treated with oral gancyclovir., Interpretation and Conclusions: Subcutaneous Campath-1H administered to CLL patients with residual BM disease after FAMP proved to be safe and effective. Of nine patients, three obtained a molecular CR and five converted into a morphologic and immunophenotypic CR. In four of seven patients submitted to PBSC mobilization, this treatment also allowed a harvest uncontaminated by CD5/CD19 double-positive CLL cells, which was polyclonal for IgH gene rearrangement in three cases.