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COMUNICARI SESIUNEA EDUCATIONALA

EVOLUTIACLONALAINANEMIAAPLASTICA Ljubomir Petrov Institutul Oncologie Ion Chiricuta Cluj Napoca Universitatea de Medicina si Farmacie Iuliu Hateganu, Clinica de Hematologie Anemia aplastica (AA) este o boala clonala a celulei stem hematopoietice caracterizata prin pancitopenie si grade diferite de hipocelularitate medulara. AA dobandita, in peste 50% din cazuri este rezultatul unui atac imun mediat celular, asupra celulei stem hematopoietice. Exista numeroase dovezi care atesta prezenta unei celule stem hematopoietice reziduale clonale (enzimatice, citogenetice). Celulele T citotoxice responsabile de anemia aplastica s-au dovedit a fi si ele (oligo) clonale. Tratamentul anemiei aplastice consta in transplant allogenic de celule stem hematopoietice (Allo- SCT) sau imunosupresie (IS). Spre deosebire de Allo-SCT cu potential curativ la din pacienti, IS este urmata de o refacere partiala a hematopoiezei cu risc de resuta si de evolutie clonala: hemoglobinuria paroxistica nocturna (HPN), sindromul mielodisplazic (SMD) sau leucemia acuta. Nu se cunoaste mecanismul exact alexpansiunii clonei HPN, prezenta la debut la peste 50% din pacientii cu AA. SMD este rezultatul evolutiei clonale a unor celule stem anormale cu telomeri scurti instabile genetic.Leucemia acuta postAAare un mecanism patogenetic asemanator. Interesant este faptul ca 2 din complcatiile clonale tardive a AA tratate cu imunosupresoare pot coexista cu AA ( sindromulAA/HPN si SMD hipoplazic). Factorii de risc pentru SMD secundar post AA s-au dovedit a fi: varsta, numarul de cure de imunosupresie, splenectomia si adaosul de androgeni. Se discuta rolul pe cate l-ar putea avea administrarea de G-CSF in schemele de imunosupresie. Tratamentul complicatiilor clonale tardive in AA este dificil deseori. Allo-SCT si introducerea in arsenalul terapeutic a anticorpilor anticomplement reprezinta singurele modalitati terapeutice eficiente la ora actuala. CLONAL EVOLUTION INAPLASTICANEMIA Ljubomir Petrov Ion Chiricuta Cancer Institute University of Medicine and Pharmacy, Hematology Department Aplastic anemia (AA) is a clonal hematopoietic stem cell disease characterized by pancytopenia and various degrees of bone marrow hypocellularity. Acquired AA is in more than 50% of cases the result of a cellular autoimmune mediated attack against hematopoietic stem cells. There are many enzymatic and cytogenetic data attesting to the presence of a residual hematopoietic stem cell clone. The cytotoxic T-cells responsible for the immune attack were also proven to be (oligo)clonal. The treatment of AA consists of allogeneic hematopoietic stem cell transplantation (Allo-SCT) or immunosuppression (IS). As opposed to Allo-SCT, which has curative potential in of cases, IS results in partial recovery of hematopoiesis with a risk of relapse and clonal evolution: paroxysmal nocturnal hemoglobinuria (PNH), myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). The PNH clone is present at diagnosis in over 50% of AA patients. The exact mechanism of the PNH clone expansion is unclear. MDS is the result of the clonal evolution of an abnormal stem cell, genetically unstable due to the presence of short telomeres. Post-AAAML has a similar pathogenetic mechanism.

It is interesting to note that 2 of the late clonal complications of IS treated AA may actually coexist with AA. (theAA/PNH syndrome and hypoplastic MDS). The risk factors for post AA MDS are the following: age, the number of IS regimens, splenectomy and androgen therapy. The possible role of G-CSF added to immunosuppression regimens is discussed. The treatment of late clonal complications ofAAis often difficult.Allo-SCT and the recent introduction of anticomplement monoclonal antibodies are the only effective current treatments. TRANZIIAIN HEMOPATIILE MALIGNE - EXPERIENACLINICII DE HEMATOLOGIE COLEA AR Lupu UMF Carol Davila Bucureti Clinica de Hematologie, Spital Clinic Colea, Bucureti, Romnia Bolile hematologice maligne cronice sunt afeciuni clonale ale celulei stem pluripotente hematopoietice a crei capacitate de proliferare nu mai este controlata i prezint anomalii morfologice i funcionale. Acest proces care sta la baza caracteristicilor patogenice, clinice i histologice n cazul fiecrei afeciuni n parte, poate fi documentat prin evidenierea unor evenimente care se produc la nivel citogenetic i moelcular.Transformarea n faza acut de boal poate reprezenta fie evoluia clonei maligne originale, fie se poate dezvolta o malignitate nou.Procesul de tranziie poate fi asociat cu modificri la nivel molecular, cu un prognostic nefavorabil i influeneaz supravieuirea.Factorii predictivi pentru transformare, momentul apariiei acesteia n cursul evoluiei bolii reprezint subiecte de cercetare. Din cazuistica Clinicii de Hematologie Colea am ales cteva cazuri ale unor pacieni care prezint interes din punct de vedere al particularitilor evolutive, al tipului de transformare, ncercnd s identific i posibilii factori asociai cu transformarea n cursul evoluiei bolii. THE TRANSITION IN MALIGNANT HEMOPATHIES HEMATOLOGY THE EXPERIENCE OF COLTEA CLINIC OF

AR Lupu University of Medicine Carol Davila Clinic of Hematology, Coltea Clinic Hospital, Bucharest, Romania The chronic hematologic diseases are clonal disorders of plurpotential hematopoietic stem cell which the proliferative capacity is not controlled and have morphologic and functional abnormalities.This process which is in the basis of pathogenetic, clinical and histologic characteristics may be documentated by identification of some events that undergo at citogenetic and molecular level.The transformed in acute phase of the disease represents either evolution of the orignal clone or development of a novo malignancy. The transition process may be asociated with molecular changes, with poor prognosis and influenced the survival.Predictive factors for transformation, the moment of the transformation event in he course of the disease are subjects for researches. Among the cases from Colea Clinic of Hematology I have selected a few interesting because of evolutive and transformation particularities and I tried to identified the factors associated with transition in the course of the disease. THE UPDATE OF MANAGEMENT OF ACCELERATED AND BLASTIC PHASES OF CHRONIC MYELOGENOUS LEUKEMIA Prof.Dr.Anca Roxana Lupu UMF Carol DavilaBucuresti Chronic myelogenous leukemia(CML) is a clonal myeloproliferative expansion of the multipotent mieloid stem cell, that results from neoplastic transformation and alteration of primitive myeloiod progenitor cell in their proliferative capacity.CML may have a biphasic or sometimes triphasic course.Patients who were initially diagnosed in the chronic phase(85-90%) will progress to a acute blast crisis phase(BP).Frequently, an intermediate or accelerated phase(AP), when patients become refractory to traditional, effective therapy, may precede the acute phase.CML is very well characterized leukemia at cytogenetic and molecular level.The Philadelphia chromosome is demonstrable in 90% of CML patients and 75% of patients in aggresive, acute leukemia-like phase, pass through an accelerated phase or abruptly transformation, develop other chromosome aberration in addition to the Philadelphia chromosome (trisomy 8, isochromosome 17, loss of Y chromosome, duplication of Ph chromosome).The BCR/ ABL fusion gene, mRNA, and protein are diagostic markers of CML, an active tyrosine kinase that drives the cell into uncontrolled proliferation in addition with the supression of pathways of apoptosis.Imatinib mesylate is an abl tyrosine kinase inhibitor approved as first-line treatment for CML since 2002.Several mechanism of resistance to imatinib have been demonstrated

frequently in patiens in BP. In the case of failure, resistance or intolerance to treatment with imatinib the second generation of tyrosine kinase inhibitors such as dasatinib and nilotinib may be use.The novel terapeutic options in the cases refractive to conventional therapy and that progress to the AP or BP are: cytotoxic drugs (among thus undergoing investigation as therapy in CML: homoharringhtonine, decitabine, troxacitabine, clofarabina, arsenic potassium arsenite), other abl kinase and signal transduction inhibitors, farnesyl transferase inhibitors, proteasome inhibitors, immune-based aproaches, stem cell transplantation. Key words: accelerated/blast phase of chronic myelogenous leukemia, abl kinase inhibitors GAMAPATIA MONOCLONAL CU SEMNIFICAIE NEDETERMINAT I MIELOMUL MULTIPLU INDOLENT, PROGRESIE SPRE MIELOMUL MULTIPLU Hortensia Ioni Disciplina de Hematologie - U.M.F. Victor Babe Timioara Gamapatia monoclonal cu semnificaie nedeterminat (MGUS) i mielomul multiplu indolent (Smouldering) (SMM) sunt asimptomatice, boli pre maligne caracterizate prin proliferare monoclonal a celulelor plasmatice n mduva hematogen n absena modificrilor organice ca leziuni osteolitice anemie sau insuficien renal. Pacienii cu MGUS i SMM necesit o urmrire ndelungat avnd n vedere riscul de progresie spre mielom multiplu (MM). Predicia i prevenirea progresiei MGUS i a SMM spre MM este foarte important. MGUS este cea mai obinuit discrazie plasmocitar prezent la aproximativ 3% din populaia general cu vrste peste 50 ani. Prevalena bolii crete cu vrsta. Rata de progresie la MM este de 1% pe an. SMM reprezint 15% din toate cazurile noi diagnosticate cu MM. Rata de progresie la MM simtomatic este cu mult mai mare dect la MGUS. Pacienii cu MGUS necesit identificarea factorilor de risc care sunt predictivi pentru progresie. Cel mai important factor de risc fiind tipul i mrimea componentului monoclonal. Subtipurile IgM i IgA sunt predictive pentru progresie alturi de procentul de celule plasmatice (6-9%) i prezena n ser de lanuri uoare libere (FLC). Factorii de risc pentru progresie SMM includ de asemenea tipul i mrimea imunoglobulinei, prezena unor leziuni litice osoase evideniate prin RMM i prezena celulelor plasmatice monoclonale anormale n snge. Studiile referitoare la progresia MGUS i SMM spre MM au demonstrat factori speciali care iniiaz pregresia cum ar fi: anomalii citogenetice Ras, metilare p16, myc, p53, modificarea micro mediului celular (angiogenez, supresiei imunitii mediat celulare, modularea secreiei paracrine de citochine ca interleukina 6 i VEGF). In majoritate, pacienii cu MM evolueaz din MGUS i SMM dei muli pacieni cu MM nu au recunoscute clinic aceste stadii pre maligne probabil datorit naturii asimptomatice a maladiilor. O istorie anterioar de MGUS sau SMM nu are impact asupra prognosticului MM. MONOCLONAL GAMMAPTHY OF UNDE TERMINED SIGNIFICANCE AND SMOLDERING MULTIPLE MYELOM; PROGRESSION TO MULTIPLE MYELOMA Hortensia Ionita University of Medicine and Pharmacy Victor Babe Timisoara- Department of Hematology Monoclonal gamapathy of untetermined significance (MGUS) and smoldering multiple myeloma (SMM) are asymptomatic, prenalignant disorders characteristicsed by monoclonal plasma cell proliferation in the bone marrow and absence of end organ damagesuch as osteolytic bone lesions, anemia, or renal failure. Patients with MGUS and SMM reguire in definite follow/up given their life-lang risk of progresion to multiple myeloid(MM). Predicting and preventing the progressions of MGUS and SMM to MM is of great importance. The MGUS is the most common plasma cell dyscrasia present in approximately 3% of the general population 50 years age and older. The prevalance increases withage. The rate of progression to multiple myeloma is 1% peryear. SMM occounts for approximately 15% of 11 .... cases with newly diagnosed MM. The risk of progression to MM is much hig her than observed with MGUS. Patients with MGUS needs identification of risk factors predictiv of progression to MM. The most important risk factor is the type and the dimension of monoclonal component. IgA subtypes are predictive for progression with the percent of the plasma cells (6-9%) and presents. Free light chains in the serum. The risk factors of progression in SMM includes the tipe and level of immunoglobuline, the presence of ... lesions by magnetic resonance imaging (MRI) and the presence of monoclonal plasma cells in the blood. The studies abount progression of MGUS and SMM to MM showed special factors predictive for progression: Ras cytogenetic abnormalities, p16 metilation, myc; p53 modification of celular mycro invionement (angiogenesis interleukine 6 and VEGF).

Patients with MM evolive froom MGUS or SMM evan though patients with MM do not have pre-malignant clinical stages. Hystory of MGUS and SMM daes not have impact in the prognostic of MM. SINDROMUL MIELOPROLIFERATIV CRONIC DE TRANZITIE Gabriel Gaman,Amelia Gaman,C.Moisa UMF Craiova Chiar daca sindroamele Mieloproliferative cronice prezinta un fenotip heterogen ,totusi patologic ele au un mecanism comun,si anume dereglarea unei tirozin kinaze sau a unui receptor de citokina. Recent descoperirea mutatiilor genei pentru janus kinaza 2 si a genei pentru receptorul trombopoetinei asociate cu cromozomul Philadelphia negativ la pacientii cu sindrom MP cronic,au condus la reevaluarea clasificarii sindroamelor MP si a oferit noi posibilitati de diagnostic si tratament. In trecut au fost identificate rearanjari cromozomiale ale genelor receptorilor pentru factorul de crestere derivat plachetar+/- alfa(PDGFRA)si beta(PDGFRB) si ale receptorului factorului de crestere (FGFR1)si JACK2.Mutatii ale genei KIT care codifica pentru receptorul celulei STEM au fost descoperite in mastocitozele sistemice In mod clasic, cele 4 entitati ale sindromului mieloproliferativ cronic se pot metamorfoza astfel : -Leucemia Granulocitara Cronica poate trece in trombocitemie esentiala si metaplazie mieloida cu mielofibroza. -Policitemia vera poate trece in LGC ,TE si MMM -TE in LGC,PV si MMM -MMM-in LGC -Sindromul PV-MM apare la 50% din pacientii cu policitemie vera.Tranzitia apare in medie la 10 ani dupa momentul diagnosticului existand cazuri individuale in care poate aparea la intervale mai scurte sau mai lungi de timp Najean a considerat ca faptul ca in cel putin 15 ani aceasta problema reprezinta o complicatie clinica majora afectand 50% din pacienti. PV-MM este caracterizata prin: cresterea spenomegaliei,eritrocite in picatura ,fibroza extinsa medular,tablou leucoeritroblastic,numar de eritrocite normal sau scazut. Anemia este rezultatul sechestrarii la nivelul splinei a hematiilor ,eritropoiezei ineficiente si proceselor extramedulare de eritropoieza a hematiilor cu viata scurta. Combinarea anomaliilor PVE la trombocitopenie sau la defectele plachetare calitative sunt des intalnite in aceasta faza a bolii.Pacientul cu PV-MM este supus unui mare risc de a dezvolta leucemie acuta. TE ,PV si MMM au aceeasi evolutie clinica si acelasi fenotip.Agravarea starii clinice este des intalnita.TE poate evolua spre mielofibroza /MMM.secundara. Caracteristicile biologice comune ale sindroamelor mieloproliferative cronice sunt prezenta coloniilor eritrocitare endogene(EEC),supra expresia genei PRV1mRNA la nivelul eritrocitei si o scadere a MPL membranare de la nivelul megacariocitelor.Impreuna aceste caracteristici arata faptul ca defectele moleculare intalnite in sindroamele mieloproliferative sunt foarte asemanatoare. Mai multe grupuri au identificat mutatia JACK2 V617K la majoritatea pacientilor cu PV si la aproximativ 50% din pacientii cu TE si MMM.JACK2 este una din cele 4 Janus kinaze(KAK) care se leaga la nivelul domeniului intracitoplasmatic al receptorului JACK2 mediaza semnalele receptorilor1 monodimerici : -EPO-R -G-CSF-R -MPL1 si MPL2-R,si este de asemeni implicata in semnalizarea KIT. Mutatiile JACK2 reduc expresia MPL la nivelul suprafetei celulare. Analiza predecesorilor hematopoetici demonstreaza prezenta cromelor homozigote pentru JACK2 V617K la majoritatea pacientilor cu PV si absenta la majoritatea pacientilor cu TE. Studii cantitative pe ADN-ul granulocitelor au aratat ca nivelul alelelor mutante la majoritatea pacientilor cu TE este mai scazut decat la pacientii cu PV sau MMM(20% versus>50%) La jumatate din pacientii cu sindrom mieloproliferativ cronic nu a fost demonstrata nici o anomalie recurenta.Studiile citogenetice au aratat un spectru larg de anomalii ce nu pot fi incadrate in clasificarea makerilor pentru ca ele reprezinta o minoritate. Printe cele mai frecvente anomalii citogenetice ale JACK2V617K sunt deletia 20q si trisomia 9.Alte anomalii : -deletia 13q,12p -trisomiile+ 8,+19,+21 -aberatie cromozomiala 1q -pierderile de la nivelul cromozomilor 7 si 4. Schimbarile epigenetice pot apare in sindroamele MP cronice.Hipermetilarea SOCS1 la cazurile cu TE

JACK2V617K-pozitive sau TE,PV si MMM negative . Raman intrebari in legatura cu mecanismele ce conduc la o mutatie unica sau o cale defectiva care genereaza diferitele fenotipuri ale bolii. CHRONIC MYELOPROLIFERATIVE DISORDERS TRANSITION G.GAMAN,AMELIAGAMAN,C.MOISA UMF CRAIOVA. Despite being phenotypically heterogeneous, MPDs share a common mechanism of pathogenesis: the deregulation of either a tyrosine kinase or a cytokine receptor. Recently, the discovery of mutations in the genes for the Janus kinase 2 (JAK2) and the thrombopoietin (TPO) receptor (MPL) gene, in Philadelphia chromosome - negative MPD led to the reassessment of MPDs classification and provided new tools for diagnosis and treatment. Earlier, chromosomal rearrangements involving the genes for platelet-derived growth factor receptors +/- alpha (PDGFRA) and beta (LPDGFRB), fibroblast growth factor receptor-1(FGFR1)and JAK2 were identified. Mutations in the KIT gene, which encodes the stem cell factor receptor, were found in systemic mastocytosis. Classically, the 4 conditions of chronic myeloproliferation can be transformed one into another in this way: - Chronic Myelogenous Leukemia (CML) is transformed into Essential Thrombocythemia (ET) and into Myelofibrosis with myeloid metaplasia (MMM). -Polycythemia vera (PV) pass into CML, in MMM and in ET. -MMM into CML. -ET into MMM and PV. The syndrome PV-MM occurs in 5-50% of patients with polycythemia vera. The transition occurs, on average, 10 years after the initial diagnosis, but in individual cases, it can occur after either shorter or longer intervals. Najean had reported that 15 years or more after the initial diagnosis, this complication is a major clinical problem, affecting almost 50% of patients. PV-MM is characterized by: -increasing spenomegaly -tear drop red cell morphology -extensive bone marrow fibrosis -leucoerythroblastic blood picture -a normal or decreasing red blood cell mass. The anemia that characterizes the spent phase is primarily a result of splenic pooling, ineffective erythropoiesis, and extramedullary production of red blood cells with a shortened red cell survival. Bleeding abnormalities PVE to thrombocytopenia or qualitative platelet abnormalities are especially common during this phrase of the disease. Patients with PV-MM are at high risk for the development of acute leukemia. ET, PV and MMM share a general pattern of clinical evolution and phenotypical mimicry. Clinical progression is frequently observed. ET can evolve into PV, and both (ET and PV) can progress to secondary myelofibrosis /MMM. The biological features common to these MPD are the presence of endogenous erythroid colonies (EEC), the over expression of PRV1mRNAin granulocytes and the low lever of membrane MPL in the megakaryocytic lineage. Together, these features suggest that the molecular defects underlying these MPD would be very similar. Several groups identified the JAK 2V617K mutation in most patients with PV and 50% of patients with ET and MMM. JAK 2 is one of the four Janus kinases (KAK) these proteins bind the intracytoplasmic part of cytokine receptors through their FERM domain. JAK2 mediates signaling of type 1 monodimeric receptors: -EPO-R -G-CSF-R -MPL1 and MPL2-R,and is also involved in signaling by KIT. Mutant JAK 2 reduces MPL cell surface expression. Analyses of hematopoietic progenitors demonstrate that homozygous clones for JAK2V617K are present in most PV patients. Quantitative studies on granulocyte DNAshowed that levels of mutated allele in most ET patients is lower than in PV or MMM patients(20% versus >50%). In half of the malignancies with myeloproliferation features, no recurrent abnormalities has been shwn. Cytogenetic studies show a wide spectrum of abnormalities that cannot be used as unikyng classification markers, because they only account for a minority of cases. Among the most frequent cytogenetic abnormalities, the 20q deletion and trisomy 9 are found in

JACK2V617K positive classic MPD Other abnormalities: -del 13q,12p -trisomies +8,+19,+21 -gain of 1q -chromosome losses -7,-4 Epigenetic changes may occur in MPD. Chyphermenthylation of SOCS1 in cases of JACK2V617K-positive ET or negative ET,PV and MMM. Questions remain about the mechanisms leading a unique mutation or defective pathway to generate different disease phenotypes. Optimizarea si standardizarea metodei Real Time PCR cantitativ pentru detectia transcriptului BCR-ABL in LMC: situatia actuala in laboratorul de biologie moleculara al Centrului de Hematologie si Transplant Medular Stefan Berceanu Rodica Talmaci1, Daniel Coriu1,2,Adriana Colita1,2 1-Universitatea de Medicina si Farmacie Carol Davila, Bucuresti 2-Institutul Clinic Fundeni, Bucuresti Monitorizarea moleculara a nivelului de transcript BCR-ABL prin Real Time PCR cantitativ (RQ-PCR) este din ce in ce mai utilizata pentru analiza raspunsului terapeutic la pacientii cu Leucemie Mieloida Cronica (LMC). Aceasta metoda a devenit esentiala in era terapiei cu inhibitori de tirozin kinaza, pentru situatiile cand nivelul residual al clonei leucemice este scazut sub nivelul de detectie prin analiza citogenetica efectuata pe preparate din maduva osoasa. Cresterea nivelului de transcript BCR-ABL este un indicator precoce al pierderii raspunsului terapeutic si astfel, se impune modificarea strategiei de tratament. Din acest motiv este importanta monitorizarea moleculara regulata a pacientilor cu LMC. Incepand cu acest an in departamentul nostru si-a inceput activitatea laboratorul de biologie moleculara, laborator care utilizeaza platforma LightCycler de real time PCR cantitativ. In laboratorul nostru suntem preocupati in obtinerea unor rezultate valide si reproductibile pe care le putem realiza numai acordand o importanta speciala respectarii si optimizarii fiecarei etape din protocolul de lucru recomandat de European LeukemiaNet si grupul Europe Against Cancer: colectarea probelor biologice, extractia ARN-ului, reactia de revers transcriptie, analiza si interpretarea datelor de PCR cantitativ. In aceasta lucrare se prezinta rezultatele obtinute si se analizeaza problemele intalnite. Optimization and standardization of a Real Time quantitative PCR method for detection of BCR-ABL transcripts in CML patients: actual situation in molecular biology laboratory of Center of Haematology and Bone Marrow Transplantation Stefan Berceanu Rodica Talmaci1, Daniel Coriu1,2,Adriana Colita1,2 1-University of Medicine and Pharmacy Carol Davila, Bucharest 2-Fundeni Clinical Institute, Bucharest Molecular monitoring of BCR-ABL transcript level by Real Time quantitative PCR (RQ-PCR) is increasingly used to asset treatment response in patients with Chronic Myeloid Leukemia (CML). This has become particularly relevant in the era of tyrosine kinase inhibitors therapy when residual level of leukemia usually fall below the level of detection by bone marrow cytogenetic analysis. Because a rising level of BCR-ABL is an early indication of loss of response and thus the need to reassess therapeutic strategy, regular molecular monitoring of individual patients is clearly desirable. Starting with this year in our department just have started the activity a new molecular biology lab using a LightCycler platform. Our main concern is to get valid RQ-PCR data, and for that it is imperative to consider and optimize each stage of the procedure, including samples collection, RNA extraction, reverse transcription, and the quantitative PCR. Here we present our achievement and some of the problems encountered. METAMORFOZABLASTICAALEUCEMIEI GRANULOCITARE CRONICE: MECANISME SI TRATAMENT Dan Coli,Adriana Coli Centrul de Hematologie i Transplant Medular Institutul Clinic Fundeni, Bucureti Evoluia natural a leucemiei granulocitare cronice (LGC) sfrete n mod implacabil cu o leucemie acut Ph+, mieloid sau limfoid (75 i respectiv 25% din cazuri), extrem de sever (metamorfoza sau criza blastic). Aceast

evoluie poate fi cupat numai cu ajutorul allotransplantului de celule stem hematopoietice (Allo-TCSH) sau mult ntrziat prin administrare de Imatinib Mesilate (IM). Efectuat preferenial n faza iniial precoce, Allo-TCSH realizeaz remisiuni nentrerupte lungi (50-70% cazuri la 3 ani) cu anse de vindecare (< 2% recderi/an la subiecii cu remisiune complet mai lung de 5 ani). Administrarea IM de la diagnostic (400 mg/zi), prelungete cel puin de 2 ori durata fazei cronice iniiale, amnnd astfel instalarea crizei blastice. Rata anual a progresiei dup 5 ani de evoluie fr evenimente de boal n timpul tratamentului cu IM este de 0,9%. Pierderea rspunsului la IM reprezint o form secundar (dobndit) de rezisten la tratament i coincide cu reactivarea proteinei oncogenice p210BCR-ABL, molecula-int a IM. Oncoproteina p210BCR-ABL este o tirozin-kinaz (TK), care produce fenotipul de boal. ExpresiaTK BCR-ABL este permanent, autonom i progresiv. TK BCR-ABL ar putea fi implicat direct sau indirect, (prin alterarea mecanismelor de reparare a ADN), n achiziia anomaliilor genetice nentmpltoare asociate n diverse combinaii cu metamorfozarea blastic. In 60-80% din cazuri, anomalia Ph se asociaz cu altele, numerice (+8, +13, al 2-lea crz.Ph) sau structurale [i17q, t(3:21), t(7:11)], iar la nivel molecular cu mutaiile p53 i ale locusului INK4A/ARF asociate frecvent cu criza blastic mieloid i, respectiv, cu cea limfoid. Tratamentul crizei blastice (CB) nu este protocolat. Bolnavii sunt de 2 categorii: cei cu CB instalat dup tratament cu IM i cei naivi, care au fcut alte tratamente sau au fost depistai direct n faza de metamorfozare. La pacienii pretratai cu IM se recomand efectuarea analizei moleculare a TK BCR-ABL. Depistarea unei mutaii care confer rezisten absolut la IM (ex.T315I) indic renunarea la IM. La toi ceilali este de ncercat rspunsul la dozele mrite (600-800 mg/zi) de IM, care induc 34% rspunsuri hematologice (RH) complete sau reconvertiri la faza cronic, 18% rspunsuri citogenetice (RCi) i o supravieuire median de 6,9 l. Ali inhibitori ai TK BCR-ABL (Nilotinib, Dasatinib) pot fi ncercai n cazurile rezistente la IM, cu excepia celor cu mutaia T315I. Nilotinib (2 x 400 mg/zi) induce 42% RH n CB mieloid, 31% RH n CB limfoid i 27% RCi la pacienii cu mutaii ale TK. Dasatinib (2 x 70 mg/zi) produce rspunsuri complete hematologice i citogenetice n ambele forme de metamorfozare: 27% RH i 26% RCi n CB mieloid i 29% RH i 50% RCi n CB limfoid. Durata general a rspunsurilor a fost < 6 luni. Polichimioterapia cu scheme bazate pe citarabin/antraciclin pentru transformarea mieloid sau pe vincristin/prednison pentru formele limfoide ca alternativ la inhibitorii TK, ofer performane efemere de acelai ordin de mrime. Asocierile ntre citostatice i inhibitori ai TK pot fi sinergice sau aditive. Allo-TCSH la pacienii eligibili este o opiune pentru pacienii aflai n remisiune complet sau reconvertii la faza cronic. THE BLASTIC METAMORPHOSIS OF THE CHRONIC MYELOID LEUKEMIA (CML): MECHANISMS AND TREATMENT. Dan Coli,Adriana Coli Center of Hematology and Bone Marrow Transplantation Clinical Institute Fundeni, Bucharest The natural evolution of CML ends implacably with an extremely severe acute Leukemia Ph+, of myeloid of lymphoid type (75 and respectively 25% of cases), named metamorphosis or blastic crisis BC. This evolution can be stoped by the allotransplant of hematopoietic stem cells (Allo-THSC) or delayed by the treatment with Imatinib Mesilate (IM) which prolongs 2 times long the duration of the initial chronic phase of the disease. The evolution to BC is promoted by an oncoprotein (p210BCR-ABL), an autonomous active tirosin-kynase (TK), engendered by the Philadelphia (Ph) translocation [t(9:22)], the hallmark of the disease. The evolution to BC is marked by a nonrandom genetic instability which supplements the Ph chromosome with numeric (+8, +13, the 2nd Ph chr.), structural [i17q, t(3:21), t(7:11)] and molecular (p53 and INK4A/ARF mutations) abnormalities (60-80% of cases in BC). The treatment of BC is not firmly formulated. Being the fact of the central position of TK BCR-ABL , in the pathogenesis of the disease the inhibitors of the enzyme (i.e. Imatinib, Nilotinib and Dasatinib) began to be recomended as front-line therapy. They realise hematologic and cytogenetic remissions or reconversion in chronic phase of the BC, but with short duration (~6 mo.). The cytostatic polichemotherapy (the models of acute high risk leukemias) offers also ephemeral results. The allo-THSC has better outcome for the eligible patients reconverted to the chronic phase or being in complete remission after the above mentioned treatments. Gamapatia monoclonal Cu semnificaIe nedeterminat, mielomul Multiplu Smoldering, Mielomul Multiplu cor,elaIi patogenice M.Badea#, Daniela Badea* #Clinica de Hematologie, *Disciplina de Fiziologie; Univ de Medicin i Farmacie Craiova Discraziile plasmocitare sunt proliferri limfoide B cu grad de maturare semnificativ ce permit sinteza de Ig sau fraciuni ale acestora.

Gamapatia monoclonal cu semnificaie nedeterminat (MGUS) este o boal clonal caracterizat prin infiltraie plasmocitar medular 10%, CM 3g/dl, n absena leziunilor organice. Rar MGUS are potenial evolutiv ctre o limfoproliferare agresiv (MM, amiloidoz, boal Waldenstrom) majoritatea bolnavilor decednd din alte cauze. Mielomul multiplu smoldering (SMM) este o boal cu caracter malign, cu plasmocitoz medular 10%, CM n general 3g/dl, fr leziuni organice i complicaii majore; potenial evolutiv frecvent ctre MM activ. Mielomul Multiplu (MM) este o boal malign activ cu plasmocitz medular 10%, CM 3g/dl, caracterizat de prezena leziunilor organice semnificative. Discraziile plasmocitare i au originea ntr-o celul ce a traversat centrul germinativ, a suferit fenomenul de switch izotipic i pe cel al mutaiilor somatice, fiind absente variaiile intraclonale. Genetica MM este complex i heterogen: cuprinde proliferri non-hiperdiploide ce posed translocaii primare ale IgH (40-50%), proliferri hiperdiploide (4875cromozomi)(40%) i alte tipuri de proliferri (20%). Translocaiile IgH cuprind 8 tipuri de proliferri mprite n 3 grupe (cyclina D1, MAF i MMSET/FGFR3). Proliferrile hiperdiploide prezint trisomii ale cromozomilor impari 3, 5, 7, 11, 15, 19 i 21 i rar translocaii IgH. Ambele tipuri de leziuni apar timpuriu n evoluia proliferrii, ele fiind identificate n procente relativ similare, att n MGUS ct i n MM. Afectarea locusului IgH apare foarte probabil n procesul de switch izotipic i mai rar n cel al mutaiilor somatice. Nu se cunoate patogenia trisomiilor i nici modalitatea cum acestea contribuie la iniierea i/sau evoluia procesului malign. Dei cu relevan incontestabil aceast ncadrare genetic nu prezint o semnificaie clinic deosebit, ntruct MM pare s includ mai multe tipuri de proliferri cu caracteristici diferite n ceea ce privete atat evenimentele ce iniiaz proliferarea, ct i caracteristici generale: dependena de micromediul medular, manifestarile clinice, prognosticul sau rspunsul la terapie. Impactul evolutiv i prognostic este oferit de alte carecteristici biologice, anomalii citogenetice sau de biologie molecular, cu prevalen aprox similar n cele dou grupe de proliferri menionate: translocaiile secundare ale IgH, del 13q, anomalii ale cii Ras, NFkB, a proteinei p53, sau a RB. Anomaliile de laborator cu impact asupra progresiei n MGUS sunt multiple, diverse i controversate: amplitudinea CM, prezena izotipului IgA sau IgM, procent medular crescut de plasmocite, reducerea Ig policlonale i, recent, anomalii ale raportului lanurilor uoare n ser 0,26 i 1,65. coala de la Barcelona identific dou grupuri de bolnavi cu SMM cu caracteristici similare la diagnostic, dar care n timp se difereniaz: grupul n care CM rmne stabil (nonevolving) fa de grupul (evolving) cu rat crescut de evoluie ctre MM, n care CM se amplific semnificativ n timp. Astfel, MGUS/SMM cu caracter evolutiv poate fi considerat de la nceput un MM incipient, n comparaie cu nonevolving MGUS/SMM, ce reprezint o leziune stabil. Prin prisma ipotezei celulei stem a neoplaziei, certificat deja n MM, se ridic desigur problema heterogenitii biologice a acesteia, dar i a importanei relaiei cu micromediul medular, cel putin la un numar semnificativ de cazuri. Monoclonal gammopathy of undetermined significance, Smoldering multiple myeloma and Multiple Myeloma pathogenic corelations M.Badea#, Daniela Badea* #Dept. of Hematology, *Dept.of Physiology; Univ. of Medicine and Pharmacy Craiova The plasma cell disease are B cells proliferation with advanced grade of maturity witch permitted immunoglobulin (Ig) or Ig fragments synthesis. Monoclonal gammopathy of undetermined significance (MGUS) is a clonal disease characterized by plasma cells (PC) infiltration of bone marrow (BM) <10%, CM<3g/dl, in the absence of organic lesions. The evolutionary potential towards an aggressive lymphoma (MM, amiloidozis, Waldenstrom disease) is rare, the majority of patients dying from other causes. Smoldering multiple myelomaSMM is a malignant disease with BM plasmacytosis >10%, CM usually>3g/dl, without organic lesions and major complications; frequently evolving towards active MM. Active MM is a malignant disease with BM plasmacytosis > 10%, CM> 3g/dl, characterized by end-organ damage related to PC proliferation. The PC proliferations originate in a cell that has traversed the germinal center, has undergone an izotipic switch and somatic mutations in the absence of intraclonal variations. The genetic makeup of MM is complex and heterogeneous; containing non-hyperdiploid proliferations that poses primary translocations of IgH (40-50%) hyperdiploid proliferations (48-75 chromosomes)(40%) and other types of proliferations (20%). IgH translocations contain 8 types split into 3 groups (cyclin D1, MAF and MMSET/FGFR3). The hyperdiploid proliferations presents trisomies of the odd chromosomes 3,5,7,11,15,19 and 21 and rarely IgH translocations. Both types of lesions appear early in the evolution of the proliferations, being identified in relatively similar percentages in both MGUS and in MM. The lesions of the IgH locus seem very probable in the izotic switch process and worse, the somatic mutation. The pathogenesis of

the trisomia is unknown as is the way in which this contributes to the initialization of the malignant process. Although with incontestable relevancy this genetic classification, does not present a major clinical significance, since MM seems to include many types of proliferations with different characteristics with regard to the events that initialize the proliferation, but also in general features: dependency on the BM microenvironment, clinical manifestations, prognostic, or response to therapy. The evolutionary and prognostic impact is created as much by these biological characteristics, cytogenetic or molecular biology abnormalities with prevalence similar to the two groups: secondary translocations of IgH, del 13q, Ras pathway abnormalities, NFkB, the protein p53, or RB. Laboratory abnormalities that impact the progression of MGUS are multiple, diverse and controversial: the concentration of CM, the presence of IgA or IgM isotype, the high percent of BM cells, the reduction of the polyclonal Ig and recently, the abnormal free light-chain ratio, defined as below 0.26 (indicating excess of lambda chains) or above 1.65 (indicating excess of kappa chains) With regards to SSM, the school of Barcelona recognize a group of patients with similar features at diagnostic, while CM is stable (nonevolving) versus the group (evolving) with a higher rate of evolution towards MM, in which CM increase significantly with time. Otherwise, MGUS/SMM with evolutionary character may be considered from the beginning an incipient MM compared to the nonevolving MGUS/SMM which represents a stable disease. From the point of view of the neoplastic stem cell hypothesis, already certified in MM, the problem of the biological heterogeneity is very clear, but is also important to clarify the relationship of this cell with bone marrow microenvironment, at least for a significant number of cases.

COMUNICARI VARIA

ROLUL TRATAMENTULUI COMBINAT SI EVOLUTIA POSTTRATAMENT LA PACIENTII CU LIMFOAME MARGINALE CU SPLENOMEGALIE. Autori: A. M. Vladareanu*, A. Petre*, C. Ciufu*, D. Casleanu*, H. Bumbea*, M. Onisai* , I. Voican*, M. Begu*, C.Marinescu*, S.Radesi *C Dobre***, V.Vasilache*, V. Popov, ,H.Pantu, ** S. Neagu**, M.Grigoriu, ** , C Savlovshi**, D.Vasile** * Clinica de Hematologie, Spitalul Universitar de Urgenta ,Bucuresti ** Clinica de Chirurgie, Spitalul Universitar de Urgenta ,Bucuresti *** Institutul V.Babes, Bucuresti REZUMAT: Limfoamele marginale fac parte din categoria limfoamelor indolente, cu evolutie favorabila sub tratament. Am prezentat un studiu retrospectiv luind in discutie pacientii diagnosticati cu Limfoame marginale in Clinica de Hematologie SUUB timp de 2 ani. Au fost luati in studiu atat pacientii cu Limfoame marginale nodale care asociau splenomegalie cat si pacientii cu Limfoame marginale splenice primitive..Diagnosticul s-a pus pe criteriul histopatologic si imunohistochimic al ganglionilor sau splinei, insotit de analiza flowcitometrica a maduvei si sangelui periferic in formele cu descarcare. Sunt prezentate optiunile terapeutice si evolutia pacientilor sub tratament specific. S-a analizat eficienta tratamentului in cazul pacientilor initial splenectomizati apoi chimiotratati fata de cei la care tratamentul a continut chimioterapia ca prima linie. Mentionam ca in cadrul tratamentului polichimioterapic s-au folosit si anticorpi monoclonali, conform protocoalelor terapeutice. Concluzie: Pacientii care au primit tratament combinat care a inclus chimioterapie, imunoterapie si tratament chirurgical ( splenectomie) au avut o evolutie favorabila apreciata ca rata de remisiuni si supravietuire fara resuta. . Splenectomia este o optiune terapeutica cu rol important in tratamentul Limfoamelor marginale cu splenomegalie fie de prima intentie, fie in completarea tratamentului medicamentos iar indicatia ei trebuie formulata distinct in cazurile selectionate. . THE COMBINED TREATMENT ROLE AND THE EVOLUTION AFTER THERAPY IN MARGINAL NHL WITH SPLENOMEGALY PATIENTS Authors: A. M. Vladareanu*, A. Petre*, C. Ciufu*, D. Casleanu*, H. Bumbea*, M. Onisai* , I. Voican*, M. Begu*, C.Marinescu*, S.Radesi *C Dobre***, V.Vasilache*, V. Popov, ,H.Pantu, ** S. Neagu**, M.Grigoriu, ** , C Savlovshi**, D.Vasile** *Hemathology Department of the Emergency Universitary Hospital, Bucharest **Surgery Department of the Emergency Universitary Hospital, Bucharest ***V.Babes Institute, Bucharest ABSTRACT : Marginal non-Hodgkin lymphomas are indolent type of lymphomas, with favorable course under therapy. We present a retrospective analysis , considering the Marginal Lymphoma patients diagnosed in our department in the last 2 years, including nodal marginal lymphomas with splenomegaly, also splenic marginal lymphoma patients. The diagnosis was on hystopathologic and immunohystochemical examination of the lymph node and spleen, together with bone marrow flow-cytometry analysis and peripheral blood flow-cytometry in leukemic forms of the disease. We are analyzing the therapeutic options and under treatment evolution of the patients, such as : the efficiency of the treatment in patients with prior splenectomy and chemotherapy as a second-line treatment comparing to patients having first-line chemotherapy. We also used monoclonal antibodies during the therapy, according to international regimens. Conclusion : Patients receiving combined therapy : chemotherapy, immunotherapy and surgical treatment (splenectomy) have had a favorable course of the disease, considering remission rates and disease free survival without relapse. The splenectomy represents an important therapeutic option like first-line therapy or after chemotherapy; the recommendation of splenectomy must be very well chosen in clearly selectioned cases. FACTORI DE PROGNOSTIC IN LEUCEMIALIMFOCITARACRONICA

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Horia Bumbea,Ana-Maria Vladareanu Spitalul Universitar de Urgenta Bucuresti, Romania Rezumat Sistemele de prognostic utilizate cel mai frecvent in leucemia limfocitara cronica sunt sidtemul Rai si Binet. Se asociaza in prezent si alti markeri la aceste sisteme de prognostic, legate de boala si statusul pacientului. Markerii imunofenotipici si genetici / moleculari reprezinta un grup important de factori de prognostic. Dintre markerii imunofenotipici remarcam markerii clasici : imunofenotipul aberant CD33, CD13, CD14, CD36 imunofenotip atipic FMC7, CD22 markeri solubili sCD23, sCD25, sCD27 markeri de activare CD38 surogat pentru statusul mutatiei IgVH ZAP-70 cyclin D1, superexpresia bcl-2 molecule de adeziune CD54 (ICAM-1), sCD44 Markerul imunofenotipic cel mai important a fost mult timp CD38, introdus de Damle si colab. in 1999, ca un marker asociat statusului mutatiei IgVH, dar rezultatele au fost discordante fata de determinarea prin tehnici moleculare, in timp ce expresia ZAP-70 se coreleaza mult mai bine cu statusul mutatiei IgVH, iar tehnica de analiza prin flowcitometrie este considerata metoda optima (Crespo si colab, 2003), desi unele centre inca mai efectueaza studii de standardizare a acestei metode. In aceeasi masura sunt utilizati ca factori importanti de prognostic: aberatiile cromozomiale (13q-, 11q, 17p), lungimea telomerelor, activitatea telomerazei, timpul de dublare limfocitar, concentraia beta-2 MG, nivelul seric al sCD23, activitatea sTK. Un element nou il aduce stratificarea in subgrupe prognostice a LLC pe baza asocierii imunofenotipice a FMC7, CD20 inalt pozitiv, CD23 slab pozitiv, CD38 inalt pozitiv (Habib si Finn 2006). Toti acesti factori predictivi reprezinta factori suplimentari care se adauga la stadializarea clinica prognostica, care ramane inca baza evaluarii prognostice initiale a bolnavului cu LLC. PROGNOSTIC FACTORS IN CRONIC LYMPHOCYTIC LEUKAEMIA Horia Bumbea,Ana-Maria Vladareanu Spitalul Universitar de Urgenta Bucuresti, Romania Abstract The most important prognosis systems in chronic lymphocytic leukaemia were clinical systems Rai and Binet. There were associated many other markers, related to disease and to the patient status. Immunophenotypic markers have been introduced among the important prognosis factors. They could be classified as: atypical immunophenotype FMC7, CD20++, aberrant immunophenotype like myeloid markers CD14, CD36, CD13, CD33; soluble markers sCD23, sCD25, sCD27; activation markers (CD38); surrogate for IgVH mutation status (ZAP-70); cyclin D1, bcl-2 overexpression; adhesion molecules: CD54 (ICAM-1), sCD44. The most important immunophenotypic marker was CD38, introduced in 1999 by Damle et al., as a strong prognosis marker associated with IgVH mutation status, but molecular studies found many cases with discordant results. A better marker seems to be the novel ZAP-70 as prognosis marker associated with IgVH mutation status, and the best method for analysis is flowcytometry (Crespo et al, 2003). Despite the method for detection need to be standardiazed, it is the best way to analyze very quickly the IgVH mutation status. There are used as important pronostic markers cromozomial aberrations (13q-, 11q, 17p), telomer length, telomerase activity, serum beta-2 MG level, lymphocyte doubling time, serum sCD23, sTK activity. Prognostic stratification of CLL was found related to the complex immunophenotype: FMC7, CD20 high pozitive, CD23 low pozitive, CD38 high pozitive (Habib and Finn 2006). All these predictive factors represents only additional to the clinical staging systems which are still the basement of the initial prognostic evaluation and decision of treatment in patients with chronic lymphocytic leukaemia. EVOLUTIACLONALATARDIVAINTR-UN CAZ DEANEMIEAPLASTICA TRATAT IMUNOSUPRESIV Ljubomir Petrov Institutul Oncologic Ion Chiricuta Cluj Napoca Universitatea de Medicina si Farmacie Iuliu Hateganu, Clinica de Hematologie

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Anemia aplastica este o boala a celulei stem hematopoietice caracterizata prin pancitopenie si grade variate de hipocelularitate. Patogeneza nu este pe deplin elucidata. Exista dovezi in favoarea depletiei imune a celulei stem hematopoietice prin limfocite T citotoxice. Principalele modalitati terapeutice constau in transplant allogeic de celule stem si imunosupresie. Dupa tratamentul imunosupresor asistam uneori la o evolutie clonala spre: hemoglobinurie paroxistica nocturna (HPN), sindrom mielodisplazic ( SMD) sau leucemie acuta mieloida (LAM). Prezentam observatia clinica a unui pacient cu anemia aplastica severa care a avoluat dupa tratamentul imunosupresor spre HPN si SMD. Bolnavul M.R. de 20 de ani a urmat in 1998 un tratament imunosupresor cu globulina antitimocitara (GAT) cu persistenta unei pancitopenii moderate fara complicatii sau necesar de transfuzii. Dupa 4 ani anemia se accentueaza pacientul devenind dependent de transfuzii. Examinarile efectuate la Clinica de Hematologie din Cluj si la clinica din Italia confirma diagnosticul de HPN. Dupa inca 6 luni biopsia osteo medulara pune in evidenta modificari displazice triliniare. Cariotipul este normal. Tratamentul in continoare consta in transfuzii de masa eritrocitara, dinazol si corticoizi. Anemia aplastica severa si foarte severa tratate prin transplant allogenic de celule stem sunt curabile intr-un procent de 50-75%. Dupa imunosupresi rata de raspuns este de 75%, insa exista riscul recaderii si evolutiei clonale spre HPN, SMD sau LAM. Cazul prezentat a avut o evolutie spre primele doua posibilitati. CLONAL EVOLUTION INAPATIENT WHIT SEVERE APLASTICANEMIATREATED WHIT IMMUNOSUPPRESION Ljubomir Petrov Ion Chiricuta Cancer Institute University of Medicine and Pharmacy, Hematology Department Aplastic anemia is a disease of hematopoietic stem cell characterized throught pancitopenic and different grades of hipocellularity. Pathogenesis it is not fully elucidated. There are proofs in favour of immunity clack of the hematopoietic stem cell throght cytotoxic T cell. The mains therapeutic treatments ways are based on allogenic stem cell transplant and immunosuppressive drug therapy. After the immmunosuppresion is done we can see sometimes that clonal evolution developing: PNH, MDS orAML. We are showing the clinical observation of the patient having a severe aplastic anemia wich evolution after immunosuppresion went towards PNH/MDS. The patient M.R. 20 years old had in 1998 an immunosuppresion with antithymocyte globulins (GAT) developing a moderate pancytopenic diseas without complications or blood transfusions necessary. After 4 years the anemia was more severe and the patient became blood transfusion dependent. Examinations done at Hematology Department in Cluj and Italy have confirmed the PNH diagnostic. After six mounths a bom marrow biopsy was done, showing modifications: trilineage dysplasia. The karyotype it is normal. The further treatment is based on transfusions of erithocytary mass, danazol and prednisone. Severe aplastic anemia and very severe are treated throught allogenic stem cell transplant are healing in proportion of 50% to 75%. After immunosuppressive treatment a 75% rate is aletainable, but exists the risk of relapse and a clonal evolution towards PNH, MDS orAML. This patient had en evolution characterized by these two possibilities. Quality of life beyond survival: endocrine treatment in major thalassemic patients Simona Fica*, Florentina Vladareanu***, Anca Zirnea**, Alice Albu**, Carmen Barbu*, Rodica Rotaru**, Larisa Nitu***, Daniela Marinescu***.

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*Departament of Endocrinology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania ** Elias Hospital, Bucharest, Romania *** National Institute of Transfusional Hematology, Bucharest, Romania Homozygous -thalassemia is a genetic disorder of globin chains synthesis characterized by ineffective erythropoiesis and chronic anaemia requiring regular transfusions in order to overcome the complications of anaemia and compensatory bone marrow expansion. In Romania thalassemia major is not a common disease, with a prevalence of only 0,5%, but it represents a serious medical condition. Excess of iron acumulations resulting from transfusions leads to endocrine disturbances. Aim of the study: to assess the prevalence of endocrine disturbances in -thalassemic patients and to evaluate de benefit of hormone replacement therapy. Patients: 78 patients (38 females and 40 males) with major -thalassemia with a mean age of 19.456.82 years referred to our clinic from the National Institute of Transfusional Hematology. Methods: All the patients were evaluated clinically (age, sex, height, weight, pubertal status by Tanner) and biologically. LH, FSH, estradiol, testosterone, PTH, TSH, free T4, insulin, GH, IGF1 were measured by chemiluminescence, BMD (bone mineral density) was measured by Dual-energy x-ray absorptiometry (DXA); mean ferritin value was used to assess iron overload. Results: 65 patients at pubertal and adult age (83,3%) in our group had hypogonadotropic hypogonadism and 48 patients (61,5%) had pathological short stature with great impact on their life quality. Delayed puberty (21 patients34,4%) and arrested puberty (18 patients -29,5%) were the most common clinical presentation of hypogonadism especially in male patients with a major impact on sexual development and final height. Moreover, 11 patients (14%) had primary hypothyroidism, 5 patients (6,4%) hypoparathyroidism, 3 patients (3,8%) diabeted mellitus and 6 patients (7,6%) insulin resistance. Severe osteoporosis (Z score >-2,5DS) with great risk of fracture was found in 20 of 22 patients evaluated for their bone mineral density by DXA method suggesting a high prevalence of osteoporosis in these patients. We also found a significantly higher mean ferritin value in patients with endocrine disturbances of any type compared to subjects without endocrinopathies. Patients with hypogonadism received hormone replacement therapy (females with transdermal estradiol for delayed puberty and secondary amenorrhea; males with depot testosterone undecanoate i.m.) with major benefit on sexual development (all patients advanced 1-2 Tanner stages), pubertal growth and prevention of osteoporosis. Thalasemic patients on growth hormone therapy had a growth velocity increment greater than 4 cm above the previous year. Patients with osteoporosis received antiresorptive therapy combinated with calcium - vitamin D supplements with major improvement of life quality. Conclusions: early endocrine evaluation and tratment are necessary in order to improve the life quality of thalassemic patients. Calitatea vietii obiectivul tratamentului endocrin la pacientii cu -talasemie majora Simona Fica*, Florentina Vladareanu***,Anca Zirnea **,AliceAlbu**, Carmen Barbu*, Rodica Rotaru**, Larisa Nitu***, Daniela Marinescu***. *Clinica de Endocrinologie, Universitatea de Medicine si Farmacie "Carol Davila", ** Spitalul Elias, Bucuresti, Romania *** Institutul National de Hematologie, Bucuresti, Romania -talasemia majora este o afectiune genetica datorata unui defect cantitativ de sinteza al lantului de globina caracterizata prin eritropoieza ineficienta si anemie cronica necesitand regim transfuzional pentru a preveni complicatiile anemiei si expansiunea compensatorie a maduvei hematopoietice. In Romania desi prevalenta este doar de 0,5%, talasemia prezinta un impact major asupra calitatii si sperantei de viata a pacientilor. Scopul studiului: evaluarea prevalentei modificarilor endocrine cat si beneficiul terapiei de substitutie hormonale instituite. Material si metoda: studiul a fost efectuat pe un lot de 78 de pacienti (38 femei si 40 barbati) diagnosticati cu talasemie majora la Institutului National de Hematologie Bucuresti avand o varsta medie de 19,456,82 ani. Pacientii au fost evaluati clinic (varsta, sex, inaltime, greutate, stadiu Tanner, istoric menstrual) si biologic. Au fost efectuate dozari hormonale pentru: LH, FSH, estradiol, testosteron, TSH, FT4, GH, IGF1, PTH, insulinemie in cadrul sectiei de Endocrinologie a Spitalului Elias. Densitatea mineral osoasa (BMD) a fost evaluata prin efectuarea absorptiometriei duale cu raze X (DXA); depozitele siderozice au fost evaluate prin masurarea feritinei serice.

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Rezultate: Disfunctiile endocrine ce determina aparitia complicatiilor cat si afectarea severa a calitatii vietii pe lotul studiat sunt: hipogonadismul hipogonadotrop (65 de pacienti la varsta pubertala si adulta -83,3%), hipotrofia staturo-ponderala (48 de pacienti -61,5%), hipotiroidismul primar (11 pacienti -14%), hipoparatiroidismul primar (5 pacienti -6,4%), diabet zaharat (3 pacienti -3,8%), insulinorezistenta 6 pacienti -7,6%). Pubertatea intarziata (21 pacienti -34,4%) si pubertatea oprita in evolutie (18 pacienti- 29,5%) sunt cele mai frecvente manifestari clinice ale hipogonadismului cu impact major asupra dezvoltarii sexuale si a inaltimii finale. Osteoporoza severa cu risc de fractura (DXA, scor T> -2,5 DS) a fost evidentiata la 20 din cei 22 de pacienti investigati. Numarul si severitatea afectiunilor endocrine se coreleaza semnificativ statistic cu valoarea feritinei serice. Terapia hormonala de substitutie a fost benefica pe lotul studiat: pacientii diagnosticati cu hipogonadism in tratament cu hormoni sexuali au inregistrat o progresie pubertala semnificativa (1-2 stadii Tanner pe scara dezvoltarii pubertale) cat si preventia osteoporozei; la pacientii cu hipotrofie staturo-ponderala in tratament cu hormoni de crestere s-a observat accelerarea vitezei de crestere (evaluata la peste 4 cm in ultimul an de terapie). Pacientii cu osteoporoza au primit tratament antiresorptiv cu bifosfonati, calciu si vitamina D cu evolutie favorabila. Concluzii: evaluarea endocrinologica timpurie a pacientilor cu -talasemie majora este necesara pentru diagnosticul si terapia complicatiilor endocrine reversibile in speranta unei vieti normale. Tratamentul cu doze scazute de 6-mercaptopurina (6MP) la pacientii cu leucemie acuta mieloida secundara (LAMs) mielodisplaziei si mieloproliferarilor cronice Andrei Colita, Anca Lupu,Oana Ciocan, Gabriela Barca, Mihaela Closca, Carmen Saguna, Silvana Angelescu, Doina Barbu,Anca Ciobanu,Ana Maria Ivanescu, Madalina Vasile, Oana Patranoiu, Simona Crintea, Delia Mut Popescu Spitalul Clinic Coltea Bucuresti Obiectiv: evaluarea rezultatelor terapiei cu doze mici de 6MP si a evolutiei la pacientii varstnici cu LAMs Pacienti si metode: 8 pacienti cu LAMs urmariti in perioada Sept. 2002 March 2007; varsta mediana 76 ani (interval 66 81 ani); M/F: 3/5. Diagnosticul a fost stabilit dupa examinarea aspiratului de maduva osoasa si in 4 cazuri a fost confirmat prin biopsie osoasa. Patru pacienti au avut LAN secundara mielodisplaziei (SMD), 2 dupa boli mieloproliferative cronice Ph-negative (1 mielofibroza postpolicitemica, 1 mieloproliferare neclasificabila ambii pozitivi pentru mutatia JAK2 (V167F))si 2 cu puseu blastic de leucemie mieloida cronica. Chimioterapia initiala a constat in cure 3+7 in 6 cazuri, si cure TRAMPCO pentru cele 2 cazuri de puseu blastic. Dozele de 6MP au fost de 100 - 150 mg/saptamana. Scopul introducerii terapiei cu doze mici de 6MP a fost paliativ in conditiile in care pacientii nu au obtinut raspuns hematologic la chimioterapia initiala sau ca urmare a aparitiei de complicatii infectioase sevre consecutive inductieie. Decizia initierii acestui tratatment a fost facuta cu acordul pacientilor si familiilor acestora. Rezultate: la 4 pacienti s-au obtinut rezultate deosebit de bune:
Sex Varsta Diagnostic Evolutie Urmarire
66 luni 24 luni* 12 luni 15 luni 1. M 77 LAM post SMD RC 2. F 69 LAM post SMD RC 3. F 76 LAM post mIelofibroza RC 4. M 66 LMC puseu blastic Faza cronica * pierdut di evidenta dupa 24 luni; pozitiv pentru mutatia JAK2

Alti 2 pacients sunt in viata 1 cu LAM post SMD in remisiune partiala dar dependent de transfuzii, celalalt cu LAM post mieloproliferare neclasificabila prezinta leucocitoza si trombocitoza persistente (a fost necesara asocierea de hydroxiuree si methotrexate). Dupa parerea nostra este posibila descrierea unui subgrup de pacienti varstnici cu LAMs care ar putea beneficia de chimioterapie cu doze reduse. 6 Mercapto-purine (6MP) Low-Dose Therapy In Elderly Patients With Acute Myeloid Leukemia (AML) Secondary To MyelodisplasiaAnd Myeloproliferative Diseases. Andrei Colita, Anca Lupu,Oana Ciocan, Gabriela Barca, Mihaela Closca, Carmen Saguna, Silvana Angelescu, Doina Barbu,Anca Ciobanu,Ana Maria Ivanescu, Madalina Vasile, Oana Patranoiu, Simona Crintea, Delia Mut Popescu Coltea Clinical Hospital, Bucharest

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Aim of the study: to evaluate the results of low-dose 6MP therapy and outcome in elderly patients with AML. Patients and methods: 8 patients with AML where followed between Sept. 2002 March 2007; median age 76 years (range 66 81 years); M/F: 3/5. Diagnostic was established after bone marrow aspiration examination, and in 4 cases with confirmation of trephine bone biopsy. Four patients had AML following myelodisplasia (MDS), 2 after Ph-negative chronic myeloproliferative diseases (1 postpolycythemic myelofibrosis, 1 unclassified myeloproliferation both were positive for JAK2 (V167F) mutation) and 2 with blastic crisis of chronic myeloid leukemia. Chemotherapy consisted in 3+7 courses in 6 cases, and TRAMPCO regimens for the 2 cases of blastic crisis. The dose of 6MP was 100 - 150 mg/week. The purpose of low-dose 6MP therapy was palliation after failure of conventional therapy or after severe infectious complications during induction. Treatment decision was made after consulting the patients and their families. Results: 4 patients had very good responses:
Gender Age Diagnosis
1. 2. 3. 4. M F F M 77 69 76 66 AML post MDS AML post MDS AML post myelofibrosis CML blastic crisis

Outcome

Follow-up
66 month 24 month* 12 month 15 month

CR CR CR Chronic phase * lost from follow-up after 24 month; positive for JAK2 mutation

Other 2 patients are alive 1 with AML with partial response but transfusion dependent, the other with unclassified chronic myeloproliferation has persistent thrombocytosis and leucocytosis (therapy with hydroxiurea and methotrexate had to be associated). In our opinion there might be a group of elderly patients with AML that would have a real benefit in terms of survival and quality of life using low-dose 6 mp therapy. Thalidomida poate fi o alternativa de tratament in mielomul multiplu? ( experienta pe 22 de cazuri) Dr Gabriela Barca, Dr Nicoleta Berbec, Dr. Andrei Colita, Dr Doina Barbu, Dr Silvana Angelescu, Dr. Valentin Barca*, Dr Oana Patrinoiu, Dr. Madalina Vasile, Prof Dr. Delia Mut Popescu Spitalul Clinic Coltea Hematologie UMF Carol Davila Introducere: Thalidomida a fost scoasa din uzul clinic in 1962 datorita teratogenitatii sale severe-dar efectul sau antiangiogenic si imunomodulator inclusiv inhibarea factorului de necroza tumorala alfa au impus reintroducerea sa in practica ca un agent oral foarte eficient in tratamentul mielomului multiplu. Thalidomida exercita un rol antitumoral in mielomul multiplu prin diferite mecanisme:a) inhiba cresterea si supravietuirea celulelor mielomatoase, b)moduleaza adeziunea celulelor mielomatoase la stroma medulara prin inhibarea Il-6 si a altor citokine, c)interfera cu factorul nuclear de legare aADNkB, d) are efect stimulator direct pe ambele tipuri de celule T, f) are efect antiangiogenetic Material si metode: Prezentam folosirea thalidomidei la un numar de 22 de cazuri de mielom multiplu. Datele generale ale pacientilor au fost: 12 pacienti cu MM IGG, 8 pacienti cu MM IGA; 2 pacienti cu mielom micromolecular; 16 pacienti au primit tratamentul dupa mai mult de 12 cure PCT fiind considerate mieloame refractare la chimioterapie, 4 pacienti dupa 6 cure PCT si 2 pacienti dupa 1 cura PCT, maximum follow-up 5 ani si 4 luni. Thalidomida a fost folosita la toti pacientii cu dexametazona (cura Thalidex), unul a continuat cu Thalidex cu Alkeran ( cura MPT) iar intre cure pacientii au primit doze diminuate de thalidomida. Dozele folosite au fost intre 50-400mg/zi. Rezultate; Toti pacientii au avut raspuns favorabil manifestat prin: cresterea valorilor hemoglobinei, scaderea VSH, scaderea componentei monoclonale cu ameliorarea aspectului electroforezei cu scaderea valorilor imunoglobulinei pe imunograma, dar durata raspunsului pentru 3 pacienti a fost de scurta durata. Reactiile adverse dezvoltate au fost: neuropatie periferica la un pacient care a impus scaderea dozelor, constipatie rebela la 1 un pacient care a renuntat la administarea medicamentului, un pacient a dezvoltat edem al fetei care a impus intreruperea tratamentului, un altul a dezvoltat sub tratament leucemie cu plasmocite cu determinari cutanate si cerebrale si un pacient a decedat la 6 saptamani dupa inceperea tratamentului dupa o scurta ameliorare, dar medicamentul a fost administrat in stadiul final al bolii. Nici un pacient nu a dezvoltat pana in prezent complicatii trombotice. Concluzii: Thalidomida este un medicament eficient in tratamentul mielomului multiplu fiind, pe cazurile avute in tratament, superior curelor clasice de chimioterapie. Reactiile adverse au fost minime si numai intr-un singur caz au impus intreruperea tratamentului.

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Background: Thalidomide-removed from widespread clinical use by 1962 because of severe teratogenicity-has antiangiogenic and immunomodulatory effects, including the inhibition of tumor necrosis alpha factor. It has now returned to practice as an effective oral agent in the management of multiple myeloma. Thalidomide exerts an antimyeloma effect through different mechanisms: a)it can directly inhibit the growth and survival of myeloma cells, b) it modulates cell adhesion and interrupts the adhesion of myeloma cells to bone marrow stromal cells. This leads to the inhibition of interleukin-6 (IL6) and other cytokines production by stromal cells that are crucial for myeloma cell growth and survival, c)it interferes with DNA binding of nuclear factor-kB, d) it has direct stimulatory effects on both T and natural killer cells, f) has a direct antiangiogenic effect. Aims We report the use of thalidomide with for 22 cases of multiple myeloma. The general data of the group were:12 patients with MM IGG, 8 patients with MM IGAand 2 patients with micromolecular myeloma; of this group 16 patients received the treatment after more than 12 PCT cures being considered myeloma refractory to chemotherapy; 4 patients after 6 PCT cures and 2 patients after 1 PCT cure; maximum follow-up was 5 yars and 4 months. The thalidomide was used for all patients with dexametazone (Thalidex cure) and after Thalidex one patient got Thalidex with Alkeran (MPT cure); without any other drug associations. The daily doses used were 50mg-400mg. All patients reacted favorably expressed by increase in hemoglobin level, ESR drop in values, decrease of the monoclonal component cu electroforetic improvement with decreased immunoglobulins. In 3 patients the positive response only lasted shortly. Side effects developed were: peripheral neuropathies in 1 patient which required decrease of thalidomide dose; 1 patient developed edema necessitating treatament discontinuation; 1 patient a developed plasma cell leukemia with cutaneous and cerebral determinations under treatment, 1 patient deceased in 6 weeks from the treatment onset after a brief period of improvement (the medications was though given in the final stage). No patient developed thrombotic complications to this date. Conclusions: Thalidomide is an efficient drug in treating multiple myeloma and proved superior to classical chemotherapy cures. The side effects were minimal and required only in one case treatment discontinuation. Raspunsul citogenetic la terapia cu Glivec in CML 4 ani de experienta Daniela Iancu A.Georgescu, I.Morosanu Hematologie- Laborator Citogenetica, Institutul Clinic Fundeni, Bucuresti, Romania Rezumat LMC a fost prima boala maligna caracterizata printr-o anomalie cromozomiala castigata, markerul specific find cromozomul Ph rezultat prin t (9:22) (q34: q11) iar la nivel genic are loc fuziunea genelor BCR,ABL. S-au monitorizat 127 bolanvi cu LMC print-un studiu dinamic la intervale de timp fixe (3, 6 9, 12, 24,36, 48 luni) urmarind raspunsul citogenetic la terapia cu Glivec. Raspunsul la terapie s-a abordat prin evaluarea numarului de celule purtatoare de cromozomi Ph si evaluarea modului de raspuns al fiecarui bolnav. Concluzia este ca majoritatea bolnavilor (72%) are o capacitate de raspuns la terapie care este neschimbata de la debut si astfel pot fi impartiti in 2 categorii: sensibili sau rezistenti. Timpul de raspuns al fiecarui bolnav depinde in mare masura de complexul genelor sale mutante inca neidentificate. The cytogenetic responce to the Gleevec therapy in chronic myeloid leukemia (CML) - 4 years of experience Daniela Iancu A.Georgescu, I.Morosanu Hematologie- Laborator Citogenetica, Institutul Clinic Fundeni, Bucuresti, Romania Abstract Leukemia myeloid chronic was the first malignant disease characterized through chromosomial abnormality, the specific marker being the Philadelphia chromosome, a translocation t ( 9:22 ) (q 34; q11) and at genic level is formed the gene BCR,ABL fusion One hundred twentyseven (127) CML patients were monitorized during a dynamic study at differents moments of the evolution at 3, 6, 12, 18, 24, 36, 48 months by evoluation of the cytogenetics response to the therapy with Gleevec. The response to the therapy was analysed by the evolution of the member of cells with chromosome Ph and the evaluation of the modality of response for each patient. The conclusion of the study is that the majority of the patients (72%) has an unchanged capacity of response at the

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therapy with Gleevec from the onset to they can be devided in 2 categories: good responders and resistents to the treatment . The type of response for each patient is more dependent, it's of complex mutantes genes not yet identified LEUCEMIACU PLASMOCITE: DATEACTUALE DE BIOLOGIE SI TRATAMENT Dan Coli,Adriana Coli Centrul de Hematologie i Transplant Medular Fundeni, Bucureti Leucemia cu plasmocite (LPl) este definit prin prezena a 2 x 109/L plasmocite monoclonale n circulaie ( 20% Pl n formula leucocitar). Este o form rar de discrazie plasmocitar n strns relaie cu procesele fiziopatologice ce caracterizeaz mielomul multiplu (MM). Studiile citogenetice evideniaz n LPl anomalii structurale i numerice asemntoare cu cele ale MM, dar cu prevalena alterrilor cu semnificaie prognostic nefavorabil. In comparaie cu MM, celulele din LPl au o rat de proliferare mai ridicat. Aceste aspecte explic evoluia sever a LPl, cu supravieuire global foarte scurt. Se descriu 2 forme de prezentare a LPl: primar (de novo) 60% din cazuri i secundar (n cadrul fazei terminale a unui MM recunoscut), mai agresiv, cu rspuns general la tratament mai redus (16-19% din cazuri fa de 50-75% n forma primar) i cu supravieuire median mai scurt (3 l fa de 18,4 l n forma primar). Majoritatea autorilor ncadreaz ambele forme ale LPl n faza extramedular a MM unde apar cu o inciden cuprins ntre 3,8% (forma primar) i 2% (forma secundar). Tratamentul LPl se suprapune n general peste cel al MM n recdere sau refractar: polichimioterapie (PCT) autotransplant de celule stem hematopoietice (ATCS), Thalidomid (Thal), Bortezomib (BZM). Combinaia clasic Melphalan Prednisone a fost abandonat n favoarea PCT, (ex. VAD, VCMP/VABP sau hiper-CVAD) care are performane de 3 ori mai ridicate. ATCS, efectuat n remisiune aduce o supravieuire medie de cca. 40 l, cu o median de 20 l (extreme 7 106+ l). Thal Dexametazon produce rspunsuri complete i pariale n inducie sau n cazuri rezistente la alte terapii. BZM este eficient n cazuri rezistente sau n inducie n monoterapie sau n combinaii (ex. BZM + CFA + DXM). Intr-o serie de 12 cazuri cu LPl primare i secundare s-au obinut rspunsuri la 11 pacieni (92%) cu 2 remisiuni complete. Supravieuirea median fr progresie i global au fost de 8 i de 12 l, respectiv. PLASMACELL LEUKEMIA:ACTUAL DATAREGARDING THE BIOLOGYAND TREATMENT Dan Colita,Adriana Colita Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest Plasma cell leukemia (LPI) is defined by the presence of 2 x 109/L circulating monoclonal plasmocytes ( 20% plasmocytes on blood smear). There is a rare entity of plasmocytic discrazia, in very close connection with physiopathology of Multiple Myeloma (MM). The cytogenetic studies show in LPI structural and numerical abnormalities similar with those from MM, but with the prevalence of the abnormalities with unfavorable prognostic risk. In comparison with MM, the cells from LP1 have a higher proliferation rate. These aspects explain the severe evolution of LP1 with a very short global survival. There are two distinct presentation forms: primary (de novo) - 60% of cases and secondary (terminal phase of a diagnosed Multiple Myeloma), which is more aggressive, with a lower response rate (16-19% of cases vs. 50-75% in primary form) and a shorter median survival (3 mo vs. 18, 4 mo respectively). The majority of the authors included both forms of LPI in the extramedullary phase of MM, with a incidence between 3,8% (primary form) and 2% (secondary form).The treatment of LPI is the same like for refractory or relapsed MM: chemotherapy (PCT), autologous stem cell transplantation (ATSC), Thalidomide (Thal), Bortezomib (BZM). The classical combination Melphalan + Prednisone was abandoned in favor of polichemotherapy (ex VAD, VCMP/VABP or hiperCVAD), which are 3 times more efficient. After ATSC done in remission was reported a survival average of 40 months with a median of 20 months (between 7 106 mo). Thal +/-Dex can obtain complete or partial remission for refractory cases to other therapies. BZM is efficient in refractory cases or in induction, in monotherapy or in combinations (ex. BZM+CFA+ DXM). In a series with 12 cases with primary and secondary LPI was reported 11 responses (92%) with 2 complete remissions. Disease free survival and global survival were 8 and 12 mo, respectively. Amiloidoza sistemica familiala non-neuropata ( tip Ostertag ) determinata de un nou tip de lizozim mutant D. Coriu1, C. L. Murphy2, D.Kestler2, S. Wang2, G. Becheanu1, C. Dobrea1 &A. Solomon2

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1 University of Medicine "Carol Davila", Bucharest, Romania 2 University of Tennessee Graduate School of Medicine, Knoxville, TN, USA Amiloidoza asociata lizozimului (ALys) este o boala rara determinata de mutatii aparute in al doilea exon din gena lizozimului care codifica precursorul proteic amiloidogenic. Pana in acest moment au fost identificate patru variante diferite (I56T, D67H, W64R, F57I) capabile sa reduca stabilitatea proteinei si sa induca fibrilogeneza. Noi raportam un alt tip de Alys identificat la un barbat de 52 ani cu manifestari predominant hepatice (investigatiile medicale efectuate ulterior indica ca si alti membrii din familie au aceeasi boala). Acest tip de Alys este determinat de o mutatie punctiforma identificata pentru prima data in gena lizozimului. Examinarea in lumina polarizata a preparatelor histologice din biopsia hepatica colorate cu rosu de Congo obtinute de la proband ( si alti doi frati) arata depozite interstitiale de material birefringent caracteristic pentru amiloid. Acest material a fost extras din sectiunile tisulare fixate in parafina, purificate in faza de reversie HPLC si apoi dupa digestia triptica peptidele rezultate sunt analizate chimic prin spectrometrie de masa in tandem (MS / MS). Aceasta analiza a identificat 109 din cei 130 de aminoacizi care reprezinta structura primara a lizozimul wild type. Nu au fost gasite peptidele care corespund aminoacizilor 11- 15, 63- 69 si 114-122. Pentru a identifica structura primara completa a acestei proteine am efectuat analiza ADN ului genomic izolat din sange periferic. Dupa amplificarea prin PCR a celor trei exoni din gena lizozimului s-a efectuat secventierea nucleotidelor. Aceasta analiza a aratat ca exonul II contine (in aditie la gena normala) o mutatie punctiforma in codonul 85 ( GAT => GGT) care implica substitutia acidului aspartic (D) cu glicina (G) la pozitia 67 din structura proteinei (D67G). Astfel, rezultatele noastre adauga la variantele deja cunoscute in literatura un nou tip de lizozim implicat in amiloidoza sistemica familiala non- neuropata. Familial non-neuropathic systemic amyloidosis ( Ostertag- type ) associated with a novel lysozyme mutation D. Coriu1, C. L. Murphy2, D.Kestler2, S. Wang2, G. Becheanu1, C. Dobrea1 &A. Solomon2 1 University of Medicine "Carol Davila", Bucharest, Romania 2 University of Tennessee Graduate School of Medicine, Knoxville, TN, USA Lysozyme- related amyloidosis (ALys) has been associated with mutations in the second exon encoding the amyloidogenic precursor protein. To date, four different variants have been identified (I56T, D67H, W64R, F57I), all of which were deemed capable of reducing protein stability and enhancing fibrilogenesis. We now report another case of ALys in a 52-year-old male who had predominant hepatic involvement (as well as a family history indicating that other members had the same disorder) and in whom we found a hitherto unreported mutation in the lysozyme gene. Examination under polarized light of Congo red-stained sections of liver biopsies obtained from the proband (and 2 brothers) revealed extensive green birefringent interstitial deposits, characteristic for amyloid. This material was extracted from 4mm-thick sections cut from formalin-fixed paraffin embedded blocks, purified by reverse phase HPLC and subjected, after trypsin digestion, to chemical analyses by tandem mass spectrometry (MS/MS). These studies identified 109 of the 130 amino acids comprising wild-type lysozyme (peptides encompassing residues 11-15, 63-69, and 114 - 122 were not found). To obtain the complete primary structure of this protein, genomic DNA was isolated from the proband's peripheral blood leukocytes and the PCR products of the 3 functional exons were synthesized. Nucleotide sequence analysis revealed that exon 2 contained (in addition to the unmutated gene) a GAT to GGT transition in codon 85, which would result in the substitution of glycine for aspartic acid at position 67. Based on X-ray crystallographic data, we posit that the resultant profound modification in tertiary structure included by the D67G mutation would render the molecule unstable and thus amyloidogenic. Our findings add to the known variants of lysozyme involved in familial systemicALys amyloidosis.

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SESIUNE TRANSPLANT MEDULAR

COMPLICATII PRECOCE DUPA ALLOTRANSPLANTUL DE CELULE STEM HEMATOPOIETICE IN LEUCEMIIACUTE D. Colita, C.Arion, Alina Tanase, Zsofia Varady, Anca Colita, Luminita Dumitrache, Ruxandra Fota, Virginia Mirea, Adriana Dumitrescu Centrul de Hematologie si Transplant Medular, Institutul Clinic Fundeni, Bucuresti Complicatiile precoce postallotransplant de celule stem hematopoietice se refera la cele care apar in primele 100 de zile dupa procedura. Majoritatea au ca element patogenic comun leziunea endoteliala data de toxicitatea terapiei de conditionare, in cadrul careia pot fi afectate oricare dintre organe, in grade si cu evolutii diferite. Pe de alta parte, datorita imunosupresiei pacientilor sau conflictului imunologic dintre receptor si donator pot apare boala de grefa contra gazda si infecti cu diferite etiologii. In Comp.TM din IC Fundeni s-au efectuat 12 proceduri de alotransplante genoidentice la pacienti cu leucemie acuta in perioada 2003 -2007, 3 pentru leucemii acute limfoblastice, si 9 pentru leucemii acute mieloblastice; 11 proceduri la adult si 1 la copil. Principalele complicatii precoce aparute au fost: mucozita grad 3, 4 (66%), boala venoocluziva hepatica (16%), microangiopatie trombotica (16%), disfunctie multiorganica (41%), rejet (8%) si esec de grefare (8%). Boala de grefa contra gazda grad II/IV a aparut la 41% din cazuri. Reactivarea citomegalovirusului datorita imunosupresiei a fost demonstrata la 66% din pacienti. 75% din pacienti au dezvoltat sindrom febril, cu evidentierea etiologiei la 85%. Nici un pacient nu a prezentat sindrom de grefare si nu s-a evidentiat nici o recadere in primele 100 de zile. Mortalitatea la 100 de zile a fost 33%. EARLY COMPLICATIONSAFTERALLOGENIC STEM CELLTRANSPLANTATION FORACUTE LEUKEMIA D. Colita, C.Arion, Alina Tanase, Zsofia Varady, Anca Colita, Luminita Dumitrache, Ruxandra Fota, Virginia Mirea, Adriana Dumitrescu Fundeni Clinical Institute, Center of Hematology and Bone Marrow Transplantation, Bucharest Early complications after allogeneic stem cell transplantation appear in the first 100 days post transplant. The majority of these have a common pathogenic event: injury of the vascular endothelium due to the toxicity of the conditioning regimen, which can affect any organ, with different grade and clinical evolutions. On the other hand, due to the immunosupression of the recipients and due to the immunological conflict between the recipient and the donor, can appear different types of infections and graft versus host disease. We report 12 allogeneic transplants for acute leukemia patients performed in BMT Unit from Fundeni Clinical Institute, between 2003-2007; 3 acute lymphoblastic leukemias and 9 acute mieloblastic leukemias; 11 procedure at adults patients and 1 at a child. The main early complications were: grade 3, 4 mucositis (66%), venooclusive disease (16%), thrombotic microangiopathy (16%), multiorgan failure syndrome (41%), rejection (8%) and graft failure (8%). Grad III/IV graft versus host disease appear in 41% cases. Cytomegalovirus reactivation due to the immunosupression was demonstrated on 66% cases. 75% of cases developed febrile syndromes with clear etiology in 85% cases. None of the patient presented engraftment syndrome and we report none relapse on first 100 days post transplant. The 100 days mortality was 33%.

APORTUL CERCETARII HIMERISMULUI HEMATOPOIETIC LA PACIENTII CU ALLOTRANSPLANT DE CELULE STEM Zsofia Varady1,Alina Tanase1, D. Colita1, Ligia Barbarii2, Ruxandra Fota1, Virginia Mirea1, Carmen Calugaroiu1 1Centrul de Hematologie si Transplant Medular, Institutul Clinic Fundeni, Bucuresti 2Institutul Medico-Legal Bucuresti

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Originea celulelor din sangele sau maduva pacientului allotransplantat poate fi identificata prin testarea markerilor genetici informativi care disting donatorul de recipient. Metodele moleculare de testare a himerismului sunt necesare pentru documentarea de rutina a grefarii cu celule de la donator, evaluarea persistentei celulelor donatorului, evaluarea riscului de rejet sau a recaderii malignitatii. In Compartimentul TM din I.C.Fundeni au fost testate 79 de probe de himerism de la 14 cazuri (donatori si receptori), prin metoda STR. 2 pacienti au fost transplantati in straianate si urmariti posttransplant in Unitatea noastra. 79% dintre probe au fost sange periferic. In 14% din receptori nu s-au putut identifica markeri informativi de himerism pretransplant, stabilirea lor efectuandu-se prin testarea celulelor epiteliale prelevate din tampoane bucale. 40/79 probe au fost himerism 100% donor. Testele de himerism complet de donor au fost corelate cu o evolutie clinica fara recadere, cu boala de grefa contra gazda cu grade diferite. Testarea himerismului a permis introducerea unui nou model terapeutic prin infuzie de limfocite de la donator ca si diagnosticul precoce al rejetului si recaderii bolii maligne. THE CONTRIBUTION OF THE CHIMERISM TESTING FOR THE PATIENTS WITH ALLOGENEIC STEM CELLTRANSPLANT Zsofia Varady1,Alina Tanase1, D. Colita1, Ligia Barbarii2, Ruxandra Fota1, Virginia Mirea1, Carmen Calugaroiu1 1Fundeni Clinical Institute, Center of Hematology and Bone Marrow Transplantation, Bucharest 2 Mina Minovici Foreinsic Medicine, Bucharest In allogeneic stem cell transplant, the origin of patient cells from marrow or peripheral blood can be identified by testing informative genetic markers, who can distinguished between donor and recipient. Molecular methods for evaluating chimerism are necessary for routine documentation of donor cell engraftment; assess the risk of rejection or recurrent malignancy. We tested by STR method 79 samples from 14 cases (donors and recipients) evaluated in BMT Unit from Fundeni Clinical Institute. 2 patients were transplanted in foreign countries and followed after in Fundeni BMT Unit. 79% of samples were from peripheral blood. In 14% cases pretransplant informative markers samples were not available and we used material from a buccal scraping for detecting recipient alleles. 40/79 samples were 100% donor chimerism. The complete donor chimerism was correlated with a clinical evolution without relapse and with different grade of graft versus host diseases. Due to testing the chimerism we could introduce a new therapeutic model with donor lymphocyte infusion and we could diagnose earlier rejection and relapse of malignity. AUTOTRANSPLANTUL DE CELULE STEM HEMATOPOIETICE IN BOALA HODGKIN (EXPERIENTA CENTRULUI DE HEMATOLOGIE SI TM DIN I.C.FUNDENI) Alina Tanase, Zsofia Varady, D.Colita, C.Arion, Anca Colita, Luminita Dumitrache, Ruxandra Fota, Virginia Mirea, Adriana Dumitrescu Centrul de Hematologie si Transplant Medular, Institutul Clinic Fundeni, Bucuresti Autotransplantul de celule stem hematopoietice reprezinta indicatia standard de tratament pentru pacientii cu Boala Hodgkin cu recadere chimiosensibila sau peste a doua remisiune completa. In cazurile de Boala Hodgkin remisiune partiala sau boala refractara, autotransplantul de celule stem reprezinta o optiune clinica. In Comp TM din IC Fundeni, in perioda 2001-2007 s-au efectuat 21 de proceduri de autotransplant la Boala Hodgkin; 14 femei/ 7 barbati, cu o medie de varsta de 24,95 ani (17-39 ani). 3/21 pacienti au avut sub 18 ani in momentul transplantului. Indicatia de autotransplant a fost pentru BH cu recadere chimiosensibila la 12/21 si remisiune partiala la 9/21 pacienti. Mobilizarea de celule stem s-a efectuat la majoritatea cazurilor dupa cura tip DHAP + G-CSF, cu o recolta in medie de 11,39 x106CD34/kgc. Regimul de conditionare a fost BEAM la 17/21 pacienti, tip BEAM la 3/21 pacienti si LACE la 1 pacient. Grefarea s-a produs in medie in ziua +11 (+9+13). Principalele complicatii precoce posttransplant au fost: mucozita grad mai mare de 2 (15/21), sindrom febril (19/21). Mortalitatea la 100 zile a fost de 4,7% (1/21pac). Certificarea remisiunii complete la 100 de zile posttransplant prin PET scan s-a efectuat la 6/20 pacienti. Recaderea la 1 an a fost de 25% (5/20 pacienti). Autotransplantul de celule stem in Boala Hoddgkin reprezinta o metoda terapeutica eficienta, fara complicatii majore, cu mortalitate legata de procedura sub 5%, comparabila cu literatura. AUTOLOGOUS STEM CELL TRANSPLANTATION IN HODGKIN DISEASE (THE EXPERIENCE OF BMT UNIT - BUCHAREST CLINICAL FUNDENI INSTITUTE) Alina Tanase, Zsofia Varady, D.Colita, C.Arion, Anca Colita, Luminita Dumitrache, Ruxandra Fota, Virginia Mirea, Adriana Dumitrescu Fundeni Clinical Institute, Center of Hematology and Bone Marrow Transplantation, Bucharest

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The autologous stem cell transplant represent standard indication of treatment for patients with Hodgkin Disease in chemosensitive relapse or more than second complete remission. For the cases with Hodgkin disease in partial remission or refractory disease, the autologous stem cell transplant represents only a clinical option. Between 2001-2007, in BMT Unit from Clinical Institute Fundeni we performed 21 procedures for Hodgkin Disease; 14 female/7 male, average age 24,95 years (17-39). 3/21patients had less than 18 years old on day of transplant. The indication of autotrasplant was for Hodgkin disease in chemosensitive relapse at 12/21 and partial remission at 9/21 patients. We harvested the stem cells after mobilization with DHAP +G-CSF protocol at majority of patients, with an average of 11,39 x 10 6 CD34/kgc. The conditioning regiment was BEAM at 17/21 patients, BEAM like at 3/21 patients and LACE at 1 patient. The engraftment was reported in average on day +11 (+9 +13). The main complications early after transplant were: > grad 2 mucosities at 15/21 patients and febrile syndrome at 19/21 patients. The 100 days mortality was 4,7% (1/21 patients). Certification of the complete remission by PET Scan at 100 days after transplant was reported at 6/20 patients. One-year relapse was 25%(5/20 patients). Autologous stem cell transplantation represents an efficient therapeutical method, without major complication, with transplant related mortality under 5%, similar with literature. FOTOFEREZAEXTRACORPOREALA(ECP) IN BOALACRONICADE GREFACONTRAGAZDA Virginia Mirea, Carmen Calugaroiu,Alina Tanase, Zsofia Varady, Dan Colita Fotochimioterapia extracorporeala (ECP extracorporeal photochemotherapy) este un tratament de imunomodulare, definit ca expunerea extracorporeala la iradiere cu lumina ultravioleta (UVA) a leucocitelor patogene in prezenta unei substante fotosensibilizante, 8-methoxypsoralen (8-MOP), urmata de reinfuzarea celulelor in circuitul sanguin al pacientului. Fotofereza extracorporeala (ECP) este o modalitate imunoterapeutica a carei eficacitate clinica a fost demonstrata in limfomul cutanat cu celule T / sindrom Sezary (CTCL), in scleroza sistemica si in alte boli autoimune, in complicatiile transplantului de organe (rejet) sau de maduva hematogena (boala de grefa contra gazda GvHD/graft versus host disease - acuta si cronica). Terapia celulara prin fotofereza extracorporeala reprezinta o abordare noua, promitatoare, in managementul terapeutic al cazurilor rezistente/dependente/intolerante la terapia imunosupresoare din diferite boli mediate imun si mai ales din complicatiile medicinei de transplant. Fotofereza extracorporeala este o procedura recent introdusa in cercetarea mondiala (dupa anii 1987 de Richard Edelson), fiind folosita in premiera nationala la un pacient cu boala de grefa contra gazda (GvHD) cronica forma cutanata pe 65% suprafata corporala si leziuni lichenoide jugale, aflat in ziua 273 dupa allotransplant sibling de celule stem hematopoietice periferice, cu chimerism 100%, cu tri-terapie imunosupresoare cu Cellcept 2g/zi, cortizon 50 mg/zi si Methotrexat 7,5 mg/saptamana. Pentru realizarea procedurii ECP s-a utilizat un sistem deschis, folosind aparatul de leucafereza in flux continuu Cobe Spectra (protocol autoPBSC), cu iradiere UVA in doza de 2J/cm2 (aparat PUVA Light), dupa fotosensibilizare cu 8 MOP in doza finala de 200ng/ml, cu retransfuzarea imediata a produsului ECP la pacient. Au fost realizate 12 proceduri ECP aplicand schema 2xECP/saptamana timp de 4 saptamani (ECP intensiv) urmata de schema de discontinuare cu 2xECP/2 saptamani, apoi lunar. Sub terapie cu ECP s-a eliminat MTX de la debut si s-a inceput reducerea dozelor cortizonice cu 4 mg la 2 saptamani. Evolutia a fost nefavorabila, cu accentuarea leziunilor cutanate si aparitia de noi leziuni eritemato-ulcerative, fapt ce a determinat intreruperea terapiei prin ECP si introducerea unui nou imunosupresor (Prograf). La peste 570 zile post transplant pacientul are o evolutie favorabila cu leziuni inactive hipo- si hiperpigmentate pe 95% suprafata corporala si leziuni lichenoide pe mucoasa jugala. Desi evolutia acestui pacient a fost nefavorabila sub terapia de fotofereza extracorporeala, literatura de specialitate arata ca rata de raspuns la ECP in GvHD cronic este de 59%, permitand scaderea dozei de corticoizi in 63% din cazuri si obtinandu-se ameliorari clinice de 74% in leziunile cutanate, 86% in leziunile mucoase, 72% in afectarea hepatica, 43% in afectarea pulmonara si 80% in afectari articulare. Extracorporeal photochemotherapy (ECP) IN GRAFT VERSUS HOST DISEASE Virginia Mirea, Carmen Calugaroiu,Alina Tanase, Zsofia Varady, Dan Colita Extracorporeal photochemotherapy (ECP) is an imunomodulating treatment defined like an extracorporeal UVA

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irradiation of pathological leucocytes using a photosensitive drug 8-methoxypsoralen (8-MOP), followed by the intravenous reinfusion of photoirradiated cells to the patient. The extracorporeal photochemotherapy (ECP) is an immunotherapeutic alternative and its clinical efficiency was demonstrated in CTCL / Sezary syndrome, systemic sclerosis and other autoimmune diseases, in organ transplant's failure or complications of bone marrow transplant (Graft versus Host Disease GvHD acute and chronic forms). Cellular therapy using ECP treatment is a new promising modality in therapeutical management of patients with resistance / dependency / intolerance to the appropriate immunosuppressive therapy in several immune mediated diseases, and especially in complications in transplant medicine. Extracorporeal photochemotherapy (ECP) is a newly worldwide research procedure (introduced after 1987's by Richard Edelson), being applied for the first time in our country to a patient with chronic GvHD cutaneous form involving 65% body surface and mucosal lichenoid lesions, on day 273 after allotransplant with sibling peripheral haematopoietic stem cells, in treatment with Cellcept 2g/day, corticosteroids 50 mg/day and Methotrexate 7,5 mg/week. To performe the ECP procedure, we used the open system, with the continuous flow apheresis machine Cobe Spectra (autoPBSC protocol), UVA irradiation for a dosage of 2J/cm2 (PUVA Light System), after photoactivation with 8 MOP (final dose of 200ng/ml), followed by immediate reinfusion of the ECP product to the patient. Twelve ECP procedures were performed on an intensive schedule (2 successive ECP/week for 4 weeks) followed by discontinuation of ECP treatment (2xECP every 2 weeks / 4 weeks). Under ECP as alternative treatment, the MTX was excluded since the beginning and was reduced the corticosteroids dosage with 4 mg every 2 weeks. It was observed an unfavourable evolution, with aggravation of the skin lesions and appearing of new active skin lesions, that decided to stop the ECP therapy and to introduce a new immunosuppressive drug (Prograf). After 570 days posttransplant the patient has a good clinical status (IK =100%) with hypo- and hyperpigmented skin lesions covering 95% body surface and unmodified mucosal lichenoid lesions. Despite an unfavourable response to ECP at our patient, the review on ECP treatment in chronic ECP reveals 59% of response rate which allow to reduce the dosages of corticoids in 63% of cases and to obtain clinical improvements of 74% of skin lesions, 86% of mucosal lesions, 72% of liver manifestations, 43% of pulmonary involvements and 80% of joints manifestations. Transplantul de celule stem hematopoietice in anemia aplastica: niciodata nu e prea tarziu Andreea Moicean*,A.D.Ho**, Veronica Teleanu*,Alina Catana***, Erzjebet Benedek**** * Centrul de Hematologie si Transplant Medular, Institutul Clinic Fundeni ** Universitatea din Heidelberg, Germania ***Sectia de Hematologie, Spitalul Judetean Sibiu ****Sectia Clinica de Hematologie si transplant de Maduva, Targu Mures Singurul tratament curativ al aplaziei medulare este transplantul allogen de celule stem hematopoietice (P.Ljungman et all., Bone Marrow Transplantation (2006) 37, 439449). La pacientii cu varsta mai mica de 30 de ani transplantul de celule stem hematopoietice este tratamentul de electie, mai ales atunci cand exista donator inrudit HLA compatibil. Chiar si pacientii copii cu anemie aplastica non-severa dar dependenti de trasfuzii, avand donator HLA identic inrudit au ca indicatie de prima alegere transplantul de celule stem hematopoietice. La pacientii cu varsta peste 30 de ani, transplantul si tratamentul imunosupresiv dau aceleasi rezultate bune. La pacientii cu varsta de peste 45 de ani, sau la orice varsta in absenta unui donator HLA compatitibil inrudit, este obligatoriu, anterior tentativei de transplant administrarea tratamentului combinat cu thymoglobulina si ciclosporina. Prezentam 2 pacienti cu aplazie medulara ingrijiti in Clinica de Hematologie si Transplant Medular Fundeni in colaborare cu serviciile de hematologie din Sibiu, Targu Mures si Heidelberg.. Primul, un barbat diagnosticat la varsta de 9 ani. A urmat tratament substitutiv, corticoterapie, 2 serii de globulina antitimocitara (la 30 de ani si la 34 de ani), cu raspuns tranzitor. La varsta de 40 de ani, in februarue 2007, avand infectie cu virus hepatitic B, anticorpi antitrombocitari antiHLA, hemosideroza secundara transfuziilor (cardiaca, cutanata, hepatic), focare de infectie (maxilara, dentara, urinara), hipertrofie cardiaca stanga cu deficit de pompa primeste allogrefa de la fratele sau, HLA identic in Heidelberg, cu restaurarea in proportie de 80% a hematopoiezei.. Ce-l de-al doilea pacient o femeie de 19 ani, recent diagnosticata, cu forma severa (Tr ~5000/mmc), inclusa cu prioritate in program de transplant allogen donator inrudit HLA compatibil 100%, decedeaza cu hemoragie cerebrala cu inundatie ventriculara in perioada pretransplant, nefind posibil tratamentul substitutiv profilactic corespunzator. Pacientii cu aplazie medulara sunt inclusi cu prioritate in programul de allotransplant atunci cand exista donator compatibil. In Centrul de Hematologie din Institutul Clinic Fundeni (cel mai mare serviciu de hematologie din tara si centru de referinta) sunt luate in evidenta anual, in medie 11 cazuri noi de aplazie medulara, iar aproximativ 88 de

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internari pe an sunt ale bolnavilor cu aplazie medulara aflati in evidenta. Aceste internari sunt determinate de complicatiile starii de insuficienta medulara: anemie, infectie cu febra, sangerari. Doar 1-2% din pacientii romani cu aplazie medulara, au fost inclusi in program de transplant. Suplimentarea fondurilor dedicate ingrijirii pacientilor hematologici, dotarea corespunzatoare a centrelor de transfuzii pentru acoperirea necesitatilor acestor pacienti si afilierea Registrului National de Donatori de Celule Stem Hematopoietice la Registrul International, vor permite respectarea si in Romania a programului terapeutic prevazut in Ghidul Grupului European de Transplant de Maduva osoasa pentru aplazia medulara. Hematopoietic Stenm Cell Transplantation inAplasticAnemia Andreea Moicean*,A.D.Ho**, Veronica Teleanu*,Alina Catana***, Erzjebet Benedek**** * Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute ** University of Heidelberg, Germany ***Department of Hematology, Conty Hospital Sibiu ****Clinical Department of Hematology and Bone Marrow Transplantation, Targu Mures Allogeneic BMT from an HLA-identical sibling is usually the treatment of choice in patients with severe aplastic anaemia (SAA) under the age of 30 years. The choice in patients between 30 and 45 years of age is more difficult and both BMT and immunosuppression give good results. In older patients, or in the absence of an HLA-matched sibling, an initial course of a combination of ATG and cyclosporine should be given (P.Ljungman et all., Bone Marrow Transplantation (2006) 37, 439449). We present 2 patients with aplastic anemia admitted in Center of Hematology and Bone Marrow Transplantation from Fundeni Clinical Institute and followed-up in cooperation with centers for Hematology from Sibiu, Targu Mures and Heidelberg. First, a male patient diagnosed with aplastic anemia at 9 years of age. He received transfusions with erythocytes and thrombocytes, corticotherapy, two times globuline antithymocytes (at 30 and at 34 years old), with transient remission. At 40 years of age, on february 2007, having a lot of complications after a long disease history (like heart failure, hemocromatosis, alloantibody anti trombocytes and anti HLA antibody, infection with Hepatitis B Virus) he received allotransplants from his HLA identical brother with 80% restauration of hematopoiesis. The second patient is a female 19 years of age, diagnosed recently with severe aplastic anemia (Tr~5000/mmc). She had priority for inclusion in SCT programe, having a related donor (a brother HLA identic) but she died with lifethreating cerebral hemorrhagy during pretransplant hospitalisation. In conclusion, patients with Aplastic Anemia has priority for stem cell transplantation. Annualy, near 11 new patients are admitted in Center of Hematology and Stem cell Transplantation from Fundeni Clinical Institute, and 88 hospitalizations are for patients with aplastic anemia with infectious, hemorrhagic or anemia complications. Only 1-2% of aplastic anemia romanian patients received hematopoietic transplant. The financial suplement for hematological patients, an appropiate supply of transfuzional Centers in order to provide the special requests for these patients and National Donor Registry afiliation to World Donor Registry for Hematopoietic Stem Cell Transplantation would allow to romanian hematologists to apply the terapeutic protocol for aplastic anemia patients, requested by EBMT Guide.

Transplantul de celule stem hematopoietice nu poate substitui tratamentul complet anterior transplantului in bolile maligne hematologice Andreea Delia Moicean Centrul de Hematologie si Transplant Medular Institutul Clinic Fundeni Bucuresti Transplantul de celule stem hematopoietice este o componenta importanta a programului de tratament pentru bolile maligne hematologice. Transplantul in sine nu are rol curativ. Efectul lui asupra vindecarii este un efect cumulat efectului etapelor anterioare ale tratamentului. Prin ceea ce implica ea, procedura de transplant in hematologie este o metoda de abordare terapeutica a bolii reziduale. In limfoamele maligne si in leucemiile acute in special, cu cat boala reziduala la momentul transplantului este mai mica cu atat vindecarea bolii maligne prin transplant are sanse mai mari. Chiar in programul de transplant cu conditionare mieloablativa se impune aplicarea corecta si completa a programului de tratament prevazut anterior de transplant pentru o anumita boala. Omiterea unei etape de consolidare (cu doze mari sau foarte mari sau cu radioterapie) din programul terapeutic pretransplant se asociaza cu recaderea precoce post transplant si insuccesul transplantului de celule stem hematopoietice. Sunt prezentate spre exemplificare:

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- 3 cazuri de leucemie acuta cu recadere posttransplant la care evaluarea istoricului terapeutic a relevat omiterea din motive obiective a programelor pretransplant de consolidare cu doze mari de citostatice; - 1 caz de boala Hodgkin in recadere care nu a urmat pretransplant radioterapie pe campurile interesate si a recazut precoce post transplant. Experienta romaneasca in transplantul de celule stem hematopoietice in bolile maligne hematologice este limitata dar transplantarea oricarui pacient cu boala maligna trebuie sa respecte conditiile de eligibilitate prevazute in protocoalele europene de tratament, atat din punct de vedere al conditiei fizice si al tipului de boala dar si din punct de vedere al istoricului terapeutic a pacientului respectiv.

Hematopoietic Stem Cell Transplantation cannot replace the appropiate treatment for hematological malignant diseases Andreea Delia Moicean Centrul de Hematologie si Transplant Medular Institutul Clinic Fundeni Bucuresti Hematopoietic Stem cell transplantation (HSCT) is an important step during the common treatment for hematological malignant diseases. HSCT itself is not curative. It's curative effect is an aditional one to that of former steps of treatment. By its implications HSCT is a terapeutical approach of the residual disease. As in malignant lymphoma and in acute leukemias, in proportion as residual disease is low at transplant, curing the disease is more possible after HSCT. In myeloablative conditioning transplatation too, the complete and appropiate treatment before transplantation is mandatory. Omiting a high dosis consolidation or a radiotherapy consolidation before transplant associates with early relapse after transplant. For example, there are presented: - 3 patients with acute leukemia relapsed after transplant. The therapeutical history checking showed high dosis consolidation befor transplant omitting; - 1 patient with relapsed Hodgkin disease who had not before transplantation a field-involved radiotherapy. He relapsed early after transplant. Romanian experience in HSCT is very limitted but for each transplant perfomed the patient have to be eligible as european guides request: physical performance, disease features and terapeutical history. should be prepared "as soon as possible" after collection. In any case, there should be no more than 24-48 hours between collection and sample processing. 2. The panel for quick orientation or paucicellular samples includes: cCD3, MPO, cCD79a, TdT CD7, CD2, CD10, CD19, CD22 (s or c), sIg, CD13, CD33, CD34 CD45 for gating purposes. For sublineage classification and definition of clinical entities (also with adapted gating strategy): DR, CD1a, CD4, CD5, CD8, CD3 (m), IgM (c), CD14, CD117, CD56, CD65, CD41 or CD61, CD238 (glycophorinA) or CD36. . Other useful markers (>20): MPO/LF (lactoferrin) (c), CD14, lysozyme (c), CD11b, CD11c, CD15, CD16, CD35/36, CD58, CD64, CD68 (c), CD71, CD86, CD99, CD123, TCR. Therapeutic targets: CD20, CD52, CD45, CD33, CD123, CD87, CD44, uPAR(CD87)/uPACD116. These panels are intended for diagnostic purposes of acute leukemia. They may need to be completed using markers that will prove later useful for MRD detection. 3. Antibody combinations allow simultaneous analysis of 3 or 4 markers, more recently 5 or 6, and probably even more in a near future. By multicolor immunophenotyping we can identify aberrant LAIPs which allows the discrimination of leukemic cells from normal cells, impacting on MRD detection. There are also important economical advantages. Multicolor immunophenotyping has many technical problems, some combinations and fluorochromes being dependent on the type of flow cytometer or filter combinations used, which explain why it is so difficult to reach a consensus. Immunology of Bone Marrow Transplantation in Romania: development, accreditation, external quality control. aIleana Constantinescu*, Petru. Cianga**, Elena Gai***, Mihaela Melinte****, Dan Luscalov*****, Lucia

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Dican*****, Daniela Nedelcu*,Adela Toader*, Marilena Zaharia*,Anca Tica*, Daniela Vasile* *Centre of Immunogenetics and Virology, Fundeni Clinical Institute, Bucharest ** Centre of Immunogenetics, Iasi *** Centre of Immunogenetics, Targu Mures **** Centre of Immunogenetics, Timisoara ***** Centre of Immunogenetics, Cluj Napoca Introduction: HLAdetermines the fate of transplantation. Plays a role in the control of cellular interactions responsible for both cellular and humoral immune responses. Is associated with a variety of diseases. The histocompatibility barrier between recipient and donor remains a problem in that it will activate immune responses leading to graft rejection. Although immunosuppressive drugs (FK 506, Cyclosporine) will reduce rejection, the successful management of the transplant management of the transplant patients requires an understanding of the MHC also referred as the HLA system. HLA antigens are controlled by a series of highly polymorphic genes on the short aim of chromosome 6MHC.HLA class I and class II alloantigens can induce transplant immunity at both humoral (antibody) and cellular (Tlymphocyte) immune levels. Both HLA class I and class II bind small antigenic peptides for presentation to the TCR which then may lead to specific T-cell activation. The HLA alleles is considerable polymorphism of HLA is wellknown. HLA polymorphism is reflected by allelic substitution of many amino acid residues in the polypeptide chains, especially the external domains which contain the peptide binding site. This affects the spectrum of antigenic peptides presented by the different allelic types of HLAmolecules and the repertoire of responding T-cells. Material and methods: Virological assessment Both donor and recipient are tested for: VHB, VHD, VHC, HIV 1/2, CMV, EBV, HSV 1 and 2, VZV, HTLV 1/2 , rubella virus, toxoplasma gondii and chlamydia. Methods Indirect diagnostic tests (serological) Direct diagnostic tests, molecular biology tests (PCR, RT-PCR) Pre-BMT Immunological Algorithm HLA Typing by molecular biology methods PCR SSOP- sequence-specific oligonucleotide probe hybridization (high resolution) SSP sequence-specific primers (high resolution) SBT (the highest available resolution) Cross- match - CDC - ELISA - KIR genotyping match Anti-HLA antibody detection and identification - AHG CDC - ELISA - Luminex Immunological assessment post BMT: Cytokine gene polymorphism IL 2R, IL4, IL6, IL10, TNF TH1 / TH2 PCR Chimerism PCR under development Tacrolaemia Cyclosporaemia Virological assessment Results: For bone marrow transplantation the use of Sequence Based Typing (SBT) is the gold standard for HLA matching. Cytokine gene polymorphism, donor-recipient KIR genes match, are useful in prevention of acute rejection episodes, maintaining, on a long term the bone marrow allograft functionality. Donor surface NK and T cells KIR genes mismatch with the recipient could activate cellular immune response via MHC class I. Conclusions: Transplantation immunology is complex. Our Immunogenetics Centres provide expanded immunological monitoring together with virological and drug monitoring of BMT transplanted patients.

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Our goal is to offer complete integrated monitoring data and to fulfill EFI Standards. EPT helps to assess and monitor multiple components of quality, especially analytical and preanalytical.Accreditation requirements include developing maintaining and documenting an effective QA program that includes analytical external proficiency testing. Clinical and laboratory scientists should work together as a team in order to have a complete overview of the transplanted patients. <... HHHHHH Imunologia transplantului medular in Romania: dezvoltare, acreditare, control extern de calitate Ileana Constantinescu*, Petru. Cianga**, Elena Gai***, Mihaela Melinte****, Dan Luscalov*****, Lucia Dican*****, Daniela Nedelcu*,Adela Toader*, Marilena Zaharia*,Anca Tica*, Daniela Vasile* *Centrul de Imunogenetica si Virusologie, Institutul Clinic Fundeni, Bucuresti ** Centrul de Imunogenetica, Iasi *** Centrul de Imunogenetica,Targu Mures **** Centrul de Imunogenetica, Timisoara ***** Centrul de Imunogenetica, Cluj Napoca Introducere: HLA determina soarta transplantului. Joaca un rol important in controlul interactiunilor celulare responsabil pentru raspunsul imun celular si umoral si este asociat cu o varietate de boli. Bariera compatibilitatii dintre receptor si donator ramane o problema in activarea raspunsului imun legat de rejectia grefei. De asemeni, daca imunosupresia va reduce rejectia, managementul de succes al transplantului si al pacientilor transplantati necesita o intelegere a MHC, identic cu sistemul HLA. Antigenele HLA sunt controlate de o serie de gene inalt polimorfice, la nivelul bratului scurt al cromozomului 6 MHC. Aloantigenele HLA clasa I si clasa II, pot induce imunitate post transplant atat la nivel umoral cat si la nivel celular. Peptidele antigenice vor fi prezentate limofocitelor T, in compania moleculelor HLA de clasa I si clasa II. Polimorfismul HLA, este reflectat de substitutia alelica a multor reziduuri aminoacidice din lanturile polipeptidice, in special la nivelul domeniului extern care contine situsul de cuplare a peptidelor. Aceasta afecteaza spectrul peptidelor prezentate de diferite tipuri alelice de molecule HLA si repertoriul clonelor de celule T specifice. Material si metoda: Virusologie completa:Atat donatorului cat si primitorului li se fac urmatoarele teste: VHB, VHD, VHC, HIV 1/2, CMV, EBV, HSV 1 si 2, VZV, HTLV 1/2 , virusul rubela, toxoplasma gondii si clamidia. Metode: Diagnosticul indirect (serologie) Diagnosticul direct-teste de biologie moleculare (PCR, RT-PCR) Algoritmul Imunologic pre-Transplant Medular Tipizarea HLAprin metoda de biologie muleculara PCR SSOP-sequence-specific oligonucleotide probe hybridization (inalta rezolutie) SSP-sequence-specific primers (rezolutie inalta) SBT-highest available resolution Crossmatch -CDC -ELISA -Genotipare KIR Detectia si identificarea anti-HLA -AHG CDC -ELISA -Luminex Imunologie completa post transplant medular: polimorfism gene citokine, IL2R, IL4, IL6, IL10, TNF, TH1/TH2 PCR, Chimerism PCR, Ciclosporina, Tacrolimus, virusologie completa Rezultate: Pentru transplantul medular, se performeaza metoda SBT care este standardul de aur in potrivirea HLA. Poliforfismul genelor citokinelor, potrivirea genelor KIR intre primitor si donator sunt utile in prevenirea episoadelor de rejectie acuta, mentinand functionarea alogrefei de maduva osoasa pe tremen lung. Mismatch-ul intre genele KIR care codifica receptorul pe suprafata al celulelor NK ale donatorului si receptorii celulelor T pot sa genereze activarea raspunsului imun celular via MHC clasa I. Concluzii: Imunologia transplantului este complexa. Centrele noastre de imunogenetica urmaresc sa extinda monitorizarea imunologica si virusologica in acelasi timp cu monitorizarea imunosupresiei la pacientii transplantati medular.

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EPT ajuta la evaluarea si monitorizarea multiplelor componente legate de calitate, in special analitice si pre-analitice. Cerintele acreditarii necesita dezvoltarea mentinarii si documentarii a unui program complet care include testarea eficientei externe . Oamenii de stiinta din laborator si clinica trebuie sa lucreze ca o echipa pentru a avea o imagine completa a pacientilor transplantati.

National Bone Marrow Registry: development, management and EuropeanAccreditation Ileana Constantinescu*,Alina Tanase**, Zsofia Varady**, Daniela Nedelcu*,Adela Toader*, Marilena Zaharia*,Anca Tica*, Daniela Vasile*, Dan Colita** *Centre of Immunogenetics and virology, Fundeni Clinical Institute, Bucharest **Centre of BMT transplantation, Fundeni Clinical Institute, Bucharest National waiting lists for Bone Marrow donor registry (2003) The donor must give his/her informed consent according to the national legislation before blood is taken for typing and before the donor is placed on a list of donors available to be called. Histocompatibility testing for related and unrelated transplants -Virological assessment Both donor and recipient are tested for: VHB, VHD, VHC, HIV 1/2, CMV, EBV, HSV 1 and 2, VZV, HTLV 1/2 , rubella virus, toxoplasma gondii and chlamydia. -HLAtyping Must include high resolution class I and class II typing by DNA methods to determine the degree of HLA matching as appropriate for the transplant protocol. Typing of donor and recipient at the highest level of resolution required by the transplant protocol must be performed in the laboratory affiliated with the transplant centre. QC in tissue typing By choosing the best methodology. To characterize the problems (precision, accuracy) affecting the method. To assess method stability. Variables that affect the quality of results. The educational background and training of the laboratory personnel.The condition of the specimens.The controls used in the test runs. Reagents. Equipment. The interpretation of the results. The transcription of results. The reporting of results Advantages and Benefits of EFIAccreditation Exchange of information. Exchange of experience. Homogenous way of performing tests Management of Quality Control. Improving continuously our activity.EPT helps to assess and monitor multiple components of quality, especially analytical and prenalytical. Accreditation requirements include developing maintaining and documenting an effective QAprogram that includes analytical external proficiency testing. Our goal is to offer complete integrated monitoring data for all services that we provide, to maintain and promote EFI Standards and to support all Romanian Immunogenetics Centers to apply for EFI accreditation. Registrul National de Donatori de Maduva: organizare, management si acreditare europeana. Ileana Constantinescu*,Alina Tanase**, Zsofia Varady**, Daniela Nedelcu*,Adela Toader*, Marilena Zaharia*,Anca Tica*, Daniela Vasile*, Dan Colita** *Centrul de Imunogenetica si Virusologie, Institutul Clinic Fundeni, Bucuresti **Centrul de Transplant Medular, Institutul Clinic Fundeni, Bucuresti Registrul National de Donatori Onorifici de maduva dateaza din 2003. Donatorul trebuie sa semneze consimtamantul legal inainte de recoltare si inainte ca donatorul sa fie trecut pe lista de donatori onorifici de maduva. Testarea histocompatibilitatii pentru donatorii inruditi si neinruditi: Virusologie pentru primitor si donator, VHB, VHD, VHC, HIV 1/2, CMV, EBV, HSV 1 si 2, VZV, HTLV 1/2 , virusul rubela, toxoplasma gondii si clamidia. Tipizarea HLA Trebuie sa includa metoda de tipizare HLA clasa I si clasa II de inalta rezolutie care determina gradul de compatibilitate HLA pentru transplant. Tipizarea primitorului si donatorului prin metoda de cea mai inalta rezolutie ceruta de

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protocolul de transplant trebuie performata in laboratoare afiliate centrelor de transplant. Controlul de calitate in tipizare tisulara Prin alegerea celei mai bune metode, caracterizarea problemelor care afecteaza metoda (precizie si acuratete) .Stabilitatea metodei. Variabilitati care afecteaza rezultatele. Educatia si perfectionarea personalului din laborator. Starea pacientului. Reactivii. Echipamentele. Interpretarea rezultatelor. Transcrierea rezultatelor. Raportarea rezultatelor. Avantaje si beneficii ale acreditarii. Schimb de informatii. Schimb de experienta. Managementul controlului de calitate. Imbunatatirea continua a activitatii. EPT ajuta la evaluarea si monitorizarea multiplelor componente legate de calitate, in special analitice si pre-analitice. Cerintele acreditarii necesita dezvoltarea mentinarii si documentarii a unui program complet care include testarea eficientei externe . Oamenii de stiinta din laborator si clinica trebuie sa lucreze ca o echipa pentru a avea o imagine completa a pacientilor transplantati.

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ATELIER DE LUCRU EDUCATIONAL LEUCEMII ACUTE

GenomicAnalyses for Leukemia diagnosis and the identification of novel therapeutic targets Carsten Mller-Tidow* andAnca Ilea** * Department of Medicine, Hematology and Oncology, University of Mnster, Germany ** Ritus-Biotec, Codlea/Brasov Acute leukemias are a group of malignant diseases with often similiar appearance. An accurate diagnosis enables the use of the best therapy and strongly predict patients prognosis. Recent advances in the understanding of disease pathogenesis has also led to the development of improved molecular tests. Especially in acute myeloid leukemia (AML) rapid progress has been made in defining the disease associated genetic and epigenetic lesions. Two major types of genetic events have been described that are crucial for leukemic transformation: alterations in myeloid transcription factors governing hematopoietic differentiation and activating mutations of signal transduction intermediates. These processes are highly interdependent, since the molecular events changing the transcriptional control in hematopoietic progenitor cells modify the composition of signal transduction molecules available for growth factor receptors, while the activating mutations in signal transduction molecules induce alterations in the activity and expression of several transcription factors that are crucial for normal myeloid differentiation. The improved understanding of disease pathogenesis has led to an intensive search for novel drugs that are currently evaluated. CONSENSUL EUROPEAN IN IMUNOFENOTIPAREA PRIN CITOMETRIE IN FLUX A LEUCEMIILOR ACUTE Adriana Dumitrescu Laboratorul de Citometrie in flux, Institutul Clinic Fundeni, Bucuresti, Romania Citometria in flux constituie in prezent o metoda indispensabila pentru diagnosticul leucemiilor acute, obiectivele sale majore fiind determinarea liniei, identificarea leucemiilor bifenotipice (LAB, clasificarea si, in ultimul timp, identificarea fenotipurilor asociate leucemiei necesare pentru detectarea ulterioara a bolii minime reziduale (BMR). Procedura complexa si laborioasa, imunofenotiparea a suscitat numeroase dezbateri ale specialistilor implicati, incercand sa se obtina un consens. Prezentam recomandarile actuale in contextul consensului european obtinut in cadrul European Leukemia Net (ELN) (www.leukemia-net.org). Acestea se refera la: 1. precautiile preanalitice, 2. panelul de anticorpi monoclonali, 3. combinatiile anticorpilor monoclonali. 1. Etapele preanalitice care preced imunofenotiparea sunt de o deosebita importanta: - Esantionul preferat este maduva osoasa; in mod exceptional se poate utiliza sange periferic (blasti >80% sau >30 G/L) -Anticoagulantul indicat: EDTA, Heparina sau citrat Na - Volumul probei - Transportarea probei: temperatura optima de 10-250C ( nu se tine la frigider si nici la soare, in nici un caz nu se ingheata!), cat mai repede posibil, dar in cel mult 24-48 ore de la recoltare. 2. Panelul de anticorpi monoclonali necesari pentru orientare sau pentru probele sarace include: cCD3, MPO, cCD79a, TdT CD7, CD2, CD10, CD19, CD22 (s sau c), sIg, CD13, CD33, CD34 CD45 pentru gating Pentru clasificare si definirea entitatilor clinice (cu strategia potrivita de gating) sunt necesari urmatorii markeri:HLA- DR, CD1a, CD4, CD5, CD8, CD3 (s), IgM (c), CD14, CD117, CD56, CD65, CD41 sau CD61, CD238 (glycophorinA) sau CD36. De asemenea se considera ca fiind necesari si alti markeri (>20): MPO/LF (lactoferrin) (c), CD14, lysozyme (c CD11b, CD11c, CD15, CD16, CD35/36, CD58, CD64, CD68 (c), CD71, CD86, CD99, CD123, lanturi TCR. Panelul trebuie sa include si tintele terapeutice: CD20, CD52, CD45, CD33, CD123, CD87, CD44, uPAR(CD87)/uPACD116. Pentru identificarea ulterioara a BMR pot fi necesari si alti markeri.

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3. Combinatiile de anticorpi monoclonali permit analiza simultana a 3-4 markeri, mai recent 5-6 si probabil mai mult in viitor. Prin imunofenotiparea cu multe culori se pot identifica fenotipurile aberante (coexpresie, asincronisme), ceea ce permite discriminarea celulelor leucemice si a celor normale, cu impact asupra detectarii BMR. Se adauga avantaje economice. Imunofenotiparea cu mai multe culori ridica multe probleme tehnice, folosirea anumitor combinatii si fluorocromi depinzand si de tipul de citometru sau combinatiile de filtre utilizate, ceea ce explica si dificultatea de a ajunge la un consens.

EUROPEAN CONSENSUS IN FLOW CYTOMETRY IMMUNOPHENOTYPING OFACUTE LEUKEMIAS Adriana Dumitrescu Laboratorul de Citometrie in flux, Institutul Clinic Fundeni, Bucuresti, Romania Flow cytometry is a proven method for the diagnosis of acute leukemias nowadays, the objectives of acute leukemia immunophenotyping being lineage assignment, detection of biphenotypic leukemias (BAL), classification and identification of leukemia associated immunophenotypic patterns (LAIP). As a complex and laborious procedure, flow cytometry immunophenotyping has been debated several times by the specialists, trying to get a consensus. We are presenting current recommandations as concluded within European Leukemia Net (ELN) (www.leukemianet.org). These refer to: 1. Preanalytical precautions, 2. Consensual mandatory acute leukemia diagnosis panel, 3. Antibody combinations. 1. The preanalytical steps preceding immunophenotyping are of major importance: - Sampling for acute leukemia diagnosis: bone marrow is preferred, but peripheral blood samples with large blast counts (>80% or >30 G/L) can also be used. -As anticoagulant, both EDTA, Heparin or Na citrate are suitable. - The volume of the sample collected - Transportation of the sample: room temperature, i.e. between 10 and 25C is ideal. The sample should not be refrigerated and certainly not be frozen, it should not stay in the sun either. They should be prepared "as soon as possible" after collection. In any case, there should be no more than 24-48 hours between collection and sample processing. 2. The panel for quick orientation or paucicellular samples includes: cCD3, MPO, cCD79a, TdT CD7, CD2, CD10, CD19, CD22 (s or c), sIg, CD13, CD33, CD34 CD45 for gating purposes. For sublineage classification and definition of clinical entities (also with adapted gating strategy): DR, CD1a, CD4, CD5, CD8, CD3 (m), IgM (c), CD14, CD117, CD56, CD65, CD41 or CD61, CD238 (glycophorinA) or CD36. . Other useful markers (>20): MPO/LF (lactoferrin) (c), CD14, lysozyme (c), CD11b, CD11c, CD15, CD16, CD35/36, CD58, CD64, CD68 (c), CD71, CD86, CD99, CD123, TCR. Therapeutic targets: CD20, CD52, CD45, CD33, CD123, CD87, CD44, uPAR(CD87)/uPACD116. These panels are intended for diagnostic purposes of acute leukemia. They may need to be completed using markers that will prove later useful for MRD detection. 3. Antibody combinations allow simultaneous analysis of 3 or 4 markers, more recently 5 or 6, and probably even more in a near future. By multicolor immunophenotyping we can identify aberrant LAIPs which allows the discrimination of leukemic cells from normal cells, impacting on MRD detection. There are also important economical advantages. Multicolor immunophenotyping has many technical problems, some combinations and fluorochromes being dependent on the type of flow cytometer or filter combinations used, which explain why it is so difficult to reach a consensus. Limitele imunohistochimiei n diagnosticul leucemiilor acute limfoide i non-limfoide Camelia Dobrea (1),Alina Nicolae (2) 1. Institutul Clinic Fundeni, Centrul de Hematologie i Transplant Medular, Laborator Anatomie Patologica, Bucureti, Romnia 2. Spitalul Universitar de Urgenta, LaboratorAnatomie Patologica, Bucureti, Romnia Leucemia acut prezint pattern-uri caracteristice ale expresiei antigenelor de suprafa (CD antigens), care faciliteaz

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identificarea i clasificarea lor adecvat, jucnd deasemenea un rol important n instituirea terapiei. Cel mai comun sistem utilizat n clasificarea leucemiilor acute se bazeaz n principal pe caracteristicile citomorfologice, citochimice i imunocitochimice ale celulelor din frotiurile de sngele periferic i din aspiratul medular. Dac aspiratul medular este alb, biopsia de mduv osoas (din creasta iliac) devine investigaia cu implicare diagnostic major. Sistem de clasificare al leucemiilor acute WHO 2000, bazat pe sistemului Franco-Americano-Britanic (FAB) revizuit, ine cont de trsturile citogenetice i moleculare ale celulelor tumorale, n special n cazul LAL. Imunohistochimia ofer ca avantaje: arhitectura i dispoziia celulelor tumorale, dovedindu-i utilitatea n cazurile rare de leucemie acut cu mielofibroz, fr descrcare de blati n periferie i cu aspirat medular alb. Numeroase studii au ncercat s demonstraze valoarea diagnostic a anticorpilor utilizai pe biopsii de mduv osoas incluse la parafin; urmtorul panel de anticorpi este considerat n general adecvat: CD34, MPO, CD68, glycophorinA, factor VIII, CD42, lizozim,TdT, CD3, CD10, CD79a, CD20. Totui imunofenotiparea prin flow citometrie confer o mai bun evaluare a populaiei de celule blastice, fiind o investigaie multiparametric. Ea joac un rol indispensabil n identificarea corect a LAM M0, diferenierea LAP de LAM M1/M2, identificarea corect a LAL TdT-negative, precum i a variantelor neobinuite de leucemie: leucemie bifenotipic i nedifereniat. Pentru toate cazurile cu rezultate discordate ntre aceste dou metode i/sau expresie aberant de antigene, alte investigaii (analiza rearanjrii genice) sunt indicate. The limits of immunohistochemistry in diagnosis of acute lymphoid and non-lymphoid leukemia Camelia Dobrea (1),Alina Nicolae (2) 1. Pathology Laboratory - Centre of Hematology and Bone Marrow Transpantation, Fundeni Clinical Institute, Bucharest, Romania 2. Pathology Laboratory - Emergency Universitary Hospital Bucharest, Romania Acute leukemia displays characteristic patterns of surface antigen expression (CD antigens), which facilitate their identification and appropriate classification and hence plays an important role in instituting appropriate treatment. The most commonly used systems of classification of acute leukemia are based mainly on cytomorphological, enzyme cytochemical, and immunocytochemical findings in blood and bone marrow smears. If bone marrow aspiration is unsuccessful, the investigation of bone marrow biopsy specimens (from the iliac crest) becomes of major diagnostic importance. The WHO classification system of acute leukemia is based on a revision of the French-American-British (FAB) system, and takes account of cytogenic and molecular genetic findings, especially in the case ofALL. The immunohistochemistry offers the advantage of the architecture, disposition of malignant cells and also in rarely cases of acute myeloid leukemia with myelofibrosis, without peripheral discharge and bone marrow aspirate - dry tap (such asAML M7, acute panmyelosis). A lot of studies tried to demonstrate the diagnostic value of antibodies suitable for use on paraffin embedded sections from bone marrow biopsy specimens, and the following panel is generally considered suitable for subtyping: CD34, MPO, CD68, glycophorinA, factor VIII,CD42, lysosyme,TdT, CD3, CD10, CD79a, CD20. Althought immunophenotyping by flow cytometry confers a much better evaluation of blast cells being a multiparametric analysis. It plays an indispensable role in the correct identification of AML M0, differentiation of APL from AML M1/M2, correct identification of TdT-negative ALL and unusual variants, such as undifferentiated and biphenotyping acute leukemias. For all the cases with discordant results between these methods, or/and aberrant

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POSTERE

DETERMINARI BLASTICE EXTRAMEDULARE IN LEUCEMIILE ACUTE MIELOBLASTICE CARACTERISTICI EPIDEMIOLOGICE . EXPERIENTACLINICII DE HEMATOLOGIE SUUB I. Voican, A.M. Vladareanu, H. Bumbea, D. Cisleanu, S. Radesi, M. Begu, C. Ciufu, V. Vasilache, C. Marinescu, A. Petre, M. Dervesteanu, M. Onisai, R. Bucoveanu Clinica de Hematologie, Spitalul Universitar de Urgenta Bucuresti Cuvinte cheie- Leucemia acuta mieloblastica, Determinare blastica extramedulara Introducere: Determinarile blastice extramedulare (DBE), cunoscute si ca sarcom granulocitic, clorom sau mieloblastom, sunt tumori maligne constituite din blasti si granulocite in diferite stadii de maturatie. Aparitia lor reprezinta un factor de prognostic prost asociat cu o supravietuire redusa. Scopul: Identificarea unor particularitati asociate aparitiei DBE in leucemiile acute mieloblastice (LAM) de novo si secundare. Material si metoda: Prezentam un studiul retrospectiv al unui lot de 15 pacienti (cazuri consecutive) cu LAM de novo (7 cazuri) si secundare (8 cazuri) diagnosticate in clinica noastra in perioada 1.03 2005 30 06.2007. Criteriile de diagnostic utilizate corespund Clasificarii WHO a LAM. Rezultate: Repartitia lotului de pacienti pe sexe a fost de 5 femei si 10 barbati iar mediana varstei a fost de 56 ani (18-78) cu urmatoarele subtipuri morfologice identificate: LAM0 1caz, LAM1 2cazuri, LAM2 7 cazuri, LAM4 1 caz, LAM5 2 cazuri si Leucemie cu eozinofile 2 cazuri. Localizarile DBE identificate au fost: piele (1 caz), ganglioni limfatici (6 cazuri), tub digestiv (4 cazuri), sistem nervos central (1 caz), os (1 caz), sinovie (1 caz), tiroida (1 caz), muschi (2 cazuri). Cinci pacienti au prezentat DBE unice; opt au avut mai multe situsuri cu aceeasi structura histologica interesata iar in doua cazuri s-au identificat DBE in organe cu structura histologica diferita. Doar in patru cazuri DBE au precedat boala medulara. Toti pacientii au fost investigati din punct de vedere imunofenotipic dar fara a putea identifica expresia vreunui antigen particular si nici nu s-a putut stabili vreo corelatie intre subtipul morfologic LAM si localizari particulare ale DBE, posibil datorita numarului mic de cazuri avute la dispozitie. Conform datelor din literatura, pacientii cu DBE au prognostic mai prost si supravietuire mai scurta. In lotul nostru, supravietuirea globala raportata la momentul diagnosticului de DBE la pacientii cu LAM de novo a fost mai scurta fata de cei cu LAM secundara. Concluzii: DBE pot apare atat in LAM de novo cat si secundare, ca prima manifestare de boala, precedand debutul medular si periferic sau ca evenimente tarzii in evolutia leucemiei. In lotul nostru, in majoritatea cazurilor DBE au aparut dupa determinarea medulara (la pacienti deja diagnosticati cu LAM conform criteriilor clasice). Dupa cum reiese din literatura, DBE pot apare practic in orice locatie dar cele mai frecvente situsuri - in lotul nostru - au fost ganglionii limfatici si tubul digestiv; localizari absolut particulare: glanda tiroida si sinovia. Supravietuirea globala a fost mai mica in grupul pacientilor cu LAM de novo fata de grupul LAM secundare. EXTRAMEDULLARY MYELOID CELL TUMORS IN ACUTE MYELOBLASTIC LEUKEMIA EPIDEMIOLOGIC CHARACTERISTICS. THE EXPERIENCE OF HEMATHOLOGY DEPARTMENT OF THE EMERGENCY UNIVERSITARY HOSPITAL I. Voican, A.M.Vladareanu, H. Bumbea, D. Cisleanu, S. Radesi, M. Begu, C. Ciufu, V. Vasilache, C. Marinescu, A. Petre, M. Dervesteanu, M. Onisai, R. Bucoveanu Hemathology Department of the Emergency Universitary Hospital, Bucharest KEYWORDS:Acute myeloblastic leukemia, Extramedullary myeloid tumors

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Background: Extramedullary myeloid cell tumors (EMT), also known as granulocytic sarcoma, chloroma or myeloblastoma are malignant tumors of myeloblasts and granulocytes in different stages of maturation. Their development represents a poor prognostic factor and correlates with a short survival. Aims: To identify particular characteristics for EMT occurrence in de novo and secondaryAML. Methods: We present a retrospective study of 15 patients (consecutive cases) with de novo (7 cases) and secondary (8 cases)AML admitted to our hospital between 01.03.2005 and 30.06.2007 and diagnosed according to WHO criteria. Results: Among the 15 patients, 5 were females and 10 were males with a median age of 56 years, range [18-78]. The following morphologic types were identified: AML0 1 case, AML1 2 cases, AML2 7 cases, AML4 1 case, AML5 2 cases and acute leukemia with eosinophils 2 cases. All the patients were morphologicaly and imunophenotypicaly investigated. The EMT locations were: skin (1 case), lymph nodes (6 cases), gastrointestinal tract ( 4 cases), central nervous system (1 case), bone (1 case), synovia (1 case), muscle (2 cases) and thyroid gland (1 case). Five patients presented unique determination of EMT; eight had multiple sites involving the same histologic structure and in two cases EMT developed in organs with different histologic structure. In four cases, the EMT preceded the medullary disease. Althought all the patients were imunophenotypically investigated, no significant observation regarding a particular antigen expresion and no correlation between the morphologicAML type and peculiar location of EMT could be made, probably due to the small number of cases. Patients with EMT have poorer prognostic and shorter survival. In our research, the overall survival reported to the EMT diagnosis was shorter in de novoAML compared to secondaryAML Conclusion: EMT can develop in patients with de novo or secondary AML, as first manifestation of the disease, preceding the onset in marrow and peripheral blood, or as late events in the evolution of the illness. In our data, in most of the cases, the EMT succeeded the medullar involvement. As reported in the literature, the EMTs may virtually involve any location, but the most commun sites in our research were: lymph nodes and gastrointestinal tract ; rare and peculiar location were: thyroid gland and synovia. The overall survival was shorter in the de novo AML group than in secondaryAML. SINDROM BUDD-CHIARI CA EVENIMENT REVELATOR PENTRU POLICITEMIA VERA. EVOLUTIE FAVORABILASUB TRATAMENTANTICOAGULANT SI CITOREDUCTOR. PREZENTARE DE CAZ.-----I. Voican*, A.M.Vladareanu*, M.Dervesteanu*, M.Begu*, S.Radesi*, H.Bumbea*, D.Casleanu*,C.Marinescu*, V.Vasilache*, C.Ciufu*,A.Petre*.A.Ilea** * Clinica de Hematologie, Spitalul Universitar de Urgenta Bucuresti ** RitusBiotech, Codlea Introducere: Evenimentele trombotice reprezinta una din cele mai frecvente complicatii (20-30%) si principala cauza de mortalitate (30%) a pacientilor cu Policitemia Vera (PV). Aparitia lor este mai frecventa in primii trei ani de la diagnostic, putand reprezenta elementul revelator al bolii mieloproliferative cronice (BMC). Afecteaza atat teritoriul arterial cat si venos iar prezenta mutatiei JAK2V617 pare a se corela cu un risc trombotic crescut . Tromboza venelor suprahepatice (sindromul Budd-Chiari) reprezinta o localizare particulara si destul de putin frecventa a procesului trombotic, asociata unui prognostic foarte rezervat pe termen scurt, in ciuda tratamentului anticoagulant. Material si metoda: Prezentam cazul unui pacient diagnosticat concomitent cu tromboza de vene suprahepatice si BMC PV. Diagnosticul hematologic s-a bazat pe examenul histologic al maduvei osoase (Punctie Biopsie Osoasa), determinarea valorii eritropoietinei serice (EPO) si evidentierea mutatiei JAK2 V617F prin examen PCR. Sindromul de hepatocitoliza important, colestaza si semnele deficitului de productie hepatica alaturi de datele imagistice (ecografie, eco Doppler, CT-scan, endoscopie digestiva superioara) ce pledau pentru o ciroza hepatica non-virala (markeri virali hepatitici negativi) decompensata portal (varice esofagiene grad IV-V, ascita si edeme periferice) si parenchimatos (hipoalbuminemie, hiperbilirubinemie, hipocolesterolemie, modificari ale coagulogramei) au ridicat problema diagnosticului diferential cu Sindromul Mosse. Evolutia pacientului sub tratament complex ce a inclus flebotomii terapeutice repetate, citoreductie cu Hydroxiuree si anticoagulant (Heparina sodica in administrare continua urmata de anticoagulant oral) alaturi de masuri patogenice si simptomatice vizand ciroza hepatica, a fost favorabil cu normalizarea parametrilor hematologici, disparitia fenomenelor de decompensare hepatica si reducerea dimensiunilor procesului trombotic. Concluzii : Accidentul trombotic major - cu prognostic cunoscut ca extrem de rezervat asociat unei BMC justifica initierea unui tratament anticoagulant agresiv chiar in prezenta unui risc hemoragic crescut generat de o potentiala afectiune hepatica cronica cu deficit de productie a factorilor coagularii, varice esofagiene si gastropatie portala.

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BUDD-CHIARI SYNDROME AS A REVELANT EVENT FOR POLICITEMIA VERA. FAVOURABLE EVOLUTION WITHANTICOAGULANTAND CYTOTOXIC THERAPY. I. Voican*, A.M.Vladareanu*, M.Dervesteanu*, M.Begu*, S.Radesi*, H.Bumbea*, D.Casleanu*,C.Marinescu*, V.Vasilache*, C.Ciufu*,A.Petre*.A.Ilea** Background: Thrombotic events represent one of the most frequent complications (25-30%) and the main cause of death (30%) in policitemia vera (PV). They occurr especially in the first 3 years after diagnosis and may represent the revelator element for diagnosis. They affect both the arterial and the venous vessels and the presence of JAK2 V617 mutation seems to corelate with a higher thrombotic risk. The suprahepatic veins thrombosis (Budd-Chiari syndrome) represents a less frequent and odd location of the thrombotic process associated to a very poor, short term prognosis, in spite of the anticoagulant therapy. Method: We present the case of a male patient in which the suprahepatic vein thrombosis and the chronic myeloproliferative disease (CMD) were concomitentelly diagnosed. The diagnosis of PV was based upon the bone marrw biopsy apparence, the low level of serum erithropoietin and the evidence of JAK2 V617 mutation by PCR examination. The high values of liver enzimes, cholestasis and the signs of reduced liver protein production along with the paraclinic investigations (ultrasounds, Doppler exam, CT-scan, digestive endoscopy) that suggested the diagnosis of hepatic cirosis of non-viral ethiology (hepatitic viruses markers were negative) with portal decompensation ( oesofagial veins dilatations, ascitis and peripheral oedema) as well as parenchimal decompensation (low albumine, low coagulation factors, high bilirubinemia) raised the problem of the differantial diagnosis with Mosse syndrome. The patient's evolution with complex therapy that included serial flebotomy, citotoxic agents Hydroxiurea anticoagulant therapy (unfractioned Heparine followed by oral anticoagulant) and pathogenic and simptomatic measures regarding hepatic disease was good: the hematologic parameters became normal, the liver decompensation dissapeared and the thrombotic process was stopped and even diminished. Conclusions: The major thrombotic accident - known as a very bad prognostic factor associated to a CMD justifies an aggressive anticoagulant therapy in spite of an increased hemmoragic risk generated by a possible liver disease with coagulation disturbances, oesofagial varices and portal gastropathy.

SINDROM HIPEREOZINOFILIC CA MANIFESTARE PARANEOPLAZICA INTR-UN SARCOM RETROPERITONEAL. PROBLEME DE DIAGNOSTIC. Prezentare de caz-- poster I.Voican*, A.M.Vladareanu*, M.Dervesteanu*, M.Begu*, G.Simion**, A.Sandu, C.Ciufu*, A.Petre*, C.Marinescu*, S.Radesi*, M.Onisai* *Clinica de Hematologie, Spitalul Universitar de Urgenta, Bucuresti **DepartamentulAnatomie Patologica, Spitalul Universitar de Urgenta Bucuresti Introducere: Hipereozinofilia (>1,5 x 109/L) apare atat ca eozinofilie reactiva (HES secundar) ce recunoaste o multitudine de cauze subiacente, ca sindrom hipereozinofilic (HES) idiopatic cat si ca leucemie cronica cu eozinofile (LCE). Diagnosticul diferential al acestor trei entitati implica excluderea tuturor cauzelor de eozinofilie reactiva pentru HES secundar (infectioase, alergice, neoplazice, imunologice) si determinarea markerilor de anomalie mieloida clonala ( ex gena de fuziune FIP1L1/PDGFRA) care stabilesc diagnosticul de LCE; HES idiopatic este diagnosticat in absenta tuturor acestor factori. Stabilirea diagnosticului corect este esentiala pentru ghidarea tratamentului, demonstrat fiind faptul ca in LCE doze mici de Imatinib mesilat induc remisiunea competa in timp ce cazurile de HES secundar nu sunt sensibile la acest tratament. Literatura precizeaza insa ca rezultatele negative pentru FIP1L1/PDGFRA nu exclud in totalitate posibilitatea tratamentului cu Glivec, atata timp cat s-au obtinut rezultate partiale sau chiar si complete. Material si metoda: Se prezinta cazul unui pacient in varsta de 53 ani cu hiperleucocitoza (L.>140000/mmc) si eozinofilie importanta (E=78%) aparute in contextul unei tumori de loja renala stanga cu extensie retroperitoneala, insotita de determinari ganglionare abdominale, hepatice nodulare, pleuro-pulmonare micronodulare si tromboza de vena cava inferioara si vena renala stanga evidentiate imagistic. Pacientul mai prezenta: eruptie cutanata papuloeritematoasa pruriginoasa in placarde pe membre, adenopatii periferice si hepatosplenomegalie importanta pe fondul H.Bumbea*, D.Casleanu*,

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unei stari generale progresiv alterate, cu scadere ponderala importanta si subfebrilitate. Principalele elemente luate in consideratie in diagnosticul diferential au fost : Leucemie cu eozinofile si HES secundar fie unei neoplazii solide cu punct de plecare retroperitoneal fie unui limfom malign T. Absenta FIP1L1/PDGFRA (determinata prin examen PCR) si lipsa de raspuns la tratamentul cu Glivec au inclinat balanta catre diagnosticul de HES secundar, confirmat necroptic prin evidentierea unei tumori gigante retroperitoneale cu multiple determinari secundare hepatice, pancreatice, ganglionare si pleuro-pulmonare. Concluzii: Desi contextul clinic cu valori hematologice extreme (tablou leucemic) si schita initiala a unui raspuns terapeutic la inhibitor de tirozinkinaza pot sugera diagnosticul de LCE, examenul molecular isi dovedeste superioritatea si indispensabilitatea in stabilirea diagnosticului corect al SHE HYPEREOSINOPHILIC SYNDROME (HES) AS PARANEOPLASTIC MANIFESTATION IN A RETROPERITONEAL SARCOMA. DIAGNOSIS DIFFICULTIES I.Voican*, A.M.Vladareanu*, M.Dervesteanu*, M.Begu*, G.Simion**, A.Sandu, H.Bumbea*, D.Casleanu*, C.Ciufu*, A.Petre*, C.Marinescu*, S.Radesi*, M.Onisai* * Hemathology Department of the Emergency Universitary Hospital, Bucharest **Anatomopathology Department of Emergency Universitary Hospital, Bucharest Background: Hypereosinophilia (>1.5x109 /L) may be due to reactive eosinophilia (secondary HES) with multiple causes, to idiopathic HES as well as to chronic eosinophilic leucemia (CEL). The differential diagnosis among them claims to exclude all the possible causes of secondary eosinophilia ( infectious diseases, allergic reactions, immune causes and underlying neoplastic diseases) as well as to determine the markers of clonal myeloid disorder (e.g. the presence of the FIP1L1/PDGFRAfusion gene) that confirm the diagnosis of CEL; idiopatic HES is diagnosed if none of these conditions are fullfilled. The correct diagnosis is essential for treatmnent decision as it has already been demonstrated that low doses of Imatinib mesilate induce complete remission in CEL but not in secondary HES . Negative FIP1L1/PDGFRA results, however, did not rule out response to therapy (partial and even complete responses were achived). Method: We present the case of a 53 years old male patient with hiperleucocytosis (WBC>140000/mmc) and stricking eosinophilia (E=78%) along with a left renal region tumor with retroperitoneal extension, intraabdominal lymph nodes enlargement, nodular liver involvement, pleural and pulmonarry micro-noduls and inferior cava vein and left renal vein thrombosis all these were discovered on CT-scan. The patient's performance status was very low, he had fever from time to time and lost almost 25 kg. He also had an extensive eritematous rash with pruritus on his legs, palpable peripheral lymph nodes and liver and spleen enlargement. The main differential diagnosis were eosinophilic leukemia and secondary HES due to either a solid tumor or to a malignant T cell lymphoma. The absence of FIP1L1/PDGFRA(in PCR examination) and the lack of response to Glivec therapy made the secondary HES diagnosis the most probable one. This was confirmed by the necropsy which revealed a giant retroperitoneal tumor with multiple secondary locations in pleura, lungs, liver, pancreas and lymph nodes. Conclusions: Although the clinical picture and the initial response to Imatinib therapy may suggest a primary hemathologic disease, the molecular examination proves its superiority in establishing the correct diagnosis of HES.

DIFICULTI N DIAGNOSTICUL LEISHMANIAZEI DE IMPORT N ROMNIA M. L.A. Balea1, M Guran1, R Gogulescu2, E Ceauu3, M. I. Balea4 1. Spitalul Clinic Colentina, Bucureti, Romnia 2. Laboratorul Gral Medical, Spitalul Clinic Colentina, Bucureti, Romnia 3. Spitalul Clinic Boli Infecioase si Tropicale "Dr. Victor Babe" 4. INP Prof. Dr. M Nasta, Bucureti, Romnia Tabloul clinico-biologic extrem de variat al Leishmaniazei ne permite s afirmm c alturi de colagenoze, vasculite sistemice poliarterite, tuberculoz, infecia HIV aceast afeciune face parte din grupa marilor mimatori. Practic inexistent nainte de anul 1989, odat cu deschiderea granielor am diagnosticat numai n clinica noastr 5 cazuri de leishmanioza visceral: 3 subieci de sex brbtesc i 2 subieci de sex feminin, cu vrsta cuprins ntre 24 i 47 an; 4 subieci veneau din sudul Greciei i unul din sudul Italiei (Regio Calabria).

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Tabloul clinico-biologic a asociat: sindrom febril prelungit, sindrom consumptiv, hepatosplenomegalie progresiv, adenomegalie progresiv, pancitopenie care se agraveaz progresiv i sindrom umoral inflamator cu hipergamaglobulinemie policlonal. Subiecii au ajuns n clinica noastr dup 8-14 luni de suferin, interval n care, la internrile din diverse servicii medicale ipotezele de diagnostic au fost: endocardit lent, CH VHB+ cu hipersplenism i pancitopenie, PTI, boli neoplazice, toxoplasmoza visceral, LMNH, sa. Diagnosticul n clinica noastr a fost argumentat de prezena de leishmania amastigotes n macrofagele din grunjii mielomedulari. Accentum necesitatea realizrii unui examen riguros n contextul n care una din bolnave a efectuat o PBO n clinicile din Regio Calabria, ulterior n clinicile din Romnia (mai i octombrie 2006). Reexaminnd lamele din octombrie 2006 am evideniat prezena de leishmania amastigotes: 1 macrofag infectat la 100 cmpuri. n concluzie: leishmanioza visceral face acum parte din patologia ce trebuie avut n vedere i n Romnia, ntrebarea Ubi Vene i examenul riguros al PBO reprezentnd cheia diagnosticului. DIAGNOSTIC DIFFICULTIES IN IMPORTED LEISHMANIASIS IN ROMANIA M. L.A. Balea1, M Guran1, R Gogulescu2, E Ceauu3, M. I. Balea4, 1. Colentina Clinical Hospital, Bucharest, Romania 2. Gral Medical Laboratory, Colentina Clinical Hospital, Bucharest, Romania 3. Dr. V. Babe Infectious and Tropical Diseases Hospital, Bucharest, Romania 4. NIP Prof. Dr. Marius Nasta, Bucharest, Romania The extremely-polymorphous symptoms and signs of visceral Leishmaniasis allow us to state that this infection is part of a grate imitators group together with collagen diseases, systemic vasculitis polyarteritis, tuberculosis and HIV infection. With no occurrence before 1989, after the liberation of the Romanian frontiers, no less than 5 visceral Leishmaniasis have we diagnosed only in our clinic: three males and two females ages 24 47. Four of the subject had come from Southern Greece and one of subjects from Southern Italy (Reggio Calabria). The associated symptoms and signs were as follows: prolonged-fever syndrome, consumption syndrome, progressive hepatosplenomegaly, progressive adenomegaly, progressive-aggravating pancytopenia and inflammatory humoral syndrome accompanied by polyclonal hypergammaglobulinemia. The subjects came at our clinic after 8 14 months of suffering, meanwhile having been diagnosed by various medicalattendance unites with the following hypothetic diagnoses: subacute bacterial endocarditis, hepatic cirrhosis HVB+ with hypersplenism and pancytopenia, idiopathic thrombocytopenic purpura, neoplastic disorders, visceral toxoplasmosis, non-Hodgkin's lymphomas (NHLs). The diagnosis in our clinic has been argumented by the occurrence of leishmania amastigotes in the macrophages within the bone marrow grains. We emphasize that we should make a thorough examination considering the following case of a female-patient, who have been performed bone-marrow biopsy in one of the clinics in Reggio Calabria and afterwards in the clinics in Romania (May 2006 and October 2006). At a second examination, the smear obtained in October 2006 evidenced amastigotes leishmania: one infected macrophage per 100 fields. Conclusion: visceral leishmania has became part of the pathology that should be taken into account in Romania, the quest Ubi Vene and rigorous examination of bone-marrow biopsy being the key to diagnosis.

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EFECTELE SINDROMULUI DE HIPERVSCOZITATE SERIC ASUPRA SECREIEI DE ERITROPOIETIN (EPO) M. L.ABalea1, T Puscariu2, 2. C Siara1, M. I. Balea1 1. Spitalul Clinic Colentina, Bucureti, Romnia 2. Institutul Fundeni, Bucureti, Romnia 3. INP Prof. Dr. M Nasta, Bucureti, Romnia Introducere: Epo este produs primar de ctre rinichiul adult sub controlul unui mecanism de detecie a oxigenului. n afar de hipoxie, mai sunt ali civa factori care moduleaz producia de Epo, cum ar fi hipoglicemia, concentraiile crescute de calciu intracelular, eliberarea de insulin, estrogenii, androgenii i variate citokine. Scop: Demonstrarea ipotezei c hipervscozitatea seric moduleaz producia de Epo. Metod: Considernd vscozitatea seric (VS) important pentru funcia renal am evaluat nivelul Epo serice nainte de iniierea programului de plasmaferez i la 21 zile dup normalizarea VS la subiecii cu boal Waldenstrom i mielom multiplu, cu vscozitatea seric mai mare de 4cp (lotul cercetat a prezentat VS cuprins ntre 4cp i 12cp), care au necesitat plasmaferez pentru rezolvarea sindromului de hipervscozitate. Rezultatele obinute ne-au indicat scderea constant sub valoarea limit a normalului a concentraiei serice a Epo la evaluarea efectuat naintea plasmaferezei.Am constat o corelaie strns ntre magnitudinea valorilor VS i severitatea scderii valorilor Epo. Reevaluare concentraiei Epo serice la 21 zile dup echilibrarea VS ne-a indicat o cretere constant a acesteia cu 68% pn la 230% fa de valoarea iniial cu o valoare medie a creterii de 114%. Concluziile acestei etape de lucru indic VS ca participnd la reglarea secreiei de Epo, hipervscozitatea reprezentnd un factor de inhibiie a secreiei de Epo. THE EFFECT OF BLOOD VISCOSITY ON ERYTHROPOIETIN SECRETION M. L.ABalea1, T Puscariu2, 2. C Siara1, M. I. Balea1 2. Fundeni Institute, Bucharest, Romania 3. NIP Prof. Dr. Marius Nasta, Bucharest, Romania Background: Erythropoietin (Epo) is produced primarily in the adult kidney under the control of an oxygen-sensing mechanism. Besides hypoxia, there are several factors that modulate Epo production, such as hypoglycemia, increased intracellular calcium, insulin release, estrogen, androgenic steroids, and various cytokines. Aims: To demonstrate our hypothesis that the blood viscosity modulates as well Epo' s production. Methods: Considering blood viscosity's importance for kidney function we have evaluated the serum erythropoietin's level in subjects with Waldenstrom' s disease and multiple myeloma before starting the plasmapheresis program and at 21 days after the serum viscosity was normalized. The analyzed lot had viscosity between 4cp and 12cp and need plasmapheresis as a regulator of their severe hyper-viscosity syndrome. The results we obtained denoted constant decrease to the low level of normal values and under normal limits of serum Epo concentration for the evaluation made before plasmapheresis. We observed a high correlation between the high level serum viscosity and the severity of Epo' s decrease level. The reevaluation of the serum erythropoietin concentration 21 days after serum viscosity stabilizing, indicated a constant increase of the serum Epo with 68% to 230% (referring to initial values), the average increase being 114%. Our conclusions of this stage are: the serum viscosity is involved in the Epo' s release regulation; the hyper-viscosity represents an inhibitory factor of the Epo' s release. EFICIENA TERAPIEI CU ERITROPOIETINA EPOETIN BETA N SINDROAMELE MIELODISPLAZICE (SMD) M. L.ABalea1, M. Guran1, R. Stanescu1, N. Cheta2 1. Spitalul Clinic Colentina, Bucureti, Romnia 2. Laboratorul Gral Medical, Spitalul Clinic Colentina, Bucureti, Romnia Terapia cu eritropoietin EPOETIN BETA/NEORECORMON n doza de 450 u/Kg corp/sptmn a fost

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administrat unui lot format din 20 subieci cu SMD: 8 subieci cu AR i ARS i 12 subieci cu AREB i AREB t. Terapia a fost asociat n toate tipurile de SMD la care rspunsul la celelalte mijloace terapeutice a fost minim sau nul. S-au obinut rezultate foarte bune cu echilibrarea hematologic complet numai n formele de AR i ARS de SMD: 75% din subiecii cu SMD/AR/ARS au prezentat remisiune hematologic complet i susinut iar 25% din subieci au prezentat un rspuns parial, ne mai necesitnd ns terapie de substituie. n formele agresive de SMD: AREB, AREB t s-a obinut un rspuns hematologic minim la 15 % din subieci cu scderea ritmului de administrare a terapiei de substituie. n concluzie putem afirma posibilitatea utilizrii cu succes a terapiei cu EPOETIN BETA la subiecii cu SMD/AR/ARS fr rspuns la celelalte mijloace terapeutice. THE EFFECTIVENESS OF ERYTHROPOIETIN MYELODYSPLASTIC SYNDROMES (MDS) M.L.ABalea1, M. Guran1, R Stanescu1, N. Cheta2 1 Colentina Clinical Hospital, Bucharest, Romania 2 Gral Medical Laboratory, Colentina Clinical Hospital, Bucharest, Romania Erythropoietin EPOETIN BETA/NEORECORMON dosed 450 U/kg/week was administrated to a lot of 20 subjects with MDS: 8 subjects with RA and RARS and 12 subjects with RAEB and RAEB-t. This therapy was associated to all subgroups of MDS that had minimal or not any response to other therapeutic means. Effective results with complete hematological improvement was achieve only in subgroups of RA and RARS: 75% of subjects with MDS-RA and MSD-RARS had complete and sustained hematological recovery and 25% of these had a partial response, but they no more in need of supportive therapy. In subjects with aggressive form of MDS RAEB and RAEB-t the hematological response was minimal in 15% of subjects, yet decreasing administration rate of supportive therapy. In conclusion, we can state the effectiveness of EPOETIN BETA in subjects with MDS RA and RARS without response to other therapy means. EFICIENAPLASMAFEREZEI N TERAPIAPTT M. L.ABalea1, C Siara1, C Bicu1, M. I. Balea2 1. Spitalul Clinic Colentina, Bucureti, Romnia 2. INP Prof. Dr. M Nasta, Bucureti, Romnia PTT reprezint o entitate n care diagnosticul n timp util este vital. Incidena sczuta i tabloul clinico-biologic polimorf ntrzie adesea diagnosticul. Triada: trombocitopenie exprimat sau nu prin purpur anemie hemolitic microangiopatic exprimat prin icter, prezena de schizocite i eritroblati n sngele periferic, LDH maximal, hemosiderinurie afectarea renal si neurologic reprezint cheia diagnosticului i permit iniierea terapiei n timp util. Inhibiia metal-enzimei ADAMTS 13 prin anticorpi sau deficiene ale acestei enzime induc realizarea de concentraii maximale de factor von Willebrand, explic eficiena maximal a plasmaferezei. 10 subieci dintru-un lot de 12 subieci: 3 de sex brbtesc, 9 de sex feminin, cu vrsta cuprins ntre 19 i 57 ani, la care am stabilit riguros diagnosticul de PTT i am exclus CID i sindromul hemolitic uremic, au efectuat terapia prin plasmaferez. Dintre factorii favorizani ai PTT am identificat: LED, prezena de Ac. APL, terapia cu ACO, infeciile recurente cu E Coli secundare unei prostatite cronice. S-au efectuat ntre 9 i 14 edine de plasmaferez cu epurarea 1 2.6 volume plasmatice (VP) n asociere cu perfuzii PPC, corticoterapie i antibioterapie. Remisiunea s-a obinut dup 7 -14 zile de la iniierea terapiei la 9 subieci (90%); un subiect prezentat tardiv a beneficiat de o singur edin de plasmaferez. Recdere a prezentat un singur subiect de sex brbtesc, la 7 luni de la primul episod, n contextul unei infecii urinare cu E Coli netratat (neglijat 3 sptmni). Subliniem c dac rspunsul la primul episod a necesitat epurarea a 1.9 VP i s-a instalat n ziua a 7-a de tratament, la recdere a necesitat epurarea a 2.4 VP i s-a instalat dup 14 zile de tratament. La acest subiect urmeaz s apreciem oportunitatea terapiei cu Rituximab. In concluzie: plasmafereza reprezint o terapie cu eficien maximal n condiiile unui diagnostic riguros stabilit n timp util. EPOIETIN BETA/NEORECORMON THERAPY IN

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THE EFFICIENCY OF PLASMAPHERESIS IN THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP) THERAPY M. L.ABalea1, C Siara1, C Bicu1, M. I. Balea2 1. Colentina Clinical Hospital, Bucharest, Romania 2. NIP Prof. Dr. Marius Nasta, Bucharest, Romania TTP is an entity where diagnosis is due time is essential. Low incidence and the polymorphous clinical and biological symptoms and signs often delay diagnosis. The triad consisting of thrombocytopenia (accompanied or not by purpura) microangiopathic haemolytic anaemia expressed by jaundice, presence of schistocytes and erythroblasts in the peripheral blood, high level LDH, hemosiderinuria renal and neurological involvement stands for the key to diagnosis and allow the initialization of a proper therapy in due time. The inhibition of ADAMTS-13 metalloprotease by antibodies against it or deficiencies of these enzymes induces the achieving of the maximum concentration of the Willebrand factor witch explains the efficiency of plasmapheresis. Ten adult subjects from a group of twelve (three males and nine females aged between 19 and 57 years) whom were rigorously TTP diagnosed (excluding DIC and the hemolytic-uremic syndrome), have been performed plasmapheresis therapy. Among the conditions that promote TTP we have identified SLE, antiphospholipid antibodies occurrence, oral contraceptives therapy, recurrent E. Coli infections secondary to chronic prostatitis. It have been performed nine to fourteen plasmapheresis by witch 1 2.6 plasma volumes (PV) have been purged in association with FFP (fresh frozen plasma) perfusions, corticotherapy and antibiotherapy. Remission was achieved 7 14 days after the therapy in nine subjects; one of the subjects who had asked for a medical examination belatedly was only once performed plasmapheresis. Relapse was only found in one subject male 7 months after the first episode under an untreated three weeks old urinary infection with E. Coli. We emphasize that if the response to the first episode needed purging of a 1.9 PV and it occurred an the sevenths day of treatment, at the relapse it needed purging of a 2.4 PV and occurred after 14 days of treatment. In this subject we shell consider whether a Rituximab therapy should by salutary. Conclusion: plasmapheresis is a maximum - efficiency therapy provided that diagnosis should be rigorously and in due time.

IMPLICAREA PROCESULUI DE OSCILAIE GENETIC N EPISOADELE DE REACTIVARE A BOLII LUPICE M. L.A. Balea1, M. I. Balea2 1. Spitalul Clinic Colentina, Bucureti, Romnia 2. INP Prof. Dr. M Nasta, Bucureti, Romnia Introducere: Pentru a explica evoluia recurent a neutropeniei ciclice, boala Hodgkin, boala gref contra gazd, bolile de colagen, am sugerat conceptual de oscilaie genetic pe care l-am definit ca reprezentnd exprimarea alternativ a genelor materne cu genele paterne, demonstrnd paternul concentraiei antigenelor de grup A i a celor de grup B pe

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suprafaa hematiei de grupAB, patern ce corespunde unei activiti alternative a genelor materne cu cele paterne. Scop: Prezentarea de noi argumente n favoarea ipotezei c expresia genelor materne i paterne nu este un proces simultan, fiind un proces caracterizat de exprimarea alternativ a genelor materne i a genelor paterne. Metod: n aceast etap a studiului din lotul subiecilor cu LED am selectat bolnavele prezentnd grupul sanguin AB. Am evaluat n dinamic la aceti subieci raportul ntre concentraia antigenelor de grup A i a antigenelor de grup B. Metodologia folosit a cercetat cantitatea de hematii de grup AB capabile s fixeze total Anticorpii din serurile anti A i anti B. Evalurile sau repetat la intervale de 3 luni i imediat ce subiecii prezentau recdere de boal. Rezultatele obinute ne-au indicat o modificare constant a raportului concentraiei de AgA i AgB pe suprafaa hematiei de grup AB cu inversarea acestuia fa de valorile anterioare, argument pe care l aducem n favoarea implicrii procesului de oscilaie genetic, prin declanarea de reacii tip gref contra gazd n reactivarea ondulatorie, recurent a bolii lupice. Concluzie: Considerm c aceasta susine ipoteza implicrii procesului de oscilaie genetic n evoluia recurent a LES, mecanismul patogen al reactivrii episodice a LES fiind, din punctul nostru de vedere, o reacie de tip gref contra gazd ntre celulele paterne i celulele materne.

THE INVOLVEMENT OF THE GENETIC OSCILLATION PROCESS IN THE REACTIVATION' EPISODES OF THE SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) M. L.A. Balea1, M. I. Balea2 1. Colentina Clinical Hospital, Bucharest, Romania 2. NIP Prof. Dr. Marius Nasta, Bucharest, Romania Background: To explain the recurrent evolution of cyclic neutropenia, Hodgkin' s disease, GVH disease, collagen disease we suggest the concept of genetic oscillation which refers to the intermittent expression of the genes inherited from maternal line in alternation with the expression of genes inherited from paternal line. We have argued this proving that the pattern of A and B group antigens' concentration on the surface of the AB group red blood cell this pattern corresponds to the alternative activity of the maternal and paternal genes. Aims: To achieve new argues that expression of maternal and paternal gene is not a simultaneous process but a process characterized by alternation of maternal gene expression and paternal gene expression. Methods: At this stage of our study we have selected the patients with AB blood group from the subjects with SLE. We have dynamically evaluated for these subjects the ratio between the group A antigen' s (AgA) concentration and the group B antigen' s (AgB) concentration (AgA/AgB) based on the amount of AB group red blood cells that were able to totally bond antibody from anti A and anti B serum. The evaluations of AgA/AgB ratio were repeated every 3 months and immediately after the subjects presented a recurrence of disease. The results we obtained showed a constant change of AgA/AgB ratio with reversal of this ratio up to previous values. We consider this to be favourable for the involvement of genetic oscillation process in oscillatory recurrent reactivation of lupus disease, due to the he commencement of starting of graft versus host reactions. Conclusion: This fact we consider to argue the hypothesis of the involving of genetic oscillation process in the recurrent evolution of SLE; from our point of view a graft versus host type reaction between the paternal cells and maternal cells is the pathogenic mechanism of episodically reactivation of SLE. >>>>>>>>>>>>>>>>>>>>>>>>>>>>> RSPUNSUL LA CICLOSPORIN I EPOETINA BETA NTR-UN CAZ DE ERITROBLASTOPENIE PUR COMPLICND EVOLUIAUNUI LMNH CU CELULAT. M. L.A. Balea1,A. Rzvan1, M Guran1, M. I. Balea2 1. Spitalul Clinic Colentina, Bucureti, Romnia 2. INP Prof. Dr. M Nasta, Bucureti, Romnia EBPP reprezint o complicaie redutabil a sindroamelor limfoproliferative: LLC, LMNH, BH. n acest context prezentm evoluia unui bolnav de sex brbtesc n vrsta de 32 ani cu dg. LMNH cu celula T stadiul III B,

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splenectomizat, n remisiune indus terapeutic (CHOP+Bleo) care dezvolt anemie cu reticulocitopenie sever progresiv mergnd pn la absena total a reticulocitelor i dispariia corpilor Howell Jolly . Mielograma efectuat n acest context confirm eritroblastopenie pur indicnd prezena de eritroblati gigani, dismorfici, vacuolai i un raport serie mieloblastic / serie eritroblastic de 25. Evaluarea CT toraco-mediastinal exclude timom; serologia ELISA-PV B19 i HTLV I este negativ iar imunograma indic hipogamaglobulinemie sever. Se iniiaz terapie cu EPOETIN Beta care induce eritropoeza cu reapariia reticulocitelor i a corpurilor Jolly dar procentul acestora nu depete 0,3%. n context se asociaz ciclosporina n doz de 800mg/zi administrate n dou prize (12mg/Kg corp/zi) n asociere cu prednison 40mg/zi. Evaluarea la 30 zile indic amorsarea eritropoezei cu creterea procentului de reticulocite la 7,5%: mielograma indic reapariia populaiei eritroblastice cu un raport serie Mieloblastic / serie Eritroblastic de 1,5. Efectul se menine, permind dup 8 sptmni reducerea progresiv a dozelor de ciclosporin. n concluzie putem afirma eficiena terapiei imunomodulatoare cu ciclosporin n tratamentul eritroblastopeniei pure complicnd evoluia LMNH THE RESPONSE TO CYCLOSPORINE AND EPOETIN-BETA IN A CASE OF PURE RED CELL APLASIA INVOLVINGAT-CELL NON-HODGKIN'S LYMPHOMA M. L.A. Balea1,A. Rzvan1, M Guran1, M. I. Balea2 1. Colentina Clinical Hospital, Bucharest, Romania 2. NIP Prof. Dr. Marius Nasta, Bucharest, Romania Pure red cell aplasia (PRCA) is a redoubtable complication of the lymphoproliferative disorders: CLL, NHL, and Hodgkin's disease. In this context we shall show the evolution of 32 - years old male - patient who had been diagnosed with T-cell NHL, stage III B, and underwent splenectomy, in therapeutically-induced remission (CHOP + Bleo), developing progressive severe-anemia with reticulocytopenia to the extent of total lack of reticulocytes and absence of the Howell Jolly bodies, associated with severe hypogammaglobulinemia. Bone marrow examination confirms PRCA, showing giant, atypical, vacuolar erythroblasts and a myeloblastic series / erythroblastic series ratio of 25. The thoracomediastinal CT scan evaluation excludes a thymoma, the ELISA - PV B19 and HTLV 1 is negative. An Epoetinbeta (NeoRecormon) therapy shall be initialized while will induce erythropoiesis with the reappearance of the reticulocytes and of the Howell Jolly bodies but the rate will not go beyond 0.3%. Contextually, Cyclosporine shall be associated 800 mg bd (12 mg /kg/day) together with 40 mg /day of Prednisone. An evaluation after 30 days shows an improvement of erythropoiesis with an increasing rate up to 7.5% in reticulocytes: the bone marrow examination shows the reappearance of erythroblast's population with a myeloblastic series / erythroblastic series ratio of 1.5. The effect shall be kept, allowing 8 weeks afterwards the progressive reduction of the Cyclosporine doses. As a conclusion, we can state that the immunomodulating Cyclosporine therapy in the treatment of PRCA involving the NHL is efficient.

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>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>. STUDIUL EFICIENEI ERITROPOIETINEI VERSUS TERAPIA CLASIC N TRATAMENTUL ANEMIILOR ASOCIATE HEMOPATIILOR MALIGNE. M. L.A. Balea1, M Guran1, M. I. Balea2, L Mihlcescu1 1. Spitalul Clinic Colentina, Bucureti, Romnia 2. INP Prof. Dr. M Nasta, Bucureti, Romnia Anemia asociat hemopatiilor maligne reprezint un factor major de disconfort i ridic probleme dificile de tratament. Eficiena ipotetic a eritropoietinei s-a dovedit real, modalitatea optim de aplicare a acestei terapii, raportul beneficiu/cost, efectele tardive reprezint nc ntrebri care i ateapt rspunsul. Administrarea terapiei cu Epoetin beta / NeoRecormon unui lor reprezentat de 33 subieci cu hemopatii maligne la care sindromul anemic evolua de > 6 luni neinfluenat de mijloacele terapeutice clasice (dificulti n procurarea Epoetin beta n cantitate suficient) ne-a permis s evaluam obiectiv eficiena acestei terapii. Lotul cercetat este reprezentat de 33 subieci cu vrsta cuprins ntre 23 i 82 ani; 21 (61%) subieci de sex masculin i 12 (39%) subieci de sex feminin; 12 subieci cu MM, 7 subieci cu LMNH, 7 subieci cu LLC, 3 subieci cu B. Waldenstrom, 4 subieci cu SMD-ARS. Valorile hemoglobinei la iniierea terapiei cu Epoetin beta au variat ntre 6 i 10,5 g% cu o medie de 9,2 g%. Dozele de Epoetin beta/ NeoRecormon administrate au fost de 450/Kg corp/ sptmn; dup fiecare doza de Epoetin beta am administrat dou doze de fier peroral sau 1 doz de fier parenteral. Evaluarea rspunsului s-a efectuat la 30-45 zile, interval dup care am constatat un rspuns favorabil la 30 subieci (90%), obiectivat prin creteri ale hemoglobinei cu 1,2 3g%, cu o cretere medie de 1,8g% (valoarea medie atins 11 g%). Rspunsul a fost minim la 2 subieci cu SMD ARS i la un subiect cu BW, subieci la care s-a obinut doar scderea necesarului de transfuzii. Subliniem rspunsul foarte bun la 2 din cei 4 subieci cu SMDARS. Nici unul dintre subiecii tratai nu a necesitat ntreruperea terapiei, nu a prezentat efecte adverse semnificative; rspunsul s-a meninut i n urmtoarele 6 luni de monitorizare, permind distanarea intervalului de administrare la 10 respectiv 20 zile i n final, la sistarea terapiei, urmnd ca aceasta s fie reluat la nevoie. n concluzie: putem afirma c eritropoietina sub forma preparatului Epoetin beta reprezint o terapie cu eficient dovedit n tratamentul anemiei ce nsoete hemopatiile maligne cronice. THE STUDY OF ERYTHROPOIETIN EFFICIENCY VERSUS CLASSICAL THERAPY IN THE TREATMENT OFANEMIAASSOCIATED TO MALIGNANT HEMOPATHY M. L.A. Balea1, M Guran1, M. I. Balea2, L Mihlcescu1 1. Colentina Clinical Hospital, Bucharest, Romania 2. NIP Prof. Dr. Marius Nasta, Bucharest, Romania The anemia associated to malignant hemopathy is a major cause of discomfort and involves treatment difficulties. The hypothetical efficiency of Erythropoietin has been proved but the optimal scheme of therapy, the cost-benefit ratio, late effects of this therapy remained unsolved. The administration of Epoetin beta (NeoRecormon) on a group of 33 subjects showing malignant hemopathy in while the anemic syndrome had been developing for more than 6 month without being influenced by the classical therapeutic means (difficulties in securing a sufficient amount of Epoetin beta) has allowed us to make an objective evaluation of this therapy. The investigated group consists of 33 aged between 23 to 82 years old; 21 (64%) male subjects and 12 (36%) female subjects; 12 (36%) multiple myeloma affected subjects, 7 (21%) NHL affected subjects, 7 (21%) CLL affected subjects, 3 (10%) Waldenstrom disease affected subjects and 4 (12%) MDS-RARS affected subjects. The hemoglobin level at the beginning of Epoetin beta therapy included values from 6 g to 10.5 g%, the average value being 9.2 g%. The Epoetin beta doses administrated have been of 450 U/Kg/week; after each dose of Epoetin beta we have administrated two doses of oral ferrum or one dose of parenteral ferrum. The evaluation of the response was made 30-45 days later and it showed a favorable response in 30 subjects (90%) due to an increase in the hemoglobin of 1.2-3g %, the average increasing being 1.8 g% (the average value reached 11 g%). The response was minimal in two MDSRARS affected subjects and in one Waldenstrom disease affected subject, subjects in witch only a decrease of the

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transfusions needed was achieved. The optimum response in two of the four MDS-RARS affected subjects is noticeable. To none of subjects under treatment was an interruption of the treatment needed as no important adverse effects had been shown. The response was unchanged for 6 months of follow up, which therefore allowed enlarging the administration interval to 10 and, respectively, 20 days and finally brought to an interruption of the therapy, while was to be resumed if needed at later date. Conclusion: we can state that the erythropoietin administered as Epoetin beta is an efficiency-proved therapy in the treatment of anemia as associated to chronic malignant hemopathy. >>>>>>>>>>>>>>>>>>>>>>>>>>> PUSEELE BLASTICEALE MIELOPRILIFERRILOR CRONICE Ph NEGATIVE A.Parvu,A. Vasilache,A. Bojan,A. Cucuianu, L. Urian, T. Torok, M. Patiu, C. Basarab, C. Coldea, L. Petrov -U.M.F.Iuliu Hatieganu Cluj-Napoca -Institutul Oncologic Ioan Chiricuta Cluj-Napoca Crizele blastice ale metaplaziei mieloide cu mielofibroz (MMM), policitemiei vera (PV) i trombocitemiei eseniale (TE) sunt mai putin frecvente decat ale leucemiei granulocitare cornice (LGC), n cazul acestor boli decesele aprnd in general din alte cauze. Am studiat pacienii cu MMM, PV, TE acutizate , internai n secia Hematologie Cluj intr-o perioada de 24 de ani. Au existat 20 de cazuri (13 MMM, 4 PV, 3 TE). Vrsta medie a pacienilor a fost de 53 de ani ( extremele: 25-68 ani).Intervalul de la luarea n eviden a pacienilor pn la acutizare a fost n medie de 28,6 luni ( cu extremele ntre 272 luni). Acutizrile au fost de linie mieloblastic, diagnosticul fiind stabilit citologic. Tratamentul a fost n cele mai multe cazuri (14) chimioterapic i n 6 cazuri paleativ ( simptomatic, substitutiv). Tratamentul citostatic a constat n scheme de polichimioterapie ( Hidroxiuree n doz mare+Ara-C, Etoposide+ Thioguanin+ Idarubicin, Ara-C+ o antraciclin) sau monochimioterapie cu Hidroxiuree. Evoluia a fost nefavorabil n majoritatea cazurilor. A existat un singur pacient care a reintrat n faza cronic ( un caz de MMM), dar dup un an a suferit o alt criza blastica. Supravieuirea a fost n medie de 6 luni pentru ntreg lotul de pacieni , 5,5 luni pentru MMM, 10 luni pentru PV, 3,5 luni pentru TE. n concluzie, acutizrile sindroamelor mieloproliferative cornice Philadelphia negative sunt mai rar ntlnite decat ale LGC, evoluia lor fiind nefavorabil, iar supravieuirea din momentul acutizrii fiind foarte scurt (6 luni). BLASTIC PHASES OF PHILADELPHIANEGATIVE MYELOPROLIFERATIVE DISORDERS A.Parvu,A. Vasilache,A. Bojan,A. Cucuianu, L. Urian, T. Torok, M. Patiu, C. Basarab, C. Coldea, L. Petrov -Iuliu Hatieganu University Cluj-Napoca - Ioan Chiricuta Oncological Institute Cluj-Napoca The blastic phase of Polycythemia Vera (PV), Essential Thrombocythemia (ET) and Myelofibrosis with Myeloid Metaplasia (MMM) is less frequent than blastic phase of Chronic Myeloid Leukemia ( CML). In case of CML death occurs usually after blastic phase. The pacients suffering of PV, ET or MMM die of different causes. We studied the pacients going through the blastic phase of PV, ET and MMM treated in our department between 1980-2004. There were 20 cases (13 MMM, 4 PV, 3 ET). The age range was between 25 to 68, the average being 53. The period between diagnosis and blastic phase was on an average 28,6 months with the extremes between 2 and 72 months. The blastic phase was myeloid in all cases and the diagnosis was based on citology. In the most cases (14) the treatment was chemotherapy. In 6 cases the treatment was palleative ( blood transfusions, symptomatic treatment). We administrated polichemotherapy (high doses Hidroxyurea + Ara-C, Thioguanina + Etoposide + Idarubicine, Ara-C + Farmorubicine) or monochemotherapy (Hydroxyurea ). The evolution was unfavorable in most cases. There was a single pacient who reentered the chronic phase. Unfortunately, after a year he relapsed. The survival rate vas an average of 6 months for all the pacients, 5,5 months for blastic phase of MMM, 10 months for blastic phase of PV, 3,5 months for blastic phase of ET. As a conclusion, blastic phase of myeloproliferative disorders ( others than CML) are less frequent, the prognosis in infaust and the survival rate of the pacients in blastic phase is low, 6 month on average.

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>>>>>>>>>>>>>>>>>>>>>>> SINDROMUL MIELODISPLAZIC SECUNDAR TERAPIEI CU IMATINIB (GLIVEC) THE MYELODYSPLASTIC SYNDROME SECONDARYTO IMATINIB THERAPY(GLIVEC) Denisa Bratu Clinica de Hematologie, Institutul Clinic Fundeni, Bucuresti Lucrarea i propune efectuarea unui studiu retrospectiv avnd ca subiect aprecierea dezvoltrii sindromului mielodisplazic ca maladie secundar terapiei cu Imatinib la pacienii internai n Clinica de Hematologie a Spitalului Clinic Fundeni. Se urmresc parametrii de laborator, apariia primelor semne de displazie(frotiu de snge periferic, aspirat medular, biopsia medular), tipul de mielodisplazie (dup noile clasificri, dac este cazul), evoluia pn n prezent (corelare statistic doz, durat,). S-au luat n studiu 110 pacieni(cei cu fiele de tratament n eviden la data efecturii aprilie-iunie 2007). Majoritatea fiind tratai anterior i asociat, semnele de displazie s-au amplificat n urma tratamentului cu Glivec far a se evidenia apariia unor subclone mielodisplazice. Nu exist o corelaie statistic ntre doz, durata tratamentului i modificrile displazice urmrite. Lucrarea se ncadreaz ntr-un proiect mai larg de cercetare a acestei maladii pe teritoriul rii noastre. Cuvinte cheie: terapie, Imatinib, sindrom mielodisplazic Abstract The paper purpose to evidence a study, have as subject the development of myelodysplastic syndrome secondary to Imatinib therapy to the patients hospitalized in the Clinic of Haematology Fundeni Clinical Institute.We study the laboratory parameters,the first signs of myelodysplasy (blood sample ,bone marrow aspirate and biopsy),the type of myelodysplasy(in the new classification if the syndrome exist), the evolution until present( statistic correlation) .We studied 110 patients (with treatment evidence april- june 2007).Most are treat before and associated ,so the signs of dysplasia are amplified after Glivec without evidence a clone .A statistic correlation ( dose, length, the dysplastic morphological features) was not validate. The study belong to a larger project of research in this disease in our country. Key words: therapy, Imatinib, Myelodysplastic Syndrome <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<

O VARIANTANEOBISNUITA ASINDROMULUI RICHTER: LIMFOMUL HODGKIN Laura Urian Institutul Oncologic Ion Chiricuta Cluj Napoca, Clinica de Hematologie In general termenul de sindrom Richter se refera la limfomul non Hodgkin difuz cu celule mari, agresiv care apare ca modalitate evolutiva particulara la 3-10% din pacientii cu leucemie limfatica cronica cu celule B. In ultima decada s-a descris insa o varianta mai rara a sindromului Richter: limfomul Hodgkin. De regula aceste cazuri se prezinta in stadiiAnnArbor avansate si raspund slab la tratament. Pacientul K.S. de 55 ani este diagnosticat cu leucemie limfatica cronica cu celule B in ianuarie 1998. Clinic prezinta adenopatii generalizate de 2-4 cm si hepatosplenomegalie, iar hematologic: leucocitoza (13000/i) cu 95% limfocite in tabloul sangvin, trombocitopenie. Urmeaza tratament intermitent cu leukeran. Din septembrie 2001 bolnavul acuza transpiratii nocturne profuze, hepatosplenomegalia se accentueaza si apar mase ganglionare abdominale. In iunie 2002 se prectica o biopsie ganglionare axilara, aspectul histologic fiind leucemie limfatica cronica. Persista semnele generale, motiv pentru care, se rebiopsiaza un ganglion supraclavicular stang. Examenul histopatologic completat cu imunohistochimie stabilesc diagnosticul de limfom Hodgkin tip predominanta limfocitara. Se institue polichimioterapia (VCAEP), fara raspuns dupa 3 cicluri PCT. Bolnavul decedeaza dupa 6 luni de la stabilirea diagnosticului cu septicemie, insuficienta hepato-renala. Cazul prezentat este printre putinele cazuri de limfom Hodgkin ca varianta a sindromului Richter. Evolutia cu semne generale si lipsa de raspuns la tratament citostatic reprezinta particularitatile acestor modalitati evolutive a leucemiei limfatice cronica. UNUSUALALTERNATIVE OF RICHTER SYNDROME: HODGKIN LYMPHOMA Laura Urian Hematology Department, Oncologycal Institute Cluj-Napoca

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Generaly the term of Richter Syndrome (RS) concerns a non Hodgkin lymphoma with large cells, agresive which appears as particulary evolution in 3-10% patiens with chronic lymphocytic leukaemia (CLL) with B cells. As a general rule, these cases appear asAnnArbor advanced stages with a poor treatment response. A 55 year old K.S. patient which diagnosis of CLL with B cells was established on January 1998 clinical appears to have generalized enlarged lymphadenopathy of 2-4 cm and hepatosplenomegaly and haematologicaly: leucocytosis (13.000/l) with 95% lymphocytes trombocytopenia. It fallows an intermittent treatment with leukeran. Since September 2001 the patient complains heavy perspiration during night, hepatosplenomegaly is more evident and appear abdomilal lymphadenopaty. In June 2002 as a result of axillar lymph node biopsy a CLL as established. All these general aspects it is a motive to a new biopsy of left cervical lymph node. After hystopathological examination and immunohystochemystry establish the diagnosis of Hodgkin lymphoma of lymphocitary predominant type. Apolichemioterapy (VCAEP) is instituted but without results after 3 cycles. After 6 months since the diagnosis was established the the patient dies of septicemy, hepato renal failure. It is a Hodgkin lymphoma as a seldome alternative of Richter syndrome. This evolution with it's general marks and lack of response of chemotherapy represents the particulary progressive evolution of chronic lymphocytic leukemia. >>>>>>>>>>>>>>> CARACTERISTICI CLINICO-BIOLOGICE, EVOLUTIVE SI DE PROGNOSTIC ALE HEMOPATIILOR MALIGNE FAMILIALE EXPERIENTACLINICII DE HEMATOLOGIE COLTEA O.CIOCAN*, A.CIOBANU**, M.CLOSCA**, I.CARAUSU**, C.SAGUNA*, C.MIHAI**, E.COLES**, A.LUPU* * UMF Carol Davila Bucureti Clinica de Hematologie, Spital Clinic Colea, Bucureti, Romnia **Clinica De Hematologie Coltea, Bucuresti, Romania INTRODUCERE: In etiopatogenia hemopatiilor maligne sunt implicati atit factori interni ai gazdei, cit si factori externi ambientali ce pot sa induca modificari in raspunsul imun. Factorii implicati in carcinogeneza si mecanismele responsabile de anomaliile genetice nu sunt inca pe deplin cunoscuti. Se considera insa ca exista o serie de factori etiopatogenici asociati cu un risc crescut de aparitie a hemopatiilor maligne: deficite imune congenitale, deficite immune dobindite(transplant de organe, infectia HIV-SIDA), bolile autoimune(sindrom Sjogren, artrita reumatoida); infectii virale ( virusul Ebstein Bar, HTLV I, virusul hepatitic C), expunerea la toxice( pesticide, vopsele, solventi), medicamente ( terapie imunosupresiva, metotrexatul, AINS, steroizi, estrogeni), istoric familial de neoplazie sau hemopatie maligna (riscul este mai mare la cei cu antecedente heredo-colaterale de afectiuni hematologice maligne), infectii cronice, etc. MATERIAL SI METODE: Bazindu-ne pe datele existente in literatura despre existenta agregarilor familiale de hemopatii maligne familiale vom prezenta din cazuistica pe 5 ani a Clinicii de Hematologie Coltea 4 cazuri de pacienti inruditi cu hemopatii maligne.Trei din cazuri sunt limfoame maligne nonhodgkiniene aparute la rude de gradul I ( parinte/copil, frate/frate) si un caz de mielom multiplu aparut intr-o familie ( sot/sotie). REZULTATE:Scopul acestui studiu a constat in urmarirea pe de o parte a factorilor declansatori (existenta unor deficite immune, prezenta unor infectii virale, expunerea la toxice) precum si a caracteristicilor clinicobiologice, evolutive si de prognostic. CONCLUZII: Hemopatiile maligne familiale sunt rare, aparitia lor nu poate fi asociata cu un anumit factor de risc, agregarea lor fiind pur intamplatoare in cazurile prezentate.

CLINICAL AND BIOLOGICAL CHARACTERISTICS RELATED TO THE EVOLUTION AND PROGNOSIS OF MALIGNANT FAMILY HEMATOLOGIC DISEAES EXPERIENCE OF COLTEAHEMATOLOGY CLINIC O.CIOCAN*, A.CIOBANU**, M.CLOSCA**, I.CARAUSU**, C.SAGUNA*, C.MIHAI*, E.COLES**,A.LUPU* * University of Medicine Carol Davila Clinic of Hematology, Coltea Clinic Hospital, Bucharest, Romania **Coltea Hematology Clinic, Bucharest, Romania

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INTRODUCTION: The etiopathogenic study of malignant hemopathies implicates internal factors of the host as well as external factors of the environment that can modify the immune reaction. The factors implicated in the carcinoma genesis and the mechanisms responsible for the genetic anomalies are not yet very well known. Even so, some of the etiopathogenic are associated with a more frequent apparition of the malignant hematological diseases: congenital immune deficits and acquired immune deficits immunodeficiency - (organ transplant, HIV-AIDS), autoimmune diseases (Sjogren syndrome, rheumatoid arthritis); viral infections (Ebstein Bar virus, HTLV, Helicobacter pylori, hepatitis virus C), exposure to toxics( pesticides, paints, solvents), medication (immunosuppressive therapy, metotrexatul,AINS), family history of neoplazic disease or malignant blood disease, chronic infections. MATHERIAL AND METHODS: Considering the already existing literary date regarding the existence of family associations of malignant blood diseases, we will present 4 cases of malignant family blood diseases, out of the 5-year history of Coltea Hematology Clinic.Three of the cases are non Hodgkin malignant lymphoma, on first degree relatives (parent/son, brother/brother) and one case is a multiple myeloma in a family (husband/wife). RESULTS: The purpose f this study is the observation of initiating factors (the existence of immune deficits, the presence of viral infections, and exposure to toxics) as well as of clinical and biological characteristics related to the evolution and prognosis. CONCLUSIONS: Family malignant blood diseases are rare, and their apparition can not be associates with a certain risk factor, their unit is accidental in this cases. >>>>>>>>>>>>>>>>>>>>>>>>>>>> LIMFOMUL LIMFOCITIC DIFUZ ASOCIEREA CU VIRUSUL HEPATITIC B, PARTICULARITATI DE RASPUNS LATRATAMENT, EVOLUTIE (PREZENTARE DE CAZ) A.LUPU*, O.CIOCAN*,A.CIOBANU**, M.CLOSCA**, I.CARAUSU**, C.SAGUNA*, C.MIHAI** * UMF Carol Davila Bucureti Clinica de Hematologie, Spital Clinic Colea, Bucureti, Romnia **Clinica De Hematologie Coltea, Bucuresti, Romania INTRODUCERE: Limfoamele maligne non-Hodgkiniene sunt tumori ale sistemului celular al imunitatii, neoplazii cu aspecte histopatologice, trasaturi clinice, evolutive, de prognostic si agresivitate foarte variate.Implicarea unor virusuri ocogene in etiopatogenia acestor hemoaptii maligne a fost evidentiata de multe studii.Cercetarile efectuate au evidentiat limfotropismul virusului hepatitic C pentru celule mononucleare.Nu se cunoaste inca rolul virusului hepatitic B in limfogeneza si modul in care influenteaza prognosticul. MATERIAL SI METODE: Vom prezenta cazul unui pacient in virsta de 55 ani diagnosticat in 2004 in Clinica de Hematologie Coltea cu limfom malign nonhodgkin limfocitic difuz- diagnostic confirmat pe baza examenului histopatologic si imunohistochimic al unui ganglion biopsiat.Boala s-a dovedit a fi refractara la chimioterapie cu persistenta sindromului tumoral si, in evolutie, a prezentat un puseu citolitic ocazie cu care s-a depistat si prezenta virusului hepatitic B - asociat in aceeasi perioada si cu o zona zoster. REZULTATE: Imunodepresia generata de boala in sine si de tratamentul specific, la care s-au adaugat infectiile virale si activitatea biologica a hepatitei cu virus B au impus modularea regimurilor terapeutice incercate pentru oprirea progresiei bolii, o alta particularitate in acest caz fiind si reactia alergica la anticorpi monoclonali (rituximab si alemtuzumab). CONCLUZII: Ramine de cercetat daca infectia cu virusul hepatitic B are un rol in etiopatogenia limfoamelor cu celula B, precum si daca afecteaza expresia clinica, evolutia si prognosticul acestor hemopatii maligne. THE DIFFUSE LYMPHOCITE LYMHPOMA ASSOCIATION WITH B HEPATITIS CHARACTERISTICS TO TREATMENT, EVOLUTION (CASE PRESENTATION) VIRUS, RESPONSE

A.LUPU*, O.CIOCAN*,A.CIOBANU**, M.CLOSCA**, I.CARAUSU**, C.SAGUNA*, C.MIHAI** * University of Medicine Carol Davila Clinic of Hematology, Coltea Clinic Hospital, Bucharest, Romania **Coltea Hematology Clinic, Bucharest, Romania

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INTRODUCTION: The malignant non-Hodgkin lymphoma are tumors of the immunity of the cell system, malignity with histopathology aspects, with different clinic, evolution, prognosis and agressivity. Several studies have underlined the implication of cancer viruses in the etiopathogeny of the malignant blood diseases. Research has underlined the lympho tropism of the C hepatic virus for the mononucleal cells. The role of the hepatic B virus in the lympho genesis and the influence on the prognosis is not yet determined. MATHERIAL AND METHODS: We shall present the case of a 55-year old patient, diagnosed in 2004 in Coltea Hematology Clinic with non Hodgkin malignant lymphocyte diffuse lymphoma - diagnosis confirmed by the histopathology and immune histo chemical exam of a biopsy ganglion. The disease did not respond to chemo therapy and the tumor syndrome persisted; in evolution, the patient had a citolitic crisis which permitted the identification of B hepatitis virus, associated with zone zoster. RESULTATSE: The immune depression generated by the disease and by the relevant treatment and the virus infections and biological activity of the B hepatitis virus has determined the nature of the therapy regimes for stopping the disease, which is also associated in this particular case with an allergic reaction to monoclonal antibodies (rituximab and alemtuzumab). CONCLUSIONS: The role of the B hepatitis virus in the etio pathogeny of B cell lymphomas, its influence on the clinical expression, evolution and prognosis of these malignant blood diseases is yet to be determined. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> RATA RASPUNSULUI CITOGENETIC SUB TRATAMENTUL CU IMATINIB MESILAT IN FAZA CRONICA TARDIVAALEUCEMIEI MIELOIDE CRONICE A.P. Rosca*,A.C. Colita**, C.Arion**, D. Coriu**,A.D. Moicean**, R. Niculescu**, I.Ursuleac**, E. Niculescu-Mizil**, R. Stoia**, D. Ostroveanu**, D. Iancu** * Doctorand U.M.F. Carol DavilaBucuresti PDR Brasov ** Centrul de Hematologie si Transplant Medular St. Berceanu-Institutul Clinic Fundeni Bucuresti Obiectivul terapiei tintite cu imatinib mesilat in leucemia mieloida cronica este de a induce raspunsuri citogenetice si moleculare complete, ceea ce contribuie la imbunatatirea supravietuirii libere de boala. Prezentam rezultatele studiului retrospectiv efectuat in perioada 1.01.2001-1.06.2007 pe un lot de 55 pacienti cu leucemie mieloida cronica-faza cronica tardiva. Criteriile de includere in studiu sunt : pacientii ce au efectuat minim 12 luni alte modele terapeutice( hydreea, interferon, cytosar) pina la inceperea tratamentului cu imatinib si la care s-au efectuat minim 2 examene citogenetice la interval de cel putin 6 luni. Lotul de 55 pacienti este alcatuit din 27 barbati cu virsta medie de 49,63 ani si 28 femei cu virsta medie de 49,75 ani. Durata medie de la diagnostic si pina la inceperea tratamentului cu imatinib a fost de 51 luni (minim 12 luni, maxim 146 luni).Sub tratamentul standard cu imatinib 400 mg/zi, rata raspunsului citogenetic la 12 luni a fost : 48,1%RCM, 48,1% RCm si 3,8%RCC. Cresterea dozei de imatinib la 600 mg/zi la 20 pacienti a imbunatatit RCC la 24 luni la 18%.Corelatia raspuns citogenetic-risc relativ Hasford a evidentiat ca majoritatea pacientilor ce au atins RCM(52,8%) se aflau in grupa de risc intermediar. In concluzie, initierea terapiei cu imatinib mesilat chiar in faza cronica tardiva a leucemiei mieloide cronice induce raspunsuri citogenetice, iar stratificarea pacientilor pe grupe de risc relativ si monitorizarea periodica prin studiu citogenetic si RT-PCR permite optimizarea raspunsului terapeutic.

THE CYTOGENETIC RESPONSE AT PATIENTS WITH CHRONIC PHASE CHRONIC MYELOID LEUKEMIA TREATED WITH IMATINIB MESYLATE A.P.Rosca*,A.C.Colita**, C.Arion**, D.Coriu**,A.D.Moicean**, R.Niculescu** I.Ursuleac**, E.Niculescu-Mizil**, R.Stoia**, D.Ostroveanu**, D.Iancu** * Doctoral training U.M.F. CAROL DAVILA Bucuresti PDR Brasov ** Center of Hematology and Bone Marrow Transplantation St. Berceanu-Fundeni Clinical Institute Bucharest

The purpose of the therapy with imatinib mesylate in the chronic myeloid leukaemia is to provoke full cytogenetic and molecular responses, fact that contributes to the development of the free of illness survival.

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We are presenting the results of the retrospective study made during 1.01.2001 -1.06.2007 on a lot of 55 patients with chronic myeloid leukaemia late chronic phase. The criteria to get included in the study are: patients who passed for minimum 12 months other therapy methods (hydreea, interferon, cytosar) until beginning the treatment with imatinib and who did not made at least 2 cytogenetic exams in an interval of at least 6 months. The lot of 55 patients comprises 27 men with an average age of 49,63 years and 28 women with an average age of 49,75 years. The average period from diagnosis until beginning the treatment with imatinib was of 51 months (minimum 12 months, maximum 146 months). With the standard treatment with 400 mg/day of imatinib, the cytogenetic response at 12 months was : 48,1%RCM, 48,1% RCm and 3,8%RCC. Increasing the imatinib dose to 600 mg/day, in the case of 20 patients it improved the RCC in 24 months at 18%. The correlation cytogenetic response relative risk Hasford has marked out that the majority of the patients that reached RCM (52,8%) were in the group of intermediary risk. Conclusively, the beginning of therapy with imatinib mesylate from the late chronic phase of myeloid leukaemia leads to cytogenetic responses, and grouping the patients on relative risk levels and periodical monitoring by cytogenetic study and RT-PCR allows the optimization of therapy response. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> CORELATIA FACTORI DE PROGNOSTIC CRONICA SUPRAVIETUIRE GLOBALA IN LEUCEMIA MIELOIDA

A.P.Rosca**, E.Gheroghita*, G.Vulcan*, C.Paripas*, R.Pirau*, R.Birsasteanu* * Spitalul Clinic Judetean de Urgenta Brasov- Sectia Hematologie **Policlinica de Diagnostic Rapid Brasov Estimarea supravietuirii pacientilor cu leucemie mieloida cronica(LMC) se poate realiza prin aplicarea sistemelor de scor prognostic Sokal si Hasford. Prezentam rezultatele studiului retrospectiv efectuat in perioada 1 ian.1997 1 iunie2007, pe un lot de 49 pacienti cu virsta medie de 55 ani. Lotul este reprezentat de 24 femei cu virsta medie de 55,6 ani si 25 barbati cu virsta medie de 54,4 ani.Perioada medie de urmarire a fost de 38,7 luni(minim 5 luni, maxim 138 luni), cu precizarea ca la momentul actual 27 pacienti sunt in viata. Aplicind scorul Sokal s-au obtinut cele 3 grupe de risc relativ(RR): 12,24% crescut, 53,05% intermediar si 34,7% scazut, fara diferente intre virstele medii ale celor cu RR crescut si RR intemediar(67,3 ani, respectiv 63,6 ani), insa semnificativ statistic scazuta la cei cu RR scazut(37,5 ani). S-au consemnat 22 decese(44,9%) care au avut o perioada medie de urmarire de 34,3 luni, iar 27 pacienti(55,1%) erau in viata la inchiderea studiului, avind o rerioada medie de urmarire de 42,26 luni. Supravietuirea la 48 luni a lotului studiat a fost de 28,4%, dintre care 4,1% RR crescut, 12,2% RR intermediar si 12,2% RR scazut. In concluzie, supravietuirea pacientilor cu LMC este influientata de factorii de prognostic, dar si de terapia efectuata, in lotul studiat 51,02% pacienti beneficiind de tratament cu interferon si doar 10,2% cu imatinib mesilat, in ambele situatii ca terapie de linia a doua. CORRRELATION OF PROGNOSIS FACTORS LEUKEMIA GLOBAL SURVIVAL LEVEL IN CHRONIC MIELOID

A.P.Rosca**, E.Gheroghita*, G.Vulcan*, C.Paripas*, R.Pirau*, R.Birsasteanu* * County Emergency Clinic Hospital Brasov- Hematology Department ** Policlinic of Fast Diagnosis Brasov The forecast of survival of patients with chronical mieloid leukemia (LMC) can be made by applying the systems of prognosis score Sokal and Hasford. We are presenting the results of the retrospective study performed in the period January, 1, 1997 June, 1, 2007, on a group of 49 patients with average age of 55 years. The lot is represented by 24 women with average age of 55.6 years and 25 men with average age of 54.4 years. The average follow-up period is of 38.7 months (minimum 5 months, maximum 138 months), mentioning that at the moment 27 patients are alive. Applying the Sokal score we obtained 3 relative risk groups (RR) : 12,24% increased, 53,05% intermediary and 34,7% low , without differences between the average ages of the patients with increased RR and intermediary RR (67,3 years, respectively 63,6 years), but

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significantly low from a statistical point of view at the patients with low RR (37,5 years). 22 deaths were registered (44,9%) which had an average follow-up period of 34,3 months, while 27 patients (55,1%) were alive when ending the study, having an average follow-up period of 42,26 months. The survival percentage at 48 months of the studied group was of 28,4%, wherefrom 4,1% with increased RR, 12,2% with intermediary RR and 12,2% with low RR. Conclusively, the survival of patients with LMC is influenced by prognosis factors, but also by the therapy used, in the studied lot 51,02% patients receiving treatment with interferon and only 10,2% with imatinib mesyilate, both situations with therapy on second line. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> DEFICIENTASEVERADE FVIIAL COAGULARII IMPLICATII DIAGNOSTICE SI TERAPEUTICE Andrei Colita,Anca Lupu, SimonaAvram, Iosefina Rusu,Ana Maria Ivanescu, Madalina Vasile, Delia Mut Popescu Spitalul Clinic Coltea Bucuresti Prezentam cazul unui barbat tanar de 36 de ani, cu diagnosticul de Deficienta severa de FVII al coagularii care pana la varsta de 33 ani nu a prezentat istoric de sangerari desi si-a indeplinit serviciul militar intr-o unitate de parasutisti si suferit multiple traumatisme fracturi costale multiple. Istoric Pacientul s-a prezentat pentru prima data in srviciul nostru in urma cu 3 ani pentru anemie ferpriva de cauza necunoscuta. La aceea data s-a decelat a prelungire a timpilor cogularii PT> 60 sec, iar investigatiile suplimentare au aratat deficit de FVII nivel de 20%, si nivel normal al altor factori ai coagularii. Pacientul a fost pierdut din evidenta din evidenta pana in aprilie 2007 cand a revenit in serviciul nostru cu anemie feripriva severa si epistaxis repetat. Evaluarea coagularii a aratat alterarea suplimentara a timpilor coagularii cu PT 128 sec si scaderea semnidicativa a nivelurilor de FVII la 5,6%. Evaluare functiei heaptice a fost normala, nu s-a decelat nici o infectie virala hepatica. La momentul respectiv am luat in calcul o deficienta dobandita de F VII probabil prin mecanism autoimun. In acest sens au fost efectuate teste de amestec cu plasma normala care au exclus prezenta de inhibitori ai FVII. De asemenea, lipsa de raspuns la tratament imunosupresiv (corticoizi) a fost un alt argument pentru excluderea patogeniei autoimune. Pacientul a primit mai multe administrari de concentrat de FVII (NovoSeven) in conditiile unor sangerari nazale de intensitate medie. Particularitatea o constituie instalarea unei deficiente cu severitate progresiva de FVII in lipsa unei patologii heaptice sau a unor mecanisme autoimune. CASE OF SEVERE COAGULATION FVII DEFICIENCY DIAGNOSTICAND THERAPEUTIC ISSUES Andrei Colita,Anca Lupu, SimonaAvram, Iosefina Rusu,Ana Maria Ivanescu, Madalina Vasile, Delia Mut Popescu Coltea Clinical Hospital - Bucharest Case report of a male patient , 36 years old. Until the age of 33 the patient had no major bleeding events although he performed his medical service in an airborne unit and he had several traumas multiple costal fractures. Diagnosis: Factor VII deficiency Medical history the patient was first reffered to our unit 3 years ago for severe iron deficirent anemia (of unknown origin). At the time coagulation tests reveled prolonged PT (>60sec); further evaluation of coagulation showed a 20% level of F VII, with normal levels for other factors tested (F VIII, F X). The patient was lost from medical follow-up until recently when he was again reffered to our service with moderate iron deficient anemia and reccurent nasal bleeding. Coagulation showed prolonged PT of 128 sec and a second dosage revealed a level of 5,6% of F VII . Evaluation of liver function was normal, no viral hepathitic infection was revealed. At that time point we considered that a further evalution of the mechanisms of F VII deficiency (autoimmune) is indicated. To explore this hypothesis simple test of mixture study with addition of normal plasma to the patient sample of plasma in different concentrations and mesurements of additional coagulations tests were performed. This test excluded the presence of FVII inhibitors. According to mixture tests results and of the lack of improvement after immunosupresive therapy (coticosteroids) an

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autoimmune mechanism was ecluded. The patient reived several administrations of FVII concentrate (NovoSeven) due to important nasal bleeding. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< TRANSFORMARE BLASTICA RAPIDA INTR-UN CAZ DE METAPLAZIE MIELOIDA CU MIELOFIBROZA LAUN PACIENT DE 26ANI Tunde Torok *, L.Petrov *,A.Bojan*,A.Vasilache**, L.Urian*,A.Cucuianu *,A.Zsoldos**, M.Patiu**, C.Basarab** *UMF Cluj Napoca, ** Institutul Oncologic Cluj Napoca Autorii prezinta un caz de metaplazie mieloida cu mielofibroza (MMM) debutat la un tanar in varsta de 26 ani. MMM reprezinta o entitate din bolile mieloproliferative cronice caracterizata prin fibroza medulara, splenomegalie si tablou leucoeritroblastic cu dacriocite. Varsta medie de debut al bolii este de 60 ani, fiind foarte rara la indivizi tineri, doar aproximativ 5 % din cazuri debuteaza sub varsta de 40 ani. La acesti pacienti tineri singura sansa de supravietuire o reprezinta transplantul medular . Evolutia bolii este variabila, la unii indolenta, la altii rapida, cu supravietuire sub un an, principalele cauze de deces fiind transformarea leucemica, insuficienta cardiaca si infectiile. Datele din literatura releva urmatorii factori de prognostic cu valoare predictiva pentru supravietuire: Hb<10g/dl, prezenta simptomelor constitutionale si blasti in TS periferic >1% la diagnostic. Pacientul in varsta de 26 ani s-a prezentat la Clinica de Hematologie in iulie 2003 pentru un sindrom anemic, scadere in greutate si dureri in hipocondrul stang din cauza splenomegaliei. Datele de laborator au relevat pancitopenie, tablou leucoeritroblastic cu 10% blasti in TS si LDH crescut, fiind prezenti toti factorii de prognostic negativ. Avand in vedere varsta foarte tanara s-au pus probleme de diagnostic diferential, insa pe baza medulogramei si a biopsiei osteomedulare s-a putut stabili diagnosticul de MMM. A urmat un tratament cu Hidroxiuree si transfuzii de MER cu ameliorarea starii generale si a situatiei hematologice. Din ianuarie 2004 a prezentat o crestere progresiva a procentului de blasti in TS periferic la 46% in luna iunie cand s-a reinternat cu alterarea starii generale si a decedat la scurt timp datorita unor complicatii infectioase, decesul survenind astfel la un an de la stabilirea diagnosticului. RAPID PROGRESSION TO ACUTE LEUKEMIA IN A CASE OF MYELOFIBROSIS WITH MYELOID METAPLAZIAINA26 YEARS-OLD PACIENT Tunde Torok *, L.Petrov *,A.Bojan*,A.Vasilache**, L.Urian*,A.Cucuianu *,A.Zsoldos**, M.Patiu**, C.Basarab** *UMF Cluj Napoca, ** Institutul Oncologic Cluj Napoca We present the case of a 26 years-old male patient who was diagnosticated in our clinic with myelofibrosis with myeloid metaplasia (MMM) . MMM is a chronic myeloproliferative disorder caractherised by myelofibrosis, splenomegaly and leucoeritroblastic anemia with teardrop-shaped red blood cells.The median age at presentation is 60 years. MMM is an uncommon disorder in young individuals, only about 5% of patients have less then 40 years at presentation. The only possibility of cure in this pacients is hematopoietic stem cell transplantation. The clinical course is variable, some patients survive for less than a year while others present an indolent course. Data form literature suggest that there are 3 factors associated with shorter survival: Hb< 10g/dl, constitutional symptoms and circulating blasts >1% . The pacient presented in our clinic in iuly 2004 with anemia-related symptoms, weight loss and left upper quadrant pain due to splenomegaly. Laboratory tests revealed pancytopenia, leucoeritroblastic blood smear with teardrop-shaped erytrocites and 10% blasts. He presented all the 3 negative prognostic factors. Although the young age raised some differential diagnostic questions , based upon the bone marrow aspirate and biopsy we could establish the diagnosis of MMM. The patient was given Hidroxiuree and RBC transfusions with amelioration of hematologic parameters and clinical state. From January 2004 the patient started to present a continuous increase of blasts in peripheral blood smear .He was hospitalized in june with bad physical state and died shortly due to infectious complication in about an year after diagnosis. >>>>>>>>>>>>>>>>>>>>>>>>> RASPUNS CITOGENETIC SI MOLECULAR MAJOR DUPA DASATINIB INTR-UN CAZ DE LEUCEMIE MIELOIDACRONICAIN FAZABLASTICA.

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CucuianuA1, Rege G2, Dima D1, Patiu M1, Basarab C1, Saglio G2, Petrov L1 1.Institutul Oncologic Ion Chiricuta, Sectia Hematologie, Cluj-Napoca, Romania 2.Spitalul San Luigi, Sectia Hematologie, Torino, Italia Leucemia mieloida cronica (LMC) in faza blastica are un prognostic deosebit de sever, in special in cazurile rezistente la imatinib. Introducerea recenta in practica a noilor inhibitori de tirozin kinaze de tip molecule mici ar putea ameliora semnificativ prognosticul acestor pacienti Prezentam cazul clinic al unei paciente de 62 ani diagnosticata in Martie 2006 cu LMC faza cronica Philadelphia pozitiva. A fost initial tratata cu Hydroxiuree apoi in Iulie 2006 s-a inceput Glivec, 400mg/zi. Cariotipul, repetat la debutul tratamentului cu Glivec arata 90% Ph fara alte anomalii aditionale. S-a obtinut o remisiune hematologica dar la un control de rutina in Noiembrie 2006 s-a observat leucocitoza moderata (14,000) cu 47% blasti, cu un fenotip CD13, CD33, CD34 si cu expresia aberanta a CD10. Cariotipul a aratat Ph 100% fara anomalii aditionale. S-a debutat Glivec 600mg/zi dar pacienta a tolerat greu tratamentul, cu aparitia unei hepatocitolize marcate. Pe langa toleranta scazuta, cresterea dozei de Glivec nu a avut efect hematologic, motiv pentru care s-a intreupt. Ulterior, s-a inceput dasatinib 2 X 70mg zilnic. La iceput tratamentul a fost bine tolerat cu obtinerea dupa aproximativ o luna a unei remisiuni hematologice. A persisitat o moderata hepatocitoliza si colestaza, insa efectul advers cel mai important a fost aparitia unei colectii pleurale recidivante, necesitand repetate evacuari, iar ulterior reducerea dozei de dasatinib la 100mg/zi si adaosul de corticoizi in doza mica. Cariotipul effectual la 3 luni de la debutul dasatinib a relevant un raspuns citogenetic major (1 din 20 mitoze Ph pozitiva). Analiza moleculara (RQ-PCR), efectuata la 6 luni a relevant 17 copii de BCR-ABL/10,000 copii ABL (0.17%), deci aproape o reducere de 3-log a masei leucemice. Frecventa evacuarilor pleurale a scazut in timp; la momentul actual pacienta nu a mai avut pleurezie semnificativa de 2 luni, iar tratamentul cu prednison a fost stopat. Acest caz clinic subliniaza progresul realizat in ultimii ani in tratamentul LGC, chiar si in cazurile avansate, datorita introducerii noilor inhitori de tirozin kinaze. MAJOR CYTOGENETIC AND MOLECULAR RESPONSE AFTER DASATINIB IN A PATIENT WITH CHRONIC MYELOID LEUKEMIAIN BLASTIC PHASE CucuianuA1, Rege G2, Dima D1, Patiu M1, Basarab C1, Saglio G2, Petrov L1 1. 2. Ion Chiricuta Cancer Institute, Hematology Dept, Cluj-Napoca, Romania San Luigi Hospital, Hematology Department, Torino, Italy

Chronic myeloid leukemia in blastic phase carries an adverse prognosis, especially in imatinib-resistant cases. The recent development of the newer small molecule typosine kinase inhibitors may change the outlook in these patients We present the clinical case of a 62 year old female who was diagnosed in March 2006 with chronic phase, Philadelphia positive chronic myeloid leukemia (CML). She was initially treated with Hydroxiurea and in July 2006 Glivec was started at a dose of 400mg/day. The karyotype, repeated when Glivec was started showed 90% Philapdelphia positive mitoses without additional abnormalities. A hematological remission was subsequently obtained. A routine control in November 2006 showed mild leucocytosis (14,000) with 47% blasts, with a CD13, CD33, CD34 and aberrant CD10 phenotype. The caryotype showed 100% Ph without additional abnormalities. Glivec at 600mg/day was started but the patient tolerated it poorly, developing important hepatocytotysis. Besides being poorly tolerated, Glivec at 600mg/day had no hematological effects, therefore Glivec was withdrawn. Subsequently, the patient was started on dasatinib 2 X 70mg daily. In the beginning, she has tolerated dasatinib relatively well, with the achievement in about a month of a complete hematological remission. A moderate hepatocytolysis and colestasis persisted. A recurrent problem was bilateral pleural effusion requiring repeated evacuations and subsequently a reduction of dasatinib to 100mg daily and the addition of small doses of prednisone. The caryotype after 3 months of treatment revealed a major cytogenetical remission (1 in 20 mitoses Ph positive). The RQ-PCR, performed a 6 months showed 17 copies of BCR-ABL/10,000 copies of ABL (0.17%), therefore an almost 3-log reduction of the leukemic load. The frequency of pleural evacuations decreased over time and at the time of writing she has had no pleural effusion for 2 months and the prednisone was stopped. This case underscores the progress being made in recent years in the treatment of CML, even in advanced phases, due to the introduction of the newer small molecule tyrosine kinases.

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>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> ACUTIZAREA LEUCEMIEI GRANULOCITARE CRONICE: BLASTOZA DE 20% SAU DE 30% CA SI CRITERIU DEFINITORIU? Delia Dima,Andrei Cucuianu, Mariana Patiu, Carmen Basarab, Ljubomir Petrov Universitatea de Medicina si Farmacie Iuliu Hatieganu Cluj-Napoca. Catedra de Hematologie Introducere. Leucemia granulocitara cronica (LGC) este caracterizata printr-o evolutie bifazica: faza cronica, in care aspectul clinic este relativ indolent, iar cel hematologic este caracterizat printr-un procent mic de celule blastice si faza blastica, terminala, in care aspectul clinic si hematologic este asemanator unei leucemii acute cu complicatii legate de sindromul de insuficienta medulara si procent crescut de celule blastice. Criteriul definitoriu pentru faza blastica este in prezent un procent de blasti periferici sau medulari de peste 30%. Acest prag de 30% era pana nu demult identic ca si criteriu de diagnostic si in leucemiile acute mieloide (LAM). Recent, OMS a modificat pragul de diagnostic in LAM la 20% blasti. Material si metoda. Am incercat sa determinam, intr-un studiu retrospectiv pe 31 de cazuri diagnosticate si urmarite pana la deces in clinica noastra, care a fost impactul unui procent de blasti de 20% comparativ cu procentul standard de 30% asupra evolutiei ulterioare a cazurilor. Mentionam ca toate cazurile au fost tratate cu chimioterapie conventionala, datand din perioada premergatoare utilizarii in clinica noastra a unor terapii cu potential de schimbare reala a cursului bolii cum ar fi alfa-interferonul sau imatinib mesilatul. Rezultate. Supravietuirea medie de la observarea unui procent de blasti periferici sau medulari de 20% a fost de 11.2 luni comparativ cu 6.9 luni (p=0.0002) dupa depasirea pragului de 30%. Desi diferenta este statistic semnificativa, daca se compara perioada mediana de atingere a pragului de 20% cu cea a celui de 30%, diferenta nu este semnificativa (39 fata de 42 de luni de la diagnostic), cu alte cuvinte, dupa o perioada relativ lunga de evolutie cronica, depasirea pragului de 20% a fost urmata la foarte scurt timp de atingerea celui de 30% in majoritatea cazurilor. Discutii. In opinia noastra, decelarea unui procent de 20% de blasti periferici sau medulari ar trebui sa constituie semnalul pentru schimbarea atitudinii terapeutice. Pe de alta parte, in viitorul apropiat, in conditiile unei urmariri complexe, atat citologice cat si citogenetice si moleculare, s-ar putea ca criteriile de faza blastica sa nu se mai bazeze pe un simplu procent de celule imature ci mai degraba pe decelarea precoce a evolutiei genetice si epigenetice a celulei leucemice. BLASTIC TRANSFORMATION IN CHRONIC MYELOID LEUKEMIA : 20% OR 30% BLASTS AS DEFINING CRITERIUM? Delia Dima,Andrei Cucuianu, Mariana Patiu, Carmen Basarab, Ljubomir Petrov Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca. Hematology Dept. Background. Chronic myeloid leukemia (CML) is characterized by a biphasic evolution : chronic phase, with a relatively indolent clinical course and a low percentage of blast cells and the blastic, terminal phase in which the clinical and hematological aspect resembles acute leukemia. The defining criterium for blastic phase is currently 30% peripheral or marrow blasts. This 30% threshold was until not long ago the same as the criterium for acute myeloid leukemia (AML). Recently, WHO has lowered the diagnostic threshold forAML to 20% blasts. Material and methods. We tried to determine, in a retrospective study on 31 patients diagnosed and followed until death in our department which was the impact of a 20% peripheral or marrow blast percentage compared to the standard 30% on the evolution of these patients. All cases were treated with conventional chemotherapy; at the time, in our department, no patients were treated with alpha-interferon or imatinib mesylate. Results. The median survival from the moment a 20% blast percentage was observed was 11.2 luni compared to 6.9 months since a 30% percentage was observed (p=0.0002). Even though the difference was statistically significant, when we compared the time from diagnosis until a 20% blast percentage and a 30% percentage respectively were observed, the difference was not statistically significant (39 vs 42 months), in other words, after a relatively long chronic phase evolution, reaching a 20% blast level was shortly followed by the 30% threshold in most cases. Discutii. In our opinion, the detection of a 20% blood or marrow percentage should signify acutisation, prompting treatment change. On the other hand, in the near future, when complex cytogenetic and molecular analysis will become more widespread and reliable, it is possible that the blastic phase criteria will not be based anymore on a mere

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percentage of immature cells, but rather on the early detection of genetic and epigenetic progression of the leukemic clone. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>..... LIMFOAMELE SPLENICE IALE TRACTULUI GASTROINTESTINAL I. Macarie1, G. Oltean1, S. Demian1, M. Macarie2, M. Cndea1, B. Dorcioman3 1-UMF Trgu Mure, Clinica Medical 1, 2-Spitalul Clinic Judeean de Urgen Trgu Mure, 3-Laboratorul Central, Spitalul Clinic Judeean de Urgen Trgu Mure Introducere Limfoamele extraganglionare reprezint aproximativ o treime din totalul limfoamelor, dar exist i cazuri n care incidena lor ajunge la 50%. Cele cu localizare gastric sau splenic sunt cele mai frecvente, alturi de cele cutanate constituind marea majoritate a limfoamelor extraganglionare. Material i metod Am luat n studiu un lot de 54 de pacieni cu limfoame extraganglionare. Diagnosticul a fost precizat prin examenul histopatologic al unei biopsii obinute n principal prin laparatomie cu gastrectomie sau splenectomie. Mult mai rar au fost diagnosticate prin biopsie endoscopic sau prin imunofenotiparea limfocitelor din sngele periferic sau din aspiratul medular. Rezultate Pacienii cu limfom extraganglionar au reprezentat 29,83% din totalul cazurilor de limfom diagnosticate. Cele mai frecvente localizri au fost limfoamele gastrice (27%), splenice (23%) i cutanate (19%). Vrsta medie a pacienilor cu limfom gastric a fost de 53,86 ani (CI 95% 47,03-60,69), iar a celor cu limfom splenic de 53,84 ani. Vrsta medie la diagnostic a pacienilor cu limfoame cutanate este semnificativ mai mare dect a celor cu limfoame gastrice sau splenice. Majoritatea limfoamelor extraganglionare sunt agresive, forma histologic cea mai frecvent fiind limfomul difuz cu celule mari B pentru cele gastrice. n lotul studiat, n cazul limfoamelor splenice a predominat limfomul zonei marginale. Concluzii Pacienii cu limfoame extraganglionare gastrice sau splenice au un prognostic similar sau chiar mai bun dect al pacienilor cu limfoame cu debut ganglionar. Evoluia lor este totui eterogen. n lotul studiat nu au existat pacieni cu infecie HIV. Limfoamele T sunt localizate la nivelul intestinului n lotul studiat. SPLENICAND GASTROINTESTINALTRACT LYMPHOMAS I. Macarie1, G. Oltean1, S. Demian1, M. Macarie2, M. Cndea1, B. Dorcioman3 1-UMPh Trgu Mure, Medical Clinic 1, 2-Trgu Mure County Clinical Emergency Hospital, 3-Central Laboratory, Trgu Mure County Clinical Emergency Hospital Introduction Extranodal lymphomas account for approximately one third of all lymphomas, but in some reports their incidence is close to or even above 50%. The gastric and splenic lymphomas are the most frequent and, together with cutaneous lymphoma represent the vast majority of the extranodal lymphoma. Matherial and method We studied the characteristics of 54 patients with extranodal lymphomas. The diagnosis was based on patological examination of biopsies obtained by laparatomy and gastrectomy or splenectomy. In rare cases the diagnosis was possible by endoscopic biopsy or immunophenotyping of the lymphocytes from peripheral blood or bone marrow aspirate. Results The patients with extranodal lymphomas represented 29,83% of all cases. The most frequent were gastric lymphomas (27%), splenic lymphomas (23%) and lymphomas of the skin (19%). The mean age at diagnosis in patients with gastric lymphoma was 53.86 years (CI 95% 47.03-60.69), and in splenic lymphoma was 53,84 years. The mean age at diagnosis is significantely higher for patients with cutaneous lymphomas compared to patients with gastric or splenic lymphomas. Most extranodal lymphomas are aggressive, the most frequent type beeing diffuse large B-cell lymphoma for gastric lymphoma. Marginal zone lymphoma was the predominant type for splenic lymphomas. Conclusions The patients with extranodal gastric or splenic lymphomas have a prognosis similar or even better than patients with nodal lymphomas. Their clinical evolution is however heterogenous. In this study there were not patients with HIV infection. T-cell lymphomas were almost exclusively involving the small bowell. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< REZULTATELE TRATAMENTULUI CU ERITROPOIETIN LA PACIENII CU SINDROM MIELODISPLAZIC DINTR-UN SINGUR CENTRU DIN ROMNIA.

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Aurelia Tatic, Iulia Ursuleac, Tatiana Puscariu, R.Gologan, Dana Ostroveanu, Adriana Colita, D.Colita, Aristica Poenaru, Emilia niculescu-Mizil,Andreea Delia Moicean, Otilia Georgescu,Anca Ion Clinica de Hematologie, Institutul Clinic Fundeni, Bucureti Introducere. Anemia este cea mai frecventa manifestare clinica in sindromul mielodisplazic(SMD).Adesea este severa, necesitand transfuzii si determinad scaderea calitatii vietii.Tratamentul cu Eritropoietina umana recombinata (Epo) in SMD cu risc scazut amelioreaza anemia in aproximativ 20-40% din pacientii cu SMD, scade necesarul transfuzional si imbunatateste calitatea vietii.Rata raspunsului la tratament depinde de subtipul FAB si nivelul seric al eritropoetinei.Tratamentul concomitent cu Epo si G-CSF creste rata raspunsului. Metoda. Am evaluat raspunsul la tratamentul cu Epo administrat subcutanat in doza de 150 u/kg de 3 ori pe saptamana la 27 de pacienti diagnosticati in Clinica de Hematologie a Institutului Clinic Fundeni in perioada 2005-iunie 2007. Pacientii au fost clasificati conform criteriilor FAB. Caracteristicile lotului au fost: 12 barbati (44,44%), 15 femei (66,66%), limitele de varsta au fost intre 41-80 ani (mediana 65,16 ani). Subtipurile de SMD au fost: anemia refractara (AR) 19 pacienti (70,37%), anemie refractara cu sideroblasti inelari (ARSI) 5 pacienti (18,52%), anemie refractara cu exces de blasti (AREB) 3 pacienti (11,11%).Am dozat nivelul eritropoietinei serice la 11 pacienti. Raspunsul al tratament a fost evaluat astfel:raspuns complet (RC cresterea nivelului Hb peste 2 gr/dl, fara transfuzii), raspuns partial (RP- crestera nivelului Hb peste 1gr/dl, reducerea necesarului transfuzional si ameliorarea calitatii vietii) si fara raspuns (FR) dupa 3 luni de tartament. Rezultate: raspunsul la tratament a fost : 7 pacienti cu nivel seric al eritropoietinei 150 U/L 4 RC, 2 FR, 1 RP si 4 pacienti cu nivel seric al eritropoetinei intre 150500 U/L-1 RC, 2 RP, 1 FR; 8 pacienti care au primit Epo ca tratament de prima intentie : 5RC ( 4 AR, 1 ARSI), 2 RP (2 AR), 1 AR fara raspuns la 3 luni; 19 pacienti tratati anterior : 5RC (5AR), 9 RP (5AR, 3ARSI, 1AREB), 5 FR ( 2AR, 1ARSI, 2AREB). Concluzii: administrarea Epo la pacientii cu SMD risc scazut reduce necesarul transfuzional si imbunatateste calitatea vietii. Cele mai bune rezultae s-au obtinut in AR cu nivel scazut al Epo serice si cand Epo a fost aministrata ca pima intentie. RC a fost obtinuta la 10 pacienti ( 9AR, 1ARSI). RESULTS OF THE TREATMENT WITH ERYTHROPOIETIN IN MYELODYSPLASTIC SYNDROME FROM A SINGLE ROMANIAN CENTER Aurelia Tatic, Iulia Ursuleac, Tatiana Puscariu, R.Gologan, Dana Ostroveanu, Adriana Colita, D.Colita, Aristica Poenaru, Emilia niculescu-Mizil,Andreea Delia Moicean, Otilia Georgescu,Anca Ion Fundeni Clinical Institute, Haematology Department, Bucharest, Romania Introduction. The anaemia is the most frequent clinical manifestation in myelodysplastic syndromes (MDS). It is often severe, transfusion dependent and associated with impaired quality of life. Treatment with recombinated human erythropoietin (rHuEpo) in low risk MDS improves anaemia in aproximately 20% - 40% of patients with MDS, reduces transfusion needs and improves quality of life. Response rate depends on FAB subtypes and serum erythropoietin level. Concomitant treatment with rHuEpo and G-CSF rises response rate . Method. We evaluated the response to the treatment with rHuEpo given subcutaneously at a dose of 150U/kg thrice weekly to 27 patients diagnosed in Fundeni Clinical Institute treated with rHuEpo between 2005-june 2007. The patients were classified according to FAB criteria. The characteristics of the group were: 12 males ( 44,44%), 15 females (66,66%), age range between 41-80 years (median 65,16). The MDS subtypes were: refractory anaemia (RA) 19 patients (70,37%), refractory anaemia with ringed sideroblasts (RARS) 5 patients (18,52%), refractory anaemia with excess of blasts (RAEB) 3 patients ( 11,11%). We have dosed serum Epo levels to 11 patients. All patients were evaluated as: complete response (CR increase of Hb above 2 gr/dl, without transfusion needs), partial response (PRincrease Hb above 1gr/dl, reduction of the transfusion frequency and an improvement of quality of life) and without response after 3 months of treatment. Results:The treatment responses were: - 7 patients with serum Epo levels <150U/L (4 CR, 1 PR, 2 without response) and 4 patients with Epo level between 150-500U/L (1 CR, 2 PR, 1 without response). - 8 patients (32%) were treated with rHuEpo as first intention: 5 CR (4 RA, 1 RARS), 2 PR (RA), 1 RA without response to 3 months ; - 19 patients with prior treatments: 5 CR (5 RA), 9 PR (5 RA, 3 RARS, 1 RAEB ), 5 without response (2 RA, 1 RARS, 2 RAEB ).

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Conclusions: rHuEpo administration in patients with low risk MDS reduced transfusion needs and improved quality of life. The most favorable results were in RA with low serum Epo level and when rHuEpo was given as first line of treatment. Complete remission was obtained in 10 patients (9 RA, 1 RARS). <<<<<<<<<<<<<<<<<<<<<<<<<<<< LIMITE ALE TRATAMENTULUI CU THALIDOMIDA LA PACIENTI CU MIELOM MULTIPLU CU DETERMINARI EXTRAMEDULARE Gabriela Barca, Nicoleta Berbec, Andrei Colita, Doina Barbu, Silvana Angelescu, Valentin Barca*, Camelia Dobrea, Oana Patrinoiu, Madalina Vasile, Delia Mut Popescu Spitalul Clinic Coltea Hematologie * UMF Carol Davila Introducere: Leucemia cu plasmocite (LP) este o varianta mult mai rara si agresiva de mielom multiplu care apare la 2% din cazuri si poate apare in evolutia unui mielom multiplu ( LP secundara). Dezvoltarea de determinari tumorale extramedulare este foarte rara in timpul tratamentului cu thalidomida. Obiective si descrierea cazului: Prezentam 2 cazuri de pacienti cu mielom multiplu tratati cu Thalidomida care desi au raspuns la tratament cu ameliorarea componentei monoclonale atat pe electroforeza cat si pe imuonograma au continnuat sa dezvolte plasmocitoame extramedulare care nu au raspuns la tratament. - cazul unei paciente de 68 de ani cu mielom multiplu rezistent la chimioterapie si tratamentul cu talidomida. In ciuda unei remisiuni partiale de scurta durata, boala a trecut intr-o faza leucemica cu dezvoltarea unor formatiuni tumorale cutanate si a unui sindrom Claude-Bernard-Horner.Evaluarea hematologica a evidentiat aplazie medulara iar periferic 20-30% plasmocite mielomatoase. Biopsia cutanata a unor formatiuni tumorale a diagnosticat un limfom malign nonhodgkinian cu celula mare B iar evaluarea neurologica si rezonanta magnetica nucleara au evidentiat mici tumori intracerebrale.Pacienta a facut corticoterapie intensiva cu talidomida si iradiere locala cutanata la care s-a obtinut regresia formatiunilor cutanate dar manifestarile neurologice au evoluat si pacienta a decedat cu coma neurologica. cazul unui pacient de 64 de ani cu mielom multiplu biclonal la care boala a debutat cu plasmocitomvertebral si care dupa un raspuns favorabil al componentei monoclonale a dezvoltat plasmocitoame cutanate si vertebrale. Discutii si concluzii: Aparitia tardiva a fazei leucemice poate fi secundara chimioterapiei prelungite dar determinarile cutanate si neurologice la acesti pacienti dupa tratamentul cu thalidomida sugereaza ca thalidomida este activa pe celula mielomatoasa medulara dar inactiva in determinarile extramedulare LIMITATIONS OF THALDOMIDE USE FOR MULTIPLE MYELOMA WITH EXTRA-MEDULAR DETERMINATIONS: Gabriela Barca, Nicoleta Berbec, Andrei Colita, Doina Barbu, Silvana Angelescu, Camelia Dobrea, Valentin Barca*, Oana Patrinoiu, Madalina Vasile, Delia Mut Popescu Spitalul Clinic Coltea Hematologie * UMF Carol Davila Introduction: Leukemia with plasmocites (LP) is a rare and rather agressive version of multiple myeloma wich appears in 2% of the medical practice, this form may also appear in the evolution of the common multiple myeloma as a secondary LP. The development of extramedular tumors is very rare during the use of Thalidomide. Objectives and description of the medical researsch: we present 2 cases of patients with Thalidomide treatment who although initially responed favorably to treatment (with good results on imunogram and electrophoresis) continued to develop extra-medular plasmocitocytic tumors. - female patient of 68 yrs. old with a refractory myeloma to chemoterapy , for this resean we prescibed Thalidomide. In spite of a short period of remission, the disease passed into a leukemic stage with development of a underskinned tumors and of a Claude-Bernard-Horner sindrome. The hematological evaluation revealed a medular aplasia and pheripheric 20-30% myloma plasmocites. The underskinned byopsy revealed plasmoblast cells and the neurological evaluation and magnetic resonance revealed. Yhe involvment of CNS. The patient followed an intensive Thalidomide therapy and local irradiation which were followed by a regression of the undeskinned formations. However due to unfavorable neurologic developments the patient deceased with a neurologic coma. -the case of male patient of 64 yrs. old, with bi-clonal multiple myeloma in which case the disease started with a vertebral plasmocitom. After a favorable response with Thalidomide (with reduction of the monoclonal component) the patient developed underskinned and vertebral plasmoblast tumors.. Conslucions: The late appaearence of the leukemic stage may follow the long use of chemotherapy. However, the underskinned and neurologic determinations after the use of thalidomide suggests that Thalidomide is active over the medular myloma cells but inactive in extra-medular determinations.

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< < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < TRATAMENTUL CU ALEMTUZUMAB INTR-UN CAZ DE MYCOZIS FUNGOIDES STADIU AVANSAT, POLICHIMIOTRATAT A.Vasilache*,A.Parvu*, C.Basarab*, C.Baican**, L.Petrov* * I.O.C.N. Cluj- Napoca, Clinica Hematologie **U.M.F Cluj-Napoca, Clinica Dermatologie Alemtuzumab- campath-1H este un ac monoclonal IgG, umanizat, anti CD 52, exprimat pe majoritatea LB si LT normale si neoplazice, cu efecte demonstrate in leucemia limfatica cronica, leucemia prolimfocitara cu cel.Tsi preventia bolii grefa contra gazda la pacientii cu transplant allogen de cel stem. In limfomele cutanate cu cel.T, in special mycozis funfoides(MF) si sdr.Sezary(SS) experienta cu alemtuzumab, desi redusa, este incurajatoare. Prezentam cazul primei paciente tratate in serviciul nostru cu alemtuzumab (mabcampath) pentru MFcu evolutie din 2001si multiple linii de tratament anterioare, in momentul debutului tratamentului cu boala progresiva, avansata.Tratamentul cu mabcampath a durat 8 sapt.S-a administrat subcutan 3mg-10mg-30mg/zi progresiv, apoi 30mg/zi de 3 ori/sapt, fara fecte adverse legate de administratre.Ameliorarea aspectului pielii a aparut dupa primele administrari, cu reducerea marcata a eritrodermiei, pruritului, infiltratului cutanat, onicodistrofiei dar fara influentarea tumoretelor cutanate, disparitia li atipice din SP dupa 2 sapt, toxicitate hematologica(pancitopenie la 3 sapt, care s-a mentinut), infectii legate de imunosupresia data de medicament? de multiplele porti de intrare de la nivelul pielii?, fara semne de reactivare a CMV(ac anti CMV-IgG prezenti la debutul tratamentului). Apreciem ca raspunsul la tratament a fost important dar de scurta durata, urmat de progresia bolii( la 6 sapt a reaparut descuamarea , extinderea si exulcerarea tu cutanate), intreruperea tratamentului si deces datorita complicatiilor infectioase.Experienta noastra legata de unicul pacient cu MF/SS tratat cu mabcampat confirma observatiile anterioare si perspectivele acestui tip de tratament in LCCT. METODE SPECIFICE DE LABORATOR PENTRU DIFERENIEREA POLIGLOBULIILOR. IMPLICAII CLINICE Tatiana Pucariu1, Anca Ilea2, Daniela Ostroveanu1, Camelia Dobrea1, Emilia Niculescu-Mizil1, Adriana Coli1, Andreea Moicean1, Camelia Ghilic1, Viorica Iacob1 1Clinica de Hematologie-Institutul Clinic Fundeni 2Ritus Biotec, Codlea, jud. Braov Determinarea mutaiei JAK2V617F la anumii pacieni cu SMPC este o metod introdus recent la noi n ar i, deocamdat, mai puin accesibil. Prin acest studiu s-a urmrit evaluarea a 17 pacieni internai cu poliglobulie (suspectai de PV sau TE), care au beneficiat de investigarea mutaiei JAK2V617F, alturi de alte metode specifice de laborator, folosite n mod curent n clinica noastr: dozarea eritropoietinei serice, studiul progenitorilor eritroizi in vitro i determinarea fosfatazei alcaline leucocitare. Valorile obinute prin investigaiile de mai sus precum i valoarea hematocritului, a hemoglobinei, numrul leucocitelor i al trombocitelor au permis stabilirea unor corelaii i o ierarhizare a testelor folosite, n funcie de eficacitatea interpretrii cazurilor din acest studiu. LABORATORY SPECIFIC METHODS IN POLYCYTHEMIADIFFERENTIATION. CLINICAL IMPLICATIONS Tatiana Pucariu1, Anca Ilea2, Daniela Ostroveanu1, Camelia Dobrea1, Emilia Niculescu-Mizil1, Adriana Coli1, Andreea Moicean1, Camelia Ghilic1, Viorica Iacob1 1Clinica de Hematologie-Institutul Clinic Fundeni 2Ritus Biotec, Codlea, jud. Braov The detection of JAK2V617F mutation in patients with MPD is a recent method less accessible in our country at once. Seventeen patients having polycythemia (PV or ET supposed diagnostic) were evaluated. They enjoyed of JAK2V617F determination together with other specific laboratory methods, currently applied in our clinic: dosage of serum erythropoietin, erythroid progenitor cell in vitro assay and leukocyte alkaline phosphatase score. The values obtained by using the methods above mentioned, the hematocrit value and leukocytes and platelets number

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in the same cases allowed to establish correlations and a hierarchy of the methods, depending on patients evaluation efficiency in this study. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> MODALITI EVOLUTIVE N GAMAPATIAMONOCLONAL CU SEMNIFICAIE NECUNOSCUT Anca Bojan,Mariana Patiu, Anca Vasilache, Mariana Patiu, Carmen Basarab, C,Coldea, A.Cucuianu,Laura Urian, Tunde Torok,M.Zdrenghea,Cristina Grandore, L.Petrov 1-Institutul Oncologic "Ion Chiricuta"Cluj-Napoca 2-Universitatea de Medicina si Farmacie "Iului Hatieganu" Cluj-Napoca Gamapatia monoclonal cu semnificaie necunoscut este o afeciune premalign caracterizat printr-o proliferare limitat a plasmocitelor n mduva osoas, care determin o cretere a proteinei monoclonale n ser ,dar la valori sub 3 g/l, fr afectare organic (lipsesc anemia, afectarea renal,leziunile osoase i hipercalcemia determinate de proliferarea plasmocitar) Rata de tranfformare n mielom multiplu este de 1-2% pe an.Principalii factori predictori ai transformrii maligne sunt:nivelul proteinei monoclonale, tipul proteinei monoclonale, raportul anormal al lanurilor uoare n ser,procentul plasmocitelor din mduva osoas, creterea resorbiei osoase, prezena proteinei Bence Jones n cantiti minime. n lucrarea de fa am realizat un studiu retrospectiv al pacienilor cu gamapatie monoclonal cu semnificaie necunoscut urmrii n clinica de Hematologie Cluj-Napoca.Au fost urmrii 68 de pacieni cu GMSN diagnosticai ntre 1990-2002, cu o urmrire medie de 78 de luni.Vrsta pacienilor a fost cuprins ntre 51 i 84 de ani.Tipul imunologic al gamapatiei a fost:IgG la 55 de pacieni (80,9%),IgA la 10 pacieni(14,08%),i IgM la 3 pacieni(5,02%).55% dintre pacieni au avut un nivel al proteinei monoclonale sub 2g%,iar 45%,ntre 2 i 3 g%,Plasmocitoza medular a fost sub 6% la 48% dintre pacieni i ntre 6 i 9% la 52% dintre pacieni.Evoluia pacienilor a fost urmtoarea:41 de pacieni (60%)au decedat din cauze nelegate de mielom, 20 de paciei (30%) au avut nivel stabil al proteinei monoclonale,iar 7 pacienti (10%) s-au transformat n mielom multiplu (5pacieni),sindrom limfoproliferativ (1 pacient),macroglobulinemie Waldenstrom (1 pacient).Factorii cu valoare prognostic pentru transformarea malign au fost nivelul proteinei monoclonale i nivelul plasmocitozei medulare. In concluzie pacienii cu gamapatie monoclonal care prezint la diagnostic valori ale proteinei monoclonale peste 2 g%i o plasmocitoz medular ntre 6 i 9%, necesit o urmarire mai atent,la un interval mai scurt de timp, datorit riscului mai mare de transfotmare malign. EVOLUTION AND PROGNOSTIC FACTORS IN MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE Anca Bojan,Mariana Patiu, Anca Vasilache, Carmen Basarab, A.Cucuianu,C.Coldea Laura Urian, Tunde Torok,M.Zdrenghea,Cristina Grandore, L.Petrov 1-Oncological Institute "Ion Chiricuta"Cluj-Napoca 2-University of Medecine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca Monoclonal gammopathy of undetermined significance (MGUS) is an asymptomatic pre-malignant disorder characterized by monoclonal plasma cell proliferation in the bone marrow and absence of organ damage such as anemia, renal failure, osteolytic bone lesions,hypercalcemia. The rate of progression to multiple myeloma or related malignancy is 1-2% per year.The principals risk factors for progression of MGUS are:the size and type of the monoclonal protein, an abnormal free light chain ratio, the presence of the Bence Jones protein, the bone marrow percentage of plasma cells,the bone resorbtion aumentation. The present study is a retrospective one,of 68 patients,with MGUS, followed-up in the Oncological Institute of ClujNapoca.The median follow-up was of 78 mounths.The patients were between 51 and 84 years old.The immunological type of MGUS was:IgG:55 patients(80,9%), IgA:10 patients(14,8%), IgM:3 patients(5,02%).55% of the patients had a monoclonal protein<2g% and 45% between 2 and 3 g%.The medular plasmocytosis was <6% in 48% of the patients,and between 6 and 9% in 52% of the patients.The patients evolution was the following:41 patients (60%) dyed for causes unrelated of multiple myeloma,in 20 patients (30%) the level of the M protein was stable and 7 patients with MGUS were transformed in malignant desorders:multiple myeloma:5 patients,lymphoproliferative disorders:1

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patient, Waldenstrom macroglobulinemia:1 patient.The risk factors for the malignant transformation were: the size of the M protein and the bone marrow plasmocytosis. In conclusion,the MGUS patients with a a monoclonal protein >2 g% and a medular plasmocytosis between 6 and 9%,must be attentively followed-up,because of the high risk of malignant transformation. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< SARCOM MIELOID GANGLIONAR ABDOMINAL CA MODALITATE DE PREZENTARE A MIELOFIBROZEI CRONICE IDIOPATICE. PREZENTARE DE CAZ E. Niculescu-Mizil1, C. Dobrea1, D. Ostroveanu1, T. Puscariu1, D. Vasilache1, N. Zamfirescu2, C. Ghilic1, A. Ilea3, C. Mller-Tidow4 1Centrul de Hematologie si Transplant Medular Fundeni,2Clinica de Gastroenterologie Fundeni 3Spitalul Codlea, 4Universittsklinikum Mnster/Germania Mielofibroza Cronica Idiopatica (MCI) se caracterizeaza prin anemie, splenomegalie, tablou leucoeritroblastic al sangelui cu eritrocite in picatura si grade variate de mielofibroza (exceptand stadiul prefibrotic timpuriu al bolii). In acest poster prezentam cazul unei femei in varsta de 74 de ani, cardiopata, internata in Centrul de Hematologie si Transplant Medular Fundeni pentru stabilirea etiologiei unor adenopatii tumorale abdominle acompaniate de hepatomegalie. Clinic, pacienta asocia un sindrom anemic si scadere ponderala semnificativa. Hemograma a evidentiat doar anemie moderata. Concluzia examenului histopatologic si imunohistochimic al ganglionului recoltat prin laparotomie a fost de sarcom mieloid (determinare extramedulara de sindrom mieloproliferativ). Biopsia osoasa a completat diagnosticul evidentiin un aspect de MCI in faza hipercelulara cu grad 1 de mielofibroza. Testele de biologie moleculara (bcr-abl si Jak 2) au fost negative. Pacienta a urmat tratament cu Hidroxiuree si Neorecormon doar 3 luni, deoarece a decedat prin complicatii cardiologice. Sarcomul mieloid este caracteristic determinarilor extramedulare in leucemiile acute sau in puseul blastic al leucemiei mieloide cornice. In MCI metaplazia mieloida localizata in alte organe apare in stadiile manifeste ale bolii, mai ales dupa o evolutie indelungata. Particularitatea acestui caz este reprezentata de debutul ganglionar atipic, neansotit de semnele tipice MCI. ABDOMINAL NODAL MYELOID SARCOMA AS PREZENTATION MODALITY OF CHRONIC IDIOPATHIC MYELOFIBROSIS. CASE EXPOSURE E. Niculescu-Mizil1, C. Dobrea1, D. Ostroveanu1, T. Puscariu1, D. Vasilache1, N. Zamfirescu2, C. Ghilic1, A. Ilea3, C. Mller-Tidow4 1Centrul de Hematologie si Transplant Medular Fundeni,2Clinica de Gastroenterologie Fundeni 3Spitalul Codlea, 4Universittsklinikum Mnster/Germania Chronic idiopathic Myelofibrosis (CIMF) is characterized by anemia, splenomegaly, leuko-erythroblastic blood picture, tear drop erythrocytosis, and varying degrees of bone marrow reticulin and collagen fibrosis (except prefibrotic early-stage of disease). In this poster we present the case of a cardiac, 74 years old women, admitted in Fundeni Hematological and Bone Marrow Transplantation Center for the investigation of the etiology of tumorous abdominal adenopathyes accompanied with hepatomegaly. Clinically, the patient associated an anemic syndrome and significantly weight loss. The hemogram showed moderate anemia. The histopathological and immunohistochemistry exam of the abdominal lymph node harvested by laparotomy, established the myeloid sarcoma aspect (extramedullary determination of myeloproliferative syndrome). The bone marrow biopsy completed the diagnosis with CIMF in hypercellular stage with grade 1 of myelofibrosis. The molecular biology tests (bcr-abl and Jak 2) were negative.After 3 months of treatment with Hydroxyurea and Neorecormon the patient died because of cardiac complication. The myeloid sarcoma characterized the extramedullary determination of acute leukemia and blastic transformation of chronic myeloid leukemia. In CIMF the myeloid metaplasia appear in manifestation stages of the disease, especially after a long evolution. The particularity of this case is represented by atypical nodal debut, without the typical signs of CIMF. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

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TREI CAZURI DE ASOCIERE A UNOR BOLI MIELOPROLIFERATIVE CRONICE CU LIMFOPROLIFERARI. EXPERIENTAPERSONALA E. Niculescu-Mizil1, C, Dobrea1, D. Ostroveanu1, A. Dumitrescu T. Puscariu1, D. Vasilache1, C. Ghilic1, A. Ilea2, C. Mller-Tidow3 1Centrul de Hematologie si Transplant Medular Fundeni, 2Spitalul Codlea, 3Universittsklinikum Mnster/Germania Asocierea dintre neoplaziile hematologice (in special leucemia limfatica cronica LLC) si alte malignitati a fost descrisa in literatura. Lucrarea prezinta trei cazuri de boli mieloproliferative cronice diagnosticate concomitent cu limfoproliferari. In toate cazurile s-au efectuat investigatii de laborator complexe, pentru diagnosticul riguros al ambelor tipuri de hemopatii asociate. Astfel, toti pacientii au facut teste citologice, imunofenotipice, histopatologice si imunohistochimice, teste citogenetice si de biologie moleculara. Intr-un caz s-au efectuat culturi de celule limfoide si mieloide din maduva osoasa. In alt caz s-au facut teste citogenetice si imunfenotipice pe ganglionul limfatic. Doua cazuri au fost LLC in stadiu precoce, primul asociat cu leucemie mieloida cronica (LMC) Ph1+. Al doilea pacient avea adaugata LLC o hiperplazie megakariocitara cu trombocitoza periferica. Testele de biologie moleculara efectuate in Germania au fost negative pentru mutatia Jak 2 si bcr-abl (cantitativ) dar pozitive pentru testul calitativ bcr-abl la a 2 a repetare. Ulterior, testul bcr-abl efectuat la MD Andersson Cancer Center (SUA) a fost negativ, stabilindu-se diagnosticul de trombocitemie esentiala. Al treilea caz asocia un limfom limfoblastic T (cu celule mononucleare mieloperoxidazo pozitive si cromozom Ph1+ in ganglionul biopsiat) cu un sindrom mieloproliferativ cronic bcr-abl major atipic pozitiv. Aceste cazuri ridica problema mecanismului patogen si anume daca evenimentul oncogen s-a produs la nivelul celulei stem primordiale neorientate inca spre nici o linie celulara sau au existat mai multe mecanisme care au actionat asupra celulelor stem deja 'comise' spre linia mieloida sau limfoida. THREE CASES OF ASSOCIATION BETWEEN CHRONIC MYELOPROLIFERATIVE DISORDERS AND LYMPHOPROLIFERATIVE DISEASES. PERSONAL EXPERIENCE E. Niculescu-Mizil1, C, Dobrea1, D. Ostroveanu1, A. Dumitrescu T. Puscariu1, D. Vasilache1, C. Ghilic1, A. Ilea2, C. Mller-Tidow3 1Centrul de Hematologie si Transplant Medular Fundeni, 2Spitalul Codlea, 3Universittsklinikum Mnster/Germania The association between hematological malignancies (especially chronic lymphocytic leukemia CLL) with other cancers was described in the literature. The work presents three cases with concomitant diagnosis of chronic myeloproliferative and lymphoproliferative diseases. In all cases were performed complex laboratory investigations for a strict diagnosis of both associated blood diseases. All the patients performed cytology, flow-cytometry, histopathology and immunohistochemestry, cytogenetic and molecular biology tests. In one case, lymphoid and myeloid cells cultures from bone marrow were effectuated. In another case, cytogenetic and immunophenotypic tests on the lymph node were executed. Too cases were CLL in early stage, the first associated with Ph1+ Chronic Myeloid Leukemia (CML). The second patient had added to CLL megakaryocytic hyperplasia with peripheral thrombocytosis. The molecular biology tests performed in Germany were negative for Jak 2 si bcr-abl (quantitative) mutations but positive for qualitative bcr-abl 2nd round. Ulterior, the bcr-abl test effectuated in MD Andersson Cancer Center (USA) and the diagnosis of essential thrombocythemia was established. The third case was T lymphoblastic lymphoma (with myeloperoxidase positive and Ph1+ chromosome positive in lymph node mononuclear cells) associated with an atypical major bcr-abl positive chronic myeloproliferative syndrome. These cases raise the problem of pathogenic mechanism videlicet if the mutant event happened primordial, uncommitted stem cell level or they were more mechanisms who acted on already committed to myeloid or lymphoid stem cells. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< EVOLUTIASI METAMORFOZAREABOLILOR MIELOPROLIFERATIVE CRONICE E. Gheorghita, Raluca Pirau, Genica Vulcan, Alina Rosca, Mihaela Lazaroiu, Carmen Paripas, Loredana Botos, Nicoleta Palade Spitalul Clinic Judetean de Urgenta Brasov, sectia Hematologie Autorii si-au propus sa analizeze evolutia si modul de metamorfozare a diferitelor forme de afectiuni cuprinse in cadrul bolilor mieloproliferative cornice (BMTC: policitemia vera-PV, metaplazia mieloide cu mielosclerozaMMM, leucemia granulocitara cronica-LGC, trombocitemia esentiala-TE).

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Au fost inclusi in studiu 549 pacienti cu BMPC (femei/ barbati=1,28, cu varste extreme 21-88 ani), aflati in evidenta la sectia de Hematologie a SCJUBrasov, in perioada 01.01.1978-01.08.2007; din acesti pacienti 248 sunt in viata, restul de 301 au decedat din diverse motive (infectii, hemoragii, tromboze, transformare leucemica, insuficienta cardiaca, insuficienta renala, insuficienta hepatica). Distributia lotului pe afectiuni a fost: 186 pacienti cu PV(33,88%), 145 pacienti cu LGC (26,42%), 113 pacienti cu MMM (20,58%), 105 pacienti cu TE (19,12%). Din totalul BMPC s-au metamorfozat in evolutie113 cazuri, respectiv 22 din cazurile cu PV (6 cazuri in TE, 10 cazuri in MMM, 3 cazuri in LGC si 3 cazuri in LA) in medie la 66,07 luni de la debut, respectiv 73 din cazurile cu LGC (7 cazuri in MMM, 1 caz in TE, 65 cazuri in LGC puseu blastic) in medie la 30,08 luni de la debut, 6 din cazurile cu MMM (4 cazuri in MMA, 1 caz in PV, 1 caz in LGC) in medie la 57,25 luni de la debut, 12 cazuri cu TE( 3 cazuri in LGC, 2 cazuri in PV, 2 cazuri in PV ulterior in MMA, 3 cazuri in MMM si 2 cazuri in SMD), in medie la 36,29 luni de la debut. De mentionat ca pacientii cu PV metamorfozati in LA au fost tratati astfel: 1 caz a fost tratat cu hydree si s-a transformat in LAM in 2 ani, iar ceilalti doi au fost tratati cu hydree si alkeran si s-au transformat in LAM si respectiv LAL, in 14 si respectiv 6 ani. In concluzie in topul afectiunilor mieloproliferative cronice cu transformarea cea mai tardiva se mentine PV (66,07 luni), urmata de MMM (57,25 luni), in timp ce LGC si TE au prognostic mai nefavorabil.

THE EVOLUTION AND THE METAMORPHOSIS OF THE CHRONIC MYELOPROLIFERATIVE DISEASES poster E. Gheorghita, Raluca Pirau, Genica Vulcan, Alina Rosca, Mihaela Lazaroiu, Carmen Paripas, Loredana Botos, Nicoleta Palade Spitalul Clinic Judetean de Urgenta Brasov, sectia Hematologie The authors proposed to analyse the evolution and the way of metamorphosis of the different conditions included in the chronic myeloproliferative diseases (Chronic Myelogenous LeukemiaCML, Polycythemia VeraPV, Essential ThrombocytemiaET, Myeloid Metaplasia with Myelofibrosis-MMM). The study included 549 patients with a form of chronic myeloproliferative disease (women/men = 1.28, with ages ranging between 21 and 88 years), in the evidence if the Hematology ward of the Emergency Clinical Hospital Brasov from 1.01.1978 1.08.2007. 248 of the patient are alive, the other 301 died of various reasons (infections, hemorrhage, thrombosis, leukemic transformation, heart failure, kidney failure, liver failure, etc.).The patients are distributed as it follows : 186 patient with PV (33.88%), 145 patients with CML (26.42%), 113 patients with MMM (20.58%), 105 patients with ET (19.12%) . Of all the chronic myeloproliferative diseases included, 113 cases metamorphosised during the period of evolution. 22 cases of PV changed as it follows : 6 patients in ET, 10 patients in MMM, 3 patients in CML, 3 patients in acute leukemia, in a mean period of 66.07 months from the original diagnosis. 73 cases of CML suffered metamorphosis during the period of evolution : 7 cases changed into MMM, 1 case changed into ET, 65 cases changed into CML blastic crisis, in a mean period of 30.08 monts from the diagnosis. 6 of the cases known with MMM evolved as it follows : 4 cases into acute MMM, 1 case in PV and 1 case in CML in a mean period of 57.25 months from the initial diagnosis. 12 cases of ET suffered the following evolution : 3 cases into CML, 2 cases into PV, 2 cases into PV then into MMM, 3 cases into MMM and 2 cases into myeolodysplastic syndrome, in a mean period of 36.29 months from the onset of the disease. We would like to mention that the patients diagnosed with PV who evolved into acute leukemia were treated as it follows : 1 case received Hydrea and evolved into Acute Myelogenous Leukemia in a period of 2 years; the other 2 patients received Hydrea and Alkeran and evolved into Acute Myelogenous Leukemia in 14 years, respectively into Acute Lymphoblastic Leukemia in 6 years. In conclusion, on top of the chronic myeloproliferative diseses, the latest metamorphosis in suffered by the PV (66.07 months), followed by the MMM (57.25 months), because CML and ET have a worse prognosis. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< DIFICULTI N DIAGNOSTICUL HEMOFILIEI A I B CU INHIBITORI MANAGEMENTULTRATAMENTULUI. Institutul Clinic Fundeni Clinica de hematologie si transplant medular Stefan Berceanu Bucuresti DATE DE LABORATOR I

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Uscatescu Valentina , Ostroveanu Daniela , Stoia Razvan , Georgescu Otilia . Tehnicieni : Chiriac Elisabeta , Taru Viorica , Viziru Claudia . ISTORIC : Anticorpii antifosfolipidici cuprind o familie de imunoglobuline caracterizata printr-un patern de reactivitate intr-o serie de teste de laborator . Aceasta familie include lupusul anticoagulant (LA) , anticorpii anticardiolipinici (ACA) si anticorpii care produc teste biologic fals pozitive in testele serologice pentru sifilis . Scopul prezentarii noastre a fost de a determina prevalenta acestor anticorpi la pacientii hemofilici si cu boala von Willebrand si sa determinam relatia cu infectiile produse de hepatita B (HBV) , hepatita C (HCV) sau HIV . Aceasta scurta prezentare este o parte dintr-un studiu prospectiv, pentru monitorizarea inhibitorilor factorilor coagularii la pacientii hemofilici si nonhemofilici si din acest punct de vedere sa putem institui un tratament corect . SCOP: Pacientul , hemofilic sau nonhemofilic poate produce anticorpi din diferite subclase de Ig G, directionati impotriva diferitilor epitopi ai moleculei de FVIII ( multi anticorpi sunt comuni in populatia hemofilica) . Acesti anticorpi se leaga de domeniile C2 ( sauA2) ale FVIII . Pierderea domeniului C2 care se leaga de fosfolipidul procoagulant fosfatidilserina pe plachetele activate si celulele endoteliale si de factorul von Willebrand , duce la reducerea activitatii procoagulante . STUDIUL POPULATIONAL Acest scurt studiu a demarat in urma observatiilor clinice anumiti pacienti chiar cu un tratament corect si cu o buna monitorizare a terapiei au o recuperare mai lunga . In acelasi timp se pare ca dozele de complex coagulant antiinhibitori este mai mare . METODE TEHNICI DE LABORATOR Recoltarea de sange : se recolteaza sange venos pentru determinarea PT, APTT , TT, FVIII , FIX , Fibrinogen , KGT , dRVVT , TITT , PNP . FVIII s-a determinat coagulologic si cromogenic . S-au efectuat numaratori complecte (HGL) , VSH , teste functionale renale si hepatice , proteine serice si determinarea imunoglobulinelor .S-au efectuat teste pentru infectiile cu HIV , HCV, HBV. Statusul imunologic s-a efectuat prin determinarea CD4. Nivelul viremiei pentru HIV s-a analizat prin PCR . S-au efectuat teste serologice pentru sifilis (VDRL) . LA s-a diagnosticat bazat pe testele KCT, TITT , sau dRVVT cu teste pozitive PNP . ACAs-a diagnosticat prin prezentaACAIgAsi /sau ACAIg M-anticorpi . APTT corectat (dependent de temperatura si timp ) a fost determinat pentru identificarea inhibitorilor anti FVIII sau anticorpilor antifosfolipid si a fost confirmat prin testul Bethesda . Testele de corectie au fost realizate imediat dupa amestecul plasmatic , dupa 1 ora de incubatie la 37 grade Celsius si imediat dupa amestecul plasmelor separate si incubate . REZULTATE Dezvoltarea inhibitorilor anti FVIII reprezinta o complicatie majora la pacientii hemofilici desi in studiul abordat de noi prevalenta inhibitorilor anti FVIII si LA a fost mai scazuta decat in alte studii similare .Prezenta lupusului anticoagulant poate interfera cu testele de prim diagnostic al FVIII coagulologic mimand un inhibitor al FVIII . Am investigat modalitatile prin care lupusul anticoagulant determinat prin dRVVT poate da valori fals pozitive ale titrului de inhibitori determinati prin metoda Bethesda . DISCUTII Anticorpii antifosfolipidici pot apare in populatia cu hemofilie astfel ca un test pozitiv dRVVT este comun cu inhibitorii anti FVIII . Poate fi posibil ca anticorpii antifosfolipidici sa se lege de fosfolipidele din plasma de normal in tehnica Bethesda care duce la un dRVVT slab pozitiv. Din cauza rarietatii acestei interferente , trialuri controlate randomizate nu au fost efectuate , pentru a putea compara direct tratamentul sau sa exprimam factorii care pot duce la aceste modificari . Bibliografie : nti factor VIII inhibitors and lupus anticoagulants in haemophilia patients (Blanco ) ; A chromogenic assay allows reliable measurement of FVIII levels in the presence of strong lupus anticoagulants (Mastre )

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DIFFICULTIES IN THE DIAGNOSIS OF HAEMOPHILIA A AND B WITH INHIBITORS LABORATORIES DATAAND THE MANAGEMENT OF THE TREATMENT Uscatescu Valentina, Ostroveanu Daniela , Stoia Razvan, Georgescu Otilia Tehnicieni : Elisabeta Chiriac , Viorica Taru ,Claudia Viziru Clinical Institute Fundeni, Department Of HaematologyAnd Bone Marrow Transplantation BACKGROUND: Antiphospholipid antibodies comprise a family of immunoglobulins characterised by their pattern of reactivity in a number of laboratory test. This family include lupus anticoagulant (LA), anticardiolipin antibodies (ACA) and antibody causing biologic false positive serologic test for syphilis. The purpose of our presentation was therefore to determine the prevalence of these antibodies in haemophilia and von Willebrand patients and to determine the relationship with blood infections caused by hepatitis B( HBV), hepatitis C (HCV), or HIV viruses . This short presentation is a part from a large study started as prospective observation for monitoring the inhibitors against coagulation factors in haemophilic and nonhaemophilic patients and from this point of view to manage the treatment. AIMS: An individual patient, either nonhaemophilic or haemophilic, can produce antibodies of different IgG subclasses directed against different epitopes on the FVIII molecule (multiple antibodies is much common in patients with haemophilia). These antibodies bind to the C2 (or A2) domain on FVIII. Loss of the C2 domain, which binds to the procoagulant phospholipid phosphatidylserine on activated platelets and endothelial cells and to von Willebrand factor, leads to a reduced procoagulant activity. PATIENT POPULATION This short study has started during clinical observations that some of our patients even with a correct treatment and good monitoring of the therapy have a long recovery. In the same time it seems that the dosages of antiinhibitorcoagulant complex are much higher . METHODS: BLOOD SAMPLING: Venous blood was collected for determination of PT, APTT, TT, FII, FIX, Fibrinogen, KGT, dRVVT, TITT, PNP. Coagulation and chromogenic FVIII were performed. A full blood count, erythrocyte sedimentation rate, renal and liver function tests, serum protein and immunoglobulins were performed. Were tested HIV, HCV and HBV infection. Immunological status was performed by CD4 determination. HIV viral charge was analysed by PCR. Serologic test for syphilis (VDRL) was done. LAwas diagnosed based on the coexistence of KCT, TITT or dRVVT with PNP positive test. ACAwas diagnosed by the presence ofACAIgAand/orACAIgM antibodies. APTT correction (time and temperature dependent) were determined to identify anti FVIII inhibitors or antiphospholipid antibodies and it was confirmed by the Bethesda assay. These correction tests were realized immediately after the mixture, after one hour of incubation at 370C and immediately after the mixture previous separately incubation. RESULTS: The development of anti-factor VIII inhibitors are a major clinical complication in haemophilia our prevalence of anti FVIII inhibitors and LA was lower than in other studies. A lupus anticoagulant may interfere with the one - stage factor VIII clotting assay mimicking a Factor VIII inhibitor. We investigated whether a lupus anticoagulant, as detected by the dilute Russell's viper venom time (dRVVT), may falsely elevates a positive Bethesda titer. DISCUSSION: Antiphospholipid antibodies can develop in haemophilic population so our findings suggest a positive dRVVT common with a Factor VIII inhibitor. It may be possible that antiphospholipid antibody bound to the phospholipid in the normal plasma in the Bethesda assay which provoke a dRVVT weakly positive. Because of the rarity of these disorders, randomized controlled trials have not been conducted either to compare treatments directly or to examine the factors indicating a favourable outcome. REFERENCES Anti factor VIII inhibitors and lupus anticoagulants in haemophiliaApatients ( Blanco ) ; A chromogenic assay allows reliable measurement of FVIII levels in the presence of strong lupus anticoagulants (Mastre)

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>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> VALOAREA EXAMENULUI GENETIC IN LEUCEMIILE ACUTE MONITORIZAREATRATAMENTULUI Veronica Teleanu Clinica de Hematologie, Institutul Clinic Fundeni, Bucureti Examenul citogenetic a devenit investigatie absolut obligatorie in cadrul diagnosticului, stratificarii si monitorizarii leucemiilor acute. Caracterizarea din punct de vedere al modificarilor genetice in leucemiile acute comporta doua nivele de sensibilitate 1) examenul citogenetic clasic si 2) analiza moleculara. A. Valoarea analizei genetice in Leucemiile acute mieloblastice. 1. La diagnostic- examenul citogenetic clasic permite stratificarea pacientior in trei grupe de prognostic: prognostic bun ( t(8;21), inv16, t(16;16), t(15;17) ), prognostic intermediar ( cariotip normal, restul modificarilor care nu se incadreaza in grupele 1 si 3), prognostic nefavorabil ( modificarile complexe de cariotip). In cadrul grupului cu prognostic bun si nefavorabil conduita terapeutica poate fi transata de la diagnostic. Studiile au dovedit faptul ca prima categorie raspunde bine la chimioterapia cu doze mari de cytarabina (+/-antraciclina sau amsacrina). In grupul cu prognostic nefavorabil, rezultatele obtinute cu chimioterapie sunt nesatisfacatoare, allotransplantul de CSP influentand semnificativ supravietuirea acestor pacienti. La pacientii cu prognostic intermediar, un procent semnificativ este reprezenat de pacientii cu cariotip normal la care identificarea markerilor moleculari este esentiala. In prezent, cu impact asupra prognosticului si in ghidarea terapiei sunt analizate mutatiile genei FLT3( FLT3 ITD) si NPM1 (nucleophosmina sau numatrina). Identificarea FLT3 ITD este asociata cu un prognostic nefavorabil, cu raspuns slab la chimioterapie. Identificarea mutatiiloe la nivelul NPM1 confera un prognostic favorabil. 2. monitorizarea raspunsului la chimioterapie-studiile au aratat ca persistenta modificarilor citogenetice de la diagnostic in Ia RC morfologica, confera un prognostic nefavorabil asupra parametrilor de supravietuire B. Valoarea analizei genetice in Leucemiile acute limfoblastice. 1. La diagnostic imunofenotiparea este esentiala. Analiza markerilor genetici permite totodata incadrarea in grupe de risc ( standard, inalt si foarte inalt). Modificarile citogenetice minum obligatoriu de cercetat sunt t(9;22) ( risc foarte inalt) si t(4;11) (risc inalt). Daca nu pot fi identificate prin examen citogenetic clasic vor fi cautate prin tehnici moleculare ( FISH, RT-PCR). Pentru monitorizarea bolii mnime reziduale (BMR) in LAL, la diagnostic, se impune identificarea modelului rearajamentelor regiunilor jonctionale ale genelor Ig sau TCR, considerate DNA fingerprints ale clonei leucemice. 2. Monitorizarea raspunsului terapeutic si ghidarea terapiei. Identificarea BMR (prin RQ-PCR) este ceruta in protocoale actuale de tratament al LAL atat la adult cat si la copil. Se realizeaza astfel o abordare secventiata a stratificarii riscului: o prima stratificare la diagnostic in functie de factorii conventionali de risc si o a doua stratificare a pacientilor cu risc standard in funcie de MRD. Din punct de vedere clinic se desprind urmatoarele consecinte a) redefinirea criteriilor de RC ( RC moleculara) b) redefinirea unor noi factoi de prognostic ( stratificarea in funcie de BMR) c) ghidarea si monitorizare terapiei in functie de BMR. THE VALUE OF GENETIC ANALYSIS IN ACUTE LEUKEMIAS-RISK STRATIFICATION AND THERAPY OPTIONS Veronica Teleanu Clinic of Hematology, Fundeni Clinical Institute, Bucharest The cytogenetic examination is an essential tool for the diagnosis, risk stratification and treatment monitoring in acute leukemias. From genetic point of view, there are two levels of sensibility that can be distinguished: 1. the classical cytogenetic analysis and 2. the molecular analysis of genetic abnormalities. A. The value of the genetic analysis in adult acute myeloid leukemias (AML) 1. At diagnosis- based on the cytogenetic pretreatment findings, patients are stratified in three prognostic groups: favorable risk group ( t(8;21), t(16;16), inv16, t(15;17)), intermediary risk group( normal cytogenetics NC, and abnormalities that are not included in the firs and third group), adverse risk group ( complex caryotype). For the favorable and adverse prognostic groups, the therapeutic strategies can be underlined from the beginning. The first cathegory of patients respond well to postremission therapy with high doses of cytarabine( +/- anthracycline or amsacrine) whereas the results that are obtained with chemotherapy in the adverse risk group being dismal, allogeneic stem cell transplantation considerably improving survival for these patients. Within the intermediary prognostic group, STRATIFICAREA RISCULUI SI

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a significant proportion display NC and further molecular markers are needed for risk stratification. There are several markers under investigation. The most important ones with clinical impact are the mutation of the FLT3 gene ( FLT3 ITD) and the mutation of the NPM1 gene ( nucleophosmine or numatrine). Identification of the FLT3ITD is associated with a poor outcome, whereas mutation of the NPM1 gene are associated with a favorable course and treatment response. 2. Treatment monitoring- studies showed that identification of cytogenetic pretreatment abnormalities in first morphologic complete remission, worsens survival. B. The value of genetic analysis in acute lymphoblastic leukemia (ALL) in adults 1. At diagnosis-immunophenotyping is essential. Genetic markers contribute to risk stratification ( standard risk group, high risk group, very high risk goup). Minimal genetic screening is required for t(9;22) ( very high risk) and t(4;11) (high risk). If these can not be identified by classical cytogenetic examination, further molecular genetic analysis must be performed ( FISH, RT-PCR). For monitoring the minimal residual disease (MRD) in ALL, the specific jonctional regions of rearranged immunoglobulin Ig genes and T-cell receptor, TCR genes are analysed. 2. Therapy monitoring and treatment guiding. MRD evaluation (by RQ-PCR) is incorporated in the modern treatment protocols for adult and childhood ALL. Thus, a secvential risk stratification is applied: firs at diagnosis based on conventional risk factors and second, during treatment, based on MRD. Few clinical consequences can be withdrawn: a) refinig the complete remission criterias(e.g. molecular complete remission) b) refining of new prognostic factors (MRD based risk stratification)c) risk factors driven therapy >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> CRIZABLASTICAIN LEUCEMIAMIELOIDACRONICALAPACIENTII TRATATI CU IMATINIB O.Georgescu,M.Anitei,AColita, D.Ostroveanu,D.Iancu Clinica de hematologie Fundeni, Bucuresti Leucemia mieloida cronica(LMC) evolueaza in majoritatea cazurilor catre o faza mai agresiva ,cu raspuns prost la tratamentul care controla faza cronica. Aceasta tranzitie poate fi brusca sau trecand printr-o etapa intermediara, numita faza accelerate. Progresiunea de la faza cronica la cea accelerate poate fi anuntata de noi anomalii cromozomiale si de cresterea expresiei BCR-ABL. Autorii prezinta un studiu efectuat pe 150 pacienti eligibili cu LMC tratati cu Imatinib in perioada 2001-2007. Se iau in discutie particularitatile de evolutie a LMC si rezultatele tratamentului efectuat. Sunt prezentate cazurile care au evoluat catre faza accelerata sau criza blastica, tipul morfologic al crizei blastice, anomaliile cromozomiale asociate si raspunsul la tratamentul cu Imatinib. BLAST CRISIS IN CHRONIC MYELOID LEUKEMIAPATIENTS TREATED WITH IMATINIB O.Georgescu,M.Anitei,AColita, D.Ostroveanu,D.Iancu Fundeni Clinical Institute, Bucharest In most cases of Chronic MyeloidLeukemia(CML),the patient's desease eventually changes to a more aggressive phase,which is poorly responsive the therapy that the formerly controlled the chronic phase. The transition can be unexpectedly or gradually including an accelerated phase.Progression of chronic phase is marked by additional chromosomial abnormalities,and an increase in BCR-ABL expression. The authors present a study on 150 eligible patients with CML admitted in our hospital between 2001-2007.They discuss about the specific features of the desease and the treatment results.They also present the cases with accelerated or blastic phase,the morphologic type of blastic crisis,chromosomial abnormalities and the response to Imatinb treatment. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< PARTICULARITATI EVOLUTIVE INTR-UN CAZ DE LEUCEMIE MIELOIDACRONICA

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O.Georgescu,M.Anitei, D.Ostroveanu,C.Dobrea,D.Iancu Clinica de hematologie Fundeni Leucemia mieloida cronica (LMC) este o afectiune clonala caracterizata printr-o translocatie cromozomiala specifica :t(9;22)(q34;q11).Boala progreseaza ,cu o supravietuire medie de 3-5 ani,de la o faza cronica la o faza refractara (faza accelerate sau faza blastica terminala). Autorii prezinta cazul unei paciente de 56 ani care a avut o supravietuire de aproximativ 9 ani.Cazul este interesant prin faptul ca la 6 luni de la diagnostic pacienta a intrat in criza blastica,dar dupa chimioterapie intensiva (TRAMPCOL) a revenit la faza cronica.Ulterior,pacienta a efectuat 2 ani tratament cu Interferon si apoi cu Imatinib.Desi examenul de maduva osoasa a aratat mentinerea fazei cronice,studiile citogenetice au aratat evolutivitatea bolii. Din xi 2006 pacienta a inceput sa prezinte infectii repetate,iar analizele efectuate au aratat pancitopenie severa,far aca examenul de maduva sa prezinte elemente de aplazie medulara sau fibroza. In ciuda tratamentului antibiotic intens,al corticoterapiei si substitutiei,trombocitopenia a persistat,pacienta decedand prin hemoragie cerebrala. Autorii pun in discutie etiologia pancitopeniei :infectioasa versus aplazie secundara fazei terminale a LMC.

SPECIFIC FEATURES OF CLINICAL EVALUATION INACASE OF CHRONIC

MYELOID LEUKEMIA

O.Georgescu,M.Anitei, D.Ostroveanu,C.Dobrea,D.Iancu Fundeni Clinical Institute, Bucharest Chronic Myeloid Leukemia (CML) is a stem cell disorder characterized by a specific chromosomial disorder: t(9;22)(q34;q11).The desease progress within a median time of 3-5 years,from an indolent initial chronic phase to a refractory acute leukemia,describe as terminal blast crisis. The authors pesent a 56 years female with CML who had a 9 years survival.6 month from onset ,the patient develops blast crisis,but after intensive chemotherapy (TRAMPCOL-like) she underwent to chronic phase.Two years the patient's therapy was Interferon and afterwards,Imatinib. Althrougt,the marrow biopsy showed chronic phase,the cytogenetic analisis showed complex chromozomial abnormalities. From November 2006 the patient presented many infections, and analyses releaved severe pancytopenia, although marrow biopsy had no aplastic or fibrotic features. The therapy consisted in broad-spectrum antibiotics, corticosteroids and supportive care but severe thrombocytopenia persisted and unfortunately she died with brain hemoragy. The authors discuss about the ethiology of pancytopenia: infections versus terminal blast crisis aplasia. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< LIMFOM SPLENIC VERSUS METAPLAZIE MIELOIDA- DIFICULTATI DE DIAGNOSTIC- PREZENTARE DE CAZ O.Georgescu,M.Anitei, D.Ostroveanu,C.Dobrea R.Stoia,V.Uscatescu Clinica de hematologie Fundeni Metaplazia mieloida (MMM) este o boala mieloproliferativa caracterizata prin leucoeritroblastoza, eritrocite in picatura, hepatosplenomegalie cu hematopoieza extramedulara si o maduva hipercelulara cu fibroza asociata. Autorii prezinta un caz de MMM diagnosticat post-mortem prin examenul histopatologic al splinei si ganglionilor abdominali. Este vorba despre un barbat de 59 ani internat pentru leucocitoza si reactie leucemoida, trombocitopenie, hepatocitoliza, hepatosplenomegalie, adenopatie celio-mezenterica (19mm). Biopsia osoasa a aratat panmieloza cu deviere la stanga dar cu fibroza absenta. In acest context ne-am orientat catre un sindrom limfoproliferativ cronic si s-a practicat splenectomie in scop diagnostic.

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Din pacate, pacientul a decedat in ziua a-3-a postoperator prin sangerare difuza, iar examenul histopatologic al splinei si ganglionilor abdominali, efectuat post-mortem, a stabilit diagnosticul de MMM.

SPLEEN LYMPHOMA VERSUS AGNOGENIC MYELOID METAPLASIA- DIFFICULTIES IN DIAGNOSISCASE PRESENTATION O.Georgescu,M.Anitei, D.Ostroveanu,C.Dobrea,R.Stoia,V.Uscatescu Fundeni Clinical Institute, Bucharest Agnogenic myeloid meplasia (AMM), a chronic myeloproliferative disease, is characterised by leukoerythroblastosis and dacriocytes in peripheral blood,hepato-splenomegaly with extramedulary hematopoesis and a hipercellular marrow with fibrosis. We present a 59 year male admitted in our hospital with AMM established post-mortem.At presentation : leukocytosis with leukemoid reaction, thrombocytopenia, persistent elevated of serum transaminases, hepatosplenomegaly, celiomesenteric lymph node (19 mm). Bone marrow biopsy releaved panmyelosis and left shift , but no fibrosis. We thought that splenectomy could be more important for diagnosis. Unfortunatelly, the patient died three days after splenectomy. The histopatologic diagnosis of the spleen and lymph node made post-mortem wasAMM. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< CARACTERISTICILE PACIENILOR CU LIMFOM DIFUZ CU CELUL MARE B I HEPATIT VIRAL C Hortensia Ionita, Maria Iordache, Ioana Ionita, Rodica Mihaescu, Liviu Cheveresan, Maria Cheveresan, Claudiu Ionita, Doina Nicola, Dacian Oros UMF VICTOR BABES Timisoara Spitalul Clinic Municipal Timisoara, Clinica de Hematologie Introducere: hepatita viral C (HCV) este implicat n etiologia unor subtipuri de limfom non Hodgkin (LNH) ca i limfomul difuz cu celul mare B (DLBCL). Scop: am analizat caracteristicile unui lot de 82 pacieni cu DLBCL asociat cu HCV. Metod: am analizat retrospectiv profilul clinico-biologic al unui lot de 82 pacieni internai n Clinica de Hematologie Timioara n perioada 1993 2003. Toi pacienii au fost HIV negativ i au prezentat anticorpi HCV + prin metoda ELISA. Analiza statistic a fost efectuat cu programele EPI INFO 6 i INSTAT. Vrsta medie a pacienilor a fost 52,2 ani cu un raport brbai/femei = 1/1; determinri extranodale n 48 de cazuri, din care primitive extranodale 25(30.5%) i secundare extranodale 23(28%). Cele mai importante determinri extranodale au fost: stomacul, splina, ficatul i pielea. Tratamentul a fost CHOP sau de tip CHOP, un numr redus de pacieni a beneficiat de tratament CHOP i Rituximab. Rezultate: perioada de urmrire a fost de 48 luni, obinndu-se o supravieuire la 5 ani de 59%, n timp ce supravieuirea fr semne de boal la 5 ani a fost de 34%. Pacienii au prezentat: semne B n procent de 85%; IK <70 la 48,8%; IPI la diagnostic a fost sczut la 16%, intermediar spre sczut la 24%, intermediar spre nalt la 35% i nalt la 25%; 35 pacieni au prezentat Bulky disease; stadiul clinic a fost I,II/III,IV = 40/41; determinare medular n 14 cazuri; LDH = 672, 024 598,128 U/L, VSH=50,45 37,73mm/1h; Ki67=51,90 22,16. In 5% din cazurile cu DLBCL i HCV chimioterapia a fost ntrerupt datorit insuficienei hepatice. Concluzii: este important de cunoscut caracteristicile clinico-biologice ale pacienilor cu limfom disfuz cu celul mare B asociat cu hepatit viral C pe loturi mai mari de pacieni, lucru care ar clarifica legtura ntre infecia cu virusul hepatic C i limfoamele non Hodgkin agresive. Este necesar continuarea studiului prezentat pentru a evalua supravieuirea difereniat a subtipurilor nodale i extranodale de limfoame.

DIFFUSE LARGE B CELL LYMPHOMAAND HEPATITIS C VIRUS INFECTION CLINICO-BIOLOGICAL CHARACTERISTICS

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Hortensia Ionita, Maria Iordache, Ioana Ionita, Rodica Mihaescu, Liviu Cheveresan, Maria Cheveresan, Claudiu Ionita, Doina Nicola, Dacian Oros UMF VICTOR BABES Timisoara Spitalul Clinic Municipal Timisoara, Clinica de Hematologie Background: The Hepatitis C Virus (HCV) infection is involved in the etiology of some subtypes of non Hodgkin's lymphoma (NHL) as diffuse large B cell lymphoma (DLBCL). Aims: We analyzed the clinico-biological characteristics of a group of 82 patients with DLBCL associated with HCV infection. Methods: We did a retrospective analysis of the clinical and biological profile of 82 patients hospitalized in the Hematology Clinic during 1993-2003. All patients were HIV negative and they were positive at diagnosis for the HCV antibodies Elisa method. The statistical analysis was performed with the special programs EPI INFO 6 and INSTAT. The group had : medium age - 52,2 years; males/females=1/1; extranodal determinations - 48 cases - primitive extranodal 25 cases (30.5%) and secondary extranodal 23 cases (28%). The most important extranodal determinations were the stomach, the spleen, the liver, the skin. The treatment was CHOP or CHOP-like regiments. A small number of cases received CHOP and Rituximab. Results: Medium follow-up was 48 month for the survivors and the overall survival at 5 years was 59%, while failure free survival at 5 years was 34%. B signs - 66 patients (80,5%); IK < 70 40 cases (48,8%);IPI at diagnosis was 16% low, 24 % int.low, 35% int/high and 25% high; Bulky disease - 35 cases (42,7%); clinical stage I,II/III,IV=40/41; medullar determination - 14 cases (17,2%); LDH = 672,024598,128 U/l; ESR = 50,4537,73 mm/h; Ki67 = 51,9022,16. In 5% of DLBCL and HCV positive patients the chemotherapy was discontinuous because of the hepatic failure. Conclusions: It is important to recognize the clinical and biological features of DLBCL with HCV positive patients for bigger groups, which could clarify the connection between HCV infection and aggressive non Hodgkin lymphomas. It is also necessary to continue the study in order to evaluate the differentiate survival of nodal and extranodal types of lymphomas. <<<<<<<<<<<<<<<<<<<<<<<<<<<<< PROFILUL CLINICO-BIOLOGICAL PACIENILOR CU MIELOM MULTIPLU LAPRIMAPREZENTARE Ioana Ionita, Hortensia Ionita, Ruxandra Laza, Rodica Mihaescu, Maria Iordache, Kinga Vasile UMF VICTOR BABES Timisoara Introducere: n ciuda experienei clinice dobndite pn acum recunoaterea mielomului multiplu n stadii incipiente este nc nesatisfctoare. Scop: s analizm profilul clinico-biologic al pacienilor cu mielom multiplu (MM) la prima prezentare n clinic, pentru a identifica factorii care ar putea crete eficiena diagnosticului precoce. Metod: am analizat un lot de 125 pacieni cu gamapatie monoclonal tratai n Clinica de Hematologie Timioara n perioada ianuarie 1999 - mai 2005. Am analizat structura grupului, perioada asimptomatic n evoluia bolii, natura manifestrilor clinice, modificrile biologice i paraclinice, structura diagnosticelor de mprumut, clinicile care ne-au trimis pacienii i stadiul bolii. Rezultate: diagnosticele au fost MM - 88% din pacieni, boala Waldenstrom 8%, Plasmocitom solitar 7%, MGUS 5%. Modificrile biologice au fost: VSH crescut-15%, anemie 15%, hipergamaglobulinemie 8%, hiperproteinemie 1,5% i migrare monoclonal 1,5%. Cel mai important semn clinic a fost durerea osoas, urmat de manifestri neurologice. Clinicile care au contribuit la identificarea bolii au fost de Medicin Intern, Gastroenterologie, Nefrologie, Neurochirurgie, Cardiologie, Dializ, Pneumoftiziologie, Neurologie, Urologie, reumatologie etc. La diagnostic pacienii erau n std.I 11%, std.II-16%, std.III-73%. Diagnosticele de mprumut au fost anemie, boala lombar, tumor toracic, gamapatie monoclonal, insuficien renal cronic, radiculonevrit, boala reumatic etc. Ce este important n rezultatele studiului este faptul c 74% din pacienii cu suspiciune de mielom au fost trimii din alte uniti spitaliceti, nu din cadrul unitilor de medicin primar i faptul c procentul de pacieni n stadiul III la diagnostic a fost de 73%.

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MULTIPLE MYELOMA- CLINICO-BIOLOGICAL PROFILEAT FIRST PRESENTATION Ioana Ionita, Hortensia Ionita, Ruxandra Laza, Rodica Mihaescu, Maria Iordache, Kinga Vasile UMF VICTOR BABES Timisoara Background: Despite all the clinical experience gained since now, the recognition of the disease in early stage continues to be unsatisfying. Aims: In order to identify the factors which could increase the efficiency of the early diagnosis, we analised the clinicobiological profile of multiple myeloma (MM) patients at their first presentation. Methods: We analized a group of 125 patients with monoclonal gamapathy treated in the Hematology Clinic of Timisoara during ianuary 1999 - may 2005. We studied the structure of the analysed group, the asimptomatic period in the disease evolution, the nature of the clinical manifestations, biological and paraclinical modifications, the structure of borowed diagnostics, the clinics that sent us patients with MM suspicion, the disease stage. Results: 88% of MM patients, 8% of Waldenstrom disease, 7% of solitary plasmocytoma and 5% of MGUS. Biological modifications were: increased ESR 15%, anemia 15%, hypergamaglobulinemia 8%, hyperproteinemia 1,5%, monoclonal migration 1,5%. The most important clinical sign was the bone syndrom, followed by neurological manifestation. The profile of the clinics that contribued to the identification of the disease was: internal medicine, gastroenterotogy, nephrology, neurosurgery, cardiology, dialisis, pneumophtisiology, neurology, urology, reumatology and others. At diagnosis patients were in stage I 11%, stage II 16%, stage III 73%. Borowed diagnosis were: anemia, lumbar disorder, toracic tumor, monoclonal gamapathy, chronic renal failure, radiculonevritis, reumatic disorder and others. What is realy important in the results of our study is that 74% of the patients with MM suspicion came from other hospital units not from the primary medicine units and also the percent of patients in stage III at diagnosis was 73%. Conclusions: 73% of patients were stage III at first presentation which means that there are some problems to recognise and supervise this disease at primary medicine units. There are some biological test that remain unused for the patients which could contribue at early diagnosis of MM. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< DEPISTAREASTRILOR TROMBOFILICE EREDITARE EXPERIENACLINICII DE HEMATOLOGIE M.Ioni1, Rodica Pcurar2, Doina Nicola2, Ioana Ioni, Delamarian Maria Mihaela2, C.Ioni2, D.Oro1, Monica Chereji1, Hortensia Ioni1 1.Disciplina de Hematologie U.M.F.Victor Babe Timioara 2.Clinica de Hematologie Spitalul Clinic Municipal Timioara Introducere Principalele cauze ale trombofiliei ereditare cunoscute pn n prezent sunt: deficitele proteinelor C (PC) i a proteinei S (PS), mutaii ale genelor factorilor II i V, deficitul antitrombinei III (ATIII) i nivelul crescut de Factor VIII:C precum i hiperhomocisteinemie. Avnd n vedere costurile ridicate pentru diagnosticul unei trombofilii ereditare se pune ntrebarea care pacieni trebuie testai i care sunt testele screening pentru depistarea strilor trombofilice ereditare. Material i metod. Dup atestarea clinic i biologic a strii de hipercoagulare am investigat pacienii pen urmtoarele teste de screening de depistare a unei trombofilii ereditare: analiza global a cii proteinei C, Proteina C, Proteina S, Rezistena la Proteina C activat, Fibrinoliza, Anticoagulantul lupic, Mutaia protrombinei, Creterea niv.F.VIII, Lipide. Am analizat un lot de 135 pacieni care au fost adresai Clinicii de Hematologie n ultimii 5 ani la care s-a ridicat suspiciunea de trombofilie ereditar i care au prezentat manifestri tromboembolice. In selecia pacienilor am utilizat urmtoarele date care sugereaz prezena unei trombofilii ereditare: tromboz aprut la vrst tnr (15-45 ani);istoric familial de tromboze; tromboze aprute n teritorii atipice: vena port, vene hepatice, vene mezenterice, vene axilare, vene cerebrale, artere retiniene, renale; tromboze recurente cu sau fr factori precipitani i n ciuda terapiei adecvate, aprute n teritorii diferite de la un episod trombotic la altul; necroz cutanat

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indus de tratamentul cu antivitamina K. Rezultate S-a constatat absena oricrei deficiene la 62% din cazuri. Deficit de Proteina C la 13% cazuri. Deficit de Protein S la 16% cazuri.Deficit mixt de proteina C i S la 3% cazuri, rezisten la proteina C activat la 6 cazuri. Concluzii. Incidena deficitului funcional de Protein C i S i proteina C activat la pacienii cu boal tromboembolic recurent crete cnd selecia pacienilor este foarte strict, astfel nct aceast testare devine deosebit de eficient. Aceast testare trebuie continuat la rudele pacienilor pentru a avea o atitudine terapeutic i o profilaxie adecvat.

DIAGNOSIS OF HEREDITARYTHROMBOFILIA. THE EXPERIENCE OF OUR HEMATOLOGY CLINIC M.Ioni1, Rodica Pcurar2, Doina Nicola2, Ioana Ioni1, Delamarian Maria Mihaela2, C.Ioni1, D.Oro1, Monica Chereji1, Hortensia Ioni1 1.University of Medicine and Pharmacy Victor Babe Timisoara- Department of Hematology 2.County Hospital Timisoara Backround: The most important causes of the Hereditary Thrombofilia are: protein C (PC) deficiency; protein S (PS) deficiensy, mutations of factor II and V genes, antitrombine III (AT III) defiency, high level of factorVIII: C and hy per homocysteinemia. The high cost of the tests for the diagnosed of there .... trombophilia make us wonder wich are the patients that shoul be tests and what are the screening tests for this disease. After clinical and biological diagnosis of hypercoagulant phosphilipide sindrom. After we excluded the antiphospholipide sindrom we performed the folowing screening test for the diagnosed of the hereditary, thrombophilia: The global analisis of the protein C pathway, the protein C, protein S, the resistence to activated protein C, fibrinolisis, lupic anticoagulant; protrombine mutation....of FVIII; lipide levels. Matherials and methods: We analised a group of 135 patients which were adressed to the Hematology Clinic in the lost 3 years with the suspicion of hereditary, thrombophilia after thromboembolic manifestations. In the selection of the patient we used the following data: thrombosis in youngh patients (15-45 years); familia hystory of thrombosis thrombosis in unusual sites: part vein; hepatic vein; mesenteric vein; axilar vein; cerebral vein; retinian artery; renal artery recurent thrombosis whit or without agravating factors despite therapy, cutaneus necrosis due to antivitamine k therapy. Results. No deficiency in 62% of the cases, Proteinc C deficiency 13% of the cases, Protein S deficiency 16% of the patients, mixt protein C ands deficiency 6 cases. Conclusions: The incidence of Protein C and S deficiency, and activated protein C resistance in patients with recurent thrombosis increases when the selection of the patients is very strict, so the screening test are very efficient. The screening tests shoul continue for the family of our patients for an adegvate prophilaxy an therapy.

<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< TRATAMENTUL CU MABCAMPATH N LEUCEMIALIMFATIC CRONIC Hortensia Ioni1, Maria Cheverean2, L.Cheverean1, Ioana Ioni1, Rodica Mihescu1, Maria Iordache1, M.Ioni2, Despina Clmar1 1.Disciplina de Hematologie U.M.F.Victor Babe Timioara 2.Clinica de Hematologie Spitalul Clinic Municipal Timioara Introducere: MabCampath este primul anticorp monoclonal care i-a dovedit eficiena n tratamentul pacienilor cu LLC-B, care au fost tratai cu ali ageni alkilani sau care au reczut dup tratamentul cu Fludarabin MabCampath este un anticorp monoclonal direcionat mpotriva antigenului de suprafa limfocitar CD52.

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CD52 este exprimat pe suprafaa att a celulelor benigne ct i maligne: limfocite B i T, monocite i macrofage dar nu i pe celulele stem hematopoietice i foarte rar pe granulocite. Material i metod. Au fost tratate n Clinica de Hematologie un numr de 10 pacieni cu LLC- tip B conform protocolului de tratamente. i-a dovedit eficiena clinic mai ales la pacienii pretratai. Iniial cu administrare intravenoas: 30mg x 3 spt timp de maxim 12 sptmni Pe parcursul terapiei se impune profilaxia infeciilor cu Biseptol i Famciclovir sau echivalent i 2-3 luni dup. Actual exist posibilitatea de administrare s.c., cu efecte secundare locale minore, dar cu meninerea indicaiei profilaxiei infeciilor. Doza este de 10mg/zi s.c. de 3 ori pe spt., timp de 18 sptmni. Indicat la pacieni anterior tratai cu ageni alkilani i la care nu s-a obinut remisiune complet sau parial, sau s-a obinut o remisiune de scurt durat (mai puin de 6 luni) dup tratamentul cu Fludara. Indicat n tratamentul de consolidare n CLL, cu scopul de a eradica celulele leucemice reziduale de la nivel medular. Rezultate. MabCampath a fost asociat cu rate de rspuns obiective semnificative (76%), la pacienii intens pretratai. Rspunsul la MabCampath a fost rapid i durabil. Infecii de gradul 3-4 au survenit la 28% din pacieni. Majoritatea efectelor adverse au survenit n cursul primei administrri, dar au fost uoare sau moderate ca severitate. S-a constatat o reducere considerabil a masei tumorale asociat cu reducerea sau dispariia hepatosplenomegaliei dup administrarea de MabCampath la majoritatea pacienilor, incluznd att responderii ct i pe cei cu boal stabil. Concluzii. MabCampath a fost bine tolerat avnd n vedere starea precar a acestui grup de pacieni la momentul iniierii terapiei. S-a constatat ameliorarea sau dispariia simptomelor B i a altor simptome dup administrarea de MabCampath la majoritatea pacienilor, incluznd att responderii ct i pe cei cu boal stabil conform criteriilor NCI. Dup administrarea MabCampat s-a observat prelungirea perioadelor fr chimioterapie, fa de tratamentele anterioare. MABCAMPATH THERAPY IN CRONIC LYMPHOCYTIC LEUKEMIA Hortensia Ioni1, Maria Cheverean2, L.Cheverean1, Ioana Ioni1, Rodica Mihescu1, Maria Iordache1, M.Ioni1, Despina Clmar1 1.University of Medicine and Pharmacy Victor Babe Timisoara- Department of Hematology 2.County Hospital Timisoara Bakround: MabCampath - is the first monoclonal antibady efficient in the treatment of. Bcell CLL patients which were treated with athor alkilating agents or relapsed after Fludarabine treatment. MabCampath is a monoclonal antibody against limfocytic CD52 surface antibody; CD52 is expreesed on the surface of benigne and malignant cells: B and T limphocytes, monocytes and macrofage, but not on the hematopoietic stem cells on very rare on granulocytes. Material and methods we treated in the Hematology Clinic ten patients with B cell CLL in the Hematology Clinic were treated 10 B cell CLL patients with MabCampath. Initial in administration: 30mg x 3 trues/week for 12 weeks. During therapy the prophilaxy with Biseptol and Famciclovir or at her equivalents is necesary and after that for 2-3 months also. There is now the posibility of subcutaneus administration with minore locale secondary efects but mentaining infections prophylaxis. The dase is 10 mg/daysc 3 times/week, 18 weeks. MabCampath is indicated in patients treated before with alkilating agents patients wit hout complete or partial remission and patients with shart duration of the remission (less/than 6 mounts) after Fludara therapy indicated in consolidation therapy in CLL for eratication of remaining leukemic cells at medulary level. Results: MabCampath was association with good response rates (76%) in patients intense pretreated response in MabCampath is rapid and durable. Gerade 3-4 infections were present in 28% of the patients. The majority of side aeffects appered during first administration but thery were mild or moderate. We could see a remarcable reduction of tumor mass associated with decreasing or disparition of hepatosplenomegaly after MabCampath administration in the majority of the patients, responders or stabile disease. Conclusions: MabCampath was well tolerated evan in this patients group. The reduction or disparition of B signs or ather simptoms after administration of MabCampath in most of the patients including responders and stable disease patients after NCI criteria. After. MabCampath administration the period without chemotherapy were larger than after prior therapyes >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

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MIELOMUL MULTIPLU -ANALIZACOMPLICAIILOR I INFLUENALOR N SUPRAVIEUIREAPACIENILOR Ioana Ioni1, Ruxandra Laza1, Maria Cheverean2,Anca Isac1, C.Ioni2, D.Oro1, Hortensia Ioni1 1.Disciplina de Hematologie U.M.F.Victor Babe Timioara 2.Clinica de Hematologie Spitalul Clinic Municipal Timioara Introducere: Mielomul multiplu (MM) este o boal malign hematologic ntlnit destul de frecvent n practica medical. MM este o limfoproliferare de tip B celular cu grad avansat de maturare, caracterizat prin acumularea plasmocitelor maligne n mduva osoas. MM prezint un interes deosebit att prin frecvena n cretere ct i prin introducerea unor metode terapeutice noi care au prelungit semnificativ supravieuirea pacienilor. Totui vrsta avansat, statusul de performan deficitar, prezena unor comorbiditi i complicaiile n legtur cu boala i chimioterapia pot influena foarte mult supravieuirea pacienilor cu MM. Scop: Ne-am propus analiza complicaiilor aprute n evoluia bolii precum i cele datorate regimurilor terapeutice aplicate i influena lor asupra duratei de supravieuire. Material i metod. Am analizat un numr de 86 pacieni cu MM care au fost internai n ultimii 5 ani 2000 2008 n Clinica de Hematologie Timioara. Lotul a cuprins 45(58%) pacieni de sex masculin i 41(42%) pacieni de sex feminin. Vrsta medie a fost de 65 ani cu limite de vrst 42-80 ani. Cei mai muli pacieni au fost diagnosticai n std.III de boal (43 std.IIIAi 35% Std.IIIB). Am analizat complicaiile infecioase, renale, neurologice, incidena fracturilor osoase, complicaiile tromboembolice i hemoragice. Complicaii infecioase au aprut la 75% din pacienii cu MM, cea mai frecvent localizare fiind cea respiratorie urmate de infecii urinare. Supravieuirea a fost influenat la 36% pacieni cu aceste tipuri de complicaii. Majoritatea pacienilor fiind n std.III de boal. Complicaii renale au fost prezente la 47% din cazuri, aproximativ 5% din pacienii n std.IIIB au decedat prin uremie. Complicaiile neurologice au fost prezente la 51% din pacienii cu MM i au avut grade variabile de severitate. Fracturile osoase au fost prezente la 39% din cazuri mai ales la nivel dorso-lombar, coaste, vertebre i la nivelul picioarelor.Acestea au influenat semnificativ supravieuirea pacienilor i calitatea vieii. Concluzii: Pacienii diagnosticai precoce n stadii timpurii de boal cu complicaii minore au avut o evoluie favorabil i o supravieuire prelungit. Se impune instituirea unui tratament precoce bine susinut n cazurile cu complicaii severe mai ales la pacienii cu stadii avansate de boal.

MULTIPLE MYELOMA COMPLICATIONSANALYSUSAND THEIR INFLUENCE IN PATIENTS SURVIVAL Ioana Ioni1, Ruxandra Laza1, Maria Cheverean2,Anca Isac1, C.Ioni2, D.Oro1, Hortensia Ioni1 1.University of Medicine and Pharmacy Victor Babe Timisoara- Department of Hematology 2.County Hospital Timisoara Backround. Multiple myeloma (MM) represents a disease of great interest either trough his increasing frequency nor after the introduction of new therapeutical methods which prolonged significantly the patients survival. Are. We proposed an analysis of the complications occured in the course of the evolution in myeloma patients and their influence in report to the survival. Materials and Methods. We analyzed a group of 86 patients with MM which were hospitalized in the last years (2000 2005) in the Clinic of Hematology Timisoara. The group was composed of 58% male, and 42 female; with a medium age of 65 years (with limits between 42 and 80 years). Most of the patients were diagnosed in stage III of disease (48% in stage IIIA and 32% in stage IIIB).Also, a percent of 65 of the patients presented IgG type multiple myeloma. We

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analyzed also the infectious complications occured, renal dysfunctions, neurological complications, incidence of pathologic fractures thromboembolic and hemoragic complications. Results. The infectious complications occurred in 75% of patients, the most frequent localization being the respiratory pathway. The survival was influenced at 36% patients with this type of complications, the majority of them classified in the III stage disease. The renal dysfunction was recognised at 47% of cases, approximately 5% of patients being in stage III of the disease died from uremia. Neurological complications were present at 59% of patients with variable degree of severity. The occurence of fractures was confirmed at 39,5% of patients especially at the dorso-lumbar vertebrae followed by fractures at legs. Fractures significantly influenced in a negative way the survival and the quality of life. Conlusions. Patients in earelier stages of the disease; with minor complications have a favorable evolution of the disease with a prolonged survival. An early treatment is imposed, well sustained in the case of some severe complications occured, especially at patients in advanced stages of the disease. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< MIELOM MULTIPLU TIP IGG. CUMUL DE NEOPLAZII PREZENTARE DE CAZ Damian Laza1, Coralia Cotoraci2,Alciona Sasu2 1 Spitalul Clinic JudeteanArad 2 Universitatea de Vest ,,Vasile GoldisArad Rezumat: prezentam un caz de mielom multiplu tip IgG std. IIA diagnosticat in 1991, care a urmat timp de un an cure tip Alkeran + Prednison si care dupa o remisiune completa de 14 ani dezvolta o tumora renala stinga (adenocarcinom cu celule clare), iar 6 luni mai tarziu un process limfoproliferativ acut. Cuvinte cheie: mielom multiplu, adenocarcinom renal cu celule clare, leucemie acuta limfoblastica.

MULTIPLE MYELOMA.ACCUMULATION OF NEOPLASIAS. CASE REPORT D. Laza, Coralia Cotoraci,Alciona Sasu Abstract: we present a case of IgG multiple myeloma stage IIA diagnosed in 1991. He was treated with Melphalan and Prednisone for a year. After 14 years of complete remission it develops a tumor of the left kidney (clear cells adenocarcinoma), and six months later an acute lymphoblastic leukemia. Key words: multiple myeloma, clear cells adenocarcinoma, acute lymphoblastic leukemia. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< EVALUAREA A 55 CAZURI DE LEUCEMIE MIELOMONOCITARA CRONICA (LMMC) CLINICII DE HEMATOLOGIE FUNDENI IN PERIOADA1977 2006 EXPERIENTA

A. Colita, I. Ursuleac, R. Gologan, B. Ionescu, A. Tatic, L. Barsan, D. Ostroveanu, C. Dobrea, T. Puscariu, D. Iancu Clinica de Hematologie Fundeni Bucuresti REZUMAT Introducere: Leucemie mielomonocitara cronica (LMMC) este o entitate patogenica controversata, caracterizata prin combinarea aspectelor de mielodisplazie si mieloproliferare. Criteriile de diagnostic in LMMC sunt: monocitoza in sangele periferic, mai mare de 1000/mmc, citopenie, mielodisplazie trilineara si mieloproliferare asociate cu hepatosplenomegalie, leucocitoza, CFU GM in numar crescut in maduva osoasa. Dupa numarul de leucocite sunt descrise doua forme de LMMC: mielodisplazica (L < 13.000/mmc) si mieloproliferativa ( L > 13.000/mmc); in functie de procentul de blasti din sangele periferic si din maduva LMMC se clasifica in doua tipuri: I. < 10% blasti medulari si 5% blasti in sangele periferic; II. 10 19% blasti medulari si/sau 5 19% blasti in sangele periferic. Procentul de blasti in maduva osoasa reprezinta un factor independent de prognostic si de predictie a evolutiei spre leucemie acuta (LA). Riscul de transformare in LAM este maxim in cazul pacientilor cu 10% blasti in maduva.

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Material si metode: Studiul retrospectiv a 55 de cazuri de LMMC internate in Clinica de Hematologie Fundeni in perioada 1977 2006 a avut ca obiective precizarea tipurilor de LMMC, a caracteristicilor clinico biologice, a tipurilor de tratamente efectuate, precum si stabilirea supravietuirii in functie de parametrii cunoscuti ca fiind factori de prognostic international (scorul Bournemouth). Rezultate: Au fost evaluate 55 de cazuri de LMMC ( 34 barbati 21 femei) cu varsta medie de 64,6 ani(38-81 ani); 29 cazuri de LMMC/SMD si 26 cazuri de LMMC/SMPC; 27 cazuri s-au incadrat in tipul I, iar 23 in tipul II, 5 cazuri neputand fi incadrati. Intervalul de la debutul simptomatologiei pana la diagnostic a fost in 23 cazuri 6 luni, in 16 cazuri > 6 luni, iar la 16 cazuri a fost neprecizat. Tratamentul a cuprins asocierea de metode suportive( 33 cazuri) cu ATRA(23 cazuri), ARA-C minidoze(19 cazuri), Hidroxiuree(19 cazuri), 6 Thioguanina/6Mercaptopurina(16 cazuri) sau cure de leucemie acuta(3 cazuri); un pacient a primit si tratament cu Epoetinum beta. Evolutia a fost spre LAM in 15 cazuri (11LAM4, 4 LAM2). Decesul s-a produs in 28 cazuri prin sepsis sau/si hemoragii asociate sau nu transformarii in LA; la 7 cazuri decesul s-a produs prin cauze nehematologice; 9 pacienti sunt in viata la incheierea studiului, iar 11 au fost pierduti din evidenta. Durata de evolutie ca LAM a fost intre 1-3 luni, iar supravietuirea s-a corelat invers proportional cu numarul de leucocite, monocitoza periferica si direct proportional cu procentul de blasti medulari, fiind cuprinsa intre 4-102 luni. Abstract Background : chronic myelomonocytic leukemia(CMML) is a controversed entity, characterized through combined myelodysplastic and myeloproliferative features such as: monocytosis > 1000/mmc, cytopenia , trilineal myelodysplasia and myeloproliferation associated with hepatosplenomegaly, leucocytosis and autonomous GM-CFU growth in bone marrow. There are 2 entities based on leucocyte number( myelodysplastic , WBC< 13000/mmc; myeloproliferative, WBC> 13000/mmc). Based on the percentage of bone marrow and peripherical blasts there are 2 types of CMML: I( < 10% blasts in marrow and 5% blasts in blood) and II(10-19% blasts in marrow and/or 5-19 % blasts in blood. The percentage of blasts in bone marrow is an independent prognostic factor and predicts the evolution to acute leukemia. Material and method: retrospective analysis of 55 cases of CMML, admitted in Fundeni Clinic of Hematology between 1977-2006; evaluation of the clinico-biological features, types of treatment, evaluation of survival depending of Bournemouth score. Results : we analyzed 55 cases of CMML(34 men, 21 women) with a median age or 64,6 years old(38-81 years); 29 cases were diagnosed with MDS/CMML, 26 cases with MPD/CMML; 27 cases were evaluated as type I, 23 cases as type II and 5 cases indefinite type. The period between the onset of the symptoms and diagnosis was 6 months in 23 cases and > 6 months in 16 cases. For 16 patients the period was unprecised. The treatment was mainly supportive(33 cases), associated with ATRA(23 cases), CAR- minidosis(19 cases), Hydroxiureea(19 cases), 6thioguanianine/6 mercaptopurine(16 cases) or acute leukemia schedules( 3 cases). 1 patient was treated with Epoetinum beta. The evolution to acute leukemia was observed in 15 cases(11 type M4/FAB, 4 type M2/FAB); the exitus was due to sepsis, hemorragia (associated or not to AML) in 28 cases, non hematological causes in 7 patients, 9 patients are alived, and 11 patients are missed from evidence. The period of evolution as AML was between 1-3 months. The survival of the patients with CMML was correlated with number of leucocytes, monocytosis and the percentage of bone marrow blasts. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< DATE DIN REGISTRUL PACIENTILOR CU SINDROM MIELODISPLAZIC AL CLINICII DE HEMATOLOGIE, INSTITUTUL CLINIC FUNDENI, BUCURESTI. IV. TRANSFORMAREAIN LEUCEMIEACUTA Didona Vasilache, Radu Gologan, Violeta Moraru Clinica de Hematologie, Institutul Clinic Fundeni, Bucuresti Introducere. Sindromul mielodisplazic grup de tulburari hematologice intalnit mai ales la varstnici este caracterizat si de un risc crescut de transformare in leucemie acuta mieloida. In cadrul grupelor FAB exista o importanta heterogenitate si in ce priveste progresia spre leucemie acuta. Realizarea Registrului SMD al Clinicii de Hematologie Fundeni a permis si analiza statistica a cazurilor din punctul de vedere al transformarii bolii. Metoda. Au fost utilizate formularele de inregistrare furnizate de Fundatia pentru SMD (presedinte prof. J.M. Bennett, SUA) completate cu datele pacientilor la prima internare in perioada 1982-2004 si clasificati dupa criteriile FAB.

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Rezultate. Din cele 404 cazuri identificate cu ajutorul Registrului SMD au fost considerate evaluabile 186 de cazuri, din care 75 cazuri transformate in LAM, adica un procent de 40,32%. Repartitia pe categoriile SMD a fost: 7 pacienti cu AR (9.33%), 2 pacienti cu ARSI (2.66%), 32 cazuri cu AREB (42.66%), 24 cazuri de AREBt (32%), 3 cazuri cu LMMC (4%) si 7 pacienti cu SMD neclasificabil (9.33%). Varsta medie a fost 58.8 (16-77). Majoritatea pacientilor s-au incadrat in grupa de varsta 61-70 ani (36%). Distributia pe sexe a prezentat o usoara preponderenta a celui masculin, cu un raport M/F de 1.2. Durata medie pana la transformarea in LAa fost de 8.3 luni (1-46). Concluzii. Acest studiu a aratat un procent general de transformare in LA pentru pacientii Registrului SMD de 40,32%, cu predominanta cazurilor AREB (42.66%) si AREBt (32%) si a sexului masculin; durata medie pana la transformare a fost de 8.3 luni. DATA FROM THE REGISTRY OF THE PATIENTS WITH MYELODYSPLASTIC SYNDROME FROM CLINIC OF HEMATOLOGY, FUNDENI CLINICAL INSTITUTE. BUCHAREST, ROMANIA. IV. PROGRESSSION TO ACUTE LEUKEMIA Didona Vasilache, Radu Gologan, Violeta Moraru Clinic of Hematology, Fundeni Clinical Institute, Bucharest. Introduction. Myelodysplastic syndromes (MDS) are a group of hematologic disorders that occur mainly in older persons and are characterized by peripheral cytopenias and an increasing risk of progression into acute myeloid leukemia (AML). A considerable heterogeneity was observed within FAB subgroups also regarding leukemic progression. The MDS Registry of the Hematology Clinic from Fundeni Clinical Institute allow us the analysis of patients regarding this leukemic progression. Methods. The primary database was represented by the MDS patients files at diagnosis admitted in our Clinic during the period 1982-2004 recorded in the registration forms provided by the MDS Foundation (USA). Results. From the general database we find 75 cases with progression to AML (40,32%). There were 7 cases with RA (9.33%), 2 patients with RARS (2.66%), 32 cases with RAEB (42.66%), 24 cases with RAEBt (32%), 3 cases with CMML (4%) and 7 patients with unclassifiable MDS (9.33%). We found a global predominance of male gender (M/F: 1.2) and a mean age of 58.8 years. Most patients were classified in 61-70 years old group of age. The mean time to AL progression was 8.3 months (1-46). Conclusions. This study indicates a general percent of progression to AML of 40,32, with a preponderance of RAEB (42.66%) and RAEBt (32%) cases and male gender and a mean time to progression of 8.3 months. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< APARITIA LEUCEMIEI GRANULOCITARE CORNICE LA 3 ANI DUPA CURA CHIRURGICALA SI TRATAMENTUL CHIMIOTERAPIC AL UNUI FIBROSARCOM TESTICULAR - CAZ SINGULAR IN LITERATURE DE SPECIALITATE!?- Catana Alina (a), Iancu Daniela (b), Patran Monica (c), Valeanu Valeria (c), Moicean Andreea (d), Teleanu Veronica (d), Olteanu Ariela (e), Draghila Livia (e), Zaharie S.(f), Dobrea Camelia (g), Mihaela Mihai (g) Mihaila R.(a), Deac M.(h), Flucus Ofelia(a) Catana I.. F.(i) a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b- U.M.F. Carol Davila, Bucuresti, c- Sectia Oncologie, Spital Clinic judetean Sibiu, d- Clinica Hematologie Fundeni, Bucuresti, e- Laborator, Spital clinic Judetean Sibiu, fAnatomopatologie, Spital clinic Judetean Sibiu, g- Anatomopatologie Fundeni, Bucuresti, h- Sectie Clinica Medicala II, Spital clinic Judetean Sibiu, I- Student an VI, M.G,Arad, Introducere: Leucemia granulocitara cronica ( LGC ), este o boala mieloproliferativa cronica care reprezinta 15-20 % din leucemiile adultului. Rareori LGC-ul apare dupa tratament radioterapic si/sau citostatic pentru alte neoplazii si la bolnavi cu transplant renal aflati sub tratament imunosupresor de lunga durata. Material si metoda: Prezentam cazul unui pacient de 54 ani, diagnosticat in 2003 cu fibrosarcom paratesticular. S-a practicat orhiectomie unilaterala, 6 cure de chimioterapie cu cisplatin 90 mg/m2 si farmorubicina 90 mg/m2, dupa care s-a sistat tratamentul, pacientul fiind fara semne de recidiva la controalele ulterioare. In 09.2006 este diagnosticat la hematologie Sibiu cu

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LGC.La diagnostic: leucocitoza importanta 134.000/mm3, cu deviere la stanga a formulei leucocitare cu pana la 2% mieloblasti, splenomegalie 18 cm, examen histopatologic M.O.: aspect de LGC faza cronica, examen citogenetic 100% cromozom Ph(+), in metafazele studiate, examen biologie moleculara: bcl abl pozitiv, ratio bcrabl/abl = 1. S-a administrat initial hidree, iar din februaire 2007 Glivec 400 mg/zi. La 6 luni de la tratament cu Glivec pacientul este in remisiune hematologica completa, cu raspuns citogenetic major, cu raspuns molecular foarte bun rotio bcrabl/abl = 0,001. Rezultate si discutii: De obicei dupa radioterapie si chimioterapie pentru tumori solide sau hemopatii maligne apar leucemii acute sau sindroame mielodisplazice. Sunt foarte rare publicatiile referitoare la aparitia LGC-lui cronic ( de obicei dupa redioterapie ). Ne punem problema daca sarcomul paratesticular nu a fost defapt un sarcom granulocitar, o tumora extramedulara rara, cu celule granulocitare imature ce poate apare de novo sau in asociere cu dezordini hematologice, cel mai frecvent cu SMD sau LAM dar poate apare inainte, concomitent sau dupa dezvoltarea LGC-ului THE APPEARANCE OF LGC AT 3 YEARS AFTER SURGICAL CURE AND CHEMOTHERAPY OF A TESTICULAR FIBROSARCOMA- SINGULAR CASE IN SPECIALITY LITERATURE. Catana Alina (a), Iancu Daniela (b), Patran Monica (c), Valeanu Valeria (c), Moicean Andreea (d), Teleanu Veronica (d), Olteanu Ariela (e), Draghila Livia (e), Zaharie S.(f), Dobrea Camelia (g), Mihaela Mihai (g) Mihaila R.(a), Deac M.(h), Flucus Ofelia(a) Catana I.. F.(i) a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b- U.M.F. Carol Davila, Bucuresti, c- Sectia Oncologie, Spital Clinic judetean Sibiu, d- Clinica Hematologie Fundeni, Bucuresti, e- Laborator, Spital clinic Judetean Sibiu, fAnatomopatologie, Spital clinic Judetean Sibiu, g- Anatomopatologie Fundeni, Bucuresti, h- Sectie Clinica Medicala II, Spital clinic Judetean Sibiu, I- Student an VI, M.G,Arad, Introduction LGC is a chronic myeloproliferative disease, wich represents 15-20% from adult leukemias. Rarely LGC appears after radiotherapy and chemotherapy for other cancers and patients with renal transplant under immunosuppressive treatment of long duration. Case report We present the case of a 54 y.o. patient, diagnosed in 2003 with paratesticular fibrosarcoma. It was performed unilateral orhiectomy, 6 cures of chemotherapy with cisplatin 90mg/m2 and farmorubicina 90mg/m2 after witch the treatment was stopped, the patient being without signs of relapse at following tests.In sept 2006 was diagnosed in the hematology Department Sibiu with LGC. At the diagnostic moment: important leukocytosis, with left deviationof leukocytes formula, with 2% myeloblast, slenomegaly 18 cm. Hysthopathological exam of bone marrow aspect of chronic LGC. Cytogenetic exam 100% chromosome Ph+ in studied metaphases.Biological molecular exam: bcr abl/abl ratio=1. Initially it was administreted hydree and from February 2007 Glivec 400mg/day.At 6 months from Glivec treatment the patient is in complete hemathologic remission, with major cytogenetic response and very good molecular response ratio bcrabl/abl=0,01. Results and discutssion Usually after radio and chemotherapy for solid tumours or malignant hemopathies appear acute leukemias or myelodisplasic syndromes.There are very rare the reports regarding the appearance of LGC (usually after radiotherapy).We take into consideration the possibility that paratesticular sarcoma was in fact a granulocytes, witch can appear de novo or in association with a hemathological disorder, most frequently with SMD or LAM. It can appear before in the same time or after the development of LGC. >>>>>>>>>>>>>>> APARITIA UNUI CAZ DE LGC FAZA CRONICA LA UN COPIL DE 17 ANI, CE LOCUIESTE INTR-O ZONA INTENS POLUATA COPSA MICA, A CAREI SORA IN VARSTA DE 21 ANI A DECEDAT PRIN NEOPLASM OVARIAN. INFLUENTAFACTORILOR DE MEDIU SI GENETICI. Catana Alina (a), Olteanu Ariela (b), Draghila Livia (b), Mocanu Liliana (b), Zaharie S. (c), Mihaila R. (a), Deac M. (d), Flucus Ofelia (a), Catana I. F. (e)

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a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b- Laborator, Spital clinic Judetean Sibiu, cAnatomopatologie, Spital clinic Judetean Sibiu, d- Sectie Clinica Medicala II, Spital clinic Judetean Sibiu, e- Student an VI, MG,Arad, Introducere: LGC-ul este o boala clonala ce rezulta din transformarea neoplazica a celulei stem pluripotente. Un studiu efectuat pe cazuri de LGC intre 2000-2004 de SEER ( Surveillance Epidemiology and End Results), Institutul National de Cancer, evidentiaza o varsta medie de aparitie de 66 ani , cu 2,6 % persoane sub 20 ani, 7,3% intre 20-34 ani, 10% intre 35-44 ani, 12,9% intre 45-54 ani, 13,8% intre 55-64 ani, 19,5% intre 65-74 ani, 23,9% intre 75-84 ani, 9,9% peste 85 ani. Mortalitatea sub 20 ani este de 1,2%, cea mai mare mortalitate fiind intre 75-84 ani de 27,1%. Material si matoda: Prezentam cazul unui pacient de 17 ani care s-a prezentat in serviciul de hematologie cu suspiciunea de leucemie acuta, sindrom dureros abdominal. Pacientul avea starea generala buna, fara hepatosplenomegalie, adenopatie axilara dreapta sub 1 cm, hipertrofie amigdaliana importanta- aspect de amigdalita cronica criptico-cazeoasa. La endoscopia digestiva superioara s-a evidentiat ulcer duodenal cronic, gastroduodenita acuta, esofogita de reflux. Biologic prezenta leucocitoza moderata 28.100/mm3, devierea formulei leucocitare pana la promielocit, fara cele doua varfuri caracteristice, 2% bazofile. FAL = 4. Examenul morfologic si histopatologic al M.O. pleda mai mult pentru reactie leucemoida decat pentru LGC. Examenul de biologie moleculara calitativ si cantitativ a evidentiat bclabl major pozitiv cu raport bclabl/abl = 1. S-a stabilit diagnosticul de LGC. S-a inceput tratamentul cu Glivec 400 mg/zi din martie 2007 cu obtinerea remisiuni hematologice complete si a unui raspuns molecular bun, ratio bclabl/abl = 0,005. Rezultate si discutii: Particularitatea cazului este varsta tanara sub 17 ani, dificultatea stabilirii corecte a diagnosticului in absenta examenului de biologie moleculara datorita criteriilor incomplete clinice, biologice si al examenului morfologic si histopatologic cu atat mai mult cu cat pacientul prezenta predominant criterii de reactie leucemoida secundara infectiei si inflamatiei amigdaliene si gastroduodenale. O alta particularitate a cazului este provenienta pacientului dintr-un mediu toxic- Copsa Mica- (cunoscut pentru cazurile de intoxicatie cu plumb), in zona noastra geografica fiind descoperite si cazuri de sindrom limfoproliferativ cronic, la cei cu intoxicatie cu plumb ceea ce ridica problema implicarii etiologice a acestuia in transformarea clonala a CSP. Pacientul a avut de asemenea o sora de 17 ani cu cancer de ovar decedata in urma cu 2 ani. Prezenta a 2 neoplazii intr-o familie, la varste tinere aduce in discutie factorul ereditar. APPEARANCE OF LGC CASE CHRONIC PHASE AT A 17 Y.O. CHILD, WHO LIVES IN A HIGH POLUTED AREA ( COPSA MICA) WHOSE 21 Y.O. SISTER DIED DUE TO AN OVARIAN CANCER. ENVIROMENT AND GENETIC FACTOR INFLUENCE. CatanaAlina (a), OlteanuAriela (b), Draghila Livia (b), Mocanu Liliana (b), Zaharie S. (c), Mihaila R. (a), Deac M. (d), Flucus Ofelia (a), Catana I. F. (e) a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b- Laborator, Spital clinic Judetean Sibiu, cAnatomopatologie, Spital clinic Judetean Sibiu, d- Sectie Clinica Medicala II, Spital clinic Judetean Sibiu, e- Student an VI, MG,Arad, Introduction LGC is a clonal disease which appears from neoplastic transformation of pluripotent stem cell. A study on LGC performed between 2000-2004 by SEER revealed mean age of appearance 66 years with cu 2,6 % persons under 20 years, 7,3% - 20-34 y, 10% - 35-44 y, 12,9% - 45-54 y, 13,8% - 55-64 y, 19,5% - 65-74 y, 23,9% - 75-84 y, 9,9% -over 85 ani. The mortality under 20y is 1,2% the greater mortality being between 75 and 84 y (27,1%) Case report We present the case of a 17 y o patient who presented in the Hemathology Department With the suspicion of acute leukemia and abdominal pain syndrome. The patient had a good general condition without hepatosplenomegaly, right axillary adenopathy of 1 cm, important tonssillary hypertrophy aspect of chronic caseous tonssilitis.Gastroendoscopy revealedchronic duodenal ulcer, acute gastroduodenitis, reflux esophagitis. Biologic: moderate leukocytosis, deviation of leukocite formula to promyelocyte, without the two caracteristic peaks, 2% bazofiles, FAL 4. Morphological and hystopathological exam of bone marrow

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pleaded more for a leukemoid reactiv than for LGC. Biological molecularrevealed bcrabl/abl ratio=1. It was established the diagnosis of LGC. It was initiated treatment with Glivec 400mg/day from March 2007, obtaining complete hematologic remission and a good molecular response, with a ratio bcrabl/abl=0,05 Results and discussions The particularithy of the case is young age (17 yo), dificulty to establish a correct diagnosis in the absence of biological molecular exam due to incomplete clinical, biological, morphological and histopathological criterias. More important the patient presented criterias of leukemoid reaction secundary to tonsyles and gastroduodenal inflamation. Another particularity of the case is the origin of the patient from a poluted environment (known for led intoxication cases) in our area being discovered also cases of chronic lymphoproliferative syndrome at those with led intoxication. This suggest the ethiologic involvment of led in clonal transformation of CSP. The patient had also a 21 yo sister with ovarian cancer deceased 2 years ago. The presence of 2 cancer in the family at young ages, sugest genetic implication.

>>>>>>>>>>>>>>>>>>>>>>> ASOCIEREA LEUCEMIEI GRANULOCITARE CORNICE CU ADENOCARCINOMUL DE UNGHI DREPT AL COLONULUI LA UN PACIENT CAREA A LUCRAT PESTE 30 ANI IN MEDIU TOXIC LA COMBINATUL CHIMIC VICTORIACatana Alina (a), Tabara Eleonora (b), Zaharie S.(c)Olteanu Ariela (d), Draghila Livia (d), Mocanu Liliana (d),Gheorghita E.(e), Vulcan Genica (e), Mocanu D. (f), Coman A (g), Mihaila R. (a), Deac M. (h), Flucus Ofelia (a), Catana I.. F. (i) a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b - Laborator, Spital clinic Pediatrie Sibiu, cAnatomopatologie, Spital clinic Judetean Sibiu, d - Laborator, Spital clinic Judetean Sibiu, e -Compartiment Hematologie Spital Clinic Brasov, f - Sectia Gastroenterologie Brasov, g -Sectia Chirugie generala II, Spital Clinic Judetean Sibiu, h - Sectie Clinica Medicala II, Spital clinic Judetean Sibiu, I - student an VI, MG,Arad Introducere: Cancerul colorectal reprezinta a doua cauza de mortalitate prin cancer, reprezentand 14% din totalul cancerelor sexul masculin avand un risc de doua ori mai mare.Adenocarcinoamele sunt tipul histopatologic cel mai frecvent de 90-95%. Material si metoda: Prezentam cazul unui pacient de 57 ani care a lucrat in mediu toxic cu acid sulfuric si azotic timp de 32 ani la combinatul chimic Victoria si care in 09.2006 a suferit un traumatism cu fractura de coaste. Analizele efectuate in acel moment au evidentiat leucotrombocitoza ( Lc = 53.100/mm3; Tr = 848000/mm3; deviere la stanga a formulei leucocitare pana la 1% mieloblasti, cu cele doua varfuri caracteristice; 11% bazofile, anemie moderata normocroma normocitara; splenomegalie moderata. Examenul morphologic si histopatologic al M.O.: aspect de lGC faza cronica , examenul biologie moleculara: bcr abl pozitiv, raport bcr abl / abl =1. S-a stabilit diagnosticul de LGC faza cronica. S-a introdus tratament cu Hidree cu recomandare ca pacientul sa se prezinte in teritoriu pentru monitorizare si initierea tratamentului cu Glivec. Evolutia clinica si biologica a fost buna cu exceptia unui sindrom anemic moderat ce a persistat 6 luni, dupa care au aparut dureri in hipocondru drept, accentuate postalimentar. S-a efectuat irigografie in teritoriu evidentandu-se formatiune tumorala de unghi drept al colonului. Ulterior a fost internat la Gastroenterologie Sibiu efectundu-se colonoscopie decelandu se polip pediculat, conopidiform de 0,5 cm la 150cm de orificiul anal iar in unghiul hepatic al colonului tumora stransa ce nu poate fi depasita cu colonoscopul. Clinic starea pacientului era foarte buna, nu prezenta metastaze pulmonare, hepatice, nici adenopatii periferice sau intraabdominale imagistic.S-a intervenit chirurgical efectuandu-se hemicolectomie tumorala vegetanta, ce cuprinde circular lumenul pe o lungine de 6 cm, cu caracter partial stenozant. Microscopic, aspect de adenocarcinom moderat diferentiat cu zone de necroza infiltrative pana in subseroasa cu reactie desmoplastica in jur si infitrat inflamator peritumoral moderat fara metastaze in 5 limfonoduli peritumorali ( Dukes B. ). Rezultate si discutii: Particularitatea cazului este descoperirea concomitenta a 2 neoplazii: LGC si adenocarcinom de colon. Ar fi fost utila imunohistochimia biopsiei colonice pentru decelarea anticorpilor anti CD 117., pozitivarea acestora ar fi impus tratament cu Glivec pentru ambele boli. Adenocarcinomul colorectal este descries ca o boala genetica, se desfosoara dupa un proces microevolutiv, in celula stem clonica apare o leziune, in mod spontan sau indusa de agenti din mediu,

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apare o clona ce dobandeste avantaj de crestere. Mecanismul este asemanator cu cel din LGC si atunci se pune intrebarea daca acelasi factor mutagen a determinat LGC- ul si adenocarcinomul, daca expunerea 32 ani la produsi de sulf si azot nu a avut un rol negativ in acest sens . Datele din literature sunt insuficiente pentru raspunsul la aceasta intrebare. ASSOCIATION BETWEEN CHRONIC GRANULOCYTIC LEUKEMIA AND RIGHT ANGLE COLON ADENOCARCINOMA AT A PATIENT WHO WORKED OVER 32 YEARS IN POLLUTED ENVIRONMENT (CHEMICAL FACILITYVICTORIA) Catana Alina (a), Tabara Eleonora (b), Zaharie S.(c)Olteanu Ariela (d), Draghila Livia (d), Mocanu Liliana (d),Gheorghita E.(e), Vulcan Genica (e), Mocanu D. (f), Coman A (g), Mihaila R. (a), Deac M. (h), Flucus Ofelia (a), Catana I.. F. (i) a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b - Laborator, Spital clinic Pediatrie Sibiu, cAnatomopatologie, Spital clinic Judetean Sibiu, d - Laborator, Spital clinic Judetean Sibiu, e -Compartiment Hematologie Spital Clinic Brasov, f - Sectia Gastroenterologie Brasov, g -Sectia Chirugie generala II, Spital Clinic Judetean Sibiu, h - Sectie Clinica Medicala II, Spital clinic Judetean Sibiu, I - student an VI, MG,Arad Introduction Colorectal cancer represents the second cause of mortality by cancer, representing 14% of cancers. Male sex has a twice greater risk.Adenocarcinoma is the most freqvent hystopathologic type (90-95%) Case report We present the case of a 57 yo patient who worked in sulfuric and azotic acid polluted environment for 32 years in Chemical Facility Victoria and who in sept 2006 suffered a trauma with ribs fractures. Analises performed at that moment reveled leukothrombocytosis, deviation left of leukocyte formula to 1% myeloblasts with two characteristic peaks, 11% basofiles, moderate normochrome, normocyte anemia, moderate slenomegaly. Morphologic and hystopathologic exam of bone marrow :aspect of LGC Chronic phase. Biologic molecular exam: bcr abl/abl=1, bcrabl positive. It was esthablished the diagnosis of LGC Chronic Phase. It was initiated theraphy with hidreea with the recommendation to monitor and initiate treatment with glivec in territory. Clinical and biological evolution was favorable except the persistence for 6 months of a moderate anemic syndrome, after witch appeared pain in the right hypocondrum, exacerbated after meals.. Irigography was performed in territory wiich revealed a tumor on the right angle of the colon. After that he was admitted in the Department of Gastroenterology Sibiu, where colonoscopy was performed. Pediculat polip 0,5 cm from 10 cm anal orifice, wich obdurate the hepatic angle of the colon, not allowing the colonoscopy further.The general condition of the patient was good; he didn't have imagistic pulmonary or hepatic metastasies, nor peripheral or intraabdominal adenopathies. Surgery was performed (hemicolectomy),vegetant tumor wich involve the lumen circulary, on a length of 6 cm, with partial stenosis. Microscopy: moderate differentiated adenocarcinoma with areas of necrosis infiltrating the subserosa, with desmoplastic reaction reaction and moderate inflammatory infiltrate peritumoral,without metastasies in 5 peritumoral lymphonodes(Dukes B) Results and discution The particularity of the case is the concomitant finding of 2 cancers: LGC and colon adenocarcinoma. It would have been useful the immunohistochemical analysis of tumour for detection of CD 117 antibodies, the positive antibodies would impose the treatment woth Glivec for 2 diseases. Colorectal adenocarcinoma is described as a genetic disease witch follow the course of a microevolutive process; in clonal stem cell appears a lesion, spontaneously or induced by environmental factors witch gain a growth advantage. The mechanism is similar with that of LGC so it raises the question if the same mutagenic factor caused LGC and adenocarcinom, of exposure for 32 yearsto sulfuric and azotic acid had negative rol in this case. Data from literature are insufficient to answer this question <<<<<<<<<<<<<<<<<<<<<< ASOCIEREA MIELOMULUI MULTIPLU IG G STADIUL III CU FEOCROMOCITOMUL, PROBLEME DE CONDUITATERAPEUTICA. Catana Alina(a), Podia Claudia(b), Mihaila R(a), Paun Diana(c), Paun S(d), Gherlan Iuliana(c), Hortopan D(c), Olteanu Ariela(e), Draghila Livia(e), Zaharie Alina(e), Zaharie S(f), Beca Maria(g), Deac M.(g), Flucus Ofelia (a),SolomonAdelaida(g) Catana I. F.(h) a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b-Policlinica Endocrinologie, Spital Clinic Judetean Sibiu,

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c-Institut Clinic Parhon,Bucuresti, d-Spitalul Clinic de Urgenta Floreasca, Chirurgie Generala, Bucuresti, e-Laborator, Spital clinic Judetean Sibiu f-Anatomopatologie, Spital Clinic Judetean Sibiu, g-Sectie Clinica Medicala II, Spital Clinic Judetean Sibiu, h-student an VI MG,Arad Introducere: Mielomul multiplu (M.M.) este o tumora maligna de limfocit B. Asocierea sa cu alte tumori maligne este din ce in ce mai frecventa dar de obicei apare in cursul evolutiei sale dupa tratament cu agenti citostatici , in special melfalanul si ciclofosfamida. Asocierea sa cu feocromocitomul este o raritate. Feocromocitomul este o tumora cu celule cromatofine secretante de epinefrina si norepinefrina care se poate asocia cu hiperparatiroidismul si carcinomul medular tiroidian in cadrul sindromului MEN 2a ( neoplazie endocrina multipla). Poate fi malign (malignitatea fiind data de invazia locala directa in tesuturi ce nu au celule cromafine), evolutia este lenta legata de complicatiie HTA: cardiomiopatie catecolica, colaps, ileus functional, stenoza de artera renala. Supravetuierea la 5 ani a feocromocitomului malign este 23-44%. Material si metoda: Prezentam cazul unei paciente tinere de 49 ani, diagnosticata cu MM Ig G, stadiul III A lambda secretor in decembrie 2005. Prezenta valori crescute a TA pana la 280/130 mmHg si valori crescute ale glicemiei mai ales dupa administrare de cortizon cand a dezvoltat doua episoade de encefalopatie hipertensiva, insuficienta ventriculara stanga si tahiaritmie. Pacianta afirma existanta unei matusi cu tumora suprarenaliana. Toate aceste date au ridicat suspiciunea de feocromocitom, confirmat prin aspectul CT- ului abdominal si acidului vanil mandelic crescut. Pacienta a refuzat interventia chirurgicala astfel ca pentru afectiunea hematologica cure VAD nu s-au mai administrat iar curele VMPC au fost incomplete fara cortizon. Orice incercare de introducere a cortizonului s-a soldat cu puseu de encefalopatie hipertensiva. S-a obtinut doar o scadere a CM cu 25%, iar fluctuatiile TA si valorilor glicemiei au devenit tot mai mari. Existenta unei matusi cu feocromocitom, a nodulilor tiroidieni au ridicat si suspiciunea de MEN 2a. In aprilie 2007 s-a practicat ablatia unei tumori suprarenaliene drepte de 10 cm dura invadanta in peretele posterior si lateral al venei cave inferioare si al unui chist hepatic de 6 cm. Postoperator valorile TA s-au mentinut sub 130/70 mmHg, cu doze reduse de hipotensoare, s-a renuntat la tratamentul cu insulina, apoi la cel cu antidiabetice orale, pacienta avand glicemii sub 100 mg/dl. Valorile catecolaminelor serice au fost normale, VSH, calcemia au fost normale, CM a scazut cu 72%. In prezent se afla intr-o faza de platou , in tratament cu interferon. Concluzii: Din cunostiintele noastre in literatura de specialitate este descris un singur caz de MM. asociat cu feocromocitomul malign si cu o tumora mielomatoasa maxilara, in 1958. O alta particularitate a cazului este monitorizarea si tratarea dificila a unei paciente cu valori tensionale foarte mari, la care s-ar fi impus tratament cortizonic la care celula mielomatoasa este sensibila,dar in absenta administrari lui rezultatele au fost nesatisfacatoare. Sanctiunea terapeutica a oricarui feocromocitom este chirurgicala. Chimioterapia prin utilizarea melfalanului si ciclofosfamidei a avut foarte probabil efect pozitiv asupra tumorii suprarenaliene. Invazia venei cave inferioare si examenul histopatologic au pledat pentru feocromocitom malign ceea ce aduce in discutie riscul de recidiva postoperator, la aceasta adaugandu-se si incarcatura ereditara. Monitorizarea pacientei este obligatorie pentru ambele afectiuni chiar daca in acest moment ambele sunt in remisiune. THE ASSOCIATION BETWEEN IGG MM STAGE IIIA WITH FEOCHROMOCITOMA- THERAPY CONDUCTION PROBLEMS Catana Alina(a), Podia Claudia(b), Mihaila R(a), Paun Diana(c), Paun S(d), Gherlan Iuliana(c), Hortopan D(c), Olteanu Ariela(e), Draghila Livia(e), Zaharie Alina(e), Zaharie S(f), Beca Maria(g), Deac M.(g), Flucus Ofelia (a), SolomonAdelaida(g) Catana I. F.(h) a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b-Policlinica Endocrinologie, Spital Clinic Judetean Sibiu, c-Institut Clinic Parhon,Bucuresti, d-Spitalul Clinic de Urgenta Floreasca, Chirurgie Generala, Bucuresti, e-Laborator, Spital clinic Judetean Sibiu f-Anatomopatologie, Spital Clinic Judetean Sibiu, g-Sectie Clinica Medicala II, Spital Clinic Judetean Sibiu, h-student an VI MG,Arad Introduction Multiple Mieloma(MM) is a lymphocytes B maligne tumor. Its association with other maligne tumor is more and more frequent but the tumor usually appears after the treatment with cytostatic agents such as cyclophosfamide and melphalan. The association between MM and feocromocitoma is very rare.Feocromocitoma is a cromaphine cell tumor that secrets epinephrine and norepinefrine and it can be associated with hyperparathyroidism and medular thyroid

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carcinoma- part of the MEN 2a(multiple endocrine neoplasia). It can be maligne(Its malignancy given by the direct local invasion in tissues that do not have cromatofine cells) and the slow evolution of the disease is given by the HBP(high blood presure) complications: catecolic cordiomiopathy, colaps, functional ileus, renal artery stenosis. The 5 year survival for feocromocitoma is 23-44% Method abd material We report the case of a 49y.o. patient diagnosed in December 2005 with MM IgG stage IIIA lambda secreting. She had HBP(up to 280/130 mmHg) and high blood sugar especially after cortisone administration-when she developed two episodes of hypertensive encephalopathy, left ventricular ventricular insufficiency and tahiaritmia. The patient confirms the existence of an aunt wih suprarenalian tumor.All this data made us suspect the existence of feocromocitoma- confirmed by the abdominal CT scan aspect and also by the high levels of vanilmandelic acid. The patient refused surgery so the VAD cycles for the hematholgic disease were not administred anymore and the VMPC cycles were incomplete without the cortisone. Any attempt to administer cortisone was followed by hypertensive encephalophaty. We obtained a 25% drop of CM and the variations of blood pressure and blood sugar increased. The existence of the aunt with feocromocitoma and the thyroid nodes made us suspect MEN2a. In april 2007 a right suprarenalian tumor (10cm diameter hard, invading in the posterior and lateral wall of the inferior vena cava) and a hepatic 6cm cyst-were excised. After the surgery the blood pressure was bellow 130/70mmHg(with low doses of hypotensive medicine), the insulin was not administreted anymore and than the oral antidiabetic medication was also suppressed, the levels of blood sugar being bellow 100mg/dl; The levels of serum cathecolamines were normal also the ESR, calcium levels; the CM lowered (droped) 72%. Presently she is in a remission phase, being treated with interferon. Conclusion From our knowledge there is one case of MM associated with feocromocitoma and a mielomatose maxillary tumordescribed in the specially literature-1958.Another particularity of the case was the difficult monitoring and treatment of a patient with very high blood pressure for wich cortisone would have been indicated (the mielomatose cell being sensitive to cortisone) but because it was not tolerated, the results were unsatisfactory. The treatment of any feocromocitoma should be surgical. The chemotherapy with cyclophosfamide and melphalan probably had a positive effect on the suprarenalian tumor. The invasion in the inferior vena cava and the histopathological test-indicate malignancy wich makes us discuss the relapse of the tumor after surgery, the eredity being also involved. The monitoring for both conditions is mandatorory even if both are presently in remission. <<<<<<<<<<<<<<<<<<<<<<< DIAGNOSTICAREA UNUI CAZ DE HIPERPARATIROIDISM PRIMAR PORNIND DE LA INVESTIGAEA ETIOLOGIEI UNEIANEMII FERIPRIVE REFRACTARE LATRATAMENTUL CU FIER PER OSCatana Alina (a), Podia Claudia (b), Ghemigian Adina (c), Mocanu D.(d), Mihaila R. (a), Deac M.(e), Flucus Ofelia (a), SolomonAdelaida(e), Catana I. F.(f) a.-Compartiment hematologie, Spital Clinic Judetean Sibiu, b.Clinica Endocrinologie, Spital Clinic Judetean Sibiu, c.Institut Clinic Parhon,Bucuresti, d.- Gastroenterologie, Spital clinic Judetean Sibiu, e.- Sectie Clinica Medicala II, Spital clinic Judetean Sibiu, f.- Sudent an VI. M.G,Arad; Introducere: Anemia feripriva este cel mai frecvent tip de anemie. La femeia activa sexual cauza ginecologica reprezintea prima etiologie de luat in calcul. Tulburarile de absorbtie a fierului associate cu hiperparatiroidismul apar extrem de rar. Material si metoda: Prezentam cazul unei paciente cunoscute de 25 ani cu anemie feripriva la care nu s-a gasit o sursa de sangerare si care a primit tratament cu fier per os fara a depasi valori de 9 gr/dl. In ianuarie 2007 a fost internata cu sindrom anemic sever cu caracter feripriv la Gastroenterologie Sibiu. Colonoscopia a fost fara modificari, endoscopia digestiva superioara a decelat gastrita acuta eroziva, Helicobactre Pilori negativa. A primit tratament substitutiv cu masa eritrocitara, apoi cu Maltofer fol, controlul hematologic la 1si la 2 luni dupa tratamentul cu fier per os, a evidentiat cresterea necorespunzatoare a parametrilor hematologici, hemoglobina pana la 9,5 gr/dl; electroforeza hemoglobinei a exclus sindroamele talasemice, consulturile ginecologice efectuate nu au evidentiat modificari in sfera ginecologica.S-a exclus sindromul Demon Meigs ( luat in discutie prin prezenta de lichid in fundul de sac Duglas). S-a administrat Venofer injectabil sub care sindromul anemic s-a corectat; s-a luat in discutie tulburari de absorbtie a fierului. Doua determinari de laborator au aratat valori crescute ale fosfatazei alkaline serice care au determinat dozarea calcemiei ce avea valori crescute si a fosforemiei , valori scazute; s-a suspicionat un hiperparatiroidism , confirmat de catre medicul endocrinolog din Sibiu, pe baza datelor clinice ( poliurie, polidipsie , astenie, bradicardie, constipatie) coroborate cu datele de laborator(FAS, calcemie crescuta, fosfatemie scazuta, PTH mult crescut 127 pg/ml ( VN sub 65 ) paraclinice (eco tiroidian evidentiaza formatiune nodulara hipoecogena cu vascularizatie prezenta peri si intranodular ,

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posterosuperior de lobul stang tiroidian, densitometria osoasa evidentiind aspect de osteoporoza ( -2,8 ). S-a stabilit diagnosticul de adenom paratiroidian superior stang, hiperparatiroidism primar, osteoporoza secundara. Continuarea investigatiilor la C.I. Parhon, prin scintigrafie si CT confirma nodul paratiroidian lob stang pol superior al tiroidei ; S-a intervenit chirurgical excizandu-se adenomul paratiroidian. Sub tratament cu alfa D3 0,5 micrograme /zi si THE DIAGNOSES OF A CASE OF PRIMARY HYPERPARATHYROIDISM STARTING FROM THE INVESTIGATION OF THE ETIOLOGY OFAFERIPRIVEANEMIATHAT DID NOT RESPOND TO ORAL IRON THERAPY Catana Alina (a), Podia Claudia (b), Ghemigian Adina (c), Mocanu D.(d), Mihaila R. (a), Deac M.(e), Flucus Ofelia (a), SolomonAdelaida(e), Catana I. F.(f) a.-Compartiment hematologie, Spital Clinic Judetean Sibiu, b.Clinica Endocrinologie, Spital Clinic Judetean Sibiu, c.Institut Clinic Parhon,Bucuresti, d.- Gastroenterologie, Spital clinic Judetean Sibiu, e.- Sectie Clinica Medicala II, Spital clinic Judetean Sibiu, f.- Sudent an VI. M.G,Arad; Introduction The feriprive anemia is the most frequent type of anemia. The ginecological cause is the first to consider for the sexually active woman. The iron absortion disturbance connected with hyperparathyroidism appear very rarely. Method and material We report the case 25 year old woman, known with feriprive anemia for wich no bleeding causes were discovered the patient receiving iron orally but the hemoglobin did not rise to more than 9g/dl. In prima 2007 she was admitted in Gastroenterology Department of the Sibiu Country Hospital- with severe feriprive anemia. The colonoscopy was normal, the superior digestive fiberscopy revealed acute erosive gastritis Helicobacter Pilori negative. She received blood transfusions and than maltoferfol. The hemathological check up after 1 and 2 months of oral iron therapy showing no significant increase of hemoglobine (up to 9,5 g/dl); the hemoglobin electrophoresis excluded thalasemia syndromes and the gynecology check up did not reveal any problems in the area. The Demon Meigs syndrome was also excluded (consider because of the presence of liquid in the Douglas space). Following the administration of Venofer (injectable) the anemia was corrected. We considerd the iron absortion disturbances.The lab tests showed high levels of serum calcium (high) and serum phosphor (low) we considered a hyperparathyroidism, confirmed by the endocrinologist-according to the clinical data (poliuria,polidipsia,asthenia,bradicardia,constipation), lab data (FAS, calcium high, low pfosforemia,high levels of PTH 127 pg/ml(normal value<65), paraclinical data(the thyroid ultrasound revealed a nodular hypoecogen tumor with peri and intranodular vascularization situated posterosuperior from the left thyroid lobe, the bone densitometry revealed osteoporosis (-2,8)). The diagnose was Parathyroidian left superior adenoma; Primary hyperparathyroidism, secondary osteoporosis. The scintigraphy and CTscan (CI Parhon) confirm yhe parathyroid left lobe node situated at the superior thyroid border. The parathyroid adenoma was surgically removed. Under treatment with alfa D3 0,5g/day and calcium 1 g/day-the levels of calcium, phosphor, FAS, PTH became normal. In the present the patient is not anemic. Conclusion The particularity of the case is the diagnosing of a primary hyperparathyroidism starting with the investigation of a feriprive anemia. The specialy literature describes anemia connected with hyperparathyroidism in one case due to iron deficiency and in another case due to maturation factors deficiency. >>>>>>>>>>>>>>>>>>>>>>>>>>.. EVOLUTIA IMPRESIONANTA A DOUA CAZURI CU MIELOM MULTIPLU REFRACTARE LA CHIMIOTERAPIE, CU COMPLICATII OSOASE MULTIPLE, SUB TRATAMENT CU VELCADE (BORTEZOMIB) - CAZUL 1 CU LUXATIE SI TELESCOPARE DE VERTEBRA C2, ABLATIE DE C3, GREFON OSOS DIN CREASTA ILIACA, FRACTURI COSTALE STANGI IV-XI; CAZUL 2 CU FRACURA SUBTROHANTERIANAFEMUR DREPT SIABLATIE TUMORAVERTEBRALATORACALAT9. Catana Alina (a), Boca Liliana (b), Secelean M. (b), Draghila Livia (d), Olteanu Ariela (d), Zaharie Alina (d), Zaharie S.(e),Mihaila R. (a), Deac M. (f), Flucus Ofelia (a),SolomonAdelaida(f) Catana I. F. (g) a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b-Neurochirurgie, Spital Clinic Judetean Sibiu, cNeurochirurgie Cluj, d- Laborator, Spital clinic Judetean Sibiu, e- Anatomopatologie, Spital clinic Judetean Sibiu, fSectie Clinica Medicala II, Spital clinic Judetean Sibiu, g- Student an VI, M.G.,Arad

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Introducere: Mielomul multiplu (M.M.) este o afectiune maligna de limfocit B., reprezentund a-2-a malignitate ca frecventa dupa LMNH, 10% din afectiunile maligne, 1% din toate cancerele. Supravietuirea la 5 ani s-a imbunatatit mult in ultimi 5 ani datorita noilor agenti terapeutici. Alegerea unui agent sau combinatii, depinde de mai multi factori, incluzand varsta, statusul de performanta, factorii de prognostic, stadiul bolii; cei mai multi pacienti cu mielom primesc in cursul bolii lor mai multe linii terapeutice si in general eficacitatea si durata raspunsului diminua cu fiecare regim folosit. Tratamentul cu Velcade reprezinta o noua sansa pentru pacienti cu mielom. Material si metoda: Prezentam doua cazuri cu mielom multiplu (52 ani, 53 ani) care au beneficiat de terapia cu Velcade si putem spune ca aceasta a constituit pentru ei o terapie de salvare. Cazul I: Un pacient diagnosticat in 2004 cu MM micromolecular, stadiul III B, nefropatie mielomatoasa, insuficienta renala cronica stadiul II, cardiostimulare electrica permanenta pentru boala de nod sinusal. S-au administrat cure Alexanian, patologia cardiaca nu a permis cure VAD. In ianuare 2007 pacientul prezenta boala progresiva cu dureri osoase, osteolize costale,de omoplati, fracturi costale stangi de la coasta 5 la coasta 11. In martie 2007 apar osteolize vertebrale importante C3, C4, tasare si telescopare pe os patologic cu luxatie C2, cu osteoliza C5, C6, L2-L5, pareza plex brahial stang. S-a facut radioterapie cervicala 8 grey, corticoterapie, s-a intervent neurochirurgical pentru a se preveni tetraplegia ce era iminenta. S-a practicat excizie vertebra C3, grefon osos tricotat din creasta iliaca stanga, placuta cu 3 suruburi. In martie 2007 prezenta dureri osoase, fractura pe os patologic, sindrom anemic (9,5 gr/dl), infiltrare medulara 60% cu celule mielomatoase, sindrom de retentie azotata ( uree=125 mg/dl, creatinina 2,8 mg/dl; clearance la creatinina 18,9 ml/minut, VSH 103 mm/ h) s-au administrat doua cicluri Velacde 1 mg/m2, doza ajustata datorita clearanceului renal-- sub care infiltratul medular a scazut sub 3 %, VSH= 20mm/ora, functia renala s-a imbunatatit- uree 43 mg/dl, creatinina 1,6mg/dl , permitand tratament cu Zometa. Cazul II . Diagnosticat in iunie 2006 cu MM IgG, stadiul III, cu ablatie de corp vertebral (T 9), fractura subtrohanteriana femur drept pe os patologic, osteosinteza cu tija metalica Ender , la care s-a obtinut un raspuns partial initial cu scaderea componentului monoclonal cu 65 % dupa care, pacientul a recazut in martie2007 cand au aparut dureri atroce, osteolize extinse, predominant costale, refractare la antialgice, necesitand administratre continua de Fentanil. Dupa doua cicluri Velacde 1,3 mg/m2, componentul monoclonal a scazut cu 84%, durerile osoase au devenit suportabile, fara necesar de antialgice. Concluzii: Optiunile terapeutice la acesti pacienti au fost limitate iar complicatiile osoase foarte grave. Pentru primul pacient transplantul de maduva osoasa nu intra in discutie, insuficienta renala si afectarea cardiaca limita paleta terapeutica. Inceperea concomitenta a tratamentului cu Velcade (2 cicluri obtinute prin donatie de la firma Janssen Cilag), a permis cuplarea celor doi pacienti, care au primit impreuna 3,5 mg (1 flacom / adm), Sansa de utilizare a acestui medicament a fost sansa de supravetuire a acestor pacienti. THE IMPRESSING EVOLUTION OF TWO CASES OF MM RESISTANT TO CHEMOTHERAPY- CASE1: LUXATION OF THE C2 VERTEBRA, SURGICAL EXCISION OF THE C3 VERTEBRA AND REPLACEMENT WITH A PIECE OF THE ILIAC BONE, LEFT RIB FRACTURES (RIBS IV-XI). CASE2: RIGHT SUBTROHANTERIAN FEMUR FRACTUREAND SURGICAL REMOVAL OF T9- THORACALVERTEBRA Catana Alina (a), Boca Liliana (b), Secelean M. (b), Draghila Livia (d), Olteanu Ariela (d), Zaharie Alina (d), Zaharie S.(e),Mihaila R. (a), Deac M. (f), Flucus Ofelia (a),SolomonAdelaida(f) Catana I. F. (g) a-Compartiment hematologie, Spital Clinic Judetean Sibiu, b-Neurochirurgie, Spital Clinic Judetean Sibiu, cNeurochirurgie Cluj, d- Laborator, Spital clinic Judetean Sibiu, e- Anatomopatologie, Spital clinic Judetean Sibiu, fSectie Clinica Medicala II, Spital clinic Judetean Sibiu, g- Student an VI, M.G.,Arad Introduction MM is a maligne B limhocyte tumora,second in frequency after the LMNH, representing 10% of all maligne conditions;1% of all cancers. The surviving after 5 years improved very much in the last 5 years due to new therapeutical agents. The choice for one agent or combination depends on many factors including age, performing status, prognostic, degree of disease; most of the patients with MM receive more than one therapy line and generally the effectives and the duration of the response diminishes with every line that is used. The treatment with Velcade represents a new chance for the patients with MM

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Method and material We report two cases of MM(age 52 and 53) that benefited from the therapy with Velcade, wich for them constituted a saving therapy. Case1: The patient was diagnosed in 2004 with MM micromolecular, stage IIIB, cronic renal insufficiency stage II., permanent electric cardiostimulation for sinus node disease, Alexanian cycles were administred the cardiac pathology did not permit the instituting of VAD cycles. In January 2007 the disease was progressive with pain and osteolisis of the ribs and scapulae, rib fractures from rib 5-11. In march 2007 important vertebral osteolisis of C5,C6,L2-5, left brachial plexus paresis. Cervical radiotherapy (8Gy) and corticotherapy were administred, also the neurosurgical intervention was necessary in order to prevent the imminent tetraplegia.. The C3 vertebra was surgically removed and replaced with a piece from the iliac bone wich was fixed in place with 3 screws. In marc 2007 the patient had bone pain, pathological bone fracture anemia (9,5 g/dl hemoglobin), medular infiltrationwith mielomatose cell 60%, nitrogen retention syndrome (urea-125mg/dl,creatinin 2.8mg/dl,creatinin clearance 18,9ml/min; ESR 103mm/h)). Two cycles of Velcade were administered 1mg/m2 (the dose was adjusted accordind to the renal clearance)- under the treatment. The medular infiltrate droped under 3 %, ESR 20mm/h,the renal function improved (urea 43mg/dl, creatinin 1,6 mg/dl) wich allowed the administration of Zometa. Case2: The patient was diagnosed in june 2006 with MM IgG stge IIIA, surgical remual of the nineth thoracal vertebra, right subtrohanterian femur fracture (pathological bone fracture)-osteosinthesis with Ender metal . Initially a partial response was obtained the monoclonal component droping 65% after which there was a relapse in march 2007 when the patient presentend excruciating pain due to extended osteolisis mainly at the ribs.The pain persisted in spite of the pain medication administreted, the patient needing continous Fentanyl administration. After 2 cycles of Velcade 1,3 mg/m2 the CM droped 84%, the rib pain becamebearable, the pain medication not being needed anymore. Conclusion The therapeutical choises(options) were limited for these patients and the bone complications were serious. For the first patient was out of discussion, and the renal insufficiency and cardiac pathology limited the therapy options. The simultaneous treatment of the 2 patients with Velcade (obtained through donation from the Janssen Cilag firm) was possible (1 viel3,5mg being administreted to the 2 patients together. The patients chance of survival was the use of this medicine. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>> BENEFICIUL ASPIRINEI IN DOZE MICI,LA PACIENTII CU POLICITEMIE VERA SI TROMBOCITEMIE ESENTIALA Gabriel Gaman,Amelia Gaman,C.Moisa,Daniela Cioroianu,Adela Delcea UMF Craiova. Pe un lot 112 pacienti cu Policitemie vera si Trombocitemie esentiala(69 pacienti cu Policitemie vera,43 pacienti cu Trombocitemie esentiala,cu varste cuprinse intre 39 si 68 ani) a fost urmarita evolutia sub tratament specific(93 pacienti-Hidroxiuree,19 pacienti-INF-alfa,3x106 x3x3 saptamani)si simptomatic(Aspirina sau Trombo-Ass,40300mg/zi,in doza medie de 170 mg/zi). Evenimentele hemoragice trombotice care au aparut la acest lot (perioada 1997-2007)au fost comparate cu evenimentele de acelasi fel inregistrate pe un lot similar de pacienti(55 pacienti cu Policitemie vera, 39 pacienti cu Trombocitemie esentiala),lot la care tratamentul respectiv nu a fost prescris ,a fost ignorat sau administrat numai in primele zile de spitalizare. Comparind cele doua loturi s-a constatat o reducere semnificativa a manifestarilor de tip trombotic la pacientii care au urmat cu strictete tratament cuAspirina sau Trombo-ass,cu dozele amintite. Incidenta accidentelor hemoragice a fost similara la cele doua loturi de bolnavi. THE BENEFITS OF LOW DOSE ASPIRIN IN PATIENTS WITH POLYCYTHEMIA VERA AND ESSENTIAL THROMBOCYTHEMIA Gabriel Gaman,Amelia Gaman,C.Moisa,,Daniela Cioroianu,Adela Delcea UMF Craiova. We have monitored the evolution under specific treatment(93 patients-Hidroxiuree,19 patients IFN-alfa,3x106 x3x3 weeks)and symptomatic treatment(Aspirin or Trombo-Ass-40-300mg/day,in average dose of 170mg/day) of our study group, composed of 112 patients diagnosed with polycythemia vera and essential thrombocythemia(69patients diagnosed with polycythemia vera,43 patients diagnosed with essential thrombocythemia,with ages between 39 and

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68). Hemorrhagic and thrombotic events that occurred to this study group( in the period of time between 19972007)have been compared to similar events noticed on a group of patients(55 patients with polycythemia vera 39 patients with essential thrombocytemia) that haven't received this treatment (the treatment wasn't prescribed, it was ignored or it was administrated only during the first days of hospitalization). Comparing the two groups, we have noticed an important decrease of thrombotic events at the patients which strictly followed the treatment withAspirin and Trombo-Ass in the above-mentioned doses. The incidence of hemorrhagic events was similar in both groups of patients. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> INCIDENTA SINDROAMELOR MIELOPROLIFERATIVE CRONICE IN TRANZITIE LA PACIENTII CU POLICITEMIE VERA-METAPLAZIE MIELOIDALAPACIENTII CU POLICITEMIE VERA Amelia Gaman,Gabriel Gaman,C.Moisa,Adela Delcea,Daniela Cioroianu,Ionica Bizoi UMF Craiova. Dupa autorii americani MMM este considerata o complicatie tardiva ce face parte din istoria naturala a lungilor supravietuitori cu Policitemie vera. Am cautat sa verificam incidenta acesrei entitati pe un lotr de 196 pacienti diagnosticati in Clinica Medicala I ,Clinica de Hematologie din Craiova sau alte centre din tara,pacientii intrati in evidenta registrului regional de Oncologie ,Dolj Diagnosticul de sindrom PV-MM a fost stabilit intr-un numar de 47 cazuri(37 barbati si 10 femei,cu varste cuprinse intre 41 si 60 ani).Diagnosticul a fost stabilit dupa 9-22 ani de evolutie clinica a P vera, fiind sugerat de : -cresterea dimnsiumilor splinei(accentuarea splenomegaliei) -prezenta tabloului leuco-eritroblastistic -scaderea(scurtarea)hematocritului -fibroza medulara extensive(punctie medulara osoasa) -infarcte splenice. De remarcat incidenta mare a transformarilor in LA in lotul pacientilor cu PV-MM(19 cazuri,25,7%).Mentionam ca transformarea in LAa PV-MM s-a produs in intervalul 36-62 de luni de la stabilirea diagnosticului de PV-MM. THE INCIDENCE OF CHRONIC MYELOPROLIFERATIVE DISORDER IN THE POLYCYTEMIA VERA MYELOID METHAPLASYTRANSITION Gabriel Gaman,Amelia Gaman,C.Moisa,Adela Delcea,Daniela Cioroianu,Ionica Bizoi-UMF Craiova. According to American authors, myelofibrosis with myeloid metaplasia (MMM) is considered to be a late-stage complication in long-term surviving patients with polycythemia vera (PV). Our aim was to evaluate the incidence of this condition on a group of 196 patients diagnosed in the Medical Clinic and the Haematology Clinic of Craiova or other Romanian Clinics, patients registered in the County Cancer Register - Dolj. The PV-MM syndrome diagnosis was confirmed in 47 cases(37men,16 wemen,with ages between 41 and 60) ,after 922 years of clinical evolution of PV. The diagnosis was suggested by spleen enlargement (increased splenomegaly), the presence of leucoerythroblastic blood picture, depressed hematocrit values, extensive medullary fibrosis and splenic infarcts. We noticed an increased incidence of acute leukaemia in the PV-MM patients group. The transformation of PV-MM(19 cases,25,5%) into acute leukaemia occurred in a period of 36-62 months from the diagnosis moment. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<

CORELATII INTRE PARTICULARITATILE CLINICE SI CITOMORFOLOGICE IN HAIRY CELL LEUKEMIA Violeta Moraru, Daniela Ostroveanu, Didona Vasilache, Codruta Tatu, Viorica Iacob. Clinica de Hematologie, Institutul Clinic Fundeni, Bucureti

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INTRODUCERE: Leucemia cu celule cu peri,HAIRY CELL LEUKEMIA (HCL) este o forma rara de limfoproliferare cronica a adultului caracterizata prin splenomegalie,pancitopenie frecventa si prezenta de celule mononucleare anormale in sange,maduva osoasa,splina. Metoda: Studiul a fost efectuat pe un lot de 50 de bolnavi internati in Clinica de Hematologie a Institutului Clinic Fundeni in perioada 1998-2007. REZULTATE: Din acest lot 14% sunt femei si 86% sunt barbati;clinic 40% au splenomegalie usoara(<5cm) si 32% splenomegalie marcata(>5cm) ;58% hepatomegalie;26% adenopatii. DATELE DE LABORATOR au evidentiat:50% Hb<10g/ul;38% trombocitopenie(<50.000/ul) ;68%Leucopenie (<4.000/ul);66%Neutropenie (12%-Ne<1500/ul si 54%Ne<1.000/ul.)Din punct de vedere morfologic tipul de nucleu ovoid~74%,tipul convulut~18% si tipul identat~8%. Chitochimic: TRAP pozitiv la 98% dintre bolnavi; FAL crescut peste limita superioara a normalului (100 U Kaplow ) la~88% la la 88 % dintre pacienti. Histologic gradul de infiltrare al maduvei osoase a fost variabil:>50%(la 60% dintre pacienti) 20-50%(la 20 -50%(la16% dintre pacienti);< 20 % (la 24 % dintre pacienti ). CONCLUZII: Rezultatele pe lotul studiat confirma: -Boala predomina net la sexul masculin -Morfologic tipul de nucleu ovoid este predominant colerat cu o durata medie de supravietuire mai mare -Neutropenia este trasatura hematologica majora a bolii -Scorul FAL mult crescut(>180 u K)la majoritatea pacientilor -Izoenzima 5 a fosfatazei acide rezistenta la denaturarea cu acid tartric are specificitate mare -Biopsia de os-obligatorie pt diagnosticul,clasificarea in functie de aspectul nucleului si monotorizarea bolii. CORRELATIONS BETWEEN CLINICALAND CITO-MORPHOLOGICAL PARTICULARITIES IN HAIRY CELLS LEUKEMIA Violeta Moraru, Daniela Ostroveanu, Didona Vasilache, Codruta Tatu, Viorica Iacob Clinic of Hematology, Fundeni Clinical Institute, Bucharest Introduction: Hairy celles leukemia is a rare form of cronical limphoproliferation characterizated by frequent splenomegaly and frequent pancitopeny and by the presence of abnormal mononuclear cells in the blood, marrow of bone and spleen. Method: The study have been done on 50 seek people hospitalised to the Clinical Research Institute Fundeni, between 1998-2007. Result:_From this lot of individuals 14% are female and 86% male;clinical 40% suffer from a light form of spleenomegalia (<5) and 32% suffer from a severe form of it (.5); 58% hepatomegalia; 26%ADENOPATII. The laboratory test result show that:50%Hb<10g/dl; 38% thrombocytopenia(<50.000/ul);68%leucopenia(<4000ul) 66% 66 66 66 %neutropenia (12%Ne<1500/ul and 54% Ne<1000/ul. From the morphological point of view:~74% the ovoid nucleus type,~18% convolutional type,~8% sameness type. Citochemical: -positiv trap at 98% from the ill persons -high FAL over the superiour limit of normal (100U. Kaplow) at~88% from the patiens. Histology: the amount of infiltrarion of marrow was variable:>50%(at 60% from the patiens);20-50%(at16%);<20% (at 24%) Conclusions:The results on the studied percentage confirm: -The illness prevails to the male sex -Morphologicaly,the type of ovoid nucleus predominates correlated with a longer survival period -Neutropenia is the major hematological feature of the illness -The FAL is highly over (180uk) at most patiens -The bone biopsy-obligatory for the diagnostic,clasification term the aspect of nucleus and the detection of the disease. <<<<<<<<<<<>>>>>>>>>>>>>>>>>>>>>>>>>>> VALOAREA TESTULUI COLONIILOR DE CELULE HEMATOPOIETICE IN VITRO IN PRACTICA

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TRANSPLANTULUI DE CELULE STEM HEMATOPOIETICE A.D. Moicean, T. Puscariu Centrul de Hematologie si Transplant Medular, Institutul Clinic Fundeni, Bucuresti Tehnica de clonare a celulelor progenitoare ale tesutului hematopoietic in vitro in vederea obtinerii unui anumit tip de colonii celulare a fost imaginata in urma cu cativa zeci de ani. S-a observat ca progenitorii hematopoietici introdusi in medii de cultura semisolide (cu suport de agar, metilceluloza sau fibrina) pot genera colonii (clone) granulocitare, monocitare, eritroide, megacariocitare si limfocitare in prezenta unor factori stimulatori specifici (factori de crestere hematopoietici). In Romania metoda amintita a fost adaptata si aplicata in laboratorul de hematopoieza al Institutului Clinic Fundeni in anul 1980 pentru studiul unor afectiuni hematologice clonale. Din anul 2000 aceasta metoda modificata dupa standardele laboratoarelor de referinta din strainatate, este aplicata si pentru testarea capacitatii functionale a celulelor grefonului conservat prin congelare contolata in azot lichid in vederea transplantarii in Departamentul de Transplant Medular. Ipoteza de lucru este aceea prin care modelul de crestere a coloniilor de celule hematopoietice in vitro si studiul celulelor formatoare de colonii granulo-monocitare (CFC-GM) si a celulelor formatoare de colonii eritroide (CFC-E si CFC-EB) permite anticiparea refacerii hematopoiezei in vivo la pacientul transplantat si atribuirea standardului de calitate grefonului recoltat. Material si metoda: In perioada 2000 2005 au fost efectuate teste de viabilitate cu albastru de tripan la celulele recoltate in grefoanele a 19 pacienti cu boli maligne hematologice si la 4 donatori sanatosi de celule stem hemtopoietice. Celulele din 39 de grefoane au fost pregatitite pentru a fi cultivate in mediu semisolid imediat dupa recoltare. Din esantionul recoltat celulele mononucleare au fost separate in gradient de densitate, intr-un amestec ficoll-hypaque cu densitate de 1.077g/ml. Dupa doua spalari succesive celulele au fost resuspendate in mediul de cultura si au fost numarate intr-o camera de numarat (hemocitometru). Dupa calcularea numarului de celule pentru o placuta de cultura, s-au cultivat celulele in monostrat de metilceluloza, in prezenta factorilor de crestere hematopoietici. Culturile au fost incubate1214 zile la 37oC in atmosfera de 5%CO2 si umiditate maxima. Pentru citirea coloniilor aparute s-a folosit un microscop inversat. Aglomerarile de mai mult de 40 de celule s-au considerat colonii, iar acelea formate din mai putin de 40 de celule s-au considerat grupuri (clusters). Rezultate: In 3 cazuri de grefoane cu numar mic de celule CD34+ numarul de colonii obtinute in vitro a fost foarte bun, intervalul de timp asteptat pana la grefare fiind comparabil cu cel obsevat la grefoanele cu numar mare de celule recoltate (7 11 zile). Intr-un caz s-a observat o discrepanta intre numarul crescut de celule CD34+ in grefonul recoltat numarate prin tehnica citometriei in flux si numarul extrem de scazut de colonii in cultura, ceea ce ar putea fi explicat printr-un numar mare de celule in apoptoza recoltate, incapabile de a reface hematopoieza. Numarul de CFC-GM este factor de prognostic de mare fiabilitate pentru capacitatea de refacere a hematopoiezei de catre grefonul transplantat VALUE OF HEMATOPOIETIC COLONIES IN VITRO ASSAY FOR HEMATOPOIETIC STEM CELLS TRANSPLANTATION PRACTICE. A.D. Moicean, T. Puscariu Centrul de Hematologie si Transplant Medular, Institutul Clinic Fundeni, Bucuresti Modern treatment of hematologic diseases comprises also stem cell transplantation. The two main goals of this treatment approach are to substitute the deffective hematopoiesis (inssuficient or neoplastic) and to allow an aggressive treatment which produces a prolonged or deffinitive myelosupression in order to eradicate the malignant cell clone. The main steps of a stem cell transplantation are: obtaining a good graft, preparing the patient for receiving and accepting the transplantation procedure, the stem cell transplantation itself and early and late medical care after transplantation. The graft is a stem cell concentrate obtained frequently from hematogenous bone marrow or from peripheral blood. The outcome of a patient who has undergone a bone marrow transplantation depends critically on the quality of the graft. There were developed different strategies for appreciating the grafts quality. Of these, the most important is to obtain in vitro hematopoiesis cell cultures. In this way, we can evaluate in vitro growth modalities of the graft cells and the potential for in vivo recovering of the hematopoiesis. The growth pattern of the hematopoietic cell colonies in vitro is an important prognostic factor for transplanted patients. The aim of this project is to develop a standardized method to appreciate the growth pattern of the graft. Material and methods: Between 2000 2005 peripheral stem cells grafts was harvested from 19 patients with malignant hematopoietic diseases and from 4 related donors. Cells from 39 grafts were prepared for cultivating in semi-solid medium just after harvesting. Harvested mononuclear-cells were separated in density gradient ficoll-hypaque mixture,

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density 1.077g/ml. Then they were two times washed and suspended again in culture medium and counted in hemocytometer. Knowing the cells number for each culture-plaque, the cells were cutivated in methylcelulosis monolayer with hematopoietic growth factors. The culture were incubated at 37oC and 5%CO2 and maximum humidity 12-14 days. An inversed microscope was used for results reading. The mass with more than 40 cells was a colony and that with less than 40 cells was a cluster. Results: In 3 fable grafts (low number of CD34+ cells) the number of in vitro colonies was high and the time until engraftment in vivo was as that found for high number of in vitro colonies grafts. In one case we found a discrepancy between the high number of CD34+ cells counted in flow-citometry and the low number of in vitro GM-CFU, due to a high number of apoptotic cells harvested. The in-vitro GM-CFU number is a good prognostic factor for engraftment after hematopoietic stem cell transplantation. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

DISCORDAN NTRE ASPECTUL MORFOLOGIC I CEL IMUNOFENOTIPIC AL BLATILOR NTR-UN CAZ DE LEUCEMIEACUTA-PREZENTARE DE CAZ Delia Mut Popescu1, Anca Roxana Lupu1, Nicoleta Berbec1, Adrian Wolf 1, Simona Crintea1, Doina Barbu1, Silvana Angelescu1, SimonaAvram1, Horia Bumbea2 1Clinica Hematologie, Spitalul Clinic Colea, Bucureti, Romnia 2Clinica Hematologie, Spitalul Universitar de Urgen, Bucureti, Romnia INTRODUCERE: n diagnosticul leucemiilor acute, boli neoplazice ale celulelor stem hematopoietice, un rol esenial l dein investigaiile paraclinice, mai ales examinarea sngelui periferic i mduvei osoase hematogene din punct de vedere morfologic dar i imunofenotipic. Imunofenotiparea celulelor leucemice prin citometrie n flux poate face lumin n cazurile dificil de interpretat ca aspecte morfologice. MATERIALE I METODE: Prezentm cazul pacientei F.S. n vrst de 64 de ani din Trgovite, trimis n ianuarie 2007 de la Spitalul Judeean Trgovite n Clinica de Hematologie a Spitalului Clinic Colea cu diagnosticul de leucemie acut limfoblastic. Suspiciunea de diagnostic a fost ridicat pe baza hemoleucogramei i a frotiului de snge periferic efectuate n Clinica Medical a Spitalului Judeean Trgovite, fiind observat leucocitoz cu 90% limfoblati. n laboratorul de morfologie al Clinicii de Hematologie din Spitalul Clinic Colea Bucureti au fost efectuate hemoleucograma cu examen al frotiului de snge periferic colorat Giemsa, examenul citomorfologic al frotiurilor de aspirat medular colorate Giemsa, examenul citochimic al celulelor medulare pe frotiuri de aspirat medular colorate PAS i pentru mieloperoxidaz. De asemenea, a fost realizat imunofenotiparea celulelor din aspiratul medular prin citometrie n flux n laboratorul de citometrie n flux din cadrul Clinicii de Hematologie a Spitalului Universitar de Urgen Bucureti, cu un aparat Becton-Dickinson. Din motive obiective, s-a putut folosi doar un panel restrns de anticorpi monoclonali. REZULTATE: Frotiul de snge periferic l-a confirmat pe cel de la Spitalul Judeean Trgovite, decelnd un procent asemntor de limfoblati. Examenul citomorfologic al aspiratului medular pe frotiuri colorate Giemsa a decelat aceleai celule blastice cu aspect slab difereniat sau limfoid. Coloraiile citochimice infirm aspectul morfologic limfoid al blatilor, coloraia pentru mieloperoxidaz fiind pozitiv la nivelul blatilor medulari iar coloraia PAS fiind negativ pentru aceleai celule. Prin citometrie n flux a fost identificat o populaie blastic n procent de 94% ce sugera diagnosticul de leucemie acut mieloblastic, probabil M1. CONCLUZII: Particularitatea cazului const n discordana care a existat, n ceea ce privete celulele blastice, ntre aspectul

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morfologic din coloraia Giemsa pe de o parte i aspectul citochimic i imunofenotipic pe de alt parte. Interpretat iniial ca o leucemie acut limfoblastic n dou laboratoare de hematologie diferite, ulterior a fost confirmat ca leucemie acut mieloblastic, probabil M1, diagnostic susinut i de rspunsul bun la terapia specific acestui tip de leucemie, fiind subliniat nc o dat rolul imunofenotiprii n stabilirea cu certitudine a naturii blatilor. BIBLIOGRAFIE Pun Radu (sub red.)- Tratat de Medicin intern, Hematologie, Editura Medical, Bucureti, 1999 Wintrobe,s Clinical Hematology, 11 th Ed, Lippincott Williams & Wilkins Publishers, 2003 <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<

LEUCEMIE ACUT PROMIELOCITAR ASOCIAT CU SINDROM DE COAGULARE INTRAVASCULAR DISEMINAT-PREZENTARE DE CAZ Delia Mut Popescu1, Anca Roxana Lupu1, Carmen aguna1, Adrian Wolf 1, Doina Barbu1, Silvana Angelescu1, SimonaAvram1, Horia Bumbea2 1Clinica Hematologie, Spitalul Clinic Colea, Bucureti 2Clinica Hematologie, Spitalul Universitar de Urgen, Bucureti INTRODUCERE Leucemia acut promielocitar (M3 FAB) reprezint un subtip de leucemie acut mieloblastic caracterizat prin proliferarea n mduva osoas hematogen a unor promielocite atipice. Aceast form de leucemie are o evoluie clinic i caractere biologice diferite fa de alte leucemii acute mieloblastice iar asocierea acesteia cu sindromul de coagulare intravascular diseminat i confer o gravitate deosebit. MATERIALE I METODE Prezentm cazul pacientului D.A. din Constana, n vrst de 17 ani, internat n Clinica Hematologie Spitalul Clinic Colea Bucureti prin transfer de la Spitalul Judeean Constana-Clinica Medical. Pacientul a fost investigat n Clinica Hematologie-Spitalul Colea att prin examen clinic ct i din punct de vedere paraclinic: hemogram cu frotiu de snge periferic, examinare morfologic a mduvei osoase hematogene prin frotiuri de aspirat medular colorate Giemsa, teste de hemostaz, etc. Imunofenotiparea celulelor din aspiratul medular prin citometrie n flux a fost efectuat n Clinica Hematologie-Spitalul Universitar de Urgen Bucureti, cu un aparat Beckton Dickinson. REZULTATE La Spitalul Judeean Constana, pacientul s-a prezentat n octombrie 2006 cu febra, odinofagie, hipertrofie amigdalian i sindrom hemoragipar cutaneo-mucos sever. In sngele periferic au fost decelai 28% mieloblati. Pacientul a fost internat prin transfer n Clinica Hematologie-Spitalul Colea Bucureti, unde, examenul citomorfologic al aspiratului medular deceleaz 80% promielocite atipice. Imunofenotiparea acestor celule prin citometrie n flux, folosind un panel restrns de anticorpi, sugereaz imunofenotip de promielocit. Aspectul frotiului de snge periferic i testele de hemostaz prezint modificri caracteristice coagulrii intravasculare diseminate. Hemoculturile efectuate evideniaz Pseudomonas. Se instituie tratament specific acestui tip de leucemie acut, tratament al coagulrii intravasculare diseminate i tratament antibiotic, evoluia pacientului fiind favorabil. CONCLUZII Gravitatea cazului nc de la debutul clinic, subliniaz importana efecturii unor investigaii paraclinice complete imediat dup prezentarea unui pacient avnd leucemia acut ca diagnostic de suspiciune, stabilirea rapid a tipului exact de leucemie acut i a complicaiilor fiind extrem de importante pentru salvarea vieii pacientului. BIBLIOGRAFIE

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Pun Radu (sub red.)- Tratat de Medicin intern, Hematologie, Editura Medical, Bucureti, 1999 Wintrobe,s Clinical Hematology, 11 th Ed, Lippincott Williams & Wilkins Publishers, 2003 <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< folosite la tratarea primului cancer. Chiar daca aceasta lista te poate speria, trebuie sa ai foarte clar in minte si beneficiile pe care chimioterapia le poate aduce in viata ta. Vei putea trai cel putin zece ani fara probleme! >>>>>>>>>>>>>>>>>>>>>>>>>>> Rolul Splenectomiei N LLC M.Badea#, Daniela Badea*,Amelia Genuche, Doriana Du# #Clinica de Hematologie, *Disciplina de Fiziologie, Disciplina de Medicin Interrn; Univ de Medicin i Farmacie Craiova Introducere. Beneficiul splenectomiei efectuat pentru complicaiile leucemiei limfatice cronice LLC, inclusiv anemia hemolitica autoimun (AHAI), trombocitopenia imun (PTI), hipersplenismul i splenomegalia simptomatic este pus la indoial de unii cercettori. O parrte din bolnavii cu LLC n stadii avansate dezvolt splenomegalie i pancitopenie refractar ce rspunde uneori la derivaii depurin sau la CHOP. Un numr de studii sugereaz beneficiul splenectomiei prin eliminarea unei zone majore de boal, controlul hipersplenismului ameliorarea citopeniilor imune refractare i chiar o ameliorare a supravieuirii globale. Material si metoda. Lotul cuprinde un numar de 165 de bolnavi cu LLC aflai n evidena Clinici de hematologie Craiova nrolai n perioada 1990-2006. Vrsta medie la diagnostic a fost de 62,7 ani iar perioada medie de urmrire de 5,2 ani. Rezultate. Din totalul de 165 de cazuri de LLC 7,87 % au prezentat citopenii imune. Dintre acestea 4,2% s-au dovedit refractare la corticoterapie plus chimioterapie antineoplazica motiv pentru care s-a practicat splenectomia. Cea de-a doua indicaie a splenectomiei a reprezentat-o compresiunea mecanica 1,81% i citopeniile severe nonimune 2,42%. Toi cei 3 bolnavi cu spenomegalie compresiv au prezentat ameliorare evident a simptomatologiei. Dintre cei 7 bolnavi cu AHAI la doi s-a normalizat valoarea Hb, 4 au prezentat creteri ale valrii Hb de peste 2 gr/dl mce au persistat mai mult de 2 luni, iar 1 caz nu a raspuns. Din 5 bolnavi cu PTI doi au prezentat reveniri la valorile normale ale numrului de plachete dup splenectomie, a depit valoarea de 50.000/mm3 la ali doi, iar la unul nu s-a modificat. Durata medie a rspunsului a fost n medie de 24,1 luni. Durata medie a supravieuirii post splenectomie a fost de aprox 32,5 luni. Mortalitatea postoperatorie a fost nula, dar 2 bolnavi au prezentat morbiditate postoperatorie semificativ. Concluzii. Consideram splenectomia ca o metod terapeutic eficient, n LLC prin remisiunile i durata acestora n cadrul citopeniilor i prin ameliorarea simptomelor mecanice. Procedura terapeutic este asociat cu mortalitate i morbiditate redus. Impactul asupra supravieuirii este incert dar ameliorarea parametrilor sanguini permite administrarea unor doze eficiente de droguri mielosupresoare The SPLENECTOMY IN chronic lymphocytic leukemia M.Badea#, Daniela Badea*,Amelia Genuche, Doriana Du# #Dept. of Hematology, *Dept.of Physiology, Dept. of Internal Medicine; Univ. of Medicine and Pharmacy Craiova Introductions. The benefit of splenectomy, performed for complications of chronic lymphocytic leukemia (CLL) including autoimmune hemolytic anemia, thrombocytopenia, hypersplenism, and symptomatic splenomegaly, has not been clearly demonstrated. A number of patients with advanced CLL develop refractory splenomegaly and pancytopenia. This syndrome often responds to effective chemotherapy with nucleoside analogs or CHOP-type regimens. A number of studies have suggested hematologic and survival benefits from splenectomy in patients with CLL. Suggested benefits include removal of the major site of disease, control of hypersplenism, and improvement in immune- mediated cytopenias. Materials and methods. The lot contains 165 CLL patients under the care of the Hematology Clinic of Craiova enrolled in the period of 1990-2006. The mean age at diagnosis was 62.7 years, and the average follow-up was 5.2 years.

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Results. From the total of 165 cases of CLL 7.87% demonstrated immune cytopenias. From these 4.2% proved to be refractory to corticotherapy and chemotherapy which is why splenectomy was applied. The second indicator of splenectomy was mechanical distress (1.81%) and non-immune cytopenias (2.42%). All 3 patients with mechanical distress were relieved of their symptoms. Among 7 patients with immune anemia a level was normalized in 2, improved in 4 and showed no change in 1 case. Among 5 patients with immune thrombocytopenia, platelet count was normalized in 2, improved in 2 and was unchanged in 1 case. Duration of response lasted for a mean period of 24.1 months. Mean survival after splenectomy was 32.5 months. There was no operative mortality but 2 patients had significant post-operative morbidity. Conclutions. We found splenectomy to be efficacious in providing durable remissions of refractory cytopenias and in relieving symptomatic splenomegaly in the majority of patients with CLL. The procedure is associated with a low perioperative mortality and modest morbidity. Although the impact on survival is uncertain, the improved peripheral blood counts may allow the administration of adequate doses of myelosuppressive chemotherapy. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< Leucemia limfatic Cronic I malignitIle secundare M.Badea#, Daniela Badea*,Amelia Genuche, Narcisa Frticiu# #Clinica de Hematologie, *Disciplina de Fiziologie, Disciplina de Medicin Interrn; Univ de Medicin i Farmacie Craiova Introducere Malignitile secundare reprezint o complicaie relativ obinuit n evoluia LLC . Bolnavii cu acest tip de leucemie pot dezvolta LMNH cu celula mare B cunoscut i ca sindrom Richter, boal Hodgkin, mielom multiplu i rar leucemie acut limfoblastica. Asociat exist i o cretere mdest dar semnficativ a malignitilor non limfoide/solide melanom malign, neoplasm laringian, bronho-pulmonar, cerebral, de stomac sau de vezic urinar, dar i hematologice precum leucemia acut non-limfoblastic. Material si metoda. Studiul nostru cuprinde un numr de 165 bolnavi cu LLC, nrolai ntre 1990 i 2006 ce aparin unui singur centru (Clinica de hematologie Craiova). Vrsta medie la diagnostic a fost de 62,7 ani iar perioada medie de urmrire de 5,2 ani. Rezultate. Rata apariiei celei de-a doua neoplazii solide n lotul nostru de bolnavi cu LLC a fost de 3,03%: 2 neoplasme bronho-pulmonare, i cte un caz de neoplasm gastric, de prostat i sn. n primele trei localizari trebuie avut n vedere rolul carcinogenetic al fumatului, 3 dintre acetia fiind fumtori. Rata evoluiei ctre o malignitate hematologic este de 2,42% : 2 LMNH cu celule mare i cte un caz de leucemie prolimfocitar i boal Hodgkin cu predominen limfocitar forma nodular. Majoritatea bolnavilor cu evoluie ctre cea de a doua malignitate au fost in stadii avansate III-IV (77,77%) i sunt de sex masculin (66,66%). Terapia primit anterior diagnosticului celei de-a doua neoplazii a cuprins in 65,71% alkilante, 57,14% au primit secvenial i analogi de purin, iar un singur caz a primit numai fludarabin. Diagnosticul celei de-a doua maligniti a fost evideniat in primul an de la diagnosticul limfoproliferarii cronice (LLC) la un bolnav, numrul de noi cazuri (2) fiind constat pentru celelalte intervale de timp respectiv 1-3 ani 4 7 ani i peste aceasta durata. Concluzii. Studiul nostru retrospectiv relev c riscul dezvoltrii unei neoplazii secundare n LLC este modest dar semnificativ 5,4%. Malignitile dezvoltate sunt comune ca form histologic i localizare: LMNH cu celul mare B, neoplasme bronho-pulmonare, gastrice. Cea de-a doua neoplazie apare mai frecvent la sexul masculin si n stadiile avansate ale proliferrii limfoide. Patogena celei de-a doua neoplazii poate lua n calcul imunodeficiena asociat LLC, chimioterapia administrat, infeciile virale, vrsta bolnavilor etc. Pare prudent ca bolnavii cu LLC sa evite expunerea la stimuli cu potenial carcinogenetic, precum fumatul sau expunerea la soare. The second malignancy IN chronic Lymphocytic leukemia M.Badea#, Daniela Badea*,Amelia Genuche, Narcisa Frticiu# #Dept. of Hematology, *Dept.of Physiology, Dept. of Internal Medicine; Univ. of Medicine and Pharmacy Craiova Second malignancies are frequent complications in patients with chronic lymphocytic leukemia (CLL). Patients with this leukemia may develop diffuse large cell lymphoma (known also as Richter's syndrome), Hodgkin's disease, prolymphocytic leukemia, multiple myeloma and acute lymphoblastic leukemia. Significantly increased risks of solid cancers in CLL was also modestly but significantly elevated: malignant melanoma, cancers of the larynx, the lung,

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brain, stomach and bladder. Materials and methods. The lot contains 165 CLL patients under the care of the Hematology Clinic of Craiova enrolled in the period of 1990-2006. The mean age at diagnosis was 62.7 years, and the average follow-up was 5.2 years. Results. The rate of appearance of the second malignancy was 3.03%: two lung cancers and a case of gastric, prostate, and breast. In the first three cases we must take into account the carcinogenic role of smoking. The rate of evolution towards a hematological malignancy is 2.42%: two LMNH with large cells and a case of prolymphocytic leukemia and Hodgkin's disease. The majority of patients who evolved towards the second malignancy was in the advanced stages III-IV (77.77%) and was males (66.66%). The therapy contained 86.71% in alkylating drugs, 57.14% received sequential and purine analogs and one case received only fludarabine. The diagnosis of the second malignancy was made in the first year of the diagnostic of the CLL; the number of new cases was two for the other time periods: 1-3 years, 4-7 years and throughout this period. Conclusions. Our data indicate that the overall risk of developing a second cancer is modestly but significantly elevated (5,45%), in persons with CLL. The hematological and solid malignancy was common in regard to the type and localization: LMNH with large cells and lung cancer. The second neoplasm was more frequent in males and in the advanced stages of the disease. It would also seem prudent to urge patients with CLL to avoid exposures to carcinogens such as tobacco smoke and excessive sunlight. <<<<<<<<<<<<<<<<<<<

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COMUNICARI ASISTENTE MEDICALE

ROLUL PROFESIONAL IN MANAGEMENTALASISTENTEI MEDICALE Doina Mircea Eugenia Bontea, Marcela Dumitrescu Centrul de Hematologie i Transplant Medular Stefan Berceanu, Institutul Clinic Fundeni, Bucuresti Viitorul, nu mai este ceea ce eram obisnuiti sa fie. Unii oameni se dezvolta prin schimbare, iar altii mai degraba o evita, dar toti pot beneficia de ea si cu o pregatire adecvata se pot bucura de ea. Schimbarea este o oportunitate atat pentru sucees cat si pentru esec. Sa ne concentram pe alternativa succesului si sa-i incurajam si pe altii sa faca la fel. Scoicilor nu le place prea mult nisipul, dar fac perle minunate din el. Poti sa vrei sa faci lucrul potrivit si chiar sa doresti sa il faci din motive juste. Degeaba insa daca nu aplici principiile corecte. Daca lucrand mai mult, mai inteligent si mai repede, nu rezolvam nimic,atunci care e solutia? O data trait timpul e pierdut definitiv, de aceea trebuie sa invatam sa il folosim cu intelepciune. Oamenii care-si asculta constiinta si traiesc asa cum le dicteaza ea, nu au satisfactii iluzorii, nu se gandesc niciodata sa actioneze conform oglinzii sociale si nu-si extrag siguranta din faptul ca sunt ocupati clipa de clipa. Au un simt aproape sacru al responsabilitatii de a contribui semnificativ si la calitatea vietii altora. Sunt atatea lucruri pe care le putem face pentru a le schimba in bine, indiferent de amploarea Sferei noastre de Influlenta. Speram ca fiecare dintre noi va reusi sa se concentreze la propria-i constiinta daruind sin focul sau interior, lumina si caldura lumii care il inconjoara. EFECTELE CHIMIOTERAPIEIASUPRABOLNAVILOR DE LEUCEMIE Mariana Filip Mariana Marinic, Marcela Toma Centrul de Hematologie i Transplant Medular, Institutul Clinic Fundeni, Bucureti Curele de chimioterapie sunt insotite adesea si de efecte secundare neplacute, care difera foarte mult de la o persoana la alta, chiar in cadrul aceleiasi "combinatii" de medicamente. Nimeni nu-ti poate spune cu exactitate care vor fi simptomele si ce amploare vor avea. In marea majoritate a cazurilor, "neplacerile" cauzate de tratament sunt autolimitate, organismul reusind sa se recupereze integral inainte de cura urmatoare - acesta fiind si scopul distantarii de cateva saptamani intre doua cure consecutive. Pacientii aflati in tratament antineoplazic prezinta cel mai frecvent: oboseala, caderea parului, greata - voma, pierderea poftei de mancare, diaree sau constipatie, afte bucale, modificarea aspectului pielii, tulburari nervoase periferice, afectarea maduvei osoase hematogene (cea care fabrica celulele sanguine). Nu trebuie insa ignorate efectele secundare ireversibile ce se instaleaza insidios ducand la instalarea unor leziuni cardiace (adriamicina), pulmonare (bleomicina, busulfanul), renale (cisplatinul), nervoase (vincristina) etc. Este posibil ca la distanta de ani de zile sa apara un al doilea cancer indus de medicamentele folosite la tratarea primului cancer. Chiar daca aceasta lista te poate speria, trebuie sa ai foarte clar in minte si beneficiile pe care chimioterapia le poate aduce in viata ta. Vei putea trai cel putin zece ani fara probleme! ROLUL ASISTENTEI MEDICALE DE HEMATOLOGIE IN ASIGURAREA UNUI CLIMAT DE SIGURANTA A PACIENTILOR Dorina Tilihoi, Daniela Olareanu,Ana Maresescu, Laura Oprea Spitalul Clinic Judetean Sibiu Compartiment Hematologie

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Nu luam cu noi decat binele pe care l-am facut Saint-Lambert Bolile hematologice, mai ales cele care presupun chimioterapie si spitalizari dese si indelungate nu sunt usor de suportat si de acceptat de catre pacient si au un impact puternic asupra acestuia. De multe ori preocuparea asistentei este mai degraba centrata asupra sarcinilor de indeplinit decat asupra persoanei bolnave, mai ales in cazul pacientilor in stare grava cu multe tratamente cand asistenta este supraaglomerata. De aceea pentru a asigura un climat de siguranta a pacientului asistenta trebuie sa fie capabila de disponibilitate, de vointa de a ajuta si de o deschidere fata de altii. In cursul ingrijirilor asistenta discuta cu pacientul, raspunde la intrebarile sale, il asculta, il incurajeaza si ii comunica acestuia intelegerea sa empatica. Acest contact cu pacientul este un pretext pentru a realiza relatii de incredere, respect reciproc, ceea ce confera ingrijirilor un caracter uman - o conditie a calitatii actului medical. THE ROLE OF NURSE TO CREATEASAFE ENVIRONMENT FOR PATIENTS IN HEMATOLOGY SECTION Dorina Tilihoi, Daniela Olareanu,Ana Maresescu, Laura Oprea County Clinical Hospital Sibiu Hematologic Section We take with us only the good we've done Saint-Lambert The hematological diseases, especially those who need chemotherapy with often and long spitalization are not easily accepted by the patient and they have a great impact over him. Many times the nurse's concern is pointed over the medical tasks rather than the person she has to cure.This fact happens especially when the nurse take care of patients in critical condition because the medical tasks are so many and she is overcrowded. That's why, in order to create a secure environment for the patient, the nurse must have the disponibility and the desire to help and keep an open-mind towards the others. In the act of nursing, the nurse talks with the patient, answers to his questions, puts an end to his worries and comfort him.She also emphasizes with him. This kind of contact is a pretext to realize a trust wordly relationship based on mutual respect which confers a human touch to the act of nursing the condition of a qualified medical act.

ACCIDENTE POST TRANSFUZIONALE SI CONDUITAAISITENTEI MEDICALE IN PREVENIREALOR Nela Constantin Sanda Ristea, Ecaterina Stoica Centrul de Hematologie i Transplant Medular, Institutul Clinic Fundeni, Bucureti Transfuzia de sange este, in prezent una dintre metodele de tratament cu cele mai grave riscuri. Pericolul cel mai mare il constitue necunoasterea indicatiilor si limitele acestei metode de tratament. Personalul medical trebuie sa respecte anumite reguli atat inainte cat si in timpul transfuziei, sa semnaleze imediat medicului eventualele accidente imediate sau tardive ale acesteia, si sa adopte o conduita necesara pentru a putea restabilii starea pacientului sau chiar pentru a-i putea salva viata. Aceasta lucrare va evidentia cateva din accidentele transfuzionale si conduita necesara adoptata de om pentru solutionarea si nu in ultimul rand evitarea lor. INGRIJIREAPACIENILOR CU HEMOFILIE Lenua Bratu Cornelia Cioclteu, Georgeta Vlad Centrul de Hematologie i Transplant Medular, Institutul Clinic Fundeni, Bucureti Hemofilia este o boal cunoscut nc din antichitate. Aceasta este o afeciune congenital ce se manifest prin deficitul de factori de coagulare. Cele mai ntlnite forme de hemofilie (hemofilia A i B) au la baz deficitul de factor VIII

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respectiv factor IX. Pe lng aceste forme de hemofilie exist i alte forme ntlnite mult mai rar ca: hemofilia C, deficit de factor XII, deficit de factor V etc. Principala caracteristic a hemofiliei este tendina la sngerare recidivant i prelungit. Rolul asistentei medicale n aceast situaie este, n funcie de gravitatea cazului, de a administra tratamentul cu antialgice, hemostatice i substituieni pentru corectarea deficitului de factori. Cel mai important tratament n aceste situaii ramne msurile de profilaxie, care constau n instruirea pacientului i a rudelor acestuia privind regulile de comportament n cazul acestei boli. Dei aceast boal necesit tratament pe parcursul ntregii viei, pacientul nu trebuie demoralizat ci ncurajat s nu simt diferena dintre el i o persoan sntoas. ROLUL ASISTENTEI MEDICALE IN TRATAMENTUL CU MABCAMPATH LA PACIENTII CU LEUCEMIE CRONICALIMFOCITARA(L.L.C.) Silvia-Mihaela Dragomir Carolina Pricope, Tincua Ptracu Centrul de Hematologie i Transplant Medular, Institutul Clinic Fundeni, Bucureti Leucemia cronic limfocitar este o boal progresiv i incurabil ntlnit n special la pacieni peste 60 de ani mai ales la brbai, cu o perioad de supravieuire de 7-10 ani de la diagnosticare. Tratamentul cu MabCampath este un tratament nou, folosit n cazurile n care terapia cu Fludara nu a dat rezultate. Dozele de tratament sunt agresive i pacienii trebuiesc atent monitorizai nainte i dup fiecare administrare. Datorit faptului c MabCampath este un tratament puternic alergizant, necesit premedicaie adecvat la fiecare administrare (paracetamol, antihistaminice, glucocorticoizi). Cu profilaxie i premedicaie adecvat, efectele secundare pot fi mpiedicate i rezultatul tratamentului s fie cel scontat. Rolul asistentei medicale este foarte important n managemetul tratamentului cu MabCampath. Un management adecvat face ca toi pacienii care urmeaz tratamentul cu MabCampath s primeasc cele mai bune avantaje n urma administrrii acestui medicament, i anume prelungirea perioadei de supravieuire.

ROLUL ASISTENTEI MEDICALE IN MONITORIZAREA TULBURARILOR CARDIACE LA PACIENTII IN PROCEDURA DE TRANSPLANT VIORICAMANEA-AS.MED.PR. DEP.TRANSPLANT MEDULAR.I.C.F GEORGIANATUDOR-AS.MED.PR.TRANSPLANT MEDULAR.I.C.F Transplantul de maduva osoasa este o procedura terapeutica, prin care se asociaza la o cura chimioterapica high doses de conditionare la final si infuzarea grefonului medular. Procedura se adreseaza pacientilor cu afectiuni hematologice maligne: leucemii, limfoame, mielom multiplu, anemie aplastica si alte afectiuni oncologice : neuroblastom, sarcom Ewing s.a. Transplantul cu celule stem hematopoetice este o procedura terapeutica foarte agresiva. Cu precadere, allotransplantatii pot dezvolta complicatii grave imediate sau care pot surveni ulterior, avand efecte de lunga durata, chiar definitive asupra calitatii vietii pacientului-biologic si social. Bolile cardiace nu fac obiectul hematologiei, insa in anumite conditii pot complica mai mult decat s-a estimat evolutia starii de sanatate a pacientului; asistentele medicale sunt implicate direct in sesizarea si recunoasterea simptomelor cardiace, ceea ce preuspune o buna pregatire profesionala, informatii de specialitate si conduita terapeutica de urgenta. Factorii favorizanti: chimioterapicele cu toxicitate cardiaca mare (antracicline, ciclofosfamida etc), iradierea toracelui superior poate cauza boli ale arterelor coronare, pericardita, cardiomiopatii, boli valvulare, tulburari de conducere (bradicardie, tahicardie), accidente hipo/hipervolemice prin aport de solutii PEV sau transfuzii. Metode de depistare: monitorizarea functiilor vitale: T.A, puls, SPO2, respiratii, temperatura, calculul balantei hidrice la 12 si 24 ore, recunoasterea simptomatologiei clinice si din acuzele pacientului informarea si pregatirea pacientului pentru a comunica orice acuza sau schimbare in statusul bolii. Metode de supraveghere : monitor, tensiometru, examinare, anamneza, solicitarea urgenta a prezentei medicului curant sau dinATI. Obiective: interventia rapida a medicului si asistentei medicale. Concluzii: necesitatea efectuari unor cursuri de urgente medicale si pentru interpretarea EKG pentru a recunoaste un traseu modificat fata de unul sinusal, normal. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<

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PROFILAXIACOMPLICATIILOR HEMORAGICE PE PERIOADATRANSPLANTULUI CU CELULE STEM ELENATOMA-AS.MED.PR.C.T.M-I.C.FUNDENI. MIHAELAIANCU-AS.MED.C.T.M-I.C.FUNDENI INTRODUCERE: Toxicitatea hematologica, cauzata de chimioterapie/radioterapie supune pacientul hematooncologic unui risc mare de sangerare, motiv pentru care este important ca acestia sa primeasca informatiile si educatia necesara in vederea colaborarii pe parcursul procedurii de transplant. OBIECTIVE: Scopul acestui studiu este sa elaboreze un protocol referitor la profilaxia riscului de hemoragie si sintetizarea informatiilor in vederea transmiterii pacientilor cu scopul intelegerii riscurilor si reducerii fricii si stresului cauzate de noua situatie medicala. METODE: Intocmirea protocolului anterior transplantului in doi pasi: 1. Elaborarea unui document standardizat informativ pentru personalul medical. 2. Elaborarea unui document destinat pacientilor si familiilor acestora pentru intelegerea informatiilor transmise oral. EVALUARE: Atat pacientii cat si personalul medical trebuie sa obtina o observatie zilnica a tuturor semnelor de sangerare, fiind notate toate incidentele si complicatiile aparute. CONCLUZII: Graficele si informatiile scrise rentregesc informatiile orale si subliniaza importanta aplicarii masurilor de preventie atat de pacienti cat si de personalul medical, iar cunostintele despre simptomele sangerarii au ca rezultat o implicare mai mare a pacientului in procesul de ingrijire. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< OPTIMIZARI IN NURSINGUL COPIILOR CU AFECTIUNI HEMATOLOGICE IN PROCEDURA DE TRANSPLANT MEDULAR. EXPERIENTE DIN INSTITUTUL GEANINAGASLINNI GENOVA, ITALIA. NORICAIONESCU-AS. MED.C.T.M.-I.C. FUNDENI ELENACALDARARU-AS. MED. PR.,C.T.M.- I.C. FUNDENI Nursingul copiilor cu afectiuni hematologice este focalizat in principal pe nevoile si functiile alterate de efectele secundare chimioterapiei administrate in doze mari si mai putin pe efectele izolarii sociale temporare in perioada de transplant si a calitatii vietii a acestor micuti suferinzi. Efectele secundare medicatiei cu citostatice in doze mari sunt: greata si varsaturi urmate de mucozita care duc la suspendarea temporara a alimentatiei orale; imunitate scazuta; trombocitopenie; VOD ( boala veno-ocluziva); izolarea sociala temporara; alterarea calitatii vietii Lucrarea se bazeaza pe observatia activitatii personalului medical, a familiei si personalului non-medical care isi desfasoara activitatea in sectia de Transplant Medular din Institutul Geanina Gaslinni- Genova Italia timp de doua luni si a muncii in Centrul de Transplant Medular din Institutul Clinic Fundeni Bucuresti, timp de cinci ani. OBIECTIVE: prevenirea infectiilor si a hemoragiilor; prevenirea mucozitei si a anorexiei; recunoastrea si identificarea semnelor si simptomelor in VOD; imbunatatirea calitatii vietii; coplianta maxima la tratament cu suferinte minime. METODE: respectarea riguroasa a protocoalelor de lucru si a circuitelor in sectie; instruirea si informarea familiei si a copilului in legatura cu normele si regulile igienice si alimentare; facilitarea accesului familiei si a personalului non-medical venit in ajutorul bolnavului (fundatii, biserica, voluntari, etc); autoinstruirea si formarea continua a personalului medical. CONCLUZII: Un nursing de calitate atinge efectul scontat numai prin respectarea riguroasa a tehnicilor si ingrijirilor acordate cat si prin sustinerea lui intr-un climat psihosocial adecvat.

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Acesti copii, ca toti copiii de altfel, au nevoie sa-si traiasca putin si din copilarie caci zambetul si picaturile lor de fericire ne dau feed-beak-ul pozitiv in munca noastra desfasurata cu pasiune. <<<<<<<<<<<<<<<<<<<<<<< REGIMUL IGIENO-DIETETIC INALIMENTATIAPACIENTILOR NEUTROPENICI OANAOTILIANICULITA-AS.MED.PR.C.T.M-I.C.FUNDENI. FLORINABERECZKI-AS.MED.C.T.M-I.C.FUNDENI INTRODUCERE: Poate fi aplicat tuturor pacientilor neutropenici din sectiile de hematologie. Definitie: Regimul alimentar limitat microbian este una din numeroasele masuri preventive pentru reducerea ratei infectiilor la pacientii neutropenici. OBIECTIVE: Scaderea numarului microorganismelor din alimente care alcatuiesc flora saprofita sau parazita din acestea si din tractul gastro-intestinal. Gasirea unor alimente adaptate la bucataria romaneasca care sa poata fi pregatite termic, diversificarea meniurilor in scopul promovarii mentinerii nutritiei orale. METODE: -informarea din materiale de specialitate (articole jurnalul pentru nurse editat de EBMT), internat cu bibliografia existenta in acest scop; -perfectionarea in centre de transplant din strainatate a asistentelor medicale; -adaptarea alimentatiei la conditiile existente in Romania; -cunoasterea fiziopatologiei tractului gastro-intestinal a pacientului imunodeprimat; -stabilirea statusului nutritional al pacientului; -promovarea teoriilor privind sterilizarea alimentelor prin preparare termica, pasteurizare, etc. -alcatuirea unui ghid cu linii directoare privind meniuri posibile in spital si acasa; -stabilirea unor masuri de prevenire si transmitere a infectiilor nozocomiale prin alimente contaminate, manevre si circuite necontrolate. CONCLUZII: Regimul igienodietetic cu alimente bine controlate bacteriologic are un rol important in ingrijirea pacientilor cu cancer atat pentru a preveni aparitia infectiilor digestive cat si pentru a promova gasirea unor cai de imbunatatire a alimentatiei orale care sa poata fi coordonate de dietetician, individualizat la permisivitatea hranirii orale. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< INTRETINEREACATETERELOR VENOASE CENTRALE IN C.T.M. SI SECTIILE DE HEMATOLOGIE. PROTOCOL INFORMATIV DANIELASEBE-AS.MED.PR.C.T.M-I.C.FUNDENI. DOINITALICA-AS.MED.C.T.M-I.C.FUNDENI DEFINITIE C.V.C.: Cateterul venos central este un dispozitiv de acces vascular central. Abordul vascular se face in functie de scopul utilizarii cateterului la nivelul venelor: subclavie, jugulara sau femurala. CLASIFICAREACATETERELOR IN FUNCTIE DE SCOP: -cateter de afereza pentru celule stem hematopoetice -cateter pentru administrarea chimioterapiei, tratamentelor intravenoase, alimentatiei parenterale si transfuzarea produselor sangvine in procedura de transplant medular. OBIECTIVE: a. mentinerea abordului venos central in vederea administrarii tratamentelor necesare b. mentinerea asepsiei cateterului si a tegumentului METODE: Se adreseaza celor doua tehnici necesare - ingrijirea plagii cateterului; - ingrijirea si spalarea cailor cateterului si montarea liniilor perfuzabile; - alcatuirea unui protocol de lucru pentru asistentele medicale in acest scop de catre medicul epidemiolog, medicii din sectie si asistenta sefa; - alcatuirea protocolului de respectare a circuitelor si tehnicilor de ingrijire: circuitul steril materialele sterile pregatite in prealabil pentru administrare in hota cu flux laminar, separat de circuitul materialelor contaminate/utilizate;

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- baia/dusul. CONCLUZIE: Respectarea cu strictete a procedurilor este necesara pentru evitarea contaminarii cu germeni patogeni si prevenirea infectiilor nozocomiale pe aceasta cale. C.V.C. este un dispozitiv medical foarte util si practic pentru pacientii imunodeprimati prin chimioterapii repetate de lunga durata sau radioterapie. C.V.C-ul reprezinta o necessitate in ingrijirea pacientilor din hematologie si oncologie. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> BOALA DE GREFA CONTRA GAZDA HEPATICA, COMPLICATIE AALLOTRANSPLANTULUI CU CELULE STEM - STUDIU DE CAZ MIHAELASILVIACONSTANTIN-AS.MED.PR.,C.T.M.-I.C.FUNDENI GINABOSTANARU AS. MED.,C.T.M.-I.C.FUNDENI Boala grefa contra gazda (GVHD) ramane o complicatie majora a transplantului medular. Primele organe afectate de GVHD sunt: tegumentele, tractul gastro-intestinal, sistemul hepato-biliar, plamanii. GVHD este rezultatul atacului imunologic de catre limfocitele citotoxice ale donatorului asupra maduvei osoase a primitorului. Complicatiile hepatice ce pot aparea in urma transplantului allogen sunt: boala veno ocluziva (BVO) boala grefa contra gazda (GVHD), complicatii datorate infectiilor orale (fungice, bacteriene) STUDIUL DE CAZ avut in urmarirea noastra un pacient, sex barbatesc, 51 ani, cu diagnosticul SMPC pentru care a primit o allogrefa cu cellule stem, de la donator familial-HLA identic; imunohematologic intre donator si primitor exista incompatibilitate de grup. Din ziua +160 dupa transplant acuza prurit tegumentar, elemente de mucozita bucala grad III. Paraclinic, se constata o crestere a enzimelor hepatice AST=614mg/dl, ALT=1200mg/dl, BT=8,02, suspicionandu-se o hepatita toxica sau virala - neconfirmata de testele virusologice; la clinica din Italia se practica biopsie hepatica - se evidentiaza cellule hepatice cu aspect de GVHD ac.hepatic. Desi pacientul a fost transplantat in Italia, posttransplant, din ziua +60 a fost permanent urmarit si tratat in CTM Fundeni, primul caz cu aceasta complicatie din allogrefele noastre aducand imformatii practice clinice si paraclinice noi pentru echipa noastra. CONCLUZIE: experienta dobandita cu acest caz clinic, urmarit in ultimile 10 luni, in CTM Fundeni, a carui evolutie este buna la bilantul de un an dupa transplant ne incurajeaza si ne ofera posibilitatea de a aborda cu profesionalism alte cazuri in viitor. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> GHID INFORMATIV PENTRUASISTENTELE MEDICALE PRIVIND INGRIJIRILEACORDATE PACIENTILOR NEUTROPENICI RODICAIULIAGHELASEAS.COORDONATOR C.T.M.-I.C.FUNDENI GEORGETAVERONICACIOBANESCUAS.MED. I.C.FUNDENI INTRODUCERE: Ghidul isi propune sa aduca protocoale de lucru utilizate in C.T.M. privind ingrijirile acordate pacientilor neutropenici si masuri epidemiologice de prevenirea transmiterii infectiilor interioare. SURSE UTILIZATE: protocoale de lucru intocmite de medical epidemiolog,medicii din sectie si asistenta sefa; protocoale intocmite de EBMT Nurser Group adaptate conditiilor din departamentul nostrum; materiale publicate in Journal for BMT Nursing; bibliografie de specialitate de pe internet.

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OBIECTIVE: stabilirea unei conduite unice de ingrijiri, corecta, cu mici particularitati in cazurile complicate; informarea si pregatirea pacientului cu masurile pe care trebuie sa le adopte in asistenta proprie; asigurarea unui echilibru psihoemotional si tonus constant; Obiectivul major = optimizarea ingrijirilor si prevenirea infectiilor. CONCLUZII: Necesitatea alcatuirii unui astfel de ghid pentru stabilirea unei conduite corecte si eficiente care sa asigure o buna preventie a infectiilor la pacientii neutropenici. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> RECOLTAREASANGELUI Livia Doria Prvan*, Gabriela Iovan, Cristina Serban, Cristina Mihai, Mioara Cojocaru Clinica de Hematologie Coltea, *UMF Carol Davila Introducere : Recoltarea sangelui reprezinta poate cel mai important aspect in obtinerea unor rezultate corecte in activitatea de laborator clinic. Este cunoscut faptul ca o recoltare corecta duce in mod clar la obtinerea unor rezultate de o calitate superioara, care sa beneficieze de o acuratete si reproductibilitate corespunzatoare cerintelor NCCLS. De asemenea, calitatea materialelor sanitare folosite reprezinta un factor decisiv, poate, in raportarea rezultatelor corecte pentru toate investigatiile de laborator clnic. Prezentare : Pornind de la ordinea recoltarii probelor biologice conform normelor NCCLS, sunt analizate etapele recoltarii ( pregatirea pacientilor, a materialelor sanitare, recoltarea propriu-zisa, transportul probelor catre laborator etc. ) si variabilele care pot interveni si pot fi prevenite in toate aceste etape. Fiecare tip de proba biologica ( sange, ser, plasma ) la care se face referire in prezentare trebuiesc recoltate in vase speciale ( de regula eprubete tip vacumtainer ), cu ace de calitate corespunzatoare si, nu in ultimul rand, dupa o pregatire specifica a pacientului. Mediul in care se face recoltarea trebuie sa fie curat si sigur, sa se respecte intimitatea pacientilor si, de asemenea, pacientii sa fie implicati in propria ingrijire medicala. Identificarea corecta a pacientilor si, respectiv a probelor recoltate, cantitatea de sange prelevata, integritatea tuburilor, prelucrarea primara in laborator si efectuarea propriu-zisa a analizelor solicitate sunt prezentate detaliat in lucrarea de fata. Sunt analizate in acelasi context si variabilele care influenteaza rezultatele testelor precum starea pacientilor, locul si modul recoltarii, tipul de proba prelevata etc. Concluzii : Recoltarea corecta a probelor de sange si implicit obtinerea unor rezultate de laborator care sa asigure o evaluare corecta a starii de sanatate a pacientului sau o monitorizare corecta a taratmentului este dependenta atat de factori ce tin de personalul care face prelevarea, respectiv analizarea probelor cat si de factori ce tin de infrastructura locala. Toate acestea au drept urmare un act medical de inalta tinuta : ingrijire spitalicesca de calitate, un mediu curat si sigur, implicarea pacientilor in propria ingrijire medicala, protectia intimitatii pacientului, ajutarea pacientilor la parasirea spitalului. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< ROLULASISTENTEI MEDICALE IN INGRIJIREABOLNAVILOR CU PANCITOPENIE Mihaela Camburu Tia Bararu, Marcela ulu, Marilena Dumitru Centrul de Hematologie i Transplant Medular, Institutul Clinic Fundeni, Bucuresti Asistenta medicala este cea care sta cel mai mult la patul bolnavului si este alaturi de acesta in momentele cele mai dificile. Un astfel de moment foarte dificil pentru pancietul cu neoplazii hematologice este perioada de pancitopenie care urmeaza tratamentului citostatic. Asistenta medicala trebuie sa asigure terapia suportiva in aceasta perioada. Aceasta cuprinde terapia durerii, suportul psihologic cat si metodele de ingrijire ale pacientilor care prezinta complicatii hematologice sau infectioase. Masurile suportive sunt un aspect important al terapiei in tratamentul bolnavilor imunosupresati prin chimioterapie. Dintre procedurile de izolare, spalarea si dezinfectia mainilor pacientului si a tuturor persoanelor care intra in contact cu acesta, este singura masura cu benificii universale dovedite .

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Terapia de ingrijire cuprinde proceduri de izolare, de igiena a alimentatiei, igiena corporala a tegumentelor si a mucuoaselor, monitorizarea temperaturii, recoltarea analizelor, administrarea antibioticelor si a produselor de sange respectand cu strictete normele de igiena si dezinfectie. <<<<<<<<<<<<<<<<<<<<<< ASPECTEALE INGRIJIRII SI TRATAMENTULUI PACIENTILOR CU MIELOM MULTIPLU Veronica Ene Mihaela Despa, Rodica Popa Centrul de Hematologie si Transplant Medular, Institutul Clinic Fundeni, Bucuresti Mielomul multiplu este o proliferare neoplazica clonala plasmocitara. Deoarece est e o boala complexa ce se poate manifesta in diferite moduri, in practica medicala se intalnesc multiple situatii ce trebuiesc corect interpretate si abordate. In Clinica de Hematologie Fundeni exista o vasta experienta privind ingrijirea si tratamentul pacientilor cu mielom multiplu datorita numarului mare de internari inregistrat anual pentru aceasta afectiune (~750 internari /an). Comunicarea isi propune sa prezinte cateva principii generale de abordare a pacientilor mielomatosi, sa expuna principalele aspecte ale abordarii specifice (adaptate diverselor situatii) rezultate din experienta acumulata in practica zilnica. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<< ROLUL ASISTENTEI MEDICALE IN STRATEGIA DE PREVENIRE SI COMBATERE A INFECTIILOR NOZOCOMIALE Luminia Moldoveanu Doina Diaconi , Paula Srbu Clinica de Hematologie Inst.Cl.Fundeni Bucuresti Infectia nozocomiala este infectia care se produce in sanul unor colectivitati.Apare fie prin contactul cu un bolnav necunoscut aflat in perioada de incubatie, fie prin intalnirea unor bolnavi cu boli diferite sau prin organizarea defectuoasa a circuitelor. In hematologie infectiile reprezinta un factor important care duce la pierderea pacientului. Strategia antiinfectioasa in sectia de hematologie include obligatoriu: controlul mediului,metode de prevenire,metode performante de diagnostic si strategii eficiente de terapie antiinfectioasa. Asistenta medicala ocupa un rol cheie in strategia de combatere si prevenire a infectiilor nozocomiale:educa pacientul privind gesturile de igiena, supravegheaza gesturile de autoingrijire ale pacientului,recolteaza probele pentru diagnosticul microbiologic si bacteriologic,respecta ea insasi un protocol foarte riguros de asepsie si antisepsie ,sesizeaza medicul asupra primelor semne de infectie ale pacientului. RECOLTAREASANGELUI Livia Doria Prvan*, Gabriela Iovan, Cristina Serban, Cristina Mihai, Mioara Cojocaru Clinica de Hematologie Coltea, *UMF Carol Davila Introducere : Recoltarea sangelui reprezinta poate cel mai important aspect in obtinerea unor rezultate corecte in activitatea de laborator clinic. Este cunoscut faptul ca o recoltare corecta duce in mod clar la obtinerea unor rezultate de o calitate superioara, care sa beneficieze de o acuratete si reproductibilitate corespunzatoare cerintelor NCCLS. De asemenea, calitatea materialelor sanitare folosite reprezinta un factor decisiv, poate, in raportarea rezultatelor corecte pentru toate investigatiile de laborator clnic. Prezentare : Pornind de la ordinea recoltarii probelor biologice conform normelor NCCLS, sunt analizate etapele recoltarii ( pregatirea pacientilor, a materialelor sanitare, recoltarea propriu-zisa, transportul probelor catre laborator etc. ) si variabilele care pot interveni si pot fi prevenite in toate aceste etape. Fiecare tip de proba biologica ( sange, ser, plasma ) la care se face referire in prezentare trebuiesc recoltate in vase

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speciale ( de regula eprubete tip vacumtainer ), cu ace de calitate corespunzatoare si, nu in ultimul rand, dupa o pregatire specifica a pacientului. Mediul in care se face recoltarea trebuie sa fie curat si sigur, sa se respecte intimitatea pacientilor si, de asemenea, pacientii sa fie implicati in propria ingrijire medicala. Identificarea corecta a pacientilor si, respectiv a probelor recoltate, cantitatea de sange prelevata, integritatea tuburilor, prelucrarea primara in laborator si efectuarea propriu-zisa a analizelor solicitate sunt prezentate detaliat in lucrarea de fata. Sunt analizate in acelasi context si variabilele care influenteaza rezultatele testelor precum starea pacientilor, locul si modul recoltarii, tipul de proba prelevata etc. Concluzii : Recoltarea corecta a probelor de sange si implicit obtinerea unor rezultate de laborator care sa asigure o evaluare corecta a starii de sanatate a pacientului sau o monitorizare corecta a taratmentului este dependenta atat de factori ce tin de personalul care face prelevarea, respectiv analizarea probelor cat si de factori ce tin de infrastructura locala. Toate acestea au drept urmare un act medical de inalta tinuta : ingrijire spitalicesca de calitate, un mediu curat si sigur, implicarea pacientilor in propria ingrijire medicala, protectia intimitatii pacientului, ajutarea pacientilor la parasirea spitalului. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< ROLULASISTENTEI MEDICALE IN INGRIJIREABOLNAVILOR CU PANCITOPENIE Mihaela Camburu Tia Bararu, Marcela ulu, Marilena Dumitru Centrul de Hematologie i Transplant Medular, Institutul Clinic Fundeni, Bucuresti Asistenta medicala este cea care sta cel mai mult la patul bolnavului si este alaturi de acesta in momentele cele mai dificile. Un astfel de moment foarte dificil pentru pancietul cu neoplazii hematologice este perioada de pancitopenie care urmeaza tratamentului citostatic. Asistenta medicala trebuie sa asigure terapia suportiva in aceasta perioada. Aceasta cuprinde terapia durerii, suportul psihologic cat si metodele de ingrijire ale pacientilor care prezinta complicatii hematologice sau infectioase. Masurile suportive sunt un aspect important al terapiei in tratamentul bolnavilor imunosupresati prin chimioterapie. Dintre procedurile de izolare, spalarea si dezinfectia mainilor pacientului si a tuturor persoanelor care intra in contact cu acesta, este singura masura cu benificii universale dovedite . Terapia de ingrijire cuprinde proceduri de izolare, de igiena a alimentatiei, igiena corporala a tegumentelor si a mucuoaselor, monitorizarea temperaturii, recoltarea analizelor, administrarea antibioticelor si a produselor de sange respectand cu strictete normele de igiena si dezinfectie. <<<<<<<<<<<<<<<<<<<<<< ASPECTEALE INGRIJIRII SI TRATAMENTULUI PACIENTILOR CU MIELOM MULTIPLU Veronica Ene Mihaela Despa, Rodica Popa Centrul de Hematologie si Transplant Medular, Institutul Clinic Fundeni, Bucuresti Mielomul multiplu este o proliferare neoplazica clonala plasmocitara. Deoarece est e o boala complexa ce se poate manifesta in diferite moduri, in practica medicala se intalnesc multiple situatii ce trebuiesc corect interpretate si abordate. In Clinica de Hematologie Fundeni exista o vasta experienta privind ingrijirea si tratamentul pacientilor cu mielom multiplu datorita numarului mare de internari inregistrat anual pentru aceasta afectiune (~750 internari /an). Comunicarea isi propune sa prezinte cateva principii generale de abordare a pacientilor mielomatosi, sa expuna principalele aspecte ale abordarii specifice (adaptate diverselor situatii) rezultate din experienta acumulata in practica zilnica. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<< ROLUL ASISTENTEI MEDICALE IN STRATEGIA DE PREVENIRE SI COMBATERE A INFECTIILOR NOZOCOMIALE

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Luminia Moldoveanu Doina Diaconi , Paula Srbu Clinica de Hematologie Inst.Cl.Fundeni Bucuresti Infectia nozocomiala este infectia care se produce in sanul unor colectivitati.Apare fie prin contactul cu un bolnav necunoscut aflat in perioada de incubatie, fie prin intalnirea unor bolnavi cu boli diferite sau prin organizarea defectuoasa a circuitelor. In hematologie infectiile reprezinta un factor important care duce la pierderea pacientului. Strategia antiinfectioasa in sectia de hematologie include obligatoriu: controlul mediului,metode de prevenire,metode performante de diagnostic si strategii eficiente de terapie antiinfectioasa. Asistenta medicala ocupa un rol cheie in strategia de combatere si prevenire a infectiilor nozocomiale:educa pacientul privind gesturile de igiena, supravegheaza gesturile de autoingrijire ale pacientului,recolteaza probele pentru diagnosticul microbiologic si bacteriologic,respecta ea insasi un protocol foarte riguros de asepsie si antisepsie ,sesizeaza medicul asupra primelor semne de infectie ale pacientului.

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HEMATOLOGIE TRANSFUZIONAL
Raport ASIGURAREACALITII N TRANSFUZIE I. Culea, F. Vldreanu Institutul Naional de Hematologie Transfuzional Bucureti, Romnia Transfuzia sanguin este un domeniu n expansiune care se bazeaz pe interacia mai multor discipline. Monitorizarea ntregului lan de la ven la ven este o condiie pentru a se asigura att calitatea i sigurana sngelui, componentelor sanguine ct i o terapie sanguin intit. Legislaia european: Directiva 2002/98/CE; Directiva 2004/33/CE; Directiva 2005/61/CE; Directiva 2005/62/CE; Ghidul UE-GMP; Directiva 2003/94CE i cea romneasc: Legea 282/2005; Ordinele Ministerului Sntii Publice 1214/2006; 1228/2006; 1227/2006; 1226/2006; 1225/2006; 1237/2007; 1193/2007 ajut centrele de transfuzie sanguin s-i introduc un sistem al calitii. Beneficiile majore ale acestui sistem sunt: definirea unei politici a calitii; stabilirea obiectivelor calitii; implicarea unui personal: calificat, instruit i responsabil; existenta unui sistem de evaluare a riscurilor si erorilor; un management mbuntit al resurselor; o mbuntire continu a calitii. Realizarea obiectivelor calitii depinde de un sistem de asigurare a calitii bine proiectat. Conceptele de baz ale asigurrii calitii , bunele practici de producie i controlul calitii sunt interrelate. Astfel, activitile de asigurare a calitii monitorizeaz performana: a) proceselor, oferind informaii despre modificrile (shifts ) i tendinele (trends ) acestora; b) personalului implicat n diferitele etape ale procesului de la ven la ven; c) metodologiei de laborator, pe baza rezultatelor obinute n schemele de control extern al calitii. Raport ELEMENTE DEASIGURAREACALITII N IMUNOHEMATOLOGIE S. Sirian, Fl. Vldreanu Institutul Naional de Hematologie Transfuzional Bucureti, Romnia Transfuzia de snge practic ce interfer cu toate specialitile, implic, prin problematica sa, multiple riscuri, unul dintre acestea fiind incompatibilitatea eritrocitar donator-primitor de snge. De aceea, pentru a asigura un grad nalt de securitate transfuzional, este necesar implementarea unui program de Asigurare a Calitii (QA) n imunohematologie, program care asigur performane conform cerinelor standard, care trebuie s se menin constant la acelai nivel. Garania realizrii obiectivelor programului QA o constituie respectarea strict a Procedurilor Operatorii Standard (SOP) privind testrile imunohematologice, pentru donatorii i primitorii de snge, tehnicile, algoritmurile, aparatura, reactivii, nregistrrile, de ctre un personal permanent instruit. In perioada 1998-2006, programele variate de instruire iniial i continu, testrile imunohematologice efectuate conform algoritmurilor stabilite, cu reactivi i aparatur de bun calitate, au determinat creterea securitii transfuzionale. In prezent, aceast bun experien va fi transpus n programul QA de imunohematologie, pentru concordana cu cerinele CE i ale legislaiei naionale. Raport VIRUSURI HEPATITICE (HAV, HBV, HCV) ACTUALITI I POSIBILITI DE REDUCEREALE RISCULUI TRANSFUZIONAL M. Pecec,A. Necula Institutul Naional de Hematologie Transfuzional Bucureti Riscul rezidual de transmitere prin transfuzie al unei infecii virale este determinat pe de o parte de mrimea ferestrei serologice negative, care depinde de sensibilitatea testelor de triere i de rapiditatea creterii i mrimea viremiei, care la rndul lor depind (ntr-un mod neclarificat nc) de mrimea dozei infectante primite, iar pe de alt parte de incidena infeciilor n (sub)populaia donatorilor. Infeciile cu HBV sau/i HCV sunt cele mai frecvent ntlnite, att pe plan local

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ct i pe plan european. La 17 i respectiv 12 ani (1990 pentru HBV i 1995 pentru HCV) dup introducerea trierii prin EIA, raportul dintre prevalenele sau/i cel dintre valorile riscului rezidual n cele dou zone, dei s-a redus, este n continuare de ordinul 102, pe plan local raportul dintre prevalenele HBV i HCV diferind cu un factor de 5-10 n funcie de localitate. Unul din factorii care contribuie la meninerea diferenelor este faptul c pe plan local sensibilitatea testelor de triere, dei mult mbuntit fa de momentul introducerii EIA, a rmas n urm fa de zona centru-Vest a UE n care s-a trecut n jurul anului 2000 la teste de tip NAT. Mai recent, n zona centru-Vest a UE tinde s se generalizeze suplimentarea trierii pentru HBV prin introducerea anti-HBc (EIA) i anti-HBs (EIA), n efortul de a asigura oarecum detecia VHB 'variant'' iar ultima i pentru orientarea plasmei recoltate ctre producerea de imunoglobuline specifice anti-HBs. n cel puin o locaie dintr-o zon de endemie sczut (DRK BadenWuertemberg-Kassel) nu s-a putut documenta retrospectiv utilitatea/eficiena anti-HBc folosit alturi de NAT n scderea riscului rezidual. ntruct situaia ntr-zon de endemie medie spre ridicat este potenial diferit i n absena unor date reprezentative, o alegere ntre introducerea direct a unei tehnici de tip NAT i suplimentarea/modernizarea trierii cu tehnici de tip EIA sau a unei combinaii NAT+EIA, bazat pe eficiena n reducerea riscului rezidual , presupune un studiu experimental extensiv pe unui numr de donri de ordinul 104. Raport RETROVIRUSURI (HIV-1/HIV-2, HTLV-I/HTLV-II) N PERIOADA 2000 2006: RISCUL TRANSFUZIONAL REZIDUAL A. Necula, M. Pecec. Institutul Naional de Hematologie Transfuzional, Bucureti, Romnia. Introducere: Riscul rezidual de transmitere prin transfuzie a infeciilor virale este legat n principal de existena ferestrei serologice negative i de incidena infeciilor n populaia int pentru selecia donatorilor. Conform EuroHIV (2006), monitorizarea prevalenei infeciei HIV n rndul donatorilor de snge este un instrument vital pentru evaluarea securitii sngelui. n acest raport se prezint bilanul ultimilor apte ani de triere pentru (anti-)HIV-1/HIV-2 care au aprut n zon dup 1985 i pentru (anti-) HTLV-I care este endemic. Metode: Trierea curent se efectueaz cu teste EIA combinate Antigen+Anti-HIV-1+2, respectiv de tipul captur-anticorpi, bazate exclusiv pe antigene recombinante, pentru HTLV-I/II. Reactivitile repetabile sunt confirmate n Western Blot sau/i Line-Immuno-Assay (LIA), respectnd criteriile OMS pentru HIV-1/HIV-2, respectiv ale H.E.R.N. pentru HTLV-I/HTLV-II. Prevalene i incidenele se exprim la 100.000 de cazuri, respectiv donri. Rezultate: n perioada considerat prevalena medie antiHIV-1 n donatorii de snge la prima donare (DSPD) a fost de 25,8 (din care 1,9 7,3% seroconvertori receni) fa de aproximativ 6 n rile vestice ale UE ( EuroHIV, 2006). n donrile repetate de snge (DRS) incidena medie a fost de 2,4 la 100000 donri (din care 0,6 25,5% seroconvertori receni semnificativ mai muli [p>0.001] dect la DSPD) fa de sub 1 la 100000 n rile vestice ale UE. Numrul DRS potenial infecioase a fost de 1,2 la 100000 reprezentnd 51% din totalul cazurilor detectate n aceast categorie. Un singur caz de infecie cu HIV-2 a fost identificat n perioada considerat. Prevalenele maxime la DSPD au fost nregistrate n trei centre din zona de sud a rii , Arge (95), Bucureti (84)i Constana (50), care au cumulat 58% din totalul pozitivilor detectai, colectnd 19% din totalul colectei provenite de la DSPD. Prevalena general a anti-HTLV-I in DSPD a fost de 58 la 100,000 cu maxime locale peste 100 n Sud-Est, zon n care s-au putut documenta cteva seroconversii la DDRS. Incidena general n DRS a sczut de la 118 la 100000 n trim.4 1999 i s-a stabilizat la aproximativ 1 la 100000. 3 16 cazuri deATL sunt confirmate anual n Bucureti ( 5 n 2006). Concluzii: Fa de momentul introducerii trierii specifice, riscul rezidual de transmitere prin transfuzie a HIV-1 i HLTV-I, dei considerabil mai mic, rmne mult mai ridicat dect n zona de vest a UE. Dat fiind c virusurile par s circule mai rapid ntre DDRS riscul poate fi diminuat n continuare n primul rnd prin mbuntirea criteriilor de selecie a donatorilor. Definirea profilului donatorului seroconvertor si evaluarea prevalenei infeciilor n alte grupuri de populaie , ca inte poteniale, ar contribui la adoptarea de criterii mbuntite de selecia a donatorilor.

Comunicare TEHNOLOGIA PRIN TESTAREA ACIZILOR NUCLEICI (NAT) FOLOSIT N TESTAREA SNGELUI TRANSFUZAT. STADIUL IMPLEMENTRII METODEI N EUROPA.

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Francoise Le Flohic Director Regional Ilex Ltd. Comunicare EPIDEMIOLOGIAINFECIILOR CU HIV, HEPATITELE B I C N ROMNIA. A. Streinu Cercel, D.Oelea Institutul Matei Bal Bucureti Comunicare IMPACTUL ASUPRA SECURITII TRANSFUZIONALE A SCREENING-ULUI TESTRII ACIZILOR NUCLEICI (NAT) N DONAREA INDIVIDUAL. CARACTERIZAREA INFECIILOR OCULTE CU HEPATITA B. Nico Lelie Director tiinific Chiron Novartis Comunicare TEHNICI DE EVIDENIEREAANTICORPILOR ANTICERITROCITARI CU SEMNIFICAIE CLINIC. S. Sirian, M. Radulian Institutul Naional de Hematologie Transfuzional Bucureti, Romnia Introducere. Anticorpii antieritrocitari din sistemele OAB, Rh, Kell, Kidd, Duffy, MN, Ss, Lewis, Pp fixatori sau nefixatori de Complement, pot determina reacii hemolitice transfuzionale (RHT) i boal hemolitic a nou-nscutului (BHNN). Obiectiv. Utilizarea n laboratorul de imunohematologie a tehnicilor adecvate pentru evidenierea anticorpilor cu semnificaie clinic pentru evitarea reaciilor hemolitice transfuzionale i managementul BHNN. Metode, tehnici, reactivi. Hemaglutinare n faz lichid i n coloan (DiaMed, ScanGel, Ortho, BioVue) n mediu albuminos, salin, TCI cu ser antiglobulinic polivalent, teste enzimatice i determinri de subclase IgG. Identificarea anticorpilor cu semnificaie clinic conduce la selecie de snge compatibil cu aceti anticorpi. Cazuistic: 8034 primitori de snge, gravide, nou nscui, donatori de snge. Rezultate: frecvent aloimunizare : 11,51% din care anticorpi anti-D 32,5 %, anti-D+C 7,3%, anti-Kell 5,4%,antiE 5,7%, anti-Ce, antiD+C, anti-D+E 3,17%, urmai de anticorpi anti-JK, anti-Fya, anti-Ss simpli sau combinai 0,3%. Concluzii: Evidenierea corect a anticorpilor antieritrocitari cu semnificaie clinic, urmat de politica transfuzional adecvat, permite evitarea reaciilor hemolitice transfuzionale i a strategiei eficiente n BHNN. Comunicare EVOLUTIA REACTIILOR POSTTRANSFUZIONALE PRIN UTILIZAREA PRODUSELOR SANGUINE DELEUCOCITATE SI IN FENOTIP EXTINS Rh-KELL LA PACIENTII POLITRANSFUZATI CU TALASEMIE MAJORA M.D. Voicu, Fl. Vldreanu, S. Sirian, L. Niu, C.I. Calot Institutul Naional de Hematologie Transfuzional Bucureti, Romnia Introducere: -Talasemia major se caracterizeaz printr-o anemie severa dependent de transfuzii sanguine pe toat durata vieii. Pentru o dezvoltare corespunztoare a acestor pacieni s-a introdus regimul de hipertransfuzie cu meninerea hemoglobinei pretransfuzionale la valori peste 9g/dl. Material si metod: Studiul se refer la cei 100 de pacieni cu talasemie major aflai n evidena INHT. Toi aceti pacieni efectueaz transfuzii cu concentrate eritrocitar deleucocitat, izogrup, izo Rh i n fenotip Rh(D)-Kell la intervale de 2-6 sptmni. Rezultate: Necesarul transfuzional

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al acestor pacieni este n medie de 25unitai/an ajungndu-se chiar i la 40 uniti/an. Acest numr mare de transfuzii i frecvena lor la intervale de 2-3 sptmni a determinat imunizarea acestor pacieni, att mpotriva antigenelor leucocitare ct i mpotriva celor eritrocitare, cele mai frecvente reacii posttransfuzionale fiind cele de tip frison-febra, erupii cutanate. Din anul 2000 s-a nceput transfuzarea acestor pacieni n fenotip extins Rh(D)-Kell, iar din 2004 s-au introdus i concentrate deleucocitate, astfel nct, n prezent, toi aceti pacieni cu talasemie major sunt transfuzai cu produse fenotipate i deleucocitate, reaciile posttransfuzionale imediate disparnd. Concluzii: Dei fenotiparea i deleucocitarea ridic mult costul unitii de snge transfuzat i, de multe ori exist fenotipuri mai greu de gsit , beneficiile folosirii acestor produse pentru pacienii politransfuzai sunt extrem de mari, astfel nct este imperios necesar depunerea tuturor eforturilor pentru meninerea acestor standarde n terapia transfuzional. Comunicare COMPLIANA LA TRATAMENTUL CHELATOR DE FIER (DESFERAL) LA PACIENII CU TALASEMIE MAJORAFLAI IN EVIDENAI.N.H.T. IN PERIOADA.2000-2006 Fl. Vldreanu, M. D. Voicu, L. Niu, C.I. Calot Institutul Naional de Hematologie Transfuzional Bucureti, Romnia Introducere: La pacienii cu -talasemie major care nu primesc chelator de fier, acumularea progresiva a fierului duce la complicaii cardiace, hepatice i endocrine. Compliana la tratamentul chelator de fier este definit ca modalitatea n care comportamentul pacienilor coincide cu prescripia medicului i anume modul n care acesta ader la schema de injecii subcutanate prescrise cuprinznd doza de chelator, nr.ore/zi si nr.zile/sptmn. Material si metod: Studiul cuprinde 100 pacieni cu -talasemie major aflai n evidena INHT n tratament transfuzional i chelator de fier cronice. Monitorizarea ncrcrii cu fier i eficiena tratamentului chelator de fier a fost realizat prin determinarea periodic (semestrial sau trimestrial ) a feritinei serice. Debutul tratamentului chelator a fost la valori ale feritinei serice de aproximativ 1000ng/ml i peste vrsta de 2,5 ani. Tratamentul chelator de fier const n administrarea subcutanat de Desferal, n perfuzii lente de 8-12 ore , 5-7 zile/sptmn n doze medii de 20-50 mg/kgc n funcie de vrsta pacientului i nivelul feritinei serice. Rezultate: Introducerea Programului Naional din 1996 ce asigur accesibilitatea la tratamentul chelator i punerea la dispoziie a dispozitivelor de infuzie i a consumabilelor a dus pentru o scurt perioad la o foarte bun compliana la tratament. Totui, terapia chelatoare este dificil i mpovrtoare, procesul este consumator de timp i se repet zilnic pe toat durata vieii. Beneficiile se acumuleaz pe termen lung astfel nct, nici efectele pozitive , nici cele negative ale tratamentului nu sunt resimite imediat. Factorii asociai unei proaste compliane au fost: lipsa contientizrii efectelor secundare ale suprancrcrii cu fier ; faptul ca renunarea la cteva doze nu are consecine imediate, ci din contr permite o reducere a efectelor secundare locale; tratamentul este consumator de timp restricionnd astfel activitile zilnice; aspectele psihologice ; reacii locale la tratament; aspecte materiale legate de costul consumabilelor. Concluzii: O bun complian la tratamentul chelator asigur o supravieuire ndelungat, o reducere semnificativa a complicaiilor suprancrcrii cu fier i o calitate bun a vieii. Este foarte important identificarea tuturor aspectelor ce reduc compliana la tratament i contientizarea pacienilor i a familiilor acestora n legtur cu beneficiile tratamentului. Introducerea cat mai rapida a tratamentului chelator oral ar mbuntii semnificativ aderenta la terapia chelatoare. Comunicare TULBURRILE DE CRETERE I HIPOGONADISM PREZENTE LA PACIENII POLITRANSFUZAI CU TALASEMIE MAJOR Fl. Vldreanu, M.D. Voicu, L. Niu, C.I. Calota Institutul Naional de Hematologie Transfuzional Bucureti, Romnia Introducere. Programul transfuzional n regim de hipertransfuzie i o bun complian la tratamentul chelator de fier au condus o mbuntire semnificativ a speranei de via i a calitii vieii pacienilor cu talasemie major. In ciuda progreselor terapeutice, tulburrile de cretere i hipogonadismul hipogonadotrop au rmas cele mai frecvente complicaii ale perioadei de adolescen a acestor pacieni. Material si metod. Studiul se refer la pacienii cu talasemie major, cu vrste peste 12 ani fetele si 13 ani bieii, politransfuzai i n terapie chelatoare de fier (Desferal)

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monitorizat prin determinarea periodic a feritinei serice. Rezultate. Principalele cauze implicate n tulburrile de cretere si de maturaie sexual sunt hipoxia tisular cronic i toxicitatea fierului. Un tratament transfuzional corect asigur o cretere normal a copilului talasemic n prima decad de via. Dup aceast perioad i n absena tratamentului chelator de fier corect apar tulburri de cretere i de dezvoltare sexual. Civa pacieni din cei urmrii au prezentat niveluri anormale ale hormonului de cretere. Hipogonadismul hipogonadotrop este cea mai frecventa complicaie endocrina la pacienii cu talasemie si o cauza importanta a tulburrilor de crestere.20% din adolesceni au prezentat deficit staturo-ponderal si la 60% dintre ei s-a identificat hipogonadism. La 45% din pacienii aduli s-a constatat deficit staturo-ponderal si 75% dintre ei au prezentat hipogonadism. Concluzii. Aderarea la regimul de hipertransfuzie i o bun complian la tratamentul chelator duc la o limitare a complicaiilor endocrine pentru aceti pacieni. Exist totui pacieni, care dei au nivele sczute ale ncrcrii cu fier , prezint tulburri de cretere i/sau hipogonadism hipogonadotrop, implicai fiind factori ca: toxicitatea chelatorului, anemia cronic, boli cornice hepatice si variaia susceptibilitii la ncrcarea cu fier. Comunicare ESTIMAREA FRECVENEI GRUPELOR DE SNGE OAB I BUCURETI A. Zgrean, M.Hoinrescu, D. Vuculescu Centrul de Transfuzie Sanguin Bucureti. Romnia In anul 1914 soii Hirszfeld au descoperit, pe soldaii frontului din Salonic, o diferen n ceea ce privete grupele de snge, de la o populaie la alta. Mc. Arthur i Penrose au estimat frecvena grupelor A,B,O n populaia de pe glob la urmtoarele valori: O=62,3% A=21,5% B=16,2% dar aceste procente difer mult n funcie de zona geografic, ras, structura populaiei. Frecvena grupelor de snge pe teritoriul Romniei a fost estimat ultima dat , n urm cu 36 ani, cu ocazia statisticii din 1971. Aceast estimare se prezenta astfel: O= 32,68% A=43,15% B=16,50% AB=7,65%. Prezenta lucrare are ca scop verificarea n ce msur datele actuale se ncadreaz n aceleai estimri procentuale. Statistica a fost realizat la nivelul Municipiului Bucureti, urmnd s fie extins la nivel de ar. A fost luat n studiu un lot de 5000 donatori de snge prezentai la CTSMB ntr-un interval de 72 de zile. Rezultatele au fost urmtoarele: O=34,30% A=40,86% B=16,86% AB=7,98%. In privina sistemului Rh, procentul de negativi n populaie este de 11,7% iar corelat cu sistemul ABO se prezint astfel: pentru Grup O 4,28%, A 4,82%, B 1,66%, AB 0,94%. Studiul cuprinde i o evaluare a repartiiei sistemelor ABO si Rh pe sexe ct i frecvena antigenului D=0,54% n lot. In urma acestui studiu s-a observat c frecvena grupelor sanguine, pentru Municipiul Bucureti, nu difer semnificativ de cea din 1971. In concluzie, nu au intervenit schimbri majore n structura populaiei n ultimii 36 de ani. Pentru o evaluare la nivel de ar se impune extinderea studiului pe un lot mai mare de donatori, din diverse centre urbane ale Romniei. Comunicare IMPLEMENTAREASISTEMULUI DE MANAGEMENTAL CALITATII IN CTSMB M.Hoinrescu, E.Negoi Centrul de Transfuzie Sanguin al Municipiului Bucureti, Romnia Introducere : Urmare a Directivei 2002/98/CE prin articolul 11 se impune un sistem de management al calitii n toate centrele de transfuzie, inclusiv n Romnia. Evaluarea situaiei din Centrul de Transfuzie Sanguin al Municipiului Bucureti (C.T.S.M.B.) s-a fcut n comparaie cu Centrul de Transfuzie Johannes Gutenberg din Mainz, Germania (CT Mainz). Material si metod: S-a pornit de la documentaia elaborat privind implementarea sistemului de management al calitii n CTSMB, materialul prezentat de directorul Centrului de Transfuzie Johannes Gutenberg din Mainz Germania dr. Walter Hitzler, materialele prezentate de personalul medical n vizita de studiu in acest centru, documentaia privind aparatura, reactivii, metodele de lucru si situaia statistica 2006 n ce privete numrul de donatori i de componente sanguine obinute n acest an in CTSMB. Evaluarea CTSMB fa de CT Mainz s-a fcut n ceea ce privete circuitul donatorilor, dotarea laboratoarelor cu aparatur si reactivi, testele obligatorii, componentele sanguine i metoda de obinere, recompensarea donatorilor. Rezultate, concluzii: In urma evalurii CTSMB n comparaie cu CT Mainz a rezultat necesitatea implementrii ct mai rapide a unui sistem de management al calitii in CTSMB, pentru creterea securitii in transfuzie si mbuntirea continua a calitii produselor transfuzionale. Putem considera c Rh PE TERITORIUL MUNICIPIULUI

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activitatea CTSMB se desfoar la un nivel apropiat de cel al unui centru de transfuzie din Germania, n condiiile n care nu beneficiaz de aceleai mijloace financiare. Comunicare STUDIU COMPARATIV PRIVIND TIPURILE DE GERMENI IDENTIFICAI N ULTIMIIANI N PRODUSELE SANGUINE LABILE TESTATE DIN ROMANIA FA DE DATELE RAPORTATE PE PLAN INTERNAIONAL O. Coban1, M. Dobreanu1, T. Lazr2 1)Institutul Naional de Hematologie Transfuzional Bucureti, Romnia 2)Facultatea de Biologie Bucureti, Romnia Ca urmare a experienei din ultimii ani a laboratorului de control bacteriologic, n identificarea germenilor contaminani ai produselor sanguine labile (PSL), se remarc o diferen semnificativ ntre tipurile de germeni raportai pe plan internaional i cei identificai n Romnia. Principalii germeni care contamineaz produsele de snge raportai pe plan internaional sunt: Yersinia enterocolitica, Klebsiella sp, Escherichia coli, Enterobacter aerogenes, Citrobacter freundii, Pseudomonas sp, Flavobacterium Sp, Campilobacter jejuni, etc. n Romnia s-au identificat urmtoarele tipuri de germeni contaminani: Staph. aureus coag.+, Eubacterium sp, Propionibacterium acnes, Staph. hominis, Bacillus cereus, Clostridium sp, Bacillus sp, Listeria monocytogenes, Chryseomonas luteola, Erysipelotrix rhusiopathiae, etc.Cauzele acestor diferene s-ar putea rezuma astfel: pentru identificarea microorganismelor psicrofile (Yersinia enterocolitica, .a.), care cresc lent la 4C, este necesar controlul bacteriologic al produselor de snge dup 2530 de zile sau la expirare, ceea ce nu este nc o practic curent n Romnia. n timp ce pe plan internaional sunt raportate contaminri cu germeni cu rezisten crescut la factorii fizico-chimici utilizai la dezinfecia locului venopunciei i foarte bine adaptai multiplicrii n diverse medii derivate din snge (Yersinia enterocolitica, Serattia ssp, Pseudomonas ssp), n Romnia germenii identificai aparin florei mezofile i care se caracterizeaz printr-o mare varietate, inclusiv sporogeni, precum i germeni sensibili la factori fizici: Staphilococcus, Bacillus, Clostridium, Chryseomonas, Erysipelotrix, Listeria, Propionibacterium. O posibil explicaie ar fi lipsa unui sistem de monitorizare permanent a procedurii de venopuncie la donatori n condiii de asepsie n Romnia. Comunicare ETAPELE PE CARE LE PARCURGE COMPARTIMENTUL DE CONTROL DE CALITATE IN CENTRUL DE TRANSFUZIE SANGUINABRASOV IN VEDEREAVALIDARII BIOLOGICEAHEMOCOMPONENTELOR L.A.Munteanu, M.Foca, L. Florea Centrul de Transfuzie Sanguin Braov, Romnia Introducere. Controlul de calitate hematologic si bacteriologic al produselor sanguine labile (PSL), mpreun cu celelalte teste de calificare a donrii, reprezint principalele instrumente care asigur securitatea i calitatea sngelui total si a componentelor sanguine. Scopul acestui control este confirmarea faptului ca PSL obinute i distribuite de ctre CTS ndeplinesc parametrii hematologici i microbiologici specificai n normativele naionale i internaionale. Material i metod. Pentru controlul hematologic se controleaz 1% din fiecare tip de produs sanguin pe lun, prin metoda nedistructiv, pentru valorile hemoglobinei (Hb), hematocritului(Ht), numrul de leucocite i trombocite prin folosirea metodei clasice de numrare cu camera Burker-Turk. Pentru controlul bacteriologic se utilizeaz pungile satelite BACTIVAM , unitile de snge validate i expirate (mai ales concentrate trombocitare) i uniti rebutate (negative pentru markerii virali), care se nsmneaz pe medii de hemocultur Bio-Merieux HEMOLINE PERFORMANCE DIPHASIQUE pentru izolarea bacteriilor aerobe si HEMOLINE PERFORMANCE ANAEROBIE pentru izolarea bacteriilor anaerobe. Flacoanele se incubeaz la termostat la 37C, citindu-se rezultatele la 48h si la 14 zile. Rezultate. In cursul anului 2006 n vederea controlului hematologic s-au testat 293 uniti PSL : 43 snge total, 106 concentrate eritrocitare, 44 plasme proaspete si 100 concentrate trombocitare. Toate plasmele testate s-au ncadrat n standardele cerute. Din unitile de snge total doar una nu a corespuns din punctul de vedere al nivelului de Hb/unitate (minim 45g/unitate). 9 concentrate trombocitare nu au corespuns din punctul de vedere al numrului total de trombocite/unitate, situndu-se sub standardul de 0,5x1011 trombocite/unitate. 45 de concentrate eritrocitare au fost neconforme din punctul de vedere al nivelului de Hb/unitate. In cadrul controlului bacteriologic, n cursul anului 2006

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s-au testat 339 uniti PSL. Probele au fost urmrite zilnic, cu citire la 48h si citire finala la 14 zile. Din totalul probelor testate, s-a nregistrat o probabil cretere bacterian la 22 de probe. Nu s-au nregistrat rezultate pozitive la 48h. La 14 zile au aprut pozitive 16 probe pe mediu pentru germeni aerobi i 6 probe pentru germeni anaerobi. Nici unul din concentratele trombocitare testate nu a aprut contaminat bacterian (dei sunt cele mai supuse riscului iar unele dintre ele au fost nsmnate dup termenul de expirare). Toate unitile de snge total au rmas negative. O singura unitate de plasma a aprut pozitiva la 14 zile, datorita tulburrii bulionului aerob. Restul probelor pozitive au fost concentrate eritrocitare : 2 au prezentat colonii bacteriene crescute pe agarul de pe peretele flaconului, 1 a prezentat hemoliz, restul au determinat tulburarea mediului aerob. 2 probe au aprut pozitive pe ambele flacoane de hemocultur, datorit tulburrii mediilor, sugernd contaminarea accidental la nsmnare. Concluzii. Devierea de la standardele hematologice nu a fost att de semnificativ n nici unul din cazuri pentru a necesita invalidarea produsului din aceast cauz. Unitile PSL pozitive la controlul bacteriologic au fost retrase din circuit, unele fiind oricum rebutate anterior nsmnrii. Comunicare STUDIUL FRECVENEI ANTIGENELOR HLA IN POPULAIA DE DONATORI POTENIALI DE MDUVA OSOAS IN VEDEREAALCTUIRII REGISTRULUI NAIONAL (STUDIU PRELIMINAR) D.Ilinca, M. Duescu,A. Bardan, R. Tranulis, L. Ulea, R. Caisn Institutul Naional de Hematologie Transfuzional Bucureti, Romnia. Distribuia antigenelor HLA in Registrul Naional este un parametru important n dezvoltarea acestuia. Acest parametru este n strnsa legtur cu frecvena antigenelor HLA in populaia local. Autorii au studiat frecvena antigenelor HLA la un numr de 595 persoane nenrudite, 95% caucazieni, 5 % populaie cu alte origini etnice. Antigenele au fost determinate in anul 2006 prin tehnica serologic CDC pentru locusurile ABDRDQ (550 persoane) si SSP (45 persoane) n 2007. Antigenele cel mai frecvent ntlnite au fost HLA- A2 (48,9%), A1 (26,7%), A24 (20,3%),A11 (15%), B35 (30,4%), B51 (20,8%), B18 (20%), B44 (13,6%), B60 (12,9%). Frecvena din populaia noastr a fost comparat cu date din literatura de specialitate pentru populaia caucazian. Antigenul HLA B27 ntlnit la 90% din persoanele cu afeciuni reumatismale (spondilita anchilozant, sindrom Reiter, boala Crohn, uveit anterioara acut) , a avut o frecven de 8,5 % n lotul studiat, asemntoare cu frecvena citat n literatur pentru populaia caucazian. Antigenele HLA- A34, A 66, B46, B53, B58, B63 au fost gsite cu o frecven sub 1%. Cu frecven sub 5 % au fost antigenele HLAA28, A29, A33, A31, A30, B37, B47, B61, B45, B49, B50. Antigenele DR cu frecven crescut au fost DR11 (37,8%), DR15 (24,5%), DR17 (19,8%), DR1 (15,6%), DR7 (15,2%), DR13 (14,6%), DR14 (8,9%). Cu frecven sub 5% sunt: DR12, DR10, DR8, iar pentru DR18 si DR9 frecvena a fost sub 1%. Datele pentru DQ sunt asemntoare cu cele din literatur. Frecvena cea mai mare o are DQ1 (30,5%), DQ7 (28,6%), DQ2 (15,4%) si DQ4 (1,6%). DQ8 si DQ9 au frecvene sub 1%. Datele actuale privind frecvena antigenelor HLA n populaie sunt n concordan cu rezultatele testrii a 182 de bolnavi n ateptarea unui transplant de mduv osoas (MO) i a 476 de persoane nrudite, efectuate n anul 2006, n care am gsit 57 de donatori compatibili (29 %). Pentru restul de 70 % din bolnavi, care nu au donator n familie, registrele de donatori voluntari rmn unica speran. Pentru pacienii cu fenotipuri rare gsirea unui donator compatibil rmne o problema att n familie ct i n Registrul Naional de donatori. Creterea numrului de donatori voluntari de MO reprezint unica ans de compatibilitate pentru cei cu antigene rare. Comunicare RECRUTAREA DE DONATORI VOLUNTARI NEINRUDITI DE MADUVA OSOASA PENTRU REGISTRUL NATIONAL. SONDAJ DE OPINIE. I.M.Duescu1,R.Caisn1,L.Ulea1, A.Bardan1,R.Tranulis1, D.Ilinca1 Fl.Vldreanu1,M.Hoinrescu2, D.Goa2, M.Popa2,A.Crstea2,D.Ureche3,D.Florea4,L.Florea5,D.Ilcenco6,M.Iugulescu7,D.Crian8 1)Institutul Naional de Hematologie Transfuzional - Bucureti; 2)CTSMB; 3)CTS Sibiu; 4)CRTS Tg.Mures ; 5)CTS Braov ; 6)CRTS Iai ; 7)CTS Brila ; 8)CTS Maramure Introducere : Transplantarea de celule stem reprezint un procedeu terapeutic relativ rspndit la ora actual, fiind folosit cu succes n tratarea multor boli maligne. Pentru pacienii eligibili este singura metod cu potenial de vindecare.

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Transplantul constituie de fapt procedura de susinere i reanimare hematologic pentru refacerea hematopoiezei pe baza celulelor stem din grefon dup chimio- si radioterapie mieloablative. Gsirea unui donor cu o buna compatibilitate HLA este una din condiiile eseniale pentru reuit unei grefe de mduv. Prima cutare ncepe n familie, dar numai 25% din pacieni beneficiaz de un astfel de donor, pentru restul fiind nevoie de gsirea unui donator nenrudit. Realizarea de alogrefe de la donator nenrudit necesit existena unui Registru de Donori Voluntari Nenruditi. Un astfel de registru presupune o activitate complex, obiectivul principal fiind atragerea donorilor. Acestora trebuie s li se explice c donarea de celule stem nu este periculoas, fiind asemntoare din multe puncte de vedere cu donarea de snge. De asemenea este gratuit, confidenial i voluntar, se efectueaz numai cu consimmnt scris. Material si metod : In studiul de fa ne-am propus s realizm o prim evaluare a gradului de disponibilitate pentru a dona mduv osoas, cu scopul de a identifica att posibilele motivaii n favoarea donrii ct i cele mai frecvente bariere pentru a deveni donator. Studiul a fost realizat pe un grup int omogen, reprezentat de donatori de snge din 7 centre de donare din Bucureti i din ar. Au fost introdui n studiu subieci cu vrste cuprinse ntre 20 si 49 ani eligibili pentru alctuirea unui astfel de registru. Sondajul s-a realizat sub forma unui chestionar anonim completat cu ocazia donrii de snge. Rspunsurile au fost analizate pe subgrupe i anume : sex , nivel de instruire, mediul de via. Rezultate i concluzii : Sondajul a scos n eviden faptul c, dei majoritatea subiecilor au auzit de donarea de mduv (70%din donatorii cu studii medii i 86,8% din donatorii cu studii superioare), o mare parte din acetia recunosc c nu tiu ce reprezint acest procedeu (67,2% din donorii cu studii medii i 43,5% din cei cu studii superioare). In ceea ce privete interesul acordat acestui subiect, rspunsul a fost DA n cazul a 73,5% i respectiv 78,8% din subiecii interogai. La ntrebarea direct privind acordul pentru donarea voluntar i anonim de mduv, aprox. 20% au rspuns negativ, 27% au rspuns ferm pozitiv si 53% au solicitat lmuriri suplimentare pentru a putea rspunde la aceast ntrebare. Studiul arat clar faptul c unul din principalele obstacole n activitatea de constituire a unui registru de donatori de mduv l constituie lipsa de informare. Este nevoie de o aciune susinut de informare folosind mijloace scrise, video .a., prin care s se explice clar pentru ce este necesar acest registru, cine se poate nscrie pentru donare, cnd se doneaz, cum i unde se poate face nscrierea, cum se desfoar selecia unui donator, etapele donrii, cum se face prelevarea, care sunt obligaiile donatorului ,care sunt rezultatele transplantului. Statisticile arat c numrul maxim de combinaii HLA este estimat la 11.4x1018 iar n cadrul unui singur grup etnic numrul de combinaii HLA este estimat la 2,6x106. Se estimeaz c un registru de donatori, pentru a fi eficient, are nevoie de cel puin 200 000 persoane nscrise pentru a putea asigura gsirea unui donator compatibil pentru 85% din pacienii cu antigene relativ frecvente. Comunicare CRETEREAMOTIVAIEI PENTRU FIDELIZAREADONATORILOR . CERCETAREAA700 DONATORI DE SNGE DIN DOU CENTRE DE TRANSFUZIE SANGUIN DIN AR. A. Bugner1, L.Burta2,A.M. Dobrot3 1) Institutul Naionale de Hematologie Transfuzional Bucureti 2) Centrul de Transfuzie Sanguin Arad 3) Centrul de Transfuzie Sanguin - Constana S-a alctuit i s-a aplicat un chestionar de 15 ntrebri unor donatori care aveau minimum 3 donri sau mai mult de 3 donri. Numrul subiecilor pe care s-a aplicat chestionarul a fost de 700. Chestionarul urmrea n principal, s discearn mecanismul prin care un donator devine donator neremunerat, motivele fidelizrii i motivele renunrii la donare. Cele mai importante concluzii ale chestionarului au fost: a) In procesul recrutrii de donatori, cei mai importani recrutori sunt chiar nii donatorii de snge, ceea ce ne conduce la ideea realizrii unor seminarii pentru donatori, seminarii care au fost un succes n rile europene. b) Condiiile de donare sunt considerate de asemenea foarte importante, ca i ntregul traseu parcurs de donator. Foarte important este relaia personal - donator, ceea ce conduce la ideea necesitii susinerii unor cursuri pentru personalul implicat n donarea de snge.

Comunicare INCIDENTAALOIMUNIZARII PRIN SARCINAI DIAGNOSTICUL EI D. P. Florea

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Centrul Regional de Transfuzie Sanguin Tg-Mure, Romnia Boala hemolitic a noului nscut este nc o cauz frecvent de morbiditate i mortalitate perinatal chiar dac incidena ei a sczut in ultimii ani prin efectuarea imunoprofilaxiei cu imunoglobulina anti D, la gravidele Rh (D) negativ care au nscut un copil Rh pozitiv. In Romnia pe primul plan n ceea ce privete specificul anticorpilor responsabili de boala hemolitic neonatal este antigenul Rh(D). Motivul principal pentru persistena acestei configuraii etiologice este incompleta protecie conferit de administrarea imunoglobulinei anti- D. Scopul studiului nostru este acela de a arta importana testelor de depistare a aloanticorpilor antieritrocitari materni n cursul sarcinii precum i prevalena cazurilor de izoimunizare la gravidele Rh D negativ monitorizate n laboratorul nostru. Perioada de studiu a fost martie 2006 aprilie 2007 , pacienii gravide Rh negativ i nou nscui provenii din mame imunizate. Protocolul de lucru a cuprins: 1.Determinarea grupei sanguine A,B,O, Rh. 2.Determinarea fenotipului Rh Kell. 3.Determinarea Rh D slab prin testul Coombs indirect. 4. Depistarea anticorpilor iregulari antieritrocitari n serul pacientei. 5. Identificarea anticorpilor iregulari antieritrocitari n cazurile cu depistare pozitiv. 6. Evaluarea cantitativ a anticorpilor prin titrare.7.Determinarea grupului A B O , Rh , testul Coombs direct la nou nscut din sngele de cordon. In intervalul studiat s-au efectuat 1636 determinri la 545 gravide Rh negative. Depistarea a fost pozitiv in 27 de cazuri ( 4,9 %) din totalul gravidelor testate. In privina specificitii anticorpilor am gsit : 74 % cazuri cu anticorpi anti Rh (D), 11 % cazuri cu anticorpi anti Kell, 7,5% cazuri cu anticorpi anti Lewis, 7,5 % cazuri cu anticorpi nespecifici. Din analiza datelor prezentate se constata ca cea mai mare parte a cazurilor de aloimunizare se datoreaz antigenului Rh (D), in timp ce in tarile in care imunoprofilaxia anti D se practica riguros de foarte muli ani procentul aloimunizrii anti (D) 1 2 %. din cazuri. Credem ca situaia din Romnia poate fi mbuntit prin : a)implicarea serioas a Ministerului Sntii n elaborarea regulamentelor si normelor privind diagnosticul si tratamentul Bolii Hemolitice a Noului nscut; b)efectuarea corect a imunoprofilaxiei anti D urmat de monitorizarea eficienei profilaxiei; c)practicarea de rutin a unui test de evaluare a hemoragiei feto-materne. Comunicare EVALUAREAHEMORAGIEI FETO-MATERNE PRIN ELUTIAACIDA D. P. Florea Centrul Regional de Transfuzie Sanguin Tg-Mure, Romnia Introducere. Mecanismul etiologic cheie n cazul aloimunizrii prin sarcina este transferul transplacentar al eritrocitelor fetale n circulaia matern sau hemoragia feto-matern. Determinarea volumului de eritrocite fetale este un element de baz al monitorizrii si profilaxiei corecte a bolii hemolitice a noului nscut . In Romnia aceasta evaluare nu se efectueaz in nici o instituie de profil. Unul din cele mai utilizate teste screening pentru aprecierea hemoragiei feto-materne este testul Kleihauer bazat pe rezistena hemoglobinei fetale la eluia acid ; acest test se practic de foarte muli ani n toate rile n care exist prevederi legale n domeniul profilaxiei bolii hemolitice a noului nscut. Scopul lucrrii este de a prezenta protocolul de validare al metodei alese de noi (n literatura de specialitate exist mai multe variante pentru acest test). Material i metod. Validarea metodei s-a efectuat n mai multe etape : 1. Stabilirea caracteristicilor necesare pentru reactivii utilizai, calibrarea echipamentelor (microscop, centrifug) ; 2. Elaborarea S.O.P.- ului (Procedura de operare standard) , pe baza Bunelor practici de laborator , Standardelor de calitate i recomandrilor internaionale. 3. Instruirea urmat de evaluarea personalului din laborator pentru executarea operaiunilor. 4. Realizarea a patru serii de control : a)control negativ; b)control slab pozitiv 0,2% ; c)control slab pozitiv 0,3% ;d)control intens pozitiv 1%. 5. Realizarea a mai multor probe din eantioane de cercetat provenind de la gravide Rh negativ. 6. Analiza i compararea datelor rezultate din interpretrile celor 5 serii de teste. Protocolul de lucru pentru validarea metodei a fost ntocmit, aprobat i pus n practic n perioada mai noiembrie 2006. Dup efectuarea unui mare numr de testri s-au gsit rezultate concordante n ceea ce privete aspectul frotiului colorat cat si a proporiei de hematii fetale gsite cu ocazia aplicrii formulei de calcul. Concluzii: este c aceast metod este un test simplu care necesit echipament de laborator obinuit i datorit faptului c nu implic costuri deosebite poate fi utilizat cu succes n orice laborator spitalicesc ca metod screening pentru evaluarea hemoragiei feto-materne. Comunicare

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ALOIMUNIZAREAANTIERITROCITAR NANEMIAHEMOLITICAUTOIMUN M. Radulian, S. Sirian Institutul Naional de Hematologie Transfuzional Bucureti, Romnia. Scopul lucrrii: estimarea eficacitii tehnicilor imuno-hematologice utilizate la bolnavii cu Anemie hemolitic autoimun (AHAI) i identificarea allo-anticorpilor n vederea asigurrii securitii transfuzionale a acestora. Material i metod: Lotul investigat 411 pacieni cu diagnosticul de anemie hemolitic autoimun idiopatic sau secundar unei hemopatii maligne. Metode: fenotipaj OAB-Rh-Kell, test antiglobulinic direct (TCD) efectuat cu seruri antiglobulinice poli i monospecifice, determinri subclase IgG, screening i identificare de anticorpi prin metodele standard pe seruri nediluate i seruri diluate 1/5 n ser fiziologic, testul de eluie, teste de auto-absorbie i absorbii difereniale. Rezultate: TCD pozitiv n toate cazurile (>2) a fost de tip IgG (224 cazuri), C3d (81cazuri), IgG+C3d (89 cazuri), IgG+C3d+IgA(12 cazuri ) sau IgG+IgA+IgM (5 cazuri). In 73 seruri nu s-a depistat prezena nici unui anticorp prin nici una din tehnicile utilizate. In 223 seruri s-a identificat numai prezena de autoanticorpi. In 97 seruri s-au identificat att auto- ct i allo anticorpi prin screening de anticorpi efectuat pe seruri diluate 1/5 n SF (52 seruri), prin metoda autoabsorbiei (20 seruri) sau prin metoda absorbiilor difereniale (25 seruri). 18 seruri conineau numai allo-anticorpi, detectai prin tehnici standard. Autoanticorpii erau anticorpi de tip la cald (257 cazuri) anti-e, anti-ce, anti-D, antiCe, anti-nl, anti-K) i de tip la rece 63 cazuri anti-H, anti-HI, anti-I). Allo-anticorpii depistai aveau specificitate Rh(43 cazuri) sau n alte sisteme eritrocitare : Duffy, Kidd, Kell, Lewis, MnSs ( 40 cazuri). In 32 cazuri nu s-a putut stabili specificitatea allo-anticorpilor. Pentru evaluarea riscului de hemoliz produs de autoanticorpi, s-au determinat subclasele IgG prin Testul Coombs Indirect (TCI). Concluzii: Investigarea serurilor pacienilor cu AHAI trebuie efectuat n laboratoare cu nalt specializare, capabile de a utiliza pe lng tehnicile uzuale i tehnici speciale pentru identificarea allo-anticorpilor mascai de auto-anticorpi, n vederea asigurrii securitii transfuzionale a acestor bolnavi. Comunicare ANEMIE HEMOLITIC IMUN INDUS MEDICAMENTOS PREZENTARE DE CAZ C Posea1,AUrsachi1,AM Vladareanu2, I G Voican1, H Muresianu1 1) Spitalul Universitar de Urgen Bucureti, Romnia 2) Institutul Naional de Hematologie Transfuzional-Bucureti, Romania Cefalosporinele se asociaz frecvent cu pozitivarea testului Coombs direct dar rareori duc la anemie hemolitic de tip imun. Prezentm un caz de hemoliz imun sever dup administrarea intravenoas a sulperazonei n doz de 2g/zi timp de 14 zile. Pentru evidenierea anticorpilor antimedicament investigarea imunohematologic s-a fcut cu eritrocite test tratate cu cefoperazona i cu eritocite netratate, dar n prezena antibioticului n mediul de reacie. n serul pacientei au fost identificai att anticorpi care reacionau cu eritrocitele tratate cu medicament (mecanismul adsorbiei) ct i cu eritrocite netratate, dar n prezena drogului (mecanism de tip complexe imune). ntreruperea medicamentului a oprit procesul hemolitic i a prevenit instalarea insuficienei renale. Acest caz subliniaz importana monitorizrii pacienilor tratai cu cefalosporine pentru recunoaterea hemolizelor imune postmedicamentoase i pentru prevenirea sechelelor produse de acestea. Comunicare Cercetarea variabilelor de D partial, la donatori, cu ajutorul cartelelor DiaMed ID Partial RhD-Typing Kit L.Florea, M.Stoian Centrul de Transfuzie Sanguin- Braov, Romnia Introducere: Antigenul D din sistemul Rh, este considerat acum un mozaic de epitopi (30 de epitopi, dar, pentru scopuri practice, relevana clinic, au doar 9 tipuri). Prile absente ale mozaicului D de pe celulele individului pot, atunci cnd sunt expuse la un antigen D complet, s stimuleze producerea de anticorpi fa de epitopii care lipsesc. Variantele D parial au lips unul sau mai muli epitopi fa de RhD normal, situsurile antigenelor pot fi prezente n numr redus sau normal pe celul. Anticorpii anti-D parial au fost semnalai la pacienii cu categoria DVI care este cea mai important categorie de antigen D parial cu importan clinic. Aceast categorie a fost adesea clasificat drept D slab (Du) i

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transfuzat cu componente sanguine Rh negative. Este bine de tiut c 6% dintre Du testate au fost DVI. Material si metoda: Reactivii folosii sunt cartelele DiaMed-ID Partial Rh-Typing cu 6 microtuburi care conin antiglobulina umana polispecifica (anticorpi de iepure anti-IgG si anti-D monoclonal) incluse n gel. Kitul de grupaj ID-partial RhDTyping cuprinde 6 seruri anti-D monoclonal care pot diferenia categoriile D parial: II, IV, V, VI, VII, DFR, DBT, si RoHar. Incepnd cu 23.05.2007 am introdus testrile pentru RhD parial acestea efectundu-se conform procedurilor standard de operare att pentru donatori ct i pentru gravide. S-au testat conform algoritmului de lucru 1811 donatori si 91 gravide. Rezultate: Din cei 252 donatori RhD negativi testai conform procedurilor standard de operare, 3 donatori au fost identificai ca fiind cu D parial, respectiv DIII. In literatura de specialitate, la aceast categorie nu s-a observat imunizarea , avnd structura antigenic cea mai apropiat de antigenul D complet; aceti donatori sunt nregistrai ca RhD pozitiv. Concluzii: Pentru evitarea unor conflicte transfuzionale datorit imunogenitii antigenului D, este important cercetarea variabilelor de D parial la donatori pentru identificarea variabilei DVI. Comunicare: INCIDENAIZOIMUNIZRII LAGRAVIDE E. Savuly, C. Rou, M. Stoian, L. Florea Centrul de Trandfuzie Sanguin Braov, Romnia Introducere: Boala hemolitic a nou-nscutului este o afeciune determinat de un conflict imunologic feto-matern, prin imunizarea organismului mamei fa de un antigen eritrocitar fetal. Condiiile de instalare a imunizrii mamei survin ori de cte ori pe eritrocitele copilului se gsete un antigen care lipsete de pe eritrocitele materne, indiferent de sistemul de grupe sanguine n cauz. Astfel de incompatibiliti feto-materne au fost descrise aproape pentru majoritatea antigenelor din sistemele de grupe eritrocitare. Materiale i metode: S-a folosit tehnica de aglutinare pe plac de opalin (pentru determinarea grupei sanguine i a factorului RhOD ), tehnica de aglutinare n tub (pentru decelarea i titrarea anticorpilor imuni), tehnica de aglutinare n coloan de gel ID-DIAMED MICRO TYIPING SISTEM (pentru fenotip, depistarea, identificarea i titrarea anticorpilor imuni). S-au testat un numr de 701 gravide care s-au prezentat la CTS Braov. Rezultate: Din 123 gravide cu factor RhOD, 1 caz de imunizare cu anticorpi anti-A( 0,81%), restul fiind neimunizate. Din cele 578 gravide cu RhOD negativ : * 21 cazuri imunizare cu anticorpi anti-D (3,63%); * 2 cazuri imunizare cu anticorpi anti-C (0,34%) ; * 1 caz imunizare cu anticorpi anti-CW (0,17%); * 4 cazuri imunizare cu anticorpi anti-A(0,69%) ; * 2 cazuri imunizare cu anticorpi anti-B (0,34%); * 2 cazuri imunizare cu anticorpi anti-Lea (0,34%). n 2 cazuri s-a identificat prezena unui amestec de anticorpi imuni anti-D + anti-C. Concluzii: Incompatibilitatea de sarcin, prin intermediul factorilor D, C, duce n anumite procente la diverse grade de boal hemolitic a nounscutului. Profilaxia cu imunoglobuline anti-D a diminuat considerabil alloimunizarea feto-matern, dar nu i alte imunizri. Comunicare BOALAHEMOLITICANOU-NSCUTULUI I SELECIADE SNGE COMPATIBIL C. Rou, E. Savuly, M. Stoian, L. Florea Centrul de Transfuzie Sanguin - Braov, Romnia Introducere: Boala hemolitic a nou-nscutului prezint un interes deosebit n hematologie, i n general, n patologia uman. Boala a fost descris nc din secolul trecut. Curnd dup descoperirea sistemului Rh s-a putut preciza legtura ntre acest factor i boala hemolitic a nou-nscutului, nlturndu-se orice suspiciune etiologic. Incompatibilitatea imunologic ntre mam i ft s-a impus definitiv ca factor determinant n declanarea bolii hemolitice a nounscutului, precizndu-se un nou capitol n patologie, acela al bolilor ftului i nou-nscutului legate de o izoimunizare matern. Pn n prezent, tratamentul cel mai eficace rmne cel aplicat copilului; acesta const n natere prematur, exsanguinotransfuzie i n unele cazuri speciale, transfuzia de snge la ft intrauterin. Material i metode: S-a folosit tehnica de aglutinare n coloan de gel ID-DIAMED MICRO TYPING SISTEM. Determinrile s-au realizat utiliznd diverse cartele: pentru grup sanguin ABO/Rh, fenotip Rh/K, test Coombs direct poli i monospecific, pentru aprofundarea diagnosticului de hemoliz mediat imun, pentru determinarea calitativ i cantitativ a anticorpilor i pentru selecia de snge compatibil. Rezultate: Au fost testai 10 pacieni cu diagnostic ferm sau prezumtiv de boal

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hemolitic a nou-nscutului. Testrile au confirmat diagnosticul de boal hemolitic a nou-nscutului prin incompatibilitate n sistem Rh, n toate cele 10 cazuri; a fost necesar selecia de snge compatibil pentru exsanguinotransfuzie n 4 cazuri. ntr-un singur caz de boal hemolitic alturi de anticorpii anti-D au fost implicai i anticorpii anti-Leb. Concluzii: Aceste tehnici serologice standardizate relev implicarea anticorpului anti-D, din sistemul Rh, n marea majoritate a cazurilor de boal hemolitic a nou-nscutului. Raport QUALITYASSURANCE IN TRANSFUSION. Ioana Culea, Florentina Vladareanu. National Institute of Transfusion Hematology , Bucharest, Romania. Blood transfusion is an expending field based on interaction of more disciplines. Monitoring of the entire chain vein to vein is a condition for ensuring both the quality and safety of blood, blood components and the targeted blood therapy. European legislation: Directive 2002/98/EC; Directive 2004/33EC; Directive 2005/61/EC; Directive 2005/62/EC; Guide EU-GMP, Directive 2003/94 and Romanian legislation:282/2005; Orders of the Ministry of Public Health 1214/2006; 1228/2006; 1227/2006; 1226/2006; 1225/2006; 1237/2007; 1193/2007 support blood establishments to implement a quality system. The major benefits of this are: defining of a quality police; establishing of the quality objectives; involvement of all personal qualified, trained and responsible; existence of an errors and risks assessment system, an improvement management of the resources, a continuous improvement of the quality. Accomplishment of the quality objectives depends on a well designed system of quality assurance. The basic concepts of the quality assurance, good manufacturing practices and quality control are interrelated. So, quality assurance activities monitor the performance of the: a) processes, giving information about their trends and shifts; b) personal involved in different stages of the vein to vein chain; c) laboratory methodology according to their results got in external quality control scheme. Raport ELEMENTS OF QUALITYASSURANCE IN ERYTHROCYTIC IMMUNIHEMATOLOGY S. Sirian, Fl. Vladareanu National Institute of Transfusion Hematology Bucharest, Romania Blood transfusion, discipline that interfere with all medical specialties, involves, through its problems, multiple risks, one of residual major risk being the immunological incompatibility donor blood recipient. There for to guarantee a high level of transfusion security it is necessary to introduce a program of Quality assurance (QA) in immunohematology. The best guarantee to achieve all objectives of QA is to be strictly respectful of Standard Operating Procedures (SOP) by a trained staff. QA programs states flow-charts of immunohematological testing on donors and blood recipients, the quality of techniques, reagents, equipment and records-keeping and monitors whether personal perform all procedures in a approved, reproductible fashion. During 1998-2006 period, a variety forms of initial and continuous education, immunohematological testings on donors and recipients by aproppriate flowcharts, the good quality of reagents and equipements, led to a rising in the transfusional security. Now, we must transpose that good experience in a QA Program in order to be in accordance with the CE requirements and national law.

Raport HEPATITIS VIRUSES B AND C RECENT PROGRSSES AND POSSIBILITIES TO REDUCE THE TRANSFUSION RISK. M. Pecec ,A. Necula, National Institute of Transfusion Hematology Bucharest - Romania

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The residual risk of transfusion transmitted infections varies with the magnitude of the negative window period, which depends on the sensitivity of the screening tests and on the speed of the ramp up viremia which in turn depends (in an unknown/undocumented way) on the magnitude of the infecting inoculum on one hand and on the other hand on the prevalence of the infection in the donor population. HBV and HCV are the most frequent TTI locally as well as in the whole EU zone. Since the introduction of EIA screening, the registered prevalence continues to be higher than that in the Centre-West EU countries by a factor of 102, with five to tenfold differences between HBsAg and anti-HCV in different locations. One of the reasons is that EIAs, although the sensitivity of these tests greatly improved since their introduction (HBsAg 1990, anti-HCV - 1995), are inherently less sensitive than the NATs introduced in Centre-West EU around the year 2000. More recently, in this later zone supplemental screening for anti-HBc and anti-HBs (the later for fractionation purposes also) was almost generalized in an effort to provide for the detection of 'variant'' HBV, although the usefulness/proficiency in lowering the residual risk for HBV could not be ascertained (c.f. results by the DRK Baden-Wuertemberg-Kassel). The characteristically higher local endemic status is prone to provide for a more evident proficiency of the introduction of NAT. However, in order to determine the optimal alternative (either some variant of NAT or a combination of NAT and EIAs), the lack of representative data mandates for an extensive experimental study on a number of donors/donation around 104. Raport RETROVIRUSES (HIV-1/HIV-2, HTLV-I/HTLV-II) 2000-2006- THE RESIDUALTRANSFUSION RISK. A. Necula, M. Pecec National Institute of Transfusion Hematology Bucharest - Romania

Introduction: Residual risk of transfusion transmitted viral infections is mainly linked to the window period and to the incidence of infection in the targetted population for donor selection. According to EuroHIV (2006) monitoring HIV prevalence among blood donations is a vital tool for evaluating the safety of blood supply. We report here the results of the last seven years of screening for (anti-)HIV-1/HIV-2 which appeared after 1985 in our area and for (anti)HTLV-I which is endemic. Methods: Current screening uses combined, Antigen+Antibody EIAs for HIV-1/2 and antibody-capture EIAs based exclusively on recombinant antigens for HTLV-I/II. Repeat reactives are confirmed in Western Blot and/or Line-Immuno-Assay (LIA), in keeping with WHO criteria for HIV-1/2 and according to H.E.R.N. recommendations, respectively. Prevalence and incidence are expressed for 100.000 donors/ donations, respectively. Results: During the considered period the prevalence of anti-HIV-1 in 1-st time blood donors (FTBD) was 25.8 (with 1.9 7,3% early seroconvertors as compared to aprox. 6 in the western part of the EU (EuroHIV,2006) . In repeat blood donations (RBD) the mean incidence was 2.4 in 100000 donations (with 0.6 25,5% early seroconvertors significantly more [p>0.001] than in FTBD), as compared to under 1 in 100000 donations for the western countries of EU. The number potentially infectious RBDs was 1.2 in 100000 donations representing 51% of all cases detected in this category. Only one case of HIV-2 infection was identified during the period under consideration. The highest prevalences in FTBD were registered in three districts in the southern area , Arges ( 95), Bucharest (84) and Constanta (50) , which cumulate 58% of all detected positives, while accounting for 19% of all blood collection from FTBD. The general prevalence of anti-HTLV-I in FTBD was 58 in 100000 donors with local spikes over 100 in the South East, where a few seroconversions in RBD could be documented also. The general incidence in RBD dropped from 118 during the 4-th qrt 1999 to, and stabilised at about 1 in 100000 donations. ATL cases are regularly confirmed in Bucharest (3 to 16 per year; 5 in the last year). Conclusions: As compared to the moment of the introduction of specific screening, the residual risks for transfusion transmitted HIV-1 and HLTV-I, although considerably lowered, remain well above the levels registered in western EU. As it appears that the virus trafficking is faster in RBD, further reduction of risk would occur only through improving standards for donor selection. Defining the profile of the seroconverting donor and the assessment of the prevalence in different population groups, as potential targets, would contribute to improving donor selection criteria. Comunicare N.A.T. TECHNOLOGY IN TESTING THE TRANSFUSED BLOOD. PRESENT STEADY OF IMPLEMENTATION IN EUROPE. Francoise Le Flohic Regional Director Ilex Ltd.

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Comunicare THE EPIDEMIOLOGY OF INFECTION WITH HIV, HEPATITIS B & C IN ROMANIA. A. Streinu Cercel, D. Oelea Institute Matei BalBucharest, Romania Comunicare THE IMPACT OF THE SCREENING TESTS BZ NAT TECHNOLOGZ IN INDIVIDUAL DONATION UPON THE BLOOD TRANSFUSION SAFETY. Nico Lelie Director t. Chiron-Novartis Comunicare IMMUNOLOGICAL TECHNIQUES USED IN DETERMINATION OF CLINICAL SIGNIFICANT ANTIERYTHROCYTEANTIBODIES S. Sirian, M. Radulian National Institute of the Transfusion Hematology, Romania Background: ABO, Rh, Kell, Kidd, Duffy, MNSs, Pp, Lewis, erythrocyte antibodies are involved in hemolytic transfusional reaction (HTR) and in hemolytic disease of the new born (HDN). Objectives: using in routine immunohematology practice all appropriate methods and techniques in detection of clinical significant antierythrocytic antibodies, in order to prevent HTR and for the management of HDN. Methods, reagents: hemaglutination technique (tube and in column) in saline , albumin, indirect antiglobulin test (IAT) with polyspecific antiglobulin serum and enzymes, correlated with RhK and other erithrocytic phenotypings and elution absorption techniques. Investigated 8034 cases (patients, pregnant women, new bornes, blood donors) for the immunohematological diagnostic and for the selection of compatible blood. Results: Immunised 11.51%, antiD 325, antiD+C 7.3%, anti Kell 5.4%, anti E 5.7%, anti c 5.3% and anti cE, anti D+E, anti D+C 3.17%, another antibodies (anti Jk, anti Fy, anti S, anti s, anti M) 0.3%. Conclusion: Utilization of appropriate techniques in routine practice for the detection of clinical significant antierytrocytic antibodies, prevents HTR and helps in a good HDN management. Comunicare EVOLUTION OF POSTTRANSFUSIONAL REACTIONS BY USING LEUKODEPLETED PHENOTYPED RED CELL CONCENTRATES IN MAJOR THALASSAEMIAPOLYTRANSFUSED PATIENTS M.D. Voicu, Fl. Vladareanu, S. Sirian, L. Nitu, C. Calota National Institute of Transfusion Haematology , Romania. Introduction: Thalassaemia major is characterized by a severe haemolitical anaemia dependent of regular blood transfusions for whole life. For a proper development of those patients hypertransfusion regimen was introduced in order to maintain pretransfusion haemoglobin above 9g/dl. Material & Method: Our study group was formed of 100 patients with thalassaemia major registred at National Institute of Transfusion Haematology level.All those patients were transfused with leukodepleted red cell concentrates Rh(D)-Kell phenotyped between 2-6 weeks. Results: Transfusion requirements of those patients was in average of 25 units/year, reaching even 40 units/year. This large number of transfusions and their frequency at 2-3 weeks leads to immunization of those patients against leukocyte and red cell antigens, the most frequent posttransfusion reactionms were chilly-fever and rush. Beginning with year 2000 those patients were transfused with Rh(D)-Kell phenotyped blood products and since 2004 leukodepleted red cell concentrates were introduced, thus, nowadays, all our patients were transfused with phenotyped and leukodepleted products and posttransfusional reactions disappeared. Conclusions: Although phenotyping and leukodepleting rises

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the price of blood unit and there are also rare phenotype hard to find, the benefit of using those products for polytransfused patients is extreme high, thus is necessary to maintain this standard in transfusion therapy. Comunicare COMPLIANCE TO IRON CHELATION THERAPY WITH DESFERAL IN MAJOR THALASSAEMIA PATIENTS REGISTERED AT NATIONAL INSTITUTE OF TRANSFUSION HAEMATOLOGY LEVEL BETWEEN 20002006 Fl. Vladareanu, M. D. Voicu, L. Nitu, C. Calota, National Institute of Transfusion Hematology, Romania Introduction: In not iron chelated patients with major thalassaemia, progressive iron accumulations leads to cardiac, liver and endocrine complications. Compliance to iron chelation therapy is defined as the extend to which patient's behavior coincides with medical's prescription, more specifically defined as the extend to which the patient adheres to the prescribed infusions scheme including dose of Desferal, number oh hours per day and number of days per week. Material and Method: Our study group includes 100 patients with major thalassaemia registered at NITH level in chronic transfusion and iron chelation therapy. Monitoring iron overload and chelation efficacy was achieved by periodical assessment of serum ferritin. Chelation therapy started when serum ferritin level reach about 1000mg/ml, near 2,5 years of age. Iron chelation treatment consist in subcutaneously administration of Desferal in continuous infusions for 8-12 hours given 5-7 times per week at mean daily dose of 20-50 mg/Kg body weight according with serum ferritin level and patient age. Results: Introduction of National Program since 1996 providing accessibility to iron chelation and infusion devices leads for a short period of time to a very good compliance and treatment. However, chelation therapy is difficult and overwhelming, the process is time-consuming and must be repeated daily for the rest of patient's life. The benefits accumulate over the long-term, thus neither the positive effects not the negative effects are readily apparent, the factors associated with bad compliance were: lack of awareness about side effects of iron overload, the fact of giving up doses provides short-term comfort, relief and diminish local side effects; treatment is time consuming leading to a restrictions on a patient's activities; psychological burden; unwanted local reactions; material aspects of consumables cost. Conclusion: A good compliance to chelation therapy provides a long survival, a significant decreasing of complications due to iron overload and a good quality of life. It is verry important to identify all aspects reducing compliance and rise the awareness of patients and their families about the treatment benefits. The quickest introduction of oral chelators will lead to a significant improvement of patient adherence to therapy. Comunicare GROWTH DISORDERSAND HYPOGONADISM IN MAJOR THALASSAEMIAPATIENTS Fl.Vladareanu , M.D.Voicu, L.Nitu, C.Calota National Institute of Transfusion Hematology, Romania Introduction. Hipertransfusionregime and a good compliance to iron chelation treatment lead to a significant improvement of life expectation and quality of life for major thalassaemia. Despite therapeutical progress, growth disorder and hypogonadottop hypogonadism remain the most frequent complications for adolescents with major thalassaemia. Material and Method: Our study group is formed of major thalassaemia patients aged 12years old girls and 13 years old boys, polytransfused and chelated with Desferal, iron chelation therapy is monitorised by periodic assessment of serum ferritin. Results: Main causes involved in growth disorders and sexual maturation are chronic tissular hypoxia and iron toxicity. A proper transfusion therapy ensure a normal development of thalassaemic child for the first decade of life. After this period of time and in lack of proper iron chelation growth disorders and sexual development appear. Some of the followed patients had abnormal levels of growth hormone. Hypogonadotrop hypogonadism is the most frequent endocrine complication in major thalassaemia major and an important cause of growth disorders. 20% of thalassaemic adolescents had high-weight deficiency and 60% of them were identified with hypogonadism. 45% of thalassaemic adults were find with high-weight deficiency and 75% had hypogonadism. Conclusion: Adherence to hypertransfusion regime and a good compliance to iron chelation lead to a limitation of endocrine complication for this patients. Nevertheless, there is patients with low body iron burden who had growth disorders and/or hypogonadotrop hypogonadism, factors as chelator toxicity, chronic anaemia, chronic liver diseases and variation of iron burden susceptibility being involved in this process.

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Comunicare THE ESTIMATION OF BLOOD GROUPSAND Rh FREQUENCY IN BUCHAREST POPULATION A. Zagrean , M. Hoinarescu, D. Vuculescu The Blood Transfusion Center, Bucharest, Romania In 1914, Hirszfeld discovered a difference among the blood groups of populations in soldiers stationed in Salonic. Mc. Arthur and Penrose have estimated the frequency of the A,B and O blood groups around the world as follows: O = 62,3%, A = 21,5%, B = 16,2%, but these figures vary with geographical areas, race and population structure. The frequency of blood groups in Romania was last. estimated 36 years ago, in 1971.These statistics showed : O=32,68%, A=43,15%, B=16,5%, AB=7,65%.Our work verifies the nature in which actual data concurs with these past estimations. The statistics have been realized only in the Bucharest area but they will be applied to the entire country. The study contains a lot of 5000 blood donors present at the Blood Transfusion Center during an interval of 72 days. The results were : O=34,3%, A=40,86%, B=16,86%, AB=7,98% .Regarding the RH system, the negative percentage of the population is 11,7%, and along with ABO system, we have : O 4,28%, A - 4,82%, B- 1,66%, AB 0,94%. The study also contains an evaluation of the gender repartition of ABO and RH systems and also the frequency of the D antigen in the lot as follows : D= 0,54%. As a conclusion of this study, it has been observed that the frequency of the blood groups in Bucharest hasn't changed significantly since 1971. Therefore, there had been no major changes in the population's structure in the last 36 years. For a country-wide evaluation, a larger lot of donors must be studied. Comunicare IMPLEMENTING QUALITY MANAGEMENT SYSTEM IN BUCHAREST B.T.C. M.Hoinarescu, E.Negoita Blood Transfusion Center in Bucharest, Romania Introduction: The effect of article 11 in the 2002/98/CE Directive is the need for introducing a quality management system in all transfusion centers, including the ones in Romania. The evaluation of the Blood Transfusion Center in Bucharest (B.T.C. Bucharest) status has been made by comparison with Johannes Gutenberg Blood Transfusion Center in Mainz, Germany (BTC Mainz). Means and methods. The following have been used as starting point: the documents on the quality management system implementation in B.T.C. Bucharest: the presentation made by dr. Walter Hitzler, the director of Johannes Gutenberg B.T.C. Mainz, the presentations made by the medical staff on study visit at this Center, the documentation concerning instruments, reactive, working methods and the 2006 statistics on donor count and this year's B.T.C. Bucharest blood components productivity.In order to compare the two transfusion centers, focus was put on donor circuit, instruments and reactive lab equipment, mandatory tests, blood components and obtaining methods, donor rewards. Results, conclusions: Comparing the two transfusion centers results in the necessity of a quality management system implementation in B.T.C. Bucharest, as soon as possible, in order to increase security in transfusion and further develop the quality of transfusion products. We can consider that B.T.C. Bucharest activity takes place on a level close to that of a German transfusion center, since it does not benefit from the same financial funds. Comunicare COMPARATIVE STUDY OF DIFFERENT KINDS OF BACTERIA IDENTIFIED IN ROMANIAVS. INTERNATIONAL REPORTS OF CONTAMINATED BLOOD PRODUCTS O. Coban1, M. Dobreanu1, T. Lazar2 1)National Institute of Transfusion Hematology Bucharest; 2) Bucharest University - Biology

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Following last years experience of our Quality Control Laboratory in identification of blood products bacterial contaminants we found a semnificative difference between types of bacteria reported in international literature and those found in Romania. The most important microorganisms, which contaminates blood products, reported in other countries, are: Yersinia enterocolitica, Klebsiella sp, Escherichia coli, Enterobacter aerogenes, Citrobacter freundii, Pseudomonas sp, Flavobacterium Sp, Campilobacter jejuni, etc. In Romania there have been identified the following kinds of bacterial contamination: Staph. aureus coag.+, Eubacterium sp, Propionibacterium acnes, Staph. hominis, Bacillus cereus, Clostridium sp, Bacillus sp, Listeria monocytogenes, Chryseomonas luteola, Erysipelotrix rhusiopathiae, etc. The causes of such differences may be resumated as following: For psychrophilic germs determinations (i.e.Yersinia enterocolitica), with growth at 4C, blood products bacteriological control is necessary to be done after 25-30 days of storage, or at the end of storage, but this isn't a usual practice in Romania yet. While other countries reported blood products contaminations with high resistance bacteria to antiseptic methods used in venipuncture procedures and very well adapted for multiplication in blood environment (Yersinia enterocolitica, Serattia spp, Pseudomonas spp), in Romania contaminant microorganisms belong to a great variety of mesofile species, including sporogens, as well as vulnerable bacteria to physical agents: Staphilococcus, Bacillus, Clostridium, Chryseomonas, Erysipelotrix, Listeria, Propionibacterium. Some possible explanation may be the lack of a permanent monitoring system of venipuncture procedure in order to minimize the risk of bacterial contamination in Romania. Comunicare THE STEPS OF BIOLOGICAL VALIDATION OF BLOOD COMPONENTS IN THE QUALITY CONTROL DEPARTMENT OF THE BRASOV BLOOD TRANSFUSION CENTRE L.A.Munteanu, M.Foca, L. Florea Blood Transfusion Center Brasov, Romania Introduction. The haematological and bacteriological quality control of instable blood products (IBP), represent, near the other donating qualification tests, the main tools which assure the security and the quality of the blood and his components. The purpose of this control is the confirmation of the fact that IBP obtained and distributed by the Blood Transfusion Centre have the haematological and microbiological parameters in conformity with national and international standards. Materials and methods. For the haematological control, 1% of each blood product type is tested, every month, by non-destructive method, doing the following tests: the measurement of haemoglobin (Hb), using the HemoCue haemoglobin metre and of haematocritis (Ht); the counting of white cells and platelets using the classical Burker-Turk device. For the bacteriological control are used: the satellite bags BACTIVAM, the validated and expired blood units (especially platelet concentrates) and rejected units (negative for virus markers), which are tested on blood cultures Bio-Merieux HEMOLINE PERFORMANCE DIPHASIQUE (for aerobic organisms detection) and HEMOLINE PERFORMANCE ANAEROBIE (for anaerobic organisms detection). The bottles are incubated at 370C in a bacteriology incubator, reading the results after 48 hours and 14 days. Results. In 2006, were haematologically tested 293 IBP units: 43 units of total blood, 106 units of red cells concentrates, 44 units of fresh plasma and 100 units of platelet concentrates. All tested plasma units had normal values. From total blood units, only one had not a normal Hb/unit level (at least 45g/unit), 9 platelet concentrates had less than 0,5x1011 platelets/unit and did not answer to the standard. 45 red cells concentrates had low level of Hb/unit. In 2006, for the bacteriological control, 339 IBP units were tested. The units were examined every day+, with first reading at 48h and final reading at 14 days. From all blood samples, 22 had a probably bacterial growth. After 48 hours all units were negatives. After 14 days, 22 units were positives (16 for aerobic organisms and 6 for anaerobic organisms). All platelet concentrates were negatives (although these units are the most exposed to contamination, and some of them were tested after the expiration period). All the units of total blood were negatives. A single unit of plasma was positive after 14 days, indicated by the appearance of turbidity in the broth. The rest of positive samples were red cells concentrates : 2 presented colonies on the agar covering the side of the bottle, 1 presented haemolysis, and the rest of them turbidity in the broth. 2 units were positives on both medium bottles, with the appearance of turbidity in the broth, suggesting accidental contamination during the testing. Conclusions. In none of the cases, the deviation from the haematological standards was not very significant, to invalidate the product. The positives IBP units at the bacteriological control were rejected, some of them being previously rejected by other meanings. Comunicare THE HLA FREQUENCY IN BONE MARROW UNRELATED POTENTIAL DONORS FOR NATIONAL

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REGISTRY (Preliminary study) D.Ilinca, M. Dutescu,A.Bardan, R.Tranulis, L. Ulea, R. Caisan National Institute of Transfusion Hematology -Bucharest, Romania HLA distribution in the National Registry is a key parameter for rationally planning its evolution. This parameter is very close to HLA frequency in local population. 595 unrelated persons, 95 % Caucasians, 5 % other ethnic groups were studied for HLA antigens frequencies. HLA - A, B, DR, DQ antigens were typed by CDC techniques (550 persons) and SSP (45 persons) in 2007. The HLA most frequent antigens were: HLA- A2 (48.9%), A1 (26.7%), A24 (20.3%),A11 (15%), B35 (30.4%), B51 (20.8%), B18 (20%), B44 (13.6%), B60 (12.9%). Our results were compared with the data from literature concerning the HLA antigens frequency in Caucasian population. HLA B27 antigen found in 90 % patients with rheumatic diseases ( ankylosing spondylitis, Reiter syndrome, Crohn disease, acute anterior uveitis) had 8,5 % frequency in our group, very much alike with the frequency in Caucasian population mention in international publications. HLA antigens : A34, A 66, B46, B53, B58, B63 had under 1 % frequency . Under 5 % frequency we found for HLA - A28, A29, A33, A31, A30, B37, B47, B61, B45, B49, B50. Concerning DR antigens we found 37.8% for DR11 (a higher value comparing with the data from literature) , 24.5 % for DR15, 19.8 % for DR17 , 15.6 % for DR1, 15.2 % for DR7, 14.6 % for DR13 and 8.9 % for DR14. Under 5% frequency were: DR12, DR10, DR8, and for DR18 and DR9 the frequency was under 1%. The results for DQ were similar with those found in literature: DQ1 (30.5%), DQ7 (28.6%), DQ2 (15.4%) and DQ4 (1.6%). For DQ8 and DQ9, split from DQ3, frequency was under 1 %. The data concerning HLA frequencies in our group confirm the results obtain on 182 patients waiting for a bone marrow transplant (BMT) and 476 related donors typed in 2006 when we found quite the same HLAfrequencies. 57 patients had a HLA compatible donor in the family. For the remaining 70 % the National and International Register of Voluntary Bone Marrow Donors remain the only solution. For patients with rare phenotypes, founding a HLA compatible donor remain a problem in the family as in Registries. A high number of voluntary unrelated bone marrow donors in National and International Registries will solve the compatibility problem. Comunicare THE RECRUITMENT OF VOLUNTEER UNRELATED BONE MARROW DONORS FOR THE NATIONAL REGISRTY.PUBLIC TEST I.M.Dutescu1,R.Caisan1,L.Ulea1, A.Bardan1,R.Tranulis1, D.Ilinca1 F.Vladareanu1,M.Hoinarescu2, D.Gosa2, M.Popa2,A.Carstea2,D.Ureche3,D.Florea4,L.Florea5,D.Ilcenco6,M.Iugulescu7,D.Crisan8 1)National Institute of Transfusion Hematology - Bucharest; 2)CTSMB; 3)CTS Sibiu; 4)CRTS Tg.Mures ; 5)CTS Brasov ; 6)CRTS Iasi ; 7)CTS Braila ; 8)CTS Maramures Introduction : The stem cell transplantation is today a therapeutic tool quite common in the entire world, successfully used for the treatment of many malignancies. For the eligible patients is the only method for a possible recovery. The stem cell transplant actually represents a procedure for hematological support and recover, for hematopoiesis restoration based on graft stem cells, after chemo and radio-therapies. One of the most important condition for the success of a bone marrow transplant is the identification of a donor with a very good HLA compatibility. The first search begins in the family, but only 25% of the patients are able to have this kind of donor. The other of patients have to find an unrelated bone marrow donor. To perform an alotransplant from an unrelated donor, an Unrelated Donor Registry in necessary. This kind of registry requires a complex activity, one of the most important target beeing the donor recruitment. The potential donors must understand that the stem cells donation is not dangerous and is very like a blood donation. It is also free of charge, confidential and volunteer- is done only with a written consent. Material and method : The aim of this study was to realize a first evaluation of the willingness to donate in view to recognize the most important motives for and the most frequent barriers against becoming donor. The study was performed on a homogenous target group represented by registered blood donors from 7 blood donor centers from Bucharest and the country. Only the eligible subjects for this kind of register, with age between 20 and 49, were taken in the study. The test was performed like an anonymous questionnaire filled in the same time with blood donation. The answers were analyzed in subgroups : sex, donors level studies, urban/rural.Results and conclusions: The test emphasized the fact that the majority of the subjects have already heard about bone marrow donation ( 70% of donors with medium studies and 86,8% from those with high level studies).The problem is that a big part of them don`t know what this procedure is (67,2% of donors with medium studies and 43,5% from those with high level studies).As for the interest for the subject of donation, the answer was YES in 73,5% respectively 78,8% of the examinated subjects. To the direct question

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regarding the agreement for anonymous and volunteer bone marrow donation, we had aprox. 20% negative and 27% positive answers, and 53% who asked for more explanations in view to give an answer to this question. The study proves that one of the most important obstacle for a bone marrow donors registry set up is the knowledge deficiency.An important activity to inform the public in write or video tools is obligatory. It must be clearly explained what for is this registry necessary, who can join this file, how and where can they be put in the registry, when the donation can be done, how a donor can be selected, the steps of the donation, how the procedure is done, what are the duties of the donor, what are the expected results of the transplant. Statistics show that maximum estimate number of HLA combinations is 11.4 x 1018 and the realistic estimation of number of HLA combinations within a single ethnic group is 2.6 x 106. A donor registry needs at least 200 000 typed persons to assure the selection of a compatible bone marrow donor for 85% of the patients with frequent HLAantigens. Comunicare INCREASING MOTIVATIONAND CREATING REGULAR BLOOD DONORS RESEARCH ON 700 DONORS FROM TWO BLOOD CENTERS IN THE COUNTRY A. Bugner1, L. Burta2,A.M. Dobrot3 1) National Institute of Transfusion Hematology, Romania 2) Blood Transfusion Center Arad 3) Blood Transfusion Center - Constana A fifteen question questionnaire was created and applied on 700 regular donors (donors with at least 3 blood donations). The reason for this was to find out what the mechanism that creates a regular blood donor is, what makes a nonremunerated blood donor and why some donors give up on the blood donation. These are some of the most important conclusions that were extracted from the questionnaire results: a) In the process of recruiting blood donors, the most important recruiters are the blood donors themselves. This brings up the idea of creating blood donation promotion courses for donors, method which has been successfully used in all the European countries. b) Conditions at the blood center and the way the donors are approached are very important. This includes the way the donor is received, the room where the donor waits before giving blood, the way the nurses approach the donor and the doctor-donor relationship. Blood donation promotion courses could be useful for the blood transfusion personnel as well. Comunicare THE INCIDENCE OFALLOIMMUNISATION THROUGH PREGNANCY AND ITS DIAGNOSIS D. P. Florea Regional Center of Blood Transfusion Tg. Mure, Romania The hemolytic disease of newborn is a frequent cause of morbidity and mortality even if its incidence has dropped during the last years as a result of immunoprophylaxy with IgG anti-D, performed on pregnant women Rh(D) negative who gave birth to an Rh(D) positive child. In Romania, the most important antibody responsible for hemolytic disease of newborn is Rh(D). The main reason for the persistence of, this etiological configuration is the incomplete protection offered by IgG anti D. The purpose of our study ist to demonstrate the importance of screening tests for finding alloanticorps during pregnancy and prevalence of alloimmunisation cases in our laboratory. The period of study was mars 2006 April 2007, performed on pregnant women and newborns of immunized mothers. The work protocol consisted of: 1.Typing blood group ABO, Rh. 2.Typing Rh-Kell group. 3.Typing weak D by Indirect Coombs Test. 4.Screening irregular antibody on maternal serum. 5. Identifying irregular antibody on positive screening tests. 6. Titration of the antibody.7. Typing ABO, Rh group and Coombs direct test on newborn in cord blood. During the period of study, a number of 1636 tests were performed on 545 Rh negative pregnant women and 107 newborn. Screening was positive on 27 cases (4,9%); concerning the type of antibody: 74% anti Rh (D); b) 11% anti Kell; c) 7,5% anti Lewis; d) 7,5 % unspecified. By analyzing data, we found that in most cases the alloimunisation is caused by anti Rh(D); in others countries in which anti-D prophylaxy is being carried for

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many years the immunization by anti-D is very low (1-2%). We believe the situation in Romania could be improved by : a)the serious involvement of the Health Ministry in providing proper Guidelines for the diagnosis and treatment of the hemolytic disease of the newborn; b)monitoring the efficiency of IgG anti/D prophylaxy; c) implementing a routine test for assessing feto-maternal hemorrhage. Comunicare ASSESING OF THE FETOMATERNAL HAEMORHAGE THROUGH ACID - ELUTION TECHNIQUE D.P. Florea Regional Center of Blood Transfusion Tg. Mure, Romania The key mechanism of alloimmunisation through pregnancy is the transplacentar transfer of fetal red cells in to the maternal circulation. Quantifying fetal red cells volume is the most important element of monitoring and preventing hemolytic disease of the newborn. In Romania no profile institution does this evaluation. One of the most frequent screening test used for determinating fetomaternal hemorrhage is the Kleihauer test, based on the fetal hemoglobin resistance to acid elution. The purpose of this study is to present the protocol of validation for the method used by us (there are several other methods). This protocol was created, approved and validated during May-November 2006 in our laboratory. The method validation was performed through the next steps: 1. Choosing the necessary characteristics for the reactive, calibrating the medical equipment (centrifuge, microscope), standard operating procedures.2. Elaborating procedures for testing, based on Good manufacturing practice, Quality standards and international recommendations.3. Teaching and evaluating laboratory personnel to properly execute necessary operations. 4. Performing four control test : a)negative control; b)mildly positive control 0,2%;c)mildly positive control 0,3%; d)intensely positive control 1%. 5. Performing several tests with samples from pregnant women after a well documented protocol. 6. Analyzing and comparing results from the five series of tests. After a large number of tests we carried, we found identical results concerning the colour of slides as well as fetal red cells proportion after applying the calculating formula. As a conclusion, we can say this method is a simple test which utilizes regular laboratory equipment and as it is not expensive it can be performed successfully in any hospital laboratory as a screening method for assessing fetomaternal hemorrhage. Comunicare RED-CELLALLO-IMMUNIZATION INAUTOIMMUNE HAEMOLYTICANAEMIA(AHA). M.Radulian, S. Sirian National Institute of the Transfusion Hematology The purpose of the work : to estimate the efficiency of the methods used in Autoimmune Haemolytic Anaemia (AHA) investigations in order to identify the allo-antibodies hidden by allo-antibodies. Material and methods.: Subjects : 411 patients with idiopathic or secondary of malign diseases AHAI. Methods: ABO-Rh-Kell grouping, direct antiglobulin test (DAT) with poly and monospecific sera, IgG subclasses routine screening and identification of the antibodies by special procedures: undiluted and diluted 1/5 patient's sera in saline, the elution, auto-absorption and differential absorption methods. Results: DAT was positive in all cases (>2+), type IgG (224 sera), C3d(81 sera), IgG+C3d (89 sera), IgG+C3d+IgA (12 sera), IgG+IgA+IgM (5 sera). In 73 sera we didn't find any antibody neither by standard methods nor by the others methods; in 223 sera we identified only auto-antibodies; in 97 sera we identified both auto and allo-antibodies by 1/5 dilution sera in saline (52 sera) and also by auto-absorption method (20 sera) and by differential absorption method (25 sera); 18 sera contained only allo-antibodies detected by usual techniques. The auto-antibodies were warm antibodies in 257 sera (anti-e, anti-ce, anti-D, anti-Ce, anti- nl, anti-K) and cold autoantibodies (anti-H, anti-HI, anti-I) in 63 sera. The allo-antibodies belonged to all blood group systems : Rh-43 sera, others systems (Duffy, Kidd, Kell, Lewis, MnSs) 40 sera. In 32 sera we couldn't identify the specificity of the alloantibodies. Conclusions: The investigation of the sera from patients with Autoimmune Haemaolytic Anaemia must be performed in a specialist laboratory able to use not only the standard methods, but some others special techniques in order to assure a safe blood in transfusion of this patients.

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Comunicare AUTOIMUNE HAEMOLYTICANAEMIA DRUG INDUCED CASE REPORT C. Posea1,A. Ursachi1,A. M. Vladareanu2, I. G. Voican1, H. Muresianu1 1) Emergency Universitary Hospital-Bucharest, Romania 2) National Institute of Transfusion Hematology, Bucharest, Romania Cephalosporins are frequently associated with positive direct antiglobulin test (DAT) and may rarely cause immune hemolytic anemia. We present a case report with severe hemolytic anemia after intravenous cephoperazone 2 g daily for 14 days. Immunohematologic studies of drug-dependent antibodies were performed by using cephoperazone treated red blood cells (RBC) and untreated RBC in the presence of drug. The patient's serum contained antibodies that reacted with both drug-coated RBC (adsorption mechanism) and with uncoated RBC when cephoperazone was added to the serum (immune complex mechanism). Discontinuation of the drug rapidly resolved the hemolytic reaction and prevented the onset of renal failure. Our report underlines the importance of close laboratory and immunohematologic monitoring of patients treated with cephalosporins in order to recognize hemolytic reaction due to these antibiotics thus reducing the chance of serious sequels. Comunicare Research of the D partial variables, on blood donors L.Florea, M.Stoian Blood Transfusion Center - Brasov, Romania Introduction: The D antigen of the Rh system, is now considered a mosaic of epitopes (30 epitopes, but for practical purposes, the 9-epitope model is clinicaly satisfactory). Individuals whose cells lack parts of the D mosaic, when exposed to a complete D antigen, can start the production of antibody to the epitopes that are lacking on the individual's cells. The anti-D partial antibody had been noticed on patients within the category DVI which remains the most important category, with clinical importance. This category was often classified as weak D (Du) and was often transfused as RhD negative individuals. It should be known that 6% of the Du where actually DVI. Materials and procedure: The reactives used are Dia Med-ID Card Partial RhD-Typing with 6 microtubes containing polyspecific antihuman globulin (rabbit anti-IgG and monoclonal anti-C3d), within the gel matrix. The ID-Partial RhD-Typing kit consists of 6 monoclonal anti-D wich can aid further characterization of the RhD antigen: II, IV, V, VI, VII, DFR, DBT and RoHar. Starting from 23.05.2007 we have introduced partial RhD testing done following the standard operational procedures on both blood donors and pregnant woman. There have been tested a number of 1811 blood donors and 91 pregnant woman. Results: From a total of 252 RhD negative donors that have been tested following the standard operational procedures, 3 where identified as having D partial, more exactly DIII. We know, from specialized literature, that immunization hasn't been observed at this particular category, because of having the most resembling antigenic structure as the complete D antigen. These donors have been registered as RhD positive. Conclusions: In order of avoiding transfusional conflicts that may appear because of the immunogenity of the D antigen, it is important to research for the partial D variables on donors in order of identifying the DVI category. Comunicare MOTHER' S RHESUS ISOIMMUNIZATION, HEMOLYITIC DISEASE OF THE NEWBORN C. Rou, E. Savuly, M. Stoian, L. Florea Blood Transfusion Center Braov, Romania Introduction: Hemolytic disease of the newborn (HDN), also known as erythroblastosis fetalis, occurs when there is an incompatibility between the blood types of the mother and baby - involves incompatibility of the Rh factor or ABO blood groups. It was not until the 1950s that the underlying cause of HDN was clarified; namely, the newborn's red blood cells are being attacked by antibodies from the mother. This kind of isoimmunization occur between the mother

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and fetus in the course of ABO group system incompatibility. Methods: Agglutination technology by means of opalin plate (for ABO blood groups and Rh0D identification), tube agglutination (in order to detect and titrate the immune antibodies), and also agglutination by means of Gel Test ID-Micro Typing System (phenotype, detect, identify and titration of the immune antibodies) where used. Seven hundred one cases of pregnancy where studied in CTS Brasov. Results: From the total of 701 cases we studied, we discovered: * 123 subjects with Rh0 D positive, from witch 1 with anti-A antibodies isoimmunization (0.81%). * 578 subjects with Rh0 D negative, from witch: 21 cases with anti-D antibodies isoimmunization (3.63%); 2 cases with anti-C antibodies isoimmunization (0.34%); 1 case with anti-CW antibodies isoimmunization (0.17%); 4 cases with anti-A antibodies isoimmunization (0.69%); 2 cases with anti-B antibodies isoimmunization (0.34%); 2 cases with anti-Lea antibodies isoimmunization (0.34%). Also in 2 cases, a mixture of anti-D+ and anti-C antibodies where identified. Conclusions: Pregnancy incompatibility, by means of D and C factor, concludes some times to HDN. The anti-D prophylaxis has decreased the alloimmunization. Comunicare HEMOLITIC DISEASE OF THE NEWBORNAND BLOOD COMPATIBILITY SELECTION C. Rou, E. Savuly, M. Stoian, L. Florea Blood Transfusion Center - Braov , Romania Introduction: Hemolytic disease of the newborn (HDN), also known as erythroblastosis fetalis, occurs when there is an incompatibility between the blood types of the mother and baby - involves incompatibility of the Rh factor or ABO blood groups-. The first description of HDN is thought to be in 1609 by a French midwife who delivered twins. It was not until the 1950s that the underlying cause of HDN was clarified; namely, the newborn's red blood cells are being attacked by antibodies from the mother. Once HDN is diagnosed, treatment may be needed. This may include: intrauterine blood transfusion of red blood cells into the baby's circulation, early delivery if the fetus develops complications; or, after birth: blood transfusions, intravenous fluids, help for respiratory distress using oxygen or a mechanical breathing machine, exchange transfusion to replace the baby's damaged blood with fresh blood. Methods: Agglutination technology was used, by means of Gel Test ID-Micro Typing System. Determination was made using few test cards: for blood type ABO/Rh, Rh/K phenotype, direct antiglobulin test (DAT with polyspecific and monospecific AHG reagents), for qualitative and quantitative antibodies test, for blood type selection. Results: Ten patients with HDN diagnose where tested. Tests confirmed the initial HDN diagnose by Rh factor incompatibility, and four out of ten cases required blood replacement. In another particular case, we discovered that the anti-D antibodies where found near the anti-Leb antibodies. Conclusions: These techniques proved once again the anti-D antibodies involvement in the Hemolytic disease of the newborn.

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Poster REPARTITIA PE SEXE SI VARSTAA DONATORILOR CU A.L.T. MAI MARE DE 70 U.I. LA DONATORII NOI SI FIDELIZATI IN ULTIMII 3ANI SI IN PRIMUL SEMESTRUALANULUI 2007, LAC.T.S. BRAILA M. Iugulescu, L. Ionescu, E. Mihil Centrul de Transfuzie Sanguin Brila, Romnia Introducere. Creterea activitii ALT in ser sau in plasma este un indicator al apariiei si evoluiei unor leziuni hepatocelulare. Maladiile care pot cauza creterea activitii ALT sunt : hepatita acut si viral, mononucleoza infecioas, infeciile parazitare, bruceloza, febra galben, tumori maligne ale ficatului, hemocromatoza, leucemia. ALT poate creste de asemeni ca rezultat al alcoolismului sau obezitii. Nivelul ALT poate fi influenat de vrsta, sex sau rasa iar nivelul normal al ALT poate fi variat la populaii diferite. Obiectiv. Cercetarea creterii activitii ALT in sngele donat, ndeprtarea din transfuzie a pungilor de snge care prezint creteri peste valoarea normala a ALT si urmrirea donatorilor. Material i Metod. Pentru a pune n evidena creterea activitii ALT se utilizeaz trusa cu reactivi ALT SENTINEL (ALT Color Microwell). Probele de snge care prezint valori crescute ale ALT sunt repetate in dublet a doua zi. Donatorilor, care prezint valori crescute ale ALT n snge, li se recolteaz, cnd se prezint la urmtoarea donare, 5 ml snge de control. In anul 2004 au fost 11.730 de donatori. Din acest total, 243 de donatori au prezentat valori peste cea normala ale ALT ( 2,07% din numrul total de donatori). In anul 2005, numrul total de donatori a fost de 11.801, din acetia, 262 prezentnd valori peste limita normala a ALT (2,22% din numrul total de donatori). In anul 2006, numrul total al donatorilor a fost 11.101, din care 166 dintre ei au avut o valoare crescuta a ALT, peste limita normala (1,49% din numrul total de donatori). Acest lucru a fost posibil datorit introducerii controlului obligatoriu nainte de donare i la donatorii care prezentau valori situate n zona gri (50-70 U.I.) i recomandarea unei pauze de 6 luni de la donare cu repetarea analizei si educaie sanitar corespunztoare Concluzii: a) din numrul total de donatori care prezint ALT cu valori crescute peste limita normala ponderea o reprezint donatorii fidelizai (peste 75%); b) peste 80% dintre donatorii cu valori ALT crescute sunt de sex masculin; c) pe msur ce nainteaz in vrsta persoanele (nscute in anii 1950 si 1960) reprezint un procent de aproximativ 60% din numrul totalul donatorilor cu valori ALT peste limita normal; d) controlul ALT la toi donatorii care au prezentat valori crescute ale ALT la donarea anterioar i la cei cu valori situate n zona gri este un factor important al scderii numrului de rebuturi cu repercusiuni i asupra mbuntirii strii de sntate a populaiei prin educaia sanitar primit din partea personalului C.T.S. Poster EVOLUTIA NUMARULUI DE DONATORI DE SANGE REPARTIZATI PE GRUPE DE VARSTA SI SEX LA CTS BRAILA IN PERIOADA2000 2006 E. M. Butnaru, M. Iugulescu Centrul de Transfuzie Sanguin Brila, Romnia Introducere. Donarea de snge este un profund act umanitar fata de semeni, este un gest nobil de ajutor al omului aflat n suferin. Donarea de snge nu poate fi nlocuit de nici un fel de tratament, fiind de maxima eficienta. CTS Brila promoveaz donarea de snge benevola, neremunerat i anonim, selectarea cat mai corecta a donatorilor, creterea numrului de donatori fidelizai, clinic sntoi, selectai din grupul de populaie cu riscul cel mai redus de a avea diverse boli ce se transmit prin snge, ngrijirea donatorilor prin consiliere pre si post donare. Obiectiv: Obiectivul lucrrii de fata este analizarea evoluiei numrului de donatori de snge repartizai pe grupe de vrsta si sex in perioada 2000-2006 in C.T.S. Brila. Material si metode: La baza datelor din prezenta lucrare sta evidenta zilnica din registrele de consultaie a donatorilor, situaiile centralizate pe grupe de vrsta si sex, zilnice, lunare, trimestriale si anuale si

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programele de nregistrare a datelor. Rezultate: A crescut in timp numrul donatorilor fidelizai si in special in perioada 2005 - 2006 numrul donatorilor tineri cu grupa de vrsta cuprinsa intre 20-30 de ani. Numrul total al donatorilor a crescut progresiv din 2000 pn n 2005, apoi s-a stabilizat in jurul valorii de 11.500 . Din repartiia pe sexe se observa ca din 2000 si pana in prezent donatorii de sex masculin au fost mai muli dect cei de sex feminin in 2000-70%, 200169%, 2002-67%, 2003-66% , 2004-64%, 2005-62%, 2006-61% dar in timp procentul a sczut de la 70% in 2000 ajungnd la 61% in 2006 iar procentul de donatori de sex feminin a crescut de la 30% n 2000 la 39% in 2006. In ceea ce privete donatorii fidelizai, procentul celor de sex masculin a sczut, n timp ce procentul donatorilor de sex feminin a crescut de la 25% in 2000 la 33% in 2006, procentul total pentru donatori fidelizai masculin i feminin meninndu-se n ultimii 3 ani la 83 % din totalul donatorilor . In ultima perioad numrul donatorilor fidelizai cu grupa de vrsta 3140 ani a crescut, n timp ce grupele de vrsta 41-50 si 51-62 au sczut, ceea ce semnific ntinerirea masei de donatori de snge. Numrul donatorilor cu o donare anterioar de cel puin 5 luni , a crescut progresiv n perioada analizat. Concluzii: In perioada analizat (2000-2006) la CTS Brila: numrul donatorilor de snge a crescut progresiv, stabilizndu-se la 11.101; numrul donatorilor fidelizai s-a meninut constant n ultimii 3 ani n jurul valorii de 83%; numrul donatorilor de sex masculin este mai mare dect cel al donatorilor de sex feminin; din 2000 pn n 2006 procentul de donatori de sex feminin a crescut de la 25% la 33%. Numrul donatorilor ocazionali a crescut progresiv , ceea ce nseamn o revenire a acestora la donare, aspect pozitiv pentru C.T.S. Brila. A crescut numrul de donatori tineri n corelaie cu scderea celor cuprini n grupa de vrst 41-62 de ani. Poster INCIDENTEALE DONRII DE SNGE N PERIOADA2004 - 2006 LAC.T.S. BRILA. E.M. Butnaru, M. Iugulescu,A.Gitan Centrul de Transfuzie Sanguin Brila, Romnia Introducere. Considerate ca incidente ale donrii de snge ,cu o frecven relative sczut, dar prezente si deloc neglijabile, sunt lipotimia si hipotensiunea arteriala. Obiectiv. Studierea incidenei cazurilor de lipotimie si hipotensiune arteriala in ultimii trei ani (2004, 2005, 2006) a cauzelor acestora si realizarea unui plan de prevenire a acestor incidente . Se observa o incidena crescuta a cazurilor de hipotensiune arteriala si lipotimii in special la donatorii noi si in special la persoane tinere de sex masculin. De asemenea se observa scderea progresiva a acestor incidente post donare, in anul 2006 nregistrndu-se cele mai puine cazuri . Concluzii. Se observa incidena mai mare la donatorii de sex masculin, a cazurilor in special de lipotimie, comparative cu donatorii vechi . In primele zile ale sptmnii si de asemenea in zilele clduroase se observa o cretere a acestor incidente. Poster REPARTIIA PE SEXE I VRST A DONATORILOR NOI DEPISTAI CU HBV I HCV L A C.T.S. BRILA N ULTIMII 7 ANI M. Iugulescu, C. Babe, G.Antohi, T. Brat Centrul de Transfuzie Sanguin Brila, Romnia Introducere. n Romnia primele centre de transfuzie apar n anul 1949 iar n anul 1952 la 1 noiembrie se nfiineaz Centrul de Transfuzie Sanguin` Brila avnd ca personal un medic i dou surori medicale. Dup 1990 i pn n prezent la C.T.S. Brila a fost adus aparatur modern, recoltarea de snge se face n sistem nchis n pungi de plastic, se depisteaz markeri virali HBV,HCV,HIV,HTLV prin testarea serului donatorilor prin metoda ELIZA, se fac depistri de anticorpi iregulari, fenotipare n alte sisteme eritrocitare dect n sistemul ABO i Rh, fracionarea sngelui n ase subproduse, se face propagand pentru donarea benevol i neremunerat i exist o preocupare permanent pentru creterea calitii produselor i a tuturor serviciilor oferite donatorilor i spitalelor. Obiectiv. Lucrarea de fa are ca obiectiv prezentarea distribuiei markerilor virali HBV i HCV la donatorii noi pe grupe de vrst i sexe ncepnd din anul 2000. Material i metode Depistarea markerilor virali se face prin metoda ELISA, alternnd la dou donri consecutiv dou truse de lucru. Rezultatele.se confirm la Laboratorul Central de Referin pentru VTS. Rezultate. Total donatori 2000-2006 : din care : raportat la donatorii noi : donatori noi = 7923 (masculin = 5214: HBV poz.=359=4,531% , HCV poz. = 122= 2,340%; feminin = 2709 : HBV poz.= 139=21,754 % , HCV poz. = 83=3,064%). In total : HBV poz = 6,285% (din DN) ; HCV poz. = 2,587% (din DN). Raportat la numrul total de

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donri: HBV poz.: 498 donatori : 0,705% (masculin = 359 =0,508%; feminin= 139 = 0,197%); HCV poz. = 205 donatori : 0,290% (masculin = 122= 0,173% ; feminin = 83 = 0,118%). Concluzii finale. Donri fidelizate validate pentru HBV i HCV 2000-2006 = 69.931 din care donri invalidate = 703. Poster PREZENA ANTICORPILOR IREGULARI ANTIERITROCITARI LA DONATORII DIN C.T.S. BRILA N PERIOADA2000-2006 (POSTER) M. Iugulescu, C. Negutu, G. Demergian Centrul de Transfuzie Sanguin Brila, Romnia Introducere. Evidenierea anticorpilor iregulari antieritrocitari n serul unei persoane vizeaz prevenirea accidentelor hemolitice post-transfuzionale. Obiective : Cercetarea anticorpilor iregulari n sngele donatorului, ndeprtarea din transfuzie a pungilor de plasm depistate cu anticorpi iregulari. Material i metod: Pentru a evidenia prezena anticorpilor se testeaz serul donatorilor cu hematii test cu configuraie antigenic cunoscut. Exist dou etape n cercetarea anticorpilor iregulari: 1) Depistaj (RAI ) Test Coombs/Enzima combinat. pozitiv la dou determinri succesive; 2) Identificare (stabilirea specificitii) la INHT Bucureti: a) Test enzimatic (papaina); b) Test Coombs Indirect. Rezultate: n perioada 2000-2006 s-au efectuat 9307 testri din care: 53 cazuri au fost depistate cu RAI pozitiv; 44 cazuri au fost confirmate de INHT Bucureti. Concluzii: Procentul de RAI pozitiv la donatorii de snge n perioada cercetat a fost de 0,569%. Poster FRECVENA GRUPELOR OAB IAFENOTIPURILOR Rh NTR-UN LOT POPULAIONAL DIN ZONABUCURETI M. Radulian, S. Sirian, Fl. Vldreanu Institutul Naional de Hematologie Transfuzional Bucureti, Romnia Scopul lucrrii: o ncercare de a estima frecvena grupelor OAB i a fenotipurilor Rh prin investigarea unui numr de 6.000 de persoane. Material i metod. Subiecii: pacienii cu boli hematologice , persoane politransfuzate, femei gravide, soii i nou-nscuii acestora. Metode: tehnica aglutinrii pe lam folosind diferite seruri comerciale (DaiMED, BioRAD) i micrometoda aglutinrii n coloan (DiaMED, BioVue, ScanGel). Rezultate:Frecvena grupelor OAB: O = 34,72%, A= 44,12% (subgrup A1=37,20%, subgrup A2=6,82%), B=14,36%, AB= 6,71% (subgrup A1B = 5,12%, subgrup A2B=1,05%). Frecvena fenotipurilor Rh: Dcee=31.15%, DCCee = 20,21%, ddccee= 15,83%, DccEe=14,30%, DccEe= 11,70%, Dccee0 2,80%, dccEc=1,095, ddccee=15,83%, DccEe=14,30%, DccEe=11,70, Dccee=2,80%, dccEe=1,09%, dCcee=1,03%, DccEE=1,03%, dCee=0,24%, dccEE=0,23%, dCcEe=0,12%, DCCEe=0,12%. Concluzii: rezultatele noastre sunt foarte apropiate de datele din literatur referitoare la aria noastr geografic. Micile diferene pot fi explicate prin particularitile lotului investigat de noi.Poster TESTRI IMUNOHEMATOLOGICE ERITROCITARE CU ERITROCITE MAGNETIZATE S. Sirian, M. Radulian, Fl. Vldreanu Institutul Naional de Hematologie Transfuzional Bucureti, Romnia Introducere. Determinrile imunohematologice cu eritrocite magnetizate (Diagast) utilizeaz hemaglutinarea n microplci, cu eritrocite magnetizate permind sedimentarea lor rapid, fr necesitatea centrifugrii. Tehnic i reactivi: Fenotipri eritrocitare n sistemul OAB i RhKell, depistajul (screening-ul de anticorpi iregulari antieritrocitari prin TCI cu ser AG anti IgG, linia Diagast Freelys-Nano, comparativ cu tehnica de rutin a laboratorului (DiaMed). Rezultate: Evidenierea cu acuratee a fenotipurilor OAB , RhD standard i a celorlali factori ai sistemului Rh i K. Evidenierea anticorpilor antieritrocitari din clasa IgG(antiD, antiD+C, antiD+E, antiK, antiM). Concluzii: Tehnica cu eritrocite magnetizate, utiliznd linia Diagast Freelys, este util n determinrile obligatorii pretransfuzionale, pentru evitarea reaciilor hemolitice transfuzionale. Poster

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FRECVENTA ANTICORPILOR ANTIERITROCITARI LA DONATORII DE SANGE DIN C.R.T.S.CLUJNAPOCA IN 2006 C. Zdrenghea, E. Chiorean Centrul de Transfuzie Sanguin Cluj, Romnia Introducere : In vederea asigurrii securitii transfuzionale din punct de vedere imunohematologic, n conformitate cu legislaia intern i internaional, pe lng determinarea/verificarea grupului OAB i RhD, ca metod de rutin la toi donatorii de snge se efectueaz cercetarea anticorpilor iregulari antieritrocitari. Material i metode : In anul 2006 au fost testai 16248 donatori de snge pentru prezena de anticorpi iregulari antieritrocitari. Ca metode de lucru s-au folosit : macrometoda de hemaglutinare n faz lichid i micrometoda hemaglutinrii n gel, cu reactivi DiaMed i ScanGel. Rezultate : 242 donatori (1,50%) sunt cu anticorpi antieritrocitari iregulari prezeni. Pentru 80 s-au fcut identificri de anticorpi, cu urmtoarele rezultate :anticorpi anti-Rhesus 34 (42,5%); anticorpi anti-Lewis 35 (43,75%); anticorpi anti-Kell 3 (3,75%); anticorpi anti-papain 4 (5,0%); anticorpi anti-Duffy 1 (1,25%); autoanticorpi 3 (1,25%). Concluzii : Dei frecvena anticorpilor iregulari antieritrocitari este redus (1,50%) ,faptul c au fost identificai anticorpi cu semnificaie n transfuzia sanguin ( ex. anti-D) denot importana acestor teste, contribuind la prevenirea unor reacii transfuzionale de incompatibilitate i aloimunizrii posttransfuzionale.

Poster DISTRIBUTION ON SEX AND AGE FOR BLOOD DONORS WITH ALT OVER 70U.I. AND NEW AND FAITHFULLY DONORS IN LAST 3 YEARSAND FIRST HALF OF 2007 AT CTS BRAILA M.Iugulescu, L. Ionescu, E. Mihil Blood Transfusion Center Brila - Romania Introduction. Growing the activity of ALT in serum or in plasma is an indicator of apparition and evolution of lesions of cells of liver The diseases who causes grow activity ALT are acute and chronic hepatitis ,mononucleosis ,parasitical diseases, brucellosis , yellow fever, neoplasm of liver, hemochromatosis leukemia . ALT grow in alcoholism in obesity too . The level of ALT in function by age, sex or race and the normal level of ALT can be different for different populations. Objective. The research of growing activity ALT in blood ,elimination of blood transfusion a bags of blood who presents value for ALT over normal and following of blood donors. Material and methods. For following activity of ALT use kit of reactive ALT SENTINEL. Samples of blood with ALT over normal are repeat in doublet next day. For donors with value for ALT over normal in blood , before the next donation will be take 5 ml blood for testing. In 2004 were 11730 donors. Of this number 243 donors presents value for ALT over normal in blood(2,07%). In 2005 were 11801 donors. Of this number 262donors presents value for ALT over normal in blood(2,22%). In 2006 were 11101 donors. Of this number 166 donors presents value for ALT over normal in blood(1,49%). This is possible because introduction compulsory control before donation for donors who present value for ALT situated in gray zone(50-70UI) and recommendation a break for 6 months of donation and then repeating test and sanitary education. Conclusions. There are donors with value for ALT over normal particularly faithfully donors (over 75%). Over 80% donors with value for ALT over normal are male donors. People was born in 1950-1960 presents a percent 60% of total number of donors with value for ALT over normal. The control for ALT for all donors who presents value for ALT over normal and for donors who present value for ALT situated in gray zone(50-70UI) is a very important because in this way rejected is reduce and level of health for people is improve through sanitary education by staff of CTS Brila. Poster THE EVOLUTION OF NUMBER OF DONORS OF BLOOD DISTRIBUTES IN GROUP OFAGEAND SEX AT CENTER OF BLOOD TRANSFUSION-BRAILAIN 2000-2006 E. M. Butnaru , M. Iugulescu

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Blood Transfusion Center Brila, Romania Donation of blood is a deep humanitarian act for fellow creatures ,it is a noble gesture of help for the human being in suffering. Donation of blood can't be replace by another treatment and it is of maxim efficiency. Center of blood transfusion Brila promote donation of blood voluntary , unremunerated and anonymous, selection as well as possible of donors of blood , growing of number of faithfully donors, clinical health, care of donors through advising pre and post donation. Objective. Objective of present paper is analyzed of evolution of number of donors of blood distributes in group of age and sex at Center of blood transfusion-Brila in 2000-2006. Material and methods. At base of dates in present paper is daily evidence from consultation registers of donors, centralization situations on group of age and sex daily, monthly, quarterly and yearly and programs of recording dates. Results. Growing in time number of faithfully donors and particularly in this period 2005-2006 number of youth donors with ages from 20 at 30 years. The total number of donors grow gradual from 2000 to 2005 and then it was stabilization around at number 11101 in 2006. From distribution on sex, we see that number of male donors from 2000 at present was more than female donors in 200070%, 2001-69%, 2002-67%, 2003-66% , 2004-64%, 2005-62%, 2006-61% but in time the percent failing from 70%in 2000 at 61% in 2006 and the percent of female donors raise from 30% in 2000 at 39% in 2006. About faithfully donors, percent of male donors failed and female donors raised from 25% in 2000 at 33% in 2006, Total percent of faithfully male and female donors maintaining in last 3 years at 83% of total number. In last time, the number of faithfully donors of group age 31-40 raised what means a great number of youth donors in time group of age 41-50 and 51-62 reduced. In this time, the number of occasionally donors gradual grow. Conclusions. In this time 2000-2006 in CTS Braila. The number of blood donors grow gradual and then it was stabilization at 11101. Total percent of faithfully donors maintaining in last 3 years at 83% of total number. The number of male blood donors is more than female blood donors. From 2000 to 2006 the percent of female donors grow from 25% at 33%. In this time the number of occasionally donors gradual grow. The number of youth donors grow while the number of donors in group of age 4162 fail . Poster INCIDENTS OF BLOOD DONATION IN 2004, 2005AND 2006AT BTC BRAILA E. M. Butnaru , M. Iugulescu ,A.Gitan Blood Transfusion Center Brila, Romania Introduction. There are incidents of blood donation , with low frequency , but present and not negligible lipothymia and low blood pressure. Objective. Studying of incidents of cases of lipothymia and low blood pressure in last years and their causes and realizing one plan of prevention of these incidents. We see a growing incidents of cases of lipothymia and low blood pressure especially to new donors of blood particularly at youth male persons. From 2004 until 2006 these cases low gradual .Conclusions. Growing incidence for new male donors of blood particularly lipothymia. Growing these incidents especially in first days of week and warm days. Poster DISTRIBUTION ON SEX AND AGE FOR NEW BLOOD DONORS WITH HBV AND HCV AT CTS BRAILA IN LAST 7 YEARS M. Iugulescu, C.Babes, G.Antohi, T. Brat Center of Blood Transfusion Braila Introduction. First centers of transfusion appeared in Romania in 1949; and in 1952 to first November establishment the Center of blood transfusion Braila with one physician and two nurses. After 1990 to present in CTS Braila was bring modern equipment ,collection of blood made in close system in plastic bags , discover infectious markers HBV, HCV,HIV, HTLV through testing donor's serum with ELIZA method, discover irregular antibodies, made phenotype in another system except ABO and Rh , dividing blood in six produces, made advertising for voluntary, unremunerated and there is permanent care for improve of quality of produces and services for donors and for hospitals. Objective. This paper has got objective the presents distribution infectious markers HBV and HCV for new blood donors on the group of age and sex, beginning with year 2000. Material and methods. Discovering infectious markers through ELIZA

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method use two kits of work for two consecutive donations, alternative. Results are confirmed at Central Laboratory of Reference for VTS. Results. Total number of donors in 2000-2006 for new donors 7923 (male-5214-HBV 3594,531%, HCV-122-2,340%; female 2709-HBV-139-2,754%,HCV-83-3,064% ).Total HBV-6,285% , HCV2,587%. For total number of donations HBV 498 donors -0,705%-( male -359-0, 508%, female-139-0,197%); HCV -205 donors -0,209%(male -122-0,173%, female-83-0,118%). Conclusions. Of total number of faithfully donations in 2000-2006 are validated 69931 and only 703 invalidated. Poster THE PRESENCE OF IRREGULARS ANTI-ERYTHROCYTE ANTIBODIES FOR BLOOD DONORS AT CTS BRAILAIN 2000-2006 M. Iugulescu, C. Negutu, G. Demergian Blood Transfusion Center Brila, Romania Introduction. Made evidence the irregular anti-erythrocyte antibodies in person's serum is important for preventing hemolytic accidents post - transfusion. Objective. Researching of irregular antibodies in donor's blood , removal of transfusion all bags of plasma with irregular antibodies. Material and methods. For made evidence the presence antibodies we test donor's serum with red cells with know configuration antigenic. There are two stages in the researches irregular antibodies. 1 Finding out(RAI) Coombs Test enzyme aggregate works positive at two successive determinations. 2 Identification (specification settlement) at INHT Bucharest. A) enzymatic test (papayna). B)Coombs test indirect. Results. In this period of 2000-2006 there were 9307 testing made which 53 cases with RAI positive ,44 cases were confirmed of INTH Bucharest. Conclusions. The percentage of RAI positive for blood donors in this time was 0,569%. Poster DISTRIBUTION OF OAB BLOOD GROUPS AND Rh GENOTYPES IN A GROUP OF PEOPLE FROM BUCHARESTAREA M. Radulian, S. Sirian, F. Vladareanu National Institute of Transfusion Hematology, Romania The purpose of the study an attempt to estimate the frequency of OAB blood groups and Rh genotypes by investigation of a group of 6ooo persons. <br/> Material and methods. Subjects: patients with haematological disease, politransfused people, pregnant women, their husbands and newborns. <br/> Methods: haemaglutination on the plate using different series of commercial blood group serum (DiaMed, BioRad) and column haemagglutination micromethods (DiaMed, BioVue, ScanGel). <br/> Results: the frequency of ABO blood groups: group O = 34,72%, group A=44,12% (subgroup A1=37,29%, subgroup A2=6,82%), group B=14,36%, group AB=6,17% (subgroup A1BB=5,12%, subgroupAB=1,05). <br/> The frequencyof Rh genotypes: Dccee=31,15%, DCCee=2o,2l%, ddccee=15,83%, DccEe=14,3o%, DccEe= 11,7o%, Dccee=2,8o%, dccEe=1,09%, dCcee=1,03%, DccEE=1,03%, dCCee=0,24%, dccEE=0,23%, dCcEe=0.12%, DCCEe=0,12%.<br/> Conclusions: Our results are approximatively in correlation with the data from literature for our geographical area. However some various can be explained by the peculiarities of our investigated group of people. <br/>. Poster IMMUNOHEMATOLOGICALTESTINGS WITH MAGNETIZED-ERYTHROCYTES S.Sirian, M. Radulian, F. Vldreanu National Institute of Transfusion Hematology, Romania Background: immunohematological testings with magnetized erythrocytes (Diagast, Freelys) is a microplate method for blood grouping and antibody screening. In this technology red cells are coated with magnetic particles, which

allowed their rapidly sedimentation when they are placed on a magnet replacing the centrifugation. Methods, reagents: ABO and RhD blood grouping, RhK fenotyping, and antibodies screening by Indirect Antiglobulinic Test (IAT) with anti IgG serum, with Diagast FreelysNano Workstation, comparatively with DiaMed as routine laboratory technology. Results: The same results in ABO, RhD, RhK phenotyping. In antibody screening, IAT with anti IgG serum, detected some clinical significant IgG class antibodies such as anti D, anti D+C, antiD+E, anti Kell, anti M. Conclusion. Diagast Freelys Nano Workstation is useful in pretransfusional testings for the increasing of the transfusional safety. Poster ANTI-RED CELLSANTIBODIES FREQUENCY IN BLOOD DONORSAT BTS CLUJ-NAPOCAIN 2006 C. Zdrenghea, E. Chiorean Blood Transfusion Center - Cluj, Romania Introduction: In order to ensure the transfusion safety from immunohaematologic point of view, in compliance with the domestic and international laws, and besides the determination/verification of the OAB/RhD group all blood donors are submitted to a routine checking of the irregular anti-red cell antibodies. Material and methods: In 2006 the presence of irregular anti-red cell antibodies have been tested on 16248 blood donors. The methods used have been: haemaglutination in liquid stage, as well as micromethod of haemaglutination in gel with DiaMed and ScanGel reagents. Results: A number of 242 donors (1,5%) proved the presence of the irregular anti-red cell antibodies. Antibodies have been identified in 80 blood donors with following results: anti Rhesus antibodies 34 (42,5%); antiLewis antibodies 35 (43,75%); anti-Kell antibodies 3 (3,75%); anti-papain 4 (5,0%); anti-Duffy 1 (1,25%); auto antibodies 3 (1,25%). Conclusions: Even the frequency of the irregular anti-red cell antibodies is reduced (1,5%), the identification of the presence of antibodies with great significance for the blood transfusion (e.g. anti-D) reveals the importance of these tests, contributing to prevent the post transfusion reactions of incompatibility and alloimmunization.