- Email: [email protected]
Helicobacter pylori in primary gastric non-Hodgkin's lymphoma
Abstracts / Netherlands Journal of Medicine 48 (1996) A5 I-A 100 1990. In this cohort we studied the incidence of central nervous system (CNS) involvement and the potential role of CNS prophylaxis, including high-dose ARA-C (HDara-C). Potential risk factors for CNS relapse were assessed. CNS prophylaxis consisted of MTX i.t., HDara-C or both. HDara-C was given in the VAAP (2 g / m 2 days 1-6) and DHAP (4 g / m 2 day 2) regimens. Median follow-up was 30 months; 297 patients have died. Thirty-two NHL patients had CNS involvement at diagnosis (21 patients with primary CNS NHL and 11 with both CNS and systemic NHL) and are not included in this analysis. Fifty-five patients (10%) had a CNS relapse during follow-up (4 isolated CNS relapse and 51 with also systemic relapse). Over-all risk of CNS relapse was 25% ( 9 / 3 8 patients) for all high-grade and 12% (35/285 patients) for intermediate-grade NHL patients. Six patients initially presented with low-grade NHL but progressed or transformed into higher grades as CNS involvement presented. In the HG NHL group, CNS relapse occurred within the first 12 months, contrary to the intermediate-grade NHL with CNS relapses till 54 months after diagnosis. Out of all intermediate- and high-grade NHL patients (323), 69 (21%) received any combination of CNS prophylaxis. Of these, 15 (22%) suffered a CNS relapse. Analysis per malignancy grade disclosed that 8 out of 40 (20%) intermediate NHL patients and 7 out of 29 (24%) high-grade NHL patients had not been protected. In the 251 patients high and intermediate grade NHL patients together who did not receive prophylaxis the CNS relapse rate was 11%. The survival was extremely short after CNS relapse with a median of 2 months and parallelled a rapidly progressive systemic relapse. Risk factors for CNS relapse were histology (high-grade malignancy), nodal involvement combined with extranodal disease, extensive disease, testis localization and young age ( < 35 years). Bone marrow involvement or extranodal lymphoma per se were not separate risk factors. Preliminary conclusions: (1) Although 78% of patients who had received CNS prophylaxis were protected, further subgroup analysis is necessary to show if this treatment modality adds any benefit to patients with intermediate- and high-grade malignancy. (2) CNS relapse occur early (within 12 months) after initial diagnosis in patients with high-grade NHL, but are observed till 54 months in patients with intermediate grade NHL. (3) Most patients with CNS relapse present with systemic disease at the same time or shortly after. Over-all survival after CNS relapse is extremely short. (4) Risk factors for CNS relapse in NHL patients are high-grade NHL, testis localization, combined nodal and extranodal disease, young age and extensive disease.
12. Endocrine effects of transfusional iron overload in patients with haematoiogical malignancies. J.W.J. van Esser, A.C. Nieuwenhuijzen Kruseman, H.C. Schouten. Department of Inter-
nal Medicine, University Hospital. Maastricht, Netherlands. Although the endocrinological implications of haemosiderosis in chronic haemolytic anaemias are well "known, there are no endocrinological data on iron overload induced by transfusions given in a short time-frame. We therefore examined the influence of transfusional iron overload on the hypothalamus-pituitary-end organ (thyroid, adrenals, gonads) axis in patients with haematological malignancies and a ferritin level of 1000 / x g / m l or more. Patients with pre-existing endocrine abnormalities, active
A55
leukaemia, infection or use of iron chelators were excluded. Blood samples were drawn to determine transferrin, iron, fasting glucose level (3 times) and Hbalc. Furthermore, thyrotropin-releasing hormone (TRH), gonadotropin-releasing hormone (GnRH) and corticotropin-releasing hormone (CRH) tests were performed. Ten patients (6 males and 4 females) with a median age of 65 years (range 22-72) were included in this study. Two patients had acute leukaemia in complete remission, 1 patient had chronic lymphocytic leukaemia (RAI classification IV, without haemolysis), 1 patient had chronic myelofibrosis, 1 patient had aplastic anaemia and 5 had a myelodysplastic syndrome. On average they had received 79.2 transfusion units during 36.2 months resulting in a median ferritin level of 1700 # g / m l (range 1123-7135 p~g/ml) and median calculated transferring saturation of 82% (range 40114%). One patient developed diabetes mellitus requiring oral medication and 2 patients developed subclinical primary hypothyroidism (normal FI'4, elevated TSH). Only 5 patients could undergo TRH, GnRH and CRH testing; the others refused or had died in the meantime. No abnormalities were observed in the thyroid axis. One patient had tertiary insufficiency in both adrenal and gonadal axes. Another patient had signs of diminished hypothalamic reserve in both adrenal and gonadal axes. One patient only had a diminished hypothalamic gonadal reserve. Two patients had no abnormalities. Conclusion: Transfusional iron overload in patients with haematological malignancies can cause hypothalamic (tertiary) adrenal and gonadal diminished reserve or insufficiency after a relatively short transfusion time. In addition, subclinical primary hypothyroidism was observed in 2 patients. Whether these observations are merely iron-overload-induced or age-dependent remains to be examined.
13. Helicobacter pylori in primary gastric non-Hodgkin's lymphoma. I.A.M. Gisbertz, D.M. Jonkers, J.W. Arends, R.W. Stockbriigger, H.C. Schouten. Departments of Internal Medicine, Microbiology and Pathology, University Hospital, Maastricht, Netherlands. Gastric-mucosa-associated lymphoid tissue (MALT) tumours develop possibly in response to local infection by Helicobacter pylori (Hp). We investigated the presence of Hp and non-HP intragastric bacterial flora in 26 patients with primary gastric lymphoma, classified as low (9 cases) or high grade histology (17 cases). Serial sections were stained with haematoxylin-eosin, modified Giemsa, and in addition immunohistochemically with a specific polyclonal antibody directed against Hp. Fourteen patients (54%) showed presence of Hp in the mucosa surrounding the tumour. In the tumour no presence of Hp was found. Remarkable was the localisation of Hp in 3 cases, in which Hp was not found in the superficial epithelial layers, but deep in the epithelium. In 16 patients (61%), other bacteria (non-Hp) were seen. In the low-grade tumours we saw Hp in 67% and non-Hp in 44% of the cases. In the high-grade tumours we saw Hp in 47% and other bacteria in 71% of the cases. The percentage of Hp-positive cases in our study (54%), is lower than that reported in the literature (about 90%). This may be the result of a more specific staining method in our study, in contrast with others who therefore may overestimate the presence of lip.
A56
Abstracts~Netherlands Journal of Medicine 48 (1996) A51-AIO0
Conclusions: (1) Using a specific staining technique for Hp, only about half of the cases of gastric lymphomas are positive for Hp. which is also the prevalence of Hp in the normal population, as assessed by serological studies. (2) Hp is found in a similar frequency in low- and high-grade primary gastric lymphoma. (3) Our results suggest that non-Hp bacterial flora may play a role in the development of primary gastric lymphoma.
14. Analysis of the incidence of a mutation of factor V in patients with thromboembolic disease and the predictive value of the APTT-APC assay. P.H.M. van Golde, W.W. van Solinge, R.J. Kraaijenbagen, M.H.H. Kramer. Departments of Internal Medicine and Clinical Chemistry, Eemland Hospital, Location "De Lichtenberg". Amersfoort, Netherlands. Venous thrombosis is often inherited, indicating genetic risk factors to be involved. Recently inherited resistance to the anticoagulant action of activated protein C (APC), as a result of a mutation in the factor V gene (factor V-Leiden), was shown to be a major factor involved in thrombophilia. The routinely used method to assess this resistance is the measurement of an impaired response of the activated partial thromboplastin time (APTT-APC) assay to the addition of activated protein C (Coatest, APC Resistance Chromogenix AB) and is expressed as APC-sensitivity ratios (APC-SR), defined as APTT ( + APC) divided by APTT ( - APC). A prospective study was performed over a period of 2 years to assess the incidence of the inherited mutation of the factor V gene and the predictive value of the APTT-APC assay in patients with proven thromboembolism. Venous thrombosis was evaluated by echo-Doppler a n d / o r phlebography a n d / o r ventilation-perfusion scintigraphy. So far 181 patients have been analyzed, excluding cases with deficiency of antithrombin Ill, protein C and protein S. In these patients both the APTY-APC method and DNA analysis were performed using a PCR assay with additional restriction enzyme analysis to detect hetero- or homozygote patients with the factor V-Leiden mutation. Thromboembolism was diagnosed in 138 patients: venous thrombosis in 87 patients (63%), lung embolism in 20 patients (14.5%) and both thrombosis and lung embolism in 31 patients (22.5%). In this cohort 25 patients have already been treated with anticoagulant therapy. This group showed unreliabe APTT-APC results. PCR analysis revealed 4 patients (16%) to be heterozygotes for factor V-Leiden. From the remaining group of 113 patients, 64 cases had an impaired response in the AFIT-APC assay ( < 2.2 APC-SR), but only 25 cases (39%) showed the factor V-Leiden mutation with PCR analysis. In 4 (8%) out of 49 patients with a normal APTT-APC result ( > = 2.2 APC-SR) a heterozygote factor-VLeiden mutation could be proven. The 43 patients without proven thromboembolism were used as a control group. PCR analysis showed 3 cases (7%) with the factor V-Leiden mutation. Conclusion: These data suggest that a routinely used and standardized APTT-APC assay to detect APC resistance does not correlate with the underlying genetic mutation as can be detected with PCR and restriction enzyme analysis in patients with and without anticoagulant therapy. Therefore, to detect APC resistance, DNA analysis with PCR is advised as the superior assay.
15. Do LP(a) levels fluctuate within the circadian rhythm of fibrinolysis? P.H.M. van Golde, N.J.P. Borst, J.P. Wielders, H.Ch. Hart, A. van de Wiel. Departments of Internal Medicine
and Clinical Chemistry, Eemland Hospital, Location "De Lichtenberg", Amer~Jbort, Netherlands. Introduction: Lp(a) is a risk factor for coronary artery and peripheral vascular disease. Lp(a) is a form of low-density lipoprotein (LDL). Which surface apo-B is attached to a glycoprotein called apo(a). Apo(a) resembles plasminogen. Though apo(a) cannot be activated by the plasminogen activators t-PA and u-PA, an inhibition of fibrinolysis by Lp(a) has been demonstrated in vitro. It is postulated that Lp(a) inhibits fibrinolysis by preventing the formation of the complexes of t-PA, plasminogen and fibrin(ogen) (fragments). This effect might be due to the resemblance of the apo(a) component of Lp(a) to plasminogen, resulting in a competition of Lp(a) with plasminogen for binding to fibrin. Fibrinolysis exhibits a circadian rhythm over the day. Fibrinolytic activity peaks in the late afternoon and evening and reaches the lowest level in the early morning. This phenomenon may contribute to the high proportion of heart attacks in the early morning. Aim of the study: We want to ascertain if a circadian rhythm of Lp(a) exists, contributing to the decrease of fibrinolytic activity in the morning and resulting in the peak of coronary vascular events. Lp(a) levels and several fibrinolytic parameters (t-PA, PAI-I, PAP-complexes) were studied in 6 healthy, non-smoking male volunteers, aged 25-30 years at time: 09.00 h, 15.30 h, 23.00 h and the following day at 09.00 h. All restrained from alcohol for 1 week and received standardized metals. Results: During the day fibrinolytic parameters were as follows at 09.00, 15.30, 23.00 and 09.00 expressed as percentage of control (09.00 is 100%): t-PA activity: 127.0 +- 45.5%, 110.5__+ 34.1%, 91.1 ___32.4%; t-PA antigen: 77.7_+ 11.0%, 65.6_+ 13.4%, 79.4_+11%; PAl-activity: 84.2_+31.5%, 69.1+-55.8%, 97.7+ 69.3%; PAl-antigen: 38.9 _+8.7%, 38.2 +_ 19.0%, 110.4 _+72.0%; PAP: 115.2+_ 8.5%, 110.7+ 11.2%, 90.8_+ 18.5%; Lp(a): 105.7_+ 6.0%, 94.3+_ 17.1% and 99.7+_31.5%. Conclusion: In contrast to other parameters of fibrinolysis no circadian rhythm of Lp(a) could he demonstrated. Though Lp(a) might inhibit fibrinolysis in vitro, there are no arguments that fluctuations in Lp(a)-concentrations over the day contribute to a thrombogenic state in the early morning and the resulting peak of coronary vascular events.
16. In vivo proliferation characteristic of reactive T-lymphocytes in B-cell non-Hodgkin's lymphoma (NHL). G. Goverde, J. Raemaekers, A. Pennings, J. Bogman l, j. Boezeman, H. Wessels, T. de Witte. Departments of Haematology and Pathology 1, University Hospital St. Radboud, Nijmegen, Netherlands. Flow cytometric analysis of cell cycle kinetics in overall cell suspensions of tumour samples may produce inaccurate results due to admixture of normal reactive cells. In B-cell NHL, normal reactive T-lymphocytes are numerous and even exceed the number of malignant B-cells. We have therefore analysed the proliferation characteristics of T-cells after in vivo pulse labelling with the thymidine analogue, iododeoxyuridine (ldUrd). Nineteen lymph node samples of B-cell NHL were processed to cell suspensions, positively sorted with CD19 for B-cells and CD3 for
12. Endocrine effects of transfusional iron overload in patients with haematoiogical malignancies. J.W.J. van Esser, A.C. Nieuwenhuijzen Kruseman, H.C. Schouten. Department of Inter-
nal Medicine, University Hospital. Maastricht, Netherlands. Although the endocrinological implications of haemosiderosis in chronic haemolytic anaemias are well "known, there are no endocrinological data on iron overload induced by transfusions given in a short time-frame. We therefore examined the influence of transfusional iron overload on the hypothalamus-pituitary-end organ (thyroid, adrenals, gonads) axis in patients with haematological malignancies and a ferritin level of 1000 / x g / m l or more. Patients with pre-existing endocrine abnormalities, active
A55
leukaemia, infection or use of iron chelators were excluded. Blood samples were drawn to determine transferrin, iron, fasting glucose level (3 times) and Hbalc. Furthermore, thyrotropin-releasing hormone (TRH), gonadotropin-releasing hormone (GnRH) and corticotropin-releasing hormone (CRH) tests were performed. Ten patients (6 males and 4 females) with a median age of 65 years (range 22-72) were included in this study. Two patients had acute leukaemia in complete remission, 1 patient had chronic lymphocytic leukaemia (RAI classification IV, without haemolysis), 1 patient had chronic myelofibrosis, 1 patient had aplastic anaemia and 5 had a myelodysplastic syndrome. On average they had received 79.2 transfusion units during 36.2 months resulting in a median ferritin level of 1700 # g / m l (range 1123-7135 p~g/ml) and median calculated transferring saturation of 82% (range 40114%). One patient developed diabetes mellitus requiring oral medication and 2 patients developed subclinical primary hypothyroidism (normal FI'4, elevated TSH). Only 5 patients could undergo TRH, GnRH and CRH testing; the others refused or had died in the meantime. No abnormalities were observed in the thyroid axis. One patient had tertiary insufficiency in both adrenal and gonadal axes. Another patient had signs of diminished hypothalamic reserve in both adrenal and gonadal axes. One patient only had a diminished hypothalamic gonadal reserve. Two patients had no abnormalities. Conclusion: Transfusional iron overload in patients with haematological malignancies can cause hypothalamic (tertiary) adrenal and gonadal diminished reserve or insufficiency after a relatively short transfusion time. In addition, subclinical primary hypothyroidism was observed in 2 patients. Whether these observations are merely iron-overload-induced or age-dependent remains to be examined.
13. Helicobacter pylori in primary gastric non-Hodgkin's lymphoma. I.A.M. Gisbertz, D.M. Jonkers, J.W. Arends, R.W. Stockbriigger, H.C. Schouten. Departments of Internal Medicine, Microbiology and Pathology, University Hospital, Maastricht, Netherlands. Gastric-mucosa-associated lymphoid tissue (MALT) tumours develop possibly in response to local infection by Helicobacter pylori (Hp). We investigated the presence of Hp and non-HP intragastric bacterial flora in 26 patients with primary gastric lymphoma, classified as low (9 cases) or high grade histology (17 cases). Serial sections were stained with haematoxylin-eosin, modified Giemsa, and in addition immunohistochemically with a specific polyclonal antibody directed against Hp. Fourteen patients (54%) showed presence of Hp in the mucosa surrounding the tumour. In the tumour no presence of Hp was found. Remarkable was the localisation of Hp in 3 cases, in which Hp was not found in the superficial epithelial layers, but deep in the epithelium. In 16 patients (61%), other bacteria (non-Hp) were seen. In the low-grade tumours we saw Hp in 67% and non-Hp in 44% of the cases. In the high-grade tumours we saw Hp in 47% and other bacteria in 71% of the cases. The percentage of Hp-positive cases in our study (54%), is lower than that reported in the literature (about 90%). This may be the result of a more specific staining method in our study, in contrast with others who therefore may overestimate the presence of lip.
A56
Abstracts~Netherlands Journal of Medicine 48 (1996) A51-AIO0
Conclusions: (1) Using a specific staining technique for Hp, only about half of the cases of gastric lymphomas are positive for Hp. which is also the prevalence of Hp in the normal population, as assessed by serological studies. (2) Hp is found in a similar frequency in low- and high-grade primary gastric lymphoma. (3) Our results suggest that non-Hp bacterial flora may play a role in the development of primary gastric lymphoma.
14. Analysis of the incidence of a mutation of factor V in patients with thromboembolic disease and the predictive value of the APTT-APC assay. P.H.M. van Golde, W.W. van Solinge, R.J. Kraaijenbagen, M.H.H. Kramer. Departments of Internal Medicine and Clinical Chemistry, Eemland Hospital, Location "De Lichtenberg". Amersfoort, Netherlands. Venous thrombosis is often inherited, indicating genetic risk factors to be involved. Recently inherited resistance to the anticoagulant action of activated protein C (APC), as a result of a mutation in the factor V gene (factor V-Leiden), was shown to be a major factor involved in thrombophilia. The routinely used method to assess this resistance is the measurement of an impaired response of the activated partial thromboplastin time (APTT-APC) assay to the addition of activated protein C (Coatest, APC Resistance Chromogenix AB) and is expressed as APC-sensitivity ratios (APC-SR), defined as APTT ( + APC) divided by APTT ( - APC). A prospective study was performed over a period of 2 years to assess the incidence of the inherited mutation of the factor V gene and the predictive value of the APTT-APC assay in patients with proven thromboembolism. Venous thrombosis was evaluated by echo-Doppler a n d / o r phlebography a n d / o r ventilation-perfusion scintigraphy. So far 181 patients have been analyzed, excluding cases with deficiency of antithrombin Ill, protein C and protein S. In these patients both the APTY-APC method and DNA analysis were performed using a PCR assay with additional restriction enzyme analysis to detect hetero- or homozygote patients with the factor V-Leiden mutation. Thromboembolism was diagnosed in 138 patients: venous thrombosis in 87 patients (63%), lung embolism in 20 patients (14.5%) and both thrombosis and lung embolism in 31 patients (22.5%). In this cohort 25 patients have already been treated with anticoagulant therapy. This group showed unreliabe APTT-APC results. PCR analysis revealed 4 patients (16%) to be heterozygotes for factor V-Leiden. From the remaining group of 113 patients, 64 cases had an impaired response in the AFIT-APC assay ( < 2.2 APC-SR), but only 25 cases (39%) showed the factor V-Leiden mutation with PCR analysis. In 4 (8%) out of 49 patients with a normal APTT-APC result ( > = 2.2 APC-SR) a heterozygote factor-VLeiden mutation could be proven. The 43 patients without proven thromboembolism were used as a control group. PCR analysis showed 3 cases (7%) with the factor V-Leiden mutation. Conclusion: These data suggest that a routinely used and standardized APTT-APC assay to detect APC resistance does not correlate with the underlying genetic mutation as can be detected with PCR and restriction enzyme analysis in patients with and without anticoagulant therapy. Therefore, to detect APC resistance, DNA analysis with PCR is advised as the superior assay.
15. Do LP(a) levels fluctuate within the circadian rhythm of fibrinolysis? P.H.M. van Golde, N.J.P. Borst, J.P. Wielders, H.Ch. Hart, A. van de Wiel. Departments of Internal Medicine
and Clinical Chemistry, Eemland Hospital, Location "De Lichtenberg", Amer~Jbort, Netherlands. Introduction: Lp(a) is a risk factor for coronary artery and peripheral vascular disease. Lp(a) is a form of low-density lipoprotein (LDL). Which surface apo-B is attached to a glycoprotein called apo(a). Apo(a) resembles plasminogen. Though apo(a) cannot be activated by the plasminogen activators t-PA and u-PA, an inhibition of fibrinolysis by Lp(a) has been demonstrated in vitro. It is postulated that Lp(a) inhibits fibrinolysis by preventing the formation of the complexes of t-PA, plasminogen and fibrin(ogen) (fragments). This effect might be due to the resemblance of the apo(a) component of Lp(a) to plasminogen, resulting in a competition of Lp(a) with plasminogen for binding to fibrin. Fibrinolysis exhibits a circadian rhythm over the day. Fibrinolytic activity peaks in the late afternoon and evening and reaches the lowest level in the early morning. This phenomenon may contribute to the high proportion of heart attacks in the early morning. Aim of the study: We want to ascertain if a circadian rhythm of Lp(a) exists, contributing to the decrease of fibrinolytic activity in the morning and resulting in the peak of coronary vascular events. Lp(a) levels and several fibrinolytic parameters (t-PA, PAI-I, PAP-complexes) were studied in 6 healthy, non-smoking male volunteers, aged 25-30 years at time: 09.00 h, 15.30 h, 23.00 h and the following day at 09.00 h. All restrained from alcohol for 1 week and received standardized metals. Results: During the day fibrinolytic parameters were as follows at 09.00, 15.30, 23.00 and 09.00 expressed as percentage of control (09.00 is 100%): t-PA activity: 127.0 +- 45.5%, 110.5__+ 34.1%, 91.1 ___32.4%; t-PA antigen: 77.7_+ 11.0%, 65.6_+ 13.4%, 79.4_+11%; PAl-activity: 84.2_+31.5%, 69.1+-55.8%, 97.7+ 69.3%; PAl-antigen: 38.9 _+8.7%, 38.2 +_ 19.0%, 110.4 _+72.0%; PAP: 115.2+_ 8.5%, 110.7+ 11.2%, 90.8_+ 18.5%; Lp(a): 105.7_+ 6.0%, 94.3+_ 17.1% and 99.7+_31.5%. Conclusion: In contrast to other parameters of fibrinolysis no circadian rhythm of Lp(a) could he demonstrated. Though Lp(a) might inhibit fibrinolysis in vitro, there are no arguments that fluctuations in Lp(a)-concentrations over the day contribute to a thrombogenic state in the early morning and the resulting peak of coronary vascular events.
16. In vivo proliferation characteristic of reactive T-lymphocytes in B-cell non-Hodgkin's lymphoma (NHL). G. Goverde, J. Raemaekers, A. Pennings, J. Bogman l, j. Boezeman, H. Wessels, T. de Witte. Departments of Haematology and Pathology 1, University Hospital St. Radboud, Nijmegen, Netherlands. Flow cytometric analysis of cell cycle kinetics in overall cell suspensions of tumour samples may produce inaccurate results due to admixture of normal reactive cells. In B-cell NHL, normal reactive T-lymphocytes are numerous and even exceed the number of malignant B-cells. We have therefore analysed the proliferation characteristics of T-cells after in vivo pulse labelling with the thymidine analogue, iododeoxyuridine (ldUrd). Nineteen lymph node samples of B-cell NHL were processed to cell suspensions, positively sorted with CD19 for B-cells and CD3 for