Reviews in clinical and experimental hematology最新文献

Until recently, concerns regarding viral infections and hematologic malignancies were primarily focused on the transplantation of an allogeneic graft. In the last years, the use of immunomodulatory agents such as monoclonal antibodies (e.g. anti CD20, anti CD52) directed against lymphocyte antigens in the treatment of hematopoietic malignancies (e.g. lymphoma, chronic lymphocytic leukemia) has added a great potential to impact on the incidence, severity and timing of viral infections. Patients may acquire viral infections through several mechanisms including transfusion, community exposure or via the donor origin in the case of stem cell transplant. Endogenous reactivation of latent viruses is also commonly observed. Viral replication may lead directly to viral diseases or induce indirect effects such as increased incidence of opportunistic infections and decreased patient survival. Traditionally, herpesviruses have been and are still today the most important viruses in patients with hematologic malignancies. Nowadays, several emerging viral infections have been highlighted as being of concern in this patients' population.

Bacterial infections in patients with hematologic malignancies still represent a severe and life-treating problem. Several observational studies during the last decade have revealed that neutropenic patients with fever are a heterogeneous population with various differences regarding response to initial therapy, development of serious complications and mortality. The role of neutropenia as main risk factor for infections in hematologic patients and the definition of different level of risk related to neutrophils count and duration of neutropenia have been extensively studied and different categories of patients based on the risk of infection, mostly the condition of neutropenia, have been clearly defined. The strategies on antimicrobial therapy and supportive care in hematologic patients need to be continuously assessed, in fact new conditions favouring the occurrence of infectious complications in patients with hematologic malignancies have progressively emerged. The use of oral prophylactic antibiotics in neutropenic cancer patients is still a matter of debate. Before 2005, several trials showed how the prevention of infection can be extremely important in this setting of patients but none was conclusive. In 2005 two meta-analysis and two large randomized clinical trials gave new evidence that antibacterial prophylaxis can reduce in neutropenic patients several important outcomes including mortality. The use of the empiric antibacterial therapy represents the cornerstone of the antimicrobial strategies in the febrile neutropenic patients leading, over the span of 20 years, to a dramatic decrease of deaths: Actually beta-lactam monotherapy is commonly used for the empiric treatment of febrile neutropenia. Recently, large randomized clinical trials and meta-analysis showed that the addition of an aminoglycoside and/or a glycopeptides results in a more favourable outcome only in selected severe infections. The use of antibiotics should be prudent and safe also in neutropenic hematologic patients to prevent emergence of microbial resistance, to save costs, to reduce toxicity. For this reasons, according to the evidence, antibacterial prophylaxis should be restricted to high risk hematologic patients and empiric parenteral antibiotic monotherapy should be recommended in case of febrile neutropenia limiting the use of amynoglicosides and glycopeptides. In the next future, a major effort should be made to state in hematologic patients new risk factors which could more accurately define subgroups for targeted anti-infective strategies.

Opportunistic infections have always been pitfalls on the road of progress in the treatment of diseases that are accompanied by compromised host defences. Because of the severe morbidity and mortality associated with these infections, they have become substantial challenges for the clinicians who offer such patients care. With medical progress, the number of immunocompromised patients is still steadily climbing and it has become evident that deficiencies in host defences mechanisms are multiple as well as changing in harmony with alterations in treatment modalities for underlying diseases. Under normal circumstances, the intact epithelial surfaces of the gastrointestinal tract will prohibit invasion by micro-organisms and the mucociliary barrier of the respiratory tract prevents aspiration of fungal cells and spores, while, in contrast, dead or damaged tissue creates a nidus for infection. It is, however, questionable whether transmigration of organisms inevitably leads to infection. With the growing use of potent immunosuppressive purine analogues, fludarabine, pentostatin and cladibrine, and anti-T and anti-B cell antibodies, such as rituximab and campath, in the management of lymphoreticular malignancies, in combination with increasing emphasis on dose intensity, the number of patients at risk has almost reached levels encountered in recipients of allogenic stem cell grafts as a consequence of long-lasting deficiencies in the cellular immunity. The spectrum of opportunistic pathogens are shifting as anti-leukemic and anti-lymphoma therapy become more intensive and bone marrow transplant practices evolve. Recent studies demonstrate, that patients treated with nonmyeloablative allogeneic transplantation (or "minitransplants") to reduce transplant-related toxicity, are at high risk of contracting a serious infections. Initially bacterial infections were most problematic. However, as strategies to control bacterial infections improved, viruses demanded more attention from the clinicians but the associated morbidity declined due to advances in rapid diagnostics and the introduction of effective antivirals such as acyclovir and ganciclovir. Next to viruses, resistant bacteria, particularly Gram-positive organisms like enterococci and methicillin-resistant staphylococci urged to vigilance. It was obvious that enhanced use of antibacterials inevitably will be accompanied by selection and induction of resistant organisms. Today, opportunistic fungi have become the most frequent and dangerous pathogens. Since the 1980's the rate of nosocomial invasive fungal diseases has doubled without any sign of slowing at the turn of the millenium. During the past decades we have even observed an increased incidence of invasive fungal infections in patients who are not in an end stage of their underlying disease. Yeasts and moulds rank amongst the most frequently isolated pathogens. The relative incidence of the various fungal infections depends on geography a

The biologic, clinical and therapeutic setting is nowadays such that risk factors for infectious complications are constantly changing and progressively increasing in patients suffering from onco-hematologic conditions. In addition to situations that are well known or that are gradually being recognized related both to the underlying disease and to treatment, such as neutropenia, neutrophil dysfunction, mucosal damage, concomitant monocytopenia and lymphopenia, abnormalities within the host cellular and humoral compartments, impairments in cytokine networks, alterations in T lymphocytes/tumor interactions, crosstalks between neoplastic cells and accessory cells, etc, over the last few years we are witnessing important changes in the overall management of patients with hematologic malignancies. Historically, the categories at risk were represented by patients with acute leukemia and patients undergoing an allogeneic stem cell transplant. In both, the likelihood of eradicating the disease requires necessarily a myeloablative therapeutic strategy, complicated in the allografted patients by the risks of graft-versus-host disease (GvHD), the required immunosuppressive treatment and the recently documented role that cytokines may play in the development of acute GvHD. Considerable changes have occurred in recent years. From the identification of "new" diseases at risk (e.g. lymphomas occurring in HIV+ individuals), to the progressive and constant increase in allotransplant procedures, to the development of new transplant procedures (cord blood, matched-unrelated or mismatched donor transplant, mini-transplant, the administration of donor lymphocytes), to the development of new drugs that can induce immunosuppression, to the clinical use of certain monoclonal antibodies (MoAb), to the combined use of chemotherapy plus MoAb. These developments are associated with other general considerations. Within these: 1) the growing use of ablative therapies in diseases for which for many years the approach has been less aggressive or indeed conservative; 2) the progressive recognition of categories of patients with unfavorable prognosis for whom an aggressive approach is required; 3) the constant improvement in mean life expectancy and "biologic" age of patients; thus, the progressive changes in the definition of "old age". Taken together, this has led, on the one hand, to an increase in the categories of onco-hematologic patients at risk of infective complications and to a major focus on the immune compartment of the affected patients, and, on the other hand, to an overall broadening of the infective scenario.

Myeloid leukemias are clonal hematopoietic stem cell disorders characterized either by proliferation of one or more of the myeloid lineages (chronic myelogenous leukemia) or by clonal expansion of myeloid blasts (acute myeloid leukemia). Over the past several years our knowledge of these hematologic malignancies has increased tremendously. The result is a classification that incorporates morphologic, immunophenotypic, genetic and clinical features in an attempt to define biologically and clinically relevant entities. Nevertheless, in many tumor subtypes the pathogenic event is still unknown. Furthermore, well-defined leukemia subgroups exhibit considerable heterogeneity, arousing the suspicion that several molecularly distinct subtypes might exist within the same cytogenetic category. Therefore, an ideal classification system would ultimately be based on the underlying molecular pathogenesis, but such knowledge is not yet available. However, by surveying the expression levels of thousands of genes in parallel, DNA microarrays have recently contributed to an increasingly refined molecular taxonomy of myeloid disorders. This powerful technology is becoming well established and has been used to diagnosis cancer and predict clinical outcome, to discover novel tumor subclasses, to gain insights into pathogenesis, and to identify new therapeutic targets. While many challenges remain ahead, genomic technologies have already demonstrated tremendous potential. We expect whole genome approaches will significantly contribute to a better understanding of the pathogenesis and result in a refined molecular classification of myeloid leukemias.

The introduction of microarray analysis represents a revolution in the scientific field, allowing to investigate thousand of genes in a single experiment. Important biological insights have been revealed by this technique in several tumors: in acute lymphoblastic leukemia (ALL), these studies have allowed to identify specific patterns associated with known molecular abnormalities, as well as with phenotypic characteristics and with different prognostic features. In chronic lymphocytic leukemia (CLL), this approach has helped to dissect that this disease is a single entity with distinct variants that are characterized by a diverse IgVH mutational status, that can be discriminated by a small set of genes, has allowed to define a similarity between this disease and memory B cells and has also led to hypothesize that CLL cells from IgVH unmutated patients may be continuously stimulated in vivo, thus showing a gene profile that is reminiscent of the B cell receptor. In multiple myeloma (MM), gene expression profiles has provided insights into the disease and has offered the opportunity of stratifying patients according to the degree of aggressiveness of the disease. Current efforts are directed to the identification of patterns that may distinguish patients with a different outcome, thus providing useful prognostic information and to design experiments that may allow the identification of new therapeutic targets.

Cytomorphology and cytochemistry in combination with multiparameter immunophenotyping today are the standard methods for establishing the diagnosis of acute leukemias. In addition, cytogenetics, fluorescence in situ hybridization, and polymerase chain reaction based assays provide important information regarding biologically defined and prognostically relevant subgroups and allow a comprehensive diagnosis of well defined subentities. With regard to the clinical setting a better understanding of the clinical course of distinct biologically defined disease subtypes is needed to select disease-specific therapeutic approaches. Paralleling the increase in knowledge on deregulated pathways in leukemia the development of new therapeutics is accelerated and therefore requires a detailed and comprehensive diagnostic tool. Revealing and quantifying the expression status of many ten thousands of genes in a single analysis the microarray technology holds this potential to become an essential tool for the molecular classification of leukemias. It may therefore be used as a routine method for diagnostic purposes in the near future. Furthermore, it is anticipated that new biologically defined and clinically relevant subtypes of leukemia will be identified based on gene expression profiling. This method may therefore guide therapeutic decisions.

The myelodysplastic syndromes (MDS) are receiving unusual attention recently as great strides have been made in understanding the biology. Recognition that excessive cytokine-induced apoptosis plays a significant role in the cytopenias of the majority of patients opened the doors to anti-cytokine therapy, with thalidomide being used with success in approximately 20% patients. Other therapies that have emerged include the thalidomide analog lenalidomide which is particularly beneficial for 5q- patients as well as a subset of non-5q- patients with low or intermediate-1 risk MDS. Other targeted therapies include vitamins, agents that are cytoprotective, differentiation inducers, anti-angiogenic, or immune modulatory. In addition, inhibitors of proteasome, methylation, histone deacetylation, farnesylation, receptor tyrosine kinases, topoisomerase, and matrix mettaloproteinases have yielded encouraging responses in subsets of patients. Specific therapies have also been developed for genetic abnormalities that lead to fusion genes (TEL-PDGFR-beta, or FIP1L1-PDGFR-alpha), or abnormal proteins due to mutations/functional inactivation (FLT3), dysregulated expression (EVI-1). In a short span of ten years, the field has evolved from having no effective therapy to offer the majority of MDS patients save chemotherapy, to having one FDA approved drug, several on the way to approval, and a number of novel agents producing exciting clinical results. This chapter summarizes the novel targets and targeted therapies in the rapidly evolving therapeutic landscape of MDS.