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Context Autologous peripheral blood stem cell transplant (PBSCT) ideally should be performed in every myeloma patient, but in the elderly, the procedure might be risky because of comorbidities, and the possibility of the organism to fully compensate possible complications. Objective Our main goal was to show that the age limit for autologous PBSCT in myeloma patients can be safely shifted upwards. Design We used conditioning with melphalan, followed by autologous PBSCT for elderly patients with myeloma, using the age limit of 65 years. Setting All patients were transplanted in the bone marrow transplant unit in the University Clinic for Hematology Skopje. They underwent standard post-transplant preventive and prophylactic measures during the period of pancytopenia. Patients or Other Participants We have done a retrospective analysis of patients with MM where autologous SCT was done. The main inclusion criteria was the diagnosis, age over 65, acceptable comorbidity profile. Interventions Mobilizing and harvesting of stem cells, melphalan conditioning, and application of the graft via central venous catheter were standard for all patients. Main Outcomes Measures We evaluated the rates of transplant related mortality (TRM), post-transplant follow-up, complete remission (CR). Results Our analysis of data for 20 years shows that we performed autologous PBSCT on 25 patients with myeloma at the age of 65 or older. 17 males (68%) and 8 female (32%). Average age was 67 years (65-73). All patients received melphalan conditioning. In 23 of the patients, we used non-cryopreserved hematopoietic stem cells. In two patients we performed tandem autologous PBSCT with no major complications. 75% had HTA, 20% some level of cardiomyopathy, 48% diabetes, and 12% with inserted prosthetic aortic valves. Our oldest patient was 73 years old and was still alive 2 years posttransplant. Our transplant related mortality was 0%. Conclusions Autologous PBSCT in elderly myeloma patients can be safe and effective, with careful selection of patients, balancing the risk profile of the patient, and the benefit of the procedure. Affective supportive care, monitoring, and reducing the risk of complications is an imperative to a good result.

Context: Early-stage patients with chronic lymphocytic leukemia (CLL) are diagnosed without need for treatment, managed with following. The distinct course of the disease is diverse, and planning treatment is barely projected at diagnosis. Objective: The aim of the study was first-time evaluation of International Prognostic Score to predict time to first treatment (TFT) in Macedonian patients with early stage CLL (International Prognostic Score for early-stage CLL IPS-E). Design: Retrospective study of asymptomatic patients with CLL at early stage of disease in a period of time from January 2011 to January 2021. The median follow-up was 60 months (1-120 months). Setting: Individual patient data from 120 treatment-naive CLL patients with Binet A stage were analyzed to composed International Prognostic Score for Early-stage CLL and correlated with time to treatment failure (TTF). Interventions: We presented IPS-E using three covariates: unmutated immunoglobulin heavy variable gene (IGHV), absolute lymphocyte count higher than 15 × 109/L, and presence of palpable lymph nodes. The IPS-E was the sum of the covariates (1 point each), and separated low-risk (score 0), intermediate-risk (score 1), and high-risk (score 2-3) patients showing a distinct TFT. Results: Our evaluation has shown that 55% patients were male and 45% were female. Average age was 64 years. Using IPS-E patients were distributed in three groups: low risk with 7, 5%, intermediate risk with 44, 1% and high-risk patients 48, 3%. Average TFS was 29, 3 months for low-risk group; 28, 6 months for intermediate-risk group and 27; 1 months for high-risk group. Using prognostic nomogram, we calculated 5 years probability of survival for low, intermediate, and high-risk group: 73%, 72% and 70% respectively with projected median survival of 9, 1 year for low-risk group and 9, 0 year, 8, 9 years for intermediate and high-risk groups. Conclusions: The IPS-E is a simple prognostic model that predicts the probability of treatment necessity in patients with early-stage CLL.

Context The diagnosis of classic Hodgkin Lymphoma (cHL) appears quite straightforward, as it is built upon extended histological and immunophenotypic assessment. Hodgkin and Reed-Sternberg cells reflect monoclonal cell proliferation, presumably originating from germinal center B-cells. In general, these cells lose the B-cell phenotype, yet one-third of cHL cases express at least one B-cell marker, which in some instances leads to diagnostic difficulties in distinguishing cHL from B-Cell Lymphomas (BCL). Objective We present a diagnostically complex case of cHL CD30+/CD15+ in a 21-year-old male. Immunohistochemistry demonstrated unusual, strong expression of markers of B-cell differentiation and positivity for Epstein-Barr Virus (EBV), which brought out serious constraints in the differential diagnosis of an EBV-positive Diffuse Large BCL. Patient Case Report A previously healthy 21-year-old male presented at our institution with neck lymphadenopathy. He experienced no B-symptoms. Except for a slightly elevated sedimentation rate, blood analyses were within normal ranges. Initial PET-CT scan identified stage II disease involving supradiaphragmatic lymph nodes. Fine needle aspiration of the lymph node was suggestive of HL. However, histological examination of the surgically extirpated lymph node was puzzling. The atypical lymphoid cells expressed classical Hodgkin phenotype CD30+/CD15+, but they showed strong CD20+ co-expression. The tumor cells were strongly positive for EBV, and a diagnosis of EBV-associated BCL was assumed. In addition, high EBV loads in blood were confirmed. PCR studies for B- and T-cell gene rearrangements were negative. The tumor tissue was sent for consultative opinion in three centers independently. Immunostains were consistent; lymphoma cells were strongly positive for CD30, CD15, EBV, and EBV receptor CD21, as well as the B-cell markers CD20, Bcl-6, and MUM1. Finally, next-generation sequencing for B-cell rearrangement was negative. In absence of sufficient diagnostic criteria for EBV-positive BCL and all things considered, the diagnosis of classic HL was concluded. Conclusions In consensus with reported literature, treatment was initiated with R-ABVD regimen. Complete regression of tumor masses became evident after the first cycle. An interim PET scan is planned for further evaluation.

Context: Plasmacytoid Dendritic Cells (pDCs) are hematopoietic, type 1 interferon-producing cells. Neoplastic expansion of these cells is very rare and is classified into two different malignancies: Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) and mature pDC proliferation associated with myeloid neoplasia. Objective: We present here a diagnostically challenging case of pDC proliferation associated with AML, with an unusual occurrence in a young 26-year-old male. This patient achieved complete remission with an ALL-based chemotherapy regimen in combination with a Bcl-2 inhibitor. Patient Case Report: A 26-year-old man presented to our clinic with a 1-month history of weakness, malaise and myalgia. Blood counts and peripheral blood smear showed normocytic anemia (Hb 103 g/L) and leukopenia (WBC 2.4 x 103 μ/L) with dominant lymphocytosis, which progressed to severe leukopenia (WBC 0.8 x103 μ/L) and thrombocytopenia (PLT 18 x 103 μ/L) in two weeks. Bone marrow biopsy was performed, indicating metastatic nasopharyngeal carcinoma. He underwent detailed ORL examination, and except for nodular lymphoid tissue in the epipharynx, no other abnormalities were observed. Additionally, MRI of the neck showed normal findings. We did a second bone marrow biopsy with bone marrow aspiration. Immunophenotyping by flow cytometry showed 50% infiltration with cells with weak expression of CD45, no expression of CD34, co-expression of CD4/CD56, presence of HLADR/CD123, and expression of CD33, CD117, and cytoplasmic nTDT, suggesting BDPCN. The histological examination of the bone marrow confirmed the diagnosis, and the immunohistochemical staining excluded neoplasia of ectodermal origin. Still, the patient had no evident cutaneous lesions, organomegaly, nor lymphadenopathy. The bone marrow sample was sent for consultative opinion in a referent center, and based on the negativity of TCL1, the diagnosis of pDCS associated with AML was established. RUNX-1 mutation and other prognostic markers for AML, however, were not detected. The patient achieved complete remission with 2 cycles of Hyper-CVAD plus venetoclax and underwent stem cell transplantation. Conclusions: pDC-myeloid neoplasm should be considered as a differential diagnosis of BPDCN, and more extended immunohistochemical analysis is required for correct diagnosis.

Context Western parts of the Republic of North Macedonia are considered endemic regions for leishmaniasis. Due to the broad spectrum of hematologic manifestations of visceral leishmaniasis (VL), this anthropozoonosis may be occasionally misdiagnosed as a hematological disease. Objective We present here a patient with VL whose initial clinical and laboratory findings mimicked multiple myeloma and led us to series of diagnostic procedures for plasma cell dyscrasia. Patient Case Report A 66-year-old woman presented at our institution with a history of back pain radiating down the legs. Physical examination revealed massive splenomegaly crossing the abdominal midline. Laboratory data showed pancytopenia (Hb 91 g/L; WBC 1.8 x 109/L; PLT 26 x 109/L), and the peripheral blood smear did not show any specific findings. What led us to suspect multiple myeloma was hyperproteinemia (96 g/L) due to hypergammaglobulinemia with IgG monoclonal components (IgG 71.5 g/L). Bone marrow biopsy with bone marrow aspiration was performed, and clusters of atypical plasma cells up to 20% infiltration were noted, further confirming the initial diagnosis. Still, we noted on M-Grunwald-Giemsa-stained bone marrow aspirate smears intra- and extracellular inclusions, resembling leishmaniasis. Additionally, PCR for B-cell gene rearrangement was negative. The diagnosis of VL was reached by a positive leishmania immunofluorescence antibody test. The patient was treated with amphotericin for 10 days with protracted resolution of the symptoms. The complete recovery of the blood counts was noted within three months. Still, monoclonal IgG, although decreased, remained high at the time of last visit (IgG 55 g/L), which is within three months of treatment. Conclusions Although endemic in our country, VL is rarely included in the differential diagnosis for clinicians, especially in cases with atypical clinical presentation. This case underlies the need for hematologists to consider this condition in patients presenting with uncertain yet common hematological abnormalities.

Context Relapsed-Refractory Diffuse Large B Cell Lymphoma (RR DLBCL), which accounts for approximately one-third of patients with DLBCL, remains a major cause of morbidity and mortality. Despite advances in the management of aggressive non-Hodgkin lymphoma, the treatment of relapsed and primary refractory disease continues to be a challenge to the treating hematologist. High-dose chemotherapy (HDT) followed by autologous stem cell transplantation (ASCT) is considered standard in the treatment of patients with RR DLBCL. However, the optimal salvage regimen before ASCT has not yet been established. Design This is a retrospective study that analyzed 20 patients with RR DLBCL after anthracycline-based first-line chemotherapy (R-CHOP regimen) who received either R-DexaBEAM (dexamethasone, carmustine, etoposide, cytarabine, and melphalan; n =9) or R-ICE (ifosfamide, carboplatin, and etoposide; n =11) regimen as first salvage chemotherapy. Treatment in a patient, which achieved remission, was followed by HDT/ASCT. The patients were diagnosed and treated at the University Clinic of Hematology, Skopje. Patients and Results The overall response rate (OR) was higher for patients treated with R-ICE (54.5%; 95% confidence interval 8.03–20%) as compared to the R-Dexa BEAM group (44.4%; 95% confidence interval -8.8–16.8%), with higher complete response CR; 36.3%; vs 33.3%. Changing regimen due to failure of first salvage therapy was done in 1 patient initially receiving R- ICE, still achieved an OR of 25% with R-Dexa BEAM as second salvage therapy. For all patients proceeding to HDT/ASCT (n=10), 3-year overall survival was 70%. Conclusion The major adverse event in both groups was myelosuppression with higher but tolerable treatment-related toxicity for patients in the DexaBEAM group. Considering the small sample size, our data suggest that R-ICE salvage chemotherapy is superior to R-Dexa BEAM for patients with R/R NHL DLBCL for remission induction prior to autologous transplantation.

Context B-cell chronic lymphocytic leukemia (CLL) is a clinically heterogeneous disease. One of the most important molecular predictors, the immunoglobulin VH gene mutational status, divides CLL into two prognostic groups, where unmutated U-CLL is associated with remarkably worse prognosis than mutated M-CLL. In many studies, multiple recurring chromosomal aberrations appear to be effective prognostic markers in CLL. Objective The aim of the study was first-time evaluation of rearrangement of IG genes and genetic abnormalities in Macedonian CLL patients. Design Prospective study of Macedonian patients with CLL at early and advanced stage of disease in a period of time from January 2011 to January 2019. The median follow-up was 48 months (1-96 months). Setting Mutational status and configuration of IGHV-IGHD-IGHJ rearrangements in 90 treatment-naive CLL patients were analyzed using reverse transcriptase-polymerase chain reaction (RT-PCR) and sequencing methodology. We used multiplex ligation-dependent probe amplification (MLPA) for detection of most common genetic abnormalities. Interventions We introduced prognostic markers like cytogenetic aberrations, and mutational status of immunoglobulin heavy chain in prognostic stratification of Macedonian patients with CLL. Results Our evaluation has shown that 54.7% patients belonged to the U-CLL subset, whereas 45.3% belonged to the M-CLL subset. The most frequently expressed IGHV subgroup was IGHV3 (40%), followed by IGHV4 (29%), IGHV1(27%), and IGHV5 (3%). The most frequent subgroup with 8% were IGHV1-69*13 and IGHV4-34*0. In the IGHD and IGHJ sets, most frequently expressed genes were IGHD3 (59.7%) and IGHJ6(53.1%), respectively. We found that 80% of IGHV1, 65.6% of IGHD3, and 83.3% of IGHJ6 genes were U-CLL (p=0.0005). Frequency of genetic aberrations by MLPA were 13q14 deletion (20%) followed by 11q deletion (14%), then trisomy 12 (13%) and 17p deletion (6.6%), multiple mutations (6.7%), and NOTCH mutation (5.3%). Conclusions Our evaluation of mutational status on IGVH, IGDH, and IGJH genes in Macedonian CLL patients resulted with data that are consubstantial to those from the Mediterranean area. Novel mutations discovered in this study must be validated through large cohort studies and may offer clues to the mechanisms underlying the difference in CLL survival. In the future, therapeutic strategies targeting these genes should be evaluated and considered.

Background Acquired calreticulin (CALR) gene mutations are one of the molecular hallmarks of essential thrombocythemia (ET). It has been suggested that patients with ET with CALR mutations are associated with a distinct clinical phenotype. Patients and Methods We evaluated the clinical and molecular features of 150 patients with ET followed over a period of 15 years. The screening for the presence of insertion/deletion mutations in CALR exon 9 was done with a fluorescent polymerase chain reaction/capillary electrophoresis procedure. Sanger sequencing of CALR exon 9 was used for the characterization of mutations and for the analysis of triple-negative patients. Results CALR mutations were detected in 42 (28%) patients. The most common CALR mutations were type 1 and type 2, which were present in 11 (26.2%) and 20 (47.6%) patients, respectively. Additionally, 10 different small insertion/deletions (3 known and 7 new) were detected in 11 patients, resulting in an altered calreticulin C-terminal end. The clinical characteristics of all CALR+ patients with ET were in line with previously published data for this subset of patients. Conclusion Our results showed that a wide range of different CALR mutations are associated with a distinct ET clinical phenotype that is associated with the male gender, younger age at diagnosis, higher platelet and lower leukocyte and erythrocyte counts and lower hemoglobin level, and a milder clinical course. The relatively high frequency of new insertion/deletion mutations indicate that the use of fluorescent polymerase chain reaction followed by capillary electrophoresis is the method of choice for the analysis of these defects.

Context Imatinib, selective tyrosine kinase inhibitor (TKI), revolutionized treatment of chronic myeloid leukemia (CML) and changed the natural history of the disease. In 2013, a generic formulation came into the Republic of North Macedonia's market and replaced the original formulation, Glivec. Objective The aim of the study is to determine whether the efficacy of the generic Imatinib is the same as the original Imatinib-Glivec in patients treated for chronic myeloid leukemia in North Macedonia in terms of hematological and molecular responses in CML. Design This is an observational retrospective study using medical charts of patients diagnosed with CML in the chronic phase who were previously successfully treated with original Imatinib and subsequently switched to generic Imatinib. The patients were treated with generic Imatinib from the year 2013 to 2020. Patients or other participants 30 patients have been switched from original to generic Imatinib. All of them were receiving Imatinib at a dose of 400 mg/ daily prior and after switching. 17 (56.6%) of all patients were male, 13 (44%) were female. 28 of the patients completed the study, 2 of the patients lost their molecular response and were switched to second-generation TKI-Nilotinib. Results 30 patients have been switched to generic imatinib. Before the switch, all of the patients were in complete hematologic response (CHR), and all of them were in MMR. Patients have received generic Imatinib for a median of 88 months. Molecular response (MR) was decided with BCR-ABL1 gene transcript ratio that is reported as International Scale (IS). Complete hematologic response was accepted as white blood cells Conclusions In our observational series, most of the patients maintained their molecular response. The change from original to generic Imatinib appears to maintain efficacy and maintained CHR and MMR.

Context Acute myeloid leukemia (AML) is a hematological malignant disease that motivates the persistent struggle in the scientific world to provide effective cure. Objective The main goal of this analysis was to see if autologous stem cell transplantation (SCT) with myeloablative conditioning is still a powerful weapon that can be used against AML, providing acceptable safety and survival rates. Design We have evaluated retrospectively patients with AML where autologous SCT was performed in the period from 2000 till 2018. Evaluated the OS and transplant related mortality (TRM) as main objectives. Setting All patients were transplanted in the Bone Marrow Transplant unit in the University Clinic for Hematology Skopje. Underwent standard posttransplant preventive and prophylactic measures during the period of pancytopenia. Patients or other participants We have done a retrospective analysis of patients with AML where autologous SCT was done. The main inclusion criterion was the diagnosis, achieved complete remission with standard chemotherapy protocols and acceptable EBMT risk score. Interventions In all patients, first mobilizing and harvesting of stem cells was performed, and cryopreserved afterwards. Myeloablative conditioning was used, and application of the thawed graft done via central venous catheter. Main outcome measures We mainly evaluated the rates of overall survival (OS) and transplant related mortality (TRM). Results We have evaluated retrospectively patients with AML where autologous SCT was performed in the period from 2000 till 2018. Our group consisted of 94 patients: 45 male patients, 49 female patients. Median age at diagnosis was 44 years. In the majority of our group, we used myeloablative conditioning regimen with busulphan-cyclophosphamide, 60 patients. As auto graft we used peripheral blood stem cells (PBSC) in 78 patients, and in 16 patients we used bone marrow. The main mobilising regimen for PBSC was G-CSF + etoposide, which was performed in 44 patients. The transplant related mortality (TRM) was 2.1 %. The 5-year overall survival of our patients was 46.7 patients. The main reason for death was relapse of the primary disease (73%). Conclusions Autologous stem cell transplantation could be an acceptable therapeutic solution for patients with AML as a consolidation therapy.