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Objective This study aims to describe the epidemiological characteristics and survival rates of children with acute myeloid leukemia treated in hospitals in southern Brazil and compare them with international data. Methods A multicenter cohort study was conducted with retrospective data collection of all new patients with acute myeloid leukemia under 18 treated at five referral centers in pediatric hematology-oncology in southern Brazil between January 2005 and December 2015. Results Of the 149 patients with acute myeloid leukemia, 63.0% (n = 94) were male. The median age at diagnosis was 10.5 years (range 0–18 years) and 40.3% (n = 60) had a white blood cell count below 50,000/mm2. The most common Franco-American-British (FAB) subtype was M3 (n = 43, 28.9%). Nine (6.0%) patients had central nervous system disease. In M3 patients, overall survival (OS) was 69.2% and 3-year event-free survival was 67.7%; in non-M3 patients, these rates were 45.3% and 36.7%, respectively. In non-M3 patients, OS was significantly different between transplanted (61.8%) and non-transplanted (38.2%) patients (p = 0.031). Conclusions These results show a higher prevalence of the Franco-American-British M3 subtype than that reported in the international literature, as well as a decreased OS compared with that of developed countries. Further multicenter Brazilian studies with a larger sample size are encouraged to better understand the characteristics of acute myeloid leukemia, and to improve the treatment and prognosis in this population.

Severe aplastic anemia (SAA) is a life-threatening disease that can be cured with allogeneic cell transplantation (HCT). Haploidentical donor transplantation with post-transplantation cyclophosphamide (haplo-PTCy) is an option for patients lacking an HLA-matched donor. We analyzed 87 patients who underwent haplo-PTCy between 2010 and 2019. The median patient age was 14 years (range, 1 to 69 years), most were heavily transfused, and all received previous immunosuppression (25% without antithymocyte globulin). Almost two-thirds (63%) received standard fludarabine (Flu)/cyclophosphamide (Cy) 29/total body irradiation (TBI) 200 cGy conditioning, and the remaining patients received an augmented conditioning: Flu/Cy29/TBI 300-400 (16%), Flu/Cy50/TBI 200 (10%), or Flu/Cy50/TBI 400 (10%). All patients received PTCy-based graft-versus-host disease (GVHD) prophylaxis. Most grafts (93%) were bone marrow (BM). The median duration of follow-up was 2 years and 2 months. The median time to neutrophil recovery was 17 days. Primary graft failure occurred in 15% of the patients, and secondary or poor graft function occurred in 5%. The incidences of grade II-IV acute GVHD was 14%, and that of chronic GVHD was 9%. Two-year overall survival and event-free survival (EFS) were 79% and 70%, respectively. EFS was higher for patients who received augmented Flu/Cy/TBI (hazard ratio [HR], .28; P = .02), and those who received higher BM CD34 cell doses (3.2 × 10E6/kg) (HR, .29; P = .004). The presence of donor-specific antibodies before HSCT was associated with lower EFS (HR, 3.92; P = .01). Graft failure (HR, 7.20; P.0001) was associated with an elevated risk of death. Cytomegalovirus reactivation was frequent (62%). Haploidentical HCT for SAA is a feasible procedure; outcomes are improved with augmented conditioning regimens and BM grafts with higher CD34 cell doses.

Allogeneic hematopoietic stem cell transplantation (HCT) can cure primary immunodeficiency diseases (PID). When a HLA-matched donor is not available, a haploidentical family donor may be considered. The use of T cell-replete haploidentical HCT with post-transplantation cyclophosphamide (haplo-PTCy) in children with PID has been reported in few case series. A donor is usually readily available, and haplo-PTCy can be used in urgent cases. We studied the outcomes of 73 patients with PID who underwent haplo-PTCy, including 55 patients who did so as a first transplantation and 18 who did so as a salvage transplantation after graft failure of previous HCT. The median patient age was 1.6 years. Most of the children were male (n = 54) and had active infection at the time of transplantation (n = 50); 10 children had severe organ damage. The diagnosis was severe combined immunodeficiency (SCID) in 34 patients and non-SCID in 39 (Wiskott-Aldrich syndrome; n = 14; chronic granulomatous disease, n = 10; other PID, n = 15). The median duration of follow-up of survivors was 2 years. The cumulative incidence of neutrophil recovery was 88% in the SCID group and 84% in non-SCID group and was 81% for first transplantations and 83% after a salvage graft. At 100 days, the cumulative incidence of acute GVHD grade II-IV and III-IV was 33% and 14%, respectively. The majority of patients reached 200/μL CD4+ and 1000/μL CD3+ cell counts between 3 and 6 months. The estimated 2-year overall survival was 66%; it was 64% for SCID patients and 65% for non-SCID patients and 63% for first HCT and 77% for salvage transplantations. Twenty-five patients died, most of them due to infection early after transplantation (before 100 days). In conclusion, haplo-PTCy is a feasible procedure, can cure two-thirds of children with PID, and can be used as rescue treatment for previous graft failure. © 2020 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

Introduction: Treatment of childhood acute lymphoblastic leukemia (ALL) is based on risk stratification. This study aimed to assess the agreement between risk group classifications in the different childhood ALL treatment protocols used in a referral hospital in southern Brazil. Methods: We retrospectively reviewed the medical records of patients aged 1 to 18 years with B-cell ALL treated at a hospital from January 2013 to April 2017. Agreement between risk classifications was assessed by the kappa coefficient. Results: Seventy-five patients were analyzed. There was poor agreement between risk stratification by GBTLI 2009 and BFM 95 protocols (kappa=0.22; p = 0.003) and by GBTLI 2009 and IC-BFM 2002 protocols (kappa=0.24; p = 0.002). Risk group distribution was 13.3% for low risk, 32.0% for intermediate risk, and 54.7% for high risk based on stratification by the GBTLI 2009 protocol, and 28.0% for low risk, 42.7% for intermediate risk, and 29.3% for high risk based on stratification by the IC-BFM 2002 protocol. Overall survival was 68.6%. Conclusion: This study provides numerous points to ponder about the treatment of leukemia in Brazil. The percentage of patients classified as high risk in our sample was higher than that reported in the international literature. This difference, however, had no impact on overall survival, which was shorter than that reported in the international literature.

HSCT is performed in Brazil since the 70’s, most of them in public centers. Transplant numbers are regularly reported by most centers to the Brazilian Transplant Registry/ Brazilian Solid Organ Association (ABTO/RBT), Latin American Bone Marrow Transplant Group/ Worldwide Network for Blood and Marrow Transplantation (LABMT/WBMT), but transplant outcomes are not available in our country. The objective of this work is to understand HSCT activity and outcomes of Brazilian children. Methods The Brazilian Society of Bone Marrow Transplant and Cellular Therapy (SBTMO) has developed the initiative to collaborate with the Center for International Blood and Marrow Transplant Research (CIBMTR) to receive back deidentified aggregate nationwide data reported by Brazilian transplant centers. This was approved by the national central IRB in 2019 (Conep CAAE: 65575317.5.1001.0071, principal investigator Dr. Nelson Hamerschlak) as a research project, including data from 2008 through 2027. This is the first report of the Brazilian Pediatric Hematopoietic Stem Cell Transplant activity prepared by the SBTMO Data Managers Working Group with the data reported to the CIBMTR and returned to the country as an enhanced Data Back to Center file. Results Between 2008 and 2019, 16 of the 19 institutions reporting to the CIBMTR also reported pediatric transplants. A total of 1,929 transplants were reported in children younger than 18 years of age and, different from the adult experience, most of them are allogeneic transplants. Within the past three years, the number of allogeneic transplants from unrelated and mismatched donors have increased and are now performed more often than transplants from matched sibling donors. Unrelated cord blood grafts were rarely used. Marrow was the preferred graft source for all allogeneic transplants. Acute leukemias and severe aplastic anemia were the most common indications for HSCT. Infections were the first cause of death within 100 days post HSCT. The 2-year overall survival after HSCT with HLA-identical sibling, unrelated donors and mismatched related donors for acute lymphoblastic leukemia was 56%, 60% and 37% (p = 0.2) and for acute myelogenous leukemia, 57%, 55% and 62% (p = 0.8), respectively. Pediatric myelodysplastic syndrome and chronic myelogenous leukemia had overall survival over 80%. Severe aplastic anemia was the most common non-malignant HSCT indication and the results with matched related and unrelated transplants are excellent, > 85% survival. In conclusion, this is the first report on transplant outcomes in Brazilian children. The collaboration with the CIBMTR may be a feasible way for Latin American countries to know their transplant outcomes using a mature registry structure with several tools already in place to enhance the collaboration. We would like to acknowledge Dr Nelson Hamerschlak, principal investigator of the National protocol, Dr. Marcelo Pasquini, for his help with the collaboration between CIBMTR and SBTMO, the Brazilian institutions reporting their data, the Data Manager Working Group and the Pediatric Working Group of the SBTMO and SOBOPE.

Introdução – Esta pesquisa teve o objetivo de analisar a aquisição fonológica e sua relação com dados demográficos e a deficiência de ferro em pré-escolares da cidade de Vicente Dutra-RS. Método – Foi realizado estudo transversal, utilizando dados de hemograma (hemoglobina, ferritina e saturação transferrina) e dados sobre a aquisição da linguagem oral e da escrita numa população de 51 crianças (26 meninas, 51%), com 5,3±0,3 anos de idade. Resultados – Não foi encontrada associação da deficiência de ferro com aquisição da linguagem oral e escrita. Contudo, foi observada associação entre as variáveis aquisição fonológica e hipótese de escrita (valor sonoro), p=0,006, e aquisição fonológica e desvios fonéticos (p=0,012). Conclusões – Os dados encontrados nesta pesquisa transversal não sugerem relação entre linguagem e deficiência de ferro; contudo, amostras maiores em estudos longitudinais seriam interessantes para melhor compreensão dos achados Introduction - This research aimed to analyze the phonological acquisition and its relationship with demographic data and iron deficiency in preschool children from Vicente Dutra-RS. Method - It was performed a cross-sectional study, using hemogram data (hemoglobin, ferritin and transferrin saturation), and data on acquisition of oral and written language in a population of 51 children (26 girls, 51%), with 5.3±0.3 years of age. Results - It was not found an association between iron deficiency and acquisition of oral and written language. However, it was observed an association between the variables phonological acquisition and chance of writing (value), p = 0.006, and phonological acquisition and phonetic deviations (p = 0.012). Conclusions - The data found in this cross-sectional research do not suggest a relationship between language and iron deficiency; however, larger samples in longitudinal studies would be interesting for a better understanding of the findings Introducción - Esta investigación tuvo el objetivo de analizar la adquisición fonológica y su relación con datos demográficos y la deficiencia de hierro en preescolares de la ciudad de Vicente Dutra-RS. Método – Se realizó un estudio transversal, utilizando datos de hemograma (hemoglobina, ferritina y saturación transferrina) y datos sobre la adquisición del lenguaje oral y de la escritura en una población de 51 niños (26 niñas, 51%), con 5,3 ± 0, 3 años de edad. Resultados - No se encontró asociación de la deficiencia de hierro con adquisición del lenguaje oral y escrito. Sin embargo, se observó asociación entre las variables de adquisición fonológica y hipótesis de escritura (valor sonoro), p = 0,006, y adquisición fonológica y desvíos fonéticos (p = 0,012). Conclusiones - Los datos encontrados en esta investigación transversal no sugieren una relación entre el lenguaje y la deficiencia de hierro; sin embargo, muestras más grandes en estudios longitudinales serían interesantes para una mejor comprensión de los hallazgos

Background Strategies to mitigate the impact of COVID‐19 in special populations are complex and challenging. Few studies have addressed the impact of COVID‐19 on pediatric patients with cancer in low‐ and middle‐income countries. Methods Multicenter observational cohort study with prospective records and retrospective analyses starting in April 2020 in 21 pediatric oncology centers distributed throughout Brazil. Participants: Patients under 18 years of age who are infected by the SARS‐CoV‐2 virus (confirmed diagnosis through reverse transcriptase‐polymerase chain reaction [RT‐PCR]) while under treatment at pediatric oncology centers. The variables of interest included clinical symptoms, diagnostic and therapeutic measures. The repercussions of SARS‐CoV‐2 infection on cancer treatment and general prognosis were monitored. Results One hundred seventy‐nine patients were included (median age 6 [4–13] years, 58% male). Of these, 55.9% had acute leukemia and 34.1% had solid tumors. The presence of SARS‐CoV‐2 was diagnosed by RT‐PCR. Various laboratory markers were analyzed, but showed no correlation with outcome. Children with low or high BMI for age had lower overall survival (71.4% and 82.6%, respectively) than those with age‐appropriate BMI (92.7%) (p = .007). The severity of presentation at diagnosis was significantly associated with outcome (p

The results of hematopoietic stem cell transplant (HSCT) for primary immunodeficiency diseases (PID) have been improving over time. Unfortunately, developing countries do not experience the same results. This first report of Brazilian experience of HSCT for PID describes the development and results in the field. We included data from transplants in 221 patients, performed at 11 centers which participated in the Brazilian collaborative group, from July 1990 to December 2015. The majority of transplants were concentrated in one center (n = 123). The median age at HSCT was 22 months, and the most common diseases were severe combined immunodeficiency (SCID) (n = 67) and Wiskott-Aldrich syndrome (WAS) (n = 67). Only 15 patients received unconditioned transplants. Cumulative incidence of GVHD grades II to IV was 23%, and GVHD grades III to IV was 10%. The 5-year overall survival was 71.6%. WAS patients had better survival compared to other diseases. Most deaths (n = 53) occurred in the first year after transplantation mainly due to infection (55%) and GVHD (13%). Although transplant for PID patients in Brazil has evolved since its beginning, we still face some challenges like delayed diagnosis and referral, severe infections before transplant, a limited number of transplant centers with expertise, and resources for more advanced techniques. Measures like newborn screening for SCID may hasten the diagnosis and ameliorate patients' conditions at the moment of transplant.

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative approach to children and adolescents with high-risk acute lymphoblastic leukemia (ALL) at diagnosis or relapsed disease. Nonetheless, despite the graft versus leukemia (GVL) effect, treatment-related morbidity and mortality remains a major challenge. Moreover, the significant heterogeneity of the available data on the selection of patients, type of conditioning regimen, and type of donor hampers any definitive conclusions in the pediatric population. In 2020, the Brazilian Group for Pediatric Bone Marrow Transplantation of the Brazilian Society of Bone Marrow Transplantation and Cellular Therapy (SBTMO) and the Brazilian Society for Pediatric Oncology (SOBOPE) convened a task force to provide general guidance on HSCT for childhood ALL to providing evidence-based guidance for the appropriate management of this disease.

In recent years, there has been an expansion in the use of flow cytometry (FC) immunophenotyping in the diagnosis and monitoring of childhood solid neoplasms. Neuroblastoma (NB), in turn, is the most common extracranial solid tumor in childhood. In the present study, we sought to compare FC and anatomopathological examination (PA) / immunohistochemistry (IHC) of children diagnosed or suspected with NB. The median age was 59 months (minimum 0; maximum 325 months), of these 12 were male (57.1%, 12/21). Forty-eight samples (27 bone marrow (BM), 10 peripheral blood (PB), 8 primary tumors (PT) and 2 liver nodules (HN) and 1 rib fragment (RF)) from 21 patients were evaluated. Twenty-nine samples were from patients with clinical suspicion while 19 samples were from patients with previously confirmed diagnosis. Thirteen samples (7 BM, 5 PT and 1 HN) presented NB when analyzed in FC while 8 (3 BM and 5 PT) samples were positive for NB in the PA/IHC. They were concordant in 88.9% of the cases. No NB cells were identified in any PB. Considering the PA as the gold standard, the FC obtained a sensitivity of 100%, a specificity of 86%, a positive predictive value of 67% and a negative predictive value of 100%. This study demonstrates that FC can be used as a methodology for diagnosis and assessment of NB involvement. In addition, FC has the advantage of allowing a quick diagnosis and accurate classification of the disease, and can also assist in monitoring the treatment.

Oral mucositis (OM) is an adverse side effect among hematopoietic stem cell transplantation (HSCT) recipients. The objective of this retrospective study was to evaluate the preventive effect of photobiomodulation (PBM) applied three times per week versus seven times per week in patients undergoing HSCT. The risk factors related to the incidence and severity of OM were also assessed. This was a retrospective study that evaluated 99 HSCT recipients who received different PBM protocols. Group I received three sessions per week, and group II received daily treatment. PBM was applied using a continuous-wave diode laser (InGaAlP; MM Optics, Sao Carlos, SP, Brazil) at a wavelength of 660 nm (visible-red) and a total radiant energy of 0.24 J per point. The baseline disease, type of transplant, type of conditioning, prophylaxis against graft-versus-host disease, OM grade, absolute leukocyte and platelet counts, and levels of liver and renal function markers were collected from medical records. The patients’ age ranged from 13 to 71 years (mean/SD, 40.54 ± 16.45). No significant difference was observed between groups I and II regarding sex, age, ethnic, diagnosis, donor type, and conditioning treatment. Both PBM protocols were equally efficient in preventing OM (p = 0.34, ANOVA). Independent of the PBM protocol used, patients who received allogeneic transplant (p

Background: Our research group recently showed that the only ASNase formulation available in Brazil from 2017 to 2018 when used at the same dose and frequency as the formulation provided previously did not reach, in most cases, the serum activity considered therapeutic. Based on these data, our goal was to assess the impact of these facts on the prognosis of children with ALL at 10 different pediatric oncology centers in our country. Methods: a multicenter retrospective observational study followed by prospective follow-up. Patients aged >1 and

The long-term outcome of acute lymphoblastic leukemia has improved dramatically due to the development of more effective treatment strategies. L-asparaginase (ASNase) is one of the main drugs used and causes death of leukemic cells by systematically depleting the non-essential amino acid asparagine. Three main types of ASNase have been used so far: native ASNase derived from Escherichia coli, an enzyme isolated from Erwinia chrysanthemi and a pegylated form of the native E. coli ASNase, the ASNase PEG. Hypersensitivity reactions are the main complication related to this drug. Although clinical allergies may be important, a major concern is that antibodies produced in response to ASNase may cause rapid inactivation of ASNase, leading to a worse prognosis. This reaction is commonly referred to as "silent hypersensitivity" or "silent inactivation". We are able to analyze hypersensitivity and inactivation processes by the measurement of the ASNase activity. The ability to individualize the ASNase therapy in patients, adjusting the dose or switching patients with silent inactivation to an alternate ASNase preparation may help improve outcomes in those patients. This review article aims to describe the pathophysiology of the inactivation process, how to diagnose it and finally how to manage it.

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a therapeutic modality commonly used to treat hematological and immunological disorders. Among the main complications of allo-HSCT is the acute graft-versus-host disease (a-GVHD), a condition which accounts for a high incidence of mortality. Several genes encoding inflammatory mediators may present polymorphisms, which have been implicated in the risk of developing a-GVHD. In our study, we investigated the association between genotypes of cytokine-encoding genes and the incidence and severity of a-GVHD and survival of HSCT recipients. No statistically significant association was found between IL and 6-174 G/C, INF-γ + 874 T/A, TNF-α -238 A/G, -308 A/G and IL-10-819C/T, -592 A/C polymorphisms and the presence or severity of a-GVHD. A higher risk of a-GVHD was associated with the IL-10-1082 GG genotype compared to the AA + AG genotypes of recipients and donors. The IL-10-1082 genotype can be used as a prognostic determinant to predict which HSCT recipient will be more responsive to the transplant. Thus, cytokine gene assays may be useful in the individualization of prophylactic regimens and for an appropriate selection of immunosuppressants based on the HSCT recipient’s responsiveness.

High levels of fetal hemoglobin (HbF) reduce sickle cell anemia (SCA) morbidity and mortality. HbF levels vary considerably and there is a strong genetic component that influences HbF production. Genetic polymorphisms at three quantitative trait loci (QTL): Xmn1-HBG2, HMIP-2 and BCL11A, have been shown to influence HbF levels and disease severity in SCA. Hydroxyurea (HU) is a drug that increases HbF. We investigated the influence of single nucleotide polymorphisms (SNPs) at the Xmn1-HBG2 (rs7482144); BCL11A (rs1427407, rs4671393 and rs11886868); and HMIP-2 (rs9399137 and rs9402686) loci on baseline and HU-induced HbF levels in 111 HbSS patients. We found that both BCL11A and HMIP-2 were associated with increased endogenous levels of HbF. Interestingly, we also found that BCL11A was associated with higher induction of HbF with HU. This effect was independent of the effect of BCL11A on baseline HbF levels. Additional studies will be needed to validate these findings and explain the ample inter-individual variations in HbF levels at baseline and HU-induced in patients with SCA.

In the present paper we summarize the suggestions of a multidisciplinary group including experts in pediatric oncology and infectious diseases who reviewed the medical literature to elaborate a consensus document (CD) for the diagnosis and clinical management of invasive fungal diseases (IFDs) in children with hematologic cancer and those who underwent hematopoietic stem-cell transplantation. All major multicenter studies designed to characterize the epidemiology of IFDs in children with cancer, as well as all randomized clinical trials addressing empirical and targeted antifungal therapy were reviewed. In the absence of randomized clinical trials, the best evidence available to support the recommendations were selected. Algorithms for early diagnosis and best clinical management of IFDs are also presented. This document summarizes practical recommendations that will certainly help pediatricians to best treat their patients suffering of invasive fungal diseases. Keywords: Fungal infections, Children, Cancer

Introduction Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment for several primary immunodeficiencies. In the absence of a matched sibling or a well matched unrelated donor, the use of an haploidentical family donor can be considered. Historically, most part of haploidentical HSCT were performed with in vitro T-cell depletion techniques that aren't worldwide available, especially in middle or low income countries. The use of T-cell replete haploidentical HSCT with PTCy in children with PID has been described in only a few case-series. Objectives To report the outcomes of haploidentical HSCT with PTCy for children with severe PID Methods Retrospective chart review of 73 patients with PID who underwent haploidentical HSCT with PTCy from July 2012 to May 2019 at 9 centers in Brazil. Results Fifty-five patients received first allogeneic transplants, and 18 were rescued after graft failure of a previous transplant. Median age was 1.6 years (2 months to 19 years). Most patients were male (n=54) and had active infection at the time of transplant (n=50). Diagnoses were: severe combined immunodeficiency (n=34), Wiskott-Aldrich Syndrome (n=14), chronic granulomatous disease (n=10) and other PID (n=15). Donors were father (N=46), mother (N=24), or siblings (N=3); and cell source was predominantly bone marrow (94% of patients). Conditioning regimen was non-myeloablative (fludarabine 150mg/m2 + cyclophosphamide 29mg/Kg + TBI 200cGy) in 35 patients; and myeloblative in 38 patients (most part receiving: bussulfan + fludarabine 160mg/m2 + ATG 4-7,5 mg/Kg or alemtuzumab 0,5-1mg/Kg). GVHD prophylaxis was PT-Cy, CsA or Tacrolimus and MMF. The median follow-up of surviving patients was 24 months. Four patients died before 28 days and were not evaluable for engraftment. Sixty-one patients engrafted in a median of 15 days. The 100-day incidence of acute GVHD grades II–IV was 33% and grades III–IV, 14%. The incidence of Chronic GVHD at 1 year was 16%. Twenty-two patients died, most of them due to infection (n=15). The two-year overall survival was 66%. There was no difference in OS between patients receiving first allogeneic or rescue transplants, suggesting survival bias. Patients transplanted for WAS or SCID had a better OS compared to those transplanted for CGD (p=0,02). Conclusion In conclusion, 66% of Brazilian children with severe PID and no matched donor could be cured with haploidentical HSCT with PTCy. The high proportion of patients in our cohort transplanted with an active infection (70%) may have had a major impact in our results. The optimal conditioning regimen for these patients and long term follow up data are the objective of our ongoing studies.

espanolIntroduccion: durante el trasplante de celulas madre hematopoyeticas (TCMH) algunos factores pueden infl uir en el estado nutricional (EN) del paciente. El regimen de acondicionamiento, asi como los signos y sintomas del tracto gastrointestinal, pueden influir negativamente en la ingesta oral de alimentos. Los pacientes pueden requerir el uso de terapias nutricionales complementarias dirigidas a una ingesta calorica adecuada con el objetivo de evitar el deterioro del EN. Objetivo: el estudio tiene como objetivo describir los aspectos nutricionales relevantes para el mantenimiento del EN durante la hospitalizacion de ninos y adolescentes sometidos al TCMH en un hospital terciario. Metodo: un estudio retrospectivo con una revision de los registros medicos de los pacientes sometidos al TCMH, con edades comprendidas entre 0 y 19 anos (incompletos) entre enero de 2009 y diciembre de 2014. Se recopilaron datos sobre la ingesta de alimentos, las terapias nutricionales utilizadas y los signos y sintomas clinicos en seis tiempos: hospitalizacion, D0 (dia de infusion celular), D+7, D+14, D+21 y D+28. Resultados: se evaluaron sesenta y tres pacientes, siendo 56% del sexo masculino, con una edad media de diez anos. En el momento de la hospitalizacion 100% de los pacientes cubrian sus necesidades energeticas con la alimentacion oral, disminuyendo en el D0 (alrededor del 30%), con un uso mas prevalente de nutricion enteral y parenteral en el D+7. La inapetencia, mucositis y nauseas fueron los signos y sintomas mas frecuentes. Desde el D+21 fue posible observar un aumento en la ingesta calorica por via oral. Conclusion: los pacientes mostraron una disminucion en la ingesta de alimentos durante la hospitalizacion. Sin embargo, se ha demostrado que la prescripcion de terapias nutricionales complementarias ha reducido el impacto de la perdida de peso. EnglishIntroduction: during hematopoietic stem cell transplantation (HSCT) some factors may impact on the patient’s nutritional status (NS). Conditioning regimen, as well as signs and symptoms of the gastrointestinal tract, can negatively infl uence on oral food intake. Patients may require the use of complementary nutritional therapies aiming at an adequate caloric intake with the objective of avoiding decreasing in NS. Objective: the study aims to describe the nutritional aspects relevant to the maintenance of NS during hospitalization of children and adolescents undergoing HSCT at a tertiary hospital. Method: a retrospective study with a review of medical records of patients undergoing HSCT, aged between 0 and 19 years of age (incomplete) between January 2009 and December 2014. Data were collected regarding food intake, nutritional therapies used, and clinical signs and symptoms in six times: hospitalization, D0 (day of cell infusion), D+7, D+14, D+21 and D+28. Results: sixty-three patients were evaluated, being 56% males, with a median age of ten years. At the time of hospitalization, 100% of patients had their energy needs met by mouth, decreasing from D0 (about 30%), with more prevalent use of parental nutritional and enteral nutrition from D+7. Loss of appetite, mucositis and nausea were the most frequent signs and symptoms. From D+21 it was possible to observe an increase in caloric intake by mouth. Conclusion: patients showed decreased food intake throughout hospitalization. However, it has been shown that the prescription of complementary nutritional therapies has reduced the impact of weight loss.

Increased destruction of erythrocytes in patients with sickle cell disease results in chronic hyperbilirubinemia and leads to the formation of gallstones. The objective of this study was to determine the combined influence of alpha thalassemia, fetal hemoglobin, and the UGT1A1 polymorphism on serum bilirubin levels and cholelithiasis in patients with sickle cell disease. We analyzed 72 patients treated in the outpatient hematology unit of the Clinical Hospital of Porto Alegre. The alpha thalassemia trait was determined by multiplex polymerase chain reaction and the polymorphisms of UGT1A1 by capillary electrophoresis with tagged primers. Total and indirect bilirubin levels differed significantly between genotypes TA7/TA7 and TA6/TA6 (p

Background: Hematopoietic stem cell transplantation is a curative treatment for many patients with hematological disorders. Donor–recipient genetic disparity, especially involving the human leukocyte antigen system is a critical factor for transplant outcome. Objective: To evaluate retrospectively donor characteristics and correlations with the occurrence of acute and chronic graft-versus-host disease, disease-free survival and overall survival in a Brazilian population submitted to allogeneic hematopoietic stem cell transplantation between 1994 and 2012 in a single center. Results: Three hundred and forty-seven consecutive transplantations were included. Related transplants (81.2%) were significantly more common than unrelated transplants (18.7%); donor and recipient median ages were 34 (range: 1–61) and 33 (range: 3–65) years respectively with donor HLAs being matched for 333 (95.9%) patients. Donor gender, cytomegalovirus status and ABO incompatibility did not influence the five-year overall survival. In univariate analyses, overall survival was negatively influenced by the presence of acute graft-versus-host disease (33% vs. 47%, respectively; p-value = 0.04), unrelated transplant (41.5% vs. 50.9%, respectively; p-value = 0.045) and donors aged over 40 years (41% vs. 52%, respectively; p-value = 0.03). Older donors were associated with a higher rate of acute (52% vs. 65.8%; p-value = 0.03) and chronic graft-versus-host disease (60% vs. 43%, respectively; p-value = 0.015). In multivariate analyses, acute graft-versus-host disease [relative risk (RR): 1.8; 95% confidence interval (CI): 1.1–29; p-value = 0.008] and older donors (RR: 1.6; 95% CI 1.11–2.24; p-value = 0.013) were associated with higher transplant-related mortality. Conclusions: In transplant patients, to have a donor older than 40 years of age seems to significantly increase the incidence of acute and chronic graft-versus-host disease and transplant-related mortality with no impact on disease-free survival and overall survival. In spite of the rather small cohort of patients, these findings are similar to what is described in the literature suggesting that a younger donor should be chosen whenever possible. Keywords: Hematopoietic stem cell transplantation, HSCT, Graft-versus-host disease, GVHD

β2-Microglobulin is the major prognostic factor in multiple myeloma, a known comorbidity of Gaucher disease. We evaluated herein serum β2-microglobulin levels of 31 type 1 Gaucher patients; for 8/31 patients, pre- and post-treatment comparisons were made. Thirteen patients (on treatment = 6) had high levels of β2-microglobulin, and showed higher chitotriosidase activity and Severity Score Index, and lower concentration of platelets, than patients with normal levels. Levels of β2-microglobulin correlated with chitotriosidase activity (ρ = 0.65; p

Background: Early recognition of infectious processes in neutropenic patients is hampered by the fact that these processes may have dissimilar and non-specific clinical presentations. CD64 is a neutrophil surface marker that is not expressed in non-sensitized neutrophils. When the neutrophil is exposed to tumor necrosis factor-alpha it is activated and is measured via the CD64 index. Methods: This paper evaluated the relationship between the index value of CD64 on the first day of febrile neutropenia and a positive blood culture. The correlations with white blood count, C-reactive protein and erythrocyte sedimentation rate were also evaluated. This case-control, prospective, diagnostic study included 64 episodes of neutropenia. Case group (n = 14) comprised positive blood cultures, and the control group (n = 50), negative blood cultures. Results: The median rates of CD64 were 2.1 (a ± 3.9) in the case group and 1.76 (a ± 5.02) in the control group. There was no correlation between the value of the CD64 index and blood cultures. The CD64 index was also not correlated with C-reactive protein positivity. Further- more, the CD64 index was not able to predict blood culture positivity. The sensitivity was 64.3%, the specificity was 42%, the positive predictive value was 23.7% and the negative predictive value was 80%. For C-reactive protein, the sensitivity, specificity, positive predictive value, and negative predictive value were 71.4%, 32%, 22.7%, and 80%, respectively. Conclusion: The CD64 index is not suitable for predicting the positivity of blood cultures in this specific population of patients with febrile neutropenia.

Submitted by Guilherme Lemeszenski (guilherme@nead.unesp.br) on 2013-08-22T18:56:56Z No. of bitstreams: 1 S0102-311X2002000300037.pdf: 36967 bytes, checksum: ddbfbf49c7e36d83730f5aad124804c9 (MD5) Made available in DSpace on 2013-08-22T18:56:56Z (GMT). No. of bitstreams: 1 S0102-311X2002000300037.pdf: 36967 bytes, checksum: ddbfbf49c7e36d83730f5aad124804c9 (MD5) Previous issue date: 2002-06-01 Made available in DSpace on 2013-09-30T19:51:14Z (GMT). No. of bitstreams: 2 S0102-311X2002000300037.pdf: 36967 bytes, checksum: ddbfbf49c7e36d83730f5aad124804c9 (MD5) S0102-311X2002000300037.pdf.txt: 20318 bytes, checksum: 227b3ade745b801f759f64a2339fa62b (MD5) Previous issue date: 2002-06-01 Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-20T15:13:17Z No. of bitstreams: 2 S0102-311X2002000300037.pdf: 36967 bytes, checksum: ddbfbf49c7e36d83730f5aad124804c9 (MD5) S0102-311X2002000300037.pdf.txt: 20318 bytes, checksum: 227b3ade745b801f759f64a2339fa62b (MD5) Made available in DSpace on 2014-05-20T15:13:17Z (GMT). No. of bitstreams: 2 S0102-311X2002000300037.pdf: 36967 bytes, checksum: ddbfbf49c7e36d83730f5aad124804c9 (MD5) S0102-311X2002000300037.pdf.txt: 20318 bytes, checksum: 227b3ade745b801f759f64a2339fa62b (MD5) Previous issue date: 2002-06-01 O objetivo deste estudo foi determinar a freqüência e severidade da fluorose dentária em escolares de 5 a 12 e de 15 anos de idade da cidade de Marinópolis, São Paulo, Brasil, com o propósito de se obter um banco de dados-base inicial para o monitoramento da fluorose dentária nesta população. Foram envolvidos todos os escolares de ambos os sexos, nas idades citadas, matriculados nas instituições de ensino da referida cidade e tendo como pré-requisito a condição de residirem em Marinópolis desde o nascimento, totalizando 320 escolares. Os exames foram realizados por um examinador previamente calibrado para a aplicação do Índice de Dean. de acordo com os resultados, a prevalência de fluorose dentária no grupo estudado foi de 17,2%; no entanto, considerando apenas os graus de fluorose que determinam comprometimento estético (leve, moderado e severo), o percentual foi de 7,19%. O grau predominante foi o muito leve (10,0%) seguido pelos graus leve (5,3%), moderado (1,3%) e severo (0,6%). Conclui-se que a fluorose dentária na população estudada não se constitui em problema de amplas dimensões; estudos posteriores, contudo, são necessários, a fim de identificar as causas da presença de casos de fluorose moderada e severa. The purpose of this study was to determine the frequency and severity of dental fluorosis in 5 to 12 and 15 year-old school children in the city of Marinópolis, São Paulo, Brazil, with the purpose of obtaining a baseline data for the monitoring dental fluorosis in this population. All of the school children in the both sexes, in the mentioned ages, enrolled in educational institutions and having the pre-requirement condition of to live in Marinópolis from their birth were involved, totaling 320 school children. The exams were made by one examiner previously calibrated to use the Dean Index. According to the results, the frequency of dental fluorosis in the studied group was 17.2%, however just considering the fluorosis levels that determine aesthetic compromising (mild, moderate and severe), this percentile was 7.19%. The predominant level was the very mild (10.0%) followed for the mild (5.3%), moderate (1.3%) and severe (0.6%). Concluding that the dental fluorosis in the studied population doesn't constitute in a problem with wide dimensions, however, subsequent studies are necessary in the attempt of identifying the causes of moderate and severe fluorosis cases. Universidade Estadual Paulista Faculdade de Odontologia de Araçatuba Universidade Estadual Paulista Faculdade de Odontologia de Araçatuba

CO RR EC TE D P RO OF the juvenile forms by age of onset, rate of disease progression and age of death. There are no approved treatments for gangliosidoses. Biomarkers for evaluating disease phenotype, disease progression, and response to therapies would serve to facilitate the design and development of potential treatment of these diseases, but such biomarkers have not been identified. Increasing evidence from animal models and human cadavers suggests inflammatory mediators in the CNS play a role in disease pathology and progression. Hypothesis: The more rapid disease progression and more severe clinical phenotype of the infantile GM1and GM2-gangliosidosis relative to juvenile forms will coincide with levels of disease specific inflammatory mediators in the CNS. Methods: CSF and serum inflammatory markers were quantified by immunoassay in 8 children with infantile forms of gangliosidoses (including patients with Tay–Sachs disease, Sandhoff disease and GM1 gangliosidosis). Findings were compared to values from 4 patients with more slowly progressing forms of gangliosidoses (i.e., late-infantile, juvenile forms) and to values of 9 children with mucopolysaccharidosis (MPS) diseases. Results: Of 188 analytes assayed, elevated inflammatory markers occurredmore often in the CSF of infantile gangliosidosis patients when compared to the more slowly progressing forms of juvenile gangliosidosis and MPS disease. Five candidate biomarkers were distinguished by persistent elevation in the CSF of patients with the severe infantile phenotype: ENA-78, MCP-1, MIP-1α, MIP-1β, TNFR2. Additional candidates for CNS and serum inflammatory markers for infantile and juvenile phenotypes were found. Conclusion: This study identified candidate biomarkers of CNS inflammatory disease in infantile and juvenile gangliosidoses that are promising as markers for evaluating CNS disease progression, distinguishing infantile and juvenile phenotypes and monitoring response to future therapeutic interventions in the gangliosidoses. (Supported by Lysosomal Disease Network, NIH U54NS065768 and Pharmacotherapy for InheritedMetabolic Diseases Fellowship training program, GenzymeSanofi.)

Invasive aspergillosis is a leading cause of morbidity and mortality in immunocompromised patients, particularly in individuals with haematological malignancy and in haematopoietic stem cell transplant recipients. Nowadays, the galactomannan (GM) assay has been widely used as an indication of invasive aspergillosis, even though the test is known to generate false-positive results. The aim of this study was to compare the performance of GM and real-time PCR (qPCR) to detected Aspergillus in blood samples obtained from high-risk haematological patients. Haematological patients were screened twice weekly with GM testing, which was performed by the Platelia ELISA kit. An additional sample of whole blood (4 ml) was obtained for the purpose of qPCR testing. Sixty-four samples from 12 patients with haematopoietic stem cell transplant or haematological malignancy were studied. The overall accordance between GM and qPCR tests was 96.9 % (62 samples). Only two samples showed contradictory results, with positive GM test and negative real-time PCR results. Based on the high concordance between GM and qPCR in terms of negative results, the main utility of qPCR could be in the confirmation of positive results seen with GM testing.

This population-based study was designed to detect the prevalence of anemia in a healthy population of children (18 months to 7 years) and women (14 to 30 years) tested in 2006–2007 in the state of Rio Grande do Sul, Brazil as part of an effort to tackle this massive problem that still affects so many people in the XXI century. Anemia was defined according to the WHO. Capillary blood was measured and socioeconomic status was determined according to the Brazilian Association of Market Research Agencies. The median prevalence of anemia in 2198 children was 45.4% and in 1999 women 36.4%. Anemia decreased with age during childhood; although significantly more prevalent in lower classes individuals, it was also high in the upper classes. There are indirect evidences that the lack of iron supplementation and/or iron fortified food may play a role in it. Professionals and society wise measures of education have to be implemented in order to address possible biologic factors involved in childhood psychosocial development in southern Brazil.

This study had the objective to assess the frequency of Tregs in children newly diagnosed with ITP and ascertain whether an association exists between Tregs and platelet counts, by means of a comparison with healthy controls. This case-control study included 19 patients newly diagnosed with ITP—whose blood samples were collected at four points in time: before any therapy and 1, 3, and 6 months after diagnosis—and 19 healthy controls. Tregs (CD4+ CD25+Foxp3 T cells) were evaluated by flow cytometry. There was a statistically significant difference in platelet count between the case and control groups. There were no significant differences in Treg counts between cases and controls at any point during the course of the study and no difference in Treg counts between the chronic and nonchronic groups and no significant correlation between Tregs and platelet counts in the case and control groups. The findings of this study did not show any statistically significant correlation between Tregs and number of platelets in the case and control groups. Treg cells did not play a role in the regulation of autoimmunity in children with ITP.

Acute myeloid leukemia (AML) is a complex and heterogeneous hematopoietic tissue neoplasm. Several molecular markers have been described that help to classify AML patients into risk groups. DNA methyltransferase 3A (DNMT3A) gene mutations have been recently identified in about 22% of AML patients and associated with poor prognosis as an independent risk factor. Our aims were to determine the frequency of somatic mutations in the geneDNMT3Aand major chromosomal translocations in a sample of patients with AML. We investigated in 82 samples of bone marrow from patients with AML for somatic mutations inDNMT3Agene by sequencing and sought major fusion transcripts by RT-PCR. We found mutations in theDNMT3Agene in 6 patients (8%); 3 were type R882H. We found fusion transcripts in 19 patients, namely, AML1/ETO (n=5; 6.1%), PML/RARα(n=12; 14.6%), MLL/AF9 (0; 0%), and CBFβ/MYH11 (n=2; 2.4%). The identification of recurrent mutations in theDNMT3Agene and their possible prognostic implications can be a valuable tool for making treatment decisions. This is the first study on the presence of somatic mutations of theDNMT3Agene in patients with AML in Brazil. The frequency of these mutations suggests a possible ethnogeographic variation.Erratum to “DNMT3AMutations in Patients with Acute Myeloid Leukemia in South Brazil”

Introduction: The advent of tyrosine kinase inhibitors has changed the natural history of chronic myelogenous leukemia (CML), promoting molecular remission in a high number of patients. In 40-60% of the patients that reach deep molecular responses (RM4.5 or more) and are using imatinib mesylate for 24 months or longer, a molecular response can be maintained after the cessation of the drug. Besides improving life quality in those patients, to withdraw the medication could have a great economic impact in the health system, what is extremely important in third world countries. Objective: To estimate the economic impact of stopping imatinib mesylate in CML chronic phase patients, receiving treatment for at least 36 months and presenting deep molecular response, determinate by BCR-ABL transcripts with quantitative reverse transcriptase polymerase chain reaction (QRT-PCR), in the last 24 months. Patients and methods: A single center observational retrospective study, including all patients diagnosed with chronic phase CML, confirmed by cytogenetic or molecular exams receiving treatment at a tertiary hospital in Brazil. All patients received imatinib mesylate either in first or second line therapy. Patients presenting deep molecular response for at least 24 months, under imatinib mesylate for 36 months or more were considered eligible for discontinuation the drug. The annual coast with the treatment was estimated considering the coasts of the medication and the QRT-PCR molecular exams in the Brazilian public health system. Results: In this study, 169 patients date were analyzed, the median follow up time is 5 years (range 1-13 years), 26 (15%) of those patients are eligible for stopping imatinib mesylate according to the criteria previously mentioned. Considering the requirement of QRT-PCR exams every month in the first year of discotinuating the drug, these patients would coast proximally 1.550,00 dollars/ patients year for the public health system. This coast could be reduced to 800,00 and 520 dollars/patients year, after the second and third year of the medication withdraw, when monitoring molecular response can be done every 2 and 3 months respectively. The patients receiving imatinib mesylate, and having QTR-PCR exams every six months, in the other hand, would coast the Brazilian public health system over 31.000, 00dollars /patients year. Stopping imatinib mesylate could reduce CML chronic phase treatment coasts in up to 95%. Discussion: Discontinuating imatinib mesylate is something that must be done only in clinical trial. The economic impact projection shown in this study observed the eligibility criteria described in the literature. If stopping imatinib mesylate proves to be a safe option, studies promoting it should be done in Brazil and other third world countries, as a manner of saving resources in the health system. Furthermore, the impact in life quality free of adverse effects and the possibility of gestation in young woman is not to be ignored. Disclosures No relevant conflicts of interest to declare.

Introduction: Imatinibe, a target tyrosine kinase inhibitor, have revolutionized CP-CML treatment. Considering that it is being discussed imatinibe treatment interruption in patients with MR ≥ 4.5 lasting two years or more, we believe to be important to establish predictors of major molecular response (MMR) loss. Fluctuations in BCR-ABL transcripts are being advocated to be able to predict MMR loss, although the real impact of small fluctuations among patients with in MR ≥ 4.5 is uncertain. Objective: Correlate BCR-ABL fluctuations and MMR loss in patients considered to be in MR ≥ 4.5, as well as to recognize possible factors associated with these small fluctuations. Methods: We conducted a retrospective analysis in CP-CML patients receiving imatinibe (as first or second treatment line) that achieved MR ≥ 4.5 (defined as a 4.5 log reduction on an international scale) and surveyed for BCR-ABL fluctuations. We considered a fluctuation to be a rise of at least 0.5 log of BCR-ABL transcripts. Treatment interruptions were considered only when imatinibe was not taken for 15 or more consecutive days. The presence of comorbities was evaluated by applying the Charlson Index. Results: Fifty-eight patients were evaluated between with a median follow-up 7 years. Fifty-five percent were men and 28 were women, with a median age of 46 (18 - 93) years-old, most of the patients were older than 60 yo (75,9%). Among 32 patients evaluated by the Sokal risk score 97,5% were estimated to be low or intermediate. Twenty six patients presented at least one fluctuation. Regarding the number of fluctuations per patient, 18 presented only 1 fluctuation, 5 presented 2 fluctuations and 3 patients presented 3 fluctuations. Among those patients with at least one fluctuation 3 (11%) presented MMR loss, while there was none among patients without documented fluctuations (p=0,15). Among these three patients considered to have MMR loss, two presented fluctuations that reached MR 3.0, while the other patient presented a history of long treatment suspension. More patients that interrupted treatment presented BCR-ABL fluctuations, although this difference was not statically significant (78% vs 50% p=0,11). Conclusion: Small fluctuations among patients with MR ≥ 4.5 didn't seem to correlate with MMR loss, however we do believe that our population is underpowered to rule out this difference. We considered that it very interesting that patients which reached MR 3.0 presented MMR loss (considering that the other patient had to abandon treatment during pregnancy). Disclosures No relevant conflicts of interest to declare.

Although the graft-versus-leukemia effect of allogeneic bone marrow transplantation (BMT) is of paramount importance in the maintenance of disease remission, the role played by the autologous T-cell response in antitumor immune surveillance is less defined. We evaluated the emergence of antileukemia cytotoxic T-lymphocyte precursors (CTLp's) and the correlation of this phenomenon with maintenance of hematologic remission in 16 children with acute myeloid leukemia (AML), treated with either chemotherapy alone (5 patients) or with autologous BMT (A-BMT, 11 patients). Antileukemia CTLp's were detectable in 8 patients in remission after induction chemotherapy; none of them subsequently had a relapse. Of the 8 patients who did not show detectable CTLp frequency while in remission after induction chemotherapy, 7 subsequently experienced leukemia relapse. In patients undergoing A-BMT, molecular fingerprinting of the TCR-Vβ repertoire, performed on antileukemia lines, demonstrated that selected antileukemia T-cell clonotypes, detectable in bone marrow before transplantation, survived ex vivo pharmacologic purging and were found in the recipient after A-BMT. These data provide evidence for an active role of autologous T cells in the maintenance of hematologic remission and also suggest that quantification of antileukemia CTLp frequency may be a useful tool to identify patients at high risk for relapse, thus potentially benefiting from an allogeneic antitumor effect.

In previous studies, we showed the possibility of expanding in vitro polyclonal CTL lines directed against patient leukemia cells using effector cells derived from both HLA-matched and HLA-mismatched hematopoietic stem cell donors. Some CTL lines, especially those derived from an HLA-disparate donor, displayed residual alloreactivity against patient nonmalignant cells. In this study, we evaluated the possibility of separating in vitro CTLs with selective graft-versus-leukemia (GVL) activity from those potentially involved in the development of graft-versus-host disease (GVHD) through single T-cell cloning of antileukemia polyclonal CTL lines. We showed that CTLs that were expanded from a single T-cell clone (TCC), able to selectively kill leukemia blasts and devoid of alloreactivity towards nonmalignant cells, can be obtained from antileukemia alloreactive polyclonal CTL lines. TCCs expressed a wide repertoire of different T-cell receptor (TCR)-Vβ families, mainly produced IFNγ and interleukin 2, irrespective of CD8 or CD4 phenotype, and could be extensively expanded in vitro without losing their peculiar functional features. The feasibility of our approach for in vitro separation of GVL from GVH reaction opens perspectives for using TCCs, which are selectively reactive towards leukemia blasts, for antileukemia adoptive immune therapy approaches after hematopoietic stem cell transplantation, in particular from HLA-mismatched donors. (Cancer Res 2006; 66(14): 7310-6)

Nos últimos vinte anos, nosso serviço recebeu os pacientes com a suspeita de Leucemia Mielóide Aguda (LMA) provenientes de todas as regiões do estado. Entre março de 1980 e dezembro de 1999 analisamos 195 pacientes com idades superior a 12 e inferior a 70 anos, apresentando LMA "de novo" excetuando o subtipo M3. Na década de 80 foram registrados 102 pacientes: 47 homens e 55 mulheres. Destes, 84 receberam quimioterapia de indução com Citarabina e Daunorrubicina (esquema "7+3"), resultando no índice de remissão de 51% (43/84). As médias de sobrevidas livre de doença e global foram dez meses em 35% e 12 meses em 13% respectivamente. De jan/90 a dez/93 houve 41 novos diagnósticos e todos foram submetidos à quimioterapia com esquema "7+3" atingindo a taxa de 66% de remissão. As sobrevidas livre de doença e global foram estatisticamente (p

Background Polycythemia vera (PV) is a subgroup of myeloproliferative neoplasm (MPN) BCL-ABL1 negative. The current therapy of PV should be aimed at preventing vascular complications and avoid increasing the risk of leukemic transformation. The therapy response monitoring is based in the European LeukemiaNet (ELN) unified definition of clinical resistance and intolerance to hydroxycarbamide in polycythaemia vera consensus process, published by Barbui T et al in Br J Haematol 2010;148(6):961-963. Objectives We conducted a study to assess in our clinical practice the aplicability of the standard criteria for resistance and intolerance proposed by ELN in patients (pts) with PV that have been treated with hydroxycarbamida (HU). Methods This is a retrospective study in a cohort of pts with PV enrolled in a single Hematology University center in South Brazil. All pts were treated according to PV guidelines, and the response monitoring was based on clinical practice. All database was compared to standard criteria proposed by ELN. Intolerance /resistance was defined by: a) need for phlebotomy to keep hematocrit < 45% after 3 months of at least 2 g/d of HU or b) uncontrolled myeloproliferation (ie, platelet count > 400 x109/L and white blood count (WBC) > 10 x109/L) after 3 months of at least 2g/d of HU or c) failure to reduce massive splenomegaly by 50% as measured by palpation or failure to completely relieve symptoms related to splenomegaly after 3 months of at least 2 g/d of HU or d) absolute neutrophil count < 1.0 x109/L or platelet count < 100 x109/L or hemoglobin < 10 g/dL at the lowest dose of HU required to achieve a complete or partial clinicohematologic response or e) presence of leg ulcers or other unacceptable HU related nonhematologic toxicities, such as mucocutaneous manifestations, GI symptoms, pneumonitis or fever at any dose of HU. Results We analyzed data from 33 patients with PV assisted in the last five years in our outpatient clinical data. The ELN criteria for resistance and intolerance were accessed in these patients. At diagnosis, 42,4% of pts were younger than 61yo, and 54,5 were male. Arterial hypertension, diabetes mellitus and dyslipidemia were identified on 21, 2 and 7 pts, respectively. Only one patient was tobacco smoker at diagnosis. Total of 5 pts showed WBC > 15 x109/L, and 7 pts showed platelets > 450 x109/L. Massive splenomegaly is a rare PV manifestation in our series, occurring in 2 pts. Five patients complained of symptoms related to PV as pruritus and vasomotor phenomena at diagnosis. Less than 5% of patients had been treated with 2 g of HU for more than 3 months. In daily practice, when the patient presented hematologic toxicity, the HU was decreased and, if the hematocrit was over 45%, an occasional phlebotomy was performed. In relation to platelets (less than 400 x 109/L) and leucocyte (less than 10 x109/L) counts, these targets were not used exclusively in the clinical practice to change treatment. The intolerance was easily discriminated in patients with leg ulcers and other non-hematological events. Conclusion These criteria were done based on an expertise consensus for international criteria standardization for clinical studies. Its application in a retrospective study, using clinical daily practice data is not adequate. The reason is that in the last years the main target to treat patients was the hematocrit above 45%, the exact number of platelets and leucocytes is still not a consensus to define resistance, so different counts had been used to guide treatment, we rarely used HU doses above 1500 mg/daily to treat our patients and massive splenomegaly was observed in very few patients. These criteria should be used most for prospective studies. Disclosures No relevant conflicts of interest to declare.

Background Treatment of chronic myeloid leukemia with imatinib leads to disease remission in a majority of patients (pts), but in a subgroup of pts controlling the disease remains a challenge. One of the proposed prognostic factors for identifying this subset of pts is the treatment response in the first months of imatinib therapy. The definitions of response, warning signs and failure to treatment, with the identification of pts at greater risk of progression or failure, were revised and published in 2013 by the European Leukemia Net group. Aims To apply the new recomendations of ELN2013 in order to verify the evolution of the patients according to the response criteria at 12 months (mo) of imatinib therapy. Methods Retrospective study in a cohort of patients with CP-CML from a southern Brazilian database. All patients received imatinib 400mg as first or second-line therapy. Patient evaluation and response criteria followed the ELN2013 criteria and were classified in 3 groups according to the cytogenetic and molecular responses at 12 mo: optimal, warning and failure. An event was defined as any of the following while on therapy: death from any cause, loss of complete hematologic response, loss of complete cytogenetic response, discontinuation of therapy for toxicity or lack of efficacy, or progression to accelerated phase or blastic phase. Results Data from 98 pts with a median follow-up (FU) time of 40 mo was analysed. At 12 mo of imatinib therapy, 35 pts (36%) had optimal response according to the ELN2013 criteria. 26 (26,5%) were classified as warning and 37 (37,5%) as failure. Within the pts with optimal response, only 4 (11%) have had any event, with a median time-to-event (TTE) of 36 mo; in the warning group the event rate and TTE were 3 (12%) and 28 mo, respectively. There were no significant differences in the results between these two groups. On the other hand, within the pts with failure, 24 (65%) presented an event during FU with a TTE of 19 mo. This difference was significant compared to the two previous groups. Interestingly, within the warning group, 12 pts (46%) developed major molecular response (MMR) at any point during FU, while only 12 (32%) pts achieved RMM in the failure group. Conclusion In this cohort of CP-CML pts is established the diference in the event rate between the pts who achieve optimal or warning responses at 12 mo of imatinib treatment when compared with those with failure criteria, according to the new ELN2013 recomendations. Despite having some late responders, atention must be paid in pts in the failure group as they are in greater risk of progression or failure. As demonstrated in this analysis, the ELN2013 criteria can be applied in this population in the clinical practice. Disclosures: No relevant conflicts of interest to declare.

Abstract 4394 Introduction and objectives: Studies with mesenchymal stem cells (MSCs) have shown its benefits in hematology, mainly for Graft-versus-host disease (Lancet 371:1579–86, 2008), with three unsettled matters: (1)MSCs expansion in medium supplemented with Fetal Calf Serum (FCS) and its risk of xenoreaction (Blood 89:776–9, 1997); (2)The optimal number of cells needed for therapy is not yet defined, but there is an empirical indication for 2×106células/Kg with the need to optimize expansion, number and time wise; and (3)the utilization of third party donors. This study was designed to determine the superiority or no-inferiority of the Platelet Lysates (PL) over FCS on the expansion of MSC, the optimal cell plating density and days between each pass, and to investigate if in our conditions total nucleated cells (TNC) obtained from the washouts of HSCT explants can expand to be used at clinical grade. Methods and Results: TNC were removed from the filters and bags used in the HSCT (Cytotherapy 11:403–13, 2009) and after the first passage were plated in different concentrations (2000/cm2, 3000/cm2, 4000/cm2, 5000/cm2, 6000/cm2 and 7000/cm2) with 10% FBS or 10% PL, and the number of days reach 80% of confluence was observe (Transfusion, 49:2680–5, 2009). Next, cultures with the same plating density were fed either with 10% PL or 10% FCS and were trypsinized after seven days and counted to analyze how much they have grown in that time period. And finally, cultures were allowed to growth up to Passage 3 (P3) to test the ability to obtain clinical grade number of cells. The proliferation of mesenchymal stem cells in the presence of PL and SFB was averaged 11.88 and 2.5 times, respectively, in a period of 7 days (p = 0.005). The highest concentration of plating cells using PL, took less time (6 days) to reach confluence as compared with the three lower (7.55 to 8.55 days) (p = 0.005), and at P3 with PL we obtained from 10×109 up to 10 × 1011 cells. Conclusion: This study suggests that the PL is the best choice as a supplement to expand MSC, and allow the proliferation of a sufficient number of MSC at P3 for clinical use obtained from the washouts of HSCT explants. Disclosures: No relevant conflicts of interest to declare.

Abstract 4423 Background Treatment of chronic myeloid leukemia with imatinib leads to disease remission in a majority of patient, but in some patients (pts) controlling the disease remains a challenge. One of the proposed prognostic factors for identifying this subset of pts is the treatment response in the first months of therapy. Objectives We conducted a study to evaluate the importance of the early complete cytogenetic response (CCyR) and the factors associated with its achievement. Methods This is a retrospective study in a cohort of pts with chronic-phase chronic myeloid leukemia (CP-CML) enrolled in 14 Hematology centers in South Brazil. All pts received imatinib 400mg as first or second-line therapy. Early-imatinib treatment was considered when imatinib started before 12 months (mo) from diagnosis. Patient evaluation and response criteria followed the ELN recommendations. The ACE-27 (Adult Comorbidity Evaluation-27) is a 27 item comorbidity index for patients with cancer and assign weights from 1 to 3 based on the dysfunction grade of each condition (mild, moderate and severe, respectively). An ACE-27 score was applied to each patient. Imatinib suspensions were considered if superior to 20 days at any point during therapy. EFS was measured from the start of imatinib to the date of any of the following events while on therapy: death from any cause, loss of complete hematologic response, loss of complete cytogenetic response, discontinuation of therapy for toxicity or lack of efficacy, or progression to accelerated phase or blastic phase. Results We analyzed data from 450 pts with CP-CML diagnosed since 1990. The median age at diagnosis was 48 yr (4 – 85) and 55% were male. The median time from diagnosis to imatinib was 7 mo (0 – 178) and 71% pts were early-imatinib treated. Prior therapy with interferon was used in 60% pts. The median of follow-up was 47 mo. With 6 months of imatinib therapy, 198 pts (44%) achieved CCyR. In this group, the four year cumulative incidence of events was 33 (17%) and the EFS was 75,5%. 252 (56%) were not in CCyR at 6 months of therapy. In this group, a greater proportion of cumulative of events was observed: 86 (34%), and the EFS was 62,3%. This difference was significant (P=0,03; Figure 1). In this group of pts, 63% achieved CCyR after 6 months any time during follow up and the median time for CCyR in these pts was 17 months. The chance of achieving major molecular response (MMR) during follow up was 79% for the pts with CCyR at 6 months compared to 53% for the group with no CCyR at 6 months (P Conclusions A great proportion of pts achieve CCyR after 6 months of imatinib therapy, nevertheless, the pts who achieve CCyR by 6 months of therapy have greater proportion of major molecular response and event-free survival. Imatinib therapy should be started as soon as possible and additional efforts must be taken to avoid nonadherence. Finally, special attention should be given to pts with comorbidities as their results tend to be worse. Disclosures: No relevant conflicts of interest to declare.

Abstract 4425 Adherence to imatinib therapy has proven to be a major determinant of treatment results, but the degree of impact and the determinants of nonadherence are still contradictory. There is no information regarding adherence to imatinib therapy in the Brazilian public health system. The aims of this study were to identify the characteristics related to treatment interruptions and nonadherence and to examine how these interruptions affect treatment responses and survival. Materials and Methods We conducted a retrospective study in a cohort of patients (pts) with CP-CML enrolled in 14 Hematology centers in South Brazil. All pts received imatinib 400mg as first or second-line therapy. Early-imatinib treatment was considered when imatinib started before 12 months (mo) from diagnosis. Patient evaluation and response criteria followed the ELN recommendations. The ACE-27 (Adult Comorbidity Evaluation-27) is a 27 item comorbidity index for patients with cancer and assign weights from 1 to 3 based on the dysfunction grade of each condition (mild, moderate and severe, respectively). An ACE-27 score was applied to each patient. Imatinib suspensions were considered if superior to 20 days at any point during therapy. Two levels of analysis were performed: all kinds of interruptions (nonadherence and toxicity) and only nonadherence ones. Information for nonadherence was taken from medical and pharmacy registers (pt self-report, missing scheduled appointments and pill counts). Results We analyzed data from 185 pts with CP-CML diagnosed since 1990. The median age at diagnosis was 48 yr (4 – 85) and 55% were male. The median time from diagnosis to imatinib was 7 mo (0 – 178) and 71% pts were early-imatinib treated. Prior therapy with interferon was used in 70% pts. The median of follow-up was 47 mo. Treatment interruption was observed in 63/185 patients (34%) and was related to toxicities in 35/63 pts (55%) and to nonadherence in 28/63 pts (45%). The adherence rate was 85%. In a multivariate analysis, only late-onset imatinib treatment (Odds Ratio [OR]=36,05; p Conclusions In this cohort, a substantial proportion of pts failed to take imatinib properly, decreasing the chances of disease control. The late onset of imatinib therapy correlates with lower adherence, so front-line imatinib therapy should be started as soon as possible. Special attention should be given to pts with severe comorbidities, as they are more prone to suffer side effects or to lack adherence. Finally, pts who interrupted treatment had lower CCyR, MMR and EFS. Clinical and patient characteristics related to nonadherence Disclosures: No relevant conflicts of interest to declare.

Abstract 2300 Introduction: Imatinib mesylate (Gleevec) treatment for Chronic Myelogenous Leukemia (CML) was first introduced in Brazil in 2003, initially used as second line therapy for patients resistant or intolerant to interferon. In 2004 imatinib was adopted as front-line therapy for chronic phase (CP) and clinical experience improving since then. Close monitoring of responses achievement at scheduled time has proven to provide good predictive value for progression and event-free survival. Failure and sub-optimal responses correspond to indications for dose change or therapy switching and the identification of patients at greater risk for such events has a vital role. The aim of this study is to evaluate the impact of temporary imatinib therapy discontinuation on achievement of Major Cytogenetic Response (MCyR) and event-free survival (EFS). Materials and Methods: During the period of 1990 to 2010 a total of 185 patients from 7 CML treatment centers from Rio Grande do Sul, south Brazil, with a confirmed diagnosis of CML (Philadelphia chromosome positive [Ph+]) at CP under imatinib treatment were retrospectively analyzed. A major cytogenetic response was considered complete plus partial cytogenetic responses (Ph+ less than 35%). At least 20 metaphases were analyzed for a cytogenetic response to be evaluable. Temporary treatment discontinuation (TTD) corresponds to 20 days or more off-medication for any reason during the follow-up. Were included patients in imatinib second-line and first-line therapy. Early-imatinib treatment was considered when imatinib started before 12 months from diagnosis and late-imatinib treatment when more then 12 months lapse. EFS was measured from the start of imatinib to the date of any the following events while on therapy: death of any cause, therapy failure, any response loss, disease progression, definitive treatment discontinuation or therapy change. Descriptive statistics and Kaplan-Meier analysis (to estimate event-free survival [EFS]) were performed using SPSS software. Results: The median age at diagnosis was 48 years (range, 4–85 years) median of follow-up was 47 months (range, 7–113 months) and 55% of male sex. Preferential previous treatment was interferon in 70% of the patients and 71% were early-imatinib treatment. TTD was observed in 63/185 patients (34%) and was related to toxicities in 35/63 patients (55%), including hematological and non-hematological. Nonadherence was attributed to the remaining TTD, 28/63 patients (44%). Late-imatinib patients had significant more TTD (62%) than early-imatinib patients (26,2% [p Conclusion: In our cohort, patients with TTD were associated with lower rate of MCyR and it may be a risk factor for failure or sub-optimal responses to imatinib therapy. TTD also has a negative effect in terms of EFS in patients under imatinib treatment, possibly related to worsen cytogenetic disease control. The late onset of imatinib therapy correlates with more toxicity leading to treatment interruptions and front-line imatinib therapy should be started as soon as possible. Special attention should be given to patients who presents with side effects of any nature that could preclude the correct use of the medication. Close monitoring and early management of such adverse reactions, frequent assessment of compliance should be warrant as effort to guarantee the best chance for therapy success. Disclosures: No relevant conflicts of interest to declare.

Abstract 4557 INTRODUCTION: Advanced low grade non-Hodgkin Lymphomas have many and varied treatment options. For patients with relapsed or refractory disease, outcome following only chemotherapy protocols remains poor. The standard Conditioning Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) might be an alternative for relapsed low grade non-Hodgkin lymphomas, but its high Transplant Related Mortality (TRM), varying from 24% to 54%, accounts for a lower overall survival in this group. Reduced Intensity Conditioning (RIC) HSCT has been shown to be a good alternative to myeloablative regimens, with lower TRM, Graft versus Lymphoma Effect, and appears to be associated with improved outcome, presenting a 3 years disease free survival and overall survival from 32% to 66% and from 32% to 73%, respectively, depending on factors such as disease stage before transplantation. PATIENTS, METHODS AND RESULTS: Sixteen heavily pretreated patients with low grade non-Hodgkin Lymphoma (NHL) were submitted to RIC HSCT with matched related donors at the Bone Marrow Transplantation Unit at HCPA between the period of September 2002 to October 2009. The mean age was 43 years and were 7 patients male and 9 female. Fifty percent (8) of the patients had refractory disease pre-HSCT, 43.8% (7) were at third complete remission (CR) and 6.2% (1) at second CR. Median of CD34/kg infused was 10.7 × 106 and the median of days for engraftment was 14.53. Conditioning regimens were Fludarabine + Cyclophosphamide in 3 patients, Fludarabine + Melphalan in 7, Fludarabine + Cyclophosphamide + Rituximab in 2, Fludarabine + Cyclophosphamide + Melphalan in 1, Cyclophosphamide + Total Body Irradiation (TBI) in 1 and Fludarabine + Cyclophosphamide + TBI in 2. Acute Graft versus Host Disease (aGVHD) occurred in 50%, with 37.5% of those were steroids resistant; and 62.5% of the patients evolved to chronic GVHD, with 80% of them classified as extensive. Chimerism from 9 patients was analyzed, and 89% of them were complete. Mean overall survival was 2.95 years; 62.5% of patients were alive within 1 year and 40% within 3 years. TRM was 6.66%. Eight patients died, five of them were transplanted with refractory disease. Only 2 patients died of relapse, 5 of infections and 1 of aGVHD. CONCLUSION: Low grade NHL patients treated at HCPA with RIC HSCT had an overall survival and TRM comparable to the observed at other centers, appearing as a good alternative for this heavily treated group of patients with less toxicity than myeloablative regimens. Disclosures: No relevant conflicts of interest to declare.

Abstract 5096 Background Deferasirox is a once-daily oral iron chelator with established dose-dependent efficacy for treating transfusional iron overload. The retrospective multicenter Brazilian trial included patients (pts) from 14 sites of 10 states with a variety of transfusion-dependent anemias and was designed to evaluate the efficacy and safety of fixed starting doses of deferasirox based on transfusion history, with subsequent dose titration based on serum ferritin (SF) trends. Data were available from 105 eligible pts at 6 months of treatment and 73 pts from 1-year follow-up period. Methods Pts (aged ≥ 2 yrs) had transfusion-dependent anemia with a history of multiple transfusions (>20 transfusions) and/or SF levels ≥ 1000 ng/mL and serum creatinine level < the upper limit of normal (ULN). Deferasirox starting dose was 10-30mg/kg/day depending on transfusion requirements and subsequent dose adjustments of 5-10 mg/Kg/day (range 0–35 mg/kg/d) were done every 3 months based on changes in SF and safety parameters. Efficacy was assessed monthly by measuring change from baseline in SF levels. Safety was evaluated on a monthly basis according to the incidence and type of adverse events and measurement of laboratory parameters, including serum creatinine and liver enzyme levels. Results 105 pts (40 M, 65 F; mean age 25.0±16.6 yrs) were enrolled; 46% (n=48) aged 40 units of red blood cell (RBC); 71.5% (n=75) were on regular RBC transfusion, 56% of the pts required < 2 RBC units/month and 44% between 2 and 4 RBC units/month. Only 63% (n=66) had received prior chelation therapy: deferoxamine (DFO; 51.4%) or DFO/deferiprone combination (11.4%). Sixty-four (61%) pts started on 20 mg/kg/d and 41(39%) > 20-30 mg/kg/d, 15.2% of pts had dose increases at a median of 24 weeks after treatment initiation. Mean ± SD SF levels (μg/L) did significantly reduce at 6 months and 12 months compared to baseline (BL) [from 3132.14 ± 2237.47 to 2784.25 ± 1969.7 at 6 months (p=0.0001) and 2327.46 ± 1873.8 at 12 months (p=0.005)]. The proportion of patients with SF levels < 2000, 2000-3000 and > 3000 μg/L from BL to 6 and 12 months by percentage of patients changed from 36% to 47.5% and 52%; from 26% to 26.5% and 24.5%; from 38% to 26% and 23%, respectively. No patient discontinued the treatment. No death was reported by the investigators during the study. The most common drug-related (investigator-assessed) AEs were mild, transient diarrhea (n=15; 14.3%), rash (n=5; 4.7%), nausea (n=9; 8.5%) and headache (n=6; 5.7%). Seven pts (6.6%) had serum creatinine value >33% above BL on two consecutive visits, 3 (2.8%) of whom had creatinine increases above the ULN; there were no progressive increases or renal failure. Eleven (10.5%) pts had an increase in alanine aminotransferase < 5x ULN but no one experience increases ≥ 5x ULN; levels were already elevated in all of them. Conclusions This first multicenter Brazilian study confirms deferasirox efficacy in achieving a reduction of iron load across a wide range of pts with transfusion-related iron overload. It also supports the clinical approach to fixed starting dose of deferasirox based on iron intake from ongoing blood transfusions and current iron burden with subsequent individual dose titration every 3 months according to SF trends and safety markers. Deferasirox was generally well tolerated in pediatric and adult pts with a safety profile consistent with data from previous clinical trials. The availability of deferasirox as a once-daily oral iron chelator would potentially facilitate improved compliance, and thereby reduce morbidity and mortality from iron overload. Disclosures No relevant conflicts of interest to declare.

PURPOSE: To compare pediatric and adult therapeutic practices in the treatment of acute lymphoblastic leukemia (ALL) in adolescents. PATIENTS AND METHODS: From January 1997 to December 2007, 34 and 11 adolescents (10 to 20 years of age) were treated according to German pediatric BFM 90 and 95 and adult BFM 84 protocols, respectively. Age, B/T lineage, WBC count, complete remission, cytogenetics, and response to steroids were analyzed. Age, B/T lineage and WBC count were similar. Poor risk-cytogenetics (t (9;22),t(4;11) and hypodiploidy less than 45 chromosomes were present only in BFM 90 and 95 group. Among the different prognostic factors, we retrospectively analyzed the effect of the trial on achieving overall survival (OS) and event-free survival (EFS). RESULTS: OS in 10 years and EFS was, respectively, 68.6% and 68.7% for the pediatric protocol and 31.4% and 21.6% for the adult protocol. CONCLUSION: This study’s findings were similar to others in USA, UK, France, Italy and Holland that clearly demonstrate that current pediatric regimens are more effective for adolescents and may contribute to indicate that adolescents should be included in intensive pediatric protocols. Keywords: leukemia, survival, adolescent.

We ran a study on the prevalence of anemia in the state of Rio Grande do Sul (RS), southern Brazil. RS is in a sub-tropical Latin American area, near Uruguay and Argentina. There is no Malaria, a low prevalence of hemoglobinopaties, and HIV/AIDS. METHODS: Capillary blood of children less then 7 and women from 14 to 30 years of age were tested. Socioeconomic status was determined utilizing the classification designed by the Brazilian Association of Market Research Agencies for this purpose. A second sample of 1 year old children was submitted to total blood cell count and serum ferritin determination, and in a third group of individuals, total blood count was done along with stool parasitic analysis. RESULTS: A total of 2198 children and 1999 women with capillary blood measured were analyzed. The median prevalence of anemia in the whole state and the median hemoglobin concentration was 45, 4% and 9.90g/dl for children, and 36.1% and 11 g/dl for women, respectively. Of the aforementioned group, before two years of age, 76% were anemic, and anemia prevalence decreased with age, suggesting a nutrition deficiency. There were very few cases of severe anemia. A significant percentage of children and women belong to the middle class, with access to food and medical care. Of the 356 children tested at one year of age, 67% were anemic and of these, 90% had ferritin < 15μg/L. In the third group of individuals, 31% of 424 children less then 6 years of age were anemic and of these, only 13% tested positive for parasitic infection. CONCLUSION: The prevalence of iron deficiency anemia is very high and constitutes a severe public health problem for 1 year old children in RS, and probably for those younger then 7, and for fertile women as well, irrespectively of their socioeconomic level. Micronutrients supplementation has being neglected in RS health system. The definition of anemia plays a central role in this and has to be addressed if we want to overcome the biologic factors involved in childhood psychosocial development in Brazil.