INTRODUÇÃO: A leucemia promielocítica aguda (LPA) é um subtipo distinto de leucemia mielóide aguda (LMA), caracterizado pela presença de um acúmulo de promielócitos anormais na medula óssea e/ou sangue periférico, riscos de coagulopatias e por alterações cromossômicas estruturais envolvendo sempre o locus gênico para o receptor alfa do ácido retinóico (RAR). Corresponde morfologicamente aos subtipos M3 e M3variante de LMA, segundo a Classificação Franco- Américo- Britânica (FAB) e ao subtipo de LMA associada à translocação recíproca e balanceada entre os cromossomos 15 e 17[t(15;17)] e variantes, segundo a classificação da Organização Mundial de Saúde. O curso clínico da LPA tem sido modificado, nos últimos anos, de uma leucemia aguda rapidamente fatal para um dos mais curáveis subtipos de LMA. A introdução de agentes terapêuticos que atuam diretamente na lesão molecular, como o ATRA e o Trióxido de Arsênico, teve grande impacto na sobrevida da LPA. A eficácia do tratamento é dependente do rearranjo genético presente nas células leucêmicas, o diagnóstico morfológico é sugestivo da alteração genética, devendo ser rapidamente confirmado por técnicas de citogenética molecular. MÉTODOS: Utilizando a citogenética convencional e molecular (FISH) com sondas de fusão para o rearranjo PML-RAR e de ruptura para o gene RAR, analisou-se 62 pacientes portadores de LPA, diagnosticados por estudo morfológico/imunofetípico no HC-FM/USP entre os anos de 1997 a 2006. RESULTADOS: Dos 62 pacientes analisados, 37 (59,7%) apresentaram a t(15;17)(q22;q21) visível no cariótipo; destes, 26 (42,0%) apresentaram a t(15;17) como anormalidade clonal isolada, 10 (16,1%) apresentaram outras alterações cromossômicas clonais em adição a t(15;17) e um paciente (1,6%) apresentou uma variante complexa da t(15;17). Dezoito pacientes (29%) tiveram a confirmação da presença da t(15;17)-rearranjo PML-RAR através da técnica de FISH-fusão e sete (11,3%) não apresentaram ruptura no RAR. Ausência de sangramento ao diagnóstico (p<0,02) e a presença de morfologia M3v (p<0,01) se associaram à ausência ruptura no RAR. A taxa de sobrevida global (SG) em dois anos, entre os 55 pacientes que apresentaram a t(15;17)-rearranjo- PML-RAR ao diagnóstico citogenético, foi de 49,28%. Duas variáveis prognósticas mostraram estar estatisticamente relacionadas à pior taxa de SG nesse estudo: idade acima de 60 anos e presença de morfologia de M3v. A taxa de Sobrevida Livre de Doença em dois anos nesses pacientes foi de 72,10%.CONCLUSÃO: Cerca de 11% dos pacientes diagnosticados para LPA, através de estudo morfológico/imunofenotípico, não apresentaram diagnóstico citogenético compatível para esta doença. Na ausência de sangramento ao diagnóstico e na presença de morfologia M3v o teste de FISH deve ser priorizado. / INTRODUCTION: Acute promyelocytic leukemia (APL) is a distinct subtype of acute myeloid leukemia (AML), characterized by clonal expansion of myeloid precursors blocked at promyelocytic stage, risks of coagulopathy and presence of chromosomal translocations involving RAR (retinoic acid receptor ) gene. Corresponds to the M3 and M3variant subtypes of AML, according to the French-American-British (FAB) classification and the subtype of AML associated with balanced reciprocal translocation between chromosomes 15 and 17 [t (15; 17)] and variants, according to the World Health Organization classification. The clinical APL course has been changed in late years, from highly fatal to highly curable subtype of AML. The introduction of therapeutic agents that act directly on the molecular lesion, such as ATRA and arsenic trioxide, had a great impact on survival of APL. The efficacy of treatment is dependent on genetic rearrangement present in the leukemia cells, the morphologic diagnosis although predictive of the specific genetic lesion genetic, should be quickly confirmed by molecular techniques. METHODS: We analysed cytogenetics findings in 62 patients diagnosed as promyelocytic leukemia by morphological and immunophenotypic studies at the Hematology Service of Clinical Hospital of Sao Paulo Medical School from 1997 to 2006. For this, we used karyotype and FISH with PML-RARA fusion translocation and RARA break-apart probes. RESULTS: Of the 62 patients studied, 59.7% showed the t(15;17)(q22;q21) visible in the karyotype [42.0% had t(15;17) as the sole clonal abnormality, 16.1% showed other additional abnormalities and 1.6% had a complex variant of t(15;17)], 29% had the confirmation of the rearrangement PML-RAR through the FISH-fusion technique and 11.3% showed no break in RAR. No bleeding at diagnosis (p<0.02) and the presence of M3v morphology (p<0.01) were associated to no RAR rearrangement. The 24months overall survival of 55 patients with t(15;17) confirmed by cytogenetics was 49.28%. Two parameters were associated to worse rate of overall survival in this study: age > 60 years and M3v morphology . The 24 months disease-free survival was 72.10%. CONCLUSION: 11,3% of patients diagnosed as promyelocytic leukemia by morphological and immunophenotypic studies, showed no consistent cytogenetic diagnosis for this disease. In the absence of bleeding at diagnosis and in the presence of the M3v morphology, FISH test should be prioritized.

INTRODUÇÃO: A leucemia promielocítica aguda (LPA) é um subtipo distinto de leucemia mielóide aguda (LMA), caracterizado pela presença de um acúmulo de promielócitos anormais na medula óssea e/ou sangue periférico, riscos de coagulopatias e por alterações cromossômicas estruturais envolvendo sempre o locus gênico para o receptor alfa do ácido retinóico (RAR). Corresponde morfologicamente aos subtipos M3 e M3variante de LMA, segundo a Classificação Franco- Américo- Britânica (FAB) e ao subtipo de LMA associada à translocação recíproca e balanceada entre os cromossomos 15 e 17[t(15;17)] e variantes, segundo a classificação da Organização Mundial de Saúde. O curso clínico da LPA tem sido modificado, nos últimos anos, de uma leucemia aguda rapidamente fatal para um dos mais curáveis subtipos de LMA. A introdução de agentes terapêuticos que atuam diretamente na lesão molecular, como o ATRA e o Trióxido de Arsênico, teve grande impacto na sobrevida da LPA. A eficácia do tratamento é dependente do rearranjo genético presente nas células leucêmicas, o diagnóstico morfológico é sugestivo da alteração genética, devendo ser rapidamente confirmado por técnicas de citogenética molecular. MÉTODOS: Utilizando a citogenética convencional e molecular (FISH) com sondas de fusão para o rearranjo PML-RAR e de ruptura para o gene RAR, analisou-se 62 pacientes portadores de LPA, diagnosticados por estudo morfológico/imunofetípico no HC-FM/USP entre os anos de 1997 a 2006. RESULTADOS: Dos 62 pacientes analisados, 37 (59,7%) apresentaram a t(15;17)(q22;q21) visível no cariótipo; destes, 26 (42,0%) apresentaram a t(15;17) como anormalidade clonal isolada, 10 (16,1%) apresentaram outras alterações cromossômicas clonais em adição a t(15;17) e um paciente (1,6%) apresentou uma variante complexa da t(15;17). Dezoito pacientes (29%) tiveram a confirmação da presença da t(15;17)-rearranjo PML-RAR através da técnica de FISH-fusão e sete (11,3%) não apresentaram ruptura no RAR. Ausência de sangramento ao diagnóstico (p<0,02) e a presença de morfologia M3v (p<0,01) se associaram à ausência ruptura no RAR. A taxa de sobrevida global (SG) em dois anos, entre os 55 pacientes que apresentaram a t(15;17)-rearranjo- PML-RAR ao diagnóstico citogenético, foi de 49,28%. Duas variáveis prognósticas mostraram estar estatisticamente relacionadas à pior taxa de SG nesse estudo: idade acima de 60 anos e presença de morfologia de M3v. A taxa de Sobrevida Livre de Doença em dois anos nesses pacientes foi de 72,10%.CONCLUSÃO: Cerca de 11% dos pacientes diagnosticados para LPA, através de estudo morfológico/imunofenotípico, não apresentaram diagnóstico citogenético compatível para esta doença. Na ausência de sangramento ao diagnóstico e na presença de morfologia M3v o teste de FISH deve ser priorizado. / INTRODUCTION: Acute promyelocytic leukemia (APL) is a distinct subtype of acute myeloid leukemia (AML), characterized by clonal expansion of myeloid precursors blocked at promyelocytic stage, risks of coagulopathy and presence of chromosomal translocations involving RAR (retinoic acid receptor ) gene. Corresponds to the M3 and M3variant subtypes of AML, according to the French-American-British (FAB) classification and the subtype of AML associated with balanced reciprocal translocation between chromosomes 15 and 17 [t (15; 17)] and variants, according to the World Health Organization classification. The clinical APL course has been changed in late years, from highly fatal to highly curable subtype of AML. The introduction of therapeutic agents that act directly on the molecular lesion, such as ATRA and arsenic trioxide, had a great impact on survival of APL. The efficacy of treatment is dependent on genetic rearrangement present in the leukemia cells, the morphologic diagnosis although predictive of the specific genetic lesion genetic, should be quickly confirmed by molecular techniques. METHODS: We analysed cytogenetics findings in 62 patients diagnosed as promyelocytic leukemia by morphological and immunophenotypic studies at the Hematology Service of Clinical Hospital of Sao Paulo Medical School from 1997 to 2006. For this, we used karyotype and FISH with PML-RARA fusion translocation and RARA break-apart probes. RESULTS: Of the 62 patients studied, 59.7% showed the t(15;17)(q22;q21) visible in the karyotype [42.0% had t(15;17) as the sole clonal abnormality, 16.1% showed other additional abnormalities and 1.6% had a complex variant of t(15;17)], 29% had the confirmation of the rearrangement PML-RAR through the FISH-fusion technique and 11.3% showed no break in RAR. No bleeding at diagnosis (p<0.02) and the presence of M3v morphology (p<0.01) were associated to no RAR rearrangement. The 24months overall survival of 55 patients with t(15;17) confirmed by cytogenetics was 49.28%. Two parameters were associated to worse rate of overall survival in this study: age > 60 years and M3v morphology . The 24 months disease-free survival was 72.10%. CONCLUSION: 11,3% of patients diagnosed as promyelocytic leukemia by morphological and immunophenotypic studies, showed no consistent cytogenetic diagnosis for this disease. In the absence of bleeding at diagnosis and in the presence of the M3v morphology, FISH test should be prioritized.

Malignant transformation of cell is characterized by genomic instability that involves unbalanced changes besides other things. We analyzed genomic aberrations, promoter methylation and mutations of several clinically relevant genes using I-FISH, mFISH, mBAND, CGH array, SNP array, MLPA, MS-MLPA and MS-PCR methods. We focused on two groups of patients well known for frequent appearance of unbalanced changes - patients with malignant brain tumors (gliomas) and patients with myelodyspastic syndromes (MDS). In patients with low grade glioma (WHO grade I - II), the codeletion of 1p/19q (82,6% oligodendrogliomas and oligoastrocytomas), mutation of IDH1/IDH2 genes (87% WHO grade I-II gliomas), copy neutral loss of heterozygozyty of 17p (72,2% astrocytomas) and higher presence of unbalanced aberration in astrocytomas belongs to the most frequent findings. We described yet unpublished methylation of MLH3 gene promoter in 60,9% oligodendrogliomas and in 27,3% astrocytomas. We also observed clonal evolution in patients with recurrent tumors. We studied secondary rearrangements of deleted chromosome 5 in patients with MDS and complex karyotype and we described its most recurrent translocation partners and breakpoints. We observed chromothripsis in 49% of these patients and it was frequently associated with...

The thesis focuses mostly on discovering unrevealed causes of pathologic phenotype symptoms of patients with whom no pathologic changes in genetic material were detected by common cytogenetic methods. All samples were examined by a chip method array-CGH (comparative genomic hybridization) which detects aberrant spots without any knowledge of where they are located in the genome. In some cases the method was used to verify or specify the finding that was diagnosed during previous genetic testing. The patients were examined by this method in an accredited genetics laboratory GENvia, s.r.o. in 2013 and partly also in 2014. The theoretical part of the thesis focuses on the role of the common cytogenetic method and its diagnostic use. I also describe the basic principle of the array-CGH method and its use in prenatal and postnatal diagnostics. The practical part of the thesis describes results of all examined patients. But mostly it focuses on pediatric patients where the diagnosis correlates with their clinical symptoms. All the results were verified by another method used for the particular diagnosis. Some results were verified by FISH (fluorescence in situ hybridization) method, other ways of the results verification are described as well. In total 8 pathologic findings were discovered in patients up to 12...

As Síndromes mielodisplásicas (SMD) são doenças clonais da célula progenitora hematopoética, cursando com citopenias, medula óssea displástica e tendência à evolução para leucemia. As SMD secundárias estão associadas a fatores de risco como doenças congênitas (Anemia de Fanconi), doenças hematológicas adquiridas (aplasia medular, HPN), exposição à quimioterápicos (alquilantes, inibidores de topoisomerase II) e radioterapia e substâncias químicas (benzeno, petróleo). Agentes imunossupressores associados ou não a fatores hemopoéticos particularmente utilizados para tratamento da Aplasia medular também se associam à SMD secundária. A OMS recentemente adotou o termo síndrome mielodisplásica/neoplasia mielóde (SMD/NM) relacionada à terapêutica para englobar casos de neoplasias mielóides que preencham critérios morfológicos não somente de SMD, mas também de leucemia mielóide aguda (LMA) ou neoplasias mieloproliferativas. O objetivo do trabalho foi analisar dados clínicos, morfológicos e citogenéticos de 42 portadores de SMD/NM secundária em uma coorte de pacientes diagnosticados no SH-HCFMUSP no período de 1987 a 2008. Vinte e três pacientes (54,8%) eram homens, com mediana de idade de 53,5 (4-88) anos. 45,2% eram portadores de doenças onco-hematológicas, 26,2% de anemia aplástica, 14,3% de tumores sólidos e 14,3% de outras doenças (auto-imunes e transplante de órgãos sólidos). 33% dos pacientes utilizaram exclusivamente QT, 26% combinação QT e RT, 2% RT isolada e 28% agentes imunossupressores. Cinco (11,9%) pacientes haviam sido submetidos a TCTH autólogo para tratamento de doença oncohematológica prévia. A mediana da latência entre a doença primária e a SMD secundária foi de 85 meses (23- 221 meses). Oito pacientes foram submetidos ao TCTH alogênico aparentado para tratamento da SMD secundária. Anemia, neutropenia, plaquetopenia e blastos circulantes foram observados em 64,3%, 54,8%, 78,6% e 26,2% dos casos respectivamente. Cerca de 1/3 dos aspirados medulares apresentavam hemodiluição, 29,7% apresentavam hipocelularidade global, 62,2% apresentavam contagem de blastos superior a 5% e 14,3% sideroblastos em anel acima de 15%. Displasia da série eritróide, granulocítica e megacariocítica foi observada em 79,4%, 77,1% e 68,2% dos casos respectivamente. A histologia medular realizada em 22 casos revelou hipocelularidade global, ALIPs e nódulos linfóides em 9,1%, 23,8% e 40,9% dos casos. A detecção por imunoistoquímica de células CD34>1%, CD117>1%, agrupamento de células CD34+ e de CD117+ e da proteína p53+ foi observada respectivamente em 77,2%, 82,3%, 59%, 29,4% e 33,3% dos casos. Anormalidades clonais foram observadas em 84,3% dos casos, com grande predomínio das não balanceadas (96%), sendo 37% com monossomia 7, 44,4% cariótipos complexos e 18% com outras anormalidades . A mediana de sobrevida de sobrevida global foi de 5,7 meses, pacientes submetidos ao TCTH alogênico para tratamento da SMD/NM secundária tiveram mediana de 40 meses (p=0,007). Fatores associados à pior sobrevida incluíram: doença oncohematológica prévia, baixa contagem plaquetária, elevação de DHL e ferritina, presença de células CD117+ agrupadas, imunoexpressão positiva da p53, citogenética anormal, IPSS intermediário II ou alto risco. Nenhum parâmetro estudado do aspirado medular se associou à sobrevida. Houve tendência à associação da imunoexpressão positiva de p53 a cariótipo anormal e IPSS de maior risco. Não se observou associação entre a presença de ALIP, porcentagem de blastos na morfologia medular e células CD34+ e CD117+. Estes dados reforçam a importância da análise citogenética e da imunoistoquímica da biópsia de medula óssea para diagnóstico e prognóstico das SMD secundárias e do TCTH alogênico no seu tratamento. Mais estudos com maior número de casos devem ser realizados para confirmar a importância do escore IPSS na SMD secundárias, provavelmente substituindo a porcentagem de blastos ao aspirado medular, pela presença de células precursoras detectadas por imunoistoquímica / Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell disorders, characterized by cytopenias, dysplastic bone marrow (BM) and propensity to progress to acute myeloid leukemia. Secondary MDS are associated with risk factors such as congenital disorders (Fanconis anemia), acquired bone marrow failures, exposure to chemotherapy (alkylating agents, topoisomerase II inhibitors) agents and radiation and chemicals (benzene, petroleum). Immunosuppressive agents associated with hematopoietic growth factors are also associated with secondary MDS. The WHO classification has recently adopted the term therapy-related myeloid neoplasms for cases of myeloid malignancies that fulfill morphological criteria not only for MDS but also for AML or myeloproliferative neoplasms.The aim of the study was to analyze clinical, morphological and cytogenetic features of 42 patients with secondary MDS/MN in a cohort of patients diagnosed at our institution from 1987 to 2008. 23 patients (54.8%) were male, median age 53.5 (4-88) years. 45.2% had primary hematologic malignancies, 26.2% aplastic anemia, 14.3% solid tumors and 14.3% other diseases (autoimmune diseases and solid organ transplantation). 33% had undergone chemotherapy alone, 2% RT alone, 26% both modalities and 28% immunosuppressive agents. Five (11.9%) patients had undergone autologous HSCT for treatment of previous malignancies. The median latency between the primary disease and secondary MDS/MN was 85 (23-221) months. Eight patients underwent allogeneic HSCT (allo- HSCT) for treatment of related secondary MDS. Anemia, neutropenia, thrombocytopenia and peripheral blasts were observed in 64.3%, 54.8%, 78.6% and 26.2%, respectively. BM aspirates was poorly representative in 1/3 of cases, 29.7% global hypocellularity, 62.2% more than 5% of blast counts and 14.3% more than 15% of ring sideroblasts. Dysplasia in erythroid, granulocytic and megakaryocytic series was observed in 79.4%, 77.1% and 68.2%, respectively. Twenty two BM biopsies were performed. Global hypocellularity, ALIP and lymphoid nodules were shown in 9.1%, 23.8% and 40.9%. The immunohistochemistry showed more than 1% of CD34+ and CD117+ cells, clusters of CD34+ and CD117+ and immunoexpression of p53 protein in 77.2%, 82.3%, 59%, 29.4% and 33.3%, respectively. Clonal abnormalities were observed in 84.3% of cases with high prevalence of unbalanced (96%) rearrangements. 37% showed monosomy 7 and 44.4% complex karyotypes. The median overall survival was 5.7 for all patients and 40 months for patients treated with allo-HSCT (P=0.007). Hematologic malignancies, low platelet count, serum high LDH and ferritin, detection of CD117+ clusters, positive immunoexpression of p53, abnormal cytogenetics, intermediate-II or high-risk IPSS groups were associated with poor survival. No parameter studied from bone marrow aspirate had impact in survival. p53 expression was associated to abnormal karyotype (P=0.092) and IPSS risk (P=0.054). There was no association between the presence of ALIP, BM blast counts and immunoexpression of CD34+ and CD117+. Our study shows that cytogenetic analysis and BM immunohistochemistry are very important in diagnosis and prognosis, and that allo-HSCT could improve the survival of secondary MDS/MN. More studies with larger numbers of cases should be conducted to confirm the importance of the IPSS for secondary MDS, probably replacing the bone marrow aspirate blast counts by the immunohistochemistry detection of precursor cells

A leucemia mielóide aguda ainda apresenta altos índices de mortalidade em adultos, exceção feita à leucemia promielocítica. A otimização dos protocolos de tratamento tem sido muito discutida há 3 décadas, com resultados ainda insatisfatórios. Fatores prognósticos como idade, cariótipo e tolerância à consolidação com altas doses de citarabina guardam relação com a melhor sobrevida. Com o objetivo de avaliar diferentes protocolos de tratamento e validar estes e outros fatores prognósticos, conduzimos um estudo retrospectivo no Hospital das Clínicas da Universidade de São Paulo, analisando prontuários médicos e os eventos relacionados à leucemia mielóide aguda, de 1978 a 2007. Analisamos 400 pacientes tratados curativamente e achamos que idade abaixo de 60 anos (27% vs 7%), cariótipo favorável (53% vs 28% vs 5%) e administração de doses totais de citarabina, principalmente se acima da mediana de 45,45 gramas (68% vs 44% vs 21%) tem impacto positivo na sobrevida global em 5 anos, sendo o uso de altas doses de citarabina um fator independente. A positividade para mieloproxidase, classificação FAB e protocolo de tratamento não mostraram associação estatisticamente significante para melhores índices de sobrevida. Pudemos concluir que, se os protocolos de indução não apresentam diferenças estatísticas, a consolidação intensiva com altas doses de citarabina em pacientes abaixo de 60 anos tem impacto independente na sobrevida global, com resultados ainda melhores quando a dose total é maior ou igual a 45,45 gramas. O cariótipo também foi validado em nossa população / Acute myeloid leukemia in adults is still a highly fatal disease, except for acute promyelocitic leukemia. The optimization of treatment protocols has been debated for three decades, without satisfactory results. Prognostic factors like age, kariotype and consolidation with cytarabine in high dosis seem to correlact with a better overall survival. We conducted a retrospective study in the General Hospital of University of Sao Paulo analyzing medical records and acute myeloid leukemia outcomes to compare different treatment protocols used through 1978 to 2007. We also intended to validate international prognostic factors as the ones cited in our population. We analyzed 400 patients treated with curative intention and found better overall survival in 5 years regarding age less than 60 years (27% vs 7%), favorable karyotipe (53% vs 28% vs 5%) and high dosis cytarabine in consolidation, meanly if total dose was at least the median of 45,45 g (68% vs 44% vs 21%). Consolidation with high dosis cytarabine was an independent predictor of better overall survival. No estatistical differences were seen regarding myeloperoxidase positivity, induction protocol and FAB classification. We concluded that, if the induction protocols seem to be no different in results, consolidation with high dosis cytarabine for patients under 60 years has impact in overall survival, being even better when the total dosis is at least 45,45 g. Karyotipe has also been validated in our study population

As Síndromes mielodisplásicas (SMD) são doenças clonais da célula progenitora hematopoética, cursando com citopenias, medula óssea displástica e tendência à evolução para leucemia. As SMD secundárias estão associadas a fatores de risco como doenças congênitas (Anemia de Fanconi), doenças hematológicas adquiridas (aplasia medular, HPN), exposição à quimioterápicos (alquilantes, inibidores de topoisomerase II) e radioterapia e substâncias químicas (benzeno, petróleo). Agentes imunossupressores associados ou não a fatores hemopoéticos particularmente utilizados para tratamento da Aplasia medular também se associam à SMD secundária. A OMS recentemente adotou o termo síndrome mielodisplásica/neoplasia mielóde (SMD/NM) relacionada à terapêutica para englobar casos de neoplasias mielóides que preencham critérios morfológicos não somente de SMD, mas também de leucemia mielóide aguda (LMA) ou neoplasias mieloproliferativas. O objetivo do trabalho foi analisar dados clínicos, morfológicos e citogenéticos de 42 portadores de SMD/NM secundária em uma coorte de pacientes diagnosticados no SH-HCFMUSP no período de 1987 a 2008. Vinte e três pacientes (54,8%) eram homens, com mediana de idade de 53,5 (4-88) anos. 45,2% eram portadores de doenças onco-hematológicas, 26,2% de anemia aplástica, 14,3% de tumores sólidos e 14,3% de outras doenças (auto-imunes e transplante de órgãos sólidos). 33% dos pacientes utilizaram exclusivamente QT, 26% combinação QT e RT, 2% RT isolada e 28% agentes imunossupressores. Cinco (11,9%) pacientes haviam sido submetidos a TCTH autólogo para tratamento de doença oncohematológica prévia. A mediana da latência entre a doença primária e a SMD secundária foi de 85 meses (23- 221 meses). Oito pacientes foram submetidos ao TCTH alogênico aparentado para tratamento da SMD secundária. Anemia, neutropenia, plaquetopenia e blastos circulantes foram observados em 64,3%, 54,8%, 78,6% e 26,2% dos casos respectivamente. Cerca de 1/3 dos aspirados medulares apresentavam hemodiluição, 29,7% apresentavam hipocelularidade global, 62,2% apresentavam contagem de blastos superior a 5% e 14,3% sideroblastos em anel acima de 15%. Displasia da série eritróide, granulocítica e megacariocítica foi observada em 79,4%, 77,1% e 68,2% dos casos respectivamente. A histologia medular realizada em 22 casos revelou hipocelularidade global, ALIPs e nódulos linfóides em 9,1%, 23,8% e 40,9% dos casos. A detecção por imunoistoquímica de células CD34>1%, CD117>1%, agrupamento de células CD34+ e de CD117+ e da proteína p53+ foi observada respectivamente em 77,2%, 82,3%, 59%, 29,4% e 33,3% dos casos. Anormalidades clonais foram observadas em 84,3% dos casos, com grande predomínio das não balanceadas (96%), sendo 37% com monossomia 7, 44,4% cariótipos complexos e 18% com outras anormalidades . A mediana de sobrevida de sobrevida global foi de 5,7 meses, pacientes submetidos ao TCTH alogênico para tratamento da SMD/NM secundária tiveram mediana de 40 meses (p=0,007). Fatores associados à pior sobrevida incluíram: doença oncohematológica prévia, baixa contagem plaquetária, elevação de DHL e ferritina, presença de células CD117+ agrupadas, imunoexpressão positiva da p53, citogenética anormal, IPSS intermediário II ou alto risco. Nenhum parâmetro estudado do aspirado medular se associou à sobrevida. Houve tendência à associação da imunoexpressão positiva de p53 a cariótipo anormal e IPSS de maior risco. Não se observou associação entre a presença de ALIP, porcentagem de blastos na morfologia medular e células CD34+ e CD117+. Estes dados reforçam a importância da análise citogenética e da imunoistoquímica da biópsia de medula óssea para diagnóstico e prognóstico das SMD secundárias e do TCTH alogênico no seu tratamento. Mais estudos com maior número de casos devem ser realizados para confirmar a importância do escore IPSS na SMD secundárias, provavelmente substituindo a porcentagem de blastos ao aspirado medular, pela presença de células precursoras detectadas por imunoistoquímica / Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell disorders, characterized by cytopenias, dysplastic bone marrow (BM) and propensity to progress to acute myeloid leukemia. Secondary MDS are associated with risk factors such as congenital disorders (Fanconis anemia), acquired bone marrow failures, exposure to chemotherapy (alkylating agents, topoisomerase II inhibitors) agents and radiation and chemicals (benzene, petroleum). Immunosuppressive agents associated with hematopoietic growth factors are also associated with secondary MDS. The WHO classification has recently adopted the term therapy-related myeloid neoplasms for cases of myeloid malignancies that fulfill morphological criteria not only for MDS but also for AML or myeloproliferative neoplasms.The aim of the study was to analyze clinical, morphological and cytogenetic features of 42 patients with secondary MDS/MN in a cohort of patients diagnosed at our institution from 1987 to 2008. 23 patients (54.8%) were male, median age 53.5 (4-88) years. 45.2% had primary hematologic malignancies, 26.2% aplastic anemia, 14.3% solid tumors and 14.3% other diseases (autoimmune diseases and solid organ transplantation). 33% had undergone chemotherapy alone, 2% RT alone, 26% both modalities and 28% immunosuppressive agents. Five (11.9%) patients had undergone autologous HSCT for treatment of previous malignancies. The median latency between the primary disease and secondary MDS/MN was 85 (23-221) months. Eight patients underwent allogeneic HSCT (allo- HSCT) for treatment of related secondary MDS. Anemia, neutropenia, thrombocytopenia and peripheral blasts were observed in 64.3%, 54.8%, 78.6% and 26.2%, respectively. BM aspirates was poorly representative in 1/3 of cases, 29.7% global hypocellularity, 62.2% more than 5% of blast counts and 14.3% more than 15% of ring sideroblasts. Dysplasia in erythroid, granulocytic and megakaryocytic series was observed in 79.4%, 77.1% and 68.2%, respectively. Twenty two BM biopsies were performed. Global hypocellularity, ALIP and lymphoid nodules were shown in 9.1%, 23.8% and 40.9%. The immunohistochemistry showed more than 1% of CD34+ and CD117+ cells, clusters of CD34+ and CD117+ and immunoexpression of p53 protein in 77.2%, 82.3%, 59%, 29.4% and 33.3%, respectively. Clonal abnormalities were observed in 84.3% of cases with high prevalence of unbalanced (96%) rearrangements. 37% showed monosomy 7 and 44.4% complex karyotypes. The median overall survival was 5.7 for all patients and 40 months for patients treated with allo-HSCT (P=0.007). Hematologic malignancies, low platelet count, serum high LDH and ferritin, detection of CD117+ clusters, positive immunoexpression of p53, abnormal cytogenetics, intermediate-II or high-risk IPSS groups were associated with poor survival. No parameter studied from bone marrow aspirate had impact in survival. p53 expression was associated to abnormal karyotype (P=0.092) and IPSS risk (P=0.054). There was no association between the presence of ALIP, BM blast counts and immunoexpression of CD34+ and CD117+. Our study shows that cytogenetic analysis and BM immunohistochemistry are very important in diagnosis and prognosis, and that allo-HSCT could improve the survival of secondary MDS/MN. More studies with larger numbers of cases should be conducted to confirm the importance of the IPSS for secondary MDS, probably replacing the bone marrow aspirate blast counts by the immunohistochemistry detection of precursor cells

Cytogenetic analysis of cells of chronic lymphocytic leukemia (CLL) is difficult because of their low proliferative activity. To obtain sufficient number of mitoses for performing chromosomal analysis a suitable stimulation of cell division is needed. Using DSP30/IL2 stimulated cultivation 391 CLL samples were investigated in 5 years' period. The cultivation was showed to have high success rate (96%; 375/391) with also high rate of detection of pathological clones by both karyotype and metaphase FISH analyses (in 84% of samples; 329/391). Almost in half of samples (44%; 171/391) other aberrations than recurrent FISH (i.e. 13q14 deletion, trisomy 12, TP53, ATM genes deletions) were found. Also high frequency of translocations (37%; 144/391), complex karyotypes (28%; 111/391) and clonal evolution, which was detected in one third of all samples (34% of samples with presence of more than two clones; 133/391) and like a new event in disease duration even more frequently (in 39% of samples repeatedly investigated after stimulated cultivation; 21/54), was revealed. The presence of translocations, complex karyotypes and clonal evolution was associated with progressive form of disease (P 0,000003, resp. P 0,0002 and P 0,05/P 0,04). In cases of the recurrent deletions the detailed analysis of metaphase...

A leucemia mielóide aguda ainda apresenta altos índices de mortalidade em adultos, exceção feita à leucemia promielocítica. A otimização dos protocolos de tratamento tem sido muito discutida há 3 décadas, com resultados ainda insatisfatórios. Fatores prognósticos como idade, cariótipo e tolerância à consolidação com altas doses de citarabina guardam relação com a melhor sobrevida. Com o objetivo de avaliar diferentes protocolos de tratamento e validar estes e outros fatores prognósticos, conduzimos um estudo retrospectivo no Hospital das Clínicas da Universidade de São Paulo, analisando prontuários médicos e os eventos relacionados à leucemia mielóide aguda, de 1978 a 2007. Analisamos 400 pacientes tratados curativamente e achamos que idade abaixo de 60 anos (27% vs 7%), cariótipo favorável (53% vs 28% vs 5%) e administração de doses totais de citarabina, principalmente se acima da mediana de 45,45 gramas (68% vs 44% vs 21%) tem impacto positivo na sobrevida global em 5 anos, sendo o uso de altas doses de citarabina um fator independente. A positividade para mieloproxidase, classificação FAB e protocolo de tratamento não mostraram associação estatisticamente significante para melhores índices de sobrevida. Pudemos concluir que, se os protocolos de indução não apresentam diferenças estatísticas, a consolidação intensiva com altas doses de citarabina em pacientes abaixo de 60 anos tem impacto independente na sobrevida global, com resultados ainda melhores quando a dose total é maior ou igual a 45,45 gramas. O cariótipo também foi validado em nossa população / Acute myeloid leukemia in adults is still a highly fatal disease, except for acute promyelocitic leukemia. The optimization of treatment protocols has been debated for three decades, without satisfactory results. Prognostic factors like age, kariotype and consolidation with cytarabine in high dosis seem to correlact with a better overall survival. We conducted a retrospective study in the General Hospital of University of Sao Paulo analyzing medical records and acute myeloid leukemia outcomes to compare different treatment protocols used through 1978 to 2007. We also intended to validate international prognostic factors as the ones cited in our population. We analyzed 400 patients treated with curative intention and found better overall survival in 5 years regarding age less than 60 years (27% vs 7%), favorable karyotipe (53% vs 28% vs 5%) and high dosis cytarabine in consolidation, meanly if total dose was at least the median of 45,45 g (68% vs 44% vs 21%). Consolidation with high dosis cytarabine was an independent predictor of better overall survival. No estatistical differences were seen regarding myeloperoxidase positivity, induction protocol and FAB classification. We concluded that, if the induction protocols seem to be no different in results, consolidation with high dosis cytarabine for patients under 60 years has impact in overall survival, being even better when the total dosis is at least 45,45 g. Karyotipe has also been validated in our study population

Cytogenetic analysis of cells of chronic lymphocytic leukemia (CLL) is difficult because of their low proliferative activity. To obtain sufficient number of mitoses for performing chromosomal analysis a suitable stimulation of cell division is needed. Using DSP30/IL2 stimulated cultivation 391 CLL samples were investigated in 5 years' period. The cultivation was showed to have high success rate (96%; 375/391) with also high rate of detection of pathological clones by both karyotype and metaphase FISH analyses (in 84% of samples; 329/391). Almost in half of samples (44%; 171/391) other aberrations than recurrent FISH (i.e. 13q14 deletion, trisomy 12, TP53, ATM genes deletions) were found. Also high frequency of translocations (37%; 144/391), complex karyotypes (28%; 111/391) and clonal evolution, which was detected in one third of all samples (34% of samples with presence of more than two clones; 133/391) and like a new event in disease duration even more frequently (in 39% of samples repeatedly investigated after stimulated cultivation; 21/54), was revealed. The presence of translocations, complex karyotypes and clonal evolution was associated with progressive form of disease (P 0,000003, resp. P 0,0002 and P 0,05/P 0,04). In cases of the recurrent deletions the detailed analysis of metaphase...