Correspondence case-controlled, and clearly identified patients on warfarin and eliminated them. rFVIIa is intended to be an aid in controlling haemorrhage, not a hindrance. What then caused the increase in mortality among the rFVIIa group? There did not appear to be an increased incidence of thromboembolic complications, although an increase in microvascular events cannot be ruled-out. Although inconsistent timing of follow-up head CT scans precludes detailed analysis, there were no trends in improvement or worsening of bleeding between the control and rFVIIa groups to explain the negative results. Finally, another explanation is that rFVIIa may have detrimental effects that have not yet been realized. The limitations of this study include a relatively small study group. Also, it may be possible that the patients who received rFVIIa may have had more severe injuries or a worse prognosis, although we attempted to control for this by matching up the ISS and GCS in our control group. The results of our study conclude that administration of rFVIIa in patients with intracranial haemorrhage caused by trauma appears to be harmful. Given these findings and results
References Bartal, C., Freedman, J., Bowman, K. & Cusimano, M. (2007) Coagulopathic patients with traumatic intracranial bleeding: defining the role of recombinant factor VIIa. Journal of Trauma, 63, 725–732. Brown, C.V., Foulkrod, K.H., Lopez, D., Stokes, J., Villareal, J., Foarde, K., Curry, E. & Coopwood, B. (2010) Recombinant factor VIIa for the correction of coagulopathy before emergent craniotomy in blunt trauma patients. Journal of Trauma, 68, 348–352. Kluger, Y., Riou, B., Rossaint, R., Rizoli, S.B., Boffard, K.D., Choong, P.I., Warren, B. & Tillinger, M. (2007) Safety of rFVIIa in hemodynamically unstable polytrauma patients with traumatic brain injury: post hoc analysis of 30 patients from a prospective, randomized, pla-
of other studies, future use of rFVIIa for traumatic intracranial haemorrhage should be based on results of dedicated randomized clinical trials. Emma P. DeLoughery1 Barbara Lenfesty2 Thomas G. DeLoughery1,3,4 1
Division of Hematology/Medical Oncology, Department of Medicine,
2
Trauma Service, Department of Surgery, Oregon Health Sciences
University, Portland, OR, USA, 3Division of Laboratory Medicine, Department of Pathology, Oregon Health Sciences University, and 4
Department of Pediatrics, Oregon Health Sciences University, Portland, OR, USA. E-mail:
[email protected]
Keywords: warfarin, factor VII, blood coagulation. First published online 30 January 2011 doi:10.1111/j.1365-2141.2010.08437.x
cebo-controlled, double-blind clinical trial. Critical Care, 11, R85. McQuay, Jr, N., Cipolla, J., Franges, E.Z. & Thompson, G.E. (2009) The use of recombinant activated factor VIIa in coagulopathic traumatic brain injuries requiring emergent craniotomy: is it beneficial? Journal of Neurosurgery, 111, 666–671. Narayan, R.K., Maas, A.I., Marshall, L.F., Servadei, F., Skolnick, B.E. & Tillinger, M.N. (2008) Recombinant factor VIIA in traumatic intracerebral hemorrhage: results of a dose-escalation clinical trial. Neurosurgery, 62, 776–786. Nishijima, D.K., Dager, W.E., Schrot, R.J. & Holmes, J.F. (2010) The efficacy of factor VIIa in emergency department patients with warfarin use and traumatic intracranial hemorrhage. Academic Emergency Medicine, 17, 244–251. Stein, D.M., Dutton, R.P., Kramer, M.E., Handley, C. & Scalea, T.M. (2008) Recombinant factor
VIIa: decreasing time to intervention in coagulopathic patients with severe traumatic brain injury. Journal of Trauma, 64, 620–627. Stein, D.M., Dutton, R.P., Kramer, M.E. & Scalea, T.M. (2009) Reversal of coagulopathy in critically ill patients with traumatic brain injury: recombinant factor VIIa is more cost-effective than plasma. Journal of Trauma, 66, 63–72. Sutherland, C.S., Hill, M.D., Kaufmann, A.M., Silvaggio, J.A., Demchuk, A.M. & Sutherland, G.R. (2008) Recombinant factor VIIa plus surgery for intracerebral hemorrhage. Canadian Journal of Neurological Sciences, 35, 567–572. Zaaroor, M., Soustiel, J.F., Brenner, B., Bar-Lavie, Y., Martinowitz, U. & Levi, L. (2008) Administration off label of recombinant factor-VIIa (rFVIIa) to patients with blunt or penetrating brain injury without coagulopathy. Acta Neurochirurgica, 150, 663–668.
Evaluation of mutations in the isocitrate dehydrogenase genes in therapy-related and secondary acute myeloid leukaemia identifies a patient with clonal evolution to IDH2 R172K homozygosity due to uniparental disomy
After their initial identification in high-grade gliomas, acquired heterozygous mutations in the NADPH-dependent isocitrate
dehydrogenase (IDH) 1 and 2 genes (IDH1, IDH2) were recently described in patients with de novo acute myeloid
ª 2011 Blackwell Publishing Ltd, British Journal of Haematology, 152, 665–674
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Correspondence leukaemia (AML) (Mardis et al, 2009) and leukaemic transformation of JAK2 mutation positive myeloproliferative neoplasms (Green & Beer, 2010). These mutations lead to the substitution of arginines in the catalytic site of IDH1/2 resulting in neomorphic enzyme activity with accumulation of 2-hydroxyglutarate (Dang et al, 2009; Gross et al, 2010; Ward et al, 2010). To determine the frequency and pathogenetic impact of these mutations in patients with therapy-related AML (t-AML) or secondary AML (sAML) evolved from myelodysplastic syndromes (MDS), we performed a mutational analysis of the affected arginine residues in the IDH1 and IDH2 genes in 101 individuals with these disorders. Demographic and clinical characteristics of this cohort are presented in Table S1. At t-AML and sAML diagnosis, DNA was isolated from diagnostic peripheral blood or bone marrow samples after Ficoll enrichment, yielding >90% blast cells for direct sequencing. In patients with MDS DNA was directly isolated from bone marrow biopsy specimens without further enrichment. This study was approved by the institutional review board of the Medical University of Graz, Austria, and patients provided informed consent in accordance with the declaration of Helsinki. We identified one IDH1 (R132H) and three IDH2 mutations (2· R140Q and R172K) in 73 patients with t-AML. Thus, the frequencies of mutated IDH1 and IDH2 samples in this t-AML cohort were lower than previously reported for de novo AML (1Æ4% vs. 8Æ5%, P < 0Æ05 with Fisher¢s exact test; and 4Æ1% vs. 15Æ4%, P < 0Æ05 (Mardis et al, 2009; Ward et al, 2010)). In 28 patients with sAML, we found three mutations in IDH2 (10Æ7%; R140Q and 2· R172K) but none in IDH1. All three IDH2 mutations were also detected in bone marrow cells obtained at MDS diagnosis, demonstrating that IDH2 mutations were already acquired during the myelodysplastic phase of the disease. This is in line with a very recent report on IDH mutations in 5%–9% of patients with MDS (Kosmider et al, 2010). Clinical characteristics of the patients with an IDH mutation are summarized in Table I. Intriguingly, five of six patients with IDH mutations (where a karyotype analysis was available) showed no cytogenetic abnormalities, indicating that IDH mutations were associated with a normal karyotype also in these AML subtypes (P < 0Æ05), as has been reported for de novo AML (Mardis et al, 2009; Marcucci et al, 2010; Thol
et al, 2010; Wagner et al, 2010). Given the high prevalence of cytogenetic aberrations in t-AML, this association may also explain the lower frequencies of IDH mutations in individuals with t-AML. Indeed, 75% of our t-AML patients displayed karyotype abnormalities. As expected, all mutations identified at diagnosis of t-AML and sAML were heterozygous. However, one sAML patient showed loss of the wildtype (wt) IDH2 allele at early relapse after autologous stem cell transplantation (Fig. 1, left panel). To reveal the mechanisms leading to homozygosity of mutant IDH2, we performed copy-number variation analysis and heterozygosity mapping using Affymetrix human genomewide single nucleotide polymorphism 6Æ0 arrays. Aside from a del(7)(q21–q36), which was also identified by cytogenetic analysis, we detected copy-neutral loss of heterozygosity of 2p23Æ3–2pter and 15q25Æ1–15qter at relapse but not at diagnosis of sAML (Fig. 1, right panel). Given that the IDH2 gene is located on 15q26Æ1, these results implicate uniparental disomy (UPD) of the region carrying the mutated IDH2 allele during clonal disease evolution. This finding is of particular interest, because a consistent feature of IDH-mutated gliomas and leukaemias has been their lack of reduction to homozygosity. It was suggested that complete loss of wt IDH2 may be detrimental to proliferating cells, because wt IDH2 is crucial for providing NADPH and for the conversion of a-ketoglutarate to citrate in mitochondria (Abdel-Wahab & Levine, 2010; Ward et al, 2010). Accordingly, knock-down of IDH2 was shown to inhibit cell proliferation in a glioma cell line (Ward et al, 2010). In contrast, our patient presented with a highly proliferative disease at relapse with a doubling of peripheral blood blast counts within a few days. Although this highly aggressive phenotype might have been caused by additional genetic alterations found at relapse, these data prove that loss of wt IDH2 is not detrimental to leukaemic cells. Indeed, another patient has recently been described to harbour a homozygous IDH2 R140Q mutation (Thol et al, 2010). In summary, we report IDH mutations in a substantial fraction of t-AML and sAML patients with a normal karyotype. While heterozygous IDH2 mutations were already present in the myelodysplastic phase in individuals with sAML, one patient displayed uniparental disomy of 15q during leukaemic evolution resulting in a homozygous IDH2 R172K mutation.
Table I. Clinical characteristics of patients with IDH mutations at t-AML and sAML diagnosis. UPN
Leukaemia
Age at diagnosis (years)
Primary disease
Karyotype
IDH Mutation
6 29 37 112 3 73 51
t-AML t-AML t-AML t-AML sAML sAML sAML
65 64 75 66 68 54 64
Lymphoma AML Colon carcinoma Rheumatoid arthritis RAEB-t RAEB CMML
46, XY 46, XX NA 46, XY, t(6;12), t(10;13) 46, XX 46, XY 46, XY
IDH2 IDH2 IDH1 IDH2 IDH2 IDH2 IDH2
R140Q R172K R132H R140Q R172K R140Q R172K
Abbreviations: UPN, unique patient number; t-AML, therapy-related acute myeloid leukaemia; sAML, secondary acute myeloid leukaemia; RAEB(-t), refractory anaemia with excess blasts (in transformation); CMML, chronic myelomonocytic leukaemia.
670
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Correspondence
Fig 1. Evolution of an IDH2 R172K mutation to homozygosity in a patient with sAML (UPN 3) due to uniparental disomy. The mutational analysis of IDH2 during disease progression is depicted on the left panel. The screening of mutations was performed by polymerase chain reaction and direct sequencing using primers amplifying exon 4 of IDH2. The right panel displays copy number variation and loss of heterozygosity (LOH) of chromosome 15 in this patient. Affymetrix human genome-wide SNP 6.0 arrays were used according to the manufacturers’ protocol and results were analyzed in comparison to 60 HapMap individuals using Genotyping ConsoleTM Version 4.0.
Conflict of interest
Supporting information
The authors declare no conflict of interest.
Additional Supporting Information may be found in the online version of this article: Table SI. Clinical characteristics of sAML and t-AML patients included in this study. Abbreviations: UPN, unique patient number; sAML, secondary acute myeloid leukaemia; t-AML, therapy-related acute myeloid leukaemia; RA(EB-t), refractory anaemia (with excess blasts in transformation); CMML, chronic myelomonocytic leukaemia; MDS-U, myelodysplastic syndrome-unspecificed; RCMD, refractory cytopenia with multilineage dysplasia; ALL, acute lymphoblastic leukaemia. Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
Acknowledgement This work was supported by Leuka¨miehilfe Steiermark. Monika M. Pichler1 Claudia Bodner1 Carina Fischer2 Alexander J. Deutsch1 Karin Hiden1 Christine Beham-Schmid3 Werner Linkesch1 Christian Guelly2 Heinz Sill1 Albert Wo¨lfler1 1
Division of Haematology, 2Centre for Medical Research, and 3Institute of
Pathology, Medical University of Graz, Graz, Austria.
Keywords: acute myeloid leukaemia, myelodysplastic syndromes, molecular genetics, mutation analysis.
E-mail:
[email protected]
First published online 20 January 2011 doi:10.1111/j.1365-2141.2010.08404.x
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Correspondence
References Abdel-Wahab, O. & Levine, R.L. (2010) Metabolism and the leukemic stem cell. Journal of Experimental Medicine, 207, 677–680. Dang, L., White, D.W., Gross, S., Bennett, B.D., Bittinger, M.A., Driggers, E.M., Fantin, V.R., Jang, H.G., Jin, S., Keenan, M.C., Marks, K.M., Prins, R.M., Ward, P.S., Yen, K.E., Liau, L.M., Rabinowitz, J.D., Cantley, L.C., Thompson, C.B., Vander Heiden, M.G. & Su, S.M. (2009) Cancerassociated IDH1 mutations produce 2-hydroxyglutarate. Nature, 462, 739–744. Green, A. & Beer, P. (2010) Somatic mutations of IDH1 and IDH2 in the leukemic transformation of myeloproliferative neoplasms. New England Journal of Medicine, 362, 369–370. Gross, S., Cairns, R.A., Minden, M.D., Driggers, E.M., Bittinger, M.A., Jang, H.G., Sasaki, M., Jin, S., Schenkein, D.P., Su, S.M., Dang, L., Fantin, V.R. & Mak, T.W. (2010) Cancer-associated metabolite 2-hydroxyglutarate accumulates in acute myelogenous leukemia with isocitrate dehydrogenase 1 and 2 mutations. Journal of Experimental Medicine, 207, 339–344. Kosmider, O., Gelsi-Boyer, V., Slama, L., Dreyfus, F., Beyne-Rauzy, O., Quesnel, B., Hunault-Berger, M., Slama, B., Vey, N., Lacombe, C., Solary, E., Birnbaum, D., Bernard, O.A. & Fontenay, M. (2010) Mutations of IDH1 and IDH2 genes in
early and accelerated phases of myelodysplastic syndromes and MDS/myeloproliferative neoplasms. Leukemia, 24, 1094–1096. Marcucci, G., Maharry, K., Wu, Y.Z., Radmacher, M.D., Mrozek, K., Margeson, D., Holland, K.B., Whitman, S.P., Becker, H., Schwind, S., Metzeler, K.H., Powell, B.L., Carter, T.H., Kolitz, J.E., Wetzler, M., Carroll, A.J., Baer, M.R., Caligiuri, M.A., Larson, R.A. & Bloomfield, C.D. (2010) IDH1 and IDH2 gene mutations identify novel molecular subsets within de novo cytogenetically normal acute myeloid leukemia: a Cancer and Leukemia Group B study. Journal of Clinical Oncology, 28, 2348–2355. Mardis, E.R., Ding, L., Dooling, D.J., Larson, D.E., McLellan, M.D., Chen, K., Koboldt, D.C., Fulton, R.S., Delehaunty, K.D., McGrath, S.D., Fulton, L.A., Locke, D.P., Magrini, V.J., Abbott, R.M., Vickery, T.L., Reed, J.S., Robinson, J.S., Wylie, T., Smith, S.M., Carmichael, L., Eldred, J.M., Harris, C.C., Walker, J., Peck, J.B., Du, F., Dukes, A.F., Sanderson, G.E., Brummett, A.M., Clark, E., McMichael, J.F., Meyer, R.J., Schindler, J.K., Pohl, C.S., Wallis, J.W., Shi, X., Lin, L., Schmidt, H., Tang, Y., Haipek, C., Wiechert, M.E., Ivy, J.V., Kalicki, J., Elliott, G., Ries, R.E., Payton, J.E., Westervelt, P., Tomasson, M.H., Watson, M.A., Baty, J., Heath, S., Shannon, W.D., Nagarajan, R., Link, D.C., Walter, M.J., Graubert, T.A., DiPersio, J.F., Wilson, R.K. & Ley, T.J. (2009) Recur-
ring mutations found by sequencing an acute myeloid leukemia genome. New England Journal of Medicine, 361, 1058–1066. Thol, F., Damm, F., Wagner, K., Gohring, G., Schlegelberger, B., Hoelzer, D., Lubbert, M., Heit, W., Kanz, L., Schlimok, G., Raghavachar, A., Fiedler, W., Kirchner, H., Heil, G., Heuser, M., Krauter, J. & Ganser, A. (2010) Prognostic impact of IDH2 mutations in cytogenetically normal acute myeloid leukemia. Blood, 116, 614–616. Wagner, K., Damm, F., Gohring, G., Gorlich, K., Heuser, M., Schafer, I., Ottmann, O., Lubbert, M., Heit, W., Kanz, L., Schlimok, G., Raghavachar, A.A., Fiedler, W., Kirchner, H.H., Brugger, W., Zucknick, M., Schlegelberger, B., Heil, G., Ganser, A. & Krauter, J. (2010) Impact of IDH1 R132 mutations and an IDH1 single nucleotide polymorphism in cytogenetically normal acute myeloid leukemia: SNP rs11554137 is an adverse prognostic factor. Journal of Clinical Oncology, 28, 2356–2364. Ward, P.S., Patel, J., Wise, D.R., Abdel-Wahab, O., Bennett, B.D., Coller, H.A., Cross, J.R., Fantin, V.R., Hedvat, C.V., Perl, A.E., Rabinowitz, J.D., Carroll, M., Su, S.M., Sharp, K.A., Levine, R.L. & Thompson, C.B. (2010) The common feature of leukemia-associated IDH1 and IDH2 mutations is a neomorphic enzyme activity converting alpha-ketoglutarate to 2-hydroxyglutarate. Cancer Cell, 17, 225–234.
Heparin-induced thrombocytopenia and the utility of the 4Ts score in the Intensive Care Unit
Thrombocytopenia is common in patients admitted to the Intensive Care Unit (ICU), with reported incidence rates of 30–50% (Selleng et al, 2007). The aetiology of thrombocytopenia in this setting is usually consumptive and often multifactorial. One possible cause is heparin-induced thrombocytopenia (HIT). Despite high levels of exposure to heparin in ICU patients, it is perceived that HIT is uncommon with reported incidences of
