Iraqi Journal of Hematology

Abstract:
BACKGROUND: Chronic myeloid leukemia (CML) is one of the indolent myeloproliferative neoplasms.
It is characterized by the presence of the Philadelphia chromosome, a translocation between
chromosomes 9 and 22 or BCR‑ABL1 gene.
OBJECTIVES: The aims of this study were to evaluate characteristics of CML patients and their
molecular response to tyrosine kinase inhibitors (TKI) in Erbil city in Iraq.
PATIENTS AND METHODS: Seventy‑six patients with CML were recruited in this retrospective and
prospective study from February 2014 to March 2016, at Nanakaly Hospital for Blood Diseases in Erbil
city – Kurdistan region of Iraq. They were evaluated from clinical point of view and their laboratory
data, and molecular responses to TKI based on polymerase chain reaction were analyzed.
RESULTS: The median age of participants was 45 years; the male: female ratio was 1:0.9. The main
presenting features were abdominal fullness in 66% and splenomegaly in 95% of patients. Nearly 66%
of them had low European Treatment and Outcome Study (EUTOS) score; 70% of patient had major
or complete molecular responses (MMR/CMR). There was a significant difference between patients
who did versus who did not achieve MMR/CMR in hemoglobin level, promyelocyte, and myelocyte
percent, EUTOS, and Sokal scores (P = 0.02, 0.006, 0.03, 0.001, and 0.02, respectively).
CONCLUSION: In the current study, CML patients were at a younger age of onset, and more high
EUTOS score. The majority of patients achieved MMR with frontline Imatinib or Nilotinib and those
who switched from Imatinib to Nilotinib as well.

Abstract:
BACKGROUND: Acute myeloid leukemia (AML) is characterized by an excess number of myeloid
cells in the marrow with maturation arrest and infiltration of bone marrow (BM) and other tissues by
myeloblasts, resulting in BM failure.
OBJECTIVES: The main goal of the present study is to investigate CD200 and CD56 aberrant expression
in CD34‑positive blasts, in newly diagnosed adult AML patients and their relation with the clinical and
hematological parameters, as well as to identify their prognostic significance after induction therapy.
MATERIALS AND METHODS: This was a prospective cross‑sectional study on thirty patients with
newly diagnosed AML, who were tested for the expression of CD200, CD56 using multicolor flow
cytometry and re‑evaluated after induction therapy regimen.
RESULTS: CD200 and CD56 were aberrantly expressed in 53.3% and 20.0%, respectively, while
coexpression of both markers was observed in 13.3%. Interestingly, both markers were expressed
more in monocytic subtypes. Significantly, the induction failure in CD200 + patients was 75%, while
it was 66.7% in CD56+ patients.
CONCLUSION: The findings of this research provide insights that CD200 and CD56 were closely
related to bad prognostic parameters, including high total white blood cell count, low platelet’s counts,
and low response to induction therapy.

Abstract:
BACKGROUND: Immunophenotypic analysis of leukemic cells by multicolor flow cytometry using
different monoclonal antibodies labeled to various flourochromes, is an important, precise and rapid
investigation for diagnosis, classification, prognosis prediction, and minimal residual disease detection
in acute lymphoblastic leukemia (ALL).
OBJECTIVES: The aims of study were to study the expression of CD45, CD34, CD10, human
leukocyte antigen‑DR (HLA‑DR) in B and T‑ALL among 114 Iraqi patients and compare findings
with other reports worldwide.
PATIENTS, MATERIALS AND METHODS: A retrospective cross‑sectional study was conducted
on 114 ALL patients of various age groups from different hematology centers in Baghdad who were
referred to Flowcytometry Department at the Bone Marrow Transplantation Center/Private Nursing
Home Hospital/Medical City for immunophenotypic classification using multi‑color flow cytometry
from the January 1, 2016, to the August 31, 2016.
RESULTS: Out of 114 patients, 71 patients were pediatric patients and 43 were adults. Eighty‑three
patients were classified as B‑cell ALL and 31 patients as T‑cell ALL. There was significant association
between male gender, high white blood cells count and T‑cell ALL subtype. Negative‑dim‑moderate
CD45, positive CD34, and positive HLA‑DR expressions were significantly associated with B‑cell
ALL. Common ALL antigen was seen in 86.7% of the B‑cell ALL patients and was accompanied
cTdT expression. Aberrant myeloid antigens were observed in 22.9% of B‑cell ALL patients and in
35.5% of T‑cell ALL. About 4.8% of the patients with B‑cell ALL had aberrant T‑linage antigens while
6.5% of the patients with T‑cell ALL expressed aberrant B‑cell lineage antigens.
CONCLUSION: Immunophenotypic expression of ALL cells among Iraqi patients is to somewhat in
accordance with various researches worldwide making immunophenotyping flow cytometry a crucial
appliance in diagnosis, classification, risk stratification, and minimal residual disease detection in ALL.

Abstract:
Sinus histiocytosis with massive lymphadenopathy that known as Rosai Dorfman syndrome (RDS)
is a rare histiocytic disease which includes benign lymph nodes (LN) enlargement with extralymphatic
soft tissue involvement. The concomitant presentation of RDS with an adrenal tumor is
rarely encountered among our patients. Here in we describe a middle-aged man, presented with a
chronic history of repeated LN enlargement. The nodes had mild local discomfort and tenderness
with associated fever. LN biopsy showed sinus histiocytosis with lymphophagocytosis characterized
as emperipolesis and diagnosis of RDS was decided. After one year, the patient presented with high
blood pressure, raised blood sugar, obesity, and abdominal pain. Computerized tomography showed
a large adrenal mass, and the patient was treated urgently for his malignant blood pressure followed
by surgical excision of the left adrenal mass. The biopsy subsequently revealed non-malignant
adrenal tumor (pheochromocytoma). We are reporting successful treatment of rare case with RDS
concomitantly presented with large adrenal pheochromocytoma. He was treated medically and
surgically, the patient got recovery. RDS is a rare disease but we should consider it in patients with
repeated benign lymphadenopathy. we are emphasizing that knowledge about RDS and its disease
associations may be informative to the general medical community.

Abstract:
BACKGROUND: Hepatitis C virus (HCV) infection is a global public health problem and is a leading
cause of morbidity and death, with regional variations in genotype prevalence.
OBJECTIVES: This study aimed to explore the prevalence of anti‑HCV seropositivity among patients
with hereditary anemias, the association of anti‑HCV seropositivity with selected risk factors and the
common HCV genotypes.
PATIENTS AND METHODS: This prospective descriptive study was carried out on patients with
hereditary anemias from January 2010 through December 2014 registered at the Center for Hereditary
Blood Diseases. A total of 2778 patients (1282 males and 1496 females) were recruited, their mean
age was 13.19 ± 9.40 years. Patients were screened for HCV antibodies using an enzyme‑linked
immunosorbent assay test. Quantitation of the HCV viral load and genotype were assessed using
polymerase chain reaction (PCR).
RESULTS: The frequency of anti‑HCV seropositivity was higher in 2010 (33.7%) and declined
progressively over the following 4 years (31.7%, 20.2%, 10.8%, and 9.2%), respectively. Out of
424 patients with two positive anti‑HCV tests at least 6 months apart, 215 (50.7%) had positive results
with PCR. The most frequent genotype was 4 in 43 (56.5%), followed by 1 in 31 (40.7%) patients;
1a: 21.1% and 1b: 19.6%. A significant association was found between anti‑HCV seropositivity and
type of disease, and deferoxamine pump use, P < 0.05.
CONCLUSIONS: Anti‑HCV seropositivity is declining among multitransfused patients with hereditary
anemias in Basra, Iraq, and genotype 4 is the most common in these patients.

Abstract:
BACKGROUND: The morbidity and mortality in polycythemia vera (PV) are closely associated with
cardiovascular diseases burden and clonal evolution. These complications were primarily attributed to
abnormal rheology consequent to the raised hematocrit, leukocytosis, and thrombocytosis, and in vivo
activation of leukocytes, thrombocytes, and endothelial cells. It has been established that damage of
endothelium determines the release in circulation of specific markers including thrombomodulin (TM),
selectins, and von Willbrand factor (vWF) which are released and favor the formation of cellular aggregates.
OBJECTIVES: The objective of this study is to evaluate the pathophysiological role of endothelial
dysfunction (ED) in relation to increased risk of thrombosis in PV patients.
PATIENTS AND METHODS: In a case–control study, 53 patients enrolled in this study from Al‑Imamain
Al‑Khadimiyan Medical City, and the National Center for Hematology Diseases and Researches. They
comprised of thirty patients with PV with mean age of − 54.87 ± 13.44 years‑and another twenty‑three
patients with secondary polycythemia, whose mean age was 40.13 ± 12.21 years. Another thirty
aged‑ and sex‑matched, non‑smokers healthy volunteers comprised 16 males and 14 females were
also studied, their mean age was = 52.1 ± 11.16 years. JAK2 mutation was assessed for PV group
while Serum erythropoietin (Epo), vWF and TM were determined for all patient and control group.
RESULTS: TM was significantly different among the three studied groups (P < 0.001) as well as vWF
was significantly higher (P < 0.001) in patients with PV as compared to the patients with secondary
polycythemia and controls. Epo level was significantly lower (P = 0.004) in the newly diagnosed
patients with PV when compared to those with a history of thrombosis or longstanding disease. There
is positive correlation between JAK2 and TM (r = 0.431, P = 0.017), while negative correlation with
vWF (r = −0.565, P = 0.001) in PV patients.
CONCLUSION: ED is one of mechanisms that contribute in prothrombogenesis in PV patient.

Abstract:
BACKGROUND: The use of tyrosine kinase inhibitors has dramatically improved the prognosis of
chronic myeloid leukemia (CML). Nilotinib has been reported to be associated with hypothyroidism
and hyperthyroidism.
OBJECTIVES: The current study aims to evaluate the prevalence of thyroid dysfunction in a sample
of Iraqi patients with CML (chronic phase) treated with nilotinib and its possible association with grade
of other hematological parameters.
PATIENTS AND METHODS: Thirty‑one patients with CML and the same number of healthy controls
were enrolled in this cross‑sectional study. All the patients were on nilotinib hydrochloride for at least
6 months.
RESULTS: Approximately 10% of the patients were having hypothyroidism and 3% were hyperthyroid
while the rest (87%) were normal regarding thyroid function. There was a significant difference
between the study and control group in thyroid stimulating hormone levels (P < 0.05) with the level
being higher in the study group.
CONCLUSION: Thyroid dysfunction, particularly hypothyroidism is a clinically important adverse
effect of nilotinib. Monitoring of thyroid function is required for patients taking this drug.

Abstract:
BACKGROUND: Bone marrow examination is crucial diagnostic modality for evaluation of various
hematological and nonhematological disorders. However, marrow aspirate smears and biopsy
sections, even though performed simultaneously, are often assessed at different points of time due
to different processing methods. This sometimes results in discordance in diagnosis which adds to
the diagnostic dilemma and delays the treatment.
AIM: This study aims to compare the diagnostic accuracy and the rate of concordance between the
two modalities of bone marrow examination.
MATERIALS AND METHODS: Three hundred simultaneously performed bone marrow aspirates
and BM trephine biopsies were retrospectively analyzed over a period of 1 year. The presence or
absence of concordance was recorded. The reasons for inconclusive reports were also recorded.
The concordance rates for different hematological disorders were calculated and recorded as high
for >80%, moderate for 50%–80%, and low for <50%. The findings of discordant cases and reasons
for discordance were also tabulated.
RESULTS: A high concordance was found in cases of megaloblastic anemia, leukemias,
non‑Hodgkin’s lymphoma, and multiple myeloma; moderate concordance was found in hypoplastic
marrow and concordance was low in Hodgkin’s lymphoma, chronic myeloid leukemia (CML) in blast
phase, metastatic, and granulomatous involvement of bone marrow.
CONCLUSION: Bone marrow aspiration alone is sufficient for the diagnosis of megaloblastic anemia
and most of the hematological malignancies. Bone marrow biopsy is more appropriate for detection
of disorders with focal marrow involvement such as lymphoproliferative disorders, metastatic cancer,
focal blast crisis in CML, granulomatous lesions, and hypoplastic marrow. However, it is strongly
recommended that both should be reviewed simultaneously to ensure maximum diagnostic accuracy.