Dinesh Bhurani

Evaluating New Markers for Minimal Residual Disease Analysis by Flow Cytometry in Precursor B Lymphoblastic Leukemia

Minimal residual disease is currently the most powerful prognostic indicator in Precursor B lymphoblastic leukemia. Multiparameter flow cytometry is the most commonly used modality. Seventy three B ALL cases and 15 normal marrows were evaluated for expression patterns of leukemia markers (CD38, CD58, CD73) in all 73 cases and CD66c, CD86 and CD123 in 23 cases. CD73 was aberrantly expressed in 90.41% cases and CD86 in 60.87% B ALL cases. Thus addition of these markers in MRD panels can increase the sensitivity of the assay.

Indian Council of Medical Research consensus document for the management of non-hodgkin's lymphoma (high grade)

This consensus document is based on the guidelines related to the management of Non Hodgkins Lymphoma (High grade) in the Indian population as proposed by the core expert committee. Accurate diagnosis in hematolymphoid neoplasm requires a combination of detailed history,clinical examination, and various investigations including routine laboratory tests, good quality histology section (of tumor and also bone marrow aspirate/biopsy), immunostaining, cytogenetic and molecular studies and radiology investigations. The staging system used for adult high grade lymphomas is based on the Ann Arbor system and includes various parameters like clinical, haematology, biochemistry, serology and radiology. Response should be evaluated with radiological evaluation after 3-4 cycles and at the end of treatment based on criteria including and excluding PET. Treatment of high grade lymphomas is based on histologic subtype, extent of disease, and age of the patient. Autologous stem cell transplantation after high dose chemotherapy is effective in the treatment of relapsed NHL. Newer RT techniques like 3 dimensional conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) can significantly reduce radiation doses to surrounding normal tissues in lymphoma patients. Patients should be followed up every 3 to 4 months for the first 2 years, followed by 6 monthly for the next 3 years and then annually.

Incidence and clinical profile of tuberculosis after allogeneic stem cell transplantation

Patients post allogeneic stem cell transplantation (alloSCT) are expected to be at high risk of tuberculosis (TB) owing to underlying immunosuppression. We conducted a retrospective study in patients post alloSCT for clinical features and factors associated with TB.

Haploidentical Stem Cell Transplantation

Allogeneic haematopoietic stem cell transplantation (alloHCT) has emerged as a curative treatment modality for a variety of disorders including haematological malignancies, inherited and acquired bone marrow failure syndromes, congenital immunodeficiencies and errors of metabolism.

Umbilical Cord Blood Banking: Consensus Statement of the Indian Academy of Pediatrics

JustificationPractitioners and people need information about the therapeutic potential of umbilical cord blood stem cells and pros and cons of storing cord blood in public versus private banks.ProcessIndian Academy of Pediatrics conducted a consultative meeting on umbilical cord blood banking on 25th June 2016 in Pune, attended by experts in the field of hematopoietic stem cell transplantation working across India. Review of scientific literature was also performed. All expert committee members reviewed the final manuscript.ObjectiveTo bring out consensus guidelines for umbilical cord banking in India.RecommendationsUmbilical cord blood stem cell transplantation has been used to cure many malignant disorders, hematological conditions, immune deficiency disorders and inherited metabolic disorders, even when it’s partially HLA mismatched. Collection procedure is safe for mother and baby in an otherwise uncomplicated delivery. Public cord blood banking should be promoted over private banking. Private cord blood banking is highly recommended when an existing family member (sibling or biological parent) is suffering from diseases approved to be cured by allogenic stem cell transplantation. Otherwise, private cord blood banking is not a ‘biological insurance’, and should be discouraged. At present, autologous cord stem cells cannot be used for treating diseases of genetic origin, metabolic disorders and hematological cancers. Advertisements for private banking are often misleading. Legislative measures are required to regularize the marketing strategies of cord blood banking.

Ibrutinib to Allogenic Stem Cell Transplant in a Case of Refractory Mantle Cell Lymphoma

Mantle Cell Lymphoma (MCL) remains difficult to treat despite of availability of intensive chemo-immunotherapies with number of patients experience relapse or refractory disease. Possible cure in a relapsed/refractory (R/R) case of MCL has been described after allogeneic hematopoietic stem cell transplantation (alloSCT) [1]. Ibrutinib, a bruton’s tyrosine kinase inhibitor, acts by blocking B cell receptor signaling and has been approved by FDA as a single agent in R/R MCL cases for its favorable efficacy and toxicity profile [2–4]. Maintenance of higher PFS rates in these R/R MCL cases on Ibrutinib requires lifelong treatment with good adherence to dosing schedule. Ibrutinib monotherapy is found to be associated with (a) financial burden, (b) possible relapse in the first 2 years of treatment, and (c) acquired resistance after prolonged therapy; demonstrating poor clinical outcomes [4], which calls for different treatment strategies. These pitfalls of Ibrutinib monotherapy could be salvaged with alloSCT as reported in our current case. Here, we report a case of refractory MCL with prior three lines of chemotherapy before successful treatment with Ibrutinib followed by AlloSCT. A 53 year old male presented with jaundice, significant weight loss, hepatosplenomegaly, large lymphnodal masses at porta and peripancreatic region, and obstructive biliopathy. Lymph node histopathology with immunohistochemistry confirmed MCL, while whole body PET–CT showed extensive disease including extranodal sites and bone marrow infiltrates. Patient was planned for 6 cycles chemotherapy with R-CHOP alternating with R-DHAP followed by autologous SCT (ASCT). He received one cycle of R-CHOP and R-DHAP each, to which he developed grade-IV toxicities (abdominal pain, abdominal distension, loose stools) which required prolonged repeated hospitalization. Therefore, treatment was changed to Rituximab–Bendamustine (R–B) chemotherapy regimen which he tolerated well. Post 4 cycles of R–B chemotherapy, patient showed progression in extent of lymphoma. Further, he received bortezomib and lenalidomide based therapy for 2 cycles but again he showed progressive disease. Patient was considered for Ibrutinib monotherapy followed by alloSCT. He tolerated Ibrutinib therapy well and attained complete remission (CR) after 1 month of therapy. Thereafter, he was received reduced intensity conditioning (Fludarabine and Melphalan) and matched sibling donor peripheral blood stem cell transplantation with Methotrexate and Cyclosporine-A (CSA) for GVHD prophylaxis. Neutrophils and platelets were engrafted on day ? 11 post alloSCT. Serial monitoring for CMV DNA was negative. There was no graft versus host disease while the CSA was tapered off by day 180 post transplant. Serial PET–CT at post transplant 90 days and 18 months showed CR. At 25 months of follow up post alloSCT, patient is disease free. Primary refractory MCL is not uncommon and is a challenge to treat. Ibrutinib is a promising agent for such cases of MCL which has shown a response in nearly 2/3rd of R/R MCL patients [2, 5], but its long term utility is limited by high cost, indefinite therapy and poor long-term survival owing to loss of response because of acquired & Rayaz Ahmed rayazhemat@gmail.com

Haplo-identical Hematopoietic Stem Cell Transplant is a Possible Cure in a Patient with Relapsed Hemophagocytic Lymphohistiocytosis Syndrome

Hemophagocytic lymphohistiocytosis (HLH) is a lifethreatening hyperinflammatory syndrome of uncontrolled immune responses resulting in hypercytokinemia because of underlying primary or acquired immune defect. Currently, the only cure for primary or relapsed HLH is allogenic stem cell transplantation (AlloSCT) [1]. Our report concerns a 13-year-old boy with a relapsed distinctively blurred HLH [2], who achieved prolonged complete remission (CR) after haplo-identical stem cell transplant (Haplo-SCT) following salvage chemotherapy. A previously healthy 11-year-old boy, the youngest son of a healthy nonconsanguineous parents without family history of HLH/similar disorders in first/second-degree relatives was hospitalised at a local hospital with complaints of 106 F fever and hepatosplenomegaly and found to have Brucella infection and histiocyte proliferation in bone marrow (BM). On further investigations, he had raised serum triglyceride, serum ferritin, and low fibrinogen levels, on the basis of which he was diagnosed with HLH. Cerebrospinal fluid was normal. The genetic mutations of HLH were not tested for parents did not give consent for same. He received chemotherapy using HLH2004 protocol and achieved CR. On routine follow up, he was found to have relapse of HLH without any underlying infective stimulus, after 25 months of initial therapy for which he received etoposide-based salvage chemotherapy and attained a second complete remission. Thereafter he was referred to us for alloSCT. He had no HLA matched donor in the family, but had 3/6 HLA match with his mother with negative donor specific anti-HLA antibodies screen. Considering the relapsed nature of HLH and in need of alloSCT lacking a matched HLA donor from family, he received a Haplo-SCT using T cell replete peripheral blood stem cell (PBSC) from his mother with a CD34 cell dose of 6.06 9 10 cells/kg after Fludarabine, cyclophosphamide and TBI (FluCyTBI) conditioning. For GvHD prophylaxis, cyclophosphamide at day ? 3 and ? 4 post SCT was employed. ANC and Platelet Engraftment was achieved at day ? 16 and ? 21 of SCT respectively, and was further confirmed by 100% donor karyotype on FISH for XX analysis of peripheral blood at day ? 30. Acute GvHD (aGvHD), overall grade II with skin and gut involvement, became apparent at day ? 16 which was managed with corticosteroids. By day ? 120, he developed aGvHD of liver, which progressed to grade IV despite being on corticosteroids, etanercept and basiliximab and was controlled after Anti thymocyte globulin (ATG) therapy. He had no major infections except for chronic otitis media and UTI with Enterococcus fecalis. Currently, he has mild chronic GvHD involving oral mucosa and eyes requiring minimal immunosuppression and is disease free with maintenance of complete chimerism at day ? 840 of Haplo-SCT. Use of alloSCT for HLH has remarkably improved the survival and prognosis of patients. Henter et al. [3] demonstrated 62% survival rate at 3 years and 10% of graft failure (GF) among 65 HLH patients treated with alloSCT. Ouachée-Chardin et al. [4] reported a series of 48 primary HLH patients who received alloSCT out of which 60% received haplo-SCT, was found associated with increased treatment related toxicity, poor prognosis and 22% GF rate. Uppuluri et al. [5] reported a case of 2 young children with & Rayaz Ahmed rayazhemat@gmail.com

Florid Plasmacytosis in Angioimmunoblastic T Cell Lymphoma: A Diagnostic Conundrum

Angio-immunoblastic T-cell lymphoma (AITL) is a rare subtype of non-Hodgkins lymphoma (NHL), accounting for about 1–2% of all NHLs and 15–27% of peripheral T-cell lymphomas [1]. Most patients present with systemic lymphadenopathy, constitutional symptoms or abnormal immunological features. Abnormal laboratory test findings include cytopenias, positive Coomb’s test, polyclonal hypergammaglobulinemia, elevated LDH or presence of autoimmune antibodies. Circulating plasma cells and plasmacytoid lymphocytes have been occasionally detected in AITL patients. However, plasma cells[2 9 10 cells/ll mimicking plasma cell leukemia or exuberant reactive plasmacytosis in bone marrow in the order of [50% plasma cells including atypical forms is infrequently reported in AITL [2, 3]. We reviewed twelve cases of AITL reported in last 5 years at our institution. Bone marrow involvement by AITL was seen in one case (1/ 12 = 8.1%) while two cases (2/12 = 16.6%) revealed extensive bone marrow involvement by plasmacytes along with peripheral blood spillage, that led us to investigate for a coexisting myeloma or plasma cell leukemia. Case 1

A Case of Anastrozole-Induced Erythrocytosis

Anastrozole, a third-generation aromatase inhibitor (AI) is used as adjuvant treatment for post-menopausal women with hormone receptor positive Breast Carcinoma (BCa). Common side effects associated with the use of Anastrozole are skeletal complications, sexual dysfunction, musculoskeletal pain, thromboembolism, cardiac and cerebrovascular disease [1]. We, however, report an unvisited adverse event; erythrocytosis induced with use of anastrozole in patient with BCa. A 65-year-old South Asian, post-menopausal, non-comorbid woman underwent left breast lumpectomy and was diagnosed with Estrogen and progesterone receptor positive BCa stage TxN0M0, for which she was treated with 6 cycles of Docetaxel, Cyclophosphamide, followed by radiotherapy and subsequently started on Anastrozole 1 mg once daily in July 2014. Prior commencing anastrozole, her haemoglobin, and haematocrit levels were 11.4 gm/dl and 34% respectively, while her other blood counts were normal. In December 2017, she was found to have raised haemoglobin and haematocrit levels of 18.6 gm/dl and 59.9% respectively, normal white blood counts of 5230/cumm, platelet counts of 156,000/cumm. She had no symptoms and was normal on physical examination with normal blood pressure. Further tests revealed a normal liver and kidney function tests, a normal serum erythropoietin [EPO] levels of 6.88 [reference 3.70–31.5]. Bone marrow aspiration and biospy showed no evidence of myeloproliferation or dysplasia. JAK2 V617 and exon12 were not mutated and BCR-ABL translocation by PCR was negative. Her chest X-Ray, echocardiography and pulmonary function tests were normal. A diagnosis of secondary erythrocytosis due to Anastrozole was considered for which phlebotomy was started on regular intervals to maintain a haemoglobin level of 12–15 gm/dl. After first phlebotomy, her haemoglobin dropped to 16.2 gm/dl. AI has been known to increase testosterone levels by preventing the breakdown of testosterone into estradiol. Androgens have been associated with increased red blood cell production [2]. Gonzales and Chaupis [3] has described that testosterone causes erythrocytosis by increasing the serum EPO levels, but in our case serum EPO levels were normal, which indicates that AI induced erythrocytosis by EPO independent mechanism. On Naranjo assessment scale, the association of erythrocytosis with AI use was found to be probably associated with a score of 7, justifying our diagnosis. WHOUMC scale also depicted probable causality association of use of anastrozole with erythrocytosis [4]. To the best of our knowledge, four cases have been reported, in which the first two cases involved two boys with hypogonadism treated with letrozole and subsequently developed erythrocytosis. The third case involved 79-year-old postmenopausal lady with localized estrogen receptor positive (ER?) BCa treated with exemestane developed erythrocytosis and the forth case involved 57-year-old postmenopausal lady with invasive ER ? BCa treated with neo-adjuvant chemotherapy followed by an anastrozole and developed secondary erythrocytosis along with raised testosterone levels and haematocrit became normal after cessation of anastrozole [5]. & Narendra Agrawal narendra_ag1@rediffmail.com

Diagnostic Dilemmas in Aggressive Large B Cell Neoplasms with Enigmatic Immunohistochemical Profile: How Far Should We Investigate?

Aggressive large B-cell neoplasms include many disparate entities with marked differences in morphology, phenotype, molecular pathogenesis and clinical behavior, which affect the prognosis and require tailored therapy [1]. Differential diagnosis of plasmablastic lymphomas, from plasma cell myeloma with plasmablastic morphology, as well as Diffuse Large B-Cell Lymphoma (DLBCL) with secretory differentiation is still a common problem due to a lack of a distinctive phenotype [2]. Here, we report a case where multiple diagnostic modalities were applied in tandem to reach a conclusive diagnosis but still a consensus was difficult to achieve. A 46-year-old female presented with complaints of leftsided chest pain, radiating to the left subscapular region for one week and dyspnea for last 1–2 months. Physical examination was unremarkable. Complete hemogram showed HB = 97 g/L, TLC = 6.9x10/L with a differential count of N:40 L:46 M:011 Blast:01 My:01 PC:01; nRBC:4/100 WBCs and Platelet count = 83 9 10/L. Peripheral smear showed rouleaux formation with thrombocytopenia and occasional plasmacytoid cells. Serum calcium levels and renal function tests were within normal limits. Viral serology was negative. Skeletal survey showed no lytic/sclerotic lesions. Chest CT showed multiple nodules in bilateral lung upper lobes, paravertebral soft tissue masses, largest being at D4 para-vertebral region measuring 3.1 cm 9 2.6 cm and extending into left neural foramina, along with mild left pleural effusion. Magnetic Resonance Imaging of whole spine showed multiple para-vertebral soft tissue lesions with focal bony involvement and neural foramina compromise. A working clinico-radiological diagnosis of multiple myeloma was made and further work-up was advised. Serum LDH was 1158 U/L. Serum beta2-microglobulin level was markedly raised (1541.6 nmol/L). Serum protein electrophoresis showed a distinct M-band in the gamma region (15 g/L), which was found to be of IgA/kappa subtype on serum immunofixation studies. Bone marrow aspiration smears revealed near-total replacement of normal hematopoietic components by large atypical cells (65%) having high N/C ratio, prominent nucleoli and moderate amount of deeply basophilic cytoplasm with some of them showing eccentric nuclei. Bone marrow biopsy as well as the CT guided biopsy from D4 left para-vertebral soft tissue mass showed similar features comprising of diffuse proliferation of large neoplastic cells with central to eccentric, large hyperchromatic nuclei, few of them showing prominent nucleoli with brisk mitosis (Fig. 1). No intra-cytoplasmic or intranuclear inclusions were noted. Overall features were suggestive of a high grade Non Hodgkin Lymphoma (NHL) with plasmablastic differentiation and differential diagnosis included plasmablastic lymphoma, plasmablastic myeloma and DLBCLs with marked secretory differentiation. On IHC using primary backbone markers, these large neoplastic cells were strongly and diffusely positive for CD20, CD138, CD79A, bcl-2 and LCA with clonal restriction for kappa light chain(ISH) (Fig. 1). EBER expression (by ISH) was negative. In view of diffuse bone Disclaimers: The identity of the patient is not disclosed here in this case.