Emmanuelle Boulanger

Prognostic Factors and Outcome of Human Herpesvirus 8-Associated Primary Effusion Lymphoma in Patients With AIDS

PURPOSE Primary effusion lymphoma (PEL) is a rare high-grade B-cell non-Hodgkins lymphoma associated with Kaposi sarcoma-associated herpesvirus/human herpesvirus 8 (KSHV/HHV-8) infection, and is mostly observed in the course of HIV infection. The prognosis is poor, with reported median survival time shorter than 6 months. To date, no prognostic factor has been identified in this subset of lymphoma. PATIENTS AND METHODS We describe here a large series of HIV-infected patients with PEL, including 28 cases diagnosed in six centers during an 11-year time period. Prognosis analysis was performed using a Cox proportional hazard regression model. Statistically significant covariates were further analyzed in a forward, stepwise multivariate model. RESULTS After a median follow-up of 3.8 years (range, 10 months to 10.8 years), nine patients (32%) were still alive, and eight of them remained progression free. The median survival was 6.2 months, and the 1-year overall survival rate was 39.3%. Fourteen patients (50%) achieved complete remission, with a 1-year disease-free survival rate at 78.6%. In a multivariate analysis, only a performance status more than 2 (hazard ratio, 5.84; 95% CI, 1.76 to 19.33) and the absence of highly active antiretroviral therapy (HAART) before PEL diagnosis (hazard ratio, 3.26; 95% CI, 1.14 to 9.34) were found to be independent predictors for shorter survival. CONCLUSION Based on a retrospective series of 28 patients, two prognostic factors were identified as being independently associated with impaired clinical outcome in HIV-related PEL--(1) a poor performance status and (2) the absence of HAART before PEL diagnosis.

Severe ADAMTS13 deficiency in adult idiopathic thrombotic microangiopathies defines a subset of patients characterized by various autoimmune manifestations, lower platelet count, and mild renal involvement.

Abstract: The significance of ADAMTS13 deficiency in adult thrombotic microangiopathy (TMA) remains controversial. In an attempt to define the characteristics of adult TMA with severe ADAMTS13 deficiency, we determined 2 groups of patients on the basis of ADAMTS13 activity (undetectable or detectable). Clinical presentation, laboratory values, autoimmune manifestations, and outcome were compared between the groups. Patients were included retrospectively from 12 centers. All fulfilled the diagnosis criteria of TMA. Patients with a history of transplantation, cancer and chemotherapy, and Centers for Disease Control and Prevention (CDC) stage C human immunodeficiency virus (HIV) infection were not included. Forty-six patients were included. Thirty-one patients had an undetectable ADAMTS13 activity (<5%), and the remaining 15 patients had ADAMTS13 activity of >25%. Severe ADAMTS13 deficiency was associated with a plasmatic inhibitor in 17 cases (55%), suggesting an immune-mediated mechanism. Patients with undetectable ADAMTS13 were more frequently of Afro-Caribbean origin than patients with detectable ADAMTS13 activity (48.4% vs 13.3%, respectively; p = 0.03). As opposed to patients with detectable ADAMTS13 activity, patients with severe ADAMTS13 deficiency displayed various autoimmune manifestations that consisted of nondestructive polyarthritis (4 cases) associated in 1 case with malar rash and extramembranous glomerulonephritis, discoid lupus (3 cases), and autoimmune endocrinopathies, Raynaud phenomenon, and sarcoidosis-like disease (1 case each). In patients with severe ADAMTS13 deficiency, antinuclear antibodies, anti-double-stranded DNA antibodies, and anticardiolipin antibodies were positive in 22 (71%) cases, 3 (9.7%) cases, and 1 (3.2%) case, respectively. One patient fulfilled the criteria for the diagnosis of systemic lupus erythematosus. During follow-up, 1 patient with severe ADAMTS13 deficiency developed antinuclear antibodies, and 3 others developed anti-double-stranded DNA antibodies, in association with neurologic manifestations and anticardiolipin antibodies in 1 case. Patients with severe ADAMTS13 deficiency also had a lower platelet count (12 × 109/L; range, 2-69 × 109/L) and less severe renal failure (estimated glomerular filtration rate: 78 mL/min; range, 9-157 mL/min) than patients with detectable ADAMTS13 activity (49.5 × 109/L; range, 6-103 × 109/L; p = 0.0004, and 15.8 mL/min; range, 5.6-80 mL/min; p < 0.0001, respectively). End-stage renal failure occurred in 1 patient with severe ADAMTS13 deficiency and in 3 patients with detectable ADAMTS13 activity (3.2% vs 21.4%, respectively; p = 0.08). Flare-up and relapse episodes and survival were comparable between the groups. Taken together, these data indicate that adult idiopathic thrombotic thrombocytopenic purpura, as defined by severe ADAMTS13 deficiency, may occur preferentially in a particular ethnic group, and is characterized by severe thrombocytopenia, mild renal involvement, and a wide spectrum of autoimmune manifestations that may be completed during follow-up. Indeed, apparently idiopathic thrombotic thrombocytopenic purpura may be considered a specific autoimmune disease. Abbreviations: ANA = antinuclear antibodies, β2GP1 = β2 glycoprotein 1, dsDNA = double-stranded DNA, ELISA = enzyme-linked immunosorbent assay, ENA = extractable nuclear antigens, GFR = glomerular filtration rate, HIV = human immunodeficiency virus, HUS = hemolytic uremic syndrome, LDH = lactate dehydrogenase, TMA = thrombotic microangiopathy, TTP = thrombotic thrombocytopenic purpura, vWF = von Willebrand factor.

Prospective Study of Rituximab in Chemotherapy-Dependent Human Immunodeficiency Virus–Associated Multicentric Castleman's Disease: ANRS 117 CastlemaB Trial

PURPOSE Single-agent chemotherapy is usually effective in HIV-associated multicentric Castlemans disease (MCD). However, in most patients, chemotherapy cannot be discontinued. PATIENTS AND METHODS To evaluate the efficacy of four weekly rituximab infusions (375 mg/m(2)) after discontinuation of chemotherapy in HIV-associated MCD, 24 patients were enrolled onto a prospective open-label trial. RESULTS At study entry, the median time from MCD diagnosis was 21 months. All patients had stable disease on chemotherapy and were dependent on chemotherapy for a median time of 13 months. The median CD4 cell count was 270 x 10(6)/L, and the plasma HIV RNA was less than 50 copies/mL in 18 patients. One patient died with progressive disease at day 15, and 23 patients completed the four cycles of rituximab. Sustained remission (SR) off treatment at day 60 (primary end point) was achieved in 22 patients (92%). From day 60 to day 365, one patient died with acute respiratory failure of undetermined origin, and four patients experienced relapse. Seventeen patients (71%) were alive in SR at day 365 without specific treatment, and the overall survival rate was 92% (95% CI, 71% to 98%). Rituximab was well tolerated, and the majority of adverse events were mild to moderate infections. Mild exacerbation of Kaposis sarcoma (KS) lesions was observed in eight of 12 patients with previous KS. CONCLUSION Rituximab was both effective and safe in HIV-infected patients with chemotherapy-dependent MCD.

Prognostic value of inhibitory anti‐ADAMTS13 antibodies in adult‐acquired thrombotic thrombocytopenic purpura

In order to assess the prognostic value of inhibitory anti‐ADAMTS13 antibodies in thrombotic thrombocytopenic purpura (TTP), we performed a multicentre prospective study of 33 adult patients with idiopathic acquired TTP. Patients were treated with high‐dose plasma infusion and therapeutic plasma exchange. Patients without (group 1, n = 12) and with (group 2, n = 21) detectable inhibitory anti‐ADAMTS13 antibodies were compared for clinical presentation, treatment and outcome. Both groups were comparable for clinical presentation. All patients in group 1 achieved a sustained complete remission within a median of 7 d [95% confidence interval (CI), 4–18], which required a median plasma volume of 235 ml/kg (range, 131–1251). In group 2, 17 patients achieved a durable complete remission within a median of 23 d (95% CI, 11–32) (P = 0·001). Median plasma volume was 718 ml/kg (range, 219–3107) (P = 0·02). In group 2, there was a trend for more episodes of flare‐up than in group 1 (13 vs. 3, respectively, P = 0·07). Four patients, all from group 2, died (P = not significant). The relapse rate was comparable between both groups. We suggest that TTP with detectable inhibitory anti‐ADAMTS13 antibodies displays a worse prognosis, relative to a delayed platelet count recovery, a higher plasma volume requirement to achieve complete remission, and a trend for more frequent episodes of flare‐up.

High-dose plasma infusion versus plasma exchange as early treatment of Thrombotic thrombocytopenic purpura/hemolytic-uremic syndrome

Thrombotic thrombocytopenic purpura and adult hemolytic-uremic syndrome (TTP/HUS) have a substantial mortality rate even with currently available treatments. Although therapeutic plasma exchange is the recommended treatment of TTP/HUS, this cumbersome procedure may not be available for all patients in an emergency. In this context, plasma infusion may represent an alternative first-line therapy.We compared the effectiveness of high-dose plasma infusion (25–30 mL/kg per day) and therapeutic plasma exchange as first-line treatment of adult TTP/HUS at a single center. Two groups of patients with TTP/HUS were identified according to their initial therapy, that is, high-dose plasma infusion (19 patients) and therapeutic plasma exchange (18 patients). Clinical charts and outcomes were retrospectively analyzed. Endpoints for comparison were the duration of platelet counts below 150 × 109/L and LDH levels above normal values; the volumes of plasma administered and the duration of treatment; complete remission, relapse, and mortality rates; and treatment-related complications.Patients of the 2 groups had comparable clinical and laboratory features on admission. Sixteen patients achieved complete remission in each group. Median times to recovery of platelet counts and LDH levels were comparable between the 2 groups. Eight patients in the high-dose plasma infusion (HD-PI) group were switched to therapeutic plasma exchange because of fluid overload (6 patients), persistent biologic disturbances (1 patient), or unresponsiveness to high-dose plasma infusion treatment (1 patient). This latter patient had severe TTP/HUS that remained refractory to therapeutic plasma exchange and vincristine, and rapidly died. All 7 remaining patients achieved complete remission with therapeutic plasma exchange. Four patients in the HD-PI group and 3 patients in the therapeutic plasma exchange (TPE) group died. In the HD-PI group, 5 patients experienced a transient nephrotic-range proteinuria during treatment. Main complications in the TPE group were collapse (1 patient) and central venous catheter infection (2 patients) or thrombosis (1 patient). Three patients in each group relapsed.High-dose plasma infusion may be an efficient treatment of TTP/HUS in patients who cannot have early plasma exchange. However, the large volumes of plasma required to reach complete remission may result in fluid overload, which may necessitate subsequent therapeutic plasma exchange.

Systemic non-Hodgkin lymphoma in HIV-infected patients with effective suppression of HIV replication: persistent occurrence but improved survival.

Summary: The incidence of systemic non‐Hodgkin lymphoma (NHL) has only slightly decreased since the introduction of highly active antiretroviral therapy (HAART), suggesting that current antiretroviral strategies do not eliminate the lymphoma risk. This study evaluates the evolving characteristics of HIV and NHL between the pre‐HAART and the post‐HAART periods in 246 HIV‐infected NHL patients from a single institution. Major HIV‐related characteristics were similar in the two periods. Most patients in the post‐HAART period presented with unknown (23%), untreated (16%), or uncontrolled (37%) HIV infection. Despite an increased frequency of advanced stage IV disease in the post‐HAART period (68% vs. 53%, p = .03), the overall survival has improved, with a 2‐year survival probability of 61.6% versus 35.9%, (p < .001). This was associated with an increased complete remission rate (69% vs. 55%, p = .04) and the generalization of more intensive chemotherapy regimens. Most patients (76%) who developed NHL in the post‐HAART period had uncontrolled HIV replication. However, 27 patients (24%) developed NHL despite an effective viral suppression at NHL diagnosis. Patients who were naive to any antiretroviral therapy at NHL diagnosis had an overall survival probability very similar to that of patients with controlled HIV replication. Improvement in the overall survival rate in the post‐HAART period was associated with more intensive chemotherapy regimens, increased complete remission rate, and a likely benefit of continuation or introduction of HAART.

Bortezomib (PS-341) in patients with human herpesvirus 8-associated primary effusion lymphoma

tional, Temecoula, CA, USA) was used as the positive control for all sets of reactions. CDKN1C was not found to be methylated in the control group. All patient samples showed no band corresponding to the methylated allele of CDKN1C, while the band corresponding to the unmethylated allele was clearly visible in all of them (Fig 1). The control methylated DNA included in each set of reactions was always positive. Aberrant DNA methylation of the promoter region of CDKN1C has been found in patients with lymphoid malignancies, such as diffuse large B-cell lymphoma, and adult acute lymphoblastic leukaemia (ALL) (Li et al, 2002). It has also been suggested that its methylation may contribute to the malignant progression of gastric mucosa-associated lymphoid tissue lymphomas (Min et al, 2006) and its inactivation along with TP73 and CDKN2A has been found to predict poor prognosis in adult patients with Ph-negative ALL (Shen et al, 2003). In contrast, methylation of CDKN1C has been reported as an uncommon epigenetic event in patients with follicular lymphoma (Hayslip & Montero, 2006), AML and MDS (Brakensiek et al, 2005). The present study demonstrated the absence of CDKN1C methylation, not only in patients with AML and MDS (consistent with previous studies) but also in patients with MM, MGUS and WM. Our study population included MM patients from all disease stages and patients with myeloid malignancies with various cytogenetic abnormalities. Since mutation and deletion of CDKN1C is also rare in haematological malignancies, our data imply that CDKN1C is not a target for genetic or epigenetic inactivation in these cancer types. In summary, CDKN1C methylation is not a frequent event in myeloid and plasma cell neoplasms, suggesting that it is not an important mechanism in the pathogenesis of these diseases. Eleftheria Hatzimichael Aggeliki Dasoula Leonidas Benetatos Alexandros Makis Justin Stebbing Tim Crook Maria Syrrou Konstantinos L. Bourantas Department of Haematology, Laboratory of General Biology, University of Ioannina, Ioannina, Greece, Imperial College School of Medicine, Hammersmith Hospitals NHS Trust, and Cancer Genetics and Epigenetics Laboratory, The Toby Robins Breakthrough Breast Cancer Centre, Institute for Cancer Research, London, UK. E-mail: me00350@cc.uoi.gr

Mono/oligoclonal pattern of Kaposi Sarcoma‐associated herpesvirus (KSHV/HHV‐8) episomes in primary effusion lymphoma cells

Primary effusion lymphoma (PEL) is a rare lymphoma of B‐cell origin, developed in serous cavities. PEL tumor cells are latently infected with Kaposi sarcoma‐associated herpesvirus (KSHV) and in most cases co‐infected with Epstein‐Barr virus (EBV). In 15 primary PEL tumors including 10 EBV‐positive cases, we analyzed the fused terminal repeat (TR) regions of KSHV episomes using pulsed‐field gel electrophoresis and Southern blot. On the same genomic DNA samples, the cellular clonality was assessed by Southern blot and PCR detection of monoclonal immunoglobulin heavy chain (IGH) VDJ gene rearrangements, associated in the EBV‐infected cases, with Southern blot analysis of the fused termini of EBV episomes. Monoclonal IGH gene rearrangements were detected in 13 tumors using Southern blot, in 11 cases using PCR, and in all cases considering both methods. EBV infection was monoclonal in all EBV‐positive cases. However, only 5 PEL tumors were found to be monoclonally infected with KSHV. In the 10 other cases, we found a biclonal (2 bands; n = 4) or an oligoclonal pattern (3–6 bands; n = 6) of KSHV episomes. We hypothesized that the apparent discrepancy between viral and cellular clonalities in PEL might be due to several phenomena including complex mechanisms of genomic recircularization, insertion of duplicated sequences into the TR region and simultaneous infection of tumor cells with defective KSHV variants. KSHV infection of contaminating nontumoral cells, superinfection from lytically infected cells or viral integration events might also explain the oligoclonal pattern of KSHV infection. Several of these mechanisms, not mutually exclusive, might coexist in a single tumor.

Mutational analysis of TP53, PTEN, PIK3CA and CTNNB1/β-catenin genes in human herpesvirus 8-associated primary effusion lymphoma

This report characterizes the molecular genetic alterations harbored by neoplastic B cells in primary effusion lymphoma. By studying both cell lines and primary tumor samples, the authors show that mutations in P53 and CDKN2A/ARF although uncommon in clinical material, are associated with an EBV-negative immunophenotype Human herpesvirus 8 (HHV-8)-associated primary effusion lymphoma is a rare non-Hodgkin’s lymphoma often associated with Epstein-Barr virus (EBV) infection. Mutations in TP53, PTEN, PIK3CA, CTNNB1/β-catenin genes and deletion of CDKN2A-ARF (p14ARF-p16NK4a I ) locus were investigated in sixteen primary primary effusion lymphoma tumors and seven primary effusion lymphoma cell lines using PCR and sequencing. TP53 mutations were detected in one primary primary effusion lymphoma tumor (6.2%) and two primary effusion lymphoma cell lines (28.6%). BC-3 and BCP-1 cell lines showed PTEN gene mutations, associated with a loss of PTEN protein expression in both cases. No mutations were detected in PIK3CA and CTNNB1/β-catenin hotspot sequences. Only BC-3 contained a homozygous deletion of CDKN2A-ARF locus. Although detected at a higher frequency in primary effusion lymphoma cell lines than in primary primary effusion lymphoma tumors, TP53 and/or PTEN mutations, as well as deletion of CDKN2A-ARF locus are uncommon in primary effusion lymphoma, and are found to correlate with the EBV-negative status of primary effusion lymphoma tumors.

Diffuse large B-cell non-Hodgkin's lymphoma in a patient with autoimmune lymphoproliferative syndrome

Mutations of Fas or Fas ligand genes result in the autoimmune lymphoproliferative syndrome (ALPS) in humans. We report here a diffuse large B‐cell non‐Hodgkins lymphoma occurring in a man with ALPS. Fas‐mediated lymphocyte apoptosis was defective in vitro, owing to a mutation within the death domain of the Fas molecule. High‐dose methotrexate and doxorubicin–based chemotherapy led to complete remission of lymphoma.