Laura Magnano

MYD88 L265P Mutations, But No Other Variants, Identify a Subpopulation of DLBCL Patients of Activated B-cell Origin, Extranodal Involvement, and Poor Outcome

Purpose: Mutations in MYD88 are found in different lymphoproliferative disorders associated with particular biologic characteristics and clinical impact. The aim of this study was to analyze the incidence of MYD88 mutations and its clinical impact in diffuse large B-cell lymphoma (DLBCL). Experimental Design: The incidence, clinicobiological features, and outcome of 213 patients (115 M/98 F; median age, 65 years) with DLBCL treated with immunochemotherapy in a single institution according to MYD88 mutational status as assessed by an allele-specific PCR assay were analyzed. The cell of origin (COO) was determined in 129 cases by gene expression. Results: MYD88 mutations were found in 47 cases (22%), including L265P in 39 and S219C and M232F in 4 cases, respectively. Patients with MYD88 L265P were older, presenting frequent extranodal involvement, and mostly corresponded to activated B-cell like (ABC) subtype, whereas no preference in COO was observed in patients with other MYD88 mutations. Five-year overall survival (OS) for MYD88 wild-type, MYD88 L265P, and other variants was 62%, 52%, and 75%, respectively (P = 0.05). International Prognostic Index (IPI) (HR, 2.71; P < 0.001) and MYD88 L265P (HR, 1.786; P = 0.023) were independent variables predicting OS in the multivariate analysis. However, MYD88 L265P lost its independent value when COO was included in the model. Conclusions: Our findings indicate that MYD88 L265P mutations, but no other variants, identify a subgroup of DLBCL mainly of ABC origin, with extranodal involvement and poor outcome. Clin Cancer Res; 22(11); 2755–64. ©2016 AACR.

Rituximab, plasma exchange and intravenous immunoglobulins as a new treatment strategy for severe HLA alloimmune platelet refractoriness.

Abstract Platelet refractoriness (PR) due to HLA alloimmunization is a common and serious complication of patients receiving long-term packed red blood cell and platelet transfusions. Although most alloimmunized patients will respond to HLA-matched platelets, 20–50% of patients will remain refractory even to matched platelets. Several measures have been reported to overcome this complication, such as intravenous immunoglobulins (IVIG), plasma exchange (PE), protein A column therapy, or rituximab. We report a woman with acute myeloid leukemia secondary to myelodysplastic syndrome who was diagnosed with PR because of HLA alloimmunization. Due to difficulties in finding HLA-compatible platelet donors by cross-reactive groups in our panel of HLA-typed platelet donors, the patient received treatment with rituximab, PEs and IVIG. With this treatment strategy, the presence of HLA antibodies decreased from a panel-reactive antibody (PRA) of 89–0%. This allowed the performance of hematopoietic progenitor cell transplantation with random donor platelets. Rituximab, PE, and IVIG may be an option to overcome severe PR due to poly-specific HLA alloimmunization.

Effectiveness of thrombopoietin-receptor agonists in the treatment of refractory immune thrombocytopenia associated to systemic lupus erythematosus.

To the Editor: Thrombocytopenia is frequent in patients with systemic lupus erythematosus (SLE), occurring in 7% to 30% of patients. Less than 5% present a platelet count of < 50,000/mm3 and they usually respond to first- or second-line therapy [corticosteroids, immunosuppressive agents, intravenous immunoglobulin (IVIG), rituximab, or splenectomy]. However, a significant number of patients will not respond to these treatments or will relapse afterward1. Romiplostim and eltrombopag are 2 thrombopoietin-receptor agonist drugs that were approved in 2008 by the US Food and Drug Administration (FDA) to treat patients with chronic idiopathic thrombocytopenic purpura who have an insufficient response to conventional therapy2,3,4,5. To date, there are only 4 published cases of patients with SLE and immune thrombocytopenia successfully treated with these agents6,7,8,9 and 1 case in whom this treatment was not effective10. We describe 2 additional cases of patients with SLE and refractory immune thrombocytopenia who responded to thrombopoietin-receptor agonists. A 69-year-old woman was diagnosed with SLE in 1992 because of anemia, thrombocytopenia, positive antinuclear antibody (ANA), anti-dsDNA, anti-Sm antibodies, lupus anticoagulant, and hypocomplementemia. In 1999, a laparoscopic splenectomy was performed because of severe immune thrombocytopenia (< 10,000/mm3) that was refractory to high-dose prednisone and IVIG. She maintained a normal platelet count until March 2013 when she presented with mild epistaxis, ecchymosis, and thrombocytopenia of 22,000/mm3 without … Address correspondence to Dr. G. Espinosa, Servei de Malalties Autoimmunes, Hospital Clinic, Villarroel 170, 08036 Barcelona, Catalonia, Spain. E-mail: gespino{at}clinic.ub.es

A gene-expression profiling score for prediction of outcome in patients with follicular lymphoma: a retrospective training and validation analysis in three international cohorts

Background Patients with follicular lymphoma (FL) have heterogeneous outcomes. Predictor models able to distinguish, at diagnosis, patients at high versus low risk of progression are still needed. Methods The primary objective of this study was to use gene-expression profiling data to build a signature predictive of outcome in patients treated in the rituximab era. In a retrospectively assembled training cohort of 134 pretreatment FL patients from the prospective randomized PRIMA trial, we developed an expression-based predictor of progression-free survival (PFS) that was further evaluated in FFPE samples obtained from three independent international cohorts, using NanoString technology. The validation cohorts comprised a distinct set of patients from the PRIMA trial (n=178), a cohort from the University of Iowa/Mayo Clinic Lymphoma SPORE (n=201) and the Hospital Clinic University of Barcelona (n=109). All tissue samples consisted of pretreatment diagnostic biopsies and were confirmed as FL grade 1-3a. The patients were all treated with regimens containing rituximab and chemotherapy, possibly followed by either rituximab maintenance or ibritumomab-tiuxetan consolidation. Findings The expression levels of 395 genes were associated with a risk of progression. Twenty-three genes reflecting both B-cell biology and tumor microenvironment were retained to build a predictive model, which identified a population at an increased risk of progression (p<0.0001). In a multivariate Cox model for PFS adjusted on rituximab maintenance treatment and FLIPI-1, this predictor was found to independently predict progression (adjusted hazard ratio (HR) of the high-risk compared to the low-risk group: 3.68; 95%CI: 2.19-6.17). The digital gene expression data met quality criteria for 460/488 (94%) FFPE samples of the validation cohorts. The predictor performances were confirmed in each of the individual validation cohorts (adjusted HR [95%CI] comparing high risk to low risk groups were respectively 2.57 [1.65-4.01], 2.12 [1.32-3.39] and 2.11 [1.01-4.41]). In the combined validation cohort, the median PFS values were 3.1 (95%CI: 2.4-2.8) and 10.8 (95%CI: 10.1-NR) years in the high- and low-risk groups, respectively. The risk of lymphoma progression at 2 years was twice as high in the high-risk group (38% (95%CI: 29-46) versus 19% (95%CI: 15-24)). In a multivariate analysis, the score predicted PFS independently of anti-CD20 maintenance treatment and of the FLIPI score (hazard ratio for the combined cohort, 2.30; 95%CI, 1.72-3.07). Interpretation We developed a robust 23-gene expression-based predictor of PFS, applicable to routinely available FFPE biopsies from FL patients at diagnosis. This score may allow individualizing therapy for patients with FL according to the patient risk category. Funding Roche Company, SIRIC Lyric, LYSARC, NIH and the Henry J. Predolin Foundation, Spanish Plan Nacional de Investigacion SAF2015-64885-R.

Autologous Stem Cell Transplantation for Follicular Lymphoma: Favorable Long-Term Survival Irrespective of Pretransplantation Rituximab Exposure

High-dose chemotherapy supported by autologous stem cell transplantation (HDT/ASCT) has contributed to modify the natural history of follicular lymphoma (FL); however, an overall survival (OS) benefit has been demonstrated at relapse only after a rituximab-free chemotherapy regimen. A total of 655 patients with FL were reported to the Spanish GELTAMO (Grupo Español de Linfomas y Trasplantes de Médula Ósea) registry and underwent first ASCT between 1989 and 2007. A total of 203 patients underwent ASCT in first complete response (CR1), 174 in second complete response (CR2), 28 in third complete response (CR3), 140 in first partial response (PR1), 81 in subsequent PR, and 29 with resistant/refractory disease; 184 patients received rituximab before ASCT. With a median follow-up of 12 years from ASCT, median progression-free survival (PFS) and overall survival (OS) were 9.7 and 21.3 years, respectively. Actuarial 12-year PFS and OS were 63% (95% confidence interval [CI], 58%-68%) and 73% (95% CI, 68%-78%), respectively, for patients in CR (with a plateau in the curve beyond 15.9 years), 25% (95% CI, 19%-28%) and 49% (95% CI 42%-56%), respectively, for patients in PR, and 23% (95% CI, 8%-48%) and 28% (95% CI, 9%-45%), respectively, for patients with resistant/refractory disease (P < .001). In patients who received rituximab before ASCT, the estimated 9-year PFS and OS from ASCT were 59.5% (95% CI, 51%-67%) and 75% (95% CI, 68%-83%), respectively. Interestingly, for patients who underwent transplantation in CR ≥2 or PR ≥2 who had received rituximab before ASCT (n = 90), 9-year PFS and OS were 61% (95% CI, 51%-73%) and 75% (95% CI, 65%-80%), respectively, with no relapses occurring beyond 5.1 years after ASCT. The cumulative incidence of second malignancies in the global series was 6.7% at 5 years and 12.8% at 10 years. This analysis strongly suggests that ASCT is a potentially curative option for eligible patients with FL. In the setting of relapse, it is of especial interest in pretransplantation rituximab-sensitive patients with FL.

High serum levels of soluble interleukin-2 receptor (sIL2-R), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF) are associated with adverse clinical features and predict poor outcome in diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) is an aggressive lymphoma with heterogeneous outcomes. To improve accuracy of the international prognostic index score, new biological variables are being investigated. The aim of this study was to determine the prognostic significance of serum levels of different cytokines, namely soluble interleukin-2 receptor (sIL2-R), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF). We analyzed 197 de novo DLBCL patients (91 M/106 F; median age 66 years) treated with immunochemotherapy in a single institution. Serum cytokine determination was performed with ELISA, using the upper normal values as cut-offs. sIL-2R, IL-6 and TNF were elevated in 133, 130 and 144 cases, respectively. Elevation of each of these cytokines correlated with worse performance status, presence of B symptoms, advanced stage, elevated LDH and β2-microglobulin (P<0.03) and lower complete remission rate (P<0.001). Elevated levels of serum sIL-2R and TNF were significantly associated with shorter progression-free (PFS) and overall survival (OS), while elevated IL-6 only with shorter PFS. Early death (<4months from diagnosis) strongly correlated with elevated cytokines. Determination of serum cytokines levels is simple and adds information regarding risk of early death, response to therapy, and outcome.

Evolving M-protein pattern in patients with smoldering multiple myeloma: impact on early progression

Smoldering multiple myeloma (SMM) is a biologically heterogeneous, clinically defined entity with a variable rate of progression to symptomatic multiple myeloma (MM). Reliable markers for progression are critical for the development of potential therapeutic interventions. We retrospectively evaluated the predictive value of the evolving pattern of serum M-protein among other progression risk factors in 206 patients with SMM diagnosed between 1973 and 2012. Median time from recognition of evolving type to progression into symptomatic MM was 1.1 years (95% CI 0.5–2.0) and progression rate at 3 years was 71%. Development of the evolving type drastically worsened the prognostic estimation made at diagnosis for every covariate predictive of progression (serum M-protein size, bone marrow plasma cell infiltration, immunoparesis and Mayo Clinic risk). On average, the hazard ratio for progression to symptomatic MM increased to 5.1 (95% CI 3.4–7.6) after recognition of the evolving type. In conclusion, in patients with SMM the evolving pattern accurately predicts the risk of early progression to symptomatic disease, thereby allowing the identification of ultra-high risk patients who would be candidates for immediate therapy.

Prevalence and prognosis implication of MYD88 L265P mutation in IgM monoclonal gammopathy of undetermined significance and smouldering Waldenström macroglobulinaemia

Waldenstr€ om macroglobulinaemia (WM) is a clonal lymphoproliferative disorder characterized by the accumulation of B lymphocytes and plasma cells producing an excess of serum IgM monoclonal immunoglobulin, resulting in symptoms either from bone marrow infiltration or directly related to the paraprotein (Treon, 2009). Recent studies have shown a high frequency of the MYD88 somatic mutation L265P in patients with WM (Treon et al, 2012; Varettoni et al, 2013). The MYD88 somatic mutation L265P has been associated with disease burden and clinical features at diagnosis in patients with WM, particularly when combined with CXCR4 mutations (Treon et al, 2014). The aim of the present study was to ascertain the prevalence of MYD88 L265P mutation in individuals with IgM monoclonal gammopathy of undetermined significance (MGUS), smouldering WM (SWM) and WM patients, evaluating also its prognostic impact on progression from asymptomatic IgM gammopathies (IgM MGUS and SWM) to WM from a single institution. Ninety-eight patients (median age 70 years, range 33–92; 45 females/53 males) diagnosed with IgM MGUS, SWM or WM between May 1982 and November 2011 were retrospectively evaluated. Baseline demographics, clinical and laboratory findings were recorded, as well as treatment when required. According to the Mayo Clinic guidelines (Ansell et al, 2010), SWM was defined by a bone marrow lymphoplasmacytic infiltration over 10% and/or a serum IgM monoclonal protein ≥30 g/l, with no evidence of end-organ damage or symptoms attributed to the lymphoproliferative disorder. Patients with lower tumour burden in serum and bone marrow were classified as IgM MGUS. Progression was defined according to the International Panel Consensus (Dimopoulos et al, 2014). DNA was isolated from bone marrow slides using a commercial kit (DNeasy Blood & Tissue Kit, Qiagen, Germantown, MD, USA). MYD88 mutation L265P was analysed using quantitative real-time polymerase chain reaction (PCR) technology (qBiomarker Somatic Mutation PCR Assay, MYD88_85940, Qiagen). Briefly, allele-specific amplification is achieved by Amplification Refractory Mutation System (ARMS ) technology, which is based on the discrimination by Taq polymerase between a match and a mismatch at the 30 end of the gene. Negative and positive controls were included in each PCR plate. Statistical tests were performed with SPSS software 20 0 (IBM Corp., Armonk, NY, USA). Time to progression (TTP) and overall survival (OS) were measured in MGUS and SWM patients from diagnosis until progression or death, respectively. Survival was estimated using the Kaplan-Meir method and compared by the log-rank test. This study was approved by the Ethics Committee of the Hospital Clinic of Barcelona. The clinical characteristics of the patients are summarized in Table I. Fifty-five patients (57 1%) were classified as IgM MGUS, 30 (30 6%) as SWM and 12 as WM (12 2%). Haemoglobin levels were lower in WM (P < 0 001). Two patients with MGUS had a low haemoglobin level not related to their gammopathy. MYD88 L265P mutation was observed in 84%, 80% and 27% of WM, SWM and MGUS patients respectively. There was no difference in the detection according to light chain status. Regarding clinical characteristics according to MYD88 L265P status, there were no statistical significant differences in mean haemoglobin, lactate dehydrogenase and only a trend towards a higher serum M-protein between MGUS and SWM patients. In our 86 patients with asymptomatic IgM monoclonal gammopathies, MYD88-mutated cases showed a higher bone marrow lymphocytic infiltration (20% vs. 9%; P < 0 001) without difference in bone marrow plasma cell percentage. After a median follow-up of 4 years for surviving patients (range, 3 months to 25 years), only 5 4% of subjects with IgM MGUS (3) as compared to 23 3% with SWM (7) had developed WM (P = 0 029). Eight of the 10 patients progressing to WM carried the MYD88 L265P mutation: 2 out of 3 MGUS and 6 out of 7 SWM patients. Median TTP was longer in patients with MGUS than those with SWM (21 vs. 12 years; P = 0 001). Median OS of patients with MGUS and SWM was longer than WM cases (19 9 and 17 2 vs. 5 years; P < 0 001). Remarkably, there was a trend towards a shorter TTP in mutated vs. wild-type asymptomatic patients (median not reached vs. 22 years, P = 0 067) (Fig 1). Although it is known that the overall risk of progression to WM in IgM is approximately 1 5% per year, there are currently no clear prognostic factors to identify those patients who are at more risk (Kyle et al, 2012). Given that MYD88 L265P has been identified as a highly prevalent mutation in WM, it could be considered as the first genetic hit that promotes NF-kB and JAK-STAT3 signalling alterations. The single amino-acid mutation L265P in MYD88 Correspondence

Automated preparation of whole blood–derived platelets suspended in two different platelet additive solutions and stored for 7 days

The Atreus system (Terumo BCT) automates the preparation of blood components from whole blood donations. Intermediate platelet (PLT) products can be pooled manually or with the OrbiSac (Terumo BCT) and suspended in different PLT additive solutions (PASs) to obtain PLT concentrates (PCs). The aim of our study was to compare the in vitro PLT quality of PCs obtained with either the Atreus 2C+ and the OrbiSac or the Atreus 3C and suspended in PAS‐II or PAS‐IIIM during storage for up to 7 days.

Acquired Fanconi Syndrome Secondary to Monoclonal Gammopathies: A Case Series From a Single Center

Adult-acquired Fanconi syndrome (FS) is a rare kidneycomplication of monoclonal plasma cell disorderscharacterized by dysfunction of the proximal renaltubule, resulting in metabolic changes, bone disease,and progressive renal failure. There are limited data inthe literature, mainly isolated cases reports or smallcase series.We describe our single-institution experience with 4patients diagnosed with FS associated with mono-clonal gammopathy (2 women and 2 men) fromJanuary 2001 to December 2011.The patients had a mean age of 63.5 years at diag-nosis. In 1 patient, diagnosis of monoclonal gamm-opathy and FS was simultaneous, whereas in theremaining 3 patients, FS was recognized during thefollow-up of monoclonal gammopathy.