Laurent Pascal

Impact of ATG-containing reduced-intensity conditioning after single- or double-unit allogeneic cord blood transplantation.

We analyzed 661 adult patients who underwent single-unit (n = 226) or double-unit (n = 435) unrelated cord blood transplantation (UCBT) following a reduced-intensity conditioning (RIC) consisting of low-dose total body irradiation (TBI), cyclophosphamide, and fludarabine (Cy/Flu/TBI200). Eighty-two patients received rabbit antithymocyte globulin (ATG) as part of the conditioning regimen (ATG group), whereas 579 did not (non-ATG group). Median age at UCBT was 54 years, and diagnoses were acute leukemias (51%), myelodysplastic syndrome/myeloproliferative neoplasm (19%), and lymphoproliferative diseases (30%). Forty-four percent of patients were transplanted with advanced disease. All patients received ≥4 antigens HLA-matched UCBT. Median number of collected total nucleated cells was 4.4 × 10(7)/kg. In the ATG group, on 64 evaluable patients, ATG was discontinued 1 (n = 27), 2 (n = 20), or > 2 days before the graft infusion (n = 17). In multivariate analyses, the use of ATG was associated with decreased incidence of acute graft-versus-host disease (hazard ratio [HR], 0.31; 95% confidence interval [CI], 0.17-0.55; P < .0001), higher incidence of nonrelapse mortality (HR, 1.68; 95% CI, 1.16-2.43; P = .0009), and decreased overall survival (HR, 1.69; 95% CI, 1.19-2.415; P = .003). Collectively, our results suggest that the use of ATG could be detrimental, especially if given too close to graft infusion in adults undergoing UCBT following Cy/Flu/TBI200 regimen.

Combination of ofatumumab and reduced-dose CHOP for diffuse large B-cell lymphomas in patients aged 80 years or older: an open-label, multicentre, single-arm, phase 2 trial from the LYSA group

BACKGROUND In 2011 we reported a rituximab plus miniCHOP (reduced-dose cyclophosphamide, doxorubicin, vincristine, and prednisone) combination for patients older than 80 years with diffuse large B-cell lymphoma (DLBCL). The 2-year overall survival was 59% (95% CI 49-67) with an excess of early toxicity. To improve those results we tested the same chemotherapy protocol in combination with ofatumumab and a pre-phase treatment. METHODS For this open-label, multicentre, single-group, phase 2 trial, we recruited patients older than 80 years with untreated histologically-proven CD20-positive DLBCL, Ann Arbor stage I to IV, from 41 academic and hospital centres in France and Belgium. Patients received a pre-phase with oral vincristine (1 mg total dose 1 week before cycle 1 [day -7]) and oral prednisone (60 mg total dose starting 1 week before cycle 1, for 4 days [day -7 to day -4]) before the first cycle of the ofatumumab plus miniCHOP regimen. The regimen consisted of 1000 mg total dose of intravenous ofatumumab, 25 mg/m2 of intravenous doxorubicin, 400 mg/m2 of intravenous cyclophosphamide, and 1 mg of intravenous vincristine, on day 1 of each cycle; and 40 mg/m2 of oral prednisone on days 1-5. Ofatumumab was administered with 1000 mg of paracetamol and 50 mg of diphenhydramine. The primary endpoint was overall survival in the intention-to-treat population. The statistical analysis has been done on an intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT01195714. FINDINGS Between June 2, 2010, and Nov 4, 2011, we enrolled 120 patients. Age-adjusted International Prognostic Index was 2-3 in 68 (57%) of them. The median follow-up time was 26·8 months (IQR 24·5-30·1). The 2-year overall survival was 64·7% (95% CI 55·3-72·7) and median overall survival was not reached (95% CI 30·2-not reached). 45 patients died during the treatment, of whom 28 (62%) died due to lymphoma. The most common side-effect was haematological toxicity. Among the 120 patients, grade 3-4 neutropenia was reported in 24 (21%) patients and thrombocytopenia in two (2%), during the treatment period. Grade 3-4 anaemia was reported in six (5%) patients; seven (6%) patients had one episode of febrile neutropenia. 17 (15%) of 115 patients in the modified intention-to-treat population had red blood cell transfusions and three (3%) had platelet transfusions. INTERPRETATION Our result suggest that, in patients older than 80 years with DLBCL, ofatumumab and pre-phase treatment seem to improve overall survival compared with the previously reported data. The combination of pre-phase treatment, a monoclonal antibody against CD20, and miniCHOP can be considered a new treatment platform for use in randomised clinical trial design for DLBCL treatment in patients older than 80 years. FUNDING The Lymphoma Study Association, GlaxoSmithKline.

Cardiac iron overload assessed by T2* magnetic resonance imaging and cardiac function in regularly transfused myelodysplastic syndrome patients

The clinical impact of iron overload on morbidity and mortality in regularly transfused patients with myelodysplastic syndrome (MDS) is not clearly demonstrated. Indeed, although cardiac disease is the commonest cause of nonleukaemic deaths in low risk MDS with anaemia, it may also be a result of confounding factors in these patients, including chronic anaemia, ageing, coronary artery disease, diabetes and systemic hypertension (Malcovati et al, 2005). Cardiac assessment by T2* magnetic resonance imaging (MRI), allowing in vivo estimation of iron content, is specific for iron overload and unaffected by confounding factors. Experience in thalassaemia major patients clearly demonstrates that cardiac T2* is associated with systolic and diastolic ventricular dysfunction (Pennell, 2005). In MDS, several small studies have assessed cardiac iron overload by MRI, with controversial results. However, none of them evaluated the impact of iron overload on cardiac function (Konen et al, 2007; Di Tucci et al, 2008; Roy et al, 2011). In order to study the clinical impact of heart iron overload, we performed a cross-sectional study in 75 consecutive regularly transfused MDS patients from six centres of the Groupe Francophone des My elodysplasies. Cardiac T2* was assessed by MRI according to Anderson et al (2001), liver iron content (LIC) was assessed by MRI (Gandon et al, 2004), and cardiac function was determined by routine echocardiography assessment of left ventricular ejection fraction (LVEF). Cardiac iron overload was defined by a T2* ≤20 ms, and severe cardiac iron overload by T2* below 10 ms. LVEF <55% was considered abnormal and severe systolic ventricular dysfunction diagnosed if LVEF <35%. We defined three patient groups according to the total number of packed red blood cell (PRBC) units received: low (≤50), intermediate (50–150) and high (≥150). All statistical analyses were 2-tailed and performed with IBM SPSS Statistics v20 software (IBM, Armonk, NY, USA). P values <0 05 were considered statistically significant. Patient characteristics, including World Health Organization classification of MDS and International Prognostic Scoring System (IPSS) score, are summarized in Table I. Pre-existing cardiovascular disorder was found in 12/21, 30/37, 8/17 patients in the low, intermediate and high transfusions groups, respectively. Most patients (67/75) had lowor intermediate-1 IPSS. Median (range) serum ferritin level was 467 (150–954) lg/l at diagnosis, and 1743 (282–5000) lg/l at time of MRI study. 56/75 patients were on chelation therapy at time of MRI study (12/21, 30/37, and 14/17 in the low, intermediate and high transfusion groups, respectively), with deferasirox alone (n = 18); deferoxamine alone (n = 14); deferasirox + deferoxamine (n = 13); deferoxamine + deferiprone (n = 2). Median interval from diagnosis to MRI testing was 4 3 years (range 0 25–27 years), and the median number of PRBC units transfused was 76 (range 5–574). Cardiac MRI T2* values ranged from 6 to 74 ms (median 27). Cardiac T2* was ≤20 ms in 14 patients (18 6%), who had received a median number of 202 PRBC units since diagnosis (range 12–574). Three of them had very low T2* ≤10 ms (6, 8 5 and 10 ms, respectively) and had received 66, 290 and 396 PRBC units respectively. Hereditary haemochromatosis was excluded in the patient with T2* <20 ms who had received only 12 RBC concentrates. An inverse correlation between the number of PRBC units transfused and T2* was found (Spearman’s q = 0 347; Table I. Patient characteristics

Prognostic value of PINI index in patients with multiple myeloma.

Background:  The Prognostic Inflammatory and Nutritional Index (PINI) is a simple scoring system that aggregates two blood markers of inflammatory [C‐reactive protein (CRP) and orosomucoid] and of nutritional (albumin and prealbumin) states. It is used in routine practice in geriatric medicine, especially in hospitalized elderly patients. This study was undertaken to evaluate the usefulness of PINI index in multiple myeloma (MM), a malignancy of the elderly.

Lethal ALAS2 mutation in males X-linked sideroblastic anaemia.

X-linked Sideroblastic Anaemia (XLSA, Mendelian Inheritance in Man reference 300751), the most common type of congenital sideroblastic anaemia (CSA), results from germline mutations in the erythroid-specific form of the 5-aminolevulinate synthase gene (ALAS2). ALAS2 is the first enzyme of the haem biosynthesis pathway and is essential to support haemoglobin synthesis. Affected males typically exhibit microcytic anaemia and iron deposits in the mitochondria of erythroid precursors (ring sideroblasts). Anaemia is generally mild and patients are rarely transfusion dependent. However patients could exhibit, with time, severe parenchymal iron overload due to intestinal hyper absorption of iron (Cazzola & Malcovati, 2015). Most of the ALAS2 mutations are missense mutations with partial loss-of-function alleles; mutations in a GATA transcription factor-binding in intron 1 of the ALAS2 gene have also been reported (Campagna et al, 2014). However penetrance and phenotypic expression of XLSA is highly variable, even in a same family(Cortes~ao et al, 2004; Aguiar et al, 2014). Up to one-third of female cases may be affected, mainly by skewed X-chromosome inactivation which increases with age (Ducamp et al, 2011); one case of macrocytic anaemia in a female with dominant mutation in ALAS2 without skewed X inactivation has also been reported to alter erythropoiesis through cell non-autonomous effects (Sankaran et al, 2015). We report for the first time in a very large, four-generation pedigree a new missense mutation in the ALAS2 gene inducing a Male Lethal X-linked syndrome ascertained through an adult heterozygous female with highly skewed X inactivation with a mild form of macrocytic CSA and an excessive number of miscarriages. The proposita of this non-consanguineous family (Fig 1A; Individual III.9) was a female of European ancestry. She exhibited an unexplained congenital, non-regenerative, macrocytic, moderate anaemia, (first assessment at 6 years old). Red blood cell (RBC) transfusions were required only twice during her pregnancy. She was diagnosed with CSA when aged 23 years. A complete blood count showed a nonregenerative macrocytic [mean cell volume (MCV) 107 fl] anaemia (Hb: 107 g/l)that was not dimorphic, with red cell distribution width (RDW) -SD 52 5 fl [normal range (N):

Congenital Recessive Methemoglobinemia Revealed in Adulthood: Description of a New Mutation in Cytochrome b5 Reductase Gene

Abstract Methemoglobinemia can be acquired (oxidizing drugs or chemicals products) or inherited either by mutations affecting globin chains [M hemoglobins (M Hbs)] or by defects in the enzymatic system involved in the reduction of spontaneous Hb oxidation: nicotinamide adenine dinucleotide (NADH)-cytochrome b5 reductase. It is encoded by the CYB5R3 gene: there are two phenotypes of autosomal recessive congenital methemoglobinemia, in type II CYB5R deficiency is generalized and affects all cells, leading to an early onset, whereas in type I, the enzyme deficiency is restricted to erythrocytes, usually discovered in infancy but not exclusively. We report a new case of methemoglobinemia discovered in a patient from Bahrain who exhibited an unknown dyspnea at the age of 37 years without trigger events or oxidizing products. We discovered a new mutation in the CYB5R3 gene: exon 9, codon 266 (delGAG) (GLU) (CYB5R3: c.726_729delGAG) in the homozygous state. Appearance of methemoglobinemia in an adult usually suggests an acquired cause but our case illustrated that it could also reveal a type I mutation of cytochrome b5 reductase.

Cardiac iron overload assessed by T2* magnetic resonance imaging and cardiac function in regularly transfused myelodysplastic syndrome patients, the GFM experience: response to Bowen et al

We acknowledge the letter of Bowen, Hellstrom-Lindbergh and Steensma regarding our paper (Pascal et al, 2013), which we feel strongly suggests that a certain proportion of heavily transfused myelodysplastic sydrome (MDS) patients have significant iron cardiac overload that is very probably deleterious in some of them. The main purpose of our study was to enter the debate that has been going on for several years between, at one extreme, authors supporting ‘systematic chelation when serum ferritin is above 1000 lg/l and/or if patients have received greater than 20 packed red blood cell concentrates’ (Gattermann, 2008) and, at the other extreme, those who say that ‘there is no proof that iron overload, especially in the heart, is deleterious in any patient or that chelation is of any use (except perhaps in the allogeneic stem cell transplantation context)’ (Chee et al, 2008). The readers of Bowen et al’s letter will get the impression that they rather belong to the latter group. To answer their specific concerns, we did not describe liver magnetic resonance imaging (MRI) in detail due to lack of space. The median liver iron concentration (LIC) in our series was 340 lmol/g dry weight (gdw) (range 40–908) confirming very high total iron burdens, similar to those seen in other series of highly transfused MDS. This median level is nearly three times the 125 lmol/gdw associated with decreased overall survival in MDS patients undergoing allogeneic stem cell transplantation (Wermke et al, 2012). It is, however, known that liver iron overload develops more rapidly in the liver than the heart with transfusional iron overload, including in MDS (Virtanen et al, 2012), and therefore may not be an indication of life threatening iron overload in MDS. On the other hand, in our series, the proportion of heart MRI T2* below 20 ms in patients having received at least 50 red blood cell concentrates (18 6%) was not negligible, reaching 52 9% in patients that had received more than 150 concentrates. Receiving more than 100–150 concentrates in the disease course in low risk MDS is not rare (Rose et al, 2010). In our patients with cardiac T2* below 20 ms, 27% had severe cardiac dysfunction (with left ventricular ejection fraction <35%). Although our study was retrospective and could not clearly determine, in the genesis of cardiac failure, the respective weight of iron overload and cardiac comorbidities, the former was probably significant in patients with cardiac T2* below 20 ms, particularly when T2* was below 10 ms. We agree with Bowen et al that there is no demonstration that iron chelation may improve cardiac function in MDS patients with cardiac T2* below 20 ms. However, there is ample demonstration, in thalassaemia major patients, that adequate iron chelation reduces cardiac iron overload and improves cardiac function and survival (Hoffbrand et al, 2012). In the case of elderly multi-tranfused MDS patients, one may consider that iron overload is just one factor of cardiac failure. However, it may also be the straw that breaks the camel’s back. A general medical principle may also be that, to improve any organ failure, one should try to improve all of the implicated cofactors. This would include trying to remove iron overload by chelating agents in the present case. In brief, in the debate whether heavily transfused MDS (e.g., >50 red blood cell concentrates) should be chelated or not, taking into account the costs of chelation, its possible side effects and, on the other hand, the risk of severe organ damage, we feel that systematic cardiac MRI is a cost effective test. It identifies a relatively small but significant minority of patients (18 6% of those having received >50 red blood cell concentrates) with significant heart iron overload (with heart T2* <20 ms). In this minority of MDS patients, based on thalassaemia or other inherited anaemia results, one may reasonably consider (until results from prospective studies in MDS are available) that chelation could bring some benefit.

A Low Effective Dose of Interleukin-7 Is Sufficient to Maintain Cord Blood T Cells Alive without Potentiating Allo-Immune Responses

Slow reconstitution of T cell immunity remains a critical issue after umbilical cord blood (CB) transplantation. Although this may be a consequence of the low cell dose, it may also reflect the propensity of naïve T cells, which predominate in CB, to undergo apoptotic cell death. Exogenous interleukin 7 (IL-7) can prevent apoptosis of naïve T cells, but at high concentrations, IL-7 may also expand alloreactive T cells, thereby aggravating the risk of graft-versus-host disease. We evaluated the survival of CB T cells from 34 healthy full-term pregnancies, and we found wide interdonor variation, from 17.4% to 79.7%, of CB T cells that were still alive after being rested for 4 days in culture medium without cytokine supplementation. The viability of CB T cells was negatively correlated to infant birth weight (Spearmans ρ = .376; P = .031) and positively correlated to venous CB pH (ρ = .397; P = .027); both associations were confirmed by multivariate analysis (P = .023 and P = .005, respectively). A low supplemental concentration (100 pg/mL) of recombinant human IL-7 was sufficient to maintain the viability of cryopreserved/thawed CB T cells, with most (>80%) cells remaining in a quiescent state and without significant changes in their CD4/CD8 ratio and the proportion of CD4(+) CD31(+) PTK7(+) recent thymic emigrants. IL-7 at 100 pg/mL did not lead to any significant enhancement of the alloreactive response of CB T cells, as evaluated by proliferation rates (thymidine incorporation and carboxyfluorescein diacetate succinimidyl ester dilution) and interferon-gamma production (ELISPOT). This effective concentration of IL-7 is far lower than that obtained in vivo after pharmacological administration of the cytokine. This study suggests that administration of lower doses of recombinant human IL-7 than used in previous clinical trials may be sufficient to sustain the viability of infused CB T cells and, thus, help to accelerate naïve T cell reconstitution without potentiating their alloreactivity.