Susana Rives

Diffuse large B-cell lymphomas with plasmablastic differentiation represent a heterogeneous group of disease entities.

Plasmablastic lymphoma was initially described as a variant of diffuse large B-cell lymphoma (DLBCL) involving the oral cavity of HIV+ patients and characterized by immunoblastic morphology and a plasma cell phenotype. However, other lymphomas may exhibit similar morphologic and immunophenotypic features. To determine the significance of plasmablastic differentiation in DLBCL and examine the heterogeneity of lymphomas with these characteristics, we examined 50 DLBCLs with low/absent CD20/CD79a and an immunophenotype indicative of terminal B-cell differentiation (MUM1/CD38/CD138/EMA-positive). We were able to define several distinct subgroups. Twenty-three tumors were classified as plasmablastic lymphoma of the oral mucosa type and showed a monomorphic population of immunoblasts with no or minimal plasmacytic differentiation. Most patients were HIV+ and EBV was positive in 74%. Eleven (48%) cases presented in the oral mucosa, but the remaining presented in other extranodal (39%) or nodal (13%) sites. Sixteen cases were classified as plasmablastic lymphoma with plasmacytic differentiation. These were composed predominantly of immunoblasts and plasmablasts, but in addition exhibited more differentiation to mature plasma cells. Only 33% were HIV+, EBV was detected in 62%, and 44% had nodal presentation. Nine cases, morphologically indistinguishable from the previous group, were secondary extramedullary plasmablastic tumors occurring in patients with prior or synchronous plasma cell neoplasms, classified as multiple myeloma in 7 of the 9. Two additional neoplasms were an HHV-8+ extracavitary variant of primary effusion lymphoma and an ALK+ DLBCL. HHV-8 was examined in 39 additional cases, and was negative in all. In conclusion, DLBCLs with plasmablastic differentiation are a heterogeneous group of neoplasms with different clinicopathological characteristics that may correspond to different entities.

Clinicopathologic Significance and Prognostic Value of Chromosomal Imbalances in Diffuse Large B-Cell Lymphomas

PURPOSE To determine the clinicopathologic significance and prognostic value of chromosomal imbalances in diffuse large B-cell lymphomas (DLBCL). PATIENTS AND METHODS We have examined 64 tumors at diagnosis using comparative genomic hybridization and real-time quantitative polymerase chain reaction (PCR), single-stranded conformational polymorphism, and DNA sequencing for the analysis of several potential target genes. RESULTS The most recurrent alterations were gains of 18q (20%), Xq (15%), 2p, 7q, and 12p (14%), and losses of 6q and 17p (14%). Frequent high-level DNA amplifications were detected at 2p13-p16 and 18q21 loci. Real-time quantitative PCR detected REL and BCL11A gene amplifications in the nine patients with gains at 2p13-p16 and only in one additional patient with normal chromosome 2. Similarly, the BCL-2 gene was amplified in the 12 tumors with gains of 18q21 but in none of 39 patients with normal 18q profile. p53 gene inactivation was detected in nine of 58 (16%) tumors and was commonly associated with 17p losses. Tumors with 18q gains were significantly associated with a high number of chromosomal imbalances, primary nodal presentation, high serum lactate dehydrogenase levels, high International Prognostic Index, shorter cause-specific survival, and a high risk of relapse. Losses of 17p and p53 gene alterations were associated with an absence of complete response achievement. CONCLUSION These results suggest that DLBCLs have a characteristic pattern of genomic alterations; 18q gains or amplifications and 17p losses are associated with particular clinicopathological features and aggressive clinical behavior. Additional studies are needed to confirm these observations in larger series of patients.

Genetic basis of Congenital Erythrocytosis mutation update and online databases

Congenital erythrocytosis (CE), or congenital polycythemia, represents a rare and heterogeneous clinical entity. It is caused by deregulated red blood cell production where erythrocyte overproduction results in elevated hemoglobin and hematocrit levels. Primary congenital familial erythrocytosis is associated with low erythropoietin (Epo) levels and results from mutations in the Epo receptor gene (EPOR). Secondary CE arises from conditions causing tissue hypoxia and results in increased Epo production. These include hemoglobin variants with increased affinity for oxygen (HBB, HBA mutations), decreased production of 2,3‐bisphosphoglycerate due to BPGM mutations, or mutations in the genes involved in the hypoxia sensing pathway (VHL, EPAS1, and EGLN1). Depending on the affected gene, CE can be inherited either in an autosomal dominant or recessive mode, with sporadic cases arising de novo. Despite recent important discoveries in the molecular pathogenesis of CE, the molecular causes remain to be identified in about 70% of the patients. With the objective of collecting all the published and unpublished cases of CE the COST action MPN&MPNr‐Euronet developed a comprehensive Internet‐based database focusing on the registration of clinical history, hematological, biochemical, and molecular data (http://www.erythrocytosis.org/). In addition, unreported mutations are also curated in the corresponding Leiden Open Variation Database.

Intermediate dose of imatinib in combination with chemotherapy followed by allogeneic stem cell transplantation improves early outcome in paediatric Philadelphia chromosome-positive acute lymphoblastic leukaemia (ALL): results of the Spanish Cooperative Group SHOP studies ALL-94, ALL-99 and ALL-2005

Philadelphia‐chromosome acute lymphoblastic leukaemia (Ph+ ALL) is a subgroup of ALL with very high risk of treatment failure. We report here the results of the Sociedad Española de Hematología y Oncología Pediátricas (SEHOP/SHOP) in paediatric Ph+ ALL treated with intermediate‐dose imatinib concurrent with intensive chemotherapy. The toxicities and outcome of these patients were compared with historical controls not receiving imatinib. Patients with Ph+ ALL aged 1–18 years were enrolled in three consecutive ALL/SHOP trials (SHOP‐94/SHOP‐99/SHOP‐2005). In the SHOP‐2005 trial, imatinib (260 mg/m2 per day) was given on day‐15 of induction. Allogeneic haematopoietic stem‐cell transplantation (HSCT) from a matched related or unrelated donor was scheduled in first complete remission (CR1). Forty‐three patients were evaluable (22 boys, median age 6·8 years, range, 1·2–15). Sixteen received imatinib whereas 27 received similar chemotherapy without imatinib. Seventeen of 27 and 15 of 16 patients in the non‐imatinib and imatinib cohort, respectively, underwent HSCT in CR1. With a median follow‐up of 109 and 39 months for the non‐imatinib and imatinib cohorts, the 3‐year event‐free survival (EFS) was 29·6% and 78·7%, respectively (P = 0·01). These results show that, compared to historical controls, intermediate dose of imatinib given concomitantly with chemotherapy and followed by allogeneic HSCT markedly improved early EFS in paediatric Ph+ ALL.

‘Lymphoid’ blast crisis of chronic myeloid leukaemia is associated with distinct clinicohaematological features

It has been suggested that in blast crisis (BC) of chronic myeloid leukaemia (CML) the clinical and laboratory features of patients with ‘lymphoid’ phenotype differ from those of patients with non‐lymphoid BC. In order to assess any differences, 97 patients consecutively diagnosed with BC that followed a known chronic phase of CML were analysed. 19 patients had ‘lymphoid’ BC: in 17 the blasts expressed a B‐lineage phenotype; in the remaining two they corresponded to T lymphoblasts. Four cases of B‐lineage phenotype BC were considered as biphenotypic, due to the co‐expression of myeloperoxidase and one or two other myeloid markers (CD33, CD13 and CD68) on the blast cells; in the other six cases of B‐lineage BC the blasts expressed one or both of the myeloid markers CD33 (n = 4) and CD13 (n = 3). Patients with ‘lymphoid’ BC seldom had an acceler‐ated phase prior to BC (1/19 v 36/78 with non‐lymphoid BC, P = 0.002), had less frequent splenomegaly (9/19 v 59/78, P = 0.03) and hepatomegaly (5/19 v 45/78, P = 0.02) and showed a higher degree of marrow blast infiltration (mean value 74 ± 24% v 38 ± 23%, P < 0.0001), lesser blood basophilia (2.2 ± 2.5% v 8.2 ± 7.8%, P < 0.0001), and higher serum albumin levels (P = 0.001) than those with non‐lymphoid BC. 13 patients with ‘lymphoid’ BC (68.4%) showed a favourable response to chemotherapy regimens including vincristine and prednisone and, overall, ‘lymphoid’ BC patients survived significantly longer than the remainder (median survival 12 months v 4.7 months, P = 0.006). These results indicate that ‘lymphoid’ BC of CML has a distinct clinicohaematological profile and confirm the better prognosis of such patients.

Pandemic influenza A (2009 H1N1) in children with acute lymphoblastic leukaemia.

Pandemic influenza A (2009‐H1N1) usually results in mild clinical illness, but in some individuals it can be life‐threatening. There are no reports of this disease among paediatric patients with acute lymphoblastic leukaemia (ALL). We report ten consecutive patients with ALL and pandemic influenza treated in a single institution. Median age was 7 years (range: 3–12). All were treated with oseltamivir. There were no deaths. Two patients under intensive chemotherapy developed pneumonia and one required ventilatory support. ALL patients under maintenance treatment had mild disease. In conclusion, in our series only patients under intensive treatment developed a moderate to severe disease.

Cryopreservation of HPCs with high cell concentration in 5-percent DMSO for transplantation to children

Transfusion of cryopreserved HPCs carries a risk of serious adverse effects due to the use of DMSO. Some studies have shown that the incidence and severity of adverse reactions are dose related.1 It is desirable therefore to reduce the amount of DMSO in cryopreserved components to minimize toxicity, particularly in children. The concentration of DMSO and the concentration of cells to be cryopreserved determine the volume and the amount of DMSO infused. Previous studies2,3 describe satisfactory results using 5-percent DMSO or 3.5percent DMSO with HES. Also, high cell concentrations (up to 800 106/mL) in 10-percent DMSO have not shown a deleterious impact on function or engraftment of HPCs, either in vitro or in vivo.4 Our approach used a high cell concentration (>200 106/mL) and a low DMSO concentration (5 percent) for cryopreservation. We report hematologic recovery in patients who received such transplants. HPCs were collected from 13 consecutive patients for autologous transplant. The cells were cryopreserved with 5-percent DMSO in autologous plasma as the only cryoprotectant at a final cell concentration equal to or greater than 200 106 per mL. The cells were frozen at –80 C by immersion in a methanol bath in a mechanical freezer,5 and stored at that same temperature. All patients were conditioned with myeloablative regimens and medicated with corticosteroids, antihistamines, and diuretics prior to transfusion of their thawed, unmanipulated HPCs. There were 6 boys and 7 girls with a median age of 11.8 years (range 4.5-19.2). Diagnoses were brain tumor in 5, Ewing sarcoma in 3, Hodgkin disease in 2, neuroblastoma in 1, T-cell acute lymphoblastic leukemia in 1, and Burkitt lymphoma in 1. The median volume of the cryopreserved HPCs and their cell concentrations were 300 mL (range, 134-700) and 263 106 per mL (range, 192-390), respectively, with a median CD34+ cell content of 3.66 106 per kg (range, 2.00-6.44). Median time from cryopreservation to transplantation was 10 days (range, 9-108). The median dose of DMSO infused was 0.41 mL per kg (range, 0.13-0.58) in an HPC component with a median volume of 8.2 mL per kg (range, 2.7-11.7). Adverse effects during transfusion were minimal. One patient experienced abdominal pain and vomiting and another required treatment for hypertension with nifidipine. If the HPCs had been cryopreserved by standard protocols (cell concentration 100 106/mL in 10 percent DMSO), the median volume of DMSO and HPC component transfused would have been 1.8 mL per kg (range 0.70-4.55) and 18 mL per kg (range 7-45), respectively. A granulocyte count > 0.5 109 per L and a platelet count > 20 109 per L were achieved after a median of 11 (range 10-14) and 12 (range 10-23) days, respectively. Hematologic recovery was adequate (Hb > 100 g/L, platelets > 100 109/L, and granulocytes > 1 109/L) in 9 of 12 evaluable patients at 3 months and in 9 of 10 evaluable patients at 6 months post-transplant. The only patient not achieving the target values was a 16-year-old girl with Hodgkin disease who received abdominal radiotherapy two months post-transplant, who had a platelet count of 40 109 per L and normal Hb and granulocyte concentrations. In summary, cryopreservation using cellular concentrations greater than 200 106 per mL in 5-percent DMSO was accompanied by rapid and sustained engraftment and permitted the infusion of a reduced amount of DMSO. It is possible that these results are related to the short time between cryopreservation and transplantation in our patients. This method seems suitable for very short storage periods for HPCs. However, additional studies are needed before this procedure can be recommended for cryopreservation of HPCs for periods longer than 3 months.

Prospective surveillance study of blood stream infections associated with central venous access devices (port-type) in children with acute leukemia: an intervention program.

The use of intensive chemotherapy and central devices has improved patients survival, but it is associated with catheter-related blood-stream infections (CRBSI). An educational program was instituted for preventing CRBSI occurrence in acute leukemia pediatric patients having totally implanted central devices. The Centers of Disease Control and Prevention criteria were used as definition for CRBSI. Data collected were age, sex, diagnosis, chemotherapy, inpatient versus outpatient, microbiological data, risk factors, social risk score, and treatment performed. CRBSI rate decreased from 6.7 to 3.7/1000 catheter-days with preventive measures (P=0.05). A further decrease to 1.5/1000 catheter-days was reached after the intensification of the educational program (P=0.01). Severe neutropenia at the time of catheter insertion was related to CRBSI and to infection recurrence (P<0.05). Most of the episodes occurred during induction chemotherapy. Thirty-six CRBSI episodes occurred in 25 of 73 patients. The most frequent microorganism isolated was Staphylococcus spp. Antibiotherapy was successful in 83.3% of episodes. Six patients needed a central venous access device replacement. Our intervention program was successful to decrease the CRBSI rates and its intensification allowed a further decrease, approaching reported rates in this setting. Severe neutropenia at the time of central venous access device insertion was related to CRBSI occurrence and recurrence.

Allogenic stem cell transplantation as salvage therapy for patients relapsing after autologous transplantation: experience from a single institution

The prognosis of patients relapsing after an autologous transplant (autoSCT) is very poor. Allogenic stem cell transplantation (alloSCT) offers the possibility of curing some of these patients, at the cost, however, of a high transplant related mortality (TRM). The aim of this study was to analyze the outcome of 14 consecutive patients with hematologic malignancies, from a single institution, who underwent alloSCT for progressive disease after autoSCT. Patients had relapsed at a median of 11.5 months (range 2-72) after autoSCT and they underwent alloSCT at a median of 25.5 months (range 7-73) from the first transplant. Ten patients received HLA-identical related peripheral blood progenitor cells, three patients underwent matched-unrelated donor marrow transplants, and one patient received a mismatched related transplant. Conditioning regimens consisted of total body irradiation plus cyclophosphamide (n=5) or melphalan (n=1), or high-dose combination chemotherapy (n=8). Cyclosporin A and methotrexate were administered as graft-versus-host disease (GVHD) prophylaxis. Eight patients (57%) developed grade II-IV acute GVHD. All evaluable patients (n=6) presented extensive chronic GVHD. Overall survival at 1 year was 16% (median 3.5 months, 95% CI 0.7-10.3). Ten patients (71%) died from transplant related complications at a median of 3.5 months (range 0.7-11). Only one patient died of recurrent disease. Three patients remain alive and in complete remission at the time of this report (4, 20 and 20 months, respectively). In conclusion, alloSCT offers the possibility of a sustained control of the disease in some patients who relapse after an autoSCT. However, the procedure is associated with a high transplant-related mortality. Better results might be obtained by carefully selecting patients and by reducing the intensity of the preparative regimen.

Multiplex real-time PCR for prompt diagnosis of an outbreak of human parainfluenza 3 virus in children with acute leukemia.

IntroductionHuman parainfluenza virus type 3 (HPIV-3) causes significant morbimortality in immunocompromised patients. Outbreaks of severe pneumonitis have been previously described in this setting.Materials and methodsRetrospective observational study in children diagnosed with acute leukemia and a documented HPIV-3 infection in the context of a nosocomial outbreak occurred in a single center.ResultDuring summer 2012, an HPIV-3 infection was detected in six hospitalized children with acute leukemia. All the patients had respiratory symptoms and one of them suffered from parotitis.ConclusionEarly diagnoses using multiplex real-time polymerase chain reaction (PCR) let us control this outbreak. A phylogenetic analysis confirmed person-to-person transmission of a single HPIV-3 variant.