Valentina Bozzoli

Anemia in Hodgkin's Lymphoma: The Role of Interleukin-6 and Hepcidin

PURPOSE Cytokines play a pivotal role in Hodgkins lymphoma (HL). Because interleukin-6 (IL-6) induces expression of hepcidin, one of the principal regulators of iron metabolism, we studied the contribution of hepcidin in anemia in HL at diagnosis. PATIENTS AND METHODS Plasma samples from 65 patients with HL were analyzed for hepcidin levels using a combination of weak cation exchange chromatography and time-of-flight mass spectrometry; cytokine levels were analyzed using enzyme-linked immunosorbent assays and parameters of iron metabolism and acute-phase reaction. RESULTS Hepcidin plasma levels were significantly higher in HL patients when compared with controls, independent of the presence of anemia (P = .001). In the subset of patients with anemia, hepcidin levels inversely correlated with hemoglobin levels (P = .01). Analyzing parameters of iron metabolism, hepcidin levels showed a positive correlation with ferritin (P < .001) and an inverse correlation to iron and iron-binding capacity. Hepcidin strongly correlated to IL-6 levels (P < .001) but not to IL-10 or thymus and activation-regulated cytokine (TARC)/chemokine (C-C motif) ligand 17 (CCL17) levels. In a multivariate regression analysis, IL-6 and fibrinogen levels were independently associated with hepcidin. Higher hepcidin levels were observed in patients with more aggressive disease characteristics: stage IV disease (P = .01), presence of B symptoms (P = .03), and International Prognostic Score > 2 (P = .005). CONCLUSION Our findings suggest that in HL, hepcidin is upregulated by IL-6. Elevated hepcidin levels result in iron restriction and signs of anemia of chronic inflammation, although hepcidin-independent mechanisms contribute to development of anemia in HL.

Cell-free circulating DNA in Hodgkin's and non-Hodgkin's lymphomas

BACKGROUND Levels of cell-free circulating DNA have been correlated to clinical characteristics and prognosis in patients with cancers of epithelial origin, while there are no data on patients with B-lymphoproliferative diseases. PATIENTS AND METHODS Cell-free DNA levels in the plasma samples of 142 patients with lymphomas [45 with Hodgkins lymphoma (HL), 63 with diffuse large B-cell non-Hodgkins lymphoma (DLBCL), 24 with follicular, and 10 with mantle cell non-Hodgkins lymphoma (NHL)] at diagnosis and of 41 healthy individuals were determined using a quantitative PCR for the beta-globin gene. RESULTS Levels of circulating DNA in patients with HL, DLBCL, and mantle cell NHL were significantly higher than in controls (P < 0.01 for all). Increased levels of plasma DNA were associated with advanced stage disease, presence of B-symptoms, elevated lactate dehydrogenase levels, and age >60 years (P = 0.009; <0.0001; <0.0001; 0.04, respectively). In HL, histological signs of necrosis and grade 2 type of nodular sclerosis were associated with increased plasma DNA. Elevated plasma DNA levels were associated with an inferior failure-free survival in patients with HL (P = 0.01) and DLBCL (P = 0.03). CONCLUSION Quantification of circulating DNA by real-time PCR at diagnosis can identify patients with elevated levels that are associated with disease characteristics indicating aggressive disease and poor prognosis.

Interleukin-6 plasma levels are modulated by a polymorphism in the NF-κB1 gene and are associated with outcome following rituximab-combined chemotherapy in diffuse large B-cell non-Hodgkin lymphoma.

Abstract Peripheral blood cytokines are known prognostic parameters in diffuse large B-cell lymphoma (DLBCL) treated with chemotherapy, but their role after the introduction of rituximab is unknown. Seven polymorphisms in the promoter regions of IL-6, IL-10 and NF-κB1 genes were assessed in 167 patients with DLBCL and 99 controls and correlated with interleukin-6 (IL-6) and IL-10 plasma levels. Outcome was analyzed in 137 patients treated with rituximab-based chemotherapy. The NF-κB1 − 94ATTG deletion was associated with increased IL-6 and IL-10 in DLBCL. High IL-6 concentration correlated with unfavorable prognostic factors included in the international prognostic index (IPI) and predicted for inferior progression-free (p = 0.007) and overall survival (p = 0.02). IL-6 levels remained a significant outcome predictor also including IPI as a covariate (p = 0.006 for progression-free survival). Our data suggest that the NF-κB1 genetic background influences IL-6 production in DLBCL, and that high IL-6 concentration is an independent prognostic factor also in the “rituximab era.”

Quantification of DAPK1 promoter methylation in bone marrow and peripheral blood as a follicular lymphoma biomarker

Hypermethylation of DAPK1 promoter gene was found to be a frequent epigenetic alteration in follicular lymphoma (FL). We evaluated whether the quantification of DAPK1 methylation in the bone marrow (BM) and peripheral blood of FL patients at diagnosis and during follow-up provides important prognostic information. DAPK1 methylation was quantitated by real-time MethyLight PCR in 107 patients at diagnosis, at end of therapy, and during follow-up. Information on BCL2-IGH rearrangement and clinical characteristics were available for all patients. Aberrant DAPK1 methylation was found in 22 of 26 (85%) lymph node biopsy samples, 62 of 107 (58%) BM specimens, and 25 of 63 (40%) peripheral blood samples at diagnosis. DAPK1 methylation was greater in patients with BM infiltration and a higher Follicular Lymphoma International Prognostic Index score. The presence of aberrant DAPK1 methylation in BM significantly reduced progression-free survival following immunochemotherapy, independent of Follicular Lymphoma International Prognostic Index score. Residual or increased methylation after treatment was associated with an increased risk for relapse. With watchful waiting, greater DAPK1 methylation at diagnosis was associated with a shorter time to antilymphoma treatment. Our study indicates that quantification of DAPK1 methylation represents a prognostically relevant FL biomarker, with promising implications for risk assessment.

Primary plasma cell leukemia followed by testicular plasmacytoma

Plasma cell leukemia (PCL) is a highly aggressive plasma cell disease characterized by a poor prognosis and a low response rate to conventional therapy. Herein, we describe a 69-year-old patient with primary PCL, developing testicular disease while in complete hematological remission, following by muscle involvement and peritoneal dissemination.

Intravascular large-B cell lymphoma: when lymphoma is suspected but routine diagnostic work-up is negative.

Intravascular large B-cell lymphoma (IVLBCL) is a rare disease recognized by the WHO classification of lymphoid neoplasms as a subtype of diffuse large B-cell lymphoma (DLBCL), which is characterized by the proliferation of neoplastic cells in the lumen of small vessels without the tendency for tumor formation [1,2]. Since its first description in 1959, more than 300 cases have been reported and in recent years increasing recognition may have contributed to a higher frequency of in vivo diagnoses. As clinical presentation is non-specific and misleading, diagnosis is often delayed, and a substantial proportion of cases is diagnosed at autopsy [2,3]. Here, we report two cases of IVLBCL diagnosed at autopsy in our institution in 2008, whose clinical presentation is paradigmatic of the behavior of IVLBCL and whose description may be helpful in future for an early diagnosis of this uncommon disease. The first patient, a 71-year-old obese woman, suffering from chronic hypoxemia, obstructive sleep apnea, and thyroid multinodular non toxic goiter, was previously admitted to the hospital with a 1-month history of continuous-remittent fever resistant to multiple antibiotic treatments. On admission, laboratory findings revealed microcytic anemia, neutrophilic leukocytosis, elevation of lactate dehydrogenase (LDH) serum levels (2195 UI/L), and D-dimer (844 ng/mL). Blood, bone marrow, urine, sputum, and pharyngeal culture resulted negative, while viral infections were ruled out by serological tests. Total-body computed tomography (CT) scan showed splenomegaly (14 cm) and bone marrow aspiration and biopsy could detect neither parasitic infection nor marrow infiltration by tumor or CD20þ lymphoma cells. Tumor markers were negative while the hormonal dosages revealed a hypothyroidism with low thyroid stimulating hormone (TSH) level. Because anemia was worsening with a positive direct antiglobulin test and a pronounced increase of LDH, a diagnosis of autoimmune hemolytic anemia was made and the patient started corticosteroid therapy with a temporary subsidence of fever. A fluorodeoxyglucose positron emission tomography (FDG-PET) revealed FDG accumulation in the middle lobe of the right lung and, following the isolation of Pseudomonas aeruginosa strain from the expectoration, a new course of antibiotic therapy was administered without benefit. As the patient’s general conditions deteriorated, a non-Hodgkin lymphoma was suspected despite negative imaging and bone marrow examinations and the patient was admitted to the Department of Hematology on Day 90 from the beginning of symptoms. Laboratory findings showed a progressive rise of LDH (upto 6135 UI/L), associated with decreased albumin levels (2.4 g/dL), progressive impairment of hepatic function, and mild pancytopenia. The patient developed generalized edema and progressive hypoxemia, and on Day 97 she was transferred to the intensive care unit where she died

Response to 5-azacytidine in a patient with relapsed Hodgkin Lymphoma and a therapy-related myelodysplastic syndrome

Treatment with hypomethylating agents, such as 5-azacytidine (Vidaza; Celgene Corporation, Summit, NJ, USA), has shown efficacy in patients with high-risk myelodysplastic syndromes (MDS) (Kantarjian et al, 2007; Fenaux et al, 2009; Voso et al, 2009) and is becoming the standard of care in this setting. 5-azacytidine has been shown to prolong the time to leukaemic transformation and improve overall survival in higher risk MDS (Fenaux et al, 2009). Chromosome 7 deletions, which are frequent in therapy-related myeloid neoplasms and are associated with poor prognosis, are associated with a favourable response to 5-azacytidine (Raj et al, 2007). To our knowledge, there are no clinical data on the role of hypomethylating drugs in Hodgkin lymphoma (HL), and there is only limited experience with other ‘epigenetic’ drugs, such as inhibitors of histone deacetylases (HDAC) (Dickinson et al, 2009). We report a patient with a therapy-related MDS and a concomitant relapse of HL who was treated with 5-azacytidine. A 46-year-old man was diagnosed in 1996 with classical nodular sclerosis HL, stage IIB with supradiaphragmatic nodal involvement, and was treated with eight cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine), achieving complete remission (CR). The first relapse occurred in 2000 and treatment consisted of the Stanford V regimen, consisting of weekly administration of cytotoxic drugs (mechlorethamine, doxorubicin, vinblastine, vincristine, bleomycin, etoposide, prednisone) for 12 weeks, followed by 36-Gy involved-field radiotherapy on cervical node residue. The second relapse occurred in 2002, and was treated with DHAP (dexamethasone, cytarabine, cisplatin)-like chemotherapy, followed by autologous stem cell transplantation using BEAM (carmustine, etoposide, cytarabine, melphalan) as conditioning regimen, obtaining CR. Two years later the patient had a new, histologicallydocumented, relapse of HL with B-symptoms, and was treated with involved-field radiotherapy (total dose 4500 cGy), and four cycles of MOPP chemotherapy (mechlorethamine, vincristine, procarbazine, prednisone), achieving CR. At this time the patient had an impaired haematological reserve, which required reduction of chemotherapy dose, packed red blood cell and platelet transfusions, antibiotics and granulocyte colony-stimulating factor administration, and had relapsing episodes of paroxysmal atrial fibrillation. In 2006, due to persistent macrocytosis, mild neutropenia and thrombocytopenia, he was diagnosed with therapy-related MDS (t-MDS), with 4% bone marrow blasts, monosomy 7 and del(12)(p11) in 14 of 20 metaphases, resulting in an Intermediate-1 score in the International Prognostic Scoring System (IPSS). The t-MDS did not show any signs of progression until 2009, when platelet and absolute neutrophil counts significantly decreased, with no evidence of lymphoma involvement at the trephine biopsy. A computerized tomography (CT) scan revealed multiple enlarged subdiaphragmatic lymph nodes, with a high [18F]-2-fluoro-2-deoxy-dglucose–positron emission tomography (F-FDG PET)/CT metabolic activity, and a maximal Standardized Uptake Value (SUV) of 16 (Fig 1A). A CT-guided biopsy of the inguinal lymph node confirmed the fourth relapse of HL. At 59 years of age, the patient had an Eastern Cooperative Oncology Group (ECOG) performance status of 1, with significant comorbidities including pulmonary emphysema, hypertension, recurrent paroxysmal atrial fibrillation, an ascending thoracic aortic aneurysm, and post-surgical

Clinical and prognostic features of lymphomas arising in the head and neck region: Our experience of preferential association of different histotypes with various sites of origin in ninety patients

neck region: Our experience of preferential association of different histotypes with various sites of origin in ninety patients Bussu, F.,* Hohaus, S., Bastanza, G.,* Bozzoli, V., Tisi, M.C., Martini, M., Paludetti, G.* & Almadori, G.* *Institute of Otolaryngology, Institute of Haematology, and Institute of Histopatology, Universit a Cattolica del Sacro Cuore, Policlinico Agostino Gemelli, Rome, Italy

Primary Pancreatic Lymphoma in a Patient with Maturity Onset Diabetes of the Young type 3

Primary pancreatic lymphoma (PPL) is an extremely rare disease which occurs in pancreas, accounts for less than 1% of extra-nodal malignant lymphomas and 0,5% of cases of pancreatic masses. We report the case of PPL in a 15 year-old boy suffering from Maturity Onset Diabetes of the Young type 3 (MODY3) diagnosed at the age of 1 year.