Pattern Of Bone Marrow Infiltration Research Articles

Overall Survival In Early Stage Chronic Lymphocytic Leukemia Patients With Treatment Indication Due To Disease Progression: Follow-Up Data Of The CLL1 Trial Of The German CLL Study Group (GCLLSG)

IntroductionChronic lymphocytic leukemia (CLL) is typically diagnosed at an early stage and a watch & wait (W&W) strategy is applied. Only when the disease progresses to a more active, symptomatic form, treatment is indicated. The prospective CLL1 trial was designed to evaluate the benefit of early risk-adapted therapy with fludarabine (F) monotherapy, and to document the natural course of the disease from diagnosis. Here we present follow-up data to assess overall survival from the time point of treatment indication. MethodsAt enrolment, risk stratification was performed based on bone marrow (BM) infiltration pattern, lymphocyte doubling time (LDT), serum beta2-microglobulin (ß2-MG), and serum thymidine kinase (TK). Pts were “high-risk” (HR) if they had diffuse BM infiltration pattern and/or LDT<12 months (mo) combined with TK >7.0 U/L and/or ß2-MG >3.5 mg/L at enrolment. HR pts were randomized in a 1:1 ratio to early F (HR-F), or to W&W until classical treatment indication (HR-W&W), which was also applied to all low-risk (LR) pts. ResultsBetween 1997 and 2004, 710 pts with Binet A stage CLL were enrolled and underwent risk stratification (RS) per protocol. Median time from diagnosis to enrolment was 3.2 mo (range 0-33.7) and median follow-up time was 8.5 years (yrs) (range 0-13.9). 521 pts (73%) were stratified to LR and 189 pts (27%) to HR, of whom 93 pts (49%) were randomized to HR-F and 96 pts (51%) to HR-W&W. Median age was 60 (range 32-75) yrs, 61% were male, 34% had unmutated IGHV status; high-risk cytogenetic features (17p- and 11q-) had 3% and 8% of pts, respectively. Early intervention with F among HR pts significantly prolonged progression-free survival (PFS) (30 vs. 13 mo; p<.001) and treatment-free survival (TFS) (74 vs. 41 mo; p=0.036) but did not significantly impact overall survival (OS) (127 mo vs. not reached; p=0.75). 303 patients had received treatment due to disease progression. 23% of patients received combination chemotherapy, 22% chemoimmunotherapy, 18% monotherapy with chlorambucil, and 15% monotherapy with purine analogues. Median OS for all pts was 91 mo (95% CI, 86 to 101 mo) from start of first treatment due to active disease. Patients with high risk (HR) for disease progression according to risk stratification had a significant shorter OS from start of first treatment than patients with low risk (LR) (71 mo vs. not reached; p=0.001). Early treatment with F did not show a significant impact on survival, when patients progressed after risk-adapted F, but showed a trend to a more favorable outcome for the watch and wait arm receiving their first therapy only when they had progressed to active disease (HR-F: median OS 51 mo versus HR-W&W not reached; p=0.055). Multivariate analyses on 237 pts identified 17p-, 11q-, unmutated IGHV, ß2-MG >3.5 mg/L, and age >60 yrs as independent prognostic factors for OS for patients with progressive, active disease and treatment indication. ConclusionsMonotherapy with fludarabine is not superior to the W&W approach for the management of early stage CLL pts, since early F did not improve OS or outcome following subsequent therapies. Disclosures:No relevant conflicts of interest to declare.

Prognostic significance of whole-body MRI in patients with monoclonal gammopathy of undetermined significance

Radiological skeletal survey or computed tomography are currently applied to assess bone diseases in patients with monoclonal plasma cell disorders. Whole-body magnetic resonance imaging (whole-body MRI) allows detecting the infiltration of clonal cells in nearly the whole bone marrow compartment even before bone destruction has occurred. Those MRI results (i.e., patterns of bone marrow infiltration) have been demonstrated to be of prognostic significance in patients with symptomatic as well as asymptomatic multiple myeloma. We have therefore analyzed the findings of whole-body MRI in 137 consecutive individuals with monoclonal gammopathy of undetermined significance (MGUS). A focal infiltration pattern was detected in 23.4% of patients. Presence and number of focal lesions as well as value of M-Protein were of independent prognostic significance for progression into a symptomatic disease requiring systemic treatment (P=0.02; P<0.0001 and P=0.0005, respectively). Lower homogeneous signal intensities in T1-weighted images were related to a physiologically higher bone marrow cellularity in younger individuals (P=0.002). We conclude that whole-body MRI identifies patients with focal accumulations of presumably monoclonal cells in bone marrow with prognostic impact concerning the risk of progression into symptomatic disease.

Diagnosis and Treatment of Bone Disease in Multiple Myeloma: Spotlight on Spinal Involvement

Bone disease is observed in almost 80% of newly diagnosed symptomatic multiple myeloma patients, and spine is the bone site that is more frequently affected by myeloma-induced osteoporosis, osteolyses, or compression fractures. In almost 20% of the cases, spinal cord compression may occur; diagnosis and treatment must be carried out rapidly in order to avoid a permanent sensitive or motor defect. Although whole body skeletal X-ray is considered mandatory for multiple myeloma staging, magnetic resonance imaging is presently considered the most appropriate diagnostic technique for the evaluation of vertebral alterations, as it allows to detect not only the exact morphology of the lesions, but also the pattern of bone marrow infiltration by the disease. Multiple treatment modalities can be used to manage multiple myeloma-related vertebral lesions. Surgery or radiotherapy is mainly employed in case of spinal cord compression, impending fractures, or intractable pain. Percutaneous vertebroplasty or balloon kyphoplasty can reduce local pain in a significant fraction of treated patients, without interfering with subsequent therapeutic programs. Systemic antimyeloma therapy with conventional chemotherapy or, more appropriately, with combinations of conventional chemotherapy and compounds acting on both neoplastic plasma cells and bone marrow microenvironment must be soon initiated in order to reduce bone resorption and, possibly, promote bone formation. Bisphosphonates should also be used in combination with antimyeloma therapy as they reduce bone resorption and prolong patients survival. A multidisciplinary approach is thus needed in order to properly manage spinal involvement in multiple myeloma.

Diagnostic and Prognostic Implications of Spine Magnetic Resonance Imaging At Diagnosis in Patients with Multiple Myeloma

AbstractAbstract 3999The role of baseline spine magnetic resonance imaging (MRI) in patients with multiple myeloma who have no related symptoms or signs is controversial. In the present study, we prospectively evaluated the diagnostic and prognostic implications of whole-spine MRI taken at the time of diagnosis in patients with multiple myeloma.Patients who were newly diagnosed with multiple myeloma between 2004 and 2011 at Chungnam National University Hospital were enrolled. Abnormal MRI findings that were not detected in plain radiographs were analyzed and categorized as pathological fractures or extramedullary extension of the plasmacytoma. The bone marrow (BM) infiltration patterns on MRI were classified into five categories: homogenous diffuse, micronodular, macronodular, mixed, and normal appearance of the BM. The prognostic implications of the additional lesions found on MRI and the BM infiltration patterns were analyzed.A total of 113 patients with a median age of 65 (range, 40μ–μ89) years were enrolled in the study. Pathological fractures that were not detected in the bone survey were found in 26 (23.0%) patients, including three (2.6%) patients with no related symptoms or signs. Extramedullary extension of the plasmacytoma was detected in 22 (19.5%) patients, including 15 (13.3%) with epidural extension of the tumor. Of these 22 patients, 11 (50.0%) had no relevant symptoms or signs. Neither the additional pathological fractures nor the extramedullary extensions found correlated with the international staging system stage (ISS). The presence of pathological fractures did not influence overall survival, whereas extramedullary extension of the plasmacytoma was associated with poor overall survival in multivariate analysis (HR 3.205; 95% CI, 1.430 – 9.845; P=0.042). Of the 113 patients, 35 (31.0%) had a diffuse infiltrative pattern, 39 (34.5%) had a micronodular pattern, 15 (13.3%) had a macronodular pattern, 17 (15.0%) had the mixed type, and 7 (6.2%) appeared normal. The BM infiltration patterns did not correlate with the ISS. During follow-up for a median of 21 (range 1 – 91) months, the overall survival of patients with the mixed type (median 24.0 months; 95% CI, 22.9 – 25.1) was shorter compared to those with other patterns (median 56 months; 95% CI, 48.9 – 63.1) (P=0.030). Survival differences were not found among the other patterns.In summary, baseline spine MRI reveals not only bone lesions, but also extramedullary extension of plasmacytoma that cannot be detected in plain radiographs, even in patients with no relevant symptoms or signs. In addition, the mixed infiltration pattern on MRI is a predictor of poor overall survival. These results indicate that spine MRI should be included in the initial diagnostic investigations for patients with multiple myeloma. Disclosures:No relevant conflicts of interest to declare.

18F-FAMT in patients with multiple myeloma: clinical utility compared to 18F-FDG

L-[3-(18)F]-alpha-methyltyrosine ((18)F-FAMT) is an amino-acid tracer for positron emission tomography (PET), with uptake related to overexpression of L-type amino-acid transporter 1 and proliferative activity in tumour cells. This study evaluated the diagnostic performance of (18)F-FAMT PET compared with 2-[(18)F]-fluoro-2-deoxy-D-glucose ((18)F-FDG) PET in patients with multiple myeloma (MM). Eleven patients with MM (newly diagnosed, n = 3; relapsed after treatment, n = 8) underwent whole-body (18)F-FAMT and (18)F-FDG PET within a 2-week interval. Magnetic resonance imaging (MRI) of the spine was also performed to assess patterns of bone marrow infiltration. Tracer uptake was semi-quantitatively evaluated using maximal standardized uptake value (SUV(max)). Mean SUV was also determined for normal bone marrow and the aortic arch as mediastinal background SUV to calculate lesion-to-bone marrow (L/B) and lesion-to-mediastinum (L/M) ratios, respectively. Those values were statistically compared using Student's t test. In 8 patients showing focal infiltration on MRI, 34 FDG-avid bone lesions were identified, with each showing increased FAMT uptake. Mean SUV(max) and L/B ratio of FDG (3.1 ± 1.2 and 3.3 ± 1.9, respectively) were significantly higher than those of FAMT (2.0 ± 1.0 and 2.6 ± 1.1, respectively; p < 0.05 each). In contrast, the L/M ratio of FDG showed no significant difference to that of FAMT (2.2 ± 1.0 and 2.4 ± 1.2, respectively; p = 0.3). Clear (18)F-FAMT PET uptake was seen in most (18)F-FDG-avid lesions among patients with MM, and an equivalent semi-quantitative value was obtained using L/M ratio. Our preliminary data suggest that (18)F-FAMT PET provides a useful imaging modality for detecting active myelomatous lesions.

Evaluation of bone marrow aspirates from multiple sites for staging of canine lymphoma and mast cell tumours

This prospective study evaluated the utility of bone marrow aspirates (BMAs) obtained from multiple sites for staging of canine lymphoma (LSA) and mast cell tumours (MCTs). Forty dogs (LSA, n = 24; MCTs, n = 16) were enrolled, but only 33 (82.5%) had diagnostic bone marrow (BM) aspirates obtained from two sites for inclusion in the study. Nineteen dogs with LSA were included, and 6 (31.6%) had BM involvement. Neoplastic lymphocytes were present in BM from both sites in all of these dogs. Fourteen dogs with MCTs were included, and 3 (21.4%) had BM involvement. Neoplastic mast cells were present at both sites in two dogs and at only one site in the third. These results indicate that BMAs from multiple sites may not be needed for accurate staging of canine LSA patients, but more studies evaluating the pattern of BM infiltration in dogs with high-grade MCTs are warranted.

Diffuse Pattern of Bone Marrow Involvement in MRI Is Associated with High Risk Cytogenetics and Poor Outcome in Newly Diagnosed, Symptomatic Patients with Multiple Myeloma,

Abstract 3920Magnetic Resonance Imaging (MRI) and specific recurrent cytogenetic abnormalities offer important prognostic information for multiple myeloma (MM) patients. However, limited data are available about the association between cytogenetic abnormalities and MRI patterns of marrow infiltration. To address this issue, we analyzed 203 newly-diagnosed, symptomatic patients who were treated in a single center, in Athens (Greece). The pattern of marrow involvement in MRI was recognized as: (1) normal when there was no evidence of abnormal signal; (2) focal which consisted of localized areas of abnormal marrow; (3) diffuse, in which the normal bone marrow is completely replaced; and (4) variegated which consists of innumerable small foci of disease on a background of intact marrow. Cytogenetic studies by FISH were performed in CD138 selected plasma cells using standard methodology.Eighty-six (42%) patients had focal pattern, 79 (39%) diffuse, 28 (14%) normal and 10 (5%) variegated pattern. Due to the low number of patients with variegated pattern and to our previous finding that variegated and diffuse patterns have similar outcomes, we analyzed these two patterns together. Patients with normal MRI pattern presented with better performance status (86% had ECOG PS ≤1 vs. 47% and 45% of patients with focal or diffuse patterns, p<0.001). Patients with focal or diffuse infiltration had features of advanced disease, such as anemia (Hb <10 g/dl; p<0.001), elevated serum LDH ≥300 IU/L (p=0.008) and advanced ISS stage (p<0.001). Patients with focal MRI pattern presented less often with renal impairment (eGFR <50 ml/min; p=0.017) but more often with lytic bone disease (p<0.001).The presence of del17p was more common in patients with diffuse pattern (22% vs. 10% in patients with focal and none in those with normal pattern, p=0.04). Similarly, add1q21 was more common in patients with diffuse pattern (37% vs. 13% and 15% for patients with focal or normal pattern; p=0.038). Del13q was observed also more frequent in diffuse pattern (48% vs. 28% and 24% for focal and normal pattern, p=0.056) while there were no significant differences in the frequency of t(4;14) and t(14;16) among patients with different MRI patterns. In general, 56% of patients with diffuse MRI pattern had high risk cytogenetics [any of del17p, add1q21, t(4;14) or t(14;16)] vs. 31% and 22% of patients with focal and normal patterns (p=0.012).Most patients (70%) received first line therapy based on novel agents (thalidomide, bortezomib or lenalidomide). Response to first line therapy was similar for patients with different MRI patterns (76%, 77.5% and 75% for focal, diffuse and normal pattern, respectively). However, patients who were treated upfront with conventional chemotherapy (CC) and had a diffuse MRI pattern had inferior response (46% vs. 79% and 83% for patients with focal and normal patterns, respectively, p=0.024). When patients were treated with novel agent-based frontline therapy, the response rates were similar among MRI patterns (89%, 74% and 73% for diffuse, focal and normal MRI patterns, respectively; p=NS).The median survival for patients with normal, focal and diffuse MRI patterns was 102, 57 and 37 months, respectively (p<0.001). The respective median survival for patients who were treated with CC was: not reached yet, 51 and 23.5 months (p<0.001) and in those who received novel agent-based regimens was 47 months for diffuse pattern vs. not reached for patients with focal or normal MRI pattern (p=0.05). When we adjusted for other clinical factors and for treatment type, then diffuse MRI pattern was independently associated with poor survival (HR: 3.018, p=0.024). Other factors that were independently associated with poor survival were age (>75 years; p<0.001), CC (p=0.001), ISS (p<0.001) and serum LDH ≥ 300 IU/L (p=0.05). When high risk cytogenetics were included in the multivariate model then only high risk cytogenetics (HR: 2, p=0.046), ISS stage (p=0.027) and serum LDH ≥300 IU/L were independently associated with poor survival.In conclusion, diffuse MRI pattern of bone marrow infiltration is associated with the presence of high risk cytogenetics, such as del17p and add1q21. The strong correlation of diffuse pattern with poor survival, even in the era of novel agents, suggests the need for more effective therapies for those patients and highlights the importance of the performance of baseline MRI in all patients with symptomatic disease. Disclosures:No relevant conflicts of interest to declare.

Chronic Lymphocytic Leukemia: Proliferative and Apoptotic Profile on Lymph Node, Studied by Immunohistochemistry Including the Proliferation Centers

Abstract 2538Chronic lymphocytic leukemia (CLL) has a proliferation rate higher than previously recognized. Proliferation centers (PC) play an important role in the biology of CLL given the fact that they constitute its proliferative compartment. The complexity of the microenvironment of PC, as well as the molecular events taking place in the PC and their clinical significance remain to be elucidated.The aim was to identify the presence of PC in lymph node and other tissues, except the bone marrow; to analyze their proliferative status; to evaluate the expression of molecules implicated in the apoptotic process in PC, compared to their expression in the non-PC areas; and to correlate the aforementioned findings with the clinical and laboratory features in a series of CLL patients.Fifty patients, fulfilling the diagnostic criteria of CLL/SLL and in whom lymph node biopsy or other tissue material (44 lymph nodes, 5 spleens, 1 skin) were available, were enrolled in this study. Twenty five biopsies were performed at diagnosis while the rest prior to treatment initiation. All necessary clinical and biological data were recorded on each patient, including Binet stage, lymphocyte doubling time, bone marrow infiltration pattern, CD 38 expression, IgVH mutational status and FISH analysis for genetic abnormalities. PC were defined as pale areas containing large cells so called paraimmunoblasts and prolymphocytes, surrounded by a dark background of small lymphocytes. Immunohistochemical detection of the following molecules participating in the apoptotic process were studied in all tissue sections: Bcl-2, Fas, FasL, c-FLIP (in the PC and the non PC areas) as well as cleaved caspase 3 that was evaluated in the entire tumor area. ZAP-70 was also studied by immunohistochemistry while proliferation status was assessed by the Ki-67 immunostaining.The median age of our patients at diagnosis was 55 years (36–77). Twenty-nine (58%) had disease stage A, 17(34%) B and 4(8%) C, while 12% had B-symptoms, 26% elevated LDH levels and 25% presented with rapid lymphocyte doubling time. 39% needed treatment immediately after diagnosis.Proliferations centers were present and easily identified after staining with haematoxylin-eosin on lymph node and splenic sections with their numbers varying from case to case. Proliferation assessment revealed that median Ki67 proliferation index per PC was 10% (1–20%), while median Ki67 in the whole tissue section was 3% (1–8%) (p<0,0001).Apoptotic molecules evaluation disclosed that the expression of cleaved-caspase 3 was very low (median 0.0046%). Fas, FasL and cFLIP activity was expressed in various percentages in the PC and in the non-PC areas as shown in Table 1. Further on, in cases of overexpression of Fas and FasL, an analogous increase of cFLIP expression was not observed. Patients with elevated Ki67 proliferation index in PC area tended to express more Fas and FasL in the same areas. Strong homogenous Bcl-2 expression was observed both in the PC and in the non PC areas. Weaker Bcl-2 expression in PC compared to non PC areas was observed in 10 patients in whom a higher Fas (p=0.054) and FasL (p=0.005) was present. 48% of the cases were ZAP-70 positive. ZAP70 positivity was correlated with increased expression of cFLIP in PC (p=0.0216). The only statistically significant correlation between apoptotic molecule profile and clinical features was between an increased FasL expression in PC and B-symptoms (p: 0.0263). In univariate survival analysis, coexpression of Fas/FasL and cFLIP at increased levels in PC correlated with poor disease-free and overall survival (p=0.0031, p=0.0521 respectively).Table 1Fas, FasL and cFLIP expression in lymph node and splenic sections of CLL patientsMoleculePC median(%)Non-PC areas (median %)P valueFas50400,1581FasL30100,0107cFLIP50400,0726Proliferative centers in lymph node and splenic sections of CLL patients present particular proliferative and apoptotic profile. Inhibition of Fas mediated apoptosis in PC may not be attributable to cFLIP expression. Increased Fas,FasL and cFlip coexpression in PC was correlated with disease-free and overall survival. Disclosures:No relevant conflicts of interest to declare.

Diagnostic Difficulties of Pure Intrasinusoidal Bone Marrow Infiltration of Non-Hodgkin's Lymphoma: A Report of Eight Cases from India

Bone marrow involvement in non-Hodgkin's lymphoma is prognostically important for appropriate management. Intrasinusoidal pattern of bone marrow infiltration is poorly identified on trephine biopsies. We analyzed the clinical, hematological and histopathological spectrum of eight cases of non-Hodgkin's lymphoma showing pure intrasinusoidal bone marrow infiltration. Fever, cytopenias and blasts in circulation were the indications for bone marrow aspiration and trephine biopsies. Flow cytometry on bone marrow and immunohistochemistry on trephine sections were done. There were five cases of T-cell hepatosplenic non-Hodgkin's lymphoma (three γδ T-cell lymphoma) and three B-cell non-Hodgkin's lymphoma (two intravascular large B-cell lymphoma and one splenic marginal zone lymphoma). Except the cases with intravascular large B-cell lymphoma, all showed variable splenomegaly without lymphadenopathy. Immunohistochemistry highlighted intrasinusoidal infiltration, which was difficult to discern on hematoxylin and eosin. This brief analysis highlights that pure intrasinusoidal infiltration of extranodal non-Hodgkin's lymphoma requires a high degree of diagnostic suspicion and can be seen in various lymphomas.

Expression of CD38, but not ZAP-70, is Associated with Diffuse Infiltration Pattern and Extent of Bone Marrow Infiltration in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)

Background: The prognostic significance of the extent and pattern of bone marrow infiltration by Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) has been supplanted by newer biologic prognostic markers such as immunoglobulin heavy chain variable region (IgVH) mutation status, CD38 and ZAP70 expression, fluorescence in situ hybridization (FISH) cytogenetics, and serum markers. Expression of CD38 and ZAP-70 correlates with IgVH mutation status, and also provides prognostic value as independent markers. Materials and Methods: Seventy-four cases of CLL/SLL were reviewed and the relationship between expression of CD38, ZAP-70, and bone marrow infiltration was examined. CD38 and ZAP-70 were analyzed by a single laboratory using standardized multiparametric flow cytometry with a threshold of 20% and 30% positive cells for each. Hematoxylin and eosin stained bone marrow biopsy and aspirate clot sections were classified as showing diffuse or non-diffuse (nodular/interstitial) pattern of infiltration; the extent of infiltration was assessed by the proportion of lymphocytes on histologic sections and aspirate smears.

Frequency and Pattern of Bone Marrow Infiltration in Non-Hodgkin’s Lymphoma

Introduction: Lymphomas are malignant neoplasms arising from lymphoid tissue. They are divided into two groups i.e Hodgkin’s Lymphoma and Non-Hodgkin’s Lymphoma. Staging of Hodgkin’s Lymphoma is important for the management and treatment of the patient. This study was carried out to determine the frequency of bone marrow infiltration at the time of diagnosis as well as various patterns of bone marrow involvement. Materials and Methods: Clinical history and physical findings were recorded in the proforma. Investigations were carried out. Bone marrow aspirate and trephine biopsies were performed from posterior iliac crest. Aspirates and trephine biopsies were evaluated and assessed for cytology, marrow architecture, haemopoietic tissue and any lymphomatous infiltration. In cases with infiltration, the infiltration pattern was studied. Results: Fifty Hodgkin’s lymphoma patients were studied. Bone marrow infiltration was found in 19 (38%) cases. Among these 19 patients with infiltration 17 (89.4%) patients were of Hodgkin’s Lymphoma mixed cellularity and 2 (10.5%) had Hodgkin’s Lymphoma Nodular Sclerosis. Pattern of infiltrate was interstitial in majority of cases followed by diffuse type of infiltration. Conclusion: Bone marrow involvement in Hodgkin’s Lymphoma is more common in our setup as patients present at a later stage. It is recommended that bone marrow examination should be performed as a part of staging investigations in patients with Hodgkin’s Lymphoma.

Expression of CD38, but not ZAP-70, is Associated with Diffuse Infiltration Pattern and Extent of Bone Marrow Infiltration in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)

Expression of CD38, but not ZAP-70, is Associated with Diffuse Infiltration Pattern and Extent of Bone Marrow Infiltration in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)

Leucemia de células velludas en el embarazo: Caso clínico

Hairy cell leukemia (HCL) is a rare chronic B cell lymphoproliferative disorder that affects mostly men. It usually presents with pancytopenia, splenomegaly and bone marrow infiltration, without lymphadenopathy. Diagnosis is based on the presence of mononuclear cells with cytoplasmic projections in a blood smear, the typical bone marrow infiltration pattern and the immunophenotypic profile. HCL occurs seldom in young women and even more exceptionally during pregnancy. We report a 31-year-old woman in whom a splenomegaly was detected during routine prenatal care. Pancytopenia with 25% of hairy cells was found in her blood count. The patient was subjected to an open splenectomy and had an uneventful pregnancy. After two years of follow up, she has a normal blood count and has not required chemotherapy.

Staging Monoclonal Plasma Cell Disease: Comparison of the Durie-Salmon and the Durie-Salmon PLUS Staging Systems

To investigate the concordance of the Durie-Salmon staging system with the Durie-Salmon PLUS staging system in monoclonal plasma cell disease. Institutional review board approval was obtained, with waiver of informed consent. Lesions in 403 untreated patients (age range, 21-83 years) with monoclonal gammopathy of undetermined significance (MGUS) (n = 84), solitary plasmacytoma (n = 17), amyloid light-chain amyloidosis (n = 12), and multiple myeloma (MM) (n = 290) were first staged on the basis of the classic Durie-Salmon staging system, which included conventional radiography. After examination with whole-body (WB) magnetic resonance (MR) imaging, lesions in these patients were, in addition, staged by using the Durie-Salmon PLUS staging system. Bone marrow infiltration pattern and focal lesions described as intramedullary, transcortical, and soft-tissue lesions, were assessed. The staging levels of both systems were compared. Of 84 patients with MGUS, lesions in 33 (39%) would have been staged differently with Durie-Salmon PLUS staging system when compared with Durie-Salmon staging system (stage I MM [37%], stage II MM [0%], and stage III MM [2%]). All 17 patients with plasmacytoma showed additional focal lesions or a diffuse infiltration leading to a classification as stage I MM (76%), stage II MM (12%), or stage III MM (12%) with Durie-Salmon PLUS. Of the 149 patients with stage I MM, lesions in 81 (54%) would have been staged differently with the Durie-Salmon PLUS staging system. Of the 21 patients with stage II MM, lesions in 19 (91%) would have been staged differently with Durie-Salmon PLUS staging system when compared with the Durie-Salmon staging system. Of the 120 patients with stage III MM, lesions in 72 (60%) would have been staged differently with the Durie-Salmon PLUS staging system. Given the fact that the Durie-Salmon and Durie-Salmon PLUS staging systems were concordant in only 45% of all examined patients with monoclonal plasma cell disease, in most cases, treatment decisions depend on the staging system used and, thus, remain a matter of debate.

Immunohistochemical analysis of NOTCH1 and JAGGED1 expression in multiple myeloma and monoclonal gammopathy of undetermined significance

Notch signaling is implicated in the pathogenesis of multiple myeloma expressing high level of active Notch proteins NOTCH1 and JAGGED1 in tumor plasma cells. We investigated expression of NOTCH1 and JAGGED1 in bone marrow trephine biopsies of 80 newly diagnosed multiple myeloma and 20 monoclonal gammopathy of undetermined significance patients using immunohistochemical methods. The number of positive tumor cells was counted per 1000 tumor cells and the intensity of staining was assessed semi quantitatively. Multiple myelomas expressed NOTCH1 in 92.31% (72/78) and JAGGED1 in 92.21% (71/77) cases. NOTCH1 staining was strong in the majority of cases (59.7%), whereas JAGGED1 was predominately weak (67.6% of cases). In contrast, both markers were negative in all monoclonal gammopathy of undetermined significance cases. However, upon progression of disease from monoclonal gammopathy of undetermined significance to multiple myeloma (seen in 4 patients), analysis of the subsequent bone marrow biopsy showed weak expression of both markers in tumorous plasma cells. Immunohistochemistry results were compared with the pattern of bone marrow infiltration, plasma cell differentiation, and the presence of t(11;14)(q13,q32), t(14;16)(q32;q23),and t(4;14)(p16.3;q23) and overall survival in multiple myeloma patients. A significant correlation was found between strong NOTCH1 staining in multiple myeloma plasma cells and the diffuse type of bone marrow infiltration (P = .002) and an immature morphologic type of plasma cells (P = .043). After a median follow-up of 20.3 months, in multiple myeloma patients no difference in overall survival between NOTCH1 (P = .484) and JAGGED1 (P = .822) positive and negative cases were found. In conclusion, our results indicate importance of NOTCH1 and JAGGED1 expression in plasma cell neoplasia and a possible diagnostic value of their immunohistochemical evaluation of bone marrow infiltrates for multiple myeloma.

Increased Immunohistochemical CD138 Expression in Waldenström's Macroglobulinemia (WM) in Comparison with Splenic Marginal Zone Lymphoma (SMZL).

Abstract 5008 IntroductionDifferentiating Waldenström's Macroglobulinemia (WM) from other lymphomas and especially Splenic Marginal Zone lymphoma (SMZL), which presents common features with WM, consists a challenge. There is no characteristic molecular abnormality neither for WM nor for SMZL, while in addition, serum IgM cut off is no longer used for the diagnosis of WM. Moreover, while paratrabecular and intrasinusoidal pattern of bone marrow infiltration are described as typical of WM and SMZL respectively, there is often overlap between them. B-lymphocytes' immunophenotype is usually CD5 and CD23 negative in both entities, although deviations from this pattern may be observed; CD38, a marker of lymphocyte activation, theoretically related to lymphoplasmacytic differentiation and adverse prognosis in Chronic Lymphocytic Leukemia, may be expressed. Both WM and SMZL are included among the least reproducible diagnoses of the WHO classification when the diagnosis is based only on clinical grounds, routine laboratory tests and bone marrow biopsy (absence of lymph node or spleen biopsy or typical leukemic picture). CD138 (Syndecan) is expressed in immature as well as in terminally differentiated B-lymphocytes, especially in plasma cells. A strong CD138 expression is observed in myeloma plasma cells. AimTo evaluate firstly whether CD138 is expressed in WM and SMZL and secondly if its expression may help in the differential diagnosis of these entities. Patients and methods61 patients were studied at presentation, 40 with WM and 21 with SMZL. Among WM patients, 16 were females and 24 males with a median age of 64 years. 57% presented anemia with hemoglobin<12gr/lt, 12% lymphathenopathy and 5% splenomegaly. Among SMZL patients, there were 8 females and 13 males (median age 61 years). 70% presented anemia and 9% lymphathenopathy. In all 61 patients bone marrow was infiltrated by neoplastic cells. By definition, all WM patients had a monoclonal serum IgM paraprotein while 19% of SMZL patients secreted a serum monoclonal paraprotein, either IgM or IgG. Paraffin embedded sections of bone marrow biopsies performed at diagnosis, were stained with anti-CD138 monoclonal antibody, CD138 expression was evaluated in the bone marrow of all patients and comparison between the two patient groups was made. 10% CD 138 expression in bone marrow neoplastic cells was used as cut-off for the evaluation of positivity or negativity. Results62% of WM patients presented CD138 expression in contrast with 14% of SMZL patients. Median percentage of total CD138 expression in neoplastic cells in WM was 26.5% (range 2-100%) while in SMZL it was 8% (range 0-30%). These differences were statistically significant (p<0.01). It is interesting to note that, 3 out of 4 SMZL patients who secreted IgM at low levels did not express CD138. Otherwise in WM patients CD138 expression correlated only with serum IgM levels. In addition it was observed that 68% of WM patients expressed CD38 by bone marrow lymphocyte flow cytometry compared to 5% of SMZL (p<0.01); however this finding was not related to CD138 immunohistochemical expression. ConclusionsPatients with WM presented increased CD138 expression when compared to SMZL patients. If confirmed in larger series, CD138 expression could help differentiating the two entities. DisclosuresNo relevant conflicts of interest to declare.

Nodular pattern of bone marrow infiltration: frequent finding in immunosuppression-related EBV-associated large B-cell lymphomas

Different patterns of bone marrow (BM) infiltration by diffuse large B cell lymphomas (DLBCL) have been described. A pure nodular pattern is uncommon, and the pathologic features, as well as the clinical correlates of DLBCL manifesting this pattern in the BM have not been well characterized. We evaluated BM biopsies involved by large B cell lymphomas diagnosed at our institute over an 11-year period to assess the morphology, phenotype, cytogenetic abnormalities, and clinical features of cases associated with a nodular pattern. A distinct nodular pattern of BM involvement was noted in 14 out of 55 (25%) cases. Although both EBV+ and EBV- DLBCL with this pattern were identified, a pure nodular pattern was significantly more common in EBV+ DLBCL compared to EBV- DLBCL (8/9, 89% versus 6/46, 13%; P = 0.00002). The majority of EBV+ DLBCL associated with a nodular pattern had distinctive morphologic features (polymorphic cellular infiltrate and pleomorphic cytology), and CD30 expression was more commonly observed in this group (P = 0.0163). All EBV+ DLBCL and two out of six (33%) EBV- DLBCL had nongerminal center phenotypes. No recurrent cytogenetic abnormalities were detected in either group. Importantly, all EBV+ DLBCL occurred in individuals with immune dysfunction (organ transplant recipients, HIV infection) or in those >50 years of age. Our study indicates a much higher predilection for EBV+ DLBCL to involve the marrow in a nodular pattern compared to EBV- cases and highlights similarities in the morphologic pattern of BM involvement by previously recognized subsets of immunodeficiency-related EBV + lymphomas and the newer entity of "EBV+ DLBCL of the elderly."

UK Myeloma Forum (UKMF) and Nordic Myeloma Study Group (NMSG): guidelines for the investigation of newly detected M‐proteins and the management of monoclonal gammopathy of undetermined significance (MGUS)

Avon Haematology Unit, Bristol Haematology and Oncology Centre, Bristol, Department of Haematology, St Helier Hospital, Carshalton, Surrey, UK, Department of Haematology, Sahlgrenska University Hospital, Gothenburg, Sweden, Department of Medicine, Malmo University Hospital, Malmo, Sweden, Division of Immunity and Infection, University of Birmingham, Birmingham, Department of Clinical Biochemistry, Frenchay Hospital, Bristol, Department Haematology, University College, London, Glasgow Western Infirmary, Glasgow, UK, Department of Haematology, NTNU/St Olavs Hospital, Trondheim, Department of Haematology, Ulleval University Hospital, Oslo, Norway, Department of Haematology Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark, and Myeloma UK.

Risk factors for poor treatment outcome and central nervous system relapse in diffuse large B-cell lymphoma with bone marrow involvement

Although several studies have described the prognostic implication of bone marrow (BM) involvement (BMI) in lymphoma, studies focused on BM-involved diffuse large B-cell lymphoma (DLBCL) are very rare and small-sized. This study was performed to examine the prognostic impact of morphologic findings of BMI by lymphoma and risk factors for central nervous system (CNS) relapse in BM-involved DLBCL. Between 1993 and 2005, 675 patients were diagnosed with DLBCL, and 88 patients who had BMI at initial diagnosis were eligible for this study. The median overall survival (OS) and failure-free survival (FFS) of 88 patients were 36.6 and 20.1 months, respectively. When three variables from BM morphologic findings (the pattern of BM infiltration, extent of BMI by lymphoma, and percentage of large cells in the infiltrate) were simultaneously included into multivariate model, the increased extent of BMI by lymphoma (> or =10%) in BM area was the only negative prognostic factor, independent of the International Prognostic Index (IPI). Patients with both lower IPI scores and less extent of BMI showed an excellent prognosis with chemotherapy alone (5-year OS and FFS rates, 80% and 69%). However, morphologic BM features were not independent predictive factors for CNS recurrences. An increased lactate dehydrogenase (LDH) level at initial diagnosis was the only independent predictive factor for CNS relapse. Further efforts should be directed toward finding optimal treatment modalities based on the IPI and the extent of BMI by lymphoma. CNS prophylaxis may be considered only in patients with initial elevated LDH levels.

Comparison of whole-body MR imaging and conventional X-ray examination in patients with multiple myeloma and implications for therapy

Skeletal X-ray survey is the established method of diagnosis in patients with multiple myeloma; however, whole-body magnetic resonance imaging (wb-MRI) has become an important additional tool. The aim of this study was to compare the different patterns of infiltration on conventional X-ray examinations (X-ray survey) with findings from wb-MRI to subsequently determine the influence of wb-MRI on therapy changes. In 60 patients with a mean age of 65.1 +/- 11.7 years, wb-MRI examinations were correlated with a recent X-ray survey. The results were independently assessed by two radiologists and the patterns of infiltration were described in both modalities. Subsequently, the disease was staged according to Salmon and Durie and Salmon and Durie PLUS. Additionally, the influence of MRI on potential changes in therapy was assessed using a three-range Likert-type scale. In all, 480 skeletal regions were compared. In 183 skeletal regions, an increased degree of infiltration was identified on wb-MRI. Significant differences (p < 0.05) between the modalities could be found in the thorax, spine, pelvis, and both lower extremities. Based on wb-MRI, tumor stage was upgraded in 19 of the 60 patients using the Durie and Salmon PLUS classification. In ten out of these 19 patients (42%), the wb-MRI result was essential for making the decision to initiate further therapy due to the degree of infiltration, extramedullary tumor extension, and/or further risk of fracture. Whole-body MRI provides a more detailed assessment of the pattern of bone marrow infiltration and strongly influences therapeutic strategies.