Chronic Lymphatic Leukemia Research Articles

Study of the frequency and distribution of various types of leukemia among the patient coming to Sir T. hospital Bhavnagar

Pattern of leukemia is known to vary widely throughout the world. The characterization of distribution patterns of different subtypes of leukemia needs further study. Aim of our study is to determined the frequency and distribution of various types of leukemia among the patient coming to sir t hospital and correlate with age, sex and risk factors from period of May 2018 to April 2020. Study of the frequency and distribution of various types of leukemia among the patient coming to Sir T. hospital Bhavnagar.A retrospective study was done from May 2018 to April 2020. We analyzed the pattern of leukemia at GMCB by morphological subtype, gender, age at diagnosis, distribution according to prevalence, risk factors, laboratory parameters and clinical features of leukemia.Morphological subtyping showed that 56 cases were of acute leukemia and 42 of chronic leukemia. Acute myeloid leukemia constituted the single largest group comprising (57.2%) of all cases, followed by chronic myeloid leukemia (42.8%), acute lymphoid leukemia (20.4%) and chronic lymphoid leukemia (12.2%). The data published in this study reflects the leukemia pattern. Low grade fever, progressive pallor, weakness and body aches were the commonest symptoms (70% cases) while pallor was the frequently observed sign.

Employment of Machine Learning Models Yields Highly Accurate Hematological Disease Prediction from Raw Flow Cytometry Matrix Data without the Need for Visualization or Human Intervention

Background: Machine Learning (ML) offers automated data processing substituting various analysis steps. So far it has been applied to flow cytometry (FC) data only after visualization which may compromise data by reduction of data dimensionality. Automated analysis of FC raw matrix data has not yet been pursued. Aim: To establish as proof of concept an ML-based classifier processing FC matrix data to predict the correct lymphoma type without the need for visualization or human analysis and interpretation. Methods: A set of 6,393 uniformly analyzed samples (Navios cytometers, Kaluza software, Beckman Coulter, Miami, FL) was used for training (n=5,115) and testing (n=1,278) of different ML models. Entities were chronic lymphatic leukemia (CLL) 1103 (training) and 279 (testing), monoclonal B-cell lymphocytosis (MBL, 831/203), CLL with increased prolymphocytes (CLL-PL, 649/161), lymphoplasmacytic lymphoma (LPL, 560/159), hairy cell leukemia (HCL, 328/88), mantle cell lymphoma (MCL, 259/53), marginal zone lymphoma (MZL, 90/28), follicular lymphoma (FL, 84/16), no lymphoma (1211/291). Three tubes comprising 11 parameters per tube were applied. Besides scatter signals analyzed antigens included: CD3, CD4, CD5, CD8, CD10, CD11c, CD19, CD20, CD22, CD23, CD25, CD38, CD45, CD56, CD79b, CD103, FMC7, HLA-DR, IgM, Kappa, Lambda. Measurements generated LMD files with 50,000 rows of data for each of the 11 parameters. After removing the saturated values (≥ 1023) we produced binned histograms with 16 predefined frequency bins per parameter. Histograms were converted to cumulative distribution functions (CDF) for respective parameters and concatenated to produce a 16x11 matrix per each tube. Following the assumption of independence of parameters this simplification of concatenating CDFs represents the same information as if they were jointly distributed. The first matrix-based classifier was a decision tree model (DT), the second a deep learning model (DL) and the third was an XGBoost (XG) model, an implementation of gradient boosted decision trees ideal for structured tabular data (such as LMD files). The first set of analyses included only three classes which are readily separated by human operators: 1) CLL, 2) HCL, 3) no lymphoma. The second set included all nine entities but grouped into four classes: 1) CD5+ lymphoma (CLL, MBL, CLL-PL, MCL), 2) HCL, 3) other CD5- lymphoma (LPL, MZL, FL), 4) no lymphoma. The third set included each of the nine entities as its own class. Results: Analyzing the three classes from the first set (CLL, HCL, no lymphoma) the models achieved accuracies of 94% (DT), 95% (DL) and 96% (XG) when including all cases. By analysis of cases with prediction probabilities above 90%, DT now reached 97%, DL 97% and XG 98% accuracy, whilst losing 38%, 8% and 6% of samples, respectively. We further observed that accuracy was also dependent on the size of the pathologic clone, which is in line with the experiences from human experts with very small clones (≤ 0.1% of leukocytes) representing a major challenge regarding their correct classification. Focusing on cases with clones > 0.1% but considering all prediction probabilities accuracies were 96% (DT), 97% (DL) and 98% (XG), with loss of 5% of samples for each model. Considering cases only with prediction probabilities > 90% and clones > 0.1% accuracies were 97% (DT), 99% (DL) and 99% (XG) whilst losing 38%, 9% and 9% of samples, respectively. Further analyses were performed applying the best model based on results above, i.e. XG. Analyzing four classes in the second set of analyses (CD5+ lymphoma, HCL, other CD5- lymphoma, no lymphoma) and considering cases only with prediction probabilities > 95% and clones > 0.1% accuracy was 96% while losing 28% of samples. In the third set of analyses with each entity assigned its own class and again considering cases only with prediction probabilities > 95% and clones > 0.1% accuracy was 93% while losing 28% of samples. Conclusions: This first ML-based classifier using the XGboost model with transforming FC matrix data to concatenated distributions, is capable of correctly assigning the vast majority of lymphoma samples analyzing FC raw data without visualization or human interpretation. Cases that need further attention by human experts will be flagged but will not account for more than 30% of all cases. This data will be extended in a prospective blinded study (clinicaltrials.gov NCT4466059). Disclosures Heo: AWS: Current Employment. Wetton:AWS: Current Employment.

Effective Treatment of Cold Agglutinin Disease/Cold Agglutinin Syndrome with Ibrutinib: An International Case Series

Background In cold agglutinin mediated autoimmune hemolytic anemia (cAIHA), anti-red blood cell autoantibodies lead to complement-mediated hemolysis with or without symptoms of acrocyanosis after exposure at low temperatures. cAIHA can be divided into cold agglutinin disease (primary CAD) and cold agglutinin syndrome (CAS). The latter is secondary to diseases such as B-cell malignancies including CLL, infections or autoimmune disorders. In primary CAD, more than 90% of patients have a monoclonal IgM (mostly low level) and often a small bone marrow B-cell clone. There is no approved treatment. For patients with significant hemolytic anemia or acrocyanosis despite thermal protection, rituximab is the most accepted first line treatment with an overall response rate of 50% and median duration of response <1 year. Cytotoxic combinations such as rituximab-bendamustine produce more sustained remissions, although with concerns for long-term adverse effects and stem cell toxicity. Studies involving complement inhibitors are showing promising results on hemolysis, although cold induced peripheral symptoms (IgM mediated rather than complement-mediated) will not improve. Recent international guidelines on cAIHA suggest treatment with the Bruton tyrosine kinase (BTK)-inhibitor ibrutinib in refractory patients with cAIHA (Jäger et al Blood Rev 2020). Indeed, the underlying pathophysiology of cAIHA suggest that BTK inhibition could be effective. Aims To evaluate the efficacy of ibrutinib on anemia, hemolysis and acrocyanosis in patients with cold agglutinin-mediated AIHA (CAD/CAS). Methods An international retrospective study was undertaken of cAIHA patients (CAD/CAS) treated with BTK inhibition using a preformed questionnaire. For eligible patients, laboratory and clinical data regarding underlying disease, bone marrow pathology, hemolytic parameters and patient-reported acrocyanosis were collected at diagnosis, 30 days, 3 months, 6 months and 12 months and last date of follow up. Hemoglobin (Hb) response was considered none (NR), partial (PR, >2 g/dL Hb increase or >10g/dL) or complete (CR, >12g/dL). Adverse events were graded according to the Common Terminology Criteria, version-5.0 (2017). Results So far, 10 patients with cAIHA treated with a BTK-inhibitor (all involving ibrutinib) could be included in the study. Patients were followed from April 2014 until June 2020 at 5 centers (Italy (2), Norway, The United Kingdom and The United States). Median duration of follow up was 20 months (1-74 months). The main findings are summarized in table 1. The indication to start treatment was cAIHA based in all but 1 case (CLL). Median previous number of therapies was 2. All patients had a complement-mediated hemolytic anemia, 7 were transfusion-dependent, and 7 reported symptoms of acrocyanosis at the initiation of ibrutinib. After initiation of ibrutinib, all patients showed an improvement in hemoglobin (Median rise: 4.4 g/dL) resulting in 1 PR and 9 CR. All 7 transfusion-dependent patients became transfusion independent (5 within 30 days). In all but 1 patient, markers of hemolysis (LDH, bilirubin) improved after initiation of ibrutinib (see Figure 1). All 7 patients with acrocyanosis reported clear clinical improvement, with complete resolution of symptoms in 5. There was 1 adverse event (grade 1 bleeding). Data collection is still ongoing and future updates are expected. Conclusion Data show that ibrutinib is effective in the treatment of cAIHA with a notable and brisk improvement of both the hemolytic anemia as well as the cold induced peripheral symptoms. Although preliminary, these promising data support further research of BTK-inhibitor based treatment of cAIHA (CAD/CAS) in a prospective study. Disclosures Berentsen: Alexion, Apellis, Bioverativ and Janssen-Cilag: Other: Travel grants ; Alexion, Apellis, Bioverativ, Janssen-Cilag, True North Therapeutics: Honoraria; Apellis, Bioverativ, Momenta Pharmaceuticals and True North Therapeutics: Consultancy; Mundipharma: Research Funding. Castillo:TG Therapeutics: Research Funding; Pharmacyclics: Consultancy, Research Funding; Beigene: Consultancy, Research Funding; Kymera: Consultancy; Abbvie: Research Funding; Janssen: Consultancy, Research Funding. Treon:Bristol-Meyer-Squibb: Honoraria, Research Funding; Pharmacyclics: Honoraria, Research Funding. D'Sa:Sanofi: Honoraria; BeiGene: Honoraria, Research Funding; Janssen: Honoraria, Research Funding. OffLabel Disclosure: BTK-inhibitors (ibrutinib/acalabrutinib) are not yet indicated for the use in (primairy) cold autoimmune hemolytic anemia (cAIHA). However it is indicated for use in Waldenstrom macroglobulinemia (WM) and chronic lymphatic leukemia (CLL). Here we report retrospective data on a cohort of cases treated with ibrutinib for cAIHA mostly secondary to WM or CLL.

First Description of Upfront Target Therapy Treating AML and Bcll Presented Simultaneously As First Line

INTRODUCTION: The occurrence of acute myeloid leukemia (AML) and chronic lymphoid leukemia (B-CLL) simultaneously is rarely described. We describe a case report of AML and B-CLL, diagnosed simultaneously, without any previous treatment for any of the hematological neoplasms [1]. The patient received low-dose cytarabine (ARA-C) and Venetoclax, which is medically indicated on label for both hematological neoplasms. CASE REPORT: A 75-year-old male, presented with edema and joint pain one month before hospital admission, showing pancytopenia on a complete blood count and presence of blasts in peripheral blood. The patient was then referred to the hematology service. The morphological analysis of the bone marrow aspirate showed 67.7% of myeloblasts, compatible with AML. Bone marrow immunophenotyping was performed, which identified 34.10% of myeloblasts, compatible with AML and 50.48% of monoclonal B lymphocytes (chronic B-cell lymphoproliferative disease). In flow cytometry there were two distinct populations of myeloblasts. Type 1 myeloblasts labeling CD7 +, CD13 +, CD34 ++, CD38 ++, CD45 ++, CD56 ++, CD117 ++, CD123 +, HLA-DR +++ and MPO + / ++. The second population marked CD13 + / ++, CD34 + / ++, CD38 ++, CD45 +, CD117 ++, CD123 +, HLA-DR ++ / +++ and MPO + (30%). Monoclonal lymphocytes showed CD11c + / ++ (70%), CD19 ++, CD20 + / ++ (84%), CD22 + (39%), CD23 + / ++, CD25 +, CD31 +/-, CD43 ++, CD45 ++ / +++, CD81 + (38%), CD200 + (85%) and Lambda +. The molecular study was negative for genetic abnormalities: FLT3, KIT and NPM, configuring the patient as an intermediate risk for AML. In the cytogenetic analysis there was no growth of metaphases. Patient received simultaneous diagnosis of AML and B-CLL. As he was ineligle to intensive chemotherapy (IC), we started original protocol Subcutaneous Cytarabin+venetoclax(VIALE C). The patient had grade 2-3 AE(neutropenia managed with GCSF) ending the fourth cycle in July 2020. The evolution of hematimetric parameters and diseases are described in graphics. DISCUSSION: This is the first described case in our knowledge treated upfront with bcl2-inh target therapy for two absolutely different hematological neoplasms: AML and BCLL. Nowadays we are experiencing a new therapeutic model in oncohematology, in which the targeted therapy is gaining ground in relation to IC with excellent results. In this way, the importance of comprehension of the pathophysiological mechanism of the neoplasms and the way we can stop the disease proliferation is progressively guiding the new protocols. Elderly patients are more likely to have early treatment-related death and exhibit therapeutic resistance, limiting alternatives. We decided to start first-line treatment with ARA-C and Venetoclax [2]. Venetoclax associated with ARA-C has a manageable safety profile, producing quick and durable remissions in elderly people with AML ineligible for IC, as well as in B CLL, being the best therapeutic alternative for the case, in our opinion. Venetoclax belongs to a group of drugs called Bcl-2 inhibitors, an anti-apoptotic protein, which works by blocking this protein in the body, causing apoptosis of both neoplastic cells. The high rate of remission and low early mortality, combined with fast and durable remission, make Venetoclax and ARA-C a new and attractive treatment for the elderly [2]. In our case, the intention of the product in the first line was not B-CLL, but it would certainly be a good option for this profile of elderly patients. CONCLUSION: We report the first description of simultaneous diagnosis of AML and B CLL treated with a Bcl-2 inhibitor, demonstrating that antitumor mechanisms can be extremely effective in completely different diseases. We have a long way to go in the search for full knowledge of oncohematological diseases and targeted therapies. However, this case report shows that we are on the right track.

Longitudinal Analysis of Anemia Severity, Treatment and Healthcare Resource Utilization Among Patients with Primary Cold Agglutinin Disease in a Large US Database

Introduction Cold agglutinin disease (CAD) is a serious and rare autoimmune hemolytic anemia driven by cold agglutinin autoantibodies, which bind to red blood cells and activate the classical complement system to initiate hemolysis and anemia (Berentsen S. Hematology Am Soc Hematol Educ Program 2016). There is limited evidence on the individual and societal impact of CAD. A retrospective study of 27 patients in a US healthcare institute demonstrated fluctuations in severity of anemia over the course of the disease, and significant utilization of healthcare resources (Mullins M et al. Blood Adv 2017). The objective of this study was to understand the long-term characteristics and disease burden in patients with primary CAD from a large US Electronic Health Record (EHR) database. Methods This retrospective observational cohort study included adult patients from the Optum© EHR database between January 1, 2007 and September 30, 2019 who had ≥1 medical encounter with an autoimmune hemolytic anemia-related diagnosis code, ≥3 documentations (on different dates) of CAD and ≥1 hemoglobin (Hb) value <12 g/dL. The index date was defined as the first mention of CAD; all patients were required to have a 12-month baseline period prior to this. To limit the study to patients with primary CAD, patients were excluded if they had ≥1 medical encounter with mycoplasma, cytomegalovirus and Epstein-Barr at the index date, or ≥1 medical encounter with lymphoma, MALT lymphoma, chronic lymphoid leukemia, Waldenstrom macroglobulinemia or myeloma during the baseline period. Anemia severity (defined as the lowest Hb value in each study period), utilization of CAD-related therapies, blood transfusions and all-cause healthcare resource utilization (HCRU) were analyzed at baseline and at 6-month follow-up intervals. Although no treatment is approved in CAD, corticosteroids, immunoglobulin, rituximab, immunosuppressants, antineoplastic and biologics were considered as CAD-related therapies to reflect usual practice. Results were stratified by anemia severity category (severe [Hb <8 g/dL], moderate [Hb 8.0-10 g/dL], mild [Hb 10.1-<12 g/dL] or no anemia [Hb ≥12 g/dL]) during each follow-up interval. Severe hemolysis was defined as elevated LDH and/or elevated bilirubin. Results A total of 610 adults with primary CAD were included in the study (mean [SD] age 67.9 [14.5] years, 65.4% female). The mean (SD) duration of follow-up was 48.1 (30.6) months; 90% of patients had ≥12 months of follow-up. At baseline (0-6 months prior to first mention of CAD), 47.6% of patients had elevated bilirubin levels and 63.1% had elevated lactate dehydrogenase (LDH) levels. A high proportion of patients with CAD experienced severe or moderate anemia at baseline and in the 6 months post-baseline; this proportion tended to be lower, but still substantial, throughout the follow-up period (Table). Frequency of moderate/severe anemia or severe hemolysis events per patient year was also higher in the first 6 months: 5.70 (95% CI: 5.00, 6.49), compared with 2.92 (2.30, 3.71) and 2.43 (1.89, 3.11) events at months 19-24 and months 31-36, respectively. The median number of CAD-related treatments per patient was high in all CAD patients at 6 months and remained high during the follow-up period (Table). The most common therapies used (excluding blood transfusion) were corticosteroids, antineoplastics and biologics. The mean number of blood transfusions per patient was higher in the severe anemia category at all follow-up intervals. The number of hospitalizations and emergency room visits were generally higher in patients with increased anemia severity; outpatient visits were high in all CAD patients and remained so over the study period (Table). Conclusion This observational cohort study followed a large sample of primary CAD patients with a 4-year mean follow-up. The results highlight the long-term substantial burden of CAD on patients and healthcare systems, which generally increased with higher severity of anemia. Three years after diagnosis, the number of moderate to severe anemia or hemolysis events remained high in CAD patients, despite off-label CAD management. The need for blood transfusions was still substantial in the severe anemic population 3 years after diagnosis. This longitudinal analysis illustrates the unmet medical needs in primary CAD. Disclosures Wilson: Sanofi: Current Employment, Current equity holder in publicly-traded company. Joly:Sanofi: Current Employment, Current equity holder in publicly-traded company. Miles:Aetion Inc.: Current Employment, Other: Employee of software company that received funding from Sanofi for the current study. Kuang:Aetion Inc.: Current Employment, Other: Employee of software company that received funding from Sanofi for the current study. Pham:Sanofi: Consultancy; Alexion: Other: Speaker.

Human shelterin protein POT1 prevents severe telomere instability induced by homology-directed DNA repair.

The evolutionarily conserved POT1 protein binds single-stranded G-rich telomeric DNA and has been implicated in contributing to telomeric DNA maintenance and the suppression of DNA damage checkpoint signaling. Here, we explore human POT1 function through genetics and proteomics, discovering that a complete absence of POT1 leads to severe telomere maintenance defects that had not been anticipated from previous depletion studies in human cells. Conditional deletion of POT1 in HEK293E cells gives rise to rapid telomere elongation and length heterogeneity, branched telomeric DNA structures, telomeric R-loops, and telomere fragility. We determine the telomeric proteome upon POT1-loss, implementing an improved telomeric chromatin isolation protocol. We identify a large set of proteins involved in nucleic acid metabolism that engage with telomeres upon POT1-loss. Inactivation of the homology-directed repair machinery suppresses POT1-loss-mediated telomeric DNA defects. Our results unravel as major function of human POT1 the suppression of telomere instability induced by homology-directed repair.

弥漫性扁平黄瘤一例

Diffuse plane xanthoma (DPX) was first described by Altman and Winkelmann in 1962. Patients with DPX usually exhibit yellow, flat or slightly elevated plaques that gradually develop on the eyelids, neck, upper trunk, and flexures. Histopathologically, histiocytic foamy cells diffusely spread in the upper dermis with an admixture of lymphocytes and histiocytes. This disease may occur with either hyperlipoproteinemic or normolipoproteinemic states. DPX with hyperlipoproteinemia is associated with familial hyperlipidemia or liver cirrhosis. DPX with normolipoproteinemia is often associated with hematological problems such as multiple myeloma, lymphoma, chronic lymphatic leukemia, chronic myeloid leukemia, and chronic myelomonocytic leukemia. We report a case of diffuse plane xanthoma with hyperlipoproteinemia.

Editorial introductions

Editorial introductions

Evaluating polygenic risk scores in assessing risk of nine solid and hematologic cancers in European descendants.

Genome-wide association studies (GWAS) have identified many genetic risk variants for cancers. The utility of these variants in assessing risk of esophageal, gastric and endometrial cancers, as well as melanoma, glioma, diffuse large B-cell lymphoma, follicular lymphoma, chronic lymphoid leukemia and multiple myeloma, has not been adequately investigated. We constructed a site-specific polygenic risk score (PRS) for each of these nine cancers using their GWAS-identified risk variants. Using data from 400 807 participants of European descent in the UK Biobank, a population-based cohort study, we estimated the hazard ratios of each cancer associated with its PRS using Cox proportional hazard models. During a median follow-up of 5.8 years, 3905 incident cases of these nine cancers were identified in the cohort. The area under the receiver operating characteristic curve ranged from 0.53 to 0.69 for these cancers. Except for esophageal cancer, significant dose-response associations were observed between PRS and cancer risk. Compared to individuals in the middle quintile (40%-60%) at an average risk, those among the highest 5% of the PRS had a twofold elevated risk of melanoma, glioma, follicular lymphoma or multiple myeloma, and a fourfold elevated risk of chronic lymphoid leukemia. Using PRS, 63.0% of the participants could be classified as having an over twofold elevated risk for at least one cancer. The PRS derived using risk variants identified to date by GWAS showed the potential in identifying individuals at a significantly elevated risk of cancer for prevention.

First-line therapy of indolent non-Hodgkin’s lymphoma in routine clinical practice

The aim is to evaluate the efficacy of the first-line rituximab-containing therapy of B-cell lymphoproliferative diseases in Russian clinical practice between 2014 and 2017.
 Materials and methods. In the post-authorisation multicenter study EQUILIBRIUM were included 1 thousand patients aged from 21 to 91 with B-cell non-Hodgkins lymphoma or chronic lymphatic leukemia who had received at least 4 cycles of rituximab-containing therapy using the drug Acellbia. This article was devoted to the group of indolent non-Hodgkins lymphomas and included 253 patients: follicular lymphoma 51% of cases, marginal zone lymphoma 44% of patients, extremely rare were registered lymphoplasmacytic lymphoma and Waldenstrom macroglobulinemia in 3% and in 2% of cases, respectively. The median age in patients with indolent non-Hodgkins lymphomas was 62 years (2191 years). The vast majority of patients were diagnosed with stage IIIIV 190 (75%) of patients. More than 1/2 (53.4%) of patients in routine practice received R-CHOP therapy as a first-line. BR regimen was applied in 15.4% of cases, 14.2% of patients were treated with R-CVP/R-COP. We indicated rare use of rituximab as monotherapy in induction mode only 4.4% of patients. And 2.4% of patients were treated with fludarabine-containing therapy.
 Results. The final assessment of the effect was carried out after 68 cycles of treatment and as a result the overall effect was more than 90%: the frequency of complete remission was 61%, partial responses 32.9%. The progression admitted only in 17 (6.7%) patients among 253 observed. With a median of 15 months, the median of overall survival and event-free survival was not achieved.
 Conclusion. The use of the available and appropriate treatment according to the domestic clinical guidelines with the inclusion of the Russian biosimilar anti-CD20 monoclonal antibody Acellbia, demonstrates high direct efficacy and satisfactory long-term treatment results comparable to the retrospective analysis of the previous clinical studies of the original drug rituximab.

Prognostic Value of Soluble HLA-G and CD38 Expression in Patients with Chronic Lymphocytic Leukemia in Egypt

Background: Chronic lymphatic leukemia (CLL) is the most common hematological malignancy in adults presenting with varied clinical courses. There is an increased demand for establishing known prognostic factors for stratifying CLL patients. Aim of the work: To investigate the expression of soluble form of human leucocyte antigen-G (HLA-G) & CD 38 in CLL and to correlate our findings with a variety of clinical and laboratory variables. Patients and methods: The study included thirty newly diagnosed CLL patients. They were 18 males and 12 females with age ranged from 49–65 (a mean of 57.5 years old). Diagnosis of CLL was confirmed by flow cytometric immunophenotyping using standard lymphoma panel. CD38 expression was determined by flow cytometry. S. HLAG was measured by ELISA method. Results: Positive CD38 expression was significantly associated with lower Hb and platelets (p = 0.008 and 0.025 respectively) also with higher Beta2 microglobulin (p = 0.012). Soluble HLA G was positively correlated with the platelets count(r = 0.400, p = 0.02). Higher level of soluble form HLA-G was significantly more frequent in patients of 60 years or older (p = 0.001). The cumulative overall survival was 83.3%. Positive CD 38 expression was associated with significantly worse survival (p < 0.005). HB count < 10 gm/dl was associated with significantly worse survival (p < 0.001). Conclusion: CD38 expressions are considered powerful prognostic markers in predicting overall survival for Egyptian CLL patients and they should be assessed to decide the patient's therapy and to determine disease prognosis. Expression of soluble form of HLA-G in CLL patients by ELISA get no extra prognostic importance.

P0204PREVALENCE AND PREDICTIVE FACTORS OF BIOPSY-PROVEN NEPHROPATHY RELATED TO MONOCLONAL GAMMOPATHY

Abstract Background and Aims The prevalence of monoclonal gammopathy (MG) and kidney disease increases with age. When a patient present with both conditions, it is often necessary to perform a kidney biopsy in order to rule out a Monoclonal Immunoglobulin-Related Nephropathy (MIRN) that may require a specific therapy that targets either an overt hematological malignancy or a MG or Renal Significance (MGRS). The aim of our study was to identify factors that predict the presence of MIRN in this setting. Method This retrospective monocentric study included all patients who underwent a kidney biopsy between 2007 and 2018 with concurrent presence of GM, as defined by positive serum immuno-electrophoresis and/or Bence-Jones proteinuria. Results 328 patients were included, representing 11.8% of all kidney biopsies performed in our center during this period. Indication of biopsy was renal failure (eGFR &amp;lt;60ml/min/1.73m) in 77.4% of cases and/or proteinuria (urine protein-to-creatinine ratio &amp;gt;0.5g/g) in 75.9% of them. Median (IQR) serum creatinine was 155 μmol/L (111-233), eGFR 37.5 (22-56) ml/min/1.73m, serum albumin 29.5 (24-35) g/l. Median age was 67 (57/75), the M/F ratio was 198/130, diabetes mellitus was present in 21.3% of cases, hypertension in 53.1%. Kidney biopsy revealed that nephropathy was related to MG in 91/328 patients (27.7%). Myeloma cast nephropathy and AL amyloidosis were the most common histopathological subtypes (36 and 34% respectively), followed by monoclonal immunoglobulin deposition disease (15%) and cryoglobulinemic glomerulonephritis (8%). Patients with MIRN had more severe renal function impairment with median (IQR) serum creatinine of 176 (119-307) vs 149 (108-216) μmol/l (p=0.003) and heavier proteinuria, 3.9 (2.2-8.2) vs 2.0 (0.9-5.2) g/g (p&amp;lt; 0.001), when compared to non-MIRN patients. Hematological malignancy was diagnosed in 83 cases (25,3%) (Multiple Myeloma in 62, non-Hodgkin Lymphoma in 6, Waldenström Macroglobulinemia in 6, Chronic Lymphoid Leukemia in 6, Plasmocytoma in 3). Among them, MIRN was diagnosed in 51 (61%) cases but tumoral lympho-plasmocytic infiltration was observed in 9 (11%) cases. In this subgroup of patients, no laboratory test could predict the presence of a specific nephropathy. Among patients with no hematological malignancy (n=245), MIRN was diagnosed in 40 cases (16%) to confirm MGRS diagnosis. The markers that were most commonly associated with the presence of MGRS were positive Bence-Jones proteinuria (OR 4.7; 95%CI 2.2-10.3; p&amp;lt; 0.001), abnormal serum Free Light Chain (FLC) ratio (OR 4.2; 95%CI 1.7-10.7; p&amp;lt; 0.001), and serum electrophoresis spike &amp;gt;1.5 g/l (OR 5.9; 95%CI 2.6-13.5; p&amp;lt; 0.001). However, none of those markers had sufficient power to formally predict the result of the biopsy, as positive (PPV) or negative (NPV) predictive values were 36/41/45 % and 89/86/88 % respectively. Conclusion Almost one-third of patients with MG and kidney disease referred to our Department have biopsy-proven related nephropathy. Although negativity of Bence-Jones proteinuria and a normal serum FLC ratio are frequently associated with the absence of MGRS, kidney biopsy, beyond its diagnostic and prognostic interest, remains the most discriminating test.

Studies on the morphology of leukaemic blast cells in relation to haematological parameters

A combination of haematological parameters with morphological evaluation of peripheral blood and bone marrow blast cells is crucial for leukaemia diagnosis. FAB (French– American–British) classification is a simple and powerful diagnostic tool for leukaemia in developing countries like India. Differentiation block in the early stages of haematopoiesis and morphological characteristics of leukemic blast cells are directly related to haematological parameters. The present study is an approach to increase understanding of the simple morphological FAB classification of leukaemia in relation to haematological parameters. The present study revealed that Chronic Myeloid Leukaemia (CML) was the most common type of leukaemia , followed by Acute Myeloid Leukaemia, Acute Lymphoid Leukaemia (ALL), and Chronic Lymphoid Leukaemia (CLL) in Nagpur. Most of the cases of Acute Leukaemia had severe anaemia and thrombocytopenia. Highest variation was found in Total WBCs count of different types of leukaemia , particularly in different subtypes of AML. The present study also suggested that FAB classification is not outdated, but it does require continuous revalidation and other procedures for refinement.

TFE3 Gene Rearrangement in Perivascular Epithelioid Cell Neoplasm (PEComa) of the Genitourinary Tract.

Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms with unpredictable behavior. They are characterized by epithelioid cells, which stain with melanocytic markers, associated with spindle cells reactive for smooth muscle markers. PEComas may be sporadic or associated with the tuberous sclerosis complex, with mutations affecting mostly tuberous sclerosis complex (TSC) 2 and less frequently TSC1 genes. More recently a subtype of PEComa harboring TFE3 gene rearrangement, mutually exclusive with TSC complex mutations, has been identified. The bladder and the other genitourinary tract organs are an infrequent site of origin; to date, only 3 cases of primitive bladder PEComas, 1 prostatic PEComa, and 2 epithelioid angiomyolipomas of the kidney with TFE3 rearrangement have been described in literature. We report a bladder PEComa case with Xp11 rearrangement in a patient who previously had undergone chemotherapy for chronic lymphatic leukemia. We assessed the meaning of the presence of TFE3 rearrangement in genitourinary tract PEComas and the possible correlation of these uncommon lesions with previous chemotherapy. A better understanding of this entity's genetics may help suggest appropriate targeted therapy, which is still lacking in genitourinary tract PEComas.

Changes in long term survival after diagnosis with common hematologic malignancies in the early 21st century

Five-year survival has increased for many hematologic malignancies in the 21st century. However, whether this has translated into greater long-term survival is unknown. Here, we examine 10- and 20-year survival for patients with multiple myeloma (MM), acute lymphoblastic leukemia (ALL), acute myeloblastic leukemia (AML), chronic lymphoid leukemia (CLL), chronic myeloid leukemia (CML), non-Hodgkin lymphoma (NHL), and Hodgkin lymphoma (HL). Data were extracted from the Surveillance, Epidemiology, and End Results-9 database. Patients age 15+ with the above malignancies were included. The newly developed boomerang method was used to examine 10- and 20-year relative survival (RS) for patients in 2002–2006 and 2012–16. Ten and 20-year RS increased for each malignancy examined, with increases ranging from +4.4% units for 20-year RS for AML to +23.1% units for 10-year RS for CML. Ten year RS was >50% in 2012–16 for patients with CLL, CML, HL, NHL, and DLBCL, at 77.1%, 62.1%, 63.9%, 64.5%, and 63.0%, respectively. Survival dropped between 10 and 20 years after diagnosis for most malignancies. Long-term survival is increasing for common hematologic malignancies, but late mortality is an ongoing issue. Further study of long-term outcomes in curable malignancies to determine the reason for these later decreases in survival is indicated.

Antitumorigenic action of nelfinavir: Effects on multiple myeloma and hematologic malignancies (Review).

Protease inhibitors (PIs) inhibit HIV‑1 and HIV‑2 proteases, impeding virus replication and liberation of viral elements from infected cells. In human immunodeficiency virus(HIV) subjects receiving PI‑based treatment, an impressive decrease in the amount of HIV‑associated cancers, unconnected to viral burden or CD4 amount was observed. Research has reported that PIs have influence on cancer proliferation, spread, and survival as an effect on endoplasmic reticulum stress, proteasome, NF‑κB and Akt signalling. Nelfinavir(NFV) is a nonpeptidic PI that functions by connecting to the catalytic site of the HIV protease, thus stopping the cleavage of viral polyprotein into complete, operative proteins that are fundamental for viral survival. NFV, currently not frequently employed for antiretroviral treatment, has demonstrated noteworthy off target effects in tumor patients with or without HIV disease. NFV appears to cause cell death in tumor cells by different mechanisms, which include necrosis, apoptosis and autophagy. In this review, data from preclinical research and clinical trials are reported and the mechanisms of action of NFV and their results in the treatment of hematologic malignancies, such as acute myeloid leukemia, chronic lymphoid leukemia, and diffuse large Bcell lymphoma, and especially in patients with multiple myeloma are examined. In the future, experimental studies may help identify the role of NFV in cancer treatment and may promote the application of this drug into daily clinical practice.

Restoring Apoptosis with BH3 Mimetics in Mature B-Cell Malignancies.

Apoptosis is a highly conserved mechanism enabling the removal of unwanted cells. Mitochondrial apoptosis is governed by the B-cell lymphoma (BCL-2) family, including anti-apoptotic and pro-apoptotic proteins. Apoptosis evasion by dysregulation of anti-apoptotic BCL-2 members (BCL-2, MCL-1, BCL-XL) is a common hallmark in cancers. To divert this dysregulation into vulnerability, researchers have developed BH3 mimetics, which are small molecules that restore effective apoptosis in neoplastic cells by interfering with anti-apoptotic proteins. Among them, venetoclax is a potent and selective BCL-2 inhibitor, which has demonstrated the strongest clinical activity in mature B-cell malignancies, including chronic lymphoid leukemia, mantle-cell lymphoma, and multiple myeloma. Nevertheless, mechanisms of primary and acquired resistance have been recently described and several features such as cytogenetic abnormalities, BCL-2 family expression, and ex vivo drug testing have to be considered for predicting sensitivity to BH3 mimetics and helping in the identification of patients able to respond. The medical need to overcome resistance to BH3 mimetics supports the evaluation of innovative combination strategies. Novel agents including MCL-1 targeting BH3 mimetics are currently evaluated and may represent new therapeutic options in the field. The present review summarizes the current knowledge regarding venetoclax and other BH3 mimetics for the treatment of mature B-cell malignancies.

Abscopal Regressions of Lymphoma After Involved-Site Radiation Therapy Confirmed by Positron Emission Tomography

Patients with abscopal regressions of lymphoma after palliative involved-site radiation therapy (ISRT), detected on sequential 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), were identified by audit. A retrospective analysis was subsequently conducted to estimate the frequency of abscopal regression in follicular lymphoma (FL). Potential cases were identified at multidisciplinary lymphoma meetings and fulfilled these criteria: (1) palliative ISRT given for histologically confirmed lymphoma, (2) >2 lesions visualized on FDG-PET, (3) >1 unirradiated lesion(s) outside ISRT volume, (4) no systemic therapy delivered <2 months before radiation therapy or between radiation therapy and response assessment, (5) complete metabolic response (CMR) in ≥1 unirradiated lesions detected on serial FDG-PET/CT. All ISRT patients with FL treated in 2016 to 2018 were systematically reviewed. Seven cases of abscopal regression were identified, including 4 patients with FL. In all cases, a CMR was apparent both within the ISRT volume and in ≥1 unirradiated lesions. One patient each was identified with mantle cell lymphoma (4 Gy in 2 fractions), Hodgkin lymphoma (20 Gy in 3 fractions, then 30 Gy in 15 fractions to the same volume), and Richter transformation of chronic lymphatic leukemia (30 Gy in 10 fractions). The 4 patients with FL received either 4 Gy in 2 fractions (n = 3) or 4 Gy followed 8 months later by 30 Gy in 15 fractions (n = 1). From 2016 to 2018, 29 courses of ISRT were prescribed for multifocal FL, after which 4 of 29 (13.8%) abscopal responses were detected, including in 4 of 9 (44.4%) patients with serial PET scans. Two patients, with relapsed disease after initial abscopal responses, experienced durable CMRs with immunotherapies. In 4 of 7 cases, PET-detected abscopal regression of lymphoma occurred after 4 Gy, in 2 of 7 cases after repeated ISRT to the same volume, and in 2 of 7 was associated with subsequent complete response to immunotherapy, consistent with an immune basis for the abscopal effect. Abscopal regressions in FL appear to be more common than previously suspected.

Computational analysis of flow cytometry data in hematological malignancies: future clinical practice?

This review outlines the advancements that have been made in computational analysis for clinical flow cytometry data in hematological malignancies. In recent years, computational analysis methods have been applied to clinical flow cytometry data of hematological malignancies with promising results. Most studies combined dimension reduction (principle component analysis) or clustering methods (FlowSOM, generalized mixture models) with machine learning classifiers (support vector machines, random forest). For diagnosis and classification of hematological malignancies, many studies have reported results concordant with manual expert analysis, including B-cell chronic lymphoid leukemia detection and acute leukemia classification. Other studies, e.g. concerning diagnosis of myelodysplastic syndromes and classification of lymphoma, have shown to be able to increase diagnostic accuracy. With respect to treatment response monitoring, studies have focused on, for example, computational minimal residual disease detection in multiple myeloma and posttreatment classification of healthy or diseased in acute myeloid leukemia. The results of these studies are encouraging, although accurate relapse prediction remains challenging. To facilitate clinical implementation, collaboration and (prospective) validation in multicenter setting are necessary. Computational analysis methods for clinical flow cytometry data hold the potential to increase ease of use, objectivity and accuracy in the clinical work-up of hematological malignancies.

Neoantigens in Hematologic Malignancies.

T cell cancer neoantigens are created from peptides derived from cancer-specific aberrant proteins, such as mutated and fusion proteins, presented in complex with human leukocyte antigens on the cancer cell surface. Because expression of the aberrant target protein is exclusive to malignant cells, immunotherapy directed against neoantigens should avoid “on-target, off-tumor” toxicity. The efficacy of neoantigen vaccines in melanoma and glioblastoma and of adoptive transfer of neoantigen-specific T cells in epithelial tumors indicates that neoantigens are valid therapeutic targets. Improvements in sequencing technology and innovations in antigen discovery approaches have facilitated the identification of neoantigens. In comparison to many solid tumors, hematologic malignancies have few mutations and thus fewer potential neoantigens. Despite this, neoantigens have been identified in a wide variety of hematologic malignancies. These include mutated nucleophosmin1 and PML-RARA in acute myeloid leukemia, ETV6-RUNX1 fusions and other mutated proteins in acute lymphoblastic leukemia, BCR-ABL1 fusions in chronic myeloid leukemia, driver mutations in myeloproliferative neoplasms, immunoglobulins in lymphomas, and proteins derived from patient-specific mutations in chronic lymphoid leukemias. We will review advances in the field of neoantigen discovery, describe the spectrum of identified neoantigens in hematologic malignancies, and discuss the potential of these neoantigens for clinical translation.