Hematol Oncol Clin Research Articles

A contemporary national population-based analysis of demographics and outcomes of Hispanics with adult T-cell leukemia/lymphoma in the US.

e18771 Background: Adult T-cell Leukemia/Lymphoma (ATL) is a malignancy caused by the human T-cell leukemia virus type I with heterogenous clinical course (Blood Adv PMID29545256 J Clin Exp Hematop PMID34937829). There are endemic regions, but emigration has increased its incidence in the United States (US) (Hematol Oncol Clin North AmPMID2834087). There is a need to recognize trends and ethnic patterns to better understand this malignancy (J Oncol Pract PMID28796966 Blood Adv PMID29545256). This is the first national population-based analysis evaluating ethnic differences for HI diagnosed with ATL in the US. Methods: Data were analyzed on ATL patients in the US reported to the Surveillance, Epidemiology, and End Results (SEER) database between 2000-2018. Demographic, clinical and survival patterns were analyzed. Kaplan-Meier and Cox regression analyses were used when appropriate. Multivariate analysis and propensity score matching were performed with adjustment for age, stage and B-symptoms. Results: 598 patients (HI=65, NH=533) were diagnosed with ATL. Male sex predominated in in both. HI were diagnosed at a younger median age, 52 years (y) vs 63y for NH [p<0.001]. Most of HI presented in the age bracket of 40-60y, while NH were identified between 60-80y [p <0.001]. Regarding race, most of HI and NH were whites 82% vs 52% respectively, however, for NH Blacks and Asian/Pacific Islander were noted to be representative in the sample [p <0.001]. The majority of HI were diagnosed between 2010-2014, however for NH, same incidence was reported from 2005-2009 and 2010-2014 [p = 0.107]. For both group the presence of B symptoms was predominantly unknown. The median survival for HI was 1.5y vs 0.8y for NH. The survival probability at 2, 5 and 10y for HI corresponded to 0.474, 0.341 and 0.238, while for NH it was 0.347, 0.244 and 0.153, respectively. The OS probability at 10y had no statistically significant difference but a tendency favoring HI [p = 0.053]. On multivariate analysis, when adjusted for age, those patients who were older than 80y and between 60-80 y, had worse OS compared to those younger than 60y, with Hazard Ratio of 3.9 (95% CI: 2.7 – 5.6) and 1.7 (95% CI: 1.2 – 2.2), respectively. Conclusions: This national population-based study identified similar OS in HI diagnosed with ATL in the US. The median survival time was noted to be higher for HI and the OS had a tendency favoring this group; however, findings are not yet significant. This association should be further analyzed as there may be unique oncologic response in this ethnic minority. HI may have remarkable immunologic reaction to infection due to oncogenic viruses plus the creation of a distinct tumor microenvironment. Recognizing clinical trends and identifying genetic predictors may assist in constructing more accurate prognostic indices to deliver targeted therapy.

Iron Deficiency Anemia and Von Willebrand Disease in Women with Menorrhagia

Introduction Von Willebrand disease (VWD) is the most common bleeding disorder in adolescents and adult women that causes heavy menstrual bleeding (HMB) (Blood Adv 2020;13:3209-3216). HMB is defined as bleeding lasting >7 days or > 80 mL of blood per menstrual cycle; a broader definition includes an excessive blood loss that interferes with a woman´s physical, emotional, social and material quality of life; an underlying bleeding disorder should be considered if IDA is present (Am J Obstet Gynecol 2009;201:12.e1-12.e8 and Blood 2018;132:2134-2142). Objective Identify VWD causing HBM in patients with IDA. Materials and Methods Retrospective databased study from 2017 to 2021 of 292 women with IDA due HMB referred to our Institution. HMB was not related to systemic disease, hormonal disorders, renal or hepatic disease. The IDA studies included CBC, iron panel with ferritin levels; diagnosis was based in Clinical Guidelines: Hb< 12 gr/L, transferrin saturation (TS) <20% and ferritin <15 mcg/L (Adv Ther 2021;38:201-225); in all cases sonography was performed to rule out ovarian cyst and fibroma. For VWD, personal and familiar history of bleeding were assessed, studies included bleeding time, fibrinogen, factor VIII, factor XIII, vW antigen and vW activity on first to fourth day of menstruation, all studies were performed twice in different menstrual cycle; diagnosis was based in review articles: vW below 50 IU and bleeding history, including IDA (Hematol Oncol Clin N Am 2021;35:1085-1101). Results From 292 women with IDA, 23 (7.9%) was diagnosed with VWD. Age ranges from 14 to 54 years, median 21. vW antigen levels from 3 to 47 IU, median 28 IU. vW activity 4 to 45 IU, median 27 IU. Eleven patients had vW activity levels below 30 IU and had more significant history of mucocutaneous bleeding: epistaxis 52%, cutaneous bleeding 45%, oral cavity bleeding 42%; compared with 12 patients with vW activity between 31 and 50 IU: epistaxis 35%, cutaneous bleeding 19%, oral cavity bleeding 15%. Both groups had similar frequency of bleeding after surgical and dental procedure, 46% and 44% respectively. Treatment for IDA included oral and IV iron; treatment for HMB included hormonal therapy, desmopressin and tranexamic acid. Discussion VWD has been objectively reported in México in the first systematic analysis (Haemophila 2013;19:231-235); this observation was made mainly in mestizos of Spanish heritage and the true frequency could not be determinate, as is in the case in the majority of studies in countries worldwide; from 133 patients with bleeding disorders, 53 (39.8%) had VWD. In 124 Mexican women with history of postpartum hemorrhage, VWD was diagnosed in 61 (49.2%) (Haemophilia 2020;26:97-105). In a more recently study, VWD rate was estimated in 7.2 per million inhabitants in western Mexico (Haemophilia 2022;21:e78-e87). Our study demonstrates that VWD is present in Mexican population and has almost a rate of 8% in women with HMB, similar to reported in other studies, but this rate may be underrepresented and underdiagnosed as is in general population because lack of hematologists and diagnostic test in smaller cities, and misconception of the disease, as Mexico has heritage from Spain, England and France among other European countries with higher rates of VWD. Our study also compares the levels of VW factors, and found that patients with low levels of VW (31-50 IU) has the same bleeding phenotype as patients with VWD (< 30 IU), supporting that VWD should be diagnosed in patients with bleeding manifestations and VW factor below 50 IU (Hematol Oncol Clin N Am 2021;35:1085-1101). Finally, based in our results we recommend to investigate for VWD in patients with IDA from HMB.

Venetoclax and hypomethylating agents in older/unfit patients with blastic plasmacytoid dendritic cell neoplasm

Venetoclax and hypomethylating agents in older/unfit patients with blastic plasmacytoid dendritic cell neoplasm

Expression of Hedgehog signalling molecules inmicrocystic adnexal carcinoma.

Microcystic adnexal carcinoma (MAC) is a rare skin neoplasm that has not been characterized on a molecular basis. To assess expression profiles of Hedgehog (HH) signalling molecules in MAC and control tumours. Immunohistochemistry was performed for Sonic Hedgehog (SHH), Indian Hedgehog (IHH), Patched 1 (PTCH1) and Smoothened (SMO) on patient MAC tissue (n=26) and control tumour tissue, including syringoma (SyG; n=11), trichoepithelioma (TE; n=11) and basal cell carcinoma (BCC; n=12) tissues. Patched 1 and SMO immunoreactivity was significantly higher in BCC than in SyG, TE or MAC (P<0.001 and P<0.03, respectively). The highest IHH expression was observed in BCC and TE compared with SyG and MAC (P<0.04). Notably, the highest SHH protein expression was observed in SyG compared with MAC, TE and even BCC (P<0.001). In patients with MAC, SMO immunoreactivity significantly (r=0.51; P<0.01) correlated with PTCH1 expression. Further correlation studies did not show significant associations between the HH expression markers assessed (P>0.05). Our results indicate that alterations of the HH signalling are unlikely to play a major role in the pathogenesis of MAC, which is in contrast to the morphologically similar BCC and TE. Our observation provides additional information to the limited molecular pathology knowledge on this rare tumour.

Medically Attended Anxiety or Depression Is Increased Among Newly Diagnosed Patients with Cold Agglutinin Disease (CAD)

CAD is a rare form of autoimmune hemolytic anemia (AIHA) that accounts for approximately 20% of all AIHA and is characterized by classical complement pathway-activated hemolysis. Clinical manifestations of CAD can include complement-mediated chronic hemolytic anemia, profound fatigue, as well as transient agglutination-mediated circulatory symptoms (Berentsen et al. Hematol Oncol Clin North Am. 2015; Swiecicki et al. Blood. 2013). Recent research has shown that patients with anemia are more likely to develop depression and anxiety (Shafi et al. J Coll Physicians Surg Pak. 2018; Vulser et al. Acta Psychiatr Scand. 2016), but this has not been previously studied in patients with CAD. We conducted a matched-cohort comparison study evaluating the risk of medically attended anxiety or depression in patients with and without CAD. All patients with CAD were identified in the Optum Claims-Clinical dataset by reviewing clinical notes for CAD terms. Patients with CAD were matched (1:10) to non-CAD patients by age (±3 years), sex, race, region of residence, and active time and season and year of entry date in the Optum health plan. Inclusion criteria included 25 years of age or older with no history of anxiety or depression. Medically attended anxiety or depression was defined using International Classification of Diseases (ICD-9 and ICD-10) codes for inpatient stays and outpatient hospital visits, medication class, and procedure codes for psychotherapy. Cox regression models were built to estimate time to hospitalizations without medications or psychotherapy, medications or psychotherapy without hospitalization, hospitalization with medication or psychotherapy, or any of these outcomes adjusted for age, sex, race, region, comorbidity score, and cluster (matched CAD and non-CAD cohorts). As patients with both primary CAD (not due to secondary causes) and secondary cold agglutinin syndrome (coexisting diagnosis of malignancy or infection) were included in the primary analysis, subset analyses also were performed for patients with primary CAD. A total of 384 patients with CAD (mean [standard deviation {SD}] age: 70.0 [13.0] years) and 2789 patients without CAD (comparisons; mean [SD] age: 69.6 [12.7] years) were identified between 2006 and 2016. The mean (SD) time to event for any hospitalization, medication use, or psychotherapy was 27.7 (24.4) months for patients with CAD and 38.2 (25.6) months for comparisons with patients with CAD being 60% more likely to have medically attended anxiety or depression (adjusted hazard ratio [aHR]: 1.6; 95% confidence interval [CI]: 1.3-2.1). Patients with CAD were almost twice as likely to be prescribed medication or psychotherapy for anxiety and depression after their CAD diagnosis (aHR: 1.8; 95% CI: 1.2-2.9) or to be hospitalized for a depression or anxiety-related event along with medication or psychotherapy (aHR: 2.0; 95% CI: 1.4-2.9). There was also a nonsignificant risk for patients with CAD being hospitalized for anxiety and depression without medication or psychotherapy (aHR: 1.2; 95% CI: 0.8-1.9). Subanalysis of patients with primary CAD also were at a statistically significant increased risk for medically attended anxiety or depression (aHR: 1.8; 95% CI: 1.4-2.4) with the largest risk for prescription medication or psychotherapy (aHR: 2.7; 95% CI: 1.6-4.6). To our knowledge, this is the first study to evaluate anxiety or depression among patients with CAD. Our study indicates that medically attended depression and anxiety manifest at a higher rate in patients with CAD compared with a matched non-CAD cohort. These findings suggest that patients with CAD may experience extra-hematologic manifestations of the disease that potentially have a broader impact on their overall mental health, physical health, and quality of life. Further investigation on this topic is warranted. Disclosures Patel: Sanofi: Current Employment. Jiang:EpidStrategies: Current Employment. Nicholson:EpidStrategies: Current Employment. Frankenfeld:EpidStrategies: Current Employment. Iglesias-Rodriguez:Sanofi: Current Employment. Fryzek:EpidStrategies: Current Employment. Su:Sanofi: Current Employment.

Demographic Differences in the Treatment and Mortality of Lymphoplasmacytic Lymphoma in Texas: Does Ethnicity Play Any Role?

BACKGROUND: Social determinants and demographics exert an overwhelming influence on the health of the individual and overall population health (J Am Geriatr Soc. PMID: 28369694).The Hispanic paradox has been well characterized, demonstrating that although Hispanic patients (HisP) have higher disability, depressive, metabolic, and inflammatory risk when compared to non-Hispanic (nHisP), they continue to live long lives (J Health Soc Behav. PMID: 31771347). The characterization of these differences in hematology has not been well documented. This study seeks to characterize Lymphoplasmacytic lymphoma (LPL). LPL is a rare lymphoma of B-cell origin demonstrating an incidence of 1000 to 1500 new cases per year in the United States (Hematol Oncol Clin North Am, PMID: 31229160). Epidemiological research is not well documented in this lymphoma subtype, especially regarding the HisP. Given that Texas has the second highest state with HisP in the country (US Census Bureau), we studied the demographics of this disease and specifically researched the demographics, treatment patterns and survival between HisP and nHisP in Texas. METHODS: This is a retrospective study of a cohort of patients diagnosed with lymphoma (Hodgkin and Non-Hodgkin) from the Texas Cancer Registry (TCR) database. Patient's included were those &amp;gt;18 years of age during 2006-2016 and this study focused on the LPL subset. Standard demographic variables collected include gender, race, ethnicity, birthplace, occupation, dates at diagnosis and death, primary payer at diagnosis, subtype of lymphoma, stage, type of treatment, poverty index, and vitality status among others. The significance of variation in the distribution of categorical outcomes with ethnicity (HisP, nHisP) was assessed with Fisher's Exact tests or Pearson's Chi-square tests as appropriate; age was assessed with T-tests or Wilcoxon tests as appropriate. Survival time was measured in years from date of primary diagnosis to date of death. Survival distributions were described with Kaplan-Meier curves and significance of variation in median survival with ethnicity was assessed with log rank testing. All statistical testing was two-sided with a significance level of 5%. RESULTS AND DISCUSSION: Out of 490 patients diagnosed with LPL, 64 were HisP and 426 nHisP. Of this population, the HisP had a higher percentage of patients at the higher end of the poverty index (42.4% to 20% with p value &amp;lt;0.001) and higher rates of being uninsured or on Medicare (51.6 to 43.4% with p value &amp;lt;0.001). There were no statistically significant differences in the staging at the time of diagnosis between the two groups, mostly III/IV (HisP 65.6% to nHisP 62% P value 0.387). Treatment modalities differed slightly in that the nHisP populations were more likely to receive beam radiation than the HisP (3.4% to 0, P value 0.005) but overall chemotherapy differences were not statistically significant. The median survival time in years for HisP and nHisP was 6.8 and 7.6 respectively, and the overall survival probability was not significantly different with a P value of 0.59. The survival probabilities at 2, 5 and 10 years between HisP and nHisP were respectively, 0.657 with Confidence interval (CI)[0.545,0.792], 0.573 CI [0.455,0.722], 0.448 CI [0.32,0.627], compared to 0.766 CI [0.723,0.811], 0.620 CI [0.566,0.68], 0.129 CI [0.042,0.389]. CONCLUSION: In this study we show that in Texas, for those diagnosed with LPL, there is a statistically significant difference in the rates of poverty and insurance when comparing Hisp to nHisP. While this is true, there is no clear statistically significant difference in overall treatment or survival probability, which is consistent with the Hispanic paradox. Due to the rarity of this disease, the population size is limited which may skew the data. More research is needed in order to further characterize the differences between these two populations and determine what can be done to narrow these differences. Disclosures Diaz Duque: ADCT Therapeutics: Research Funding; Molecular Templates: Research Funding; AstraZeneca: Research Funding; Hutchinson Pharmaceuticals: Research Funding; Seattle Genetics: Speakers Bureau; Verastem: Speakers Bureau; AbbVie: Speakers Bureau.

Системные гемостатические и гемостазиологические эффекты низкой дозы фибрин-мономера на фоне действия варфарина в эксперименте

Введение. Ранее было показано, что фибринмономер (ФМ) в низких дозировках обладает системным гемостатическим действием в условиях дозированной травмы. Авторами выдвинута гипотеза, согласно которой ФМ способен оказывать регулирующее гемостатическое действие in vivo на фоне сниженного гемостатического потенциала. Цель исследования: изучение системных гемостатических и гемостазиологических эффектов ФМ на фоне дозированной травмы печени при гипокоагуляции, обусловленной приемом варфарина. Материалы и методы. В работе использовали 40 кроликов породы Шиншилла. Для индукции кумаринобусловленной гипокоагуляции животным per os вводили варфарин в дозе 0,4 0,5 мг/кг 14 дней до достижения международного нормализованного отношения (МНО) более 2,0. Далее животным в краевую вену уха вводили концентрат факторов протромбино вого комплекса (КФПК) в дозе 40 ЕД/кг, ФМ в дозе 0,25 мг/кг или плацебо. Через 1 ч после введения препаратов наносили травму печени и оценивали кровопотерю (в процентах от объема циркулирующей крови). Исследовали число тромбоцитов, активированное парциальное тромбопластиновое время, МНО, содержание фибриногена и Ддимера, оценивали результаты тромбоэластографии крови. Результаты. Объем кровопотери в группах животных после внутривенного введения ФМ и КФПК на фоне приема варфарина был в 9,1 раза и 6,7 раза меньше, соответственно, по сравнению с группой плацебо, получавшей тот же антикоагулянт. Вместе с тем ФМ не влиял на параметры коагулограммы (отсутствие видимого гемостазиологического эффекта) и тромбоэластограммы, тогда как применение КФПК в качестве антидота варфарина сопровождалось нормализацией параметров тромбоэластометрии и коррекцией гипокоагуляционного сдвига по МНО. Заключение. Установлено, что ФМ способен проявлять свое системное гемостатическое действие в условиях сниженного тромбинообразования, обусловленного нарушением синтеза витамин Кзависимых факторов свертывания крови. Данное действие реализуется без признаков восстановления гемостатического равновесия. Introduction. It was shown earlier that fibrinmonomer (FM) in low doses had a systemic hemostatic effect in a controlled injury condition. The authors suggest that FM is able to exert a regulating hemostatic effect in vivo under reduced hemostatic potential. Aim: to study the systemic hemostatic and hemostasiological effects of FM under controlled liver injury during hypocoagulation caused by warfarin administration. Materials and methods. In this study 40 Chinchilla rabbits were used. For the induction of coumarinmediated hypocoagulation, animals were administered per os warfarin at a dose of 0.4 0.5 mg/kg for 14 days, until an international normalized ratio (INR) was more than 2.0. Subsequently, a prothrombin complex concentrate (PCC) at a dose of 40 U/kg, FM at a dose of 0.25 mg/kg or placebo were administered into the marginal ear vein of the animals. An hour later, a liver injury was inflicted and blood loss was assessed (in percents of the circulating blood volume). The number of platelets, activated partial thromboplastin time, INR, levels of fibrinogen and Ddimer were studied and the results of blood thromboelastography were evaluated. Results. Blood loss volume in animals groups after intravenous administration of FM and PPC, under warfarin reception, was 9.1 times and 6.7 times less, respectively, compared to the placebo group receiving the same anticoagulant. However, FM did not affect on coagulogram parameters (no visible hemostasiological effect) and thromboelastogram, whereas the use of PPC as warfarin antidote was accompanied by the normalization of thromboelastometry parameters and hypocoagulation shift correction according to INR. Conclusion. It was found that FM able to manifest its systemic hemostatic effect in conditions of reduced thrombin formation caused by impaired synthesis of vitamin Kdependent blood coagulation factors. This effect is implemented without any signs of recovery of hemostatic balance.

PF712 PHYSICIANS’ PERCEPTIONS ON CAUSES OF PRIMARY AND SECONDARY ITP AND LEADING CAUSES OF MISDIAGNOSIS: RESULTS FROM THE ITP WORLD IMPACT SURVEY (I‐WISH)

Background:Immune thrombocytopenia (ITP) is a heterogeneous syndrome with variable clinical manifestations across patients (pts), which makes diagnosis challenging and requires tailored investigations. There is a need for improved accuracy and novel testing in diagnosing ITP and better use of existing tests, e.g. reticulated platelets, platelet antibodies.Aims:I‐WISh studied the burden of ITP and its impact on quality of life using a global pt and physicians sampling frame. This analysis reports physicians’ perspectives on the difficulties inherent in ITP diagnosis.Methods:I‐WISh is a cross‐sectional survey of 1507 ITP pts and 472 physicians across 13 countries. Participants (pts and physicians) completed a 30‐minute online survey that included demographics, signs and symptoms, impact of symptoms, and pt–physician relationships. A steering committee of expert physicians and pt advocacy ITP specialists designed and endorsed the survey materials. All physician‐reported data were collected from a single physician survey, which asked physicians about their experience and perceptions of managing ITP patients. Physicians assigned a rank of 1, 2, or 3 from a list of 15 conditions that could be misdiagnosed as ITP.Results:472 physicians with a mean number of ITP pts (SD) of 34 (50) and mean (SD) of 18 (36) newly diagnosed pts in the past year completed the survey. According to physicians’ recollections, 72% of ITP pts have primary ITP and the remaining 28% have secondary ITP. The survey revealed that exclusion of other disorders was perceived as the leading cause of delays in making an accurate diagnosis of ITP (68%). 53% of physicians indicated misdiagnosis as a contributing factor in delayed diagnosis, with 71% reporting that pts were misdiagnosed 1–25% of the time. Other contributors to delayed diagnosis were access to diagnostic examination (55%) and time to refer pts to a specialist (58%). Out of 441 responses, causes of secondary ITP featured in the top 3 were systemic lupus erythematosus (46%), drug‐induced thrombocytopenia (DIT; 46%), chronic lymphocytic leukemia (CLL; 45%), antiphospholipid syndrome (30%), hepatitis C virus (26%), autoimmune lymphoproliferative syndrome (post‐treatment) (ALPS; 23%), Helicobacter pylori infection (20%), Evans syndrome (17%), and HIV (13%) (Fig). DIT (67%) was the most frequent condition misdiagnosed as ITP, followed by aplastic anemia/myelodysplastic syndromes (MDS; 49%), liver disease (46%), hypersplenism (38%), and leukemia (29%) (Fig). 18% of pts reported being first diagnosed with another condition.Summary/Conclusion:Accurate diagnosis of ITP is difficult. No formula exists allowing accurate diagnosis in all locations and no testing is universally considered to be specific or sensitive. Secondary ITP diagnosis in as many as 28% of ITP pts adds to the difficulties of diagnosing primary ITP; this number is ∼10% higher than previous estimates (Cines et al. Hematol Oncol Clin North Am 2009;129:818). Given that the only positive diagnosis of ITP is response to ITP‐specific treatment, this would nonetheless not exclude secondary ITP. Surprisingly, the leading misdiagnosis being DIT highlights the need for better testing of DIT (currently unavailable anywhere) and the need to replace all medications the patient is taking at diagnosis. Liver disease needs to be suspected early, and testing for this could include ultrasonography (Rajan et al. Brit J Haematol 2005;23:1155). The high rate of secondary ITP and absence of specific testing for ITP contribute to the difficulties with diagnosis.image

Seasonal Patterns of Anemia, Hemolytic Markers and Healthcare Resource Utilization Among Patients with Cold Agglutinin Disease in the United States: A Retrospective Analysis

Introduction: Cold agglutinin disease (CAD) is a rare form of autoimmune hemolytic anemia in which circulating immunoglobulin M autoantibodies bind to the “I” antigen on red blood cells (RBCs), preferentially at lower temperatures (Berentsen et al. Hematol Oncol Clin North Am, 2015). This results in both agglutination of RBCs and complement-mediated hemolysis. “Cold” typically refers to the immune biology (thermal amplitude) of the antibody and not to clinical features of the disease. Although exposure to cold temperatures may precipitate both the circulatory symptoms of CAD and hemolysis (Berentsen. Br J Haematol, 2018), seasonal variation of CAD manifestations is poorly understood (Lyckholm et al. N Engl J Med, 1996; Berentsen et al. Hematology, 2007). There are no clinical trials to support the efficacy of nonpharmacologic management of CAD by cold avoidance or relocation to warm regions (Berentsen. Br J Haematol, 2018; Swiecicki et al. Blood, 2013). Given the lack of data on clinical and laboratory effects of seasonality on the manifestations of CAD, we compared hemoglobin (Hgb) as well as markers of hemolysis and healthcare resource utilization (HRU) for patients with CAD between seasons.Methods: Patients were identified from the Optum-Humedica database, containing de-identified information on medications, laboratory results, diagnoses, procedures, and clinical notes for more than 14 million people annually from all 50 states. Individuals with “cold agglutinin disease” in their clinical notes on at least 3 separate dates were considered patients with CAD. If “cold agglutinin disease” was documented on just 1 or 2 dates, patients were included only after an independent review and agreement by 2 hematologists. The laboratory parameters related to hemolysis, median minimum Hgb, median maximum bilirubin, and median maximum lactate dehydrogenase (LDH), were evaluated, as well as inpatient days, outpatient visits, emergency room visits, and transfusion days. Multivariate regression models were built to explore variation by season comparing the values in fall, winter, and spring to the values in the summer. Data were adjusted for age at baseline, gender, race, region, year, and Charlson Comorbidity Index prior to baseline and accounted for clustering of correlated observations.Results: A total of 808 patients with CAD were identified from the Optum-Humedica database for analysis from 2009 to 2016. Most patients were ≥65 years of age (66%), female (63%), white (84%), and from the Midwest (43%). The median minimum Hgb value for winter as compared with summer was decreased by 0.54 g/dL (P<0.001). The median maximum bilirubin and LDH increased by 0.12 mg/dL (P=0.005) and 42.1 U/L (P<0.001) in winter versus summer, respectively. There were no differences in inpatient days, outpatient visits, emergency room visits, or transfusion days between winter and summer (Table). No significant seasonal disease pattern in HRU was noted in these patients.Conclusions: Patients with CAD in this cohort had evidence of persistent hemolysis independent of the season. Disease manifestations as evaluated by HRU measures were fairly consistent all year long. The variations in median Hgb, bilirubin, and LDH between winter and summer were not associated with differences in clinical outcomes, as there were no significant changes in HRU or transfusion days. These data suggest that perceptions of CAD as a seasonal disorder may not be accurate and recommendations such as moving to regions with warmer climates likely provide no meaningful clinical benefit. The lack of seasonal variability in this cohort suggests that treatment considerations for patients with CAD should be season-independent. DisclosuresRöth:Pfizer: Consultancy, Honoraria, Research Funding; Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria, Research Funding; Bioverativ: Consultancy, Honoraria; Amgen: Research Funding. Fryzek:Sanofi: Research Funding. Jiang:Epidstat: Employment. Morales:Bioverativ: Employment. Broome:Bioverativ: Honoraria, Research Funding; Alexion: Honoraria.

Urinary Protein Levels in Monoclonal Gammopathy of Undetermined Significance (MGUS) and Smoldering Multiple Myeloma (SMM) Predict Severe Disease Related Complications at Myeloma Progression

Introduction and aim of the study: monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) have a distinct risk of evolving towards symptomatic multiple myeloma (MM) but it is widely accepted that they should not be treated until clinical evolution. The clinical presentation of symptomatic MM includes severe complications like acute renal failure, spinal cord compression by vertebral collapse, pathologic bone fractures which cannot be completely avoided even by strict follow-up of MGUS/SMM patients. The recent availability of effective and less toxic therapies has fueled renewed interest in the identification of prognostic models able to predict the risk of impending progression of MGUS/SMM patients to symptomatic MM and criteria for MM defining events have been recently broadened to allow an earlier start of treatment even in asymptomatic patients (Rajkumar SV et al, Lancet Oncol 2014). However, from a clinical perspective it would be more important to prevent the development of severe MM related complications by treating those MGUS/SMM considered at high risk of developing them. To this end, we have analyzed known risk factors for MGUS/SMM progression and other disease biomarkers in order to identify those able to consistently predict an high risk of "severe MM" development. Methods: we retrospectively analyzed 67 patients with symptomatic MM with a known previous history of MGUS/SMM, referred to our division from 1985 to December 2014 (23 males, 44 females; median age at MGUS/MM diagnosis 60 years). Focusing on the first assessment of their asymptomatic disease, we compared patients who subsequently developed severe CRAB criteria (Bladé J et al, Hematol Oncol Clin North Am. 2007), defined as having at least one of the following: hypercalcemia > 11.5mg/dL, creatinine > 4mg/dL, Hb < 8 mg/dL, severe bone lesions characterized by pathological fractures or causing spinal nerve compression, and called "severe MM" with patients who lacked severe CRAB symptoms at MM diagnosis, in order to identify risk factors for "severe MM" during its asymptomatic phase. Variables analyzed for comparison were: involved/uninvolved free light chains (FLC) ratio, monoclonal component (MC) quantification, presence of evolving pattern of MC (defined as an increase in the level of MC of at least 10% in 6 months), presence of immunoparesis, LDH levels, 24h-urinary protein levels, Ig isotype and bone marrow plasma cells percentage. Frequency of follow up was also considered (every 6 months or more). Time to treatment start (TTTS) from MGUS/SMM diagnosis, progression free survival (PFS) from first line treatment and overall survival (OS) were also calculated. Results: median 24-hour urine protein levels were significantly higher in MGUS/SMM patients who subsequently developed "severe MM", compared with patients without severe CRAB symptoms at MM diagnosis (140 vs 90mg/24h, p 0.022, see Figure 1), with an increased risk of severe myeloma related complications for MGUS/SMM patients with more than 200mg/24h urine proteins (Odds Ratio 2.65, p 0.037). Risk was highest in 4 MGUS/SMM patients with 24h-urinary protein levels higher than 1500mg (Odds Ratio 8.43, p 0.030) who invariably developed "severe MM". No difference were found comparing other variables. Of note, there was no difference between the two subgroups in terms of median TTTS (5.3 vs 8.3 years for MGUS patients and 1.7 vs 1.6 years for SMM, respectively), PFS ( 24.4 vs 32.2 months, respectively) and OS (nr vs 4.36), although a higher early mortality was observed in patients with "severe MM" (2 y OS 69% vs 93%).Conclusions: increased 24h-urinary protein levels (> 200mg) in MGUS/SMM patients are associated with a higher risk of the occurrence of severe CRAB symptoms at MM progression. Further data with larger series of patients are needed to better define the best predictive threshold for "severe MM". However, patients with more than 1500mg/24h urinary protein loss represent a small subgroup of MGUS/SMM patients who should better start treatment while still asymptomatic. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

PTH-142 Laparoscopic assisted surgery (Intraluminal Surgery): gastroduodenal lesions resecction and laparoscopic monitored colonoscopic polypectomy (LMCP). texas endosurgery institute experience

Introduction Intraluminal surgery began with the advent of endoscopy. Laparoscopic assisted intraluminal technique is a novel alternative to open or laparoscopic surgery. Endoscopic lesions resection is limited for the view of endoscopic, insufficient number of instrument channels, and the inability to obtain adequate margins without risking perforation. The aim of this study is to demonstrate the feasibility and safety of the use of a hybrid technique. Method From May 1990 to February 2015, all patients undergoing LMCP and early gastric and duodenal lesions were analysed and prospectively followed with control endoscopy studies, 6 months, 1 year and every year there after. Operations were performed laparoscopically in conjunction with endoscopy. Results 24 patients were undergoing to gastro-duodenal lesions resection. 10 early gastric cancer (Stage I), 6 wedge of carcinoid tumour, 4 duodenal adenocarcinoma and 4 malignant polyps at the gastro-oesophageal junction. 320 colonic polyps were removed in 270 patients. 229 polyps were adenomas (114 tubular-villus, 58 villus, and 57 tubular), 66 were carcinomas (40 mod diff, 26 highly diff), 25 with other histologic type. Conclusion Long-term follow-up demonstrated that intraluminal surgery for early gastric and duodenal cancer is a feasible and safe alternative. Malignant lesions identified during LMCP can be treated laparoscopically during the same operation. Disclosure of interest None Declared.

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Integrated genomic study of quadruple-WT GIST (KIT/PDGFRA/SDH/RAS pathway wild-type GIST).

BackgroundAbout 10-15% of adult gastrointestinal stromal tumors (GIST) and the vast majority of pediatric GIST do not harbour KIT or platelet-derived growth factor receptor alpha (PDGFRA) mutations (J Clin Oncol 22:3813–3825, 2004; Hematol Oncol Clin North Am 23:15–34, 2009). The molecular biology of these GIST, originally defined as KIT/PDGFRA wild-type (WT), is complex due to the existence of different subgroups with distinct molecular hallmarks, including defects in the succinate dehydrogenase (SDH) complex and mutations of neurofibromatosis type 1 (NF1), BRAF, or KRAS genes (RAS-pathway or RAS-P).In this extremely heterogeneous landscape, the clinical profile and molecular abnormalities of the small subgroup of WT GIST suitably referred to as quadruple wild-type GIST (quadrupleWT or KITWT/PDGFRAWT/SDHWT/RAS-PWT) remains undefined. The aim of this study is to investigate the genomic profile of KITWT/PDGFRAWT/SDHWT/RAS-PWT GIST, by using a massively parallel sequencing and microarray approach, and compare it with the genomic profile of other GIST subtypes.MethodsWe performed a whole genome analysis using a massively parallel sequencing approach on a total of 16 GIST cases (2 KITWT/PDGFRAWT/SDHWT and SDHBIHC+/SDHAIHC+, 2 KITWT/PDGFRAWT/SDHAmut and SDHBIHC-/SDHAIHC- and 12 cases of KITmut or PDGFRAmut GIST). To confirm and extend the results, whole-genome gene expression analysis by microarray was performed on 9 out 16 patients analyzed by RNAseq and an additional 20 GIST patients (1 KITWT/PDGFRAWTSDHAmut GIST and 19 KITmut or PDGFRAmut GIST). The most impressive data were validated by quantitave PCR and Western Blot analysis.ResultsWe found that both cases of quadrupleWT GIST had a genomic profile profoundly different from both either KIT/PDGFRA mutated or SDHA-mutated GIST. In particular, the quadrupleWT GIST tumors are characterized by the overexpression of molecular markers (CALCRL and COL22A1) and of specific oncogenes including tyrosine and cyclin- dependent kinases (NTRK2 and CDK6) and one member of the ETS-transcription factor family (ERG).ConclusionWe report for the first time an integrated genomic picture of KITWT/PDGFRAWT/SDHWT/RAS-PWT GIST, using massively parallel sequencing and gene expression analyses, and found that quadrupleWT GIST have an expression signature that is distinct from SDH-mutant GIST as well as GIST harbouring mutations in KIT or PDGFRA. Our findings suggest that quadrupleWT GIST represent another unique group within the family of gastrointestintal stromal tumors.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2407-14-685) contains supplementary material, which is available to authorized users.

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FigureFigureFigureA 59-year-old woman presents to the ED with a complaint of an asthma attack. Incidentally, the patient is noted to have this skin finding. What is the diagnosis and treatment for this condition? Diagnosis: Cutaneous T-cell Lymphoma: Mycosis Fungoides Non-Hodgkin's lymphoma is a relatively rare group of malignant neoplasms involving B cells, T cells, their progenitors, and, rarely, natural killer cells. A total of 4.3 percent of all new cancer cases in the United States are related to non-Hodgkin lymphoma. (Surveillance, Epidemiology, and End Results [SEER] program, National Cancer Institute; http://1.usa.gov/SaJGxa.) Cutaneous T-cell lymphoma (CTCL) represents 3.4 percent of these. CTCL is a diverse group of lymphoproliferative disorders characterized by the clonal expansion of mature T cells that infiltrate the skin. (Hematol Oncol Clin North Am 2008;22[5]:979.) Mycosis fungoides (MF) is the most common CTCL subtype, representing 44 percent of all primary cutaneous lymphomas. Primary cutaneous CD30+ lymphoproliferative disorders are the second most common subgroup of CTCLs, accounting for nearly 30 percent of these lymphomas. (Blood 2005;105[10]:3768.) Men have an increased incidence of CTCLs compared with women. The incidence of CTCL increases with age, peaking in those aged 70–84. (JAMA Dermatol 2013;149[11]:1295.) The exact cause of MF is unknown, but it is currently thought to involve chromosomal aberrations. (Cancer Res 2005;65[18]:8101), epigenetic abnormalities, and dysregulation of signaling pathways. (Semin Oncol 2006;33[1 Suppl 3]:S3.) Adhesion molecules and cytokine abnormalities have also been implicated in the pathophysiology of MF. (N Engl J Med 2004;350[19]:1978.)Figure: Various cutaneous lesions in mycosis fungoides.Patients with MF classically present with persistent, scaly patches in various shades of red and indurated, annular plaques with a central clearing. These lesions may progress to tumors or erythroderma. It should be noted that many clinical variants exist with diverse presentations that may only share diagnostic histological findings. (J Am Acad Dermatol 2002;46[3]:325.) Patients may also experience alopecia, pruritus, and dyspigmentation. (J Am Acad Dermatol 2011;64[1]:53, J Am Acad Dermatol 2011;65[2]:313.) Early diagnosis is challenging because features may overlap with known benign dermatosis, such as Acanthosis nigricans, Erythema multiforme, vitiligo, plaque-type psoriasis, and many more. (J Am Acad Dermatol 2002;47[6]:914.) Classic early patch-phase MF is characterized by lesions greater than 5 cm in diameter that vary in size, shape, and color. Most patients have multiple lesions that develop on parts of the body not often exposed to the sun, like the trunk, inner arms, thighs, and the bathing suit distribution, although this may vary. The juxtaposition of mottled pigmentation, epidermal atrophy, and telangiectasia (poikiloderma) is also relatively specific for early MF. (J Am Acad Dermatol 2005;53[6]:1053.) Patients present with patches or plaques involving less than 10 percent of the body surface area in 30 percent of MF cases while 37 percent of cases have involvement of more than 10 percent of body surface area. (Arch Dermatol 2003;139[7]:857.) The differential should include other causes of erythroderma or pruritus, such as generalized atopic dermatitis, psoriasis, drug reactions, and eczema. Also consider Sézary syndrome, the leukemic variant of MF, and other types of cutaneous lymphomas. The diagnosis of early MF involves a scoring system that considers clinical, histopathologic, molecular biological, and immunopathologic findings. The basic clinical criterion is met if a patient experiences persistent or progressive patches or thin plaques. Additional criteria include location in an area not exposed to the sun, variation in size and shape, and poikiloderma. (J Am Acad Dermatol 2005;53[6]:1053.) Treatment for MF depends on the extent of the disease, with milder cases benefiting from skin-directed therapies like topical corticosteroids (Arch Dermatol 1998;134[8]:949) or phototherapy with narrowband UVB. (J Am Acad Dermatol 2009;60[1]:39.) Combination treatments, systemic therapies, or total skin electron beam therapy may be used if escalating treatment is required. (J Am Acad Dermatol 2002;47[3]:364.) Patient prognosis varies depending primarily on staging. One cohort study of 1,263 patients with MF or Sézary syndrome found that 11.6 percent progressed to a higher stage and 8.1 percent died from the disease. The median overall survival was 24.4 years, and median progression-free survival was 16 years. Patients with stage IA limited patch and plaque MF did not experience significantly worse overall survival than matched controls. Risk factors for disease progression or death were found to be plaque stage, advanced age at diagnosis, LDH level, and tumor area. (Clin Cancer Res 2012;18[18]:5051.) This patient was diagnosed with CTCL as an outpatient and started on phototherapy treatments. Access the linksin EMN by reading this on our website or in our free iPad app, both available atwww.EM-News.com. Comments?Write to us at[email protected].

Splicing Factor 3b Subunit 1 (SF3B1) Heterozygous Mice Manifest a Hematologic Phenotype Similar To Low Risk Myelodysplastic Syndromes With Ring Sideroblasts

The link between SF3B1 mutation and the ring sideroblast (RS) phenotype in myelodysplastic syndromes (MDS) was solidified by the identification of RS in Sf3b1 heterozygous (Sf3b1+/-) mice. The identification of SF3B1 mutations in refractory anemia with RS (RARS) and RARS with thrombocytosis (RARS-T) showed the importance of RNA splicing in MDS biology. Furthermore, it opened the possibility of targeted therapy using spliceosome inhibitors in RARS/-T. However, many questions remain unanswered in linking SF3B1 dysfunction to MDS biology like the downstream targets of this gene. The identification of a robust murine model is essential to study a specific molecularly defined disease-phenotype and develop targeted therapies. We identified occasional RS in the bone marrow (BM) of Sf3b1+/- which are rarely found in current mouse models of MDS (Beachy SH, Hematol Oncol Clin North Am, 2010). However, aside from RS in the BM no other MDS features were found. Sf3b1+/- mice were originally engineered as a means to study the interaction between polycomb (PcG) genes and other protein-complexes (Isono K, Genes Dev, 2005). Homozygous Sf3b1-/- mice died at the stage of pre-implantation of the embryos while Sf3b1+/- appear healthy. Several tools have been tested to model MDS in genetically engineered mice targeting key genes in MDS. However, the creation of an ideal mouse model resembling distinct morphologic MDS subtypes is still lacking. To define a mouse model useful for preclinical therapeutic studies, we evaluated the hematologic features of Sf3b1+/- and Sf3b1+/+ mice during a long term follow-up. Five Sf3b1+/- and 5 Sf3b1+/+ mice were followed over time until 12 months of age. Blood was drawn from the retro-orbital vein every month starting from 6 months of age. Using two-sample Wilcoxon test we compared standard hematologic parameters finding a significant difference over the time between Sf3b1+/- and Sf3b1+/+: hemoglobin (g/dL) 6.9 ±0.73 vs 10.0 ±1.6 (P=0.008), red blood cells (M/uL) 8.3±0.5 vs 5.9±1.0 (P=0.008), platelets (K/uL) 731±105 vs 579±93 (P=0.008), and mean corpuscular volume (fL) 47.8±1.5 vs 45.1±1.1 (P=0.032). We did not detect any significant difference in other parameters although lymphocytes were more represented vs neutrophils, eosinophils and monocytes in Sf3b1+/- vs Sf3b1+/+ (6.3K/uL ±3.1 vs 5.8 ±1.8; P=1). Analysis of the BM, showed no difference in cell number between Sf3b1+/- (n=7) and Sf3b1+/+ (n=7) (44.1±9.1 vs 43.2 ±11; P=0.62). However, distinct dyserythropoiesis such as nuclear budding or irregular nuclei in Wright-Giemsa and occasional RS in Prussian blue stains were noted in Sf3b1+/- which were not present in Sf3b1+/+. In support of the iron overload seen in SF3B1 mutant patients (pts), a similar observation was made in Sf3b1+/- by light microscopy and rhodamine based- flow cytometry to quantify mitochondrial iron (Visconte, Abstract #64897). We also characterized the transcriptome of Sf3b1+/- and Sf3b1+/+. Total RNA was isolated from BM of age/gender matched mice, polyA cDNA was prepared from 3ug of RNA and Mouse RNA-sequencing was run on Illumina HiSeq2000. 200 exons were found differentially used in Sf3b1+/- vs Sf3b1+/+. Chromosome 1 contains the highest number of genes with at least 1 exon alternatively used similar to what we observed in SF3B1 mutant pts. In total 22 genes showed stronger differential expression in Sf3b1+/- vs Sf3b1+/+. Sf3b1 was down-regulated as expected (MFC: 0.74) in Sf3b1+/-. Studies in Sf3b1+/- mice show that Sf3b1 protein physically interacts with Class II PcG proteins (PRC1) which are relevant in MDS. When we interrogated PcG genes and others, we found lower mRNA levels of ezh2 (MFC: 0.06) and npm1 and tpr53 (MFC: 0.01 and 0.28) and no difference in asxl1 and runx1 (MFC:1.22 and 1.1) in Sf3b1+/- vs Sf3b1+/+. Jak2, dock8, and uhrf2 showed significant (P=.0003) higher expression in Sf3b1+/-. MDS is a heterogeneous disease characterized by genetic and non-genetic causes. Introduction of secondary events implicated in MDS pathogenesis can modify the phenotype of Sf3b1+/- mice. In sum, Sf3b1+/- mice after 6 months of follow-up developed macrocytic anemia, thrombocytosis, RS and dyserythropoiesis akin to human RARS/-T. Furthermore, transcriptome analysis shows exon usage/ gene expression changes similar to human SF3B1 mutants lending support that Sf3b1+/- can serve as a mouse model for studying the biology of human low risk MDS specifically that of RARS/-T. Disclosures:No relevant conflicts of interest to declare.

Multiple Myeloma International Staging System: “Staging” or Simply “Aging” System?

Because of the wide variation in multiple myeloma (MM) survival, numerous studies have focused over the past 40 years on the biological and cytogenetic prognostic values in MM patients. Since 2005, the MM International Staging System (ISS) has recognized the combination of beta-2 microglobulin (β2M) with serum albumin (SA) concentrations as the most simple and potent combination to determine the prognosis in MM patients. Curiously, the reasons for the efficiency of the combination of β2M with SA remain not clear-cut. In 2007, Fonseca and San Miguel (Prognostic factors and staging in multiple myeloma. Hematol Oncol Clin North Am 2007; 21:1115-40) underlined that cytogenetic assessment might also be useful for evaluating MM prognosis. Furthermore, new perspectives recently appeared with the genomic approach. Here, we (1) question the specific rationale for β2M and SA as prognostic markers in MM, (2) emphasize the well-documented prognostic implications of β2M and SA as potent biomarkers of comorbidity in older adults, and (3) conclude that the current MM-ISS is rather a staging system for age-related comorbidity burden (ie, aging system) than a specific MM staging system, and should not be used alone. Thus, we suggest that: (1) cytogenetics with the superscript MM-ISS could be the standard method; (2) some factors discovered using genomics could reflect the comorbidity burden and the intrinsic malignancy of MM clone, and thus needs more investigation; and (3) while waiting for standard genomic classification.

Adolescent Obesity and Paternal Country of Origin Predict Renal Cell Carcinoma: A Cohort Study of 1.1 Million 16 to 19-Year-Old Males

The incidence of renal cell carcinoma has increased in recent decades, particularly among middle-aged adults. Early precursors of renal cancer remain unclear. We evaluated the association of body mass index and height determined in late adolescence, and paternal or grandpaternal country of origin with the risk of renal cell carcinoma. Health related data on 1,110,835 males at ages 16 to 19 years who were examined for fitness for military service between 1967 and 2005 were linked to the Israel National Cancer Registry in this nationwide, population based cohort study. We used Cox proportional hazards modeling to estimate the HR of renal cell carcinoma associated with birth year, body mass index, height, father country of origin and socioeconomic indicators. During 19,576,635 person-years of followup renal cancer developed in 274 examinees. Substantial excess risk was conferred by a body mass index of greater than 27.5 kg/m(2) compared to less than 22.5 kg/m(2) (HR 2.43, 95% CI 1.54-3.83, p <0.0001). Asian or African origin was protective compared to European origin (African origin HR 0.67, 95% CI 0.49-0.92). Overweight in late adolescence is a substantial risk factor for renal cell carcinoma. European origin is independently associated with excess risk and it persists among Israeli born males. Preventing childhood obesity may be a promising target for decreasing the burden of renal cancer.

In vitro-activated tumor-bearing host T cells and the effectiveness of tumor vaccine immunotherapy

BACKGROUND AND OBJECTIVEVaccination during periods of lymphopenia may facilitate immune responses to weak self-antigens and enhance antitumor immunity. The objective of this study was to determine the effectiveness of tumor vaccine immunotherapy combined with immune reconstruction using tumor-bearing host immune cells in lymphopenia, and to investigate the role of tumor-bearing host T cells activated in vitro during immunotherapy.DESIGN AND SETTINGAnimal study conducted in the First Affiliated Hospital of Xi’an Jiaotong University from January 2009 to January 2010.PATIENTS AND METHODSLymphopenia was induced by cyclophosphamide. A reconstituted immune system with different syngeneic lymphocytes was employed, including lymphocytes from naïve rats (unsensitized group), tumor-bearing rats (tumor-bearing group), and tumor-bearing rats activated in vitro (activated group). All rats were immunized with granulocyte-macrophage colony-stimulating factor (GM-CSF)-modified NuTu-19 ovarian cancer (GM-CSF/NuTu-19) cells. Tumor vaccine-draining lymph nodes (TVDLNs) were harvested, and then stimulated to induce effector T cells (TE). TE were then adoptively transferred to rats bearing a 3-day pre-established abdominal tumor (NuTu-19), and the survival rate was calculated.RESULTSCompared with the unsensitized group, the levels of interleukin-2 (IL-2) were significantly lower in the tumor-bearing group, whereas that of IL-4 were significantly higher (P<.05). The number of CD4+ T cells secreting interferon-γ and the specific cytotoxicity of CD8+ cytotoxic T lymphocytes were significantly lower (P<.05). The survival was significantly higher in the activated group compared with the other groups.CONCLUSIONSLymphocytes from tumor-bearing rats activated in vitro can effectively reverse the immunosuppressive effects of tumor-bearing hosts.

Clonality and Phenotype in Spleens From Patients with Primary Immune Thrombocytopenia,

Abstract 3291Primary immune thrombocytopenia (PIT) results from both increased platelet destruction and insufficient platelet production. Although the development of autoantibodies against platelet glycoproteins remains central in the pathophysiology of PIT, several abnormalities in the immune modulation system have been identified (Blood 2008 Aug 15;112(4):1147; Hematol Oncol Clin North Am. 2009 Dec;23(6):1177; Hum Immunol. 2010 Jun;71(6):586);We analysed morphology, lymphocyte phenotype and heavy immunoglobulin (IgH) and TCR gamma (TCRg) gene rearrangements in spleens from 31 PIT patients to assess possible impact on diagnosis and course, in comparison with 19 spleens surgically removed for trauma.Age ranged from 15 to 68 (mean 41.61y) with M/F of 9/22 in PIT and 18 to 89 (mean: 66y) with M/F 11/8 in controls. All PIT patients experienced at least one line therapy before surgery and 4 underwent anti-CD20 immunotherapy.Immunohistochemistry for CD3, CD20, CD4, CD8, CD56, CD57, PD1, Tia1, Granzyme B, FoxP3, CD72 was made in all cases; both IgH and TCRg gene analysis were possible in 24/31 PIT and 17/19 controls, while 4/31 PIT and 2/19 controls were examined for either one (PIT: 2 TCR and 2 IgH, controls 1 TCR and 1 IgH) and 5 PIT and 1 control were excluded for unsatisfactory material. Ay histology all cases but 2 showed expanded white pulp (that was hypoplastic in the 2/4 cases that underwent Rituximab before surgery), moderate lymphocytic and modest granulocytic infiltrates in the red pulp; haemorragic lakes were present in control spleens. Immunohistochemistry showed similar stains in the 2 groups with normal distribution (white pulp: CD20+ B follicles, CD72-+ in the marginal zone, CD3+/CD4+ T cells, PD1/CD57+ T cells in the germinal centers; red pulp: regular CD20/CD3 and CD4/CD8 ratio, PD1/Tia1/Granzyme B expressed in roughly less than 20% CD3+ T cells; scattered CD57+/CD56- T cells. For molecular results see table 1 below. Monoclonality was defined if 1 or 2 peaks of amplified polymerase chain reaction products were obtained, oligoclonality with 3 to 5 peaks and polyclonality with a Gaussian peak distribution.Table 1IGHWDCtrlIGHWDCtrlPoly2015Poly-Oligo2116Oligo10Mono32Mono32TCRWDCtrlTCRWDCtrlPoly75Poly-Oligo128Oligo53Mono129Mono129The results showed no statistically significant differences between PIT and controls as for morphology, phenotype and clonality. Since a decrease in regulatory T cells (T regs) is reported in PIT among other immune-impairments (Eur J Haematol. 2007 Oct;79(4):310; Zhonghua Nei Ke Za Zhi. 2010 Mar;49(3):213;Blood. 2009 Mar 12;113(11):256) we immunostained all cases with T reg-related nuclear molecule Foxp3: in control cases few cells in the white and red pulp were observed, while in PIT spleens fewer Foxp3 positive cells could only be seen in the red pulp: although results are slightly different, the low amount of positive cells in both groups decreases the reliable reproducibility of such observation. Moreover, the use of glucocorticoids by all patients before splenectomy, could have further reduced (Eur J Haematol. 2007 Oct;79(4):310) T regs levels.Overlapping molecular results were also obtained in the two groups in agreement with previous reports (Hematology. 2009 Aug;14(4):237; Platelets. 2009 Mar;20(2):135; Int J Hematol. 2003 Dec;78(5):461; Blood. 2002 Aug 15;100(4):1388). The attempt to translate the molecular findings into immunomorphologic differences between monoclonal and non monoclonal cases failed since neither amount/distribution of B and T cells nor T cell subtypes showed evident differences. On the whole, our results show that neither lymphoid phenotype nor IgH or TCRg clonality can be used as specific features of refractory PIT or guide treatment choice. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

A male adolescent with left iliac thrombophlebitis and heterozygosity for factor V Leiden mutation

The epidemiology of deep vein thrombosis in adolescents has 2 potential associations. First, there is a demonstrated association with a congenital anomaly of the inferior vena cava (Dean SM, Tytle TL. Vas Med. 2006;11:165-169; Schnieider JG, Eynatten MV, Dugi KA, et al. J Intern Med. 2002;252:276-280). Secondly, resistance to activated protein C as a result of factor V Leiden is associated with thromboembolic disease at an early age (Price DT, Ridker PM. Ann Intern Med. 1997;127:895-903). Imaging modalities, central venous catheters, and improved life expectancy for critically and chronically ill children have resulted in an increased diagnosis of thromboembolic disease in the pediatric population (Journeycake MM, Manco-Johnson MJ. Hematol Oncol Clin N Am. 2004;18;1315-1338), and evaluation for thrombophilia should be performed for any child with thromboembolic disease.