Peripheral Lymphocytosis Research Articles

Patient-Derived Xenograft Model in B-Cell Lymphoma: A Platform for a Personalized Clinical Trial

Background: Imprecise correlation of treatment response in established cell line and cells obtained from patients (i.e., patient-primary) limits the preclinical investigation of novel compounds. Similarly, the "xenograft" models wherein human cancer cell lines are transplanted into immunocompromised mice do not represent the full spectrum of cancers. However, Patient-derived xenograft (PDX) mouse models have been shown to recapitulate the diversity of growth, metastasis, and histopathology of the original tumor. Based on our previously established mantle cell lymphoma (MCL) PDX model, we developed other B-cell lymphoma PDXs recapitulating tumor pathological and clinical characteristics, progression and response to therapeutic agents, this will provide an indispensable model system towards personalized treatment for B-cell lymphoma.Methods: We developed 34 PDX models with an implanted fetal bone chip for several B-cell lymphomas including marginal zone lymphoma (MZL), follicular lymphoma (FL), Burkitt’s lymphoma (BL), and diffuse large B-cell lymphoma (DLBCL), and MCL. We tested the in vitro efficacy of a panel of drugs among freshly isolated tumor cells from patients and tumor cells from the PDX models. We also generated a drug-resistant MCL PDX model, compared the effect of targeted drugs on the tumor burden in the drug-resistant model and identified potential therapeutic opportunity with drug combinations. We validated combination therapy in vivoand conducted next generation sequencing (NGS) using a 1,212 gene panel (OncoPlus®) on DNA from primary patient cells.Results: We collected clinical samples from 34 patients with several types of B-cell lymphomas including MCL (n=21), DLBCL (n=3), FL (n=2), BL (n=1), and MZL (n=2). Of the 34 patients, 18 (53%) were newly diagnosed and untreated clinically, 11 (32%) patients were relapsed after treatment with 1-3 chemotherapy or targeted therapy treatments, and 5 (15%) patients were treated with one-dose therapy before sample collection. All of the tumor cells, from both the patient and PDXs, showed the same drug response pattern. Consecutive ibrutinib administration to PDX mice from PT1 during G4 induced the development of an ibrutinib-resistant tumor. The cell viability of isolated PDX tumor cells treated with ibrutinib was not significantly different between G1 and G2 nor was it different between G5 and G6 (p>0.05). In addition, histological features were consistent with patient tumor histology. Furthermore, whole exome sequencing revealed fidelity between the patient and PDX tumor cells as well as between subsequent generations of the PDX. [B1] We[Z2] engrafted a patients tumor cells into NSG-hu mice to create an MCL-bearing PDX mouse model (PT28-PDX). G2 PDX cells were isolated and treated with a panel of drugs. We found that G2 PDX cells were most sensitive to bortezomib (BTZ) (Velcade®). Growth inhibition of the G2 PDX cells was significantly higher with BTZ compared to ibrutinib (p=0.002) and cells were most sensitive to BTZ compared with other agents (p≤ 0.002). Based on this finding, the patient was treated with Velcade®, rituximab and dexamethasone and responded to treatment. However, the G3 PDX became resistant to BTZ. She was then treated with a 1 cycle of rituximab and cytarabine. Soon after, we initiated three-drug combination treatment with lenalidomide (Len), rituximab (RTX) and dexamethasone (DEX) in PDX G4. Len+RTX+DEX significantly prolonged mouse survival indicating that this could be an effective regimen for this patient after BTZ relapse. As guided by the PDX, PT28 underwent Len+RTX+DEX regimen and her peripheral lymphocytosis disappeared demonstrating response.Conclusions: The PDX model with implanted fetal bone chip is a valid experimental platform that recapitulates tumor characteristics of B-cell lymphomas. Leveraging the PDX platform to identify and select drugs that are likely to be efficacious for individual patients and subsequently administering the promising agents to those who relapse after an initial therapy is the next milestone. DisclosuresWang:BeiGene: Research Funding; Asana BioSciences: Research Funding; Juno Therapeutics: Research Funding; Pharmacyclics: Research Funding; Celgene: Research Funding; Onyx: Research Funding; Kite Pharma: Research Funding; Acerta Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Distinguishing Between Hepatosplenic T-cell Lymphoma and γδ T-cell Large Granular Lymphocytic Leukemia: A Clinicopathologic, Immunophenotypic, and Molecular Analysis.

Hepatosplenic T-cell lymphoma (HSTCL) is a rare, aggressive T-cell lymphoma that can be challenging to diagnose. In particular, distinguishing HSTCL from T-cell large granular lymphocytic (T-LGL) leukemia of γδ T-cell receptor (TCR) type is difficult without examination of a splenectomy specimen. In this study, we systematically assessed a series of HSTCL cases for findings reported in the literature as supporting or not supporting the diagnosis of HSTCL. We also compared HSTCL with a group of cases of T-LGL of γδ TCR type. Criteria assessed in this study included: B-symptoms, massive splenomegaly, lymphadenopathy, extranodal involvement, peripheral lymphocytosis, lymphoma cells that expand bone marrow sinuses, lymphocyte azurophilic granules, immunophenotype, evidence of infection by Epstein-Barr virus, human immunodeficiency virus, or human T-cell leukemia virus type 1, isochromosome 7q, trisomy 8, and TCR gene rearrangement status. On the basis of the data of this study, we conclude that massive splenomegaly, bone marrow sinusoidal expansion by lymphoma cells, and lymphocytes devoid of azurophilic granules were significantly more common in HSTCL patients than in γδ T-LGL patients (P<0.0001), and these features help support the diagnosis of HSTCL.

Chronic lymphocytic leukemia: a clinical review including Korean cohorts.

Only 5th decade ago, chronic lymphocytic leukemia (CLL) was only recognized as disease group of presenting features like peripheral lymphocytosis, organomegaly including of splenomegaly. As understanding of disease biology and molecular diagnostic tools are getting improved gradually, characterization of variation in CLL’s clinical courses was facilitated, resulting in better risk stratification and targeted treatments. Consequently multiple new targeted agents have been used in treatment of CLL, it makes improved clinical outcome. Rituximab containing chemoimmunotherapy (combination of rituximab, fludarabine, and cyclophosphamide) have shown better overall response rate and progression-free survival on fit patients’ group in front-line setting, result in standard first-line therapeutic option for CLL. Furthermore, after introducing that the B-cell receptor is crucial for the evolution and progression of CLL, emerging treatments targeting highly activated surface antigens and oncogenic signaling pathways have been associated with several successes in recent decades. These include new anti-CD 20 monoclonal antibody (obinutuzumab), the bruton tyrosine kinase inhibitor (ibrutinib), the phosphatidylinositol 3-kinase inhibitor (idelalisib), and B-cell CLL/lymphoma 2 inhibitor (ABT-199 and ABT-263). So, we discuss not only general pathophysiology of CLL, but also rapidly advancing treatment strategies that are being studied or approved for treatment of CLL.

Clinical and histopathological evaluation of 16 dogs with T-zone lymphoma.

Clinical and histopathological characteristics of 16 dogs with nodal paracortical (T-zone) lymphoma (TZL) were evaluated. At initial examination, generalized lymphadenopathy was found in all dogs, and peripheral lymphocytosis was found in 10 of the 16 dogs. At initial diagnosis or during the disease course, 8 dogs (50%) were affected with demodicosis. Immunohistochemical analysis for CD3, CD20 and CD25 was performed for 6 dogs with TZL; the tumor cells were positive for CD3 and CD25 and negative for CD20. Median overall survival time was 938 days. A watchful waiting approach was adopted for 6 cases (38%), and 5 of the 6 dogs were still alive at the end of follow-up. The clinical course of TZL in dogs is generally indolent; however, many cases develop a variety of infectious and other neoplastic diseases after the diagnosis of TZL.

Deletion of Cellular Prion Protein (PrPC) Results in Peripheral Lymphocytosis and Larger Platelets

Cellular prion protein (PrPC) is a GPI-anchored cell surface glycoprotein that is expressed in the brain, blood, bone marrow (BM), and lymphoid tissue. PrPC can be converted post-translationally into scrapie-PrP (PrPSc), which is involved in the pathogenesis of neurodegenerative diseases including Creutzfeldt-Jakob disease, Kuru disease in humans, and scrapie and bovine spongiform encephalopathy in animals. However, the biological function of PrPSc has yet to be conclusively elucidated.In order to understand the role of PrPC in the hematopoietic system, we compared bone marrow, lymphoid organs and peripheral blood of PrPC knockout mice (KO) to age and sex-matched transgenic mice used as background controls (WT) expressing human PrPC under the control of a mouse PrPC promoter with a slightly augmented expression (2-fold) of PrPC. Complete blood count (CBC) showed a significant increase of WBC in KO mice (KO 9.03 ± 5.16 x109/L vs. WT 4.13 ± 1.87 x109/L, p = 0.0405; Table 1 and Figure 1). Further analysis of WBC differential revealed that the elevated number of WBC in KO mice was due to lymphocytosis. Specifically, KO mice had a 3-fold increase in the absolute lymphocyte count (KO 7.59 ± 4.63 x109/L vs. WT 2.90 ± 1.32 x109/L, p = 0.0303), as well as a higher lymphocyte percentage (KO 82.47 ± 4.20% vs. WT 70.19 ± 4.44%, p = 0.0011) compared to controls. KO mice also had a trend toward higher hemoglobin (KO 12.00 ± 4.40 g/dL vs. WT 9.84 ± 4.83 g/dL), RBC (KO 8.01 ± 2.87 x1012/L vs. WT 6.25 ± 3.11 x1012/L), and hematocrit (KO 43.94 ± 17.00 % vs. WT 36.04 ± 18.07 %) compared to WT mice. Additionally, platelet count in KO mice was higher than control mice (KO 762.20 ± 138.61 x 109/L vs. WT 661.80 ± 230.20 x 109/L). Of interest, the mean platelet volume (platelet size) was significantly increased in KO mice compared to controls (KO 6.00 ± 0.29 fL vs. WT 5.24 ± 0.56 fL, p =0.0140). Thus, absence of PrPC resulted in significant leukocytosis and specifically higher absolute count and percentage of lymphocytes, as well as larger platelets in peripheral blood.To further analyze if the observed lymphocytosis is due to abnormalities in hematopoiesis or lymphopoiesis, bone marrow (BM), thymus, spleen and lymph nodes from WT and KO mice were isolated and examined by flow cytometry using a comprehensive panel of fluorochrome-conjugated antibodies specific for all hematologic cell precursors/lineages. Analysis of all cell populations in each of these organs revealed no significant differences in the numbers of RBC and megakaryocyte in BM, and of lymphocytes in the thymus, spleen and lymph nodes (data no shown). Additionally, histological analysis of BM, thymus, spleen and lymph nodes tissue from KO and WT animals failed to show morphological differences between the two groups (data not shown). Therefore, lack of PrPC does not appear to affect hematopoiesis and lymphopoiesis.In summary, our findings indicate that PrPC deficiency translates into a significant increase in the number of lymphocytes in peripheral blood; however, development and maturation of lymphocytes in KO mice appeared normal. Therefore, PrPC might be critical in the survival and trafficking of lymphocytes in peripheral blood. The molecular mechanisms underlying the observed changes in lymphocytes and platelets, and whether there are any related changes in the functions of lymphocytes and platelets will be subject of future studies.Table 1Complete blood count (CBC) of PrPC WT and KO miceWTKOp valueMean ± SDMean ± SDWBC (109/L)4.13 ± 1.879.03 ± 5.160.0405Absolute lymphocyte count (109/L)2.90 ± 1.327.59 ± 4.630.0303Lymphocyte (%)70.19 ± 4.4482.47 ± 4.200.0011RBC (1012/L)6.25 ± 3.118.01 ± 2.870.1898HB (g/dL)9.84 ± 4.8312.00 ± 4.400.2404HCT (%)36.04 ± 18.0743.94 ± 17.000.2618PLT (109/L)661.80 ± 230.20762.20 ± 138.610.2138MPV (fL)5.24 ± 0.566.00 ± 0.290.0140SD: Standard deviation; WBC: White blood cell; RBC: Red blood cell; HB: Hemoglobin; HCT: Hematocrit; RDW: Red cell distribution width; PLT: Platelet; MPV: Mean platelet volume [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Expansion of T or B Lymphocytes after Unrelated Cord Blood (UCB) Allogeneic Stem Cell Transplantation in Adults Correlates with CMV Reactivation and Is Associated with a Better Outcome

Introduction: Peripheral lymphocytosis encountered after myeloablative (MAC) or reduced-intensity conditioning (RIC) allogeneic stem cell transplantation (allo-SCT) is an ill-defined feature. Most reports in the literature deal with large granular lymphocytes (LGL) expansions and only seldom of B-cell increases (Bellucci, Blood, 2002). With an incidence of 3 to 18%, LGL proliferations occur generally late after allo-SCT with a median onset of 9 to 16 months. Such expansions can be polyclonal, oligoclonal or monoclonal, arising from either CD3+ T-cells or CD3- NK cells or both. LGL expansion has been frequently linked to CMV reactivation, indolent clinical course and a usually favorable outcome. Most available data were mainly described in the setting of allo-SCT using bone marrow (BM) or peripheral blood (PBSC) as stem cell source. Here, we report data regarding the incidence and features of lymphocyte expansions after unrelated cord blood (UCB) transplantation.Patients and Methods: Ninety-nine UCB allo-SCT performed in adults between October 2005 and October 2014 were considered for the purpose of this study. Most patients received double CB units (n=94) and a RIC regimen (n=89), for various hematological diseases. Whenever detected, we collected the date of onset and termination of peripheral blood lymphocyte expansions (4x109/L) among the 86 UCB-SCT patients alive at 3 months post-transplant. LGL expansion was defined as sustained LGL above 0.5x109/L and/or >40% of LGL in peripheral blood (Zambello, Haematologica, 1998). Concomitant immunophenotypic results, allowed to discriminate expansions of cytotoxic T-cells (CD3+CD8+CD56+), NK-cells (CD3-CD16+/CD56+) and B-cells (CD19+). LGL expansion data were also analyzed with respect to viral reactivation episodes, acute or chronic graft vs host disease, relapse and survival.Results: Lymphocytosis was observed in 21 cases (24%; 10 females and 11 males; median age: 58 y., range: 32-69). Most patients had a myeloid-lineage disease (67%) and were in complete remission at time of UCB-SCT (76%). The median onset of lymphocyte expansion after UCB-SCT was 12.6 months (range, 1.4-49). The median initial lymphocyte count was 4.76x109/L at time of expansion diagnosis. The median duration of expansion was 12 months (range: 1-52). Twenty patients could be further analyzed phenotypically, showing 8 CD8+ T, 1 NK and 1 T-NK LGL expansions. Interestingly, 7 cases of polyclonal B-lymphocytes expansions were also documented while 3 patients presented both T CD8+ and B expansions. Of note, B-cell expansions were CD5+. For 6 patients with T-cell expansion, concomitant DNA from CD3+ sorted cells is available to test clonality.Lymphocyte expansion were from donor origin for 12/14 tested patients. Acute and chronic GVHD developed respectively in 31% and 68% of lymphocytosis patients, and in 57 and 45% of the 65 patients without lymphocyte expansion (P=NS). Comparing these two groups for viral reactivations, the rates were 86% and 76% for HHV-6 (P=NS) and 23% and 39% for EBV (P=NS) respectively. CMV reactivation was significantly more frequent in the group of lymphocytosis patients (76% vs. 29%, P=0.0001). Interestingly, CMV reactivation was significantly higher in the 10 patients of the T or NK group compared to the 7 patients with B cell expansion (100% vs 57%, P=0.05).At time of analysis, 1 patient had relapsed and 4 had died, the causes of death being disease in 1 case and transplant-related mortality in 3. These events were significantly lower than in the group of patients without lymphocytosis (p=0.003 for relapses and p=0.04 for death). Two-year disease-free survival (Fig A) and overall survival (Fig B) were significantly different at respectively 85% vs. 55% (p=0.01) and 85% vs. 63%. (p=0.03).Conclusion: Lymphocyte expansion, at 24%, is not a rare event in adults receiving UCB allo-SCT. These expansions involve equally the T or B-lineages. The latter are often CD5+ suggesting a proliferation of innate B1 cells from the UCB. Lymphocyte expansions are significantly associated with previous reactivation of CMV, but not HHV-6 or EBV. Because these cells were of donor origin, it can be postulated that they represent primo-activation upon encounter with CMV. Finally, both types of lymphocyte expansions are associated with a significant favorable outcome, suggesting a possibly bystander anti-GVL effect. [Display omitted] DisclosuresMoreau:Celgene, Janssen, Takeda, Novartis, Amgen: Membership on an entity's Board of Directors or advisory committees.

Unique Patterns of Lymphocyte Recovery Induced By Hyperbaric Oxygen Therapy Given Prior to Stem Cell Transplantation: A Case Series Report on Three Patients

Hyperbaric oxygen therapy (HBO) is being studied at our institution to improve hematopoietic stem cell homing and engraftment. Pre-clinical experiments have demonstrated that HBO therapy to the recipient prior to umbilical cord blood CD34+ cell infusion induces a low Erythropoietin (EPO) environment that results decreased erythroid differentiation and instead favored early bone marrow retention of CD34 cells with positive impact on engraftment in animal experiments1.We hereby report a case series of 3 patients who received HBO on ongoing clinical trials and demonstrated unique patterns for lymphocyte recovery associated with unique clinical presentations. Patients were exposed to 100% oxygen at 2.5 atmosphere pressure for total of 2 hours prior to hematopoietic stem cell infusion.Case 1: A 64 year old male with IgG kappa multiple myeloma who relapsed post tandem cycles of high-dose Melphalan and autologous transplants. The patient received salvage therapy with Carfilzomib and Dexamethasone and achieved a partial response following which he underwent a preparative regimen of Carmustine, Etoposide, Cytarabine and Melphalan (BEAM) with subsequent autologous transplantation on an HBO clinical trial.Post-transplant course was complicated by fever, rigors and extensive skin rash. These findings coincided with a rapid rise in white blood cell count predominantly composed of lymphocytes (Fig.2). Peripheral blood flow cytometry revealed atypical T-cell population with lymphocytes comprising 94% of total events. The majority were T cells (76%) with CD4 to CD8 ratio of 1:1 and co-expression of CD15, CD38 and HLA-DR. An associated infectious etiology was ruled out and the patient improved over a period of several days.Case 2: A 33 year old male with refractory nodular sclerosis Hodgkin Lymphoma. He initially received Doxorubicin, Bleomycin, Vinblastine and Dacarbazine (ABVD) for 2 cycles with partial response. He was then switched to Bleomycin, Etoposide, Doxorubicin, Cyclophosphamide, Vincristine, Procarbazine and Prednisone (BEACOPP). After 2 cycles of BEACOPP, a repeat PET scan showed partial response. He was then salvaged with Brentuximab followed by BEAM and autologous transplant on HBO clinical trial.The patient achieved neutrophil engraftment by day +11, of note his blood counts showed early increase in lymphocytes (86%) (Fig. 3). Post-transplant he was restarted on Brentuximab for two cycles with achievement with complete response, but his course was complicated by uveitis. An aqueous chamber fluid sample was sent for flow cytometry which showed Lymphocytes comprising 13% of total events. Flow cytometry of Cerebrospinal fluid revealed lymphocytes comprising 97% of total events. Both aqueous chamber and cerebrospinal fluids showed majority of T cells with normal CD4:CD8 ratio and antigen expression. His vision improved with topical steroid eye drops. Unfortunately, his disease progressed again off therapy.Case 3: A46 year old female with T cell large granular lymphoma who was initially treated with weekly methotrexate progressed to hepatosplenic gamma-delta T cell lymphoma and was treated with 4 cycles of hyper CVAD. Patient then received a reduced intensity preparative regimen of Fludarabine, Cytoxan, Total body irradiation and single unit umbilical cord blood transplantation on HBO clinical trial. The patient had an unremarkable post-transplant course and achieved neutrophil engraftment by day +25. Of note the patient demonstrated persistent peripheral lymphocytosis ranging between 42-64% of total white blood cell counts (Fig. 4). Bone marrow biopsies at multiple milestones showed her to be in complete remission and to be 100% donor by molecular tests.Conclusions: Three unique patterns of lymphocyte recovery are seen in association with HBO therapy given prior to hematopoietic stem cell transplantation. We hypothesize that these patterns of lymphocyte recovery are secondary to engraftment kinetics caused by HBO and low EPO environment at the time of stem cell infusion. We suspect the early robust lymphocytosis may have played a role enhancing the inflammatory milieu resulting in fevers, rigors and extensive skin rash in case one, uveitis with CSF and aqueous chamber lymphocytosis in case two and persistent peripheral lymphocytosis in case three. In all three cases, the T cell exhibited normal antigen expression on flow cytometry. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A case of double leukemia: chronic myeloid leukemia intolerant to imatinib and chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) and chronic myeloid leukemia (CML) are the most common leukemias of the elderly. However, the sequential occurrence of CML followed by CLL in the same patient is extremely rare. We present a report of a 70-year-old man who developed CLL six years after the diagnosis of CML in molecular, cytogenetic and morphologic remission. The diagnosis of CLL is confirmed by peripheral lymphocytosis. The first line therapy in CML in chronic phase is still imatinib, but in the present case the patient was intolerant to imatinib, therefore he switched to nilotinib after few months.

Fatal PTLD Accompanied by Rapid Lymphocyte Proliferation in the Early Phase of Allogeneic HSCT

Post-transplant lymphoproliferative disorder (PTLD) is a spectrum of clinically and morphologically heterogeneous lymphoid proliferations of various clonal compositions that are observed after hematopoietic stem cell transplantation (HSCT) or solid organ transplantation. The majority of PTLD cases are associated with Epstein-Barr virus (EBV) infection, while overt peripheral blood (PB) or bone marrow (BM) involvement in PTLD is uncommon in early lesions. We report a 38-year-old woman with EBV-related PTLD, with BM and PB involvement, who presented with peripheral lymphocytosis as an early lesion 1 month after haploidentical HSCT for Philadelphia chromosome-positive acute lymphoblastic leukemia was performed during first complete remission. Although PB or BM involvement of PTLD after HSCT is uncommon in early lesions, peripheral lymphocytosis can be an initial presenting manifestation of PTLD, as in this case. Keywords: Epstein-Barr virus infections; Transplantation; Lymphoproliferative disorder 중심 단어: 엡스타인 바 바이러스; 이식; 림프세포증식질환

Clinicopathological and phenotypic features of chronic NK cell lymphocytosis identified among patients with asymptomatic lymphocytosis

Chronic natural killer (NK) cell lymphocytosis is currently a provisional entity. This study demonstrated NK cell lymphocytosis in patients with asymptomatic lymphocytosis and presented the hematological and phenotypic findings. Flow cytometry analysis was performed for investigation of unexplained peripheral lymphocytosis. NK cells were determined by the phenotype of CD3-/CD16+/CD56+. Chronic NK cell lymphocytosis was defined by a NK cell count of ≥ 2 × 10(9)/L, persistent for over 6 months, no evidence of B- or T-cell clonality and no hematologic disorders. Among 190 patients with peripheral lymphocytosis, 15(7.9%) patients, age 42-72 years, were identified to have NK cell lymphocytosis, with a median NK cell count of 3.1 × 10(9)/L (range 2.1-7.3 × 10(9)/L). Persistent NK cell lymphocytosis was confirmed with a median follow-up of 18 months. CD56(bright) NK cell populations were seen in eight patients and CD56(dim) NK cells in seven patients. CD57 co-expression was seen in both CD56(dim) and CD56(bright) cells. CD7, CD2, or CD8 expression was seen in some of the NK populations. The NK cell lymphocytosis appeared stable and no progression to NK cell leukemia during the follow-up period. This study demonstrated that chronic NK cell lymphocytosis, similar to monoclonal B lymphocytosis or T-cell clones, may account for asymptomatic lymphocytosis. There were no identifiable causes of the NK cell expansion. The variable phenotype may represent the heterogeneity and pathological features of NK lymphocytosis.

TO THE PROBLEM OF DIFFERENTIAL DIAGNOSIS OF HEPATOLIENAL SYNDROME. CLINICAL OBSERVATION

A case of chronic B-lymphatic leukemia developing at the first stages with splenomegalia without peripheral lymphoadenopathy, peripheral blood leukocytosis and lymphocytosis. Is described. Moderate hepatomegalia and portal hypertension added later on permitted to diagnose cryptogenic hepatic cirrhosis, but there were no signs of hepatocellular failure typical for this diagnosis. Two years later, there occurred peripheral blood lymphocytosis, increase in peripheral and abdominal lymph nodes, lymphoid bone marrow transformation with partial cellular anaplasia in the marrow punctuate; immunophenotyping of peripheral blood cells: monoclonal B-lymphocyte proliferation corresponding to B-chronic lymphatic leukemia - small lymphocyte lymphoma. Portal hypertension was caused by location of increased lymph nodes in the portal vein system. Diagnosis of hepatic cirrhosis was annulled.

Chronic lymphocytic leukemia: a clinical review.

The most common leukemia is chronic lymphocytic leukemia (CLL). Every year, there are 15 000 new diagnoses and 5000 CLL deaths in the United States. Although therapeutic choices were once limited, treatment of this disease has vastly improved in the last decade. Evidence-based review of the diagnosis, staging, and treatment of CLL. PubMed, Cochrane Library, Scopus, and Google Scholar databases were searched through August 28, 2014. English-language peer-reviewed articles published between 2000-2014 were found using the keywords chronic lymphocytic leukemia, upfront therapy, upfront therapies, upfront therapeutic, upfront therapeutics, upfront treatment, front-line treatment, first-line treatment, front-line treatments, first-line treatments, front-line therapy, front-line therapies, randomized, randomized studies, randomized study, clinical trial, clinical trials, phase 3, and phase 3 clinical trial. Abstracts and presentations at scientific meetings were excluded. A total of 277 articles were retrieved, of which 24 met our predefined selection criteria; treatment recommendations were based on subsequent analysis of these 24 articles. The Rai and Binet systems for staging CLL were established in 1975 and 1977, respectively. However, they do not account for new disease categories such as monoclonal B-cell lymphocytosis (peripheral blood clonal lymphocytosis that does not meet other criteria for CLL). Two subsets of CLL are now recognized based on risk stratification involving molecular and cytogenetic analyses. Outcomes are improved by the addition of immunotherapy to combination chemotherapy for initial treatment in all subsets of treated patients. Overall response rates between 75% and 90% and complete responses between 22% and 45% are expected in the current era, with more than 80% of treated patients alive at 3 years. Overall, 5-year survival has increased to 66% from 60% (P < .001) in the past 10 years. Chemoimmunotherapy is the standard first-line option approach for CLL, the most common leukemia observed in adults. Treatment is initiated when the disease becomes symptomatic, and survival is high following treatment.

Shifting ecologies of malignant and nonmalignant cells following BRAF inhibition.

Clinical vignette: A 49-year-old man with stage IV BRAFV600E-driven melanoma was initiated on twice-daily 960 mg of vemurafenib for treatment of progressive and recurrent subcutaneous metastatic disease of the left lower extremity. The patient's melanoma responded well to targeted BRAF inhibition. At treatment onset, hematologic parameters were all within normal limits; however, within three months of initiating therapy, wbc were found to be elevated (to 20 K) with sustained lymphocytosis of mature phenotype. Immunophenotypic analysis was consistent with chronic lymphocytic leukemia (CLL), and FISH results revealed presence of the CLL-associated deletion in chromosome 13q14 as well as in 2p33. Vemurafenib was withdrawn after approximately one year of therapy, and subsequently, his peripheral lymphocytosis resolved and CLL regressed. Nevertheless, a monoclonal B cell population persisted even 732 days after discontinuation of vemurafenib.

PI3-Kinase Inhibitors in Chronic Lymphocytic Leukemia

The phosphatidylinositol 3-kinase (PI3K) pathway is being explored as a target of inhibition for B-cell lymphoproliferative disorders, with agents specific for inhibition of the PI3K-δ subunit showing significant clinical activity in chronic lymphocytic leukemia (CLL). Idelalisib (CAL-101, GS-1101) and IPI-145 (INK-1147) are novel oral PI3K-δ inhibitors in development, with rates of objective response of 40-60% and nodal responses exceeding 70% in relapsed and refractory CLL. High rates of response have been seen in high-risk CLL (i.e., 17p and 11q deletions), and may allow for more effective therapy in inherently chemotherapy-resistant disease. Combination chemotherapy regimens with idelalisib have similarly demonstrated favorable tolerability and activity. Like other agents that target the B-cell receptor pathway, peripheral lymphocytosis, due to drug-induced changes in lymphocyte trafficking, is common. Noteworthy toxicities include transaminitis and pneumonia/pneumonitis. Multiple studies are evaluating PI3K-δ inhibitor combination regimens, and the rationale for these ongoing and planned studies is reviewed.

A Prospective Multicenter Study Of The Bruton's Tyrosine Kinase Inhibitor Ibrutinib In Patients With Relapsed Or Refractory Waldenstrom's Macroglobulinemia

IntroductionWhole genome sequencing has revealed highly prevalent somatic mutations in WM (Hunter et al, ICML-12, 2013). MYD88 L265P is present in >90% of patients with Waldenstrom's Macroglobulinemia (WM), and supports malignant growth via signaling involving Bruton's Tyrosine Kinase (BTK). Ibrutinib inhibits BTK, and in vitro induces apoptosis of WM cells bearing MYD88 L265P (Yang et al, Blood 2013). WHIM-like mutations in CXCR4 are present in 1/3 of patients with WM, and their expression induces BTK activity and confers decreased sensitivity to ibrutinib mediated growth suppression in WM cells (Cao et al, ASH 2013, submitted). We therefore evaluated the efficacy and tolerability of ibrutinib in relapsed or refractory WM, and examined the impact of MYD88 L265P and WHIM-like CXCR4 mutations on ibrutinib response given our laboratory findings. Patients and MethodsSymptomatic WM patients who received at least 1 prior treatment were enrolled on this prospective clinical trial. Intended therapy consisted of 420 mg of oral ibrutinib daily for 2 years or until progression, or unacceptable toxicity. Sanger sequencing was used to determine MYD88 and CXCR4 mutations in sorted bone marrow lymphoplasmacytic cells (BM LPC) from 43 and 40 patients, respectively. Forty of 43 (93%) and 10/40 (25%) patients had MYD88 L265P and WHIM-like CXCR4 mutations, respectively. Results63 patients including 17 with refractory disease were enrolled; all 63 are evaluable for response and toxicity. Median baseline characteristics: Age 63 (range 44-86) ; Prior therapies 2 (range 1-6); Hematocrit 30.8% (range 24.5-41.5); Hemoglobin 10.5 g/dL (8.2-13.8 g/dL); serum IgM 3,610 mg/dL (range 735-8390 mg/dL); serum M-protein 2.14 g/dL (range 0.5-5.4 g/dL); B2M 3.9 mg/L (range 1.3-14.2 mg/L); BM disease involvement 65% (range 3.2-95%). At best response, median serum IgM levels and M-protein declined to 1,340 mg/dL and 0.84 g/dL, respectively (p<0.00001). Median hematocrit and hemoglobin rose to 38.1% and 12.6 g/dL, respectively (p<0.00001). Post-treatment bone marrow assessment at 6 months is available for 34 patients at this time, and showed a reduction from 70% to 45% in WM disease involvement for these patients (p=0.0006). With a median follow-up of 6 (range 2-15 cycles), the best overall response rate i.e. minor response (MR) or better using consensus criteria adapted from the 3rd International Workshop on WM is 81% (4 VGPR; 32 PR, 15 MR), with a major response rate (PR or better) of 57.1% and a median time to response of 4 weeks. 11 patients have stable disease, and 1 patient was a non-responder. Independent disease and response assessments are planned. Grade >2 treatment related toxicities include thrombocytopenia (n=9; 14.3%); neutropenia (n=12; 19.1%); stomatitis (n=1; 1.6%); atrial fibrillation (n=1; 1.6%); diarrhea (n=1; 1.6%); herpes zoster (n=1; 1.6%); hematoma (n=1; 1.6%); hypertension (n=1; 1.6%) and epistaxis (n=1; 1.6%). 59 patients remain on study with 7 on reduced doses of ibrutinib. Reasons for discontinuation include non-response (n=1) in a patient with wild type MYD88; MDS/RAEB (n=1) in a heavily pre-treated patient who attained PR, but who had 5q deletions pre-dating protocol therapy; thrombocytopenia (n=1) in a patient with splenic entrapment; and patient decision (n=1). In patients who underwent tumor sequencing, attainment of major responses was impacted by mutations in CXCR4, but not MYD88 L265P. The major response rate was 77% for patients with wild-type CXCR4 vs. 30% in those with WHIM-like CXCR4 mutations (p=0.018). Decreases in serum IgM (p=0.047) and IgM M-spike (p=0.012), as well as improvements in hemoglobin (p=0.058) were greater in patients with wild-type CXCR4. Patients with wild-type CXCR4 also had increased peripheral lymphocytosis following ibrutinib treatment versus those with WHIM-like CXCR4 mutations (p=0.001). ConclusionsIbrutinib is highly active, and well-tolerated in patients with relapsed or refractory WM. Rapid reductions in serum IgM and improved hematocrit occur in most patients receiving ibrutinib. The presence of WHIM-like CXCR4 mutations impacts responses and peripheral lymphocytosis in WM patients undergoing ibrutinib treatment. Disclosures:Off Label Use: Ibrutinib is a Bruton's Tyrosine Kinase (BTK)inhibitor that, in vitro, induces apoptosis of Waldenstrom's macroglobulinemia cells bearing somatic mutations of MYD88 L265P.

T-cell clonality is detected in a high frequency among patients with incidental lymphocytosis by PCR assays for TCR gene rearrangements

AimsClonal expansion of lymphocytes may account for asymptomatic lymphocytosis. Unlike monoclonal B lymphocytosis, the detection of T-cell clones is difficult using immunophenotype-based assays. This study aimed to evaluate PCR-based clonality...

English

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare disorder characterized by vascular proliferation, eosinophilia in peripheral blood samples and tissue lymphocytosis. The etiology is unknown. There is a female preponderance. It often presents as multiple, grouped red nodules in the periauricular region, scalp line, and neck. Numerous therapeutic approaches have been tried for ALHE including destructive techniques such as electrodesiccation, cryotherapy, surgical excision, radiotherapy or laser (argon, CO 2, pulsed dye). We present a disseminated ALHE (DALHE) case which was present for 12 years and aggravated for 12 months that was treated successfully by using oral isotretinoin and pentoxifylline.

T-cell prolymphocytic leukemia revealed by spinal cord compression

T-cell prolymphocytic leukemia is a lymphoid hematologic malignancy of T origin, mature, individualized well by the clinical, morphological, and immunophenotypic as well as cytogenetic aspects. We report the case of a 39-year-old man admitted in our department because of a spinal cord compression. The cerebrospinal fluid analysis had revealed an increased albuminemia level; MRI evoked a vertebral infiltration by a malignancy. Evolution was characterized by the appearance of a tumor syndrome and a peripheral lymphocytosis. Immunophenotyping and the lymph node biopsy concluded of a diagnosis of a T-cell prolymphocytic leukemia. To our knowledge, we report here the first case of T-cell prolymphocytic leukemia revealed by a spinal cord compression.

A Rare Presentation of Cutaneous Pseudolymphoma as a Preleukaemic State

A patient presented with progressive and unresponsive erythematous rash affecting his trunk and limbs over a period of 5 years. His systemic examination and extensive relevant investigations were normal throughout this period. Skin biopsies at different times showed features of annular erythema, cutaneous pseudolymphoma and sub-acute dermatitis. Five years after the initial presentation, he developed erythroderma, leonine facies, lymphadenopathy and peripheral lymphocytosis. CT chest and abdomen revealed generalised lymphadenopathy. Skin biopsy and immunophenotyping was suggestive of Sezary syndrome. However, peripheral blood smear examination was highly suggestive of T-cell prolymphocytic leukaemia (TPLL). Subsequent molecular genetic analysis was consistent with TPLL. To the best of our knowledge, there are no reports of cutaneous pseudolymphoma transforming to TPLL in the literature. The long indolent course of apparently benign skin disease before transforming into TPLL appears to be unique in our case. An analogy can be made with cutaneous T-Cell lymphoma both in terms of the difficulty in proving the diagnosis-needing multiple skin biopsies, and in the possible link between cutaneous and systemic disease. TPLL should be considered as a rare cause of erythroderma, which may clinically and histologically mimic Sezary syndrome.

A Case of Hypersensitivity to Mosquito Bites without Peripheral Natural Killer Cell Lymphocytosis in a 6-Year-Old Korean Boy

Hypersensitivity to mosquito bites (HMB) is a rare disease characterized by intense skin reactions such as bulla and necrotic ulcerations at bite sites, accompanied by general symptoms such as high-grade fever and malaise occurred after mosquito bites. It has been suggested that HMB is associated with chronic Epstein-Barr virus (EBV) infection and natural killer (NK) cell leukemia/lymphoma. We describe here a Korean child who presented with 3-yr history of HMB without natural killer cell lymphocytosis. He has been ill for 6 yr with HMB. Close observation and examination for the development of lymphoproliferative status or hematologic malignant disorders is needed.