Underwent Bone Marrow Examination Research Articles

Alemtuzumab monotherapy for T-cell prolymphocytic leukemia: an observational study in Japan.

Alemtuzumab is recommended as first-line and second-line therapies for T-cell prolymphocytic leukemia (T-PLL). This study retrospectively evaluated the efficacy and safety of alemtuzumab in nine Japanese patients with T-PLL at five participating institutions who were treated between January 2015 and August 2023. The median age at first administration of alemtuzumab was 72 years (range, 39 to 78). Two patients were treatment naïve, and seven had been treated with a median of one (range, 1 to 3) prior systemic therapy. Six patients were refractory to their most recent therapy. Three patients completed 12 weeks of treatment. The overall response rate and the complete response (CR) rate were 78% and 11%, respectively. Among the six patients who achieved a partial response, two achieved clinical CR but did not undergo bone marrow examination. One patient also achieved clinical CR but did not undergo CT or bone marrow examination for response evaluation. The median progression-free survival time was 8.1 months (95% confidence interval, 0.9 to 18.6). Three patients received readministration of alemtuzumab monotherapy after disease progression. There were no treatment-related deaths. The grade 3 or 4 nonhematologic adverse events included infusion reaction (grade 3, n = 2), cytomegalovirus reactivation (grade 3, n = 2), and pulmonary edema (grade 3, n = 1). One patient experienced Epstein‒Barr virus-positive diffuse large B-cell lymphoma 15 months after the last dose of alemtuzumab. These results confirm that the efficacy and safety of alemtuzumab monotherapy in Japanese patients are comparable to those previously reported.

Safety and Efficacy of Single Cycle Blinatumomab Plus VP Chemotherapy for High Tumor Burden Acute Lymphoblastic Leukemia in Adults

Background: Blinatumomab, a CD3×CD19 T cell-engaging antibody was developed for immunotherapy in patients with relapsed/refractory B-lineage acute lymphoblastic leukemia (R/R B-ALL) and positive minimal residual disease complete remission. However, high tumor burden is thought able to predict a lower object response rate (ORR) after treatment with blinatumomab monotherapy, so combination treatment regimens are needed to improve the therapeutic effect of blinatumomab. Previous studies have reported the clinical trial results of adding blinatumomab to chemotherapy such as Mini-hyper-CVD and CAM for the treatment of adult or infant R/R B-ALL patients. In this retrospective study, we set out to test the safety and efficacy of single-cycle blinatumomab plus VP scheme in adult R/R B-ALL patients with high tumor burden. Method: Adult patients (≥18 years of age) diagnosed as R/R B-ALL with a high tumor burden (blast count in the bone marrow >50%), previously received 1 to 3 lines of chemotherapy, and received single-cycle blinatumomab plus VP were enrolled. These patients were given blinatumomab (9μg/d in d1-d7, 28μg/d in d8-d28), vincristine 2mg/week and dexamethasone (10mg/d in d1-d14, 5mg/d in d15-d28), for a total of 28 days. For patients with Philadelphia chromosome-positive, a BTK kinase inhibitor (TKI), including imatinib/dasatinib/olverembatinib, etc., was administered simultaneously. Eligible patients were treated with allo-HSCT or CAR-T therapy after they achieved remission with single-cycle blinatumomab plus VP. All patients underwent bone marrow examination before and after treatment to determine tumor burden and therapeutic effect. Flow cytometry was used to monitor patients' MRD status, with abnormal cells ≤0.01% defined as MRD-negative. OS is defined as the time from the initiation of the treatment to death for any cause. RFS is defined as the time from achievement of CR to disease recurrence or death after the treatment. Results: Sixteen patients started this treatment between August 2021 and February 2023. The median age of the 16 patients were 29.5 years (range, 20-72), and their baseline characteristics were shown in the table. Seven of the patients were Philadelphia chromosome-positive. Prior to receiving blinatumomab, all patients had received at least first-line chemotherapy and had refractory or recurrent events. At the end of single-cycle blinatumomab plus VP treatment, 12 patients (75%) achieved objective response (CR+CRi), 1 patient (6.25%) achieved PR, 3 patients (18.75%) did not achieve response, and no patients died during treatment. Of the 12 patients in objective response, 3 patients (18.75%) achieved CR with MRD-negative, 2 patients achieved CRi with MRD-negative, and 7 patients achieved CRi with MRD-positive. Six patients were bridged with allo-HSCT after the treatment, and four patients were subsequently treated with CD19 CAR T cells. With a median follow-up of 11.07 months, the median overall survival was 23.13 months and the median RFS was 17.23 months. The majority of adverse events during treatment were mild and acceptable. Twelve patients (75%) developed fever, of which nine patients (56.25%) were diagnosed with febrile neutropenia, and eight patients (50.00%) had an infection requiring antibiotic treatment, but none required high-flow oxygen (≥6L/min) or vasoactive agents to maintain blood pressure. Almost all patients (93.75%) had myelosuppression during treatment (neutrophil in peripheral blood <1.0×10 9/L), the median time was 17.5 days (range, 0d~28d). Elevated ALT/AST was observed in only one patient. No above grade 3 cytokine release syndrome (CRS) and any grade of immune effector cell-associated neurotoxicity syndrome (ICANS) were observed. Conclusion: Blinatumomab combined with VP resulted in a higher response rate in adult R/R B-ALL patients with high tumor burden and increased tolerability and safety of the treatment.

Characterization of MDS and CMML Patients Harboring Trisomy 8 Abnormality: Clinical, Autoimmune, and Mutational Features

Introduction Trisomy 8, seen in 5-7% of MDS and CMML patients, is regarded as an intermediate-risk cytogenetic abnormality in IPSS-R but not an MDS-defining cytogenetic abnormality. Recent studies have demonstrated an association between systemic autoimmune disease and trisomy 8, attributed to CD8 positive T-cell expansion and WT1 over-expression resulting in inflammation and suppression of hematopoiesis. Further, MDS and CMML with trisomy 8 respond favorably to immunosuppressive therapy. In this study, we investigated the clinical (including autoimmune manifestations), molecular and outcome characteristics of MDS/CMML with trisomy 8 in comparison to MDS with normal karyotype. Methods We retrieved all patients with trisomy 8 by conventional cytogenetic studies from our cytogenetic files between 2015 and 2023 who underwent bone marrow examination and met the WHO/ICC criteria for MDS/CMML diagnosis. In some cases, FISH testing was performed for confirmation. Majority of patients underwent amplicon-based targeted next-generation sequencing with a panel of 81 genes associated with myeloid malignancies (2500X coverage; LOD: 2% VAF). Clinicopathologic features were collected from medical records. For comparison, we retrieved a control cohort of all MDS patients diagnosed within the same period with normal karyotype (MDS-NK) at our institution. Results From a total of 362 patients with trisomy 8 (215 treatment naïve) detected at any time point during the disease course, we identified 165 MDS/CMML patients with trisomy 8 at baseline. These included 57 (35%) with isolated trisomy 8, 21 (13%) with 1 additional and 78 (53%) with ≥2 additional cytogenetic abnormalities (meeting the criteria for complex karyotype). Recurrent additional cytogenetic abnormalities included del(13)(q11q22) (n=3) and trisomy 21, del(5q), del(11q) involving KMT2A, and loss of Y, all seen in 2 patients each. We focused our subsequent analysis on 57 treatment naïve MDS/CMML patients with isolated trisomy 8 and compared them to 162 treatment naïve MDS/CMML patients with diploid karyotype (MDS-NK) at baseline. The median age was 74 years (range, 30-90) and 34 (60%) were men, with baseline characteristics shown in Table 1. There were no significant differences in age, gender distribution, median hemoglobin, ANC, MCV or platelet counts when comparing the two populations. Trisomy 8 MDS/CMML had a higher median baseline BM blast percentage [5% (1-18%) vs. 3% (0-17%); p=0.034] compared to MDS-NK. Distribution of IPSS-R subgroups in trisomy 8 MDS/CMML revealed a significantly lower representation of “Very Low” [0% vs. 13%; p=0.0027] and “High” [18% vs. 49%; p=0.0001], and higher representation of “Very High” [16% vs. 3%; p =0.0004] categories. NGS data was available in 36 (63%) of treatment naïve patients with isolated trisomy 8. The most frequent mutation was seen in ASXL1 (n=20, 56%), followed by TET2 (n=12, 33%), RUNX1 (n=12, 33%), SRSF2 (n=8, 25), KRAS/NRAS (n=8, 22%), and EZH2 (n=7, 19%). Compared to MDS-NK, the following mutations were significantly enriched in trisomy 8: ASXL1, EZH2, STAG2, RUNX1, KRAS/NRAS, IDH2 and PTPN11. Over a median follow-up time of 19 months, 28 (49%) with trisomy 8 and 19 (12%) MDS-NK patients died. MDS/CMML with trisomy 8 had a significantly lower median overall survival (OS) compared to MDS-NK [23.7% vs. not reached; p-value: <0.0001]. A total of 27 (7.6%) MDS/CMML patients with trisomy 8 (21 with trisomy 8 at baseline) were found to have a bona fide autoimmune disease, including autoimmune uveitis/scleritis (n=3), (rheumatoid and psoriatic), polyarteritis nodosa, giant cell arteritis with polymyalgia rheumatica, autoimmune sclerosing pancreatitis, immune hemolytic anemia, synovitis, and Grave's disease. Conclusions MDS/CMML with trisomy 8 showed unique clinicopathologic characteristics compared to MDS-NK: higher baseline BM blasts, higher representation of “Very High” IPSS-R risk categories with characteristic mutational signatures and a variety of underlying autoimmune diseases.

ACUTE LEUKEMIA IN CHILDREN - AN INPATIENT DESCRIPTIVE STUDY

Acute leukemia in children causes unacceptably high morbidity and mortality in the affected patients in our population. This study was undertaken to create local data that could be used to better understand the characteristics of this disease in our set up, provide better management to the affected children and help decrease the high morbidity and mortality associated with this disease. To determine the frequency of the significant classes of acute leukemia, its subclasses and rate of remission in our study population. This study was conducted in Pediatric B Unit, Department of Pediatrics, Hayatabad Medical Complex, Peshawar, from 1st June 2017 to 31st December 2018. Using consecutive sampling technique, 90 cases were selected. All children who underwent bone marrow examination during the study period in this hospital were included in the study. Data on age, gender, indications, and major types and subclasses of leukemia was extracted from bone marrow record forms of these children and analyzed using SPSS version 20. Means and standard deviations were calculated for age and frequency and percentages for gender, types, and subtypes of leukemia and remission. 90 patients were included in this study. TLC was low in 33 (36.7%). Normal in 24 (26.6%) and raised in 33(36.7%). Acute lymphoblastic leukemia- ALL -L1 accounted for 80 (88.9%) of cases, while acute myelogenous leukemia for 10(11.1%). Acute myelogenous leukemia subtypes included AML-M5 in 5 (5.6%), AML-M2 and AML-M3 (2.2%) AML-M0 2 (2.2%), and AML-M2 1 (1.1%). 43 (47.8%) were newly diagnosed cases. 47 (52.2%) were previously diagnosed cases, of which 26 (55.3%) were in remission. Acute lymphoblastic leukemia ALL-L1 was the commonest type of leukemia with ALL-L1 subtype in all patients followed by acute myelogenous leukemia with AML-M5 the commonest subtype. Rate of response to therapy was 55.3%.

Utility of bone marrow examination in retinoblastoma and their correlation with hematological features.

Retinoblastoma makes up about 3% of all childhood malignancies. The frequency of metastatic retinoblastoma ranges from 4.8 to 11%. Assessing the bone marrow status of newly diagnosed patients is crucial because of the advantages of autologous bone marrow transplants for high-risk patients. This study aimed to determine the utility of bone marrow examination in cases of retinoblastoma and its correlation with hematological findings. This retrospective study was conducted at the Department of Pathology, King George's Medical University, Lucknow, India. A total of 34 cases of retinoblastoma with bone marrow examination were included in the study. Bone marrow infiltration was present in 17.65% (6/34) cases of retinoblastoma. Bone marrow aspirate myelogram showed that marrow metastasis in retinoblastoma was significantly linked with a reduced percentage of total myeloid cells (p=0.001) and segmented cells (p=0.006). The present study demonstrated that 15% (3/20) of retinoblastoma patients previously classified as nonmetastatic before bone marrow examination (stages I to III based on histology, imaging, and bone scan) had bone marrow metastases following bone marrow examination and were upgraded to stage IV. To conclude, a diligent and exhaustive search for metastatic cells in bone marrow is advised if the myelogram shows a reduced percentage of total myeloid and segmented cells. All stage II and stage III cases of retinoblastoma must undergo bone marrow examination for early metastasis detection, as it may result in an upgrade to stage IV disease, impacting the prognosis and necessitating distinct treatment modalities.

P105 Adult-onset mastocytosis: a retrospective review

Abstract Mastocytosis is characterized by an abnormal proliferation of mast cells in different organs, with the skin being the most frequently affected site. Adult-onset mastocytosis often follows a chronic course and is more likely to have extracutaneous involvement. We undertook a retrospective case note review of adult patients with a diagnosis of mastocytosis in our dermatology department between 2021 and 2022. Fourteen patients were identified with a female-to-male ratio of 1.8 : 1. Median age at disease onset was 46 years (range 25–75). Lesions were described as maculopapular (n = 8), macular (n = 3), telangiectatic (n = 2) and urticated (n = 1). The torso was affected in 12 patients (86%). The most commonly reported symptom was pruritus (n = 9). Other complaints included flushing (n = 3), abdominal pain (n = 2), dizziness (n = 2), weight loss (n = 2), night sweats (n = 2), syncope (n = 1), musculoskeletal pain (n = 1) and symptoms of recurrent anaphylaxis (n = 1). Two patients were asymptomatic. Darier sign was elicited in five patients and negative in two (not documented in seven). Eight patients were assessed for lymphadenopathy and organomegaly, with no detected abnormality. Eleven patients had skin biopsies; 10 (91%) had mastocytosis in the skin confirmed on histology; one patient had a nondiagnostic histological finding, but mastocytosis was diagnosed on the basis of clinical presentation. Seven patients had elevated serum tryptase levels (> 20 ng mL−1) on at least one occasion. Bone densitometry was done in five patients with elevated serum tryptase: two had osteopenia and one had osteoporosis. Eleven patients underwent bone marrow examination. Mast cell infiltration of the bone marrow was detected in four patients; KIT mutations in bone marrow were subsequently identified in three patients. Twelve patients remain under long-term follow-up. Treatments prescribed included antihistamine (n = 10), epinephrine autoinjector (n = 6), topical steroids (n = 5), vitamin D (n = 5), calcium (n = 4), H2 blocker (n = 2), bisphosphonates (n = 2), phototherapy (n = 2), leukotriene antagonists (n = 2), cosmetic camouflage (n = 1), oral sodium cromoglicate (n = 1) and KIT–tyrosine kinase inhibitor (n = 1). Despite treatments, none of the patients had regression (partial or complete) of cutaneous disease, although no fatal outcome was observed. Four (29%) cases had a final diagnosis of indolent systemic mastocytosis (all had elevated serum tryptase levels, two had anaemia). Our findings were consistent with the literature, where serum tryptase levels rather than systemic symptoms were a reliable predictor of systemic mastocytosis. Interestingly, 10 (71%) patients had mastocytosis limited to the skin, which is in contrast to the published literature, where the majority of people with adult-onset mastocytosis have systemic forms of the disease.

Diagnostic Evaluation of Haematological Diseases Based on Bone Marrow Examination

Background: Bone marrow examination is a safe invasive procedure and can provide sufficient explanation for unexplained cytopenias, leukaemia and other haematological disorders including metastases to the marrow by detailed morphological description of the marrow elements. Objective: To see the importance of bone marrow examination for the diagnosis of haematological disorders. Materials and Methods: It was a descriptive cross-sectional study comprising 196 patients who underwent bone marrow examination for evaluation of haematological disorders in the Department of Haematology, Enam Medical College and Hospital during the period of July 2012 to December 2019. Results: Total number of cases were 196, male to female ratio was 1.56:1 and majority of the patients were >18 years of age (84.69%). Common indications for bone marrow examination were pancytopenia (33.67%) and diagnosis of leukaemia/ myeloproliferative neoplasm (23.98%). In our study, haematological conditions were 79.08%. Among these malignant conditions were 55.10% and nonmalignant conditions were 23.98%. Aplastic anaemia (14.29%) and immune thrombocytopenia (7.65%) were the most common nonmalignant disorders. Common malignant disorders were acute myelogenous leukaemia (20.41%) and multiple myeloma (9.69%). Conclusion: Bone marrow examination is a simple and effective procedure in reaching the final diagnosis of haematological diseases. J Enam Med Col 2021; 11(1): 34-38

Diagnostic Significance Of Bone Marrow Examination Amongst The Patients With Abnormal Haematological Parameters.

Bone Marrow examination is considered to be the most indispensable diagnostic tool for the evaluation of many neoplastic and non-neoplastic haematological disorders. After an initial assessment of suspicious cases on abnormal laboratory parameters along with the clinical presentation of the patient marrow examination is finally required for diagnosis as well as management of many haematological malignancies as it offers a clear cytological as well as histological picture of Bone Marrow aspirate and biopsy respectively. The Objective was to evaluate the significance of Bone Marrow examination in patients with abnormal haematological parameters. A retrospective study conducted at the Pathology Department of Pak Emirates Military Hospital from (Jan-June 2022) On data from150 patients who were advised to undergo bone marrow examination due to abnormal lab parameters and peripheral smear findings after informed consent and approval from the ethics review committee, to find out the correlation of abnormal haematological parameters and aspirate findings which have led to a definitive diagnosis. Data comprising basic demographic variables (age, gender etc.), Abnormal Haematological Parameters (CBC), peripheral smear findings and Aspirate findings were analyzed using SPSS version 23.0. Out of 150 studied participants with abnormal haematological parameters 24 (16%) were diagnosed on bone marrow examination as acute leukaemia / Hodgkin's and Non-Hodgkin's lymphoma respectively, 13 (9%) cases of aplastic anaemia and Autoimmune HaemolyticAnaemia, 33 (22%)cases of hypersplenism, CML and multiple myeloma. While 22 (15%) cases were diagnosed with BME as CKD and reactive changes. Moreover, 22(15%) cases were found to have Iron Deficiency anaemia respectively. The study revealed that patients with abnormal haematological parameters should undergo bone marrow examination to ascertain the diagnosis for malignant as well as non-malignant conditions that could cause abnormal lab parameters.

A Retrospective Analysis of Bone Marrow Examination Results from a Single Center Institution: In What Situations Is Bone Marrow Examination Helpful?

Objective: Bone marrow (BM) examinations are performed to evaluate hematological abnormalities. Focusing on patients with cytopenia, we aimed to determine the circumstances under which a BM examination can assist in the diagnosis of hematologic diseases.Methods: The medical records of 738 patients who underwent BM examination from March 2011 to March 2019 at Soonchunhyang University Seoul Hospital were reviewed. In total, 234 patients underwent a BM examination to identify the cause of cytopenia. Excluded from the analysis were BM examinations performed to diagnose specific diseases and evaluate disease status.Results: Results suggesting suboptimal outcome (n=6) or BM invasion of solid tumors (n=13) were excluded. Immune thrombocytopenic purpura patients (n=52) with normal BM examination results were also excluded. One hundred sixty-three patients who underwent BM examination to determine the cause of cytopenia were included in the analysis. A comparison of non-specific results (n=56) to those pointing to an underlying hematologic disease (n=107) showed that patients with severe neutropenia or severe thrombocytopenia were more likely to be diagnosed with a hematologic disease. Specifically, as the number of severe cytopenias increased, the likelihood of a hematologic disease diagnosis was significantly augmented. Patients with end-stage renal disease, autoimmune disease, or liver cirrhosis were more likely to receive non-specific results.Conclusion: In conclusion, seeking the underlying disease or drug should be a primary target for patients with cytopenia. In cases of severe cytopenia in more than one lineage, BM examination should be strongly considered to diagnose an underlying hematologic disease.

The Clinical Profile of JAK2 Negative,Normal Erythropoeitin,Normal Arterial Oxygen Saturation Erythrocytosis in an Indian Tertiary Centre

Introduction: Polycythemia Vera (PV) is a myeloproliferative syndrome characterized by JAK2 mutation with evidence of panmyelosis in the bone marrow [WHO 2016]. PV has risk of thrombosis and transformation to myelofibrosis /leukemia. Etiologies enlisted for JAK2 negative erythrocytosis include high-oxygen affinity hemoglobin variants, 2,3 biphosphoglycerate deficiency, and germline (e.g., PHD2, HIF2A, VHL) or EPO signaling (e.g., EPOR) mutations. Investigating for such causes is not feasible in rural India. JAK2 negative erythrocytosis is the category comprising these mutations and idiopathic causes. The treatment recommendations for JAK2 negative erythrocytosis is limited. The risk of thrombosis in this group is unknown. We present the clinical profile of subgroup of JAK2 Negative erythrocytosis with normal Erythropoietin [EPO] and normal arterial oxygen saturation [PaO2] from a tertiary care center in India. Method of study: Retrospective analysis of all the patients presented to the hematology outpatient clinic with high Hb /Hematocrit >16.5/49 for males and >16/48 for females from August 2019 to November 2021 were evaluated. Secondary causes evaluated. They underwent clinical examination, Complete blood count, ABG analysis for arterial oxygen saturation, Serum EPO estimation by chemiluminescence immunoassay [Normal: 2.6 - 18.5 mIU/mL], blood JAK2 V617F and JAK2 exon 12 mutation analysis by NGS at Medgenome Labs Pvt Limited, Bengaluru, Unilateral bone marrow aspiration and biopsy if willing. Inclusion criteria: 1.Hb /HCT >16.5gram%/ 49 for men and >16gram% /48 for women. Exclusion Criteria: 1.History of smoking, cyanosis or obstructive sleep apnea, COPD or cyanotic heart disease or high altitude, anabolic steroids. 2.Family history. 3.PaO2 below normal. 4.WBC > 11000/microliter, Platelets > 450000/microliter. 5.Palpable splenomegaly. 6.Erythropoietin levels <2.6mIU/ml or>8.5mIU/ml. 7.Jak2 V617F or Exon 12 mutation in NGS. 8.Panmyelosis in bone marrow [WHO 2016 criteria] Results: Total 256 patients were with elevated Hemoglobin.122 patients were excluded in view of meeting one of the exclusion criteria. Additional 58 patients were excluded because of lack of JAK2 mutational analysis. 76 patients who met the inclusion criteria of JAK2 negative erythrocytosis with normal EPO and normal PaO2.75 patients were males, mean age was 40 years [Range:15 -75]. Mean Hemoglobin at presentation was 18gram% [Range:16.8 to 22]. Mean erythropoietin was 6.69mIU/ml [Range 3-16.3]. The median follow up was for 8 months [Range:1 month to 24 months]. 37 patients were asymptomatic at presentation, for whom high Hb was detected while screening for blood donation or as a part of routine checkup. 16 patients developed thrombosis at the presentation. Median age of the patient's developing thrombosis was 42 [range 24 to 68 years].8 patients developed stroke,3 patients developed coronary artery disease,4 patients developed venous thrombosis.15 patients had hypertension at presentation. Other presenting symptoms were headache, redness of eyes, giddiness. Only 13 patients underwent bone marrow examination, in which 9 had normal bone marrow, 4 had isolated erythrocytosis. 47 patients took aspirin regularly. 32 patients underwent phlebotomy once a month if Hb/HCT >15gram/45. 13 of the 16 patients with thrombosis at presentation were continuing aspirin and were adhering to phlebotomy during follow up.3 patients received hydroxyurea as they were not tolerating phlebotomy. No patients developed new thrombotic events during the follow up. There was no correlation with level of Hb or EPO with thrombosis. Discussion: Our retrospective of JAK2 negative erythrocytosis data showed that the majority of patients were male,48 % patients were asymptomatic and had no thrombotic complications during the follow up. 21% developed thrombotic events at presentation. The duration of follow up is short in our study. Ideal treatment for thrombosis in this group needs further clinical trials. Treatment protocol for asymptomatic patients also need further clinical trials. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Radiotherapy in the Treatment of Primary Cutaneous CD4+ Small/Medium T-Cell Lymphoproliferative Disorder

<h3>Purpose/Objective(s)</h3> Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (PCSM-LPD) is a rare disorder, typically presenting in adults as a solitary lesion in the head and neck. Data describing the role of radiotherapy (RT) in the management of PCSM-LPD are limited. <h3>Materials/Methods</h3> We retrospectively reviewed 46 patients (pts) with PCSM-LPD confirmed at our institution from 2/1/2009-11/30/2021. Clinical/treatment characteristics, response, and toxicity (CTCAE v5.0) were extracted from the medical records. Statistics were performed using Mann-Whitney U and Chi-square tests. <h3>Results</h3> The median age at diagnosis was 57 years (interquartile range (IQR) 43-67)) and 22 (48%) were female. 38 pts (83%) presented with a solitary lesion. Of 57 biopsied lesions, 28 (49%) were located in the head and neck, 19 (33%) were on the trunk, and 10 (18%) were on the upper extremities. 36 pts (78%) had systemic staging with PET/CT or CT; 8 pts (17%) underwent bone marrow examination. Histologic evaluation showed an atypical, polymorphous, lymphocytic infiltrate involving the dermis, with unequivocal epidermotropism in 2 pts (4%), and minimal/focal epidermotropism in an additional 19 pts (41%). Immunohistochemical analysis showed that all cases were positive for CD4 (n=46) and CD3 (n=45 assessed). CD7 was positive in 26 (57%), PD1 in 25 (54%), and CD5 in 24 (52%) cases. CD4:CD8 ratio was available in 20 pts, with a median of 5 (IQR 4-8). Monoclonal T-cell receptor beta/gamma rearrangements were present in 38 of 41 pts (93%) assessed. Of 44 evaluable pts, management following diagnostic biopsy included observation (16, 36%), steroid (12, 27%), steroid and RT (8, 18%), and RT (7, 16%). One additional pt achieved CR after biopsy following a course of antibiotics for bronchitis. With median follow-up of 16 months (IQR 4-85 months), pts with residual lesions after biopsy achieved CR with steroids (12/19, 63%) or RT (12/14, 86%) (p = 0.007). Seven RT pts received prior steroid with incomplete response. One pt received intralesional steroids after RT with a CR, and one pt is in partial response one month post-RT. RT was given with electrons (12, 80%) or orthovoltage (3, 20%). The median dose was 4 Gy in 2 fractions (range 4-30 Gy in 1-15 fractions); 10 pts received 4 Gy. Four pts (27%) developed a grade 1 skin reaction following RT (3 erythema, 1 itching). There was no difference in response based on RT dose (p = 0.28), RT modality (p = 0.45), or steroid use prior to RT (p = 0.92). Prescribed doses decreased after reclassification of the diagnosis from lymphoma to LPD in 2016, median 12 Gy (IQR 6-30) vs. 4 Gy (IQR 4-4) (p = 0.002). Of 36 pts with sufficient follow-up, recurrence (all out of field) occurred in 4 (11%), more commonly in pts with multiple lesions at diagnosis (3/7 vs. 1/29, p = 0.02). <h3>Conclusion</h3> PCSM-LPD has an indolent course and responds well to low-dose RT. Treatment should be guided by a multidisciplinary team.

Clinico-Hematological Study of Thrombocytopenia on the Basis of Bone Marrow Examination in a Tertiary Care Hospital

Background: Thrombocytopenia can occur in a variety of clinical conditions. Bone marrow aspiration is crucial for diagnosis. The purpose of this study was to investigate the causes of thrombocytopenia, its spectrum, and how to interpret the results of bone marrow aspiration.&#x0D; Aim &amp; Objectives: To study the cases of thrombocytopenia on the basis of bone marrow examination for correlation of bone marrow findings with clinical features, haematological parameters and other investigations in cases of thrombocytopenia. Secondary objective is to investigate the role of morphological examination of bone marrow aspiration and trephine biopsy in diagnosis of various disorders leading to thrombocytopenia.&#x0D; Results: The cross-sectional prospective study lasted two years, from May 2019 to May 2021, at a tertiary care centre where clinico-haematological evaluation of patients with thrombocytopenia was done on the basis of bone marrow examination. A total of 103 cases with thrombocytopenia underwent bone marrow examination of which most patients belonged to the age group of 41-50 with a male preponderance. Majority of the patients presented with generalized weakness and pallor. Megaloblastic anaemia was the most predominant cause followed by acute myeloid leukemia and dimorphic anaemia. More research into the pathogenesis of megakaryocytic alteration and its contribution to thrombocytopenia could lead to a better understanding of the pathogenesis of a variety of hematopoietic disorders and the identification of broader clinical applications.

Detection of Double Hit and Triple Hit Cytogenetics at Relapse Identifies a Very High Risk Subset of Relapsed/Refractory Multiple Myeloma Patients

INTRODUCTIONmSMART classifies high-risk Multiple Myeloma patients into Double Hit and Triple Hit Myeloma (DH/THM) on the basis of the number of high-risk cytogenetic abnormalities detected. While cytogenetics at diagnosis helps in the decision-making process regarding initial therapy, their role in relapsed MM is not very well studied. We aimed to study the clinical profile and outcomes of patients with DH/THM detected at relapse in a real-world setting.METHODSThe case records of all relapsed multiple myeloma patients requiring active therapy between January 2018 and December 2020 were identified. All patients underwent bone marrow examination and repeat FISH cytogenetic analysis. The diagnosis of double hit and triple hit myeloma was based on mSMART classification (Presence of two or more of the following: IgH-FGFR3 translocation, IgH-MAF translocation, TP53 deletion, gain of chromosome 1q). Their case records were retrieved and information regarding baseline characteristics, therapy and outcomes was noted.RESULTSA total of 17 patients were diagnosed with DH/THM at relapse during the study period. Median age of the cohort was 59 years with almost an equal number of male and female patients (M=9; F=8). Renal failure (serum creatinine >2.0mg/dl) was seen in 8 patients (47.1%), while bone lesions, anemia (Hemoglobin <10gm/dl) and hypercalcemia (serum calcium >12mg/dl) were seen in 12 (70.6%), 12 (70.6%) and 6 (35.3%) patients respectively. Five patients (29.4%) fulfilled the criteria for plasma cell leukemia.Twelve patients (70.6%) were in first relapse, while 3 patients were diagnosed at second relapse and 1 patient each at 3 rd and 5 th relapse respectively. All but 2 patients had received Bortezomib previously (N=15; 88.2%). Eleven patients (64.7%) had previous exposure to Lenalidomide and 8 patients (47.1%) had previous exposure to Thalidomide. Two patients had previously undergone autologous hematopoietic cell transplant. Median follow-up prior to diagnosing DH/THL was 28 months (Range- 5-89 months).All patients had gain of 1q with at least 3 copies, while 12 patients (70.6%) had 4 or more copies. The most common cytogenetic combination was IgH-FGFR3 translocation with gain of 1q which was seen in 10 patients (58.8%). This was followed by co-occurrence of TP53 deletion with gain of 1q in 5 patients (29.4%). Two patients (11.8%) had triple hit myeloma.Seven patients (41.2%) died within the first month of relapse and a further 3 patients died during the next month. Of the 10 patients who received at-least 1 cycle of therapy, 8 received triplet therapy with the combination of a proteasome inhibitor and an Immunomodulator, one patient received doublet with Lenalidomide and dexamethasone and one patient received Daratumumab based quadruplet therapy. Bortezomib based therapy was used in 5 patients and 4 patients received Carfilzomib based therapy. None of the patients underwent a 2 nd auto transplant. Two patients achieved VGPR or better with therapy. Of the 7 evaluable patients, 5 re-relapsed during follow up.The follow up of entire cohort ranged from 0 to 29 months. Sixteen patients (94.1%) died during follow up. The most common cause of death was progressive/active disease (9 patients, 56.3%) followed by a combination of active disease with sepsis (4 patients, 25%). Median OS was 1 month for the entire cohort.DISCUSSIONThe outcome of DH/THM at relapse is associated with an aggressive presentation and poor outcomes in the real-world setting. These patients are candidates for early aggressive or novel therapy or clinical trials. DisclosuresNo relevant conflicts of interest to declare.

Eltrombopag as second line treatment in patients with primary immune thrombocytopenia: A single center real life experience

Glucocorticoid treatment is the standard initial therapy for patients with immune thrombocytopenia (ITP). Despite a rate of 60–80% of initial remissions, only 30 to 50% of adults have a sustained response after discontinuation. Second line options are splenectomy, thrombopoietin-receptor agonists (TPO-RAs), rituximab and intravenous immunoglobulin. Third line treatments include a mix of immunosuppressive drugs (e.g. azathioprine, ciclosporin, etc.). Recently international guidelines have proposed a treatment algorithm formalizing TPO-RAs and splenectomy as second and third line respectively, confirming splenectomy as second line choice only in emergency. Here we present a single center observational retrospective study of eltrombopag as second line treatment. We evaluated 48 adult primary chronic ITP patients since 2003. Forty-four out of 48 patients received a first line treatment with glucocorticoids. Twenty-two (61%) patients needed a second line treatment: 18 received eltrombopag, 3 a second course of steroid and one patient underwent splenectomy. Every patient before starting eltrombopag or receiving splenectomy underwent bone marrow examination. Overall response rate to eltrombopag was 94% with a CR rate of 76% and a PR of 23%; only one patient was non responder, underwent splenectomy and received subsequent treatment with rituximab, romiplostim and cyclosporin obtaining CR. One patient developed an autoimmune pancytopenia about a month after starting TPO-RA and in addition to eltrombopag received steroid and rituximab with blood count improvement. After a median follow up of 21,1 months (range 0,4–64,7 months) 16 patients (89%) are still on therapy maintaining response. As regards safety, gastrointestinal side effects were rare and low grade; only one patient discontinued eltrombopag after few weeks, because of dizziness. One patient had a relapse of deep venous thrombosis while no major bleeding complications were observed. Our real-life single center experience confirms efficacy and safety of eltrombopag as second line treatment in chronic ITP patients.

Bone marrow examination of HIV-infected children in HAART era reveals a spectrum of abnormalities: a study from single tertiary care center of North India

Pediatric HIV is a significant contributor to childhood morbidity and mortality. As HIV infects bone marrow CD34-positive progenitor cells, the hematological abnormalities are well-expected. The viral load is much higher in children predisposing them to opportunistic infections and hematopoietic malignancies. The present study aimed to determine the spectrum of hematological abnormalities that may yield clinically useful information in HIV-infected children. This was a retrospective study of 19 HIV-infected children who underwent bone marrow examination. Overall, 20 peripheral blood and bone marrow samples were analyzed for morphological changes in all hematopoietic lineages. Immunohistochemistry was performed on trephine biopsy sections for evaluation of B and T cells and cytomegalovirus inclusions. Anemia was the most common cytopenia (95%), followed by thrombocytopenia (45%) and leukopenia (40%). Myelodysplasia was noted in 70% of cases. Dysmegakaryopoiesis was predominant in 65% of cases, while dyserythropoiesis was noted in 25% of cases. Hemophagocytosis and reactive cellular changes were noted in 20% of cases each. Benign lymphoid aggregates and granulomatous inflammation were observed in 15% and 10% of cases, respectively. Significant myelofibrosis was found in 35% of cases. One case showed infiltration by Burkitt lymphoma. Parvoviral inclusions were identified in 1 case. An interstitial increase and aggregates of CD8 + T cells and reduced CD4 + T cells were noted. CD20 + B cells were normal to mildly increased in the bone marrow. Bone marrow examination provides clinically significant information in pediatric HIV revealing the underlying cause of hematopoietic abnormalities and allows the exclusion of major hematological neoplasms.

Isolated CNS Relapse in Acute Lymphoblastic Leukemia (ALL): An Experience from a Tertiary Care Center.

Aims and Objectives In this study the various parameters of acute lymphoblastic leukemia (ALL), including the clinical features, peripheral blood and bone marrow (BM) findings, immunophenotypic and cytogenetic details in ALL cases who had isolated relapse involving the central nervous system (CNS), were studied. Patients/Materials and Methods Duration of the study is from 2015 to 2019 in which 5 ALL cases were presented to this tertiary care center. The presenting symptoms varied from headache, fever, and distension of abdomen. These cases were either on therapy or post completion of chemotherapy. The diagnosis of CNS relapse followed after the examination of cerebrospinal fluid (CSF). Patients also underwent BM examination to rule out systemic relapse. Results Age of patients ranged from 7 months to 42 years. There were three female patients. Two patients had isolated CNS relapse 3.5 years after completing therapy and succumbed to their illness. Two patients had t(9;22) while one patient had t(1;14) cytogenetic abnormality at diagnosis. One patient was diagnosed as T-ALL. Treatment offered was German Multicentre ALL protocol for induction along with 10 cycles of maintenance. Conclusion The most common hematolymphoid malignancy in children namely ALL accounts for 75% of childhood leukemias. Complete remission rates reach up to 70 to 80%. CNS involvement is known to occur in these cases. CNS relapse may occur alone or with systemic relapse. Advances in therapeutic protocols along with CNS prophylaxis have drastically brought down the rates of CNS relapse. It is essential to maintain a high degree of suspicion so that these cases of isolated CNS relapse can be identified at the earliest and definitive therapy can be offered.

HAEMATOLOGICAL DISORDERS DIAGNOSED IN ONE HUNDRED AND ONE SUCCESSIVE BONE MARROW EXAMINATION AT A TERTIARY CARE CENTRE IN QUETTA, BALOCHISTAN

Objective: To determine the frequency of haematological disorders diagnosed by bone marrow examination at a tertiary care centre in Quetta, Balochistan.&#x0D; Study Design: Prospective observational study.&#x0D; Place and Duration of Study: Department of Pathology, Combined Military Hospital Quetta, from Jan 2018 to May 2019.&#x0D; Methodology: A total of 101 one patients, who underwent bone marrow examination, were included in the study. Brief history, clinical examination and indication of procedure were also endorsed in a questionnaire designed for the study.&#x0D; Results: Bone marrow of one hundred and one patients, included in the study, were evaluated. Mean age of the patients was 32.3 ± 18.4 years. There were 68 males (67%), while 33 were females (33%) with 2:1 male to female ratio. Pyrexia of unknown origin (PUO) was the most common indication for bone marrow examination with frequency of 20.7%. Nutritional anaemia was the most prevalent benign disorder (17%), whereas Acute Lymphoblastic leukaemia (ALL) accounted about 6.8% which is highest in malignant disorders.&#x0D; Conclusion: This study has concluded that bone marrow examination is a useful technique and findings of bone marrow can modify the treatment. Thus procedure has a great diagnostic value. Both bone marrow aspiration (BMA) and bone marrow biopsy (BMB) are the complimentary techniques and supremacy of one method on other depends on the disorder.

IncRNA MVIH correlates with disease features, predicts treatment response and survival in pediatric acute myeloid leukemia.

ObjectiveLong non‐coding RNA microvascular invasion in hepatocellular carcinoma (lnc‐MVIH) is correlated with unfavorable prognosis in several malignancies, while limitedly studied in pediatric acute myeloid leukemia (AML). This study aimed to investigate the correlation of lnc‐MVIH with disease features, response to induction therapy, and survival in pediatric AML patients.MethodsA total of 129 de novo pediatric AML patients who were retrospectively analyzed and 60 children with non‐malignant hematological diseases who underwent bone marrow examination were reviewed as controls. Bone marrow mononuclear cells (BMMCs) were isolated from all participants to detect lnc‐MVIH expression by reverse transcription‐quantitative polymerase chain reaction. The complete remission status after 1 course of induction therapy, event‐free survival, and overall survival of pediatric AML patients were recorded.ResultsLnc‐MVIH was upregulated in pediatric AML patients compared with controls (p < 0.001). In pediatric AML patients, lnc‐MVIH was correlated with increased bone marrow blasts, less inv(16) or t(16;16) abnormity, and higher Chinese Medical Association (CMA) risk stratification (all p < 0.05), whereas its correlation with National Comprehensive Cancer Network (NCCN) risk stratification was not statistically significant (p = 0.098). As for prognosis, lnc‐MVIH high expression patients presented with lower complete response rate to 1 course of induction therapy (61.5% vs. 79.7%, p = 0.024), shorter event‐free survival (median 12.0 months vs. 22.0 months, p = 0.006), and overall survival (median 28.0 months vs. 42.0 months, p = 0.043) compared with lnc‐MVIH low expression patients.ConclusionLnc‐MVIH correlates with poor treatment response and unfavorable survival in pediatric AML.

Analysis of bone marrow supernatant neutrophil gelatinase-associated lipocalin and hematological parameters in hematological malignancy.

BackgroundNeutrophil gelatinase‐associated lipocalin (NGAL) is a urine biomarker related to acute renal injury. Whereas several studies have evaluated NGAL levels in hematological malignancy, using peripheral blood (PB). Recently, bone marrow (BM) NGAL level was reported to be higher than PB NGAL level in individuals with hematological malignancy, suggesting that BM NGAL would reflect BM microenvironment better than PB NGAL. We measured BM NGAL levels in patients with hematological malignancy, comparing those with NGAL levels in normal BM. We evaluated the association of BM NGAL with hematological parameters including neutrophil counts.MethodsBM samples were collected from 107 patients who underwent BM examination. Immunoassays were used to assess NGAL levels. Data on hematological parameters were collected from medical records. Intergroup comparisons were performed using the Kruskal‐Wallis H test and Pearson chi‐square test. Single and multiple regression analyses were performed to analyze the relationships.ResultsThe independent factors that affected the BM NGAL level were neutrophil counts and BM band neutrophil%, while neutrophil count was the main influencing factor. The acute myeloid leukemia (n = 18) and myelodysplastic syndrome (n = 25) groups showed statistically lower BM NGAL levels than patients with normal BM. The myeloproliferative neoplasm group (n = 34) showed higher BM NGAL levels than patients with normal BM, but this difference was not statistically significant. Neutrophil counts and BM band neutrophil% showed intergroup patterns similar to those of BM NGAL levels.ConclusionBM NGAL was related to neutrophil count and BM band neutrophil%, showing different levels according to hematological malignant disease entities.

Acute Leukemia Presenting with Musculoskeletal Manifestations: A Case Series

Abstract Introduction: Leukemia is the most common childhood malignancy accounting for 30%–40% of cases. Acute lymphoblastic leukemia is the most common leukemia in children with peak incidence in 2–6 years of age. The present study aims to assess the incidence of acute leukemia in patients presenting with musculoskeletal manifestations. Materials and Methods: This is a retrospective study conducted in a tertiary center from January 2014 to December 2018. A total of 63 children presented with musculoskeletal manifestations and underwent bone marrow examination. Based on final marrow diagnosis, the study group was divided into leukemic and nonleukemic groups. Results: Fever was the most common presenting complaint and was present in all the patients of both the groups. The occurrence of hepatosplenomegaly was comparatively higher in the leukemic group than in patients with juvenile idiopathic arthritis (JIA). The predominant type of arthritis was oligoarticular (68.15%) in the leukemic group and polyarticular (77.27%) in the nonleukemic group. Rheumatoid rash was noted in 20% of JIA patients, and none of the patients in the leukemic group had rash. The percentages of anemia, leukopenia, and thrombocytopenia were statistically higher in leukemia patients than in JIA patients. Conclusion: Bone marrow studies are a prerequisite in diagnosing leukemias. However, based on the presence of few atypical clinical and laboratory features, leukemia can be excluded in JIA patients.