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Hepatitis B virus (HBV) chronic infection causes progressive liver damage, although about 20% of patients develop extrahepatic manifestations such as cryoglobulinemic vasculitis (CV). Clinical manifestations range from mild to moderate (purpura, asthenia, arthralgia) to severe (leg ulcers, peripheral neuropathy, glomerulonephritis, non-Hodgkin lymphoma). A comprehensive review of therapeutic options for HBV-related CV is lacking. Nucleos(t)ide analogues (NA) suppress HBV replication in 90–100% of cases and induce clinical response in most patients with mild-to-moderate CV. Plasma exchange can be performed in patients with severe CV and should be considered in severe or life-threatening cases combined with high doses of corticosteroids and antiviral treatment. A cautious use of rituximab can be considered only in association with NA treatment in refractory cases. A review of the literature and an analysis of data collected by six centers of the Italian Group for the Study of Cryoglobulinemia on 18 HBV-CV nucleotide/nucleoside analogues (NAs)-treated patients were carried out.

Rituximab (RTX) represents a milestone in the treatment of mixed cryoglobulinemic vasculitis (MCV). Despite usually well-tolerated, RTX may induce different types of adverse drug reactions, including exacerbation of vasculitis. Recently, RTX biosimilar CT-P10 has been approved in Europe for the treatment of rheumatoid arthritis, but no data are available about effectiveness and safety of CT-P10 in the treatment of MCV. In this multicenter open-label study, we analyzed the safety of CT-P10 in patients with MCV treated in first-line or after a shift by RTX originator. Fifty-one consecutive MCV patients (females/males 35/16, median age 68 years, median disease duration 42 months, 51% HCV positive) were included in the study between July and December 2018 and were treated with CT-P10 (group 1). Safety and effectiveness of CT-P10 were compared with a retrospective group (group 2) including 75 consecutive patients treated with RTX originator between July 2017 and July 2018. Thirty-six patients were treated with CT-P10 for the first time, while the other 15 switched from RTX originator. RTX was administrated with high or dosage schemes (375 mg/m2 four times a week apart/1000 mg twice one week apart or 250 mg/m2 twice one week apart). During a month period after the last infusion, 13/51 adverse events (AE) were observed in group 1 and 17/75 in group 2 (p not significant). Among them, 7/13 and 6/17 (in group 1 and 2, respectively) could be considered immune-mediated AE (p not significant). At univariate analysis patients with IM-AE were more frequently males (p = 0.04) and with a lower disease duration (p = 0.03), but both the parameters were not significant at logistic regression. About clinical response after 6 months by the end of the treatment, no differences were observed between patients treated with originator and CT-P10 regarding the response to the therapy. No differences were observed in safety and effectiveness between patients naive at RTX or switching from originator. Despite the higher prevalence of immune-mediated AE among patients treated with CT-P10 than originator, we have observed no significant differences between the 2 groups. The use of a low-dosage regimen is more common in group 1 than in group 2, representing a possible bias of the study, possibly influencing the appearance of AE. Considering the cost/efficacy ratio of biosimilars, their use could be helpful to treat a large number of MCV patients with an effectiveness and safety comparable to originator. Multicenter studies including a large number of patients and the new RTX biosimilars could be useful to fully elucidate the possible risk of immune-mediated adverse events with biosimilar drugs. Considering the cost/efficacy ratio of CT-P10, its use could help to treat a large number of MCV patients with an effectiveness and safety comparable to originator.

Objective: Serum markers measured early in pregnancy have been associated with the later diagnosis of gestational diabetes mellitus (GDM). This study aims to explore the performance of a panel of first-trimester biochemical markers for the prediction of GDM. Methods: A case-control study was performed that included 12 women who developed GDM and 60 controls matched for maternal and gestational age at blood collection. Levels of pregnancy-associated plasma protein A (PAPP-A), soluble endoglin, pregnancy protein 13, and adiponectin (Adipo) were measured on residual sera used in first-trimester screening for Down syndrome. Data were analyzed by nonparametric methods. A receiver operating characteristic curve was used to calculate the detection rate (DR) obtained with a panel of significant predictors for GDM. Results: Multiples of the median values for Adipo and PAPP-A were significantly reduced in GDM cases versus matched controls. Combination of Adipo and PAPP-A yielded a DR of 63.6% at a false-positive rate of 10%. Addition of body mass index (BMI) to this panel increased DR to 72.7%. Conclusion: This study suggests that first-trimester screening with Adipo, PAPP-A, and BMI may effectively identify women at high risk for the development of GDM.

Background: The powerful drugs with direct antiviral action (DAA) against hepatitis C virus (HCV) has made it possible to eliminate the trigger factor of Mixed Cryoglobulin Syndrome (MCS) and to extend the treatment to patients who could not tolerate IFN-based antiviral regimens. However, the persistence of cryoglobulin production and MCS-related symptoms despite SVR achievement is frequently reported. Objectives: The aim of this study was to assess the persistency rate of MCS-related clinical and laboratory indexes after successful treatment with DAA. Methods: CRESO (CRyoglobulinaemia Eradication Study Observational) is a multicentre observational study promoted by the Italian Society of Infectious and Tropical Diseases (SIMIT) and the Italian Group for the Study of Cryoglobulinaemias (GISC), aimed to assess the impact of DAA therapy on MCS symptoms and cryoglobulin production. Patients could be enrolled if they presented, during the 12 months before the enrolment, a cryocrit ≥0.5% and, at least, one episode of palpable purpura or, alternatively, arthralgia and fatigue with at least one symptom among peripheral neuropathy, Raynaud’s phenomenon, lower limb ulcers or nephropathy, and a C4 level ≤8 mg/dL. Results: The present analysis was based on clinical and laboratory data of 94 patients (75.5% female with a median age of 67.5 years) that have been followed up for a median time of 24 weeks (IQR 12-24) after SVR12 achievement. At baseline the cryocrit was frankly positive in 85 (90.43%), detectable (>0.5%) in 4 and negative in 4 cases; patients with type II cryoglobulins and C4levels ≤8 mg/dL were prevalent, respectively with 81.5% and 75.9%. Low eGFR values (≤45 mL/min/1.73m2) were present in 12 cases (12.8%), 10 patients (10.6%) had a history of B-cell non-Hodgkin’s lymphoma (NHL), and 1 of hepatocellular carcinoma, while liver cirrhosis was diagnosed in 22 cases (23.4%) and glomerulonephritis in 17 cases (18.1%). Patients were treated for 12 (72 cases) or 24 (21 cases) weeks with a total of ten different IFN-free DAA regimens. SVR12 was achieved in all 94 cases. Both prevalence and median cryocrit values decreased significantly after DAA treatment (p Conclusion: CRESO study data confirm the persistence of cryoglobulin production and MCS symptoms in some patients, despite the eradication of HCV. This finding rises questions about the possible further evolution of the disease over time regardless the persistence of its original trigger. Disclosure of Interests: None declared

Objective Some of the manifestations of mixed cryoglobulinemia syndrome (MCS) can be severe or life-threatening, and should be rapidly contained but, as the therapeutic approaches to such conditions are largely based on anecdotal data, a consensus conference was organised by the Italian Group for the Study of Cryoglobulinemia (GISC) with the aim of providing a set of recommendations based on an in-depth survey of the available data and expert opinion. Methods The consensus panel, which included specialists working in different medical fields involved in the management of MCS patients, was first asked to divide the manifestations of MCS into severe or life-threatening conditions on the basis of their own experience, after which a complete literature review was carried out in accordance with the Cochrane guidelines for systematic reviews. Results Therapeutic plasma exchange (TPE) was considered the elective first-line treatment in the case of life-threatening manifestations of MCS (LT-MCS) and patients with severe clinical symptoms (S-MCS) who fail to respond to (or who are ineligible for) other treatments. The data supporting the combined use of cyclophosphamide and TPE were considered limited and inconclusive. High-dose pulsed glucocorticoid (GCS) therapy can be considered the first-line treatment of severe MCS, generally in association with TPE. Rituximab (RTX)-based treatments should be considered in patients with skin ulcers, peripheral neuropathy or glomerulonephritis, and in patients with persistent LT-MCS after TPE. In patients with hepatitis C virus-related MCS with S-MCS, viral eradication should be attempted as soon as a patient's condition allows the use of direct-acting antivirals.

Background Cryoglobulinemic vasculitis (CV) related to Hepatitis-B Virus (HBV) is rare and its treatment is ill-defined. Aims To describe clinical and treatment characteristics of HBV-related CV patients. In addition, the efficacy of treatment with antiviral agent nucleotide (NUC), including Entecavir, Adefovir, and Lamivudine, was explored. Methods In four Italian centres, 17 HBV-positive CV patients (median age 56 years, range 45–70) were enrolled. Results The extrahepatic manifestations were: purpura (100%), arthralgias (71%), peripheral neuropathy (29%), chronic hepatitis (47%), liver cirrhosis (29%), and glomerulonephritis (18%). Mixed cryoglobulinemias were type II (88%) and type III (12%). The median cryocrit was 3% (range 1–14), rheumatoid factor was 200 U/L (range 20–5850), C4 was 12 mg/dl (range 2–31), ALT 71 U/L (range 36–114). All patients were HBsAg-positive and 80% anti-HbeAg-positive. At enrollment, they were treated with steroids (eight), Entecavir (five), Alpha-IFN (two), Adefovir and Lamivudine (one each). After NUC treatment, no disease progression was observed and, in all patients, HBV-DNA became undetectable. Moreover, a regression of purpura and a reduction of cryocrit were observed. Four patients died during therapy, two of kidney failure and two of liver cirrhosis. Conclusion NUC therapy appeared to be safe and effective in CV-related HBV.

Objective To conduct a long-term, prospective, randomized controlled trial evaluating rituximab (RTX) therapy for severe mixed cryoglobulinemia or cryoglobulinemic vasculitis (CV). Methods Fifty-nine patients with CV and related skin ulcers, active glomerulonephritis, or refractory peripheral neuropathy were enrolled. In CV patients who also had hepatitis C virus (HCV) infection, treatment of the HCV infection with antiviral agents had previously failed or was not indicated. Patients were randomized to the non-RTX group (to receive conventional treatment, consisting of 1 of the following 3: glucocorticoids; azathioprine or cyclophosphamide; or plasmapheresis) or the RTX group (to receive 2 infusions of 1 gm each, with a lowering of the glucocorticoid dosage when possible, and with a second course of RTX at relapse). Patients in the non-RTX group who did not respond to treatment could be switched to the RTX group. Study duration was 24 months. Results Survival of treatment at 12 months (i.e., the proportion of patients who continued taking their initial therapy), the primary end point, was statistically higher in the RTX group (64.3% versus 3.5% [P < 0.0001]), as well as at 3 months (92.9% versus 13.8% [P < 0.0001]), 6 months (71.4% versus 3.5% [P < 0.0001]), and 24 months (60.7% versus 3.5% [P < 0.0001]). The Birmingham Vasculitis Activity Score decreased only after treatment with RTX (from a mean ± SD of 11.9 ± 5.4 at baseline to 7.1 ± 5.7 at month 2; P < 0.001) up to month 24 (4.4 ± 4.6; P < 0.0001). RTX appeared to be superior therapy for all 3 target organ manifestations, and it was as effective as conventional therapy. The median duration of response to RTX was 18 months. Overall, RTX treatment was well tolerated. Conclusion RTX monotherapy represents a very good option for severe CV and can be maintained over the long term in most patients.

Objective The objective of this review was to define a core set of recommendations for the treatment of HCV-associated mixed cryoglobulinemia syndrome (MCS) by combining current evidence from clinical trials and expert opinion. Methods Expert physicians involved in studying and treating patients with MCS formulated statements after discussing the published data. Their attitudes to treatment approaches (particularly those insufficiently supported by published data) were collected before the consensus conference by means of a questionnaire, and were considered when formulating the statements. Results An attempt at viral eradication using pegylated interferon plus ribavirin should be considered the first-line therapeutic option in patients with mild–moderate HCV-related MCS. Prolonged treatment (up to 72 weeks) may be considered in the case of virological non-responders showing clinical and laboratory improvements. Rituximab (RTX) should be considered in patients with severe vasculitis and/or skin ulcers, peripheral neuropathy or glomerulonephritis. High-dose pulsed glucocorticoid (GC) therapy is useful in severe conditions and, when necessary, can be considered in combination with RTX; on the contrary, the majority of conference participants discouraged the chronic use of low–medium GC doses. Apheresis remains the elective treatment for severe, life-threatening hyper-viscosity syndrome; its use should be limited to patients who do not respond to (or who are ineligible for) other treatments, and emergency situations. Cyclophosphamide can be considered in combination with apheresis, but the data supporting its use are scarce. Despite the limited available data, colchicine is used by many of the conference participants, particularly in patients with mild–moderate MCS refractory to other therapies. Careful monitoring of the side effects of each drug, and its effects on HCV replication and liver function tests is essential. A low-antigen-content diet can be considered as supportive treatment in all symptomatic MCS patients. Although there are no data from controlled trials, controlling pain should always be attempted by tailoring the treatment to individual patients on the basis of the guidelines used in other vasculitides. Conclusion Although there are few controlled randomised trials of MCS treatment, increasing knowledge of its pathogenesis is opening up new frontiers. The recommendations provided may be useful as provisional guidelines for the management of MCS.

This investigation was focused on the contribution of individual human leukocyte antigen (HLA)-DR and -DQ alleles to the human hepatitis C virus (HCV)(+) non-Hodgkin's lymphoma (NHL), with and without mixed cryoglobulinemia (MC), to study whether individual HLA class II alleles are expressed preferentially or equally in human HCV-specific NHL. For this purpose, peripheral blood mononuclear cells were obtained from two groups of patients with HCV(+) NHL and with or without MC (70 and 71 cases, respectively), and from 4575 blood donors. Eighty-three subjects with HCV infection only, and 118 patients with MC, only without lymphoma, were added as additional control groups. Individual HLA-DR and -DQ alleles were determined using high-resolution sequence-based typing and then data were collected by considering the HLA-DRB1 and DQB1 supertypes on the basis of common structural and functional features, proposed by in silico Bioinformatic studies. From the data, it is evidenced that the DR5-DQ3 HLA combination was strongly associated with the HCV (+) MC (+) NHL group of patients compared with bone marrow donor population (P

Cryoglobulinaemic syndrome (CS) includes clinical signs and symptoms that range from the classic triad of Meltzer and Franklin (purpura, weakness and arthralgias) to multiple organ involvement, and it may be characterised by nociceptive or neuropathic pain. Both types of pain use the same pathways and neurotransmitters, but nociceptive pain has an adaptive system and biological function whereas neuropathic pain does not. Managing CS means dealing with often very different clinical patterns, activity and severity with the aim of preventing irreversible organ damage, reducing pain, improving the patients' quality of life and reducing social costs. However, treatment is still largely empirical, and it is often delayed. The Italian Group for the Study of Cryoglobulinaemia (GISC) strongly recommended a low-antigen-content diet and colchicine for all symptomatic CS patients. Patients with mild-moderate symptoms (such as purpura, weakness, arthralgia and initial neuropathy) have been treated with low or medium doses of steroids, and, in the presence of chronic hepatitis C virus (HCV)-related hepatitis, an attempt has been made to eradicate HCV with pegylated interferon plus ribavirin. In the case of severe or rapidly progressive disease (glomerulonephritis, neuropathy, leg ulcers, widespread vasculitis or hyperviscosity syndrome), more aggressive treatment should be used (e.g., high doses of corticosteroids, plasma exchange plus cyclophosphamide or rituximab). Pain management in CS therefore depends on the type of pain (nociceptive, neuropathic or mixed), the characteristics of the patients and their co-morbidities. Drug therapy should be carefully monitored in order to obtain prompt and beneficial results.

Objective To evaluate the efficacy and safety in the long term of a retreatment regimen with Rituximab (RTX) alone administered at clinical relapse in cryoglobulinemic vasculitis (CV). Methods Thirty patients with severe HCV-related CV, previously enrolled in the multicentre Italian trial on RTX in the treatment of CV, were retrospectively evaluated after the end of the trial. All of them were managed with RTX alone at clinical relapse, if any. Disease activity at the last available follow up was defined as complete remission (absence of active disease), partial remission (response > 50% of at least one manifestation among glomerulonephritis, peripheral neuropathy or skin ulcers) or active disease. Results The mean follow up after the first RTX cycle was 72.6 (20.4) months. After the end of the trial, 21/30 (70%) patients showed an active follow up [81.7 (10.9) months)], 3/30 (10%) lost follow up and 6/30 (20%) died. 12/21 (57.1%) patients were in complete disease remission, 5/21 (23.8%) showed a partial response and 4/21 (19%) had an active disease. 17/30 (56.7%) patients needed retreatment for relapse with a mean time to retreatment of 22.3 (12.1) months. Treatment survival of this regimen was 7.6 (0.3) years. Recurrent non-severe infections occurred in 3/30, with chronic hypogammaglobulinemia in 2/3 patients. Conclusions A long-term regimen of retreatment with RTX alone given at clinical relapse seems to be effective and safe in CV, with a low rate of infections and severe hypogammaglobulinemia.

We conducted a prospective randomized clinical trial to assess the mobilizing efficacy of filgrastim, lenograstim and molgramostim following a disease-specific chemotherapy regimen. Mobilization consisted of high-dose cyclophosphamide in 45 cases (44%), and cisplatin/ifosfamide/etoposide or vinblastine in 22 (21%), followed by randomization to either filgrastim or lenograstim or molgramostim at 5 microg/kg/day. One hundred and three patients were randomized, and 82 (79%) performed apheresis. Forty-four (43%) patients were chemonaive, whereas 59 (57%) were pretreated. A median number of one apheresis per patient (range, 1-3) was performed. The median number of CD34+ cells obtained after mobilization was 8.4 x 10(6)/kg in the filgrastim arm versus 5.8 x 10(6)/kg in the lenograstim arm versus 4.0 x 10(6)/kg in the molgramostim arm (P=0.1). A statistically significant difference was observed for the median number of days of growth factor administration in favor of lenograstim (12 days) versus filgrastim (13 days) and molgramostim (14 days) (P

Purpose: Prostate cancer progression to androgen ablation refractory stage D3 corresponds to cancer cell escape from androgen withdrawal induced apoptosis. Of note, salvage chemotherapy can extend the median survival of approximately 10 months in patients with stage D3. Therefore, novel therapeutic strategies that target the molecular basis of androgen resistance are required. Materials and Methods: The MEDLINE and Current Content databases were used to find studies of the use of estrogens and somatostatin analogues for D3 prostate adenocarcinoma. We also analyzed the rationale and clinical results of our combination therapy using lanreotide and ethinylestradiol. Results: Negative experiences have been reported with somatostatin analogues as monotherapy. On the other hand, the median progression-free survival reported in our experience using lanreotide acetate plus ethinylestradiol clearly surpassed the 10-month survival historically described in stage D3 cases. Conclusions: The use of somatostatin analogues in combination therapy for D3 prostate cancer sustains the novel concept in cancer treatment in which therapies may target not only cancer cells, but also the microenvironment in combination, which can confer protection from apoptosis.

Objective The aim of this study was to validate the classification criteria for cryoglobulinaemic vasculitis (CV). Methods Twenty-three centres were involved. New patients with CV (group A) and controls, i.e. subjects with serum cryoglobulins but lacking CV based on the gold standard of clinical judgment (group B) and subjects without cryoglobulins but with clinical features that can be observed in the course of CV (group C), were studied. Positivity of serum cryoglobulins was necessary for CV classification. Sensitivity and specificity of the criteria were calculated by comparing group A vs group B. The group A vs group C comparison was done to demonstrate the possible diagnostic utility of the criteria. Results The study included 268 patients in group A, 182 controls in group B and 193 controls in group C (small vessel vasculitis, 51.8%). The questionnaire (at least 2/3 positive answers) showed 89.0% sensitivity and 93.4% specificity; the clinical item (at least 3/4 clinical involvement) showed 75.7% sensitivity and 89.0% specificity and the laboratory item (at least 2/3 laboratory data) showed 80.2% sensitivity and 62.4% specificity. The sensitivity and specificity of the classification criteria (at least 2/3 positive items) were 89.9% and 93.5%, respectively. The comparison of group A with group C demonstrated the clinical utility of the criteria in differentiating CV from CV mimickers. Conclusion Classification criteria for CV were validated in a second, large, international study confirming good sensitivity and specificity in a complex systemic disease.

The aim of the study was to evaluate peripheral blood progenitor cell mobilization by disease-specific chemotherapy in heavily pretreated patients with germ cell tumor (GCT), scheduled for high-dose chemotherapy. Thirty-four consecutive patients, 29 males and five females, with advanced GCT referred to our department for high-dose chemotherapy were evaluated retrospectively. Sixteen patients were mobilized by vinblastine 0.11 mg/kg on days 1 and 2, ifosfamide 1200 mg/m2 days 1-5 and cisplatin 20 mg/m2 days 1-5 (VeIP). In 10 patients, etoposide 75 mg/m2 days 1-5 was used instead of vinblastine (VIP), while in eight patients the mobilization was attempted by administering 7 g/m2 of cyclophosphamide. The choice of either etoposide or vinblastine was predicated upon which of these two drugs was associated with best results during premobilization chemotherapy. Cyclophosphamide was selected in patients refractory to previous cisplatin-based salvage chemotherapy. Twenty-five out of 34 patients underwent a successful PBPC collection. In 17 of them one leukapheresis procedure was sufficient to collect the target number of CD34+ cells, while in eight patients a double procedure was necessary. Altogether 33 aphereses were performed in 25 patients. In nine patients leukapheresis was not attempted. This was due to the fact that the chemotherapy failed to mobilize the target number of CD34+ cells in eight of them, treated with the VeIP mobilizing regimen, while one patient treated with high-dose cyclophosphamide rapidly progressed during therapy and for this reason leukapheresis was not undertaken. In conclusion, in heavily pretreated patients with GCT, PBPC mobilization is feasible by a further course of salvage chemotherapy. The choice of either etoposide (VIP) or vinblastine (VeIP) can be predicated upon which of these two drugs was associated with best results during premobilization chemotherapy. In our hands, VeIP seems to be less satisfactory as mobilizing treatment than VIP, possibly due to a superior number of premobilization courses of chemo therapy in some patients. Moreover, high-dose cyclophosphamide remains a good alternative for mobilizing patients refractory to salvage chemotherapy.

Cryoglobulinemic Syn&come (CS) is a multi-systemic disease, and its fatal evolution can involve different organs. Aims: To describe the most frequent causes of death in CS, by researching different evolutions between older cases and those of the last 15 years. Patients: The data of 238 patients affected by symptomatic cryoglobulinemia followed by our Medicine Department in the last 30 years are recorded in a database. 54 are presently living and being followed, 70 (36F, 34M) have died. The type II/type III ratio is 5/4. We distinguish between two groups, the oldest, without any data on HCV, and the most recent who were tested for HCV. The follow-up ranges from 0.5 to 16 years. Results: Liver diseases (25 cases, 9 with hepatic carcinomas), lymphomas and myeloproliferative diseases (12), and cardiovascular events (8) are the most reported causes of death. Sepsis, neurological syndromes, nephropathy, other malignancies and diffuse vasculitis are also reported. The median age at death was 67.2 years (58.4 in the oldest group, 71.9 in the other). Hepatic carcinomas are reported only after 1991. Conclusion: Cirrhosis complications are more frequent in patients affected by HCV. The increase in instrumental diagnostic ability and the improved survival of patients with cirrhosis account for the increase in patients with hepatic carcinomas. Improved treatment has resulted in a reduction of deaths from renal failure.

Mixed cryoglobulinaemia syndrome (MCS) is associated with a number of infectious, autoimmune and lymphoproliferative disorders, particularly chronic hepatitis C infection. Although circulating mixed cryoglobulins (cMCGs) are a frequent finding in HCV-infected patients, only a minority of them develop a frank MCS. The only available data concerning the prevalence of MCS, which is generally considered a rare disease, come from hospital records. The aim of this investigation was to estimate the prevalence of cMCGs and MCS in a population-based study. All of the adult residents in Origgio, a town of about seven thousand inhabitants in northern Italy, were mailed a validated questionnaire, and a randomly selected sample of respondents was invited to undergo a clinical examination and laboratory tests including the determination of cMCGs. The 1594 respondents to the questionnaire (54.3% women, 64.5% aged >49years) accounted for 26.4% of the total adult population. Forty-nine (3.1%) positively responded to at least two questions, including a disproportionately high number of people aged >70years (p=0.001). Of the 266 randomly selected subjects invited to undergo a clinical examination and laboratory tests, 147 accepted, 30 (20.4%) of whom had asymptomatic type III cMCGs and four MCS. The risk of cMCG positivity was independently associated with C4 levels of

Cryoglobulinemic syndrome (CS) is a relatively rare disorder. Type I cryoglobulins are associated with lymphoproliferative disorders while types II and III are associated with connective tissue diseases, lymphoproliferative disorders, and chronic infections, especially with hepatitis C virus. Indeed, CS is the most common extra hepatic manifestation of HCV and its spread is closely related to the worldwide pattern of infection with the virus. Female gender seems to be correlated with a higher prevalence of CS. The mean age at the time of first diagnosis is typically 65 years. CS most commonly takes the form of a mild, slow-progressive disorder, with a relatively good prognosis and good survival; however, in a small percentage of patients, CS has a moderate-severe clinical course. Rarely, the clinical course evolves dramatically, with multi-system involvement and life-threatening complications. The cumulative survival of patients with mixed cryoglobulinemia 10 years after diagnosis is 56–82%. The main cause of death is liver pathology, followed by sepsis, nephropathy and cardiovascular events, with an average survival of about 8 years.

Approximately 10% of the population with mixed cryoglobulinemia (MC) have no evidence of HCV infection. In these patients, a wide number of infectious agents have been associated with cryoglobulinemia, although only HBV and HIV have a well- documented role in causing the disorder. Several connective tissue (mainly systemic lupus erythematosus, Sjogren’s syndrome, and systemic sclerosis) and lymphoproliferative (in most cases B-cell non-Hodgkin lymphoma) diseases have also been shown to play an etiologic role in some cases of HCV-negative MC. Fewer than 5% of cryoglobulinemic patients show no identifiable underlying diseases and they are therefore considered as having “essential” MC. In HCV-negative MC, an occult HCV infection should also be taken into account. The clinical manifestations, cryoglobulin levels, and survival rates in MC patients with and without HCV seem not to differ significantly, although the data are conflicting. In symptomatic MC, therapy should aim at improvement or resolution of clinical manifestations, as elimination of the causative factor is impossible in most cases.

Non-Hodgkin’s lymphomas arise in HCV-positive patients with cryoglobulinemia at a frequency higher than in either the general matched population or in HCV-patients without cryoglobulinemia. The relevance of the cryogenic effect on the response to treatment and on prognosis has been poorly assessed with respect to the characteristics of this patient population, and the typical histological patterns linked to this situation have not been easily identifiable. In recent years, many biological findings have suggested a relevant role of the patient’s genetic background in favoring the malignant evolution of this disease, in which the long-lasting presence of an antigen that induces the production of cryoprecipitating immune complexes drives the expansion of lymphoid tissue in a manner that is unstable and prone to evolve toward a lymphoid malignancy.

It is important to determine whether an increase in Chromogranin A levels and neuroendocrine (NE) cell activation are associated with progression towards on hormone-independent prostate-cancer. We proposed a combination of estrogens and somatostatin analogues as therapy of NE activation in hormone-independent prostate cancer. The combined therapy with ethinyl estradiol and lanreotide offered objective and symptomatic responses in patients with limited treatment options and refractoriness to conventional hormonal therapy strategies; in particular, it offered a median overall survival that was superior to the 10–month median survival in patients with hormone refractory disease. This combined therapy also sustains the new concept in cancer treatment in which therapies may target not only cancer cells but also its microenvironment, which can yield protection against apoptosis.

Background To develop preliminary classifi cation criteria for the cryoglobulinaemic syndrome or cryoglobulinaemic vasculitis (CV). Methods Study part I developed a questionnaire for CV to be included in the formal, second part (study part II). Positivity of serum cryoglobulins was defi ned by experts as an essential condition for CV classifi cation. In study part II, a core set of classifi cation items (questionnaire, clinical and laboratory items, as agreed) was tested in three groups of patients and controls—that is, group A (new patients with the CV), group B (controls with serum cryoglobulins but lacking CV) and group C (controls without serum cryoglobulins but with features which can be observed in CV). Results In study part I (188 cases, 284 controls), a positive response to at least two of three selected questions showed a sensitivity of 81.9% and a specifi city of 83.5% for CV. This questionnaire was employed and validated in study part II, which included 272 patients in group A and 228 controls in group B. The fi nal classifi cation criteria for CV, by pooling data from group A and group B, required the positivity of questionnaire plus clinical, questionnaire plus laboratory, or clinical plus laboratory items, or all the three, providing a sensitivity of 88.5% and a specifi city of 93.6% for CV. By comparing data in group A versus group C (425 controls), the same classifi cation criteria showed a sensitivity 88.5% and a specifi city 97.0% for CV. Conclusion Classifi cation criteria for CV were developed, and now need validation.

The recognition of effector cell populations that are able to actively form conjugates with target cells is of major importance in studies of lymphocyte cytotoxicity. A number of methodologies have been described to identify the conjugates and count them, but there have been few studies of the birding capability of the different subsets of effector cells involved in the conjugation phenomenon. Here we describe a methodology that permits the study of two surface markers on lymphocytes conjugated to K562 target cells. In particular, the expression of low density CD8 (CD8 dim ) has been studied on both CD3 + and CD16 + lymphocytes bound to K562 target cells. Previously described methodologies, either optical microscopy or flow cytometry, were not able to identify the effector population by mAb double staining, especially in the case of antigens expressed at low density. The flow cytometric methodology described here permits the measurement of the binding activity of small lymphocyte subsets such as the CD3 + 8 dim+ population. However, the method could be used to study the binding activity of any effector population defined by mAb double staining.

The paper highlights the role of different HLA class II molecules in hepatic and lymphoproliferative HCV-related disorders. HLA molecules have been reviewed, according to an in silico cluster classification, based on the sequence, the biochemical structure of the pockets, and the functional characteristics of the HLA II molecules. Thus, by reducing the complexity of HLA II polymorphism, characteristics that unite different HLA molecules with specific HCV-associated pathologies may be recognized with greater case. Results show that HLA clusters associated with better dlimination of the virus are protective against HCC development, while the same clusters are associated with a higher risk of developing cryoglobulinemic syndrome and the concomitant NHL. These data added further acknowledgements on pathogenetic mechanisms associated with HCV infection. Results also highlight differences of NHL occurring in HCV-positive subjects, with or without a concomitant type II autoimmune cryoglobulinemic syndrome, suggesting that cryoglobulinemic background associated with NHL should be considered in the evaluation of the effectiveness of new therapies in the course of HCV-associated NHLs.

Background Serum cryoglobulins (SC) may be found in many diseases (1), and the presence of serum cryoglobulins is a known risk factor for lymphoma evolution in some non malignant diseases. Objectives The aim of this study was to distiguish the role of cryoglobulinemic vasculitis (CV), classified according to the recent validated criteria (1,2), and primary Sjogren9s syndrome (pSS) as risk factors of lymphoma in patients positive serum cryoglobulins. Importantly, SC, CV and pSS may occur together. Methods 950 charts from consecutive patients with positive SC were evaluated. Patients carrying both pSS and HCV infection, as well as incomplete charts, were excluded. Results 657 patients with SC were selected, 374 with CV and 283 without CV, according to the published criteria (2,3). PSS, classified according to the American-European Group Criteria was present in 96 patients (44 with CV, 52 without). Lymphoma was reported in 61/657 (9.8%) patients with SC. Among them, CV was present in 44/61 (72,1%; 14 also with pSS), and pSS in 17/61 (27,9%; and 14/17 had CV). Patients with SC with CV showed an higher prevalence of lymphoma than patients with SC without CV (44/374, 11.5% vs.17/283, 6.3%; p=0.025, OR=1.93 [95%IC: 1.08-3.39]. Patients with pSS, SC and CV also showed a higher prevalence of lymphoma than patients with pSS, SC but without CV (14/44, 31.8% vs. 3/52, 7.4%; p=0.001, OR=7.62 [95%CI 2.02-28.74]. CV and pSS were confirmed as independent risk factor for lymphoma by multivariate analysis (OR 2,18 95%CI 1,18-3,83, p=0,012; OR 2,65 95%CI 1,04-6,76, p=0,042, respectively). Infection by the hepatitis C virus (HCV) was detected in 467/561 (83,2%) patients with SC without pSS, and did not statistically predispose to lymphoma when associated with CV in this subset (p=1,0). Conclusions Cryoglobulinemic vasculitis and pSS are independent risk factors for lymphoma in patients with evidence of SC. Patients with both the conditions (CV and pSS) have the highest risk. In the follow-up of SC positive patients, a very high attention should be deserved to pSS, in particular when CV is present. References De Vita S, et al. Ann Rheum Dis. 2011; 2) Quartuccio L, et al. Rheumatology (Oxford). 2014 Disclosure of Interest None declared

The aim of this study was to investigate the quasispecies heterogeneity of hepatitis C virus (HCV) in the plasma, cryoprecipitate, and peripheral lymphocytes of chronically infected HCV patients with mixed cryoglobulinemia (MC). We studied 360 clones from 10 HCV-positive patients with MC and 8 age-, gender- and HCV genotype-matched subjects with chronic HCV infection but without MC. A partial nucleotide sequence encompassing the E1/E2 region, including hypervariable region 1 (HVR1), was amplified and cloned from plasma, cryoprecipitates, and peripheral blood mononuclear cells (PBMC), and the genetic diversity and complexity and synonymous and nonsynonymous substitution rates were determined. Heterogeneous selection pressure at codon sites was evaluated. Compartmentalization was estimated by phylogenetic and phenetic (Mantel's test) approaches. The patients with MC had 3.3 times lower nonsynonymous substitution rates (1.7 versus 5.7 substitutions/100 sites). Among the subjects with HCV genotype 1, the MC patients had significantly less complexity than the controls, whereas the diversity and complexity were similar in the genotype 2 patients and controls. Site-specific selection analysis confirmed the low frequency of MC patients showing positive selection. There was a significant correlation between positive selection and the infecting HCV genotype. The quasispecies were less heterogeneous in PBMC than in plasma. Significant compartmentalization of HCV quasispecies was observed in the PBMC of four of nine subjects (three with MC) and seven of nine cryoprecipitates. In one subject with MC, we detected a 5-amino-acid insertion at codons 385 to 389 of HVR1. Our results suggest reduced quasispecies heterogeneity in MC patients that is related to a low selection pressure which is probably due to an impaired immune response, the HCV genotype, and/or the duration of the infection. The frequent HCV quasispecies compartmentalization in patients' PBMC suggests a possible pathogenetic significance.

To determine whether a regimen of cyclosporine (CSA) and methotrexate (MTX), or CSA and hydroxychloroquine (HCQ) introduced in early rheumatoid arthritis (RA) can produce a significant improvement in clinical outcome and/or retard radiographic damage in comparison with standard monotherapy with CSA alone.One hundred five patients with active RA of less than 36 months duration, who had never previously been treated with immunosuppressive agents, were included in a 12-month, multi-center, open, randomized trial. Patients who fulfilled the criteria for early severe RA were randomized to receive either combination therapy (CSA + MTX n = 34, CSA + HCQ n = 35) or CSA alone (n = 36).CSA + MTX was more effective than the other two treatment groups in controlling RA symptoms. CSA+MTX did not show a significant radiographic progression according to Larsen-Dale (0.90 +/- 3.89 compared to baseline values, P0.05); moreover, patients treated with CSA alone or CSA+HCQ showed a significant worsening of Larsen-Dale score (2.91 +/- 5.99 and 2.97 +/- 4.28 respectively vs baseline values, P0.05), although not significant when compared with the CSA + HCQ group (P = 0.56 and 0.39, respectively).This trial indicated that CSA+MTX was more effective than the other two treatments in improving clinical data and inhibiting radiographic progression, although the differences were not significant in this relatively small study. However, the difference was significant in favor of CSA + MTX regarding ACR 50% response.

Summary Background In an attempt to mobilise peripheral blood progenitor cells (PBPC) from patients with breast cancer, Epirubicin supported with G-CSF was tested. Another aim of the study was also to optimize the procedure so that the number of leukapheresis procedures could be reduced. These cells were subsequently reinfused as hematologic rescue after high-dose chemotherapy programs. Patients and methods Twenty-nine patients received Epirubicin 150 mg/sqm + G-CSF at the dose of 5 μg/kg/bw s.c. daily, starting 24 hours after chemotherapy. Twelve had metastatic, eight inflammatory or locally advanced disease, and nine were treated in an adjuvant setting. Results The median numbers of CD34+ cells and CFU-GM collected were 12.9 × 10Vkg/bw and 111.7 × 104/kg/bw, respectively. The mean number of leukapheresis procedures per patient was 1.8 ±0.3 (range 1–3), and the mean day of the first procedure was the tenth ± 1 (range 8–13) after Epirubicin. The minimum required target for one high-dose procedure was collected in a single leukapheresis in 13 patients. Moreover, in 9 cases one procedure was adequate for two high-dose courses (i.e. >10 × 10Vkg/bw CD34+ cells). Response to Epirubicin was evaluable in 14/20 cases, with a response rate of 50%. Conclusions Epirubicin delivered at 150 mg/sqm is a very effective mobilising agent for breast cancer patients; to ameliorate the response rate other active drug(s) should be added.

BACKGROUND High-dose chemotherapy (HDCT) followed by hematopoietic stem cell support (HSCS) potentially may be curative in patients with germ cell tumor (GCT) who develop recurrent tumors or who have an inadequate response after receiving standard-dose chemotherapy. The authors report their experience with HDCT as salvage therapy for patients with GCT. METHODS Between 1986 and 2000, 84 patients with GCT, with a median age 29 years (range, 15–50 years), were treated with 105 courses of HDCT with HSCS. Patients were stratified into good, intermediate, and poor risk categories according to a validated prognostic index. RESULTS Overall, 28 patients (33%) have been continuously disease free. In the good risk group, 24 patients (69%) have been continuously disease free compared with 4 patients (13%) in the intermediate risk group (P < 0.001) and 0 patients in the poor risk group (P < 0.001). Treatment-related mortality occurred only among patients in the poor risk (n = 6 patients) and the intermediate risk groups (n = 4 patients). CONCLUSIONS In the authors' experience, HDCT induced impressive long-term remissions as salvage treatment among patients in the good risk group. Moreover, the use of validated prognostic classifications may contribute to a better definition of the role of HDCT other than improving the outcome of patients with GCT. The definitive statement on the possible role of HDCT in patients with GCT will derive from the ongoing Phase III randomized studies. Cancer 2002;95:309–15. © 2002 American Cancer Society. DOI 10.1002/cncr.10672

Background Two independent controlled randomized trials demonstrated the efficacy and safety of rituximab (RTX) monotherapy in severe cryoglobulinemic vasculitis (CV) (1, 2), with one reporting a prolonged follow-up (1). Objectives To report the very long term efficacy and safety of RTX monotherapy in severe CV since a regimen of RTX monotherapy was maintained after the end of the abovementioned trial (1). Methods Long term follow up data of a trial of RTX in severe CV (1) were analysed. During this follow-up, only RTX monotherapy was used. Disease activity at the last follow-up visit, adverse events and survival were registered. Clinical response was evaluated at the last follow-up visit, and was scored as follows: i) complete remission (no activity), partial remission (response >50% of at least one manifestation among glomerulonephritis, severe neuropathy or skin ulcers) (1), and active disease. Results After the end of the 2-year controlled trial (1), follow-up data were available in 36 patients undergoing RTX, all HCV positive. The mean follow up after the beginning of RTX therapy (1) was 70.22±20.41 months, including 29 patients followed for more than 4 years (78.4±12.6 months) and 7 patients followed for 2.4-4 years (36.4±6 months). Of them, 3 patients were lost from follow-up shortly after the end of the trial, and 9 patients died. Of the remaining 24 patients, 14/24 (58.3%) showed complete clinical remission at the last follow-up, 6/24 (25%) a partial remission, while 4/24 (16.7%) had an active disease. A first repeated RTX course (1 g two weeks apart) was required in 50% of the patients (12/24), while 25% of the patients (6/24) needed more than one course, for a total of 19 retreatments. Patients were retreated for nephritis (7/19), neuropathy (6/19), skin ulcers (7/19) or diffuse purpura (6/19). Three patients underwent a maintenance RTX regimen, all with 1 g × 2 every 6 months, with a complete and partial remission at the last follow-up noticed in 2/3 and 1/3, respectively. Recurrent infections occurred only in three patients (8%; urinary and upper respiratory), and they were related to persistent hypogammaglobulinemia in 2/3. Death occurred in 9 patients, all showing persistent active disease. Conclusions A long-term RTX therapy lasting several years is effective and safe in about two thirds of the patients with severe CV. The advantage of retreatment at relapse regimen instead of a maintenance therapy, and whether this may occur in a further subset of patients, needs further investigation. References De Vita S, et al. Arthritis Rheumatol. 2012;64(3):843-53. Sneller MC, et al. Arthritis Rheumatol. 2012;64(3):835-42. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3872

Background One of the hallmarks of overt Systemic Sclerosis (SSc) is the interstitial and perivascular fibrosis resulting in functional impairment of affected organs. During the fibrotic process, the increased collagen synthesis has been correlated to the increase of some biomarkers of collagen metabolism, but it is not know how early these biomarkers can be detected during the disease course. Objectives To evaluate the ongoing fibrotic process based on collagen biomarkers in a cohort of patients in different phases of the disease: from isolated Raynaud’s phenomenon (RP) to overt SSc. For this purpose tissue inhibitor of matrix metalloproteinases-1 (TIMP-1), hyaluronic acid (HA), aminoterminal propeptide of type III procollagen (PIIINP) and Enhanced Liver Fibrosis (ELF) test were chosen. Methods 140 consecutive adult subjects referring in approximately 6 months time were enrolled. They were classified as: 1) primary RP (pRP) [1]; 2) RP suspected secondary to SSc; 3) very early SSc [2]; 4) limited cutaneous (lc)-SSc; and 5) diffuse cutaneous (dc)-SSc. Patients with any other fibrosing disorder or treated with interferon were excluded. TIMP-1, HA, PIIINP and ELF score (derived from an algorithm of the above mentioned biomarkers) were blindly determined by an independent commercial service (iQur, UK). Statistical analysis was performed by regression modelling and ROC curve analysis adjusting for age. Results The study population consisted in 50 pRP (47 women, median age 44.5 yrs), 43 RP suspected secondary to SSc (43 women, median age 43 yrs), 16 very early SSc (16 women, median age 57.5 yrs),15 lc-SSc (14 women, median age 67 yrs), and 15 dc-SSc (13 women, median age 65 yrs). 1 patient was excluded for a recent treatment with interferon. The ELF test and HA were significantly higher in patients with very early SSc compared to subjects with RP suspected secondary to SSc (ELF test: median 8,46 vs 7,84 ng/ml, p= 0.0286; HA: median 30,62 vs 13,6 ng/ml, p= 0.03). PIIINP was significantly higher in patients with dc-SSc compared to very early SSc (median 7,23 vs 5,42 ng/ml; p= 0.006). These differences were not confirmed when these results were weighted for age. When patients with overt SSc were studied an increase of these biomarkers was observed as a trend, but only PIIINP reached a statistical significance. This last result was also confirmed once being weighed for age. Conclusions In our study, the selected biomarkers were not able to distinguish among subjects between pRP, suspected secondary RP, and patients with very early SSc. Nevertheless, these fibrosis biomarkers showed an increasing trend in different subgroups and with age, with no relation to RP duration. These data support the hypothesis that the immune perturbations and vascular injury precede the development of fibrosis, which, in turn, further exacerbates vascular and immune damage. References LeRoy EC, Medsger TA, Jr. Clin Exp Rheumatol. 1992;10:485-8. Avouac J, Fransen J, Walker UA, Riccieri V, Smith V, Muller C, et al. Ann Rheum Dis. 2011;70:476-81. Disclosure of Interest None Declared

Background Studies have found that patients who start anti-TNF therapy with lower DAS28 scores are more likely to achieve disease remission (defined using a DAS28 3.2–5.1) compared to those with high disease activity (HDA) (DAS28 >5.1). Objectives The aim of this study was to identify the clinical factors that predicted a good clinical response to anti-TNF in RA patients who had been divided into two groups according to baseline DAS28 scores (moderate: >3.2–5.1 and high: >5.1) and entered into the Lombardy Rheumatology Network (LORHEN) registry after five years of treatment with anti-TNF agents. Methods We entered into the study all patients with no previous exposure to biologic agents who were starting one of the three available anti-TNF agents (ETN, IFN or ADa), and who had been both included in the LORHEN register and followed-up for a minimum of twelve months by 1999. The prospective protocol included information on demographics, the clinical characteristics of the patients and response measures. Disease activity at baseline and after 12 six months was assessed using the DAS28, and response was evaluated according to the EULAR improvement criteria. Potential predictors of response were identified using multivariate binary logistic regression models. Results The study involved 1300 patients with established RA (326 ETA, 385 ADA, 589 INF), of whom 975 with high, and 325 with moderate, clinical activity were included in the analysis of clinical efficacy. At the start of therapy, patients had a mean age of 54.66±13.74 years, a disease duration of 7.49±7.88 years, and a baseline DAS-28 of 5.77±1.05 (HDA 6.23±0.71 vs. MDA 4.37±0.51, respectively). After a mean of twelve months, 21.39% of the patients had achieved a DAS-28 of ≤2.6 (HDA 16.17% vs. MDA 37.3%; P=0.0001) and were considered to be in remission. A total of 324 had achieved a good EULAR response (HDA 203 vs. MDA 121). A higher probability for good EULAR response in patients with HDA was associated with male gender (F vs M - OR 0.42, 95% CI 0.27-0.63; p:0.0001), a low baseline erythrocyte sedimentation rate (ESR) (OR 0.99, 95% CI 0.98-1.00; p:0.03), or an absence of comorbidities (OR 2.15, 95% CI 1.52-3.04 p:0.0001); in patients with MDA this was associated with no corticosteroids having been used (OR 2.06, 95% CI 1.12-3.77; p:0.02) and with male gender (F vs M - OR 0.48, 95% CI 0.27-0.85; p:0.01).Age, disease duration, RF and previous use of DMARDs did not predict response in this cohort of patients, but patients with HDA without concomitant comorbidities were more likely to achieve a good clinical response. Male gender was associated with a good EULAR response in both subgroups. Conclusions We found that the percentage of patients with long-standing RA and MDA treated with anti-TNF agents who achieved remission as outpatients in the community was higher than those with HDA. Furthermore, those factors that predicted good EULAR were different in patients with MDA compared to those with HDA, with the exception of male gender. Disclosure of Interest None Declared

Background the preliminary Classification Criteria for cryoglobulinemic vasculitis (CV) have been developed in 2011 by an European cooperative study (1). Objectives to validate these Classification Criteria for CV with the participation of non-European Countries. Methods 20 Centres from Europe, Egypt, and Japan partecipated. New consecutive, unselected patients with CV (Group A) and controls (subjects with cryoglobulins without a CV based on the golden standard clinical judgment; Group B) were studied. A sample size of 140 patients for each group was estimated to obtain a sensitivity (SE) and a specificity (SP) of at least 90±5%, according to the previous results (1). A dedicated chart was distributed to the Centres. The sensitivity and specificity of the 2011 Classification Criteria were calculated in the present validation series by comparing Group A versus Group B. Results 251 patients in Group A and 175 controls in Group B were recruited. The questionnaire (at least 2/3 positive answers) showed a SE of 89.2% (95% CI 85.4-93.1) and a SP of 93.7% (95% CI 90.1-97.3); the clinical item (at least 3/4 clinical items among constitutional, articular, vascular and neurologic involvement) showed a SE of 76.1% (95% CI 70.8-81.4) and a SP of 88.6% (95% CI 83.8-93.9), and the laboratory item (at least 2/3 tests, among positive rheumatoid factor, low C4, and the presence of serum monoclonal component) showed 75.1% (95% CI 69.5-80.7) of SE and 71.5% (95% CI 64.6-78.4) of SP. The final 2011 Classification Criteria (at least 2/3 positive items) showed a SE of 89.3% (95% CI 85.3-93.3) and a SP of 93.9 % (95% CI 90.3-97.6). Conclusions: Conclusion : The 2011 International Classification Criteria for the cryoglobulinemic vasculitis have been validated in a new cohort of real cases and controls. Patients where CV is suspected on clinical grounds, but where cryoglobulins are negative, cannot be classified, since positive serum cryoglobulinemia is a conditio sine qua non for classification (1). However, the performance of these criteria on this subset of patients is under evaluation. References De Vita S, et al. Ann Rheum Dis 2011;70:1183-90. Disclosure of Interest None Declared

Hepatitis C virus (HCV) infection is associated with most mixed cryoglobulinemia (MC) syndromes. In this study, HCV RNA was detected in the peripheral blood mononuclear cells of 11 (73.3%) of 15 patients with MC and in 5 (71.4%) of 7 noncryoglobulinemic patients with chronic hepatitis type C. All patients with cryoglobulinemia and 3 (42.8%) of the 7 without cryoglobulinemia (P < .05) had HCV RNA in bone marrow cells. Subjects in both groups with HCV-positive bone marrow also had HCV RNA in serum. The majority of patients with MC syndromes were infected with HCV subtypes 1b and 2a. Two patients with MC had different genotypes in serum and cells. Further studies are needed to determine which bone marrow cell population is preferentially infected by HCV and to determine if this phenomenon is involved in inducing the production of cryoglobulins.

In a multi-centre retrospective study, we compared clinical and laboratory data in 913 patients with cryoglobulinaemias, divided as: (i) essential cryoglobulinaemias; (ii) cryoglobulinaemias secondary to connective tissue diseases (CTD), lymphoproliferative or other haematological diseases (LPD), chronic liver diseases (CLD), and 'other diseases'. Purpura was the commonest presenting feature in all groups and was more common in essential cryoglobulinaemias (p 3% (p < 0.0001), C4 < 15 mg/dl (p < 0.001), HBsAg prevalence (p < 0.01) and purpura (p < 0.05). Despite the high prevalence of HCV markers in all groups, the role of HCV in essential cryoglobulinaemia is not well defined; HBV seems to play only a marginal role.

A new case of IgE myeloma is described. A 77-year-old woman presented with bone pain and fatigue. Serum protein analysis revealed a paraprotein of the IgE kappa type; bone marrow aspirate and immunofluorescence confirmed the diagnosis; ultrastructural examination showed immature plasma cells. Treatment with prednisone, melphalan, cyclophosphamide and interferon alfa did not produce any improvement and the patient died 5 months after diagnosis. The patient's clinical and laboratory data are compared with those of IgE myeloma cases reported in the literature.

The clinical and immunochemical classification of 166 patients with cryo-globulinemia are presented. 52% of the cryoglobulins were detected in patients hospitalized because of various causes. The most

The clinical and immunochemical classification of 376 patients with cryoglobulinemia is presented. In 141 cases (37.5%) the syndrome was considered idiopathic. Among the secondary forms, chronic liver diseases and connective tissue diseases shared most frequently mixed cryoglobulins (18.8 and 15.4% of cases, respectively). Another common association was that with Waldenström's macroglobulinemia: cryoglobulins were found in 20% of these patients. In 5 patients (2 with the essential form and 3 with cryoglobulinemia secondary to Waldenström's disease) a Cl-inhibitor deficiency was discovered; the complement profile was characteristic of the acquired type and episodes of angioedema occurred. Studying the clinical course of 71 cases of essential mixed cryoglobulinemia followed-up for 4-20 years we concluded that the evolution of type II and type III cryoglobulinemias is different because that of type II seems to have a more severe course and may differentiate in a lymphoproliferative disorder; the immunochemical type of cryoglobulins seems therefore to have a prognostic significance. Because of the considerable overlap in the distribution of immunochemical types among the clinical subsets, a mixed classification (both biochemical and clinical) is proposed.

The mid-term effects of radiotherapy on T and B peripheral lymphocytes of 15 patients treated for various malignancies were evaluated. All patients had a significant impairment of lymphocyte functions, as measured by blastogenesis after stimulation with phytohemagglutinin and pokeweed mitogen. Such impairment lasted for 1 year after the completion of radiotherapy, when numerical variability of T and B subpopulations, observed during and after radiation treatment, was restored to initial values.

During the last 3 years we have observed 7 cases (4.1%) of cryoglobulinemia-associated polyneuropathy out of 167 patients with demonstrated cryoglobulinemia. Nerve involvement in the course of cryoglobulinemia is usually symmetrical, affecting the distal portions of the limbs and has a chronic or chronic-relapsing evolution. In our experience, the combined treatment by plasmapheresis and glucocorticoids and/or cytostatic drugs has proved to be quite effective, particularly when instituted during the symptomatic exacerbations. Therefore, we suggest to perform a systematic investigation of the cryoglobulinemic phenomenon in every patient presenting with symptoms and/or signs of an apparently idiopathic polyneuropathy.

Ninety-three patients with essential mixed cryoglobulinemia have been followed for more than 5 years in 75% of cases; 21 patients died during this period and the mean age at death was 54 years. The most common cause of death was renal failure. The percentages of patients who survived after 5 and 10 years from the diagnosis were 87 and 74%, respectively. The cryoglobulin type seems to be an important prognostic factor: in our population the type II/III ratio is 6/7 at diagnosis, while it becomes 2/1 when the patients who died are considered.