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Epidemiological studies have demonstrated an increased incidence of MDS in patients with plasma cell disorder (PCD) i.e. multiple myeloma (MM) or MGUS and several case reports / series of co-occurring MDS and PCD have been published. The underlying pathogenesis for this condition, and if the two diseases share a common genetic lesion remains unknown. Here, we describe a cohort of 27 consecutive patients with co-occurring MDS and MM (n=6), MGUS (n=20) or plasmocytoma (n=1), diagnosed at the Karolinska University Hospital. In 5 patients, the diagnosis of MGUS preceded the diagnosis of MDS , in one patient the MDS diagnosis preceded PCD, and in 21 patients MDS and PCD were diagnosed at the same time. There was a preponderance for lower-risk MDS subgroups with only 3 patients belonging to the IPSS-R high / very high risk groups. Median overall survival for the whole cohort was 44 months. The most common mutations were TET2, SRSF2 and SF3B1. To identify potential common founder clones, we performed whole exome sequencing on isolated bone marrow myeloid-, plasma- and T-cells from 9 patients. In none of the patients, we could detect a common founder mutation and the two diseases have likely emerged from separate clones.

Background Systemic mastocytosis (SM) is a haematological disease characterised by organ infiltration by neoplastic mast cells. Almost all SM patients have a mutation in the gene encoding the tyrosine kinase receptor KIT causing a D816V substitution and autoactivation of the receptor. Mast cells and CD34+ haematopoietic progenitors can carry the mutation; however, in which progenitor cell subset the mutation arises is unknown. We aimed to investigate the distribution of the D816V mutation in single mast cells and single haematopoietic stem and progenitor cells. Methods Fluorescence-activated single-cell index sorting and KIT D816V mutation assessment were applied to analyse mast cells and >10,000 CD34+ bone marrow progenitors across 10 haematopoietic progenitor subsets. In vitro assays verified cell-forming potential. Findings We found that in SM 60–99% of the mast cells harboured the KIT D816V mutation. Despite increased frequencies of mast cells in SM patients compared with control subjects, the haematopoietic progenitor subset frequencies were comparable. Nevertheless, the mutation could be detected throughout the haematopoietic landscape of SM patients, from haematopoietic stem cells to more lineage-primed progenitors. In addition, we demonstrate that FceRI+ bone marrow progenitors exhibit mast cell-forming potential, and we describe aberrant CD45RA expression on SM mast cells for the first time. Interpretation The KIT D816V mutation arises in early haematopoietic stem and progenitor cells and the mutation frequency is approaching 100% in mature mast cells, which express the aberrant marker CD45RA.

Approximately 20% of newly diagnosed multiple myeloma (NDMM) patients harbor t(11;14), a marker of inferior prognosis, resulting in up-regulation of CCND1. These patients respond to BCL2 inhibitor experimental drug venetoclax. Furthermore, t(11;14) is reported to be associated with increased BCL2/MCL1 ratio. We investigated the use of venetoclax (400 mg daily) in a cohort of 25 multiple myeloma (MM) and AL-amyloidosis patients harboring t(11;14) and assessed safety and efficacy. Efficacy was assessed by response rate (RR) and time on treatment. Furthermore, immunohistochemistry (IHC), for BCL2 family member expression was assessed at diagnosis and relapse in the venetoclax-treated group and analyzed for correlation with clinical RR. Additionally, patient material from venetoclax non-treated group including non-t(11;14) diagnosis (n=27), t(11;14) diagnosis (n=17), t(11;14) relapse (n=7), hyperdiploidy (n=6) and hyperdiploidy+t(11;14) (n=6) was used for RNA sequencing (RNASeq) and validation by qPCR. Venetoclax treatment in t(11;14) patients demonstrated manageable safety and promising efficacy. Partial responses or better were observed in eleven patients (44%). Responding patients had significantly higher BCL2/MCL1 (p=0.031) as well as BCL2/BCL-XL (p=0.021) ratio, regardless of time of measurement before venetoclax treatment. Furthermore, an IRF5 motif was enriched (p adj.=5.9×10-8 ) in the downregulated genes in t(11;14) relapses vs. diagnoses. The RR with single agent venetoclax was 71% in AL-amyloidosis and 33% in MM, and IHC proved useful in prediction of treatment outcome. We could also demonstrate possible resistance mechanisms of t(11;14), downregulation of IRF5 targeted genes, which can be exploited for therapeutic advantages. This study was funded by Cancerfonden:190190Pj01. This article is protected by copyright. All rights reserved.

Mechanisms for late-onset neutropenia (LON) after rituximab treatment are poorly defined both for non-Hodgkin lymphoma (NHL) and for autoimmune disorders. We performed a case–control analysis of a prospective cohort of 169 evaluable consecutive rituximab-treated NHL patients to assess cytokines involved in neutro- and lymphopoiesis (G-CSF, SDF1, BAFF, APRIL) and inflammation (CRP) as possible LON mechanisms. Fifteen patients (9%) developed LON (peripheral blood /PB/ absolute neutrophil counts /ANC/

Purpose: To evaluate the safety, efficacy, and immunobiological correlates of allogeneic NK-cell–based therapy in primary chemotherapy-refractory or relapsed high-risk myelodysplastic syndrome (MDS), secondary AML (MDS/AML), and de novo AML patients. Experimental Design: Sixteen patients received fludarabine/cyclophosphamide conditioning combined with total lymphoid irradiation followed by adoptive immunotherapy with IL2–activated haploidentical NK cells. Results: NK-cell infusions were well-tolerated, with only transient adverse events observed in the 16 patients. Six patients achieved objective responses with complete remission (CR), marrow CR, or partial remission (PR). Five patients proceeded to allogeneic hematopoietic stem cell transplantation (HSCT). Three patients are still free from disease >3 years after treatment. All evaluable patients with objective responses (5/5 evaluable) had detectable donor NK cells at days 7/14 following infusion and displayed reduction of tumor cell clones, some of which carried poor prognosis mutations. Residual lin−CD34+CD123+CD45RA+ blast cells in responders had increased total HLA class I and HLA-E expression. Responding patients displayed less pronounced activation of CD8+ T cells and lower levels of inflammatory cytokines following NK-cell infusion. Intriguingly, despite omission of systemic IL2, all patients displayed increased frequencies of activated Ki-67+CD127−FoxP3+CD25hiCD4+ Treg cells of recipient origin following NK-cell therapy. Conclusions: Overall, this study suggests that high-risk MDS is responsive to NK-cell therapy and supports the use of haploidentical NK-cell infusions as a bridge to HSCT in refractory patients. Objective clinical responses and reduction of high-risk clones were associated with detectable donor-derived NK cells, immunoediting of residual blast cells, and less pronounced host immune activation. Clin Cancer Res; 24(8); 1834–44. ©2018 AACR.

Progressive multifocal leukoencephalopathy (PML) is a disease of immunocompromised patients caused by reactivation of the John Cunningham polyomavirus (JCV). A monoclonal anti-CD20 antibody rituximab is widely used as an important part of therapy for B-cell non-Hodgkin lymphomas and various autoimmune diseases. It is not fully explained how rituximab reactivates JCV. In this report, we present the case of a 61-year-old man with T-cell/histiocyte-rich large B-cell lymphoma who was treated with R-CHOP and intrathecal methotrexate. Two weeks after the first R-CHOP course he developed dysarthria, diplopia, and disturbances in motor coordination. Based on CT/MRI results showing 3 cm × 2 cm large hypodense white matter lesion in left cerebellar hemisphere, and detection of JCV in the cerebrospinal fluid (14 300 viral copies/mL), the patient was diagnosed with PML. Despite treatment attempt with cidofovir and IVIG, the patient's neurological status continued to worsen. He developed progressive motor neuron deficits but retained intact cognitive functions. The patient deceased nearly three months after onset of rituximab treatment. Rituximab is a milestone in treatment of many hematological and autoimmune diseases. Considering how widespread has the use of rituximab become, the overall risk of developing PML is relatively low. Nevertheless, since the end of 1990s several reports were published on PML development in association with usage of rituximab. The authors would like to emphasize that although the total risk of PML occurrence in patients treated with rituximab is low, it is important that physicians administrating rituximab therapy are aware of this serious complication.

Introduction Autologous stem cell transplantation (ASCT) combined with novel agents is considered as the standard treatment for eligible patients < 70(-75) years of age with multiple myeloma (MM). The number of induction cycles is usually 4-6 followed by ASCT, consolidation and maintenance. The role of consolidation is still under debate especially if complete response has been achieved and maintenance will follow. To improve the quality of life and avoid the frequent visits at hospital an all-oral treatment would be a preferred choice. Despite novel drugs, the outcome of high-risk (HR) patients is poor. We designed a phase 2 Nordic Myeloma Study Group (NMSG) trial (NCT03376672) to explore the response of ixazomib, lenalidomide and dexamethasone (IRd) induction, followed by single ASCT, IRd consolidation and risk-based maintenance either with IR or R. Here we present the response rates and safety after IRd x 4 induction in all patients and in 87% of patients before consolidation. Patients and methods This study included 120 patients in 22 NMSG sites. Patients received 4 IRd cycles as induction, ixazomib 4 mg on days 1, 8, 15, lenalidomide 25 mg on days 1-21, dexamethasone 40 mg weekly in 28-day cycles. Mobilization and ASCT were performed according to standard practice. Three months post-ASCT all patients will receive 2 IRd as consolidation followed by maintenance. Thereafter patients will be stratified to HR if any of the following FISH aberrations were found at inclusion: del17p at least 60%, t(4;14), t(14;16), t(14;20) or +1q and they receive ixazomib 4 mg on days 1, 8, 15 and lenalidomide 10 mg on days 1-21. Non-HR patients receive lenalidomide 10 mg on days 1-21. Maintenance will continue until progression (PD). Lenalidomide dose will increase to 15 mg after 3 cycles. The primary endpoint of the study is minimal residual disease (MRD) by 8-color Euroflow < 0.01%. The secondary endpoints include flow-MRD negativity by 10-5, overall response, safety and progression-free survival. Serological responses were assessed before cycles and if sCR or CR is achieved flow-MRD sampling will be performed and repeated every 6 months. Samples were taken concomitantly for later comparison with BM- molecular-MRD, blood cell-free DNA, blood heavy-light chain assay and blood mass spectrometry. Results Within 21 months 120 patients were included, 46 % of them belong to the HR group. Mobilization is by July 2020 performed for 101 (84%) patients with cyclophosphamide (Cy) + G-CSF in 74% and G-CSF alone in 26%. Plerixafor was needed in 32 (32%) patients. The median number of harvesting days was 2 (0-4) and the median number of collected CD34+ cells was 6.4 (0-19.2) x 106/kg. Four patients (4%) failed to mobilize during 1st attempt. Eighty-six (72%) patients have so far received ASCT with the median number of 3.4 x 106/kg CD34+ cells in graft. Overall response rate is 93%. The responses after IRD x 4 induction and before consolidation are presented in Table 1. Before consolidation 10 patients (8%) are out of study due to PD and 4 (3%) have been withdrawn due to toxicity. Toxicity events included hypersensitivity with hepatorenal failure, grade 3 cytopenia with liver toxicity and one unexplained encephalitis. One patient was withdrawn due to Cy toxicity. Eight additional patients are withdrawn from study, 7 by physician´s decision and 1 by patient´s decision. All these 7 patients had high tumor burden based on paraprotein level either in serum (53 - 102 g/L) or in 24h urine (7.8 - 23.2 g/24h) and achieved only stable disease (SD) during induction. Fifty-eight grade 3-4 SAE reports from 39 (33%) patients have been received and 57% of these were infections. Three patients had grade 3 liver problems and 2 patients grade 3 peripheral neuropathy. Seventeen (14%) patients have reported skin reactions, only 4 of them grade 3 events. Conclusion We present here data on response and safety after observation of all patients until post-induction phase and of 87 % of the patients until start of the consolidation phase. The ORR is 93% when all patients have received induction treatment. Nine patients achieved only SD and seven of them with high tumor burden were withdrawn before mobilization. At least VGPR after ASCT was achieved in 37%. Toxicity caused the withdrawal of 4 (3%) patients and 39 (33%) patients have reported grade 3-4 non-hematological SAEs. In all, 98/120 (82%) patients continue in the study including 80% of the HR patients. Disclosures Silvennoinen: BMS: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Cancer patients Finland: Honoraria; Janssen: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Research Funding. Waage:Janssen: Consultancy, Honoraria, Speakers Bureau; Takeda: Consultancy; Shire: Honoraria. Schjesvold:Celgene, Amgen, Janssen, Oncopeptides: Research Funding; Amgen, Celgene, Janssen, MSD, Novartis, Oncopeptides, Sanofi, SkyliteDX, Takeda: Honoraria; Amgen, Celgene, Janssen, MSD, Novartis, Oncopeptides, Sanofi, Takeda: Consultancy. Anttila:Sanofi: Research Funding; Amgen: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; BMS: Research Funding; Janssen: Honoraria, Other: Advisory Board; Takeda: Honoraria, Research Funding. Säily:Amgen: Honoraria; Abbvie: Honoraria; Celgene: Honoraria; Roche: Honoraria; Sanofi: Honoraria; Pfizer: Honoraria; Takeda: Honoraria; Janssen Cilag: Honoraria; Boehringer Ingelheim: Honoraria. Sankelo:Celgene, Amgen, Sanofi: Other: Congress travel support. Partanen:Abbvie: Honoraria, Other: Scientific Advisory Board Meeting; Behring: Honoraria; Takeda: Other: Scientific Advisory Board Meeting.

Diseases of macrophages are rare entities characterized by the accumulation of macrophages, dendritic cells or monocyte-derived cells in various tissues and organs. This article focuses on macrophage disorders which can be present in adult patients. The review highlights pathogenesis, signs and symptoms, diagnostic criteria and principles of therapy in the most frequent macrophage diseases in adults: hemophagocytic lymphohistiocytosis, Rosai-Dorfman disease, Gaucher disease, Niemann-Pick disease, and Langerhans cell histiocytosis. Since macrophage disorders can be encountered by various medical specialists, basic knowledge of these entities and their diagnostic criteria should be familiar to all physicians, including hematologists.

Background: Systemic mastocytosis (SM) is a hematological disease characterized by organ infiltration by neoplastic mast cells. Almost all SM patients have a mutation in the gene encoding the tyrosine kinase receptor KIT causing a D816V substitution and autoactivation of the receptor. Mast cells and CD34+ hematopoietic progenitors can carry the mutation, however, in which progenitor cell subset the mutation arises is unknown. We aimed to investigate the distribution of the D816V mutation in single mast cells and single hematopoietic stem and progenitor cells. Methods: Fluorescence-activated single-cell index sorting and D816V mutation assessment were applied to analyze mast cells and more than 10,000 CD34+ bone marrow progenitors across 10 hematopoietic progenitor subsets. In vitro assays verified cell-forming potential. Findings: We found that in SM 60-99% of the mast cells harbored the D816V mutation. Despite increased frequencies of mast cells in SM patients compared with control subjects, the hematopoietic progenitor subset frequencies were comparable. Nevertheless, the mutation could be detected throughout the hematopoietic landscape of SM patients, from hematopoietic stem cells to more lineage-primed progenitors. In addition, we demonstrate that FcεRI+ bone marrow progenitors exhibit mast cell-forming potential, and we describe aberrant CD45RA expression on SM mast cells for the first time. Interpretation: The KIT D816V mutation arises in early hematopoietic stem and progenitor cells and the mutation frequency is approaching 100% in mature mast cells, which express the aberrant marker CD45RA.

Hemophagocytic lymphohistiocytosis (HLH) is an underdiagnosed but life-threatening syndrome of hyperinflammation often occurring in adults with hematological malignancies (hM-HLH). The aim of the study was to describe clinical characteristics, therapy response, and outcome of adults with hM-HLH. The study included 51 adults with hM-HLH aged 23-84 years. Hyperferritinemia ≥500 µg/L was present in 96% of patients. The serum concentration of sIL-2Rα ≥ 2400 U/mL was revealed in 94% of patients. Twenty-three patients (45%) responded to therapy and achieved remission of HLH. The probability of overall survival (OS) at 6, 12, 24, and 60 months after HLH diagnosis were 42, 20, 15, and 15%, respectively. Patients with HLH during chemotherapy showed longer OS (median 124 days) than the patients who had HLH solely attributed to malignancy (median 65 days), but this difference was not statistically significant. Awareness of HLH in lymphoid and myeloid malignancies is crucial for improved survival.

Background Progressive multifocal leukoencephalopathy (PML) is a demyelinating disorder of the central nervous system caused by reactivation of the JC-virus and is in most cases associated with underlying immunosuppression. Acquired immune deficiency syndrome (AIDS) and hematological malignancies are well-known predisposing factors for PML. However, in the past ten years, various pharmacological agents have been associated with increased risk of PML. Based on the phenomenology PML can be divided into the cerebral form and the rare cerebellar form. Case presentation Here we describe a man affected by polycythemia vera (PCV) that was treated with hydroxyurea (HU) and developed PML. The initially PML presentation included ataxia as one of the main features. Brain MRI displayed widespread supratentorial and infratentorial lesions. Immunological analysis revealed absence of reactivity to a wide range of antigens. The course of disease was rapidly progressive with fatal outcome - autopsy ruled out leukemic transformation. Conclusion The occurrence of PML in PCV patients is very rare and has been reported only once. Movement disorders, such as ataxia, are also less frequent. In the present case the PML was likely multifactorial.

Introduction In the absence of a known affected family member, frequent symptoms of Gaucher disease (GD), a rare lysosomal storage disorder, such as thrombocytopenia or splenomegaly, often lead to hematological diagnostic workup. Objectives The aim of the study was to compare the clinical utility of aspiration biopsy of the bone marrow (ASP) with trephine biopsy (TB) for the diagnosis of GD type 1 (GD1). Patients and methods Six non-Jewish patients with sporadic GD1 were initially examined with ASP and TB to establish the cause of cytopenia and splenomegaly. In the current study, samples from each patient consisted of 2 bone marrow slides. On each slide, 500 nucleated cells were counted and then averaged. The composition of bone marrow TBs was assessed using digital images analyzed on a computer. Results Of 6 patients, 5 carried at least 1 N370S allele with a c.1226A>G mutation in the GBA1 gene. The median number of Gaucher cells identified during cytological assessment of bone marrow smears was 4 (range, 1-18), and the median percentage of Gaucher cells was 0.4% (range, 0.1%-1.8%). The absolute proportion of Gaucher cells in histological samples ranged from 22% to 36% (median value, 28%), and the ratio of Gaucher cell infiltrate to hematopoietic tissue ranged from 34% to 54% (median value, 47%). The median value of the ratio of Gaucher cells to hematopoietic tissue was strikingly lower when using ASP compared with TB (P = 0.028). Conclusions Our results indicate that ASP is not a reliable diagnostic tool for the detection of GD1. Thus, patients with unclear long-lasting splenomegaly and/or thrombocytopenia, in whom bone marrow aspirate cytology is negative for Gaucher cells, should be routinely referred for an enzymatic assay for GD.

The diagnosis of congenital metabolic disease can be very difficult and often extends in time. This applies particularly to metabolic diseases of milder phenotype, such as an adult form (type 1) of Gaucher disease caused by the inherited (autosomal recessive) deficiency of the lysosomal enzyme glucocerebrosidase. In this work, we present a case of 48-year-old Polish patient (living in Sweden) with lung cancer, who developed a prolonged pancytopenia complicated by sepsis after each cycle of chemotherapy. These symptoms led to initiation of hematological diagnostic work-up and the assumption that the complications are caused by Gaucher disease. Definitive diagnosis of Gaucher disease was confirmed by results of enzymatic analyses, which revealed reduced activity of glucocerebrosidase in peripheral blood lymphocytes to 0.44 μkat/kg protein (ref.: 2.1–3.8), increased activity of plasma chitotriosidase to 1241 nkat/L (ref.: T (R163X) and c.1226A>G (N370S), confirming diagnosis of type 1 Gaucher disease in the patient. The presence of the mutation c.604C>T has never been previously reported in a Polish patient with Gaucher disease. Administration of enzyme replacement therapy with imiglucerase (Cerezyme™) led to a rapid improvement of peripheral blood counts and enabled further continuation of intensive chemotherapy for lung cancer. In conclusion, the authors would like to emphasize that knowledge of the symptoms and the principles of diagnosis of Gaucher disease among hematologists is very important for efficient diagnostics of patients affected by this rare disease.

Introduction Gaucher disease (GD), caused by deficient activity of lysosomal glucocerebrosidase, results in tissue infiltration by transformed macrophages (Gaucher cells, GC), loaded with undigested glycolipids. Ensuing clinical signs and symptoms include skeletal lesions and cytopenias, and seem to be due to both local tissue replacement by pathological infiltrates but also to accompanying inflammatory response, elicited by engorged macrophages. Bone marrow GC infiltration coincides with increased microvascular density and skewed angiogenic profiles. The basis for increased risk of plasma cell (PC) dyscrasia in GD remains however still unexplained. The presented study aimed to investigate patterns of PC distribution in bone marrow of untreated GD patients, potential their clinical correlates and evolution during treatment. Methods Study material includes BM samples from 11 previously untreated GD1 patients (7 males, 4 females), followed at the Hematology Center, Karolinska University Hospital, Stockholm, Sweden. Diagnosis of GD was previously confirmed with proven deficient glucocerebrosidase activity in PB, and demonstrated GBA1 mutation. The study was performed in accordance with Declaration of Helsinki, and institutional ethical permit was obtained. Clinical data were retrieved from patient journals. After BM sampling, 10 patients began disease specific therapy, with 9 subjects receiving enzyme replacement therapy (ERT), and one treated with substrate reduction therapy (SRT). Bone marrow samples (trephine biopsies or fine needle aspirates) were taken as part of routine hematologic work-up, at baseline and, if needed, during follow-up. Samples were routinely processed at the Department of Clinical Pathology and Cytology at the same hospital. Plasma cell burden and distribution were studied in immunohistochemically stained sections (CD138), scanned at 40x magnification using the NanoZoomer S360 Digital slide scanner (Hamamatsu Photonics, Hamamatsu, Japan). NDPI.view2 Viewing software was used for scan evaluation, and image saving (JPEG format, 461 nm/pix resolution). For each sample, 5 fields with prominent Gaucher cell infiltrates (≥50% field area; GC-rich areas ), and 5 with Results At baseline, the patients were 21-86 years old (mean 58.8, median 42 yrs). All but one patient carried at least one N370S mutated GBA1 allele. Four were previously splenectomized; only one of the remainder group had no splenomegaly. Three patients had anemia, and 10 thrombocytopenia; one patient was not cytopenic. Ten patients had hyperferritinemia but only 2 had mildly increased IL-6 levels (Tab. 1). Proteinogram studies identified M-protein in only 2 subjects, with oligoclonal Ig increase in 2, and polyclonal Ig in 3 patients. Decreased Ig levels were found in 2 patients. Morphological analysis revealed multifocal, compact to dispersed Gaucher cell infiltrates, in all patients, with markedly varying GC burden. Notably, plasma cells were found in higher frequency in GC-rich areas (range 26.2-174.2/HPF), where their usual perivascular distribution pattern was only partially preserved (Fig. 1). Areas dominated by normal hematopoietic tissue demonstrated a significantly lower plasma cell infiltration (range: 2-128.2/HPF; Fig. 2). In patient 5, PC infiltration level was consistent with myeloma, M-protein was at 32 g/L, and difference in PB burden between GC-rich and non-GC areas was in his BM lower than in other patients. Follow up BM samples were obtained in 5 patients, 12-14 months from treatment onset. In 4 of those, PC burden decreased in GC-rich areas but increased in areas with dominant normal hematopoiesis (Fig. 3). The longest documented follow-up was in the SRT subject (over 6 years, patient 1), where similar trends could be observed. Patient 4 initially increased PC burden in BM, and patient 5 succumbed to myeloma and MDS shortly after study onset. Conclusion Bone marrow in GD1 demonstrates increased plasma cell density, particularly in areas affected by the disease. This phenomenon seems to be at least partly modified by disease specific therapy, albeit at a slow pace. N370S mutation was associated with dysimmunoglobulinemia but did not coincide with MGUS in most patients; unexpectedly, the myeloma patient was N370S heterozygous. Disclosures No relevant conflicts of interest to declare.

Background. The clinical presentation of Gaucher disease (GD), an inherited lysosomal storage disorder caused by the deficient activity of the lysosomal enzyme glucocerebrosidase, is highly variable, and three clinical types are distinguished based upon the presence of neurologic symptoms. Thrombocytopenia, anemia, hepatosplenomegaly, and bone manifestations are the most typical signs of GD type 1 (GD1). Case presentation. We present the case of an unsplenectomized man suffering from heterozygous GD1 with mutations of c.1226A>G (N370S) and RecNci I (L444P, A456P, and V460V) in the GBA1 gene, who developed recurrent pulmonary aspergillosis caused by Aspergillus fumigatus and a mycobacterial infection caused by Mycobacterium avium. Despite long-lasting therapy of both aspergillosis (including antifungal drugs and surgery), and the mycobacterial infection (triple therapy with rifampicin, ethambutol, and clarithromycin), recurrent positivity for M. avium and A. fumigatus was detected. Conclusions. Symptomatic lung involvement and an increased susceptibility to pulmonary infections are uncommon inGDand, if present, are often associated with more severe disease manifestations. To our knowledge, this is the first published report on the association of GD and pulmonary aspergillosis and mycobacterial infection. It illustrates the increased susceptibility of untreated GD patients to opportunistic pulmonary infections and ineffective eradication of these infections despite adequate therapy.

Apparent hematological symptoms rarely dominate the clinical picture of an underlying non-hematological malignancy. Malignancy-associated eosinophilia can result from clonal or non-clonal proliferation of eosinophils. Here, we report the case of a 59-year-old man with metastatic adenocarcinoma of the lung with an unknown primary tumor site, which presented as hypereosinophilia, anemia, lymphadenopathy, weight loss, and malaise. Bone marrow biopsy disclosed metastatic adenocarcinoma positive in immunohistochemistry for cytokeratin 7. Further assessment of specimens obtained from the bronchoalveolar lavage and biopsy of the mediastinal lymph nodes confirmed the diagnosis of the metastatic lung cancer, although the primary tumor site remained undiscovered. This case underlines that eosinophilia may represent a rare primary manifestation of an undetected malignancy, and it is thus important to consider this as part of the differential diagnosis in patients presenting with unexplained eosinophilia.

Purpose: The purpose of this study was to investigate the impact of T-cell subsets on pathologic and clinical features including disease outcome in mantle cell lymphoma (MCL). Experimental Design: Cell populations were investigated using flow cytometry in diagnostic MCL (n = 153) and reactive (n = 26) lymph node biopsies. Levels of tumor cells, T cells, T-cell subsets, and the CD4:CD8 ratio were assessed and related to pathologic and clinical parameters. Results: MCL cases with diffuse and nodular histologic subtypes showed lower levels of T cells, especially CD4+ T cells, than those with mantle zone growth pattern. Both CD3 and CD4 levels were lower in the nodular subtype than in mantle zone (P = 0.007; P = 0.003) and in the diffuse compared with the nodular subtype (P = 0.022; P = 0.015). The CD4:CD8 ratios were inversely correlated to tumor cell proliferation (P = 0.003). Higher levels of CD3+ and CD4+ T cells and higher CD4:CD8 ratios were associated with indolent disease (P = 0.043, 0.021, and 0.003 respectively). In univariate analysis, a high CD4:CD8 ratio, but not the histologic subtype, was correlated to longer overall survival (OS). In multivariate analysis, the CD4:CD8 ratio correlated with OS independently of Mantle Cell Lymphoma International Prognostic Index (MIPI) and high p53 expression (P = 0.023). Conclusion: CD3+, CD8+, and particularly CD4+ T-cell levels are higher in indolent MCL and decrease with more aggressive histology as reflected by a diffuse growth pattern. High CD4:CD8 ratio correlated independently of other high-risk prognostic factors with longer OS, suggesting a prognostic role for T cells in MCL. Clin Cancer Res; 20(23); 6096–104. ©2014 AACR.

To the Editor Ho and colleagues1 described the results of their study aimed to assess the clinical utility of a bone marrow examination in the diagnosis of hemophagocytic lymphohistiocytosis (HLH). The authors conclude that marrow findings do not reliably predict the probability of HLH, and an isolated finding of hemophagocytosis lacks specificity for HLH. We found the study interesting, but we would like to make some comments on this article. First, we think that the authors should clearly state (eg, in the title) that the study relates only to acquired HLH. Ho et al1 have also omitted important information in the abstract that the study relates only to adults (median age of patients was 54 years; range, 18–87 years). HLH, also known as hemophagocytic syndrome, is usually classified into two distinct forms: an inherited, familial form (FHL) and an …

Experimental model systems have delineated an important role for cytotoxic lymphocytes in the immunosurveillance of cancer. In humans, perforin-deficiency has been associated with occurrence of hematologic malignancies. Here, we describe an Epstein-Barr virus-positive classical Hodgkin’s lymphoma in a patient harboring biallelic mutations in STXBP2, a gene required for exocytosis of perforin-containing lytic granules and associated with familial hemophagocytic lymphohistocytosis. Cytotoxic T lymphocytes were found infiltrating the tumor, and a high frequency of Epstein-Barr virus-specific cytotoxic T lymphocytes were detected in peripheral blood. However, lytic granule exocytosis and cytotoxicity by cytotoxic T lymphocytes, as well as natural killer cells, were severely impaired in the patient. Thus, the data suggest a link between defective lymphocyte exocytosis and development of lymphoma in STXBP2-deficient patients. Therefore, with regards to treatment of familial hemophagocytic lymphohistocytosis patients with mutations in genes required for lymphocyte exocytosis, it is important to consider both the risks of hemophagocytic lymphohistocytosis and malignancy.

The prognostic role of the transcription factor SOX11 in mantle cell lymphoma (MCL) is controversial. We investigated prognostic markers in a population-based cohort of 186 MCL cases. Seventeen patients (9%) did not require any therapy within the first 2 years after diagnosis and were retrospectively defined as having an indolent disease. As expected, indolent MCL had less frequent B symptoms and extensive nodal involvement and 88% of these cases expressed SOX11. In our cohort 13 cases (7.5%) lacked nuclear SOX11 at diagnosis. SOX11− MCL had a higher frequency of lymphocytosis, elevated level of lactate dehydrogenase (LDH), and p53 positivity. The overall survival in the whole cohort, excluding 37 patients receiving autologous stem cell transplantation, was 3.1 year and in patients with indolent or nonindolent disease, 5.9 and 2.8 years, respectively (P = .004). SOX11− cases had a shorter overall survival, compared with SOX11+ cases, 1.5 and 3.2 years, respectively (P = .014). In multivariate analysis of overall survival, age > 65 (P = .001), Eastern Cooperative Oncology Group score ≥ 2 (P = .022), elevated LDH level (P = .001), and p53 expression (P = .001) remained significant, and SOX11 lost significance. We conclude that most indolent MCLs are SOX11+ and that SOX11 cannot be used for predicting an indolent disease course.

Acquired hemophagocytic lymphohistiocytosis (HLH) triggered by a known or still to be recognized malignancy is a life-threatening hyperinflammatory syndrome due to massive cytokine release from activated lymphocytes and macrophages. Malignancy-associated HLH (M-HLH) often impedes adequate treatment of malignancy and has the worst outcome compared with any other form of HLH. The incidence of M-HLH is unknown, and there are no published treatment recommendations addressed to this HLH form. Here, we report the case of a young woman with recurrent ALK1-positive anaplastic large T-cell lymphoma and M-HLH successfully treated with a modified HLH-94 protocol, allogeneic stem cell transplantation (alloSCT) and donor lymphocyte infusion (DLI). More than 3 years after DLI, the patient is alive, in complete remission from her malignancy and HLH-free, although suffering from extensive chronic graft-versus-host disease. AlloSCT and, if needed, DLI performed to consolidate remission of malignancy and HLH may have a curative impact on both entities. We propose that when discussing possible treatment options for patients with M-HLH, alloSCT should be considered in eligible individuals.

A retrospective, population-based study was conducted to evaluate the incidence, clinical features, and outcome of malignancy-associated hemophagocytic lymphohistiocytosis (M-HLH) in adults. Between January 1996 and December 2009, eight out of 887 (0.9%) patients diagnosed with hematological malignancies developed aggressive M-HLH in an area inhabited by approximately 160 000 people. Thus the estimated annual incidence of M-HLH in adulthood was 0.36/100 000 individuals/year. The clinical course of M-HLH was aggressive in all patients. Six patients were treated with a modified HLH-94 protocol; three achieved remission (durable in one case) while the others did not respond and died within an average of 2.4 months (range 1.5–3.5) after M-HLH diagnosis. Infection complicating the course of M-HLH occurred in four (50%) patients, all of whom developed fulminant M-HLH and died. Although the small study population limits the results, the long observation period strengthens its value.

Acquired or secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening hyperinflammation syndrome caused mostly by various infectious agents, autoimmune disorders or malignancy. So far, only anecdotal cases of sHLH associated with multiple myeloma have been published. We provide a review of all these reports and include a previously not published case of myeloma-associated sHLH in a 59-year-old male with complex partial epilepsy. Due to aggressive course of sHLH, increased awareness is indicated in all patients with malignancies which develop unremitting fever, cytopenia and splenomegaly. Early diagnosis and immediate introduction of adequate therapy is crucial for the outcome of HLH.

A 55-year-old previously healthy non-Jewish caucasian woman, working as a psychiatrist, presented with a several-months-long history of general weakness. The pastmedical history revealed effort bruising (Fig. 1) after harder physical work or intensive training from the age of 12 years, and periodic bilateral knee pain from the age of 15. The family history was not contributory. Full blood count showed Hb 114 g/L, WBC 3.27 10/L and platelet count 69 10/L. Laboratory investigations revealed normal liver function tests and APTT, but pathological values were observed for INR (1.3; normal range 0.9–1.2) and ferritin (817 mg/L; normal range 20–300). Neither hepatosplenomegaly nor lymphadenopathy was detected on physical examination, but further computed tomography (CT) imaging revealed slightly enlarged spleen (13.58 7.95 cm) without focal lesions (Fig. 2). Chronic ITP (idiopathic thrombocytopenic purpura) or other haematological disorder (e.g. lymphoma, myelodysplastic syndrome) was suspected, and bone marrow examination was performed, disclosing the presence of large cells with slightly basophilic, fibrillary cytoplasm (Fcrumpled tissue paper_ appearance) and eccentrically placed nuclei. These cells were identified as Gaucher cells (Figs. 3 and 4). The diagnosis of Gaucher disease (GD) was confirmed by a low activity of glucocerebrosidase in peripheral blood leukocytes (0.02 mkat/kg protein; normal range 0.2–0.7) and increased activity of plasma chitotriosidase (3260 mmol/h per L; normal range 9–244). Further direct DNA sequencing disclosed the mutation c.1226A>G (N370S) in the GBA1 gene. DNA sequencing suggested that the patient is probably homozygous for c.1226A>G, but hemizygosity with deletion in the second allele cannot be excluded. Once the diagnosis of GD was confirmed, additional work-up was conducted to establish possible additional reasons for bruising, other than thrombocytopenia. Serum protein electrophoresis and immunofixation test showed polyclonal IgM hyperglobulinaemia (3.84 g/L; normal range 0.3–2.8) without any further immunoglobulin abnormalities. Coagulation work-up revealed only border value of P-Factor XI (60%; normal range 60–140%), minimally decreased P-Factor XIII (69%; normal range 70–140%). P-Factor IX:C (0.77 kIE/L; normal values 0.45–1.90) and all other coagulation factors were within the normal limits. No platelet aggregation defects were detected. The patient did not use any antiplatelet (e.g. acetylsalicylic acid) or anticoagulant (e.g. warfarin) drugs. She was taking ascorbic acid and tranexamic acid daily in order to minimize the extent of bruising. Gaucher disease type I (GD I) can be found in all ethnic groups, but it is particularly prevalent among Ashkenazi Jews. In the general population GD I is J Inherit Metab Dis (2009) 32:758–761 DOI 10.1007/s10545-009-1217-6

Mantle cell lymphoma is a non-Hodgkin lymphoma with, in general, a poor prognosis. A minor subset of patients with an indolent disease course has however been recognized (1,2). The various growth patterns of MCL, i.e. mantle zone (MZ), nodular (N) or diffuse (D) is assumed to correlate to stage and to disease course. The genetic aberrations underlying the pathogenesis are well defined and correlate to high tumour cell proliferation and poor prognosis. However, the effect of the lymphoma microenvironment in disease development and sustainability is largely unknown. We have used flow cytometry to investigate the non-malignant cell composition of the lymph node microenvironment in a population-based cohort of 154 MCL cases diagnosed from January 1, 1998 to December 31, 2012. Flow cytometry analyses of lymph nodes, performed as part of the diagnostic process, were used to evaluate percentages of tumour cells, remaining non-malignant B-cells and T-cell subsets (CD3+, CD3+CD4+, CD3+CD8+). As lymph node T-cell numbers reflect a high tumor load in the lymph node we also investigated the CD4/CD8 ratio, which is not dependent on T-cell percentage. Data from 26 non-malignant lymph nodes were used for comparison. T-cell percentages are shown in Table 1. Clinical and other pathological parameters of the MCL cases, including MIPI, cell morphology, tumor growth pattern and cell proliferation were also evaluated. Indolent disease (n=15), defined here as requirement of treatment > two years from diagnosis, was associated with higher amount of CD3, CD3+CD4+ and higher CD4/CD8 ratio (p=0.0429, p=0.0211 and p= 0.0032 respectively). Higher tumor cell proliferation correlated negatively with the CD4/CD8 ratio (p= 0.0007). There was a significant difference in CD3 percentages between reactive lymph nodes and MCL irrespective of growth pattern (all p0.05). Furthermore, male sex negatively correlated with CD4/CD8 ratio (p=0.0268). Age was not associated to T-cell percentages, CD4/CD8 ratio or growth pattern. In survival analysis a high CD4/CD8 ratio was positively correlated with OS (p= 0.0175).Table 1T-cell percentages (% of mononuclear cells) and CD4/CD8 ratio in reactive lymph nodes and MCL with different growth patterns (marginal zone (MZ), nodular (N) and diffuse (D)) (median, range).CD3CD4CD8CD4/CD8Reactive lymph nodes n=2652.9 (17.6-75.6)39.6 (14.1-63.4)10.0 (2.4-19.2)4.2 (2.1-6.9)MCL MZ n=2530.4 (10.9-84.0)17.4 (7.4-63.2)7.9 (1.2-21.1)3.1 (0.9-7.7)MCL N n=2716.7 (2.3-71.4)9.6 (1.1-58.9)5.4 (1.1-15.2)1.8 (0.6-8.6)MCL D n=469.9 (2.0-43.7)5.5 (0.7-37.0)4 (0.4-18.1)1.6 (0.4-10.4) In conclusion, our data show that the normal lymph node microenvironment is better preserved in indolent MCL and MCL with mantle zone growth pattern. The CD4/CD8 ratio is independent of lymph node tumor burden and high CD4/CD8 ratio was found to correlate with better OS. MCL tumor cells have recently been reported to impair T-cell responses (3). Our results could reflect a disease evolution towards lower tumor cell dependency on signals from the microenvironment and/or as a lymphoma mediated suppression of immune mechanisms for tumor control in aggressive MCL. References: 1. Martin, P. et al. Outcome of deferred initial therapy in mantle-cell lymphoma. J. Clin. Oncol., 2009, 27(8): p. 1209–13 2. Nygren, L. et al. Prognostic role of SOX11 in a population-based cohort of mantle cell lymphoma. Blood, 2012. 119(18): p- 4125–23. 3. Wang, L. et al. Immune evasion evasion of mantle cell lymphoma: expression of B7-H1 leads to inhibited T-cell response to and killing of tumor cells. Haematologica, 2013. Disclosures: No relevant conflicts of interest to declare.

Abstract 1592 Introduction: Mantle cell lymphoma (MCL) constitutes 3–10% of non-Hodgkin lymphomas and affects predominantly middle-aged to elderly men. The median survival is 3–5 years and seems to improve with new therapeutic regimens. The MCL International Prognostic Index (MIPI) has been proven useful for predicting survival in MCL patients included in clinical trials, but its value in unselected population based MCL cohorts is less well known. Biological markers are increasingly used for prognostication of MCL patients, especially for defining indolent cases. Material and Methods: All 186 patients diagnosed with MCL, confirmed by IHC for cyclinD1 and/or by FISH for t(11;14), between January 1998 and June 2010 in the Stockholm region, were included in a retrospective analysis. Clinical data from patient files, diagnostic biopsies and flow cytometry data were reviewed. Last follow-up was in May 2011. The prognostic value of the following variables, evaluated at the time of diagnosis, were analyzed: age, sex, Ann Arbor stage, ECOG, B-symptoms, Hb, LDH, albumin, lymphocytosis, leukocytosis, splenomegaly, nodal, extranodal and bone marrow involvement, blastoid morphology, expression of CD23, light chain, Ki 67, p53 and nuclear SOX11. Results: The median age at diagnosis was 68.8 years (range 36.2 – 89.9); 67.4 in males and 72.1 in females, respectively. The male: female ratio was 2. Thirty patients had a known malignancy of other type before the MCL diagnosis and 12 acquired a cancer later. In 13 patients the other malignancy was the cause of death. Median overall survival (OS) time was 43 months in the whole cohort and 38 months, when excluding 39 patients receiving ASCT as part of first-line therapy. No statistically significant difference in OS was seen with respect to whether the lymphoma was diagnosed before or after 2005. In the non-transplanted patients (n=149), univariate analysis showed the following clinical variables to be negatively correlated to overall survival: age >65 years, B-symptoms, splenomegaly, ECOG >2, low albumin, and high LDH. The median survival was not reached in the low risk MIPI group, and was 79 and 34 months, in the middle and high risk MIPI group, respectively. Blastoid morphology and p53 positivity (>20%), were negatively correlated to overall survival (both with p50%, both with with p30% (p=0.061), while SOX11 positivity was related to a prolonged survival (p=0.015). Multivariate analyses showed that age >65 (HR 6.1, p2 (HR 63, p Clinically indolent MCL, defined as in retrospect not requiring treatment within two years from diagnosis, was seen in 17 patients. In two of these patients the proliferation was >30%, in one >50%, two had a p53 expression >20% and two were SOX11 negative. Therapy was never required in 9 of these initially indolent patients and only one had an autologous transplantion later in the disease course. The median OS was 72 months for the 17 indolent MCL compared with 34 months in patients requiring treatment earlier in their disease (p=0.003). The follow-up time did not differ significantly between the two groups. Conclusions: Compared to data from published clinical trials of advanced MCL, our population-based cohort of 186 cyclin D1 positive MCL patients were diagnosed at an older age, which may contribute to a shorter overall survival. Certain well-established prognostic variables seem to loose significance outside study populations. In the group of 147 non-transplanted patients multivariate analysis showed that only age, ECOG, LDH and p53 positivity were independently associated with overall survival. Leukocytosis as a variable of MIPI had no impact. Neither SOX11, CD23 or other biological markers applied at the time of diagnosis could predict for clinically indolent disease. Disclosures: No relevant conflicts of interest to declare.

Abstract 3651 Introduction: Mantle cell lymphoma (MCL) constitutes 3–10% of non-Hodgkin lymphomas and has a median survival of 3–5 years. A small number of patients are characterized by a clinically indolent disease and may not require treatment for several years. However, these are difficult to identify at the time of diagnosis due to lack of reliable predictive markers. Recently, the nuclear expression of the transcription factor SOX11 has been suggested to be of prognostic value in MCL. Materials and Methods: All 186 patients diagnosed with MCL in the Stockholm region between January 1998 and June 2010 were included. Diagnosis was according to the WHO criteria and all cases were cyclin D1 positive by IHC and/or for t(11;14) by FISH. Clinical data from patient files, diagnostic biopsies and flow cytometry data were reviewed. Patients not requiring treatment within the first two years after diagnosis were retrospectively defined as indolent disease. Patients were further categorized in nuclear SOX11 negative (n=13) and nuclear SOX11 positive (n=160) cases and in cases with indolent (n=17) versus non-indolent disease course (n=169). The following variables were evaluated at the time of diagnosis: age, sex, Ann Arbor stage, ECOG, B-symptoms, Hb, LDH, albumin, lymphocytosis, leukocytosis, splenomegaly, nodal and bone marrow involvement, MIPI, indolent disease, blastoid morphology, expression of CD23, light chain, Ki 67, SOX11 and p53. Overall survival was analyzed, excluding patients receiving ASCT (n=37). Baumgartner, S. et al presents further data on the entire cohort in the accompanying abstract. Results: The following variables were significantly more common in SOX11 negative cases (Table 1): Lymphocytosis (p=0,045), high LDH (p=0,029) and p53 positivity (p Conclusions: In a population-based cohort of 186 cyclin D1 positive MCL, 8% lacked expression of nuclear SOX11 at diagnosis. There was no enrichment of patients with an indolent disease among SOX11 negative MCL. Instead patients with SOX11 negative MCL had a higher frequency of lymphocytosis and elevated LDH at diagnosis and a shorter overall survival. MCL lacking nuclear SOX11 expression at diagnosis were more frequently p53 positive which may contribute to shorter survival in the SOX11 negative MCL subset. Disclosures: No relevant conflicts of interest to declare.