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Most patients with systemic mastocytosis bear mutations in the tyrosine kinase receptor gene c-Kit. Limited treatment options exist for mast cell leukemia, a rare form of systemic mastocytosis associated with a dire prognosis. Our aim was to investigate c-Kit mutations associated with mast cell leukemia and find new treatment for this severe form of mastocytosis.We describe here a patient with mast cell leukemia characterized by 42% of circulating mast cells associated with a previously unidentified c-Kit mutation in adult mastocytosis: dup(501-502).This patient was treated with masitinib, a novel c-Kit tyrosine kinase inhibitor, with a dramatic response observed following 3 months of treatment, including clinical improvement, disappearance of circulating mast cells, and decrease in both serum histamine and tryptase levels. In vitro and ex vivo research was performed on the patient's cells and revealed constitutive c-Kit phosphorylation in mast cell leukemia.This case highlights the importance of sequencing all c-Kit exons when the classical D816V c-Kit mutation is not found, even in adults with SM. It also indicates that masitinib may be safe and effective for the treatment for some mast cell leukemia.

Chantier qualité GA; Objectives: We evaluated whether IGL-1, a graft preservation solution containing polyethylene glycol, improves the outcome of small bowel grafts in comparison to the University of Wisconsin (UW) solution in a pig allotransplantation model.[br/] Materials and Methods: Seventeen pigs were randomly allocated to group 1 (n = 10; intestinal allotransplantation with IGL-1) and group 2 (n = 7; allotransplantation with UW). Pigs received no immunosuppression and were sacrificed on postoperative d (POD) 8. Intestinal specimens were obtained from the animal immediately before cold flushing (T0), 2 h after graft reperfusion (T1), and at sacrifice (T2).[br/] Results: Survival rate to POD 8 was 50% in group 1 compared with 16% in group 2 (P < 0.05); 62% of pigs in group 1 did not present any acute cellular rejection (ACR) compared to 16% in group 2 (P < 0.05). Severe ACR rate was 25% in group 1 and 66% in group 2 (P < 0.05). iNOS activity and intestinal caspase 3 levels increased significantly between T0 and T1 in group 1 compared to group 2 (P < 0.05). Cell necrosis increased significantly between TO and T1 in group 2 compared with group 1 (P < 0.05) whereas cell apoptosis was significantly higher at T1 compared with T0 in group 1 in comparison to group 2.[br/] Conclusions: Our results show that IGL-1 improves intestinal graft viability as compared to UW solution, possibly by reducing graft immunogenicity and by favoring intestinal epithelial repair.

International audience; Childhood multicentric Castleman disease (MCD) is a rare and unexplained lymphoproliferative disorder. We report a human herpesvirus-8 (HHV-8)-infected child, born to consanguineous Comorian parents, who displayed isolated MCD in the absence of any known immunodeficiency. We also systematically review the clinical features of the 32 children previously reported with isolated and unexplained MCD. The characteristics of this patient and the geographic areas of origin of most previous cases suggest that pediatric MCD is associated with HHV-8 infection. Moreover, as previously suggested for Kaposi sarcoma, MCD in childhood may result from inborn errors of immunity to HHV-8 infection.

Mast cell leukemia (MCL) is a rare and aggressive disease with poor prognosis and short survival time. D816V c-KIT mutation is the most frequent molecular abnormality and plays a crucial role in the pathogenesis and development of the disease. Thus, comprehensive diagnostic investigations and molecular studies should be carefully carried out to facilitate the therapeutic choice. A MCL patient’s case with rare phenotypic and genotypic characteristics is described with review of major clinical biological and therapeutic approaches in MCL.

Hepatitis C virus (HCV) infection is a well-established risk factor for the development of B cell non-Hodgkin lymphoma (B-NHL). Two main pathways have been proposed to explain the role of the virus in lymphomagenesis: 1) transformation of B cells either directly by oncogenic viral proteins, or by a hit-and-run mechanism inducing a mutator phenotype, and 2) chronic antigenic stimulation through the B cell receptor (BcR) in conjunction to the binding of the viral E2 protein to its receptor CD81. There are however conflicting data regarding whether the BcR of the lymphomatous cells are capable of directly recognizing viral proteins or, rather, they possess a rheumatoid factor (RF) activity, binding instead polyclonal immunoglobulin (IG) within immune complexes trapping the virus. To further elucidate the role of antigenic stimulation in the natural history of HCV-associated B-NHL, we analyzed the IG gene repertoire of both heavy and light chains expressed by neoplastic cells in 41 cases of HCV-associated NHL, including: 29 marginal zone lymphoma (MZL); 7 diffuse large B-cell lymphoma (DLBCL) of which 3 originated from transformed MZL ; and 5 other low-grade B-cell NHL. Tumor cells were obtained from blood in 39 cases, bone marrow and a lymph node biopsy in 1 case each. Forty-three productive IGHV-IGHD-IGHJ gene rearrangements were obtained, which displayed a clear biased gene composition as 3 IGHV genes contributed to almost half of the repertoire: IGHV1-69 (11/43, 25,6%), IGHV3-7 (5/43, 11.6%), IGHV3-21 (4/43, 9.3%). This was also true for both IGHD genes (IGHD3-22: 12/43, 27.9%), and IGHJ genes (IGHJ4: 17/43, 39.5%; IGHJ3: 17/43, 25.6%). All but 3 sequences carried somatic hypermutations (SHM) in their IGHV genes with a median identity to the germline of 97.6% (range 86.5-100%). Thirty-eight productive IG light chain rearrangement sequences were obtained from 36 cases, of which 30 (78.9%) were IGK. Similarly, they exhibited strong gene usage bias with an over-representation of IGKV3-20 (9/30, 30%), as well as IGKJ1 (11/30, 33.3%) and IGKJ2 (6/30, 20%). IG light chain sequences were found to harbor similar SHM load with a 97% median identity to germline (range 91-100%). As previously described, we observed preferential pairing of heavy and light chain genes, with 6 of the 9 IGHV1-69 cases (with available light chain sequence data) being associated with IGKV3-20. Using established criteria, we found 5 cases (11.6%) carrying stereotyped BcR i.e. IGHV-IGHD-IGHJ gene rearrangements with quasi-identical amino-acid (AA) sequences, including the highly variable complementary determining region 3 (CDR3). Three cases concerned IGHV3-7/IGHD3-22/IGHJ3 rearrangements with an 18 AA-long CDR3, and 2 concerned IGHV1-69/IGHD3-22/IGHJ4 rearrangements with a 13 AA-long CDR3. Identity within the CDR3 extended to AA encoded by randomly inserted N-region nucleotides. We failed to establish correlations between histological categories and IG repertoire, probably due to the uneven distribution of lymphoma subtypes within our cohort. In contrast, most if not all sequences with biased IG gene usage, including the 5 stereotyped BcR ones, were found amongst the 28/41 cases (68.3%) with mixed cryoglobulinemia type II and/or positive for RF (MC/RF+). These two categories of patients differed also regarding the SHM load of their IGHV genes since MC/RF+ cases were signlificantly less mutated than MC/RF- cases (median identity to germline: 97.9% vs 95.9%, p= 0.048). We then searched for similar sequences in public databases and collaborative studies. Stereotyped BcR sequences similar to those of our cases were detected in HCV-associated lymphoma, but also in other HCV-negative B-cell maligancies e.g. MALT lymphoma (some associated with RF) and chronic lymphocytic leukemia, non malignant B cells with RF activity, and non malignant marginal zone splenic B cells. Sequence similarity extended to some shared AA replacements, e.g. identical AA introduced by HSM at the same positions. In conclusion we confirm the highly biased IG repertoire of HCV-associated lymphoma. However this feature seems to be linked essentially to the presence of a MC and/or RF. As quasi-identical sequences are found in HCV-negative malignant and normal B cells, our data support the hypothesis that HCV-associated lymphomatous cells originate from precursors endowed with auto-immune properties rather than B cells expressing an anti-virus BcR. Disclosures Stamatopoulos: Gilead Sciences: Research Funding; Janssen Pharmaceuticals: Research Funding.

Introduction Diffuse Large B Cell Lymphoma (DLBCL) is the most common lymphoid malignancy, accounting for 30-40% of all Non Hodgkin Lymphomas. Gene expression profiling (GEP) has identified three main subtypes of DLBCL: Germinal Center B-cell like (GCB), Activated B-Cell like (ABC) and Primary Mediastinal B-cell Lymphoma (PMBL). Recently, Next Generation Sequencing (NGS) has enabled a more detailed characterization of DLBCL mutational profiles. Conventional techniques such as immunohistochemistry (IHC) and FISH are also widely used to describe DLBCL. However, no study has yet performed an integrative analysis of the mutational, gene expression, IHC and FISH profiles of DLBCL, in order to provide a comprehensive view of this disease. Methods 215 patients with de novo DLBCL in the prospective, multicenter and randomized LNH-03B clinical trials led by the LYmphoma Study Association (LYSA) were included in this study. Microarray-based GEP identified 81 ABC, 83 GCB, 18 PMBL and 33 other. Mutational profiles of patients' tumor DNA were established using Lymphopanel NGS, designed to identify mutations in 34 genes important for lymphomagenesis. For each recurrently mutated gene, we applied ROMER (Ritchie, Nucleic Acids Res, 2015) to perform gene set enrichment analysis on differential expression profiles of mutant and wild-type patients, using a multifactorial model accounting for subtype. The gene sets were obtained from the MSIGDB Hallmarks (Subramanian A, PNAS, 2005) and Signaturedb (Schaffer, Immunol Rev, 2006) collections. When possible, IHC was performed for IgM (n=150), MYC (n=140), BCL2 (n=148), BCL6 (n=146), CD10 (n=152), FOXP1 (n=147) and MUM1 (n=152); FISH was performed for MYC (n=131), BCL2 (n=133) and BCL6 (n=131). Results As expected, EZH2 mutations were significantly associated with upregulation of GCB gene expression (p An association between BCL6 translocations and ABC subtype was confirmed, via a correlation with ABC-enriched CD79B mutations (p=0.02), although interestingly not with MYD88 mutations. MYD88 mutations were correlated with an upregulation of genes involved in proliferation or repressed by PRDM1 (FDR=0.04 each), as well as with an upregulation of genes involved in checkpoint controls, such as E2F targets and genes involved in DNA repair (FDR=0.03 each). All MYD88 mutants expressed FOXP1 in IHC (p PMBL-enriched mutations in our cohort were frequently associated with IgM and FoxP1 negative IHC, as expected (WHO 2008 and Roschewski, Nat Rev Clin Onc). XPO1 and ITPKB mutations were correlated with JAK-STAT pathway activation in the total cohort, including upregulation of interferon-inducible genes for both gene mutations (FDR=0.02 and FDR=0.08 respectively) and upregulation of BCL6-repressed genes for XPO1 mutations only (FDR=0.02). Interestingly, CD58 mutations were significantly correlated with upregulation of Nfkb pathway target genes (FDR=0.06), perhaps due to their negative impact on CD2 activation and ROS production inhibition. Conclusion The results herein provide steps toward a comprehensive, multi-level overview of DLBCL. We highlight differential gene set expression linked to gene mutation status, as well as driver translocation-associated mutational profiles. By using an integrative analysis approach, this study broadens our understanding of DLBCL subtypes' diverse genetic backgrounds. Disclosures Briere: St. Louis Hospital, Paris, France: Employment. Salles:Celgene Corporation; Roche: Speakers Bureau; Calistoga Pharmaceuticals, Inc.; Celgene Corporation; Genentech, Inc.; Janssen Pharmaceutica Products, L.P.; Roche: Consultancy; Celgene Corporation; Roche and Gilead Sciences: Research Funding.

Introduction Le tryptophane, est un acide amine essentiel qui participe principalement a la formation des proteines, mais il est egalement a l’origine de la synthese de serotonine. L’enzyme Indoleamine 2,3-dioxygenase (IDO) catalyse la degradation du trytophane en kynurenines. Le tryptophane et ses metabolites jouent un role important dans l’immunite intestinale, l’inflammation et la motricite intestinale via la serotonine. L’activite de l’enzyme IDO peut etre induite par les cellules immunitaires et les cytokines inflammatoires, ces dernieres pouvant etre secretees par les mastocytes. La mastocytose est une maladie rare liee a l’accumulation de mastocytes dans les tissus et leur activation. Il existe des troubles digestifs chez 57 % des patients comme de la diarrhee, des ballonnements et des douleurs abdominales. L’objectif etait d’etudier le metabolisme du tryptophane chez des patients ayant une mastocytose avec des troubles digestifs (n = 26) ou sans troubles digestifs (n = 26), compares a des controles sains (n = 26). Patients et methodes Cinquante-quatre patients atteints de mastocytose et d’âge moyen de 49,9 ans ont ete inclus et compares a des temoins sains apparies en âge. Tous les patients avaient des mesures seriques du tryptophane, de la serotonine, des kynurenines et l’activite de IDO (rapport kynurenine/tryptophane) et avaient ete evalues par un gastro-enterologue referent. Resultats Tous les patients avec mastocytose avaient un tryptophane plus bas que les controles. Les patients atteints de mastocytose avec troubles digestifs presentaient une activite de IDO et des taux de kynurenines plasmatiques significativement plus elevee par rapport aux controles sains et aux patients atteints de mastocytose sans troubles digestifs. Discussion Ces resultats plaident en faveur d’une implication des mastocytes sur l’inflammation digestive chez les patients atteints de mastocytose systemiques. Les mastocytes pourraient induire une inflammation via la secretion de cytokines pro-inflammatoires induisant la production de kynurenines a partir du tryptophane au profit de la voie de la serotonine. Conclusion Ce travail est le premier se concentrant sur la voie de la kynurenine dans une maladie impliquant les mastocytes au niveau digestif et pourrait aider a comprendre la pathogenese des troubles digestifs dans la mastocytose ainsi que dans d’autres maladies mediees par des mastocytes. De nouvelles pistes therapeutiques peuvent etre ainsi envisagees dans les troubles digestifs de la mastocytose qui sont parfois au premier plan et peuvent etre tres invalidants.

Danazol has been used with success in some hematological diseases, but there is no report of this treatment in acute leukemia. We report here a case of remission of myelodysplastic syndrome with myelofibrosis in transformation after danazol therapy in a 72-yr-old man. The role of danazol in remission induction is briefly discussed.

We report 2 cases of previously healthy children, who developed, after a common parvovirus B19 infection, a sudden inflammatory response, involving predominantly T cell, directed against myocardium and leading to fatal outcome. These cases and several published case reports further our understanding of fulminating parvovirus myocarditis in children.

Background: The pathogenesis of inflammatory bowel disease (IBD) is multifactorial, with some patients presenting additional autoimmune symptoms. Inflammatory colitis associated with autoimmune (AI) liver disease appears to have clinical features different from those of “classical” ulcerative colitis (CUC). The aim of this study was to describe these features, in order to differentiate a subgroup of colitis associated with autoimmunity (CAI) from CUC. Methods: Twenty-eight consecutive children with inflammatory colitis associated with primary sclerosing cholangitis (PSC), celiac disease, or AI hepatitis were compared with a matched control group of 27 children with isolated UC. Clinical course, histology, as well as inflammatory profile in the colonic mucosa based on real-time polymerase chain reaction (PCR) were analyzed. Results: In CAI the main digestive symptoms at disease onset were abdominal pain (12/28) and bloody strings in the stool (12/28), along with a high prevalence of autoimmune diseases in relatives, as compared with bloody diarrhea in the CUC group (26/27). At diagnosis, pancolitis was seen in 18/28 CAI patients compared with 8/27 in UC. In CAI, the pathological findings were different from CUC: 1) major lesions predominantly located in the right colon; 2) pseudo-villous appearance of the mucosa, and strong infiltration with eosinophils; 3) mild glandular lesions; and 4) differing inflammatory infiltrate with reduced FOXP3, interleukin (IL)-2, and thymic stromal lymphopoietin (TSLP) levels. Evolution in CAI was less aggressive, requiring less corticosteroids/immunomodulators. Conclusions: Precise clinical, histological, and molecular analyses reveal marked differences between patients with CUC and those with associated AI phenomena, supporting the hypothesis of a distinct AI presentation of IBD. (Inflamm Bowel Dis 2012)

Summary Background The outcome of diffuse large B-cell lymphoma has been substantially improved by the addition of the anti-CD20 monoclonal antibody rituximab to chemotherapy regimens. We aimed to assess, in patients aged 18–59 years, the potential survival benefit provided by a dose-intensive immunochemotherapy regimen plus rituximab compared with standard treatment plus rituximab. Methods We did an open-label randomised trial comparing dose-intensive rituximab, doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisone (R-ACVBP) with subsequent consolidation versus standard rituximab, doxorubicin, cyclophosphamide, vincristine, and prednisone (R-CHOP). Random assignment was done with a computer-assisted randomisation-allocation sequence with a block size of four. Patients were aged 18–59 years with untreated diffuse large B-cell lymphoma and an age-adjusted international prognostic index equal to 1. Our primary endpoint was event-free survival. Our analyses of efficacy and safety were of the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT00140595. Findings One patient withdrew consent before treatment and 54 did not complete treatment. After a median follow-up of 44 months, our 3-year estimate of event-free survival was 81% (95% CI 75–86) in the R-ACVBP group and 67% (59–73) in the R-CHOP group (hazard ratio [HR] 0·56, 95% CI 0·38–0·83; p=0·0035). 3-year estimates of progression-free survival (87% [95% CI, 81–91] vs 73% [66–79]; HR 0·48 [0·30–0·76]; p=0·0015) and overall survival (92% [87–95] vs 84% [77–89]; HR 0·44 [0·28–0·81]; p=0·0071) were also increased in the R-ACVBP group. 82 (42%) of 196 patients in the R-ACVBP group experienced a serious adverse event compared with 28 (15%) of 183 in the R-CHOP group. Grade 3–4 haematological toxic effects were more common in the R-ACVBP group, with a higher proportion of patients experiencing a febrile neutropenic episode (38% [75 of 196] vs 9% [16 of 183]). Interpretation Compared with standard R-CHOP, intensified immunochemotherapy with R-ACVBP significantly improves survival of patients aged 18–59 years with diffuse large B-cell lymphoma with low-intermediate risk according to the International Prognostic Index. Haematological toxic effects of the intensive regimen were raised but manageable. Funding Groupe d'Etudes des Lymphomes de l'Adulte and Amgen.

Inherited deficiency of major histocompatibility complex (MHC) class II molecules impairs antigen presentation to CD4+ T cells and results in combined immunodeficiency (CID). Autosomal-recessive mutations in the RFXANK gene account for two-thirds of all cases of MHC class II deficiency. We describe here the genetic, clinical, and immunologic features of 35 patients from 30 unrelated kindreds from North Africa sharing the same RFXANK founder mutation, a 26-bp deletion called I5E6-25_I5E6 + 1), and date the founder event responsible for this mutation in this population to approximately 2250 years ago (95% confidence interval [CI]: 1750-3025 years). Ten of the 23 patients who underwent hematopoietic stem cell transplantation (HSCT) were cured, with the recovery of almost normal immune functions. Five of the patients from this cohort who did not undergo HSCT had a poor prognosis and eventually died (at ages of 1-17 years). However, 7 patients who did not undergo HSCT (at ages of 6-32 years) are still alive on Ig treatment and antibiotic prophylaxis. RFXANK deficiency is a severe, often fatal CID for which HSCT is the only curative treatment. However, some patients may survive for relatively long periods if multiple prophylactic measures are implemented.

Purpose The utility of [18F]fluorodeoxyglucose (FDG) positron emission tomography–computed tomography (PET-CT) in assessing response at the end of induction therapy is well documented in Hodgkin's and diffuse large B-cell lymphomas, but its role in follicular lymphoma (FL) remains undetermined. We investigated the prognostic significance of PET-CT performed after first-line therapy in patients with FL treated in the prospective Primary Rituximab and Maintenance (PRIMA) study. Patients and Methods Results of PET-CT scans performed after induction immunochemotherapy were recorded retrospectively. Patients went on to either observation or rituximab maintenance per protocol independent of the PET-CT result. Patient characteristics and outcomes were then evaluated. Results Of 122 PET-CT scans performed at the end of the induction immunochemotherapy, 32 (26%) were reported as positive by the local investigator. Initial demographic or disease characteristics did not differ between PET-CT–positive (PET-positive) and PET-CT–negative (PET-negative) patients. PET status correlated with conventional response criteria (P < .001). Patients remaining PET positive had a significantly (P < .001) inferior progression-free survival at 42 months of 32.9% (95% CI, 17.2% to 49.5%) compared with 70.7% (95% CI, 59.3% to 79.4%) in those who became PET negative. PET status, but not conventional response (complete response or complete response unconfirmed v partial response) according to IWC 1999, was an independent predictive factor for lymphoma progression. The risk of death was also increased in PET-positive patients (hazard ratio 7.0; P = .0011). Conclusion [18F]FDG PET-CT status at the end of immunochemotherapy induction in patients with FL is strongly predictive of outcome and should be considered a meaningful clinical end point in future studies.

Objectives Early onset inflammatory bowel diseases (EO-IBD) developing during the first year of life are likely to reflect inherited defects in key mechanism(s) controlling intestinal homeostasis, as recently suggested for interleukin 10 (IL10). Thus, we aimed to further elaborate the hypothesis of defective anti-inflammatory responses in patients with IBD. Methods The capacities of transforming growth factor β (TGFβ) and IL10 to inhibit proinflammatory cytokine production by monocyte-derived dendritic cells (MoDC) or peripheral blood cells (PBMC) was analyzed in 75 children with IBD, including 13 infants with EO-IBD (in whom autoimmune diseases or classical immunodeficiencies were ruled out). IL10 receptor-A/-B expression, STAT3 activation in response to IL6, IL10, IL21, IL22 were analyzed by FACS and western blotting. IL10RA and B genes were sequenced. The response to IL22 was tested in ileal/colonic tissue cultures. Tissue gene expression was analyzed by Taqman real-time polymerase chain reaction. Results Production of IL10 in response to bacterial motifs was normal in all IBD patients. In contrast to our original hypothesis, no defect of the anti-inflammatory potential of TGFβ and IL10 was observed in children with IBD or EO-IBD except two infants who presented with granuloma-positive colitis at 3 months of life: no response to IL10 was observed secondary to mutations in the α (p.R262C) or β (p.E141X) chain of IL10R, respectively, although a fully functional Jak-STAT3 pathway was present in both patients. When analyzing the regulation of intestinal bacterial clearance, we detected a defect in the patient with absent IL10 RB to upregulate protective transcripts in response to IL22, whereas all other EO-IBD patients, including the patient with an abnormal α chain, responded normally. Conclusions Impaired IL10 signaling characterizes a subgroup of IBD patients, whereas the majority of children with severe IBD including EO forms normally produces and responds to IL10. Defective IL22 signaling may additionally impair intestinal epithelial clearance. Our data point out the complexity of IBD, which represent a group of distinct diseases with several pathogenetic abnormalities.

Nasal natural killer (NK) lymphoma associated with Epstein-Barr virus (EBV) is a rare lymphoma that has not yet been reported in patients with human immunodeficiency virus (HIV). This report describes the first case, to our knowledge, of nasal NK cell lymphoma in an HIV-positive patient. A 50-year-old African man presented with an obstructive nasopharyngeal tumor, leading to the diagnosis of HIV infection. Nasal biopsy specimens showed NK cell lymphoma, confirmed on nasal tissues by morphologic, immunohistochemical, and polymerase chain reaction studies using a denaturing gradient gel electrophoresis technique that showed no T-cell receptor γ rearrangement. The EBV was detected by in situ hybridization. The patient received chemotherapy but died from infection. To our knowledge, this is the first reported case of nasal NK cell lymphoma associated with EBV in an HIV patient. Involvement of EBV in HIV non–B-cell lymphomas may represent a further manifestation of opportunistic EBV infection arising in these patients.

Background: Thiopurines are considered first-line immunomodulators for the prevention of relapse in moderate to severe pediatric Crohn's disease (CD). Early introduction of thiopurines was shown in a pediatric trial to maintain steroid-free remission in 90% of patients for 18 months. In the present study we analyzed the tolerance and efficacy of azathioprine (AZA) to maintain remission in a homogenous single-center observational cohort of children with CD. Methods: In all, 105 pediatric CD patients (male/female 68/37) were retrospectively evaluated for the efficacy of AZA (doses 1.4–4 mg/kg) to maintain remission at 6, 12, 18, and 24 months of follow-up. Overall, 93 children were included with active disease (pediatric Crohn's disease activity index [PCDAI] >30), steroid/enteral-nutrition dependency, or postileocecal resection. Remission was defined as PCDAI ≤10 without steroids. Patients requiring antitumor necrosis factor (TNF) medication, other immunomodulators, or surgery were considered to experience a relapse. Results: Based on PCDAI, steroid-free remission was achieved in 56/93 (60.2%), 37/93 (39.8%), 31/93 (33.3%), and 29/93 (31.2%) at visits month (M)6, M12, M18, and M24, respectively. Within the first 4 weeks, AZA was stopped in 10/93 patients due to adverse reactions (pancreatitis, nausea, vomiting, skin reactions, general weakness), or not introduced due to low thiopurine methyl transferase (TPMT) activity (n = 3). No neutropenia occurred in patients with normal TPMT activity. Three infectious episodes were documented requiring temporary AZA suspension. Conclusions: AZA is efficacious in maintaining remission in pediatric CD patients, but to a lesser extent than previously suggested. The majority of patients who are in steroid-free remission at 12 months remained in prolonged remission. Overall tolerance of AZA was excellent. Inflamm Bowel Dis 2011

Mutations of the EPCAM gene have been recently identified in Congenital Tufting Enteropathy (CTE), a severe autosomal recessive gastrointestinal insufficiency of childhood requiring parenteral nutrition and occasionally intestinal transplantation. Studying seven multiplex consanguineous families from the Arabic peninsula (Kuwait and Qatar) we found that most patients were homozygote for a c.498insC mutation in exon 5. The others carried a novel mutation IVS4-2A → G. Both mutations were predicted to truncate the C-terminal domain necessary to anchorage of EPCAM at the intercellular membrane. Consistently, immunohistochemistry of intestinal biopsies failed to detect the EPCAM protein at the intercellular membrane level. The c.498insC mutation was found on the background of a minimal common haplotype of 473 kb suggesting a very old founder effect (5000–6000 yrs).

Mutations of Fas or, less frequently, Fas ligand genes result in a rare inherited lymphoid disorder called autoimmune lymphoproliferative syndrome (ALPS) in which lymphoma frequency is increased. We report on a patient with ALPS who had been splenectomized for giant splenomegaly and progressively developed a voluminous abdominal tumor. The histology of the removed tumor revealed that it was an accessory spleen exhibiting typical features of ALPS involvement, as shown by the presence of a large excess of CD3+CD4-CD8- T cells and plasma cells without a detectable monoclonal population. This observation highlights the lymphoma's differential diagnosis in this context.

Objectives To investigate bone involvement in a large cohort of systemic mastocytosis (SM) patients, and evaluate the efficacy of bisphosphonate therapy. Patients and Methods From 2000 to 2004, 75 patients with SM according to WHO criteria underwent skeletal x-rays and bone mineral density (BMD) assessment. Sequential BMD assessments were performed in nine patients treated with bisphosphonate (mean follow-up 65 months). Results 37 patients (49%) had bone involvement according to both x-rays and BMD evaluations: osteoporosis (23 patients, 31%, mean lumbar spine T score: −3 SD), with vertebral fracture (13 patients, 17%), axial skeleton osteosclerosis (six patients, 8%), mixed patterns (three patients), osteopenia with pre-existing fractures (four patients) and focal osteolytic lesion (one patient). Blood count abnormalities were associated with osteosclerosis (p=0.005). In nine patients with osteoporosis and bisphosphonate therapy, mean lumbar spine BMD increased from 0.83 to 0.92 g/cm 2 (+11.1%; ie, +2.05% per year) without recurrence of vertebral fracture. Conclusion Half of adult patients with SM have bone involvement. Osteoporosis is the most prevalent bone manifestation in SM (31%). Bisphosphonate therapy seems efficient to improve lumbar spine BMD during SM-related osteoporosis. Spine x-ray and BMD should be performed in all SM patients to detect those who may benefit from anti-osteoporotic therapy.

Anorectal Hodgkin lymphoma (HL) is rare, mainly described in human immunodeficiency virus (HIV) patients with exceptional cases reported in immunocompetents. We report the case of a middle age HIV male, presenting with intestinal occlusion. Rectosigmoidoscopy showed multiple anorectal nodular and ulceronecrotic masses. The biopsy specimens revealed a diffuse polymorphous inflammatory infiltrate in the lamina propria, associated with CD30, CD20, CD3, CD15, and ALK1 scattered large Hodgkin and/or Reed Sternberg -like cells stained by LMP1 antibody and EBER. A diagnosis of EBV-associated atypical lymphoproliferative disease mimicking HL was made. These lesions remained stable for 2 years without treatment then disappeared leaving a mucosal scar. A later control biopsy showed a condylomatous lesion, without lymphoid lesion, suggesting a sexually acquired infection. Eight years later, the complete resolution of the lesion without any treatment is a strong argument against a malignant lymphoid process and raises doubts as to the reality of isolated anorectal HL in immunocompetent participants.

International audience; Mastocytosis is a rare and heterogeneous disease characterized by various biological and clinical features with different prognosis and treatments. The disease is usually divided into 2 categories: a pure cutaneous and a systemic disease. Clinical features can be related to mast cells' mediators release or to pathological mast cells infiltration. The diagnosis of mastocytosis is based on clinical, biological, histological, and molecular international criteria. Among all manifestations of the disease, gastrointestinal (GI) symptoms are common and can significantly impair the quality of life. The aim of this article is to review the data regarding GI involvement in mastocytosis. Articles dealing with clinical, pathophysiological, and therapeutic aspects of mastocytosis GI tract involvement were searched for using PubMed. GI manifestations in mastocytosis are reviewed. Pathogenesis of GI symptoms in systemic mastocytosis and their treatment are critically discussed. The most frequent GI symptoms are abdominal pain, diarrhea, nausea, and vomiting. GI lesions may involve all the digestive tract, from the esophagus to the rectum. The histological diagnosis of GI involvement is difficult. The treatment of GI symptoms aims to prevent and limit mast cells degranulation and/or its consequences and more rarely to control tumoral mast cells infiltration. The high prevalence of GI symptoms in mastocytosis and their important functional impact deserves better characterization and treatment in order to improve patients' quality of life. Diagnosis of mastocytosis GI manifestations should be evoked in the case of unexplained severe GI disorders.

SummaryWe have investigated the hearts from 153 infants found dead in their cots at ages ranging from one month to one year. The deaths occurred over a period of five years (January 1986 to December 1990) and were studied in a center for the study of the sudden infant death syndrome located in Paris. The epidemiological characteristics of this group are:male predominance (sex ratio 1.43), age less than four months (82%), and a predominance of winter deaths. These are the characteristic features ofthe sudden infant death syndrome. Ofthe 143 children studied with the permission of their parents, 24 (16.8%–12 girls and 12 boys) had histological lesions consistentwith myocarditis according to the Dallas criteria. The histological diagnosis of myocarditis is based on the association of cellular necrosis with a mononuclear or mixed inflammatory infiltrate. Cytoplasmic vacuolization, the presence of inflammatory cells in myocytes, and rupture of the cell walls of myocardial fibres are the equivalent histological signs of cellular necrosis. Myocarditis was diversely associated with respiratory, hepatic, muscular, gastrointestinal and/or neurological involvement. Twelve infants had previously been ill. Two died during the course of a serious illness. In only four cases was a viral association demonstrated. This incidence of myocardial involvement, similar to thatdescribed elsewhere in the literature, suggests that myocarditis could be a pathogenic explanation of some deaths thought on general autopsy investigation to be sudden and unexplained.

Although most classical Hodgkin lymphoma patients are cured, a significant minority fail after primary therapy and may die as result of their disease. To date, there is no consensus on biological markers that add value to usual parameters (which comprise the International Prognostic Score) used at diagnosis to predict outcome. We evaluated 59 patients (18 with primary refractory or early relapse disease and 41 responders) for bcl2, Ki67, CD20, TiA1 and c-kit expression by semi-quantitative immunohistochemical study and correlated the results with the response to treatment. The results showed that expression of bcl2 and CD20 in Hodgkin and Reed Sternberg cells, and expression of TiA1 in micro-environmental lymphocytes, and c-kit positive mast cells in microenvironment, were independent prognostic markers. These novel cHL markers could be used in association with clinical parameters to identify newly diagnosed patients with favorable or unfavorable prognosis and to better tailor treatment for different risk groups.

Defensins, endogenous antibiotic peptides, are part of the intestinal epithelial barrier. In this pilot study we analyzed the possibility of measuring fecal beta-defensin-2 (HBD2) in comparing inflammatory and noninflammatory conditions. In samples from healthy control individuals, low levels of HBD2 were detectable, which markedly rose under inflammatory conditions (P = 0.0002 vs normal control individuals), the highest levels being observed in patients with ulcerative colitis (median 356 ng/g, range 40-527). Despite frank inflammation, Crohn disease patients with colitis had significantly lower, albeit enhanced, HBD2 levels than did ulcerative colitis patients. These data confirm the possibility of quantifying HBD2 in feces and indicate that colitis in Crohn disease and colitis in ulcerative colitis differ from each other with respect to their ability to secrete HBD2.

Summary This report illustrates a lingual localization of an inclusion body fibromatosis, the so-called Reye tumor or infantile digital fibromatosis (IDF). The light microscopic features were identical to those found in IDF, showing eosinophilic perinuclear inclusions located in spindle-shaped cells arranged in interlacing fascicles. The immunocytochemical and ultrastructural findings suggested a fibroblastic andl or myo fibroblastic nature of the proli ferative cells. However, the inclusions in our case were strongly stained with vimentin and their ultrastructural appearance was in keeping with intermediate filaments. These findings have never been described in other reports of fibromatosis. Whereas most reviews state that IDF occurs exclusively on the digits, this unique case describes its possible occurence in the tongue.

We report a case of diffuse large B-cell lymphoma occurring in a patient with the hyperimmunoglobulinemia E syndrome, a rare immune disorder defined by elevated immunoglobulin E levels and recurrent bacterial and fungal infections often manifesting as cold abscesses. This case further supports the notion that patients with hyperimmunoglobulinemia E have an increased risk of lymphoid malignancies and should be closely monitored. Despite a theoretic risk of severe infectious complications, chemotherapy was well tolerated and resulted in a sustained complete remission.

Even though surgical techniques for isolated intestine, liver-intestine, and multivisceral transplantations were developed in the 1960's, very few patients were transplanted before 1990 because initial immunosuppression regimens were insufficient, making intestine transplantation impossible. Intestine transplantation resulted in death in most patients within days or months. The discouraging results of the first clinical trials were due to technical complications, sepsis, and the failure of conventional immunosuppression to control rejection. By 1990 the development of tacrolimus-based immunosuppression and improved surgical techniques, the increased array of potent immunosuppressive medications, infection prophylaxis, and suitable patient selection helped improve actuarial graft and patient survival rates for all types of intestine transplantation. The aims of this review are to describe the current status of intestine transplantation including the underlying diseases and conditions that may be indications for intestine transplantation, to identify patient populations for this indication, to provide key steps for patient evaluation, to summarize current recommendations for immunosuppression, to list the most common postoperative complications, and to discuss the international experience of small bowel transplantation compiled and analyzed by the International Intestine Transplant Registry since 1985.

BackgroundEpstein-Barr virus (EBV) is the major environmental factor associated with Hodgkin's lymphoma (HL), a common lymphoma in young adults. Natural killer (NK) cells are key actors of the innate immune response against viruses. The regulation of NK cell function involves activating and inhibitory Killer cell Immunoglobulin-like receptors (KIRs), which are expressed in variable numbers on NK cells. Various viral and virus-related malignant disorders have been associated with the presence/absence of certain KIR genes in case/control studies. We investigated the role of the KIR cluster in HL in a family-based association study.MethodologyWe included 90 families with 90 HL index cases (age 16-35 years) and 255 first-degree relatives (parents and siblings). We developed a procedure for reconstructing full genotypic information (number of gene copies) at each KIR locus from the standard KIR gene content. Out of the 90 collected families, 84 were informative and suitable for further analysis. An association study was then carried out with specific family-based analysis methods on these 84 families.Principal findingsFive KIR genes in strong linkage disequilibrium were found significantly associated with HL. Refined haplotype analysis showed that the association was supported by a dominant protective effect of KIR3DS1 and/or KIR2DS1, both of which are activating receptors. The odds ratios for developing HL in subjects with at least one copy of KIR3DS1 or KIR2DS1 with respect to subjects with neither of these genes were 0.44[95% confidence interval 0.23-0.85] and 0.42[0.21-0.85], respectively. No significant association was found in a tentative replication case/control study of 68 HL cases (age 18-71 years). In the familial study, the protective effect of KIR3DS1/KIR2DS1 tended to be stronger in HL patients with detectable EBV in blood or tumour cells.ConclusionsThis work defines a template for family-based association studies based on full genotypic information for the KIR cluster, and provides the first evidence that activating KIRs can have a protective role in HL.

Mastocytosis is characterized by a clonal mast cell proliferation with organ infiltration and uncontrolled degranulation. Although not characteristic and poorly explained, some patients develop clotting abnormalities. We retrospectively identified patients with established diagnosis of mastocytosis and related clotting abnormalities (clinical and/or biological) using the national French Reference Centre for Mastocytosis database. From our cohort of 14 adult patients with clotting abnormalities (median age 46 years [range 26–75]), 4 had a presentation suggestive of a primary hemostasis disorder alone (by their symptoms and/or abnormal clotting tests [PFA, von Willebrand's disease [vWD] screening]) and 10 had a laboratory impairment of secondary hemostasis. Among these, 7 had bleeds characteristic of a coagulation cascade disorder (severe/life-threatening in 5 and mild in 2 patients). Clotting abnormalities were of variable severity, typically related to intense crisis of degranulation, such as anaphylactic reactions, and/or to severe organ infiltration by mast cells. Importantly, classical hemostatic management with platelet transfusion, fresh frozen plasma, or vitamin K infusions was unsuccessful, as opposed to the use of agents inhibiting mast cell activity, particularly steroids. This illustrates the crucial role of mast cell mediators such as tryptase and heparin, which interfere both with primary (mainly via inhibition of von Willebrand factor) and secondary hemostasis. There was interestingly an unusually high number of aggressive mastocytosis (particularly mast cell leukemia) and increased mortality in the group with secondary hemostasis disorders (n = 5, 36% of the whole cohort). Mast cell degranulation and/or high tumoral burden induce both specific biologic antiaggregant and anticoagulant states with a wide clinical spectrum ranging from asymptomatic to life-threatening bleeds. Hemostatic control is achieved by mast cell inhibitors such as steroids.

The antiviral thymidine analog azidothymidine (AZT) is used to treat several virus-associated human cancers. However, to date the mechanism of AZT action remains unclear and thus, reasons for treatment failure are unknown. Adult T-cell leukemia/lymphoma (ATL) is an aggressive malignancy of poor prognosis. Here, we report that enduring AZT treatment of T-cell leukemia virus I–infected cells, in vitro and in vivo in ATL patients, results in inhibition of telomerase activity, progressive telomere shortening, and increased p14ARF expression. In turn, this elicits stabilization and reactivation of the tumor suppressor p53-dependent transcription, increased expression of the cyclin-dependent kinase inhibitor p21Waf1, and accumulation of p27kip1, thereby inducing cellular senescence and tumor cell death. While ATL patients carrying a wild-type p53 enter remission following treatment with AZT, those with a mutated p53 did not respond, and patients' disease relapse was associated with the selection of a tumor clone carrying mutated inactive p53.

Introduction Ataxia-telangiectasia (A-T) is a rare autosomal recessive disorder associated with mutations in the ATMgene and characterized by cerebellar ataxia, telangiectasia, immune defect, and a high incidence of lymphoid and solid cancers. We conducted a retrospective study of the patients with AT enrolled in the registry of the French National Reference Center for Primary Immune Deficiencies, in order to describe the incidence, subtypes, and outcomes of cancer and mainly of lymphoproliferative diseases (LPD) occurring in AT. Most of the LPD of this study were centrally reviewed by 2 expert hematopathologists. Patients & Results Sixty nine patients with cancers were identified among the 279 patients with AT of our cohort. Eight patients developed carcinomas, 8 acute leukemias, 3 T-cell prolymphocytic leukemias and 50 developed lymphomas. Among the lymphomas, 12 were classical Hodgkin's lymphomas (cHL), and 38 high-grade non-Hodgkin lymphomas (NHL, 26 of B-cell type, 4 of T-cell type, and 8 not phenotyped). We obtained a centralized histopathology review in 31 cases classified by pathology reports as cHL (n=6) and high-grade NHL (n=25). Cases were reviewed according to the WHO classification by H&E staining and immunohistochemistry. The presence of EBV was analyzed using antibodies to LMP and in situ hybridization for EBER. Concordance between the diagnosis established on pathology reports and the centralized review was excellent. All 6 cases of cHL were confirmed by the pathology review. The 25 cases initially diagnosed as high-grade NHL based on pathology reports fell into several WHO classification categories. Six corresponded to Burkitt's lymphomas (BL) and 12 to diffuse large B-cell lymphomas (DLBCL). Among the latter, 10 could be further classified according to cell-of-origin by the Hans algorithm as germinal center (GC, 2) and non-GC (8). Seven cases displayed polymorphic histological features reminiscent of post-transplant lymphoproliferative disorders (LPD), 5 polymorphic B cell LPD (pLPD), 1 with features of infectious mononucleosis (IM), another with features of plasmacytic hyperplasia LPD. EBV could be evaluated in 28 cases. All 6 cHL, 4 out of 11 DLBCL, all 5 pLPD, and the case of IM-like LPD were EBV positive by LMP and/or EBER staining. The 5 cases of BL that were evaluated were all EBV negative. Median age at diagnosis was 7.8 years [range 3 – 24], 14.9 [5.8 – 17.1], 12.2 [5.4 – 29] and 11 [6.3 – 17.7] for pLPD, cHL, BL and DLBCL respectively (p=ns). Median survival after diagnosis of lymphoma was 35, 8.6, 6 and 8 months for pLPD, cHL, BL and DLBCL respectively (p=ns). ATM mutation analysis was available for 20 cases (8 hypomorphic mutations, 12 loss-of-function mutations). There were no differences in age at diagnosis of lymphoma or survival according to the ATM mutation class or the EBV status. Conclusion B-cell malignancies including cHL and B-cell NHL are the most frequent malignancies in A-T and can be further classified as DLBCL, BL and cases with polymorphic features resembling post-transplant LPD. EBV seems to be associated with all cHL, approximately 50% of DLBCL and polymorphic LPD, but not with BL. The majority of DLBCL are non-GC type by immunohistochemistry. On this series of 31 patients, ATM mutation type was not associated with differences in type of lymphoma or outcome. Disclosures No relevant conflicts of interest to declare.

[Graphic][1] INTRODUCTION Mast cell disease is a clonal haematological disorder resulting in organ infiltration by mast cells and uncontrolled degranulation (mast cell activation syndrome, MCAS). Although not characteristic and poorly explained, both primary (platelet’s adhesion and aggregation) and secondary (coagulation cascade leading to thrombin formation) clotting abnormalities are observed among some patients. METHODS We retrospectively identified patients with established diagnosis of mastocytosis and related clotting abnormalities (clinical and/or biological) using the French National Reference Centre for Mastocytosis database. RESULTS AND DISCUSSION Our cohort included 14 adult patients (median age of 42 [range 26-78] years, sex ratio 3.7, CKIT D816V in 13/14 cases, median tryptase of 200 [4-1240] ng/mL). Four patients had typical symptoms and/or clotting tests (PFA, von Willebrand’s disease [vWD] screening) indicating abnormalities of primary haemostasis [Table, patient 1], with n=1 confirmed and n=2 highly suspicious of vWD. They presented with either nil (n=1) or mild (n=3) mucocutaneous bleeding. This could be due to heparin binding to von Willebrand’s factor, therefore preventing platelet aggregation. Ten patients had abnormalities of coagulation cascade (prolonged PT, aPTT, reduced clotting factors II, V, VII, X), usually transient but with bleeding in 7 cases (severe/life-threatening in 5 of them ) [Table, patient 3]. Clotting abnormalities were typically accompanied by anaphylactoid symptoms of MCAS and increased by the presence of hematopoietic organ infiltration [Table, patients 2-4]. Haemostatic management (red blood cells and platelets transfusion, fresh frozen plasma, vitamin K, antifibrinolytic) was unsuccessful, while control of mast cell activity (e.g. with and steroids) would achieve haemostasis, indicating the crucial role of mast cell mediators. These mainly include tryptase and heparin, which inhibit the intrinsic pathway, inducing an anticoagulant state. The exact prevalence of clotting abnormalities in mastocytosis remains unclear and probably underestimated. However, we found a predominance of aggressive types of mastocytosis in the population with coagulation cascade abnormalities: 50% had aggressive systemic mastocytosis associated or not with a clonal haematological non mast cell lineage disease (ASM/AHNMD), 30% had mast cell leukaemia (MCL). All deceased patients (n=5, 36% of the overall population) belonged to this group. In contrast, mastocytosis was indolent in 75% of cases in the group with primary haemostasis abnormalities. | Patient number / gender; Diagnosis | Acute phase of MCAS | H/SMG | Bleeding | Biology | Clotting after episode | | | ------------------------------------------ | --------------------------- | -------------------- | ---------------- | --------------- | ---------------------- | ------------------ | ------------------------------------------------------------------------------------------------------------ | | PLT 150-300 | PTr ≥ 70% | aPTTr ≤ 1.20 | | | #1 / M; CM | no | no | Cutaneous | N | 89% | 1.23 | Spontaneously resolved | | | #2 / M; SSM-AHNMD† | yes | no | GI bleed | N | 37% | 1.75 | Resolved after steroids | | | yes | no | GI bleed | 20 | 62% | 1.41 | Resolved after symptomatic control of MCAS. | | #3 / M; aMCL | yes | yes | Acute SDH | 87 | 61% | 1.46 | Resolved after steroids | | #4 / M; ASM-AHNMD† | no | yes | None | 138 *14 | 62% *43% | 1.39 *1.97 | Worsening clotting alongside ASM progression and unrelated to the AHNMD. Response to steroids not assessable | | | | | | | | | | | Abstract 2856. Table: Description of 4 selected patients AHNMD: associated clonal haematological non mast cell lineage disease; aMCL: acute mast cell leukemia; aPTTr: activated partial thromboplastin time ratio; CM: cutaneous mastocytosis; H/SMG: hepato or splenomegaly; GI: gastrointestinal; ISM: indolent systemic mastocytosis; N: normal; SSM: smouldering systemic mastocytosis; PLT: platelet, in x103/µL; PTr: prothrombin time ratio; SDH: subdural haematoma. Reference values are indicated below PLT, PTr, aPTTr. †: patient deceased from the disease or complications of the latter. *6 months later. CONCLUSIONS AND PERSPECTIVES Blood coagulation abnormalities in mastocytosis appear secondary to a hyperactivity of the clonal mast cell, resulting in an anticoagulant state and typically presenting in the context of MCAS and/or significant mast cell proliferation. They are particularly prevalent in aggressive types of mastocytosis, and are only successfully controlled by mast cell inhibitors, notably steroids. More data are required to better correlate clinical and biological pictures, and to assess whether standard or specific clotting tests could be used as a marker of mast cell activity and potentially of poor prognosis in patients with systemic mastocytosis. Disclosures No relevant conflicts of interest to declare. [1]: /embed/inline-graphic-2.gif

Background Advanced Systemic Mastocytosis (adSM) still have very poor prognosis. No standard of care is yet available. Midostaurin (PKC412) is a powerful TKI inhibit of VEGFR, FLT3 and most importantly the mutated CKITD816V and D816Y. Preliminarily results from an international phase II trial (Gotlib et al., Blood 2012) reported interesting results in this subgroup of patients. We report herein on the French experience of the compassionate use of PKC412 for the treatment of adSM and compare their outcome to matched adSM historical control patients (pts) who did not receive PKC412 (control group). Methods Over a period of 12 months (from August 2012, date of PKC412 Temporary Approval for Use in France), 22 pts received PKC412 and could be analysed. PKC412 100 mg twice daily was administered orally as continuous 28-day cycles until progression or unacceptable toxicity. Pts were evaluated according to the response criteria used in the recent phase 2 trial on midostaurin (Gotlib et al.). The overall survival (OS) of these 22 patients was compared to the OS of 42 age and WHO subcategories matched control adSM patients who were treated before PKC412 era. Results 2 female and 20 male pts with a median age of 65 years [35-84] received midostaurin. Overall, 21 pts (95%) with adSM (5 ASM; 2 MCL; 1 MCS; 12 ASM-AHNMD; 1 SSM-AHNMD,1) and 1 pt progressive SSM. Median number of C-Findings was 3 (0-4). Hepato- and/or splenomegaly were present in 20 (91%) and 21 (95%) pts. Median tryptase level was 204 ng/l (85-2000). Median haemoglobin level, platelet and PMN counts were respectively 10.1g/dl (6.8-13.9), 117G/L (22-289) and 2.8G/L (0.3-17). Twenty (91%) pts had cKIT D816V mutation, 2 pts had cKITWT. ASXL1 and TET2 were mutated in 3/7 and 2/7 tested, respectively. Steroids, 2-chlorodeoxyadenosine and Interferon were administered in 9, 4 and 2 pts prior to midostaurin. After a median exposure time of 6.9 [1.6-27.5] months, the overall response rate (ORR) was 77.2% including, major responses (n=13; 59%) (incomplete major in 8 pts, pure clinical in 5); partial response (n=5, 23%) (good partial in 3, minor partial in 2). Three patients were rapidly progressive ( The control group consisted in 42 pts with a median age of 65.5 years [23-84]. There were 17 ASM-AHNMD, 21 ISM-AHNMD, 2 SSM-AHNMD, 1 CM-AHNMD and 1 MCL patients. Median tryptase level was 107ng/l [19-501]. Median haemoglobin level, platelet and PMN counts were respectively 12.1g/dl [8-15], 200G/L [10-1036] and 4.6G/L [0.5-24.3]. Thirty-three (79%) pts had cKIT D816V mutation, 7 pts were cKITWT. ASXL1 and TET2 were mutated in 6/29 (21%) and 7/29 (24%) of pts tested, respectively. Steroids, 2-CdA, interferon, imatinib, thalidomide have been used in 19, 21, 6, 4, and 6 pts respectively. Survival distributions were estimated using the adjusted Kaplan-Meier method from the date of diagnosis to the last follow-up for the PKC412 treated and the control groups. Median survival time for PKC412 treated patients was significantly longer than control patients (p=0.04). Conclusion PKC412 is active in advanced SM. Despite the absence of complete remission, PKC412 gives survival advantage for patients with adSM over pts who did not receive the drug. Disclosures No relevant conflicts of interest to declare.

Wiskott-Aldrich syndrome (WAS) is an X-linked primary immune deficiency (PID) characterized by persistent thrombocytopenia, eczema and immunodeficiency. It has been suggested that these patients had an increased risk of lymphoproliferative diseases (LPD). We conducted a retrospective study in order to describe LPD occurring in patients with WAS/XLT (X Linked Thrombocytopenia with WAS gene mutation) enrolled in the French national registry for PIDs. Post- hematopoietic stem cell transplantation (HSCT) LPD were excluded. Methodology of the French National Registry for PIDs has been previously described (Clin. Immunol, 2010, ASH 2009 abstract#23950). Eight patients (4%) with LPD were identified among the 197 patients of our cohort. All patients had a WAS and presented first symptoms of WAS before the age of one year. One patient developed a LPD before the clinical diagnosis of WAS. All patients for whom histological charts were available (6/8) developed a B-cell LPD. Three of them had diffuse large B-cell lymphomas and three patients had polymorphic B-cell LPD associated with EBV and without detection of clonal IGHV rearrangement. The median age of cancer diagnosis was 18.3 years (range: 2.0-50.7). All LPD were disseminated diseases, mostly with a central nervous system involvement (4/6 patients). All patients received intensive chemotherapy, except one patient with an EBV-associated LPD who only received rituximab. Three patients obtained a complete remission (CR), two patients had a stable disease (SD) and the last one progressed on therapy. Four patients, of whom two were in CR and one in SD, received an allogeneic HSCT during the year following the diagnosis of LPD. Two patients received peripheral blood-derived stem cells and the two other patients received bone marrow-derived stem cells. There were three matched unrelated donor (MUD) and one haplotype-mismatched family donor, with no ex vivo graft manipulation. Three of these four patients were long-term survivors after LPD (2.7, 7.7 and 9.8 years). The median life expectancy for the entire cohort is 19.1 years (range: 7.8-52.0). Three patients, two of which have received an HSCT, are still alive 2.4, 2.7 and 9.8 years after the cancer onset. The median overall survival among the five remaining patients after diagnosis of LPD was 0.5 years (from 0.3 to 7.7 years). Additional details on genetic, clinical characteristics and a centralized histopathology review are currently being studied and will be presented. In conclusion, the occurrence of LPD is less frequent than expected, may occur only in patients with WAS phenotype rather than XLT. As it impairs the prognosis of patients, HSCT could be a therapeutic option for these patients, even in partial remission of LPD. Disclosures No relevant conflicts of interest to declare.

Background: HCV chronic infection is associated with an increased risk of non-Hodgkin lymphoma (NHL) occurrence. HCV-associated NHL share homologies with primary Sjögren Syndrome (pSS)-associated NHL, and especially an association with chronic antigenic stimulation and with auto-antibody presence, especially rheumatoid factor (RF) and mixed cryoglobulinemia (MC). TNFAIP3 encodes the A20 protein that plays a key role in controlling NF-kB activation. We have previously demonstrated that germline or tumor genetic impairment of A20 plays a role in lymphomagenesis in the context of pSS[1]. The aim of this study was to assess the role of variants of TNFAIP3 in patients with HCV related NHL. Methods: Sixty-one cases of HCV-associated lymphoma with available germline DNA were drawn from the 116 patients included in the LymphoC study. Total exon sequencing of TNFAIP3was performed in a discovery set of 31 cases. Then 30 additional cases and 53 controls (HCV patients without NHL) were used for extension (ie genotyping of the rs2230926 and the TT>A dinucleotide). All our cases and controls were European. Case-only associations were tested with Fischer’s exact test. Differences in lymphoma histologic type and immunological status were assessed using Fisher’s exact test. Results:Among the 61 cases, histology subsets were 23 diffuse large B cell lymphomas (DLBCL), 17 marginal zone lymphomas (MZL), 6 splenic marginal zone lymphoma (SMZL), 5 mantle cell lymphomas, 8 follicular lymphomas, 1 chronic lymphoid leukemia and 1 chronic EBV-related lymphoproliferation. RF and MC were present in 30/61 (49.2%) and 25/43 (58.1%) of the patients respectively. Among the 53 controls, RF and MC were present in 31/53 (58.5%) and 28/53 (52.8%) of the patients respectively. We found the rs2230926G variant in 6/61 (9.8%) patients with NHL and in 7/53 (13.2%) patients without NHL meaning that there was no association between this SNP and HCV-associated NHL (OR=0.72 [95%CI 0.22– 2.28] p=0.77). We did not find any association between the variant and the marginal zone subtype of the lymphoma. However, we found that, among NHL patients, the rs2230926G allele was associated with the positivity of RF (6/30 (20%) in RF+ patients compared to 0/31 (0%) in RF- patients, OR=16.7 [95%CI 0.9 – 311.5], p=0.01). We did not find any association between the rs2230926 variant and the presence of MC patients probably due to the amount of missing data and the variability of the technic of detection. Last, we previously showed that the rs2230926G was functional and able to impair the control of NF-kB activation[1]. Conclusion: This study demonstrates that a germline coding mutation of TNFAIP3leading to a small functional defect of A20 function and of control of activation of NK-kB, plays a key role in lymphomagenesis in the context of chronic antigenic stimulation of RF+ B cells. It extends the scenario already demonstrated in Sjögren’s syndrome-associated lymphomas, a concept which is both novel and paradigm-shifting in the area of lymphomagenesis and autoimmunity. Interestingly, this coding mutation is associated only with HCV-associated lymphoma and presence of RF, which clearly supports different types of lymphomagenesis pathways in patients with HCV, one of them linked to the continuous stimulation of RF+ B cells by the immune complexes between HCV antigens and anti-HCV antibodies. Reference: 1. Nocturne, G., et al., Germline and somatic genetic variations of TNFAIP3 in lymphoma complicating primary Sjogren's syndrome. Blood, 2013 122(25): p. 4068-76. Disclosures No relevant conflicts of interest to declare.

Mycobacterium smegmatis is a common environmental mycobacterium that was first identified in 1884, yet is a rare pathogen in humans. The few M. smegmatis infections reported to date have been localized and have occurred in association with a primary lesion in otherwise immunocompetent individuals. To our knowledge, no case of disseminated M. smegmatis infection has ever been reported, even in patients with severe immune deficiencies. We report a case of disseminated mycobacterial infection that was diagnosed in a 3-year-old girl. The pathogen was not identified as M. smegmatis until the patient was 6 years old. Her condition gradually worsened, and she died when she was 8 years old despite appropriate antimycobacterial therapy. No other opportunistic infections were documented. Immunological investigations revealed an inherited interferon gamma receptor 1 deficiency. This report identifies M. smegmatis as a new opportunistic agent that may be responsible for disseminated disease in immunocompromised individuals.

The present study describes a case of pulmonary arterial hypertension (PAH) associated with multicentric Castleman's disease in a patient infected with HIV type 1 and human herpes virus 8. Therapy included highly active antiretroviral therapy, warfarin, diuretics, continuous i.v. epoprostenol and 12-monthly pulses of cyclophosphamide. The patient's condition improved dramatically with complete reversibility of PAH, allowing weaning of continuous i.v. epoprostenol therapy. After 5 yrs, both Castleman's disease and PAH have not relapsed. This supports the hypothesis that control of inflammation and retroviral replication may be of interest in the context of PAH, complicating the course of an inflammatory condition associated with viral infection. In conclusion, further studies should help in characterising the best candidates for anti-inflammatory treatment in the setting of pulmonary arterial hypertension.

Background Although intestinal transplantation provides a unique situation of free access to the graft because of the presence of temporary enterostomas, evaluation of local immunosuppression is still an unresolved issue and may constitute one of the causes of grafting failure. Aims To study in a rat model of allogeneic intestinal transplantation the expression of transcription factors involved in lymphocyte activation in situ in the graft and to identify factors reflecting the efficiency of drug immunosuppression. Methods Intestinal transplantation was performed in a Brown Norway (RT1 n -donors)–Lewis (RT1 l -recipients) rat strain combination. The animals were treated with tacrolimus to induce tolerance or left untreated. Syngeneic intestinal grafts and intestine from donor rats with peritonitis were used as controls. NF- κ Bp65, p-c-Jun, interleukin 2 receptor (CD25), and major histocompatibility complex class II antigen (OX-6) expression was studied in graft biopsies on days 2 and 5 by immunohistochemistry. Results On day 2, before the onset of histologic signs of rejection, the number of cells expressing NF- κ Bp65 in the pericryptic lamina propria was significantly higher in untreated recipients of allogeneic grafts than in the other groups ( P = .009). NF- κ Bp65 expression then fell between days 2 and 5 ( P = .009). Classic markers of T-cell activation (CD25 and OX-6) were expressed during rejection in the lamina propria and on crypt enterocytes, respectively. p-c-Jun expression did not differ among the 3 groups. Conclusion NF- κ Bp65 expression in intestinal grafts is a precocious sign of local activation during rejection and could thus serve to optimize the management of immunosuppressive therapy.

Non Hodgkin lymphoma represent about 5% of childhood cancer. They are the third most common group of cancers in children and adolescents, after cerebral tumours and leukemias. They differ from adult lymphomas as they are all high grade tumours, always diffuse and often associated with extra-nodal diseases. Three main histological subtypes predominate: Burkitt, lymphoblastic and anaplastic large cell lymphomas. As the clinical progression is growing fast and treatment different between the 3 subtypes, the diagnosis must be rapidly done and with accuracy.

The influence of bone marrow biopsy (BMB) histology on prognosis and management of follicular lymphomas (FL) remains controversial. A total of 390 patients with grade 1 or 2 FL were prospectively included in the multicentric Groupe d'Etude des Lymphomes Folliculaires trial and their BMB reviewed in order (i) to quantify the ratio of lymphomatous foci (LFo) area to that of BMB size (LFo/BMB), (ii) to determine the BMB patterns for a practical grading of marrow infiltration, (iii) to assess the intra- and inter-observer reproducibility of this grading and (iv) to analyse this grading on event-free (EFS) and overall survival (OS), using univariate and multivariate analyses. A total of 267 patients (68%) had BMB involvement, with inter- and intra-observer reproducibility for classifying the patterns of involvement of 91 and 96%, respectively. Uni- and multivariate analyses demonstrated the adverse influence of (i) a ratio of LFo/BMBor = 0.1, i.e. three or four nodules/medullary space oror = 1 nodule + foci of diffuse involvement on EFS (P = 0.03) and (ii) two different histological patterns in the same BMB on EFS (P = 0.004) and OS (P = 0.001). This latter finding was only significant in patients with a high tumour burden and remained significant in multivariate analysis. These results indicate that BMB histology can predict survival of FL patients with a high tumour burden, and may help in defining their treatment.

Nodular lymphocyte predominance Hodgkin's disease (NLPHD), previously called nodular paragranuloma, is a rare entity recognized as a clinico-pathological entity distinct from classic Hodgkin's lymphoma. It is an indolent B cell lymphoma derived from a germinal center cell. NLPHD may closely resemble lymphocyte-rich classic Hodgkin's disease (LR-CHD) or T-cell or histiocyte-rich large B-cell lymphoma (TCRLBCL). A reproducible distinction between these entities is difficult but the classification is prognostically relevant. NLPHD is characterized by neoplastic "popcorn" cells CD20+ CD30- CD15- EMA+ Bcl6+ scattered within a nodular background predominantly composed of small B lymphocytes. LR-CHD neoplastic proliferation is composed of CD20+/- CD30+ CD15+/- EMA- Bcl6+/- Reed Sternberg or Hodgkin's cells, scattered within numerous CD3+ T cells. TCRLBCL is an agressive lymphoma composed of CD20+ CD30- CD15- EMA+/- Bcl6+/- polymorphic neoplastic cells, scattered within a mixture of CD3+ T cells and histiocytes. Epstein Barr virus is detectable within half cases of LR-CHD, but never in NLPHD and rarely in TCRLBCL. The transcription factors BOB1, PU-1, BSAP and IRF4 are new markers that could be useful for differential diagnosis.

The mutator phenotype caused by defects in the mismatch repair system is observed in a subset of solid neoplasms characterized by widespread microsatellite instability-high (MSI-H). It is known to be very rare in non-Hodgkin lymphomas (NHL), whereas mutator NHL is the most frequent tumor subtype in mismatch repair-deficient mice. By screening a series of 603 human NHL with specific markers of the mutator phenotype, we found here 12 MSI-H cases (12/603, 2%). Of interest, we demonstrated that this phenotype was specifically associated with immunodeficiency-related lymphomas (ID-RL), because it was observed in both posttransplant lymphoproliferative disorders (9/111, 8.1%) and HIV infection-related lymphomas (3/128, 2.3%) but not in a large series of NHL arising in the general population (0/364) ( P < 0.0001). The MSI pathway is known to lead to the production of hundreds of abnormal protein neoantigens that are generated in MSI-H neoplasms by frameshift mutations of a number of genes containing coding microsatellite sequences. As expected, MSI-H ID-RL were found to harbor such genetic alterations in 12 target genes with a putative role in lymphomagenesis. The observation that the MSI-H phenotype was restricted to HIV infection-related lymphomas and posttransplant lymphoproliferative disorders suggests the existence of the highly immunogenic mutator pathway as a novel oncogenic process in lymphomagenesis whose role is favored when host immunosurveillance is reduced. Because MSI-H-positive cases were found to be either Epstein-Barr virus-positive or -negative, the mutator pathway should act synergistically or not with this other oncogenic factor, playing an important role in ID-RL.

Background/Aims: Debate continues on whether serum and intrahepatic HCV viral loads are correlated and if HCV viral load correlates with the severity of liver disease. These difficulties may at least in part be linked to liver cell heterogeneity, when total liver extracts from HCV-infected individuals are tested for HCV RNA quantification. We have therefore investigated the feasibility of quantifying HCV replication using a laser-based microdissection technique. Methods: We compared the results with those obtained for serum HCV RNA quantification and immunochemistry in the case of HCV antigen detection in the liver. Twenty-one HCV-positive patients with chronic active hepatitis ( n =10) or cirrhosis ( n =11) were analyzed. Results: A positive correlation ( P =0.0019) was observed between HCV RNA quantifications in sera and microdissected cells. Immunohistochemistry demonstrated that HCV antigen hepatocytes were randomly distributed within liver lobules. Their percentage varied in different patients (0–40%), but did not correlate with the HCV viral load. Conclusions: We have designed a sensitive methodology to evaluate the intrahepatic HCV viral load by combining a standardized RNA quantification method with microdissected hepatocytes from frozen liver needle biopsies. Our results directly demonstrate a positive correlation between serum and intrahepatic viral loads, which therefore provides a reliable reflection of intrahepatic HCV replication.

We have previously described the identification of Artemis, a factor involved in the nonhomologous end joining (NHEJ) phase of V(D)J recombination of T and B cell receptor genes. Null mutations of the Artemis gene result in a complete absence of T and B lymphocytes that is associated with increased cell radiosensitivity, causing the radiosensitive T(-)B(-) SCID (RS-SCID) condition. We presently report the occurrence of hypomorphic mutations of the Artemis gene in four patients from two kindreds. Partially preserved in vivo activity of Artemis is associated with the presence of polyclonal T and B lymphocyte populations, albeit in reduced numbers, along with chromosomal instability and development of EBV-associated lymphoma in two of four patients. This syndrome emphasizes the role of Artemis in the NHEJ pathway of DNA repair and suggests that other, yet ill-defined, conditions associating immunodeficiency and lymphoma could be caused by mutations in genes encoding NHEJ factors.