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Background Blood transfusion is the cornerstone treatment to reduce the clinical severity of sickle cell disease (SCD), but we need to maintain the haematocrit (Hct) within an acceptable range to avoid a deleterious increase in blood viscosity. The aim of this study was to compare the effects of manual versus automated red blood cell (RBC) Exchange on haematological parameters and blood viscosity. Study design and methods This prospective, single-centre, open nonrandomized observational study included forty-three sickle cell patients: 12 had automated RBC Exchange and 31 manual RBC Exchange. Samples were collected in EDTA tubes just before and within one hour after the end of the RBC Exchange to measure the haematological parameters and blood viscosity. Results Both automated and manual RBC Exchange decreased haemoglobin S levels and leucocyte and platelet counts, but the decrease was greater for automated RBC Exchange. Manual RBC Exchange caused a significant rise in haematocrit and haemoglobin levels and did not change blood viscosity. In contrast, automated RBC Exchange decreased blood viscosity without any significant change in haematocrit and only a very slight increase in haemoglobin levels. The change in blood viscosity correlated with the modifications of haematocrit and haemoglobin levels, irrespective of the RBC Exchange procedure. When adjusted for the volume of RBC Exchange, the magnitude of change in each biological parameter was not different between the two procedures. Conclusion Our study demonstrates that the automated RBC Exchange provided greater haematological and haemorheological benefits than manual RBC Exchange, mainly because of the higher volume exchanged, suggesting that automated RBC Exchange should be favoured over manual RBC Exchange when possible and indicated.

Resume Les cellules T a recepteur antigenique chimerique (CAR T-cells) sont une nouvelle classe de traitements anticancereux produits en manipulant genetiquement des lymphocytes T autologues ou allogeniques afin de generer l’expression d’un recepteur chimerique dirige contre un antigene exprime sur la membrane de cellules tumorales. En Europe, le tisagenlecleucel (Kymriah™) dispose d’une autorisation de mise sur le marche (AMM) pour le traitement de la leucemie aigue lymphoblastique B en rechute/refractaire chez l’enfant et le jeune adulte et celui du lymphome B diffus a grandes cellules (LBDGC) en rechute/refractaire. L’AMM de l’axicabtagene ciloleucel (Yescarta™) porte sur le traitement du LBDGC et du lymphome primitif a cellules B du mediastin en rechute/refractaire. Les deux medicaments de therapie genique aujourd’hui autorises en Europe sont constitues de cellules T autologues genetiquement modifiees pour exprimer un CAR dirige contre CD19, un antigene exprime tout au long de la differenciation lymphoide B et sur de nombreuses hemopathies malignes B. Ce travail collaboratif fait partie d’une serie de travaux d’experts et a pour but de proposer des conseils pratiques pour aider les preleveurs a effectuer le prelevement des cellules mononucleees sanguines autologues et fournir le materiel cellulaire de depart a l’industriel fabricant, en vue de la production pharmaceutique de CAR T-cells.

International audience; CAR T-cells are anti-cancer immunocellular therapy drugs that involve reprogramming the patient's T-cells using a transgene encoding a chimeric antigen receptor (CAR). Although CAR T-cells are cellular therapies, the organization for manufacturing and delivering these medicinal products is in many ways different from the one for hematopoietic cell grafts or donor lymphocyte infusions. The implementation of this innovative therapy is recent and requires close coordination between clinical teams, the therapeutic apheresis unit, the cell therapy unit, the pharmaceutical laboratory, and pharmacy. Apart from the regulatory texts, which are regularly modified, and the specific requirements of each pharmaceutical laboratory, there is currently no guide to help the centers initiating their activity and there is no specific indicator to assess the quality of the CAR T-cell activity in each center. The purpose of the current harmonization workshop is to clarify the regulatory prerequisites warranted for a center to have a CAR T-cell activity and to propose recommendations for implementing quality tools, in particular indicators, and allowing their sharing.

Chimeric antigen receptor (CAR) T-cells are a new class of cancer treatments manufactured through autologous or allogeneic T cells genetic engineering to induce CAR expression directed against a membrane antigen present at the surface of malignant cells. In Europe, tisagenlecleucel (Kymriah™) has a marketing authorization for the treatment of relapsed/refractory B-cell acute lymphoblastic leukemia in children and young adults and for the relapsed/refractory diffuse large B-cell lymphoma (DLBCL). The marketing authorization for axicabtagene ciloleucel (Yescarta™) is the treatment of relapsed/refractory DLBCL and mediastinal B-cell lymphoma. Both products are "living drugs" and genetically modified autologous T cells directed against CD19 which is an antigen expressed throughout B lymphoid differentiation and on many B malignancies. This collaborative work - part of a series of expert works on the topic - aims to provide practical advice to assist collection facilities that procure the starting material i.e. blood mononuclear cells for autologous CAR T-cell manufacturing.

CAR T-cells are anti-cancer immunocellular therapy drugs that involve reprogramming the patient's T-cells using a transgene encoding a chimeric antigen receptor (CAR). Although CAR T-cells are cellular therapies, the organization for manufacturing and delivering these medicinal products is in many ways different from the one for hematopoietic cell grafts or donor lymphocyte infusions. The implementation of this innovative therapy is recent and requires close coordination between clinical teams, the therapeutic apheresis unit, the cell therapy unit, the pharmaceutical laboratory, and pharmacy. Apart from the regulatory texts, which are regularly modified, and the specific requirements of each pharmaceutical laboratory, there is currently no guide to help the centers initiating their activity and there is no specific indicator to assess the quality of the CAR T-cell activity in each center. The purpose of the current harmonization workshop is to clarify the regulatory prerequisites warranted for a center to have a CAR T-cell activity and to propose recommendations for implementing quality tools, in particular indicators, and allowing their sharing.

Background: For the last 40 years, the technique of extracorporeal photopheresis has constantly developed. Among irradiation systems, those called 'off-line' allow the validation of the quality of the cell therapy product. The inhibition of the proliferation of lymphocytes after UVA irradiation is usually verified by the tritiated thymidine assay as in vitro proliferation assay. The document presented here describes the results obtained while performing the setting up of an alternative proliferation assay using flow cytometry according to ISO 15189:2007 Standard. Methods: Cells samples taken before and after UVA irradiation were labeled with CFSE and then cultured with phytohemagglutinin. After 3 days, an analysis of the CFSE staining was realized by flow cytometry. In order to validate the shift in the method used according to Standard, the following tests were performed: 1) comparison with the reference method, 2) robustness test, 3) reagents stability. Results: Comparison method demonstrated that the sensitivity of the CFSE test is 100%, the specificity is 89% and the concordance is almost complete. The CFSE test is robust regarding parameters like cell concentration or PHA concentration. PHA and CFSE are stable for 6 months and one year, respectively. Conclusion: Validation of this alternative test, according to the ISO 15189:2007 Standard, has demonstrated good concordance with reference method. The results of the robustness and stability of reagents are appropriate for its routine use. Thus, the benefits of alternative technique make it a wise choice for the quality control of ECP in a cell therapy laboratory. © 2014 Clinical Cytometry Society.

Lymphodepletion followed by infusion of suicide gene-transduced donor lymphocytes to safely enhance their antitumor effect: a phase I/II study

Erythrocytapheresis (ER) can improve outcome in patients with sickle cell disease (SCD). A good vascular access is required but frequently it can be difficult to obtain for sickle cell patients. Arterio-venous fistulas (AVFs) have been suggested for ER in SCD supported by limited evidence. We report the largest cohort of ER performed with AVFs from three French SCD reference centers. Data of SCD patients undergoing ER with AVFs in the French SCD reference center were retrospectively collected. The inclusion criteria were: SS or Sβ-Thalassemia and AVF surgery for ER. SCD-related complications, transfusion history, details about AVF surgical procedure, echocardiographic data before and after AVF, AVF-related surgical and hemodynamical complications were collected. Twenty-six patients (mean age 20.5 years, mean follow-up 68 months [11-279]) were included. Twenty-three patients (88.5%) required central vascular access before AVF. Fifteen AVFs (58%) were created on the forearm and 11 (42%) on the arm. Nineteen patients (73%) had stenotic, thrombotic or infectious AVF complications. A total of 0.36 stenosis per 1,000 AVF days, 0.37 thrombosis per 1,000 AVF days and 0.078 infections per 1.000 AVF days were observed. The mean AVF lifespan was 51 months [13-218]. One patient with severe pulmonary hypertension worsened after AVF creation and died. We report the first series of SCD patients with AVF for ER, demonstrating that AVFs could be considered as a potential vascular access for ER. Patients with increased risk for hemodynamic intolerance of AVFs must be carefully identified, so that alternative vascular accesses can be considered. Am. J. Hematol. 92:136-140, 2017. © 2016 Wiley Periodicals, Inc.

Regulatory T cells (Treg) play a pivotal role in the control of graft-versus-host disease (GVHD) and might also influence the graft-versus-tumor effect after allogeneic stem cell transplantation. We assessed this role after donor lymphocyte infusions (DLIs) by quantifying Treg in DLI products, using the CD25, Foxp3 but also the recently identified CD127 Treg markers. Compared with others, patients in durable complete remission of their malignancy after DLI had received a lower number of FoxP3CD25, FoxP3CD127, or CD4CD127 Treg cells (P=0.04). The CD4CD127 Treg content of DLI remained significantly correlated with the hematologic response in multivariate analysis (P=0.05). Treg may thus inhibit graft-versus-tumor effect after DLI, a setting where the antitumoral effect observed is only driven by T-cell-mediated cytotoxicity, independently of any other associated treatment. In comparison with the intracytoplasmic Foxp3 marker, the membranous CD4CD127 phenotype of Treg could be particularly relevant to manipulate this cell-population, to increase the antitumoral response in strategies of allogeneic or autologous immunotherapy.

Depuis plus de 10 ans, la principale source de greffons allogeniques est obtenue par le prelevement de cellules souches du sang peripherique (PBSC) apres stimulation par des injections de G-CSF (filgrastim ou lenograstim) chez les donneurs HLA compatible apparentes ou non apparentes. En France en 2015, les PBSC representaient 67 % des greffes allogeniques. Des milliers de donneurs sains ont recu du G-CSF dans cette indication, encadree par les recommandations WMDA (donneurs non apparentes), l’EBMT et l’ABM en France. Le donneur n’ayant aucun benefice direct lors de cette procedure, le risque qu’il encourt doit lui-meme, etre proche de zero. Si l’information precise et exhaustive delivree peut etre anxiogene pour des donneurs volontaires souvent jeunes, il convient de bien l’apprehender et la systematiser (non evaluee a ce jour) a l’aide de donnees meta-analytiques dont nous disposons y compris sur les effets a long terme. Ce travail a analyse une population de 246 donneurs de PBSC et confronte les donnees aux etudes des societes savantes et organismes institutionnels charges du suivi des donneurs de PBSC.

To the editor: The risk for a hepatitis C virus (HCV) RNA–positive donor to transmit the virus to the recipient through a hematopoietic stem cell transplantation (HSCT) is constant.[1][1] Although this situation is not an absolute contraindication to donation from an HLA-identical sibling,[2][2

Background A decrease in hematocrit lengthens bleeding time. The authors studied the role of hematocrit variations in an experimental model of arterial thrombosis and bleeding. Methods The Folts model was used in 24 rabbits. After anesthesia was induced and common monitors were positioned, the right common carotid artery was exposed and a 60% stenosis was induced. A compression injury of the artery was then produced, which triggered a series of cyclic episodes of thrombosis and clot lysis (cyclic flow reductions [CFRs]). After counting the number of CFRs that occurred in 20 min (CFR1), the animals were assigned randomly to one of three groups (n = 8 in each group): control, hemodilution with rabbit homologous platelet-rich plasma, and hemodilution with gelatin solution and then reinfusion of the shed blood. The effect of hemodilution with replacement by platelet-rich plasma or by colloid was observed by recording the number of CFRs during another 20-min period (CFR2). A third period of observation (CFR3) followed shed blood reinfusion in the gelatin solution group. Ear immersion bleeding time was recorded after each CFR period. Results In the two experimental groups, the decrease in hematocrit (from 36 +/- 3% to 23 +/- 2% and from 38 +/- 3% to 23 +/- 2%, respectively; mean +/- SD) abolished CFRs (from a median of 4 to 0 and 7 to 0, respectively) and significantly lengthened bleeding time (from 76 +/- 24 s to 114 +/- 36 s and from 84 +/- 37 s to 127 +/- 29 s, respectively). Blood reinfusion in the group that received the gelatin solution caused CFR to reappear (CFR3 = 4). Conclusions Decreases in hematocrit reduced the cyclic arterial thrombosis rate and increased the bleeding time in the rabbits in this study. Hematocrit normalization caused thrombosis to reappear.

For the last 40 years, the technique of extracorporeal photopheresis (ECP) has constantly developed. Among irradiation systems, those called "off-line" allow the validation of the quality of the cell therapy product. The inhibition of the proliferation of lymphocytes after ultraviolet irradiation (UVA) is usually verified by the tritiated thymidine assay as in vitro proliferation assay. The document presented here describes the results obtained while performing the setting up of an alternative proliferation assay using flow cytometry according to ISO 15189:2007 Standard.Cells samples taken before and after UVA irradiation were labeled with CarboxyFluorescein Succinimidyl Ester (CFSE) and then cultured with phytohemagglutinin-A (PHA). After 3 days, an analysis of the CFSE staining was realized by flow cytometry. In order to validate the shift in the method used according to Standard, the following tests were performed: 1) comparison with the reference method, 2) robustness test, 3) reagents stability.Comparison method demonstrated that the sensitivity of the CFSE test is 100%, the specificity is 89%, and the concordance is almost complete. The CFSE test is robust regarding parameters like cell concentration or PHA concentration. PHA and CFSE are stable for 6 months and one year, respectively.Validation of this alternative test, according to the ISO 15189:2007 Standard, has demonstrated good concordance with reference method. The results of the robustness and stability of reagents are appropriate for its routine use. Thus, the benefits of alternative technique make it a wise choice for the quality control of ECP in a cell therapy laboratory.

Introduction Erythracytapheresis (ER) can improve outcome in patients with sickle cell disease (SCD). A good vascular access is required but can be difficult to obtain for sickle cells patients. Arterio-venous fistula (AVF) has been suggested for ER in SCD supported by limited evidence. We report the largest cohort of ER performed with AVF from three French sickle cell disease reference centers. Methods Data of SCD patients undergoing ER with AVF in the French SCD reference center were retrospectively collected. The inclusion criteria were: SS or Sβ-Thalassemia and AVF surgery for ER. AVF for hemodialysis were excluded. SCD-related complications, transfusion history, details about AVF surgical procedure, echocardiographic data before and after AVF, AVF-related surgical and hemodynamical complications were collected. Results Twenty-six patients (mean age 20.5 years; median follow-up 68 months [11; 279]) were included. Twenty-three patients (88.5%) required a central vascular access before AVF. Fifteen AVF (58%) were created on the forearm and 11 (42%) on the arm. Nineteen patients (73%) had stenotic, thrombotic or infectious AVF complications. The median AVF lifespan was 34 months [13; 66]. One patient with severe pulmonary hypertension worsened after AVF creation, and died. Conclusions We report the first series of SCD patients with AVF for ER demonstrating AVF could be considered as a potential vascular access for ER. Patients with increased risk for hemodynamic intolerance of AVF must be carefully identified, in order to consider alternative vascular accesses. Disclosures Ribeil: Bluebirdbio: Consultancy; Addmedica: Research Funding.

Avec une incidence estimee en France a 22,2/100 000 produits sanguins labiles transfuses (ANSM), la reaction allergique est un evenement indesirable frequent, potentiellement grave dont l’etiologie reste souvent inconnue. Monsieur X., 37 ans, porteur d’une nephropathie d’origine indeterminee, sans antecedent transfusionnel, a beneficie, a j6 d’une transplantation renale avec un anticorps anti-HLA dirige contre son greffon, d’un premier echange plasmatique avec du plasma frais congele inactive par Amotosalen (PFC-IA). Quinze minutes apres le debut de la procedure, alors que le troisieme PFC venait d’etre pose, le patient a presente des fourmillements, vertiges et bouffees vasomotrices, rapidement suivis d’un bronchospasme. La transfusion a ete arretee, le patient a ete traite par de l’oxygenotherapie, des bronchodilatateurs en aerosols et 60 mg de methylprednisolone IV. L’evolution a ete favorable en 2 heures. Le lendemain, il a recu 2 CGR deplasmatises bien toleres. La tryptase etait augmentee (histamine non prelevee), le dosage des Ig A etait normal, aucun nouveau medicament n’avait ete introduit. Dans ses antecedents, on retrouvait un terrain allergique (pollens, acariens, chats), un asthme, ainsi qu’un œdeme larynge a la suite d’une prise unique de ramipril, un inhibiteur de l’enzyme de conversion (IEC). Une enquete a ete menee aupres des 4 donneurs de plasma : le donneur du 3 e PFC-IA, un homme de 56 ans, etait sous perindopril, un autre IEC. Le mecanisme de transfert passif d’un allergene par le produit sanguin est probablement a l’origine de l’accident. Dans ce contexte, se pose la question des mesures preventives dont nous disposons pour ces patients allergiques a une classe medicamenteuse frequemment utilisee dans la population de donneurs de sang ? Dans le cas de patients ayant developpe des reactions severes, pourrait-on envisager de preciser ce type d’antecedent sur la prescription afin de rechercher des donneurs « free » vis-a-vis de l’allergene en question ?

Donor T cells play a pivotal role in the graft-versus-tumor effect after allogeneic hematopoietic stem cell transplantation. Regulatory T cells (T(reg)s) may reduce alloreactivity, the major component of the graft-versus-tumor effect. In the setting of donor lymphocyte infusion after hematopoietic stem cell transplantation, we postulated that T(reg) depletion could improve alloreactivity and likewise the graft-versus-tumor effect of donor T cells. The safety and efficacy of T(reg)-depleted donor lymphocyte infusion was studied in 17 adult patients with malignancy relapse after hematopoietic stem cell transplantation. All but one had previously failed to respond to at least one standard donor lymphocyte infusion, and none had experienced graft-versus-host disease. Two of the 17 patients developed graft-versus-host disease after their first T(reg)-depleted donor lymphocyte infusion and experienced a long-term remission of their malignancy. Four of the 15 patients who did not respond after a first T(reg)-depleted donor lymphocyte infusion received a second T(reg)-depleted donor lymphocyte infusion combined with lymphodepleting chemotherapy aimed to also eliminate recipient T(reg)s. All four developed acute-like graft-versus-host disease that was associated with a partial or complete and durable remission. In the whole cohort, graft-versus-host disease induction through T(reg) depletion was associated with improved survival. These results suggest that T(reg)-depleted donor lymphocyte infusion is a safe, feasible approach that induces graft-versus-host or graft-versus-tumor effects in alloreactivity-resistant patients. In patients not responding to this approach, the combination of chemotherapy-induced lymphodepletion of the recipient synergizes with the effect of T(reg)-depleted donor lymphocyte infusion. These findings offer a rational therapeutic approach for cancer cellular immunotherapy.

An excess of mixed-handedness has been repeatedly reported in schizophrenia and schizotypy. Handedness is a measure of atypical cerebral lateralization, which is considered as a risk factor for schizophrenia. Several studies have attempted to identify correlations between handedness and dimensions of psychosis but the results obtained so far remain inconclusive.To explore a possible link between mixed-handedness and the three classical dimensions of psychosis. As speech and language disorders may be associated with cerebral lateralization, we predicted a correlation between mixed-handedness and disorganized dimension.We used the Schizotypal Personality Questionnaire (SPQ) and the Edinburgh Handedness Inventory (EHI) to study the correlation between mixed-handedness scores and positive, negative or disorganized dimensions in a sample of 62 healthy subjects.We found a negative correlation between mixed-handedness and the disorganized dimension of schizotypy, as individuals with prominent mixed-handedness showed more severe disorganization.We have identified a link between mixed-handedness and the disorganized dimension that may help to identify genetic vulnerability factors involved in psychosis.

Allogeneic hematopoietic stem cell transplantation (SCT) is a widely used, cost-intensive procedure. Although pretransplant nonmyeloablative (NMA) or reduced-intensity conditioning regimens appear very promising, prospective studies comparing this approach with the conventional myeloablative (MA) approach in specific hematologic diseases are necessary, especially in patients in whom the conventional approach is not contraindicated. Cost may be an important factor in the decision-making process. We compared the costs of MA and NMA transplants in patients with acute myeloid leukemia (AML). We estimated 1-year resource utilization in 12 consecutive MA patients (median age: 39 years) and in 11 consecutive NMA patients (median age: 58 years) who underwent HLA-identical sibling SCT for AML. Resources care expenses were valued using the average daily rate for personnel costs, supplies, and room costs. Other data were directly collected from the patients' charts. Despite a trend for lower costs in NMA patients during the first 6 months, costs during the 6-12-month period were significantly higher after NMA due to late complications and readmissions (P=0.03). Finally, mean 1-year costs were not different in MA and NMA patients (P=0.75). Prospective studies comparing conventional and NMA approaches in homogeneous populations should include economic items.

The latest generation of cell separators such as Trima (Gambro), Amicus (Baxter) and AS-TEC 204 (Fresenius), allow the collection of leucocyte-reduced platelet concentrates without secondary filtration. Fresenius has recently developed the COMTEC cell separator whose performance has been evaluated by several teams in France. This new cell separator is an improved version of the Fresenius AS-TEC 204 cell separator, designed to allow more efficient platelet collections. This study reports on the experience of six French teams (from Bordeaux, Clermont-Ferrand, Creteil, Dijon, Lille and Nancy) who obtained 696 leucocyte-reduced plateletpheresis concentrates in the course of collection using the new Fresenius COMTEC cell separator. All healthy volunteer donors fulfilled French selection criteria for platelet apheresis. Donors were eligible if they had suitable venous accesses, if their bodyweight was *50 kg and if their pre-apheresis platelet count was150 x 10(9) l(-1). Between 4606 and 5229 ml of blood were processed. The mean volume of the platelet concentrates was between 439 and 493 ml (mean 460 +/- 63 ml). The platelet yield was of the order of 5.18 +/- 1.02 x 10(11) with only one platelet concentrate below the norm of 2 x 10(11) platelets (0.91 x 10(11)). No plausible explanation for this was found. The residual leucocyte levels conform to current norms. The platelet concentrates contained less than 1 x 10(6) leucocytes per concentrate (mean 0.233 +/- 0.150 x 10(6) leucocytes) in more than 97% of the components produced with95% statistical confidence. The efficacy of the cell separator (52.44 +/- 7.35%) is comparable to that of other separators. The Fresenius COMTEC cell separator makes it possible to obtain leucocyte-reduced platelet concentrates which comply with current standards both in terms of platelet content and residual leucocyte level.

Background Donor lymphocyte infusions (DLI) can produce lasting remissions in patients with relapsed chronic myeloid leukemia (CML), but are less effective in non-CML diseases. Chemotherapy-induced lymphodepletion prior to DLI, achieved with cyclophosphamide (Cy) and fludarabine (Flu), has been shown to enhance activation of donor lymphocytes and cause significantly more acute graft-versus-host disease (GVHD) than DLI alone. To safely balance the toxic versus beneficial effects of activated donor lymphocytes, we combined lymphodepleting chemotherapy with the infusion of donor T cells engineered to carry a suicide gene to treat patients with aggressive hematologic malignancies. Methods Donor T cells were transduced with a retroviral vector expressing the Herpes simplex thymidine kinase (TK) suicide gene and the human Thy-1 selection marker and expanded in culture for 15 to 19 days prior to their infusion. In this phase I/II trial, the safety and efficacy of Cy/Flu/DLI-TK was studied between February and December 2011 in 10 adults with relapsed multiple myeloma (n=5) or myelodysplasic syndrome/acute leukemia (n=5). One had previously failed to respond to at least one standard DLI while others had not received any DLI before inclusion. All were free of immunosuppressive therapy at inclusion. Patients were infused with a mean cell-dose of 5 (range: 1-10) x106 CD3+ cells/kg of which 98% were TK+ cells (range: 97%-99%). DLI products contained a mean ratio of 0.6% (range: 0.1-1.6) CD4+FoxP3+Helios+ regulatory T-cells. This trial was registered at www.clinicaltrials.gov as NCT 01086735. Results The Cy/Flu regimen was profoundly lymphodepleting and led to a mean 3-day period of neutropenia below 500 PMN/µL. Three patients developed acute GVHD following TK+ cell infusion. One patient had a grade I cutaneous GVHD resolving with local steroids. In another patient with grade III cutaneous and digestive involvement, intra-venous administration of ganciclovir (GCV) led to the complete and lasting resolution of symptoms correlated with clearance of TK+ cells in peripheral blood. A third patient had a grade III liver GVHD. Due to only partially controlled leukemia at the time of DLI, GCV treatment was postponed for one week after GVHD onset in order to support a putative GVL effect. Treatment with GCV led to the rapid disappearance of TK+ cells in peripheral blood and liver (see Figure) but without clinical improvement after 2 weeks, so that an additional immunosuppressive therapy should be instituted. Six patients, including one of the 2 treated with GCV, experienced relapse/progression of their malignancy and received additional anti-cancer therapy. With a median follow-up of 22 months after Cy/Flu/DLI-TK, 6 patients are alive, 5 of them being disease-free. In patients not treated with GCV, TK+ cells could still be detected in peripheral blood till at least 12 months after their infusion. Conclusion Lymphodepletion followed by suicide-gene-transduced T-cell infusion may help to safely enhance the immune activity of DLI, which could be further improved by regulatory T-cell depletion (Maury et al, Science Translat Medicine 2010). Disclosures: No relevant conflicts of interest to declare.

Follicular lymphomas have an indolent evolution with a median survival ranging between 8–10 years. At relapse, high-dose therapy followed by autologous stem-cell transplantation (ASCT) can be considered as an alternative to conventional chemotherapy. However, efficacy of this strategy remains controversial. The purpose of our retrospective study is to evaluate ASCT in the pre and post rituximab era as consolidation after 2nd or 3rd remission (at least PR). Between March 1989 and Apr 2004, 54 pts were treated at relapse with ASCT in our institution. At initial diagnosis, median age was 47 yrs (range 24–61) and FLIPI score was ≥ 3 in 18%. ASCT was performed in 2nd remission in 43 cases and in 3rd remission in 11 [median delay diagnosis-ASCT=44 months (range 7–139) and 53 months (range 21–227), respectively]. The conditioning regimens used were: VP16/cyclophosphamide/TBI in 33 cases, cyclophosphamide/TBI in 9, BEAM in 10 and cyclophosphamide/busulfan in 2. After ASCT, 49 pts achieved CR, 4 achieved PR and one pt progressed. In Dec 2004, with a median follow-up of 4.7 yrs, 27 pts (50%) had relapsed after ASCT with a median time to relapse of 12 months (range 2–95) and 18 pts have died. Causes of death were: lymphoma recurrence in 8 cases, secondary malignancy in 6 cases (3 MDS/AML, 2 radiation-associated solid tumors, 1 EBV associated lymphoma after a new salvage treatment including allogenic transplantation), and late infection in 4 cases, 2 of them occurring in remission (varicella and septicaemia) and 2 others after a new salvage therapy (cellulitis during chemotherapy-induced neutropenia and HHV6 encephalitis after allogenic transplantation). Ten-year overall survival (OS) from initial diagnosis was 68%. Five-year OS and event-free survival after ASCT were 74 and 52%, respectively. Patients treated at relapse before 1998 did not receive rituximab (rituximab-naive pts: n=29) and those treated after 1998 received a rituximab-based salvage regimen before ASCT (rituximab-treated pts: n=25). The main characteristics of the two populations were as indicated in the table below: | | rituximab-naive group | rituximab-treated group | |:--------------------------------------------------------------------------------:| --------------------- | ----------------------- | | N | 29 | 25 | | FLIPI at initial diagnosis (Low/Intermediate/High) % | 41/48/11 | 27/46/27 | | Median age at ASCT (yrs) | 50 (range35–60) | 52 (range 30–62) | | ASCT performed in 2nd remission | 23 | 20 | | ASCT performed in 3rd remission | 6 | 5 | | Median duration of response following last treatment line prior to ASCT (months) | 21 (range 1–91) | 11 (range1–49) | After adjusting for the follow-up (median follow-up of the rituximab-treated group: 3.8 yrs), comparison between the two groups of pts treated with ASCT at relapse shows a significantly better OS of the rituximab-treated group as compared to that of the rituximab-naive group (100 vs 61% at 4 years, p=0.01). These data suggest that the well-established efficacy of rituximab in FL is not abrogated by consolidative ASCT delivered at relapse in pts not previously treated with rituximab and further emphasize the superiority of immunochemotherapy over chemotherapy alone.

Vitamin A tolerance tests were performed on 54 anginal patients with coronary atherosclerosis. In 26 of them the curves were within normal limits, in 5 they were below normal, and in 23 they were above normal. Normal curves were found in 7 patients with primary hypercholesterolemia (2 of whom had tendon xanthoma) and in 19 other patients of whom 8 had a normal blood lipid pattern and 11 had an atypical one). Flat curves occurred in 2 patients with diabetic hyperlipemia and in 3 with an atypical blood lipid pattern. High curves were found in 1 patient with myxedema and in 8 patients with primary (essential) hyperlipemia, but also in 4 with normal blood lipids and in 10 with an atypical blood lipid pattern. The different responses to the vitamin A tolerance test confirmed the presence of different metabolic disorders underlying the various hyperlipemias associated with coronary atherosclerosis. The high curves found in 22 patients (excluding the one with myxedema) are probably related to a disturbance of the early stages of lipid metabolism (absorption, transport, storage). The variable intensity of this disturbance, essentially limited to the postabsorptive period, probably accounts for the divergent results of the simple dosage of fasting blood fats. Perhaps the majority of these cases are representative of different aspects of essential hyperlipemia of variable severity. It is justifiable therefore to detect among anginal patients those with abnormally high vitamin A tolerance curves, thus allowing for a more specific treatment.

The evolution of spontaneous variations in the coagulability of the blood following myocardial infarction has been studied in seventy untreated cases by simultaneous estimations of the prothrombin time and the heparin tolerance test (in vitro). 1. 1. Starting from the acute attack, three phases succeed one another with great regularity: 1.1. (a) Period of hypercoagulability, often extreme, occupying the first twenty-four to forty-eight hours. Very constant. 1.2. (b) Period of spontaneous, secondary hypocoagulability from second to third to eighth to fifteenth day, usually lasting about seven days. Occurred in 81.4 per cent of cases in the series. 1.3. (c) Period of late hypercoagulability, variable in degree, starting on about the eighth or tenth day and lasting usually a few weeks but possibly several months. 2. 2. The demonstration of these spontaneous fluctuations of coagulability have enabled us to elaborate a rational system of anticoagulant treatment which has been applied to seventy-one cases of infarction with good results (over-all mortality: 9.8 per cent, thrombo-embolic complications: 2.8 per cent), and a small incidence of inconsequential bleeding (12 per cent). 3. 3. Frequent studies of blood coagulability are essential to any treatment with coumarin substances. The prothrombin time by itself is not enough; measurements of the heparin tolerance in vitro must always be made at the same time.