Discontinuation of tyrosine kinase inhibitor in chronic myeloid leukemia: a retrospective cohort in east occitania.

Tyrosine kinase inhibitor (TKI) discontinuation in chronic phase chronic myeloid leukemia (CML) patients has been examined in a real-life setting in the east occitania region of France. We have collected sex, age, prognostic scores, pre-TKI treatment, TKI length and response, relapse data from patients who had stopped TKI in prolonged complete molecular remission (CMR), and analyzed relapse risk factors. Sixty consecutive patients were included from january 2010 to december 2016. Sixteen received pre-TKI treatment. Fifty-three received a first-generation TKI, and seven had a second-generation TKI in first-line therapy. The median TKI time to achieve CMR was 20.5 months [5-137]. The median TKI length before discontinuation treatment was 73 months [12-158]. Twenty-two patients (37%) relapsed with a median time to relapse of 6 months [3-27]. An intermediate or high Sokal score was the only relapse risk factor (HR = 3.32, p < 0.05) associated with relapse after TKI discontinuation. TKI discontinuation was possible without relapse for half of the patients in chronic phase CML. In a real-life cohort, a high-risk Sokal score at diagnosis appears to be an adverse prognosis feature for TKI discontinuation.

Proteolytic activity and expression of the 20S proteasome are increased in psoriasis lesional skin.

BACKGROUND: Deregulation of the proteasome pathway has been shown to be involved in the pathogenesis of several inflammatory disorders. To date limited information exists on proteasome and immunoproteasome expression and activity in psoriasis skin. OBJECTIVES: To investigate the potential role of proteasomes in the pathogenesis of psoriasis. METHODS: Thirty-six patients with psoriasis and 40 healthy subjects were included. The protein and mRNA expression levels and proteolytic activity of proteasome and immunoproteasome subunits were determined using immunohistochemistry, quantitative polymerase chain reaction and fluorogenic peptide substrate in lesional and nonlesional psoriasis skin. We additionally measured the plasmatic proteasome (p-proteasome) levels using enzyme-linked immunosorbent assay. RESULTS: We reveal an increased expression of proteasome and immunoproteasome subunits but stable mRNA levels in lesional psoriasis skin as compared with nonlesional psoriasis skin (n = 19), suggesting that proteasome and immunoproteasome expression is regulated post-transcriptionally. This proteasome overexpression was associated with a significant increase of the proteasomal chymotrypsin-like activity that was threefold higher in lesional skin than in nonlesional skin (n = 3). p-Proteasome levels were enhanced in patients with psoriasis (mean ± SEM 3960 ± 299 ng mL(-1) , range 1484-8987) when compared with controls (2535±187 ng mL(-1) , range 654-6446, P<0·001) and were significantly higher in psoriatic arthritis (4937±572 ng mL(-1) , range 2600-8987). In addition, they were correlated to the body surface area involved and appeared thus as a new biomarker of psoriasis severity. CONCLUSIONS: Altogether these results strongly suggest the involvement of the proteasome system in the pathogenesis of psoriasis and support the relevance of proteasome inhibitors in local or systemic treatment of psoriasis.

Plasma proteasome level is a reliable early marker of malignant transformation of liver cirrhosis.

BACKGROUND: Proteasomes are the main non-lysosomal proteolytic structures which regulate crucial cellular processes. Circulating proteasome levels can be measured using an ELISA test and can be considered as a tumour marker in several types of malignancy. Given that there is no sensitive marker of hepatocellular carcinoma (HCC) in patients with cirrhosis, we measured plasma proteasome levels in 83 patients with cirrhosis (33 without HCC, 50 with HCC) and 40 controls. METHODS AND RESULTS: Patients with HCC were sub-classified into three groups according to tumour mass. alpha-Fetoprotein (AFP) was also measured. Plasma proteasome levels were significantly higher in patients with HCC compared to controls (4841 (SEM 613) ng/ml vs 2534 (SEM 187) ng/ml; p<0.001) and compared to patients with cirrhosis without HCC (2077 (SEM 112) ng/ml; p<0.001). This difference remained significant when the subgroup of patients with low tumour mass (proteasome level 3970 (SEM 310) ng/ml, p<0.001) was compared to controls and patients with cirrhosis without HCC. Plasma proteasome levels were independent of the cause of cirrhosis and were weakly correlated with AFP levels. With a cut-off of 2900 ng/ml, diagnostic specificity for HCC was 97% with a sensitivity of 72%, better than results obtained with AFP. Diagnostic relevance of plasma proteasome measurement was also effective in low tumour mass patients (sensitivity 76.2% vs 57.1% for AFP). CONCLUSION: The plasma proteasome level is a reliable marker of malignant transformation in patients with cirrhosis, even when there is a low tumour mass.

Transient protection by peripheral benzodiazepine receptors during the early events of ultraviolet light-induced apoptosis.

The peripheral benzodiazepine receptor (PBR) is a mitochondrial protein involved in the formation of mitochondrial permeability transition (PT) pores which play a critical role during the early events of apoptosis. PBRs are located in many tissues and are strongly expressed in the superficial layers of human epidermis. PBRs play a protective role against free radical damage and PBR ligands modulate apoptosis. To investigate the role of PBR during the early events of ultraviolet (UV)-mediated apoptosis we compared the effects of UVB on PBR-transfected Jurkat cells and their wild type counterparts devoid of any PBR expression. Results indicate that early after UVB exposure (up to 4 h), PBR-transfected cells were more resistant to apoptosis and exhibited a delayed mitochondrial transmembrane potential drop, a diminished superoxide anions production, and a reduced caspase-3 activation. Taken together these findings suggest that PBR may regulate early death signals leading to UV induced apoptosis.

Treatment outcome and prognostic factors for primary mediastinal (thymic) B-cell lymphoma: a multicenter study of 106 patients.

PURPOSE: To define clinicopathologic features, response to treatment, and prognostic factors of primary mediastinal B-cell lymphoma (MBL), a CD20+ tumor recognized as a distinct entity among non-Hodgkin's lymphomas (NHL). PATIENTS AND METHODS: One hundred six patients presented with disease confined to thorax (86%), bulky mediastinum (73%), superior vena cava syndrome (47%), and contiguous infiltration (57%). Ninety-nine received doxorubicin-containing chemotherapy (CHT). RESULTS: Thirty-five of 99 patients were primarily CHT-resistant, and 64 responded: 23 achieved complete response (CR) and 41 achieved response with residual mediastinal abnormality. Seventy-seven percent of responders received mediastinal radiotherapy (RT). Of 64 responders, 18 (28%) relapsed: none of 23 CR patients and 18 of 41 (44%) with residual mediastinal abnormality. Relapse-free survival rate of responders was 71% at 3 years. Actuarial 3-year survival rate was 52% for all patients and 82% for responders. Predictive factors of poor outcome were identified by logistic regression; Cox survival analysis was performed on death and relapse. Pericardial effusion (P < .001) and Eastern Cooperative Oncology Group (ECOG) performance status > or = 2 (P = .009) predicted nonresponse (NR) and affected survival. Less than partial midway response to CHT predicted NR to subsequent therapies. Bulky disease was related to persistent mediastinal abnormality and risk of relapse (P = .025). CONCLUSION: MBL is an aggressive NHL with unique clinicopathologic aspects, often refractory to current CHT designed for high-grade NHL. Poor performance status and pericardial effusion predict NR and poor survival. Inadequate response after the first courses of front-line CHT predicts failure of subsequent treatment. Responders with bulky mediastinum or residual mediastinal abnormality after CHT are at risk of relapse. These factors should help to select high-risk patients for intensive treatments.

Leukemia-associated changes identified by quantitative flow cytometry. II. CD5 over-expression and monitoring in B-CLL.

The CD5 antigen density on B cells was studied on fetal spleen, cord blood, and adult peripheral blood (after immunomagnetic bead purification) using an indirect immunofluorescence technique. In fetal spleen, there was a continuum in CD5 expression, whereas all cord blood and less than 20% adult peripheral blood B cells were CD5+. Mean CD5 antigen density on these normal cells was low (3-6 x 10(3) molecules/cell); eight to 20 times lower than on normal T lymphocytes. In adult blood, less than 10% B cells expressed more than 3 x 10(3) CD5 molecules/cell. In chronic malignancies, 34/35 cases had a CD5 antigen density lower than on residual T cells, but mean antigen density was higher (14.8 +/- 2.1 x 10(3) molecules/cell) than on normal B cells. Sixteen cases of chronic lymphocytic leukemia (50%) expressed a CD5 density above 10 x 10(3) molecules/cell. This aberrantly high CD5 expression was used to detect neoplastic cells after dilution in normal lymphocytes, with a limit of detection between 1:100 and 1:1000. Quantitation of the CD5 antigen allows better characterization of the B1 population and should be used for the monitoring of chronic malignancies.

Quantification of CD24 and CD45 antigens in parallel allows a precise determination of B-cell maturation stages: relevance for the study of B-cell neoplasias.

Quantitative expression, i.e. absolute number of monoclonal antibody molecules bound per cell, was evaluated for CD24 and CD45 by flow cytometry with standards of fluorescence intensity on a panel of normal and neoplastic B cells. The CD24 antigen was expressed at homogeneous high level in fetal bone marrow and liver. Its density decreased progressively in the other normal tissues in parallel with the B-cell maturation. The ratio between CD24 density measured on fetal bone marrow B cells and that seen on adult peripheral B cells was 6:1. The CD45 antigen density was lower on fetal bone marrow cells than in the more mature stages. Fetal spleen lymphocytes and all the mature B lymphocytes displayed the same CD45 density than that seen on normal adult peripheral T cells. The CD24/CD45 antigen density ratio was precisely related to the stage of B-cell maturation. The same pattern of variation of CD24 and CD45 antigen density was seen on B-cell neoplasias, with a significantly higher value of CD24 and lower value of CD45 in acute lymphoblastic leukemias than in chronic malignancies. CD24 and CD45 antigen levels were frequently out of the range observed in the corresponding normal population. Among ALL patients, a low CD24/CD45 antigen density ratio was associated with a good prognosis. These data confirm the interest of an absolute quantitative study for widely distributed antigens.

Multiplex fluorescent RT-PCR to quantify leukemic fusion transcripts.

The detection of chimeric transcripts derived from aberrant chromosomal fusion events provides an exceptionally valuable toolfor the diagnosis of leukemia. We have developed a simple, inexpensive, reproducible, and automated method to quantify RT-PCR products. Our approach utilizesfluorescent PCRfor the co-ampification of the specific fusion transcript with an internal control (HPRT). We have also combined the advantages of real-time quantitative PCR, namely continuous fluorescent detection of PCR products with the low cost of an endpoint assay by examining in a novel manner the amount offluorescent PCR product generated during the exponential phase of amplification. This has been achieved by using the automated loading and quantification capacity of a laser-induced fluorescence capillary electrophoresis system, the ABI PRIsMS 310A, so that we can effectively monitor amplification during the exponential phase cheaply, reproducibly, and in a sensitive manner. We have carefully verified our new technique using five leukemia cell lines, each expressing a differentfusion transcript. Specificity and reproducibility (cy within 10%) have been examined and demonstrate the excellent precision of our technology. The high sensitivity levels of at least 10(-4) to 10(-6) obtainedfor the serial dilutions of the five cell lines validate the choice of our fluorescent PCR as a comparable method to other more complicated and expensive methods. Our results have allowed us to quantify PCR products and the amount of chimeric mRNA originating from the translocation breakpoint. We demonstrate that our novelfluorescent method is useful to detect and quantify residual leukemic cells in patients undergoing therapy.

B-cell chronic lymphocytic leukaemia populations respond stochastically to combinations of growth signals in vitro.

The ability of B-CLL lymphocyte populations to respond to cytokine stimulation of mononuclear cultures was examined using 3-colour immunofluorescence and multiparameter flow cytometry. The simultaneous detection of the membrane antigens CD5 and CD19, with the proliferation antigen Ki-67, allowed examination of the cell-cycle entry of the B-CLL lymphocyte population. Upon stimulation with IFN-gamma, IFN-gamma+IL-2, TPA+IL-4, between 10 and 44% of B-CLL lymphocytes from 10 patients were stimulated to enter into cell-cycle. This B-CLL response was notably more homogenous than the non-clonal lymphocyte response. Except in the case of IFN-gamma alone, T-cell response did not correlate with B-CLL response, suggesting B-CLL lymphocytes respond directly to combinations of growth signals. Considering the B-CLL population as homogenous, B-CLL lymphocytes respond in a stochastic manner.

Mediastinal B-cell lymphoma: a study of its histomorphologic spectrum based on 109 cases.

Mediastinal B-cell lymphoma (MBL) is a distinct variant of aggressive non-Hodgkin's lymphoma with characteristic clinical and biological features but less well-defined histomorphology. We reevaluated 124 biopsy specimens from 109 MBL patients of an Italian/French/German retrospective clinical study. MBL was primarily diagnosed on clinical and histological grounds in conjunction with the detection of CD20 expression by immunohistology. Cytologically, MBL features limited intralesional but considerable interindividual cytological diversity, ranging from medium-sized to very large, atypical cells. Sclerosis and necrosis are restricted to extrathymic and extranodal sites of involvement, predominantly the lung, as is angioinvasion, which predominantly affects larger vessels. The medium-sized and the large cell variants resemble marginal zone lymphoma variants, whereas the very large cell variant of MBL has not so far been found to have any extramediastinal counterpart. We conclude that MBL displays a broad morphological spectrum covering more than is implied by the term "diffuse large cell lymphoma." Because statistical analysis of cytological and histological criteria failed to correlate with prognosis in this comprehensive group of patients, we think it inadvisable further to subclassify MBL.

CD23 antigen density is related to serum gamma globulin level, bone marrow reticulin pattern, and treatment in B chronic lymphocytic leukemia.

The CD23 antigen density was evaluated by a cytofluorometric technique in 55 patients with chronic lymphocytic leukemia. The quantification method was based on the use of biological standards in indirect immunofluorescence. The CD23 antigen density was correlated with the percentage of CD23 positive cells, but antigen density appeared to be a more informative parameter. CD23 antigen density was lower in stage B than in stages A or C patients, and higher in patients undergoing chemotherapy or previously treated than in untreated patients. There was a significant negative correlation between CD23 antigen density and serum gamma globulin and IgG levels, that existed only in patients in an advanced stage of the disease. CD23 antigen density was higher in patients with abnormal bone marrow reticulin pattern. Serum gamma globulin level was lower in these patients, as well as in patients with prognostically unfavorable histologic bone marrow infiltration pattern. These data emphasize the interest of antigen density as an additional parameter and the complex relationship between CD23 expression, hypogammaglobulinemia, bone marrow histologic findings, and treatment in chronic lymphocytic leukemia.

Primary mediastinal B-cell lymphoma: update of its clinicopathologic features.

The peculiar clinical, histomorphological and biological characteristics of PMBCL are reviewed. Special emphasis is given to the frequent aggressive clinical behaviour of this lymphoma in which conventional prognostic factors seem inadequate to identify high risk cases. The need for new clinical and/or biological prognostic markers is stressed.

Visceral leishmaniasis. Persistence of parasites in lymph nodes after clinical cure.

Visceral leishmaniasis (VL) is generally associated with severe immunodeficiency (AIDS; renal, liver, and heart transplantations; haemopoietic malignancies). More rarely it can be related to an immunotolerence status such as pregnancy. Various observations report the development of leishmaniasis several months or even years after exposure to the parasite. Relapses occur rarely in patients not known to be immunocompromised, but are common after incomplete treatment. They are frequent in patients with Leishmania/HIV co-infection. Asymptomatic phases and relapses suggest that parasite can exist in the tissues for a long time before and/or after clinical onset of the disease. The mechanisms of onset of clinical leishmaniasis following exposure and infestation are highly relevant to understanding the pathology of the disease. The survival of Leishmania parasite between infection and disease or after cure is a very important issue for clinicians and epidemiologists. We describe two cases of VL occurring in a patient with lymphoma and in a pregnant woman. In both cases, parasites remained present in the lymph nodes after clinical cure.

Nephrotic syndrome associated with chronic lymphocytic leukemia resistant to immunosuppressive drugs: remission obtained by splenectomy.

Chronic lymphocytic leukemia is a common disease in the elderly but is rarely associated with a nephrotic syndrome. The rarity of this association suggests that leukemic cells may have certain properties or features that may lead to the development of glomerulonephritis. Effective medical treatment of the leukemia may not necessarily allow regression of the nephrotic syndrome; however, the effects of splenectomy on nephrotic proteinuria when associated to chronic lymphocytic leukemia have never been evaluated. We report the case of a 50-year-old male with stage C CD5+ chronic lymphocytic leukemia associated with a nephrotic syndrome due to Type I membranoproliferative glomerulonephritis. Chlorambucil and prednisone were unable to control the leukemia and the nephrotic range proteinuria, and were discontinued because of poor hematologic tolerance. A splenectomy immediately resulted in a spectacular remission of both chronic lymphocytic leukemia and the nephrotic syndrome. Spleen lymphocytes were collected and tested in quantitative flow cytometry for the expression of the main B cell associated markers. They did not exhibit any particular immunophenotypic pattern. This report of a remission of a glomerulonephritis associated with chronic leukemia following splenectomy is evidence of a possible relationship between the two diseases.

Flow-cytometric quantitation in chronic leukemias.

Flow cytometric quantitation in chronic leukemias provide relevant information in different areas. It allows the characterization of additional leukemia associated parameters, like over- or under- expression as compared to normal counterparts, that is suitable for the diagnosis of malignancy or for residual disease evaluation. It improves scoring systems for the differential diagnosis between the different chronic malignancies. It allows to find original pronostic parameters and improves the comparison of different series due to a better definition of positivity. It helps to the monitoring of immune based therapeutic regimens. It provides new relevant pathophysiological informations, for instance in the study of apoptosis, as a tool for quantitative evaluation of the apoptotic process itself and for the study of its mechanism. Since its first description by Minot and Isaacs in 1924, chronic lymphocytic leukemia (CLL) has been extensively studied, due in part as it has been demonstrated as the more frequent leukemia in the Western world (Gale and Foon 1987). In addition, clinical features, cell morphology, immunological markers, histopathology and molecular genetics have been used progressively to define and characterize a wide spectrum of chronic lymphoproliferative disorders which had been previously gathered in the same entity than CLL (Benett et al., 1989, Catovsky and Matutes 1991, Harris et al., 194). Immunologic techniques are now routinely used for diagnosis in this context. Since there is no marker specific for each of these entities, scoring systems have been proposed to help diagnosis (Matutes and Catovsky 1994), which are currently investigated in multicentric studies. Flow cytometry is now widely used for immunophenotyping purposes. It allows, in addition to the determination of the percentage of positive cells, to determine the intensity of fluorescent staining, that can be converted into antigen density provided that reagents are used under saturating concentrations and correct standards of fluorescence are tested in parallel. The concept of antigen density evaluation appears to improve the efficiency of immune techniques in the monitoring of hemopoietic malignancies (Lavabre-Bertrand et al., 1994c). The present review will focus on the specific interest of immune quantitation in the study of chronic lymphoid malignancies, with a successive emphasis on diagnosis of malignancy, distinction between the different chronic lymphopathies, prognostic and therapeutic relevance, then on pathophysiological interest.

[Chronic herpes of the pyodermatitis vegetans type in chronic cutaneous lymphoid leukemia]. / Herpès chronique à type de pyodermite végétante au cours d'une leucémie lymphoïde chronique avec localisations cutanées.

The authors report a case of chronic herpes virus infection of the face which developed in a 70-year old man already affected with chronic lymphocytic leukaemia of the B-cell type (CLL-B) with specific cutaneous localisations. Immunodepression was indicated only by marked hypogammaglobulinaemia. Cell-mediated immunity was preserved. The cutaneous lesions of the face were chronic and presented as pyodermatitis vegetans. A one-week course of acyclovir administered by intravenous infusion in doses of 5 mg/kg three times a day resulted in rapid and dramatic cure, but this result proved transient, since the virus infection relapsed 2 1/2 months later. The new episode also was successfully treated with a second course of acyclovir. The herpes virus infection had developed only on those skin areas that were specifically affected by the leukaemia; after treatment and eradication of the virus, massive lymphocytic infiltration of the dermis persisted in these areas. Involvement of the skin is rare in CLL-B and has been reported mainly in CLL-T. The lesions most frequently encountered are tuberous and papular lesions and infiltrated plaques on the forehead and ears. The pyodermatitis vegetans presentation is unusual. The reasons why viral skin lesions develop on those caused by leukaemia are unknown.

[Extensive primary cutaneous mucinosis associated with refractory anemia with excess of blast]. / Mucinose cutanée primitive diffuse associée à une anémie réfractaire avec excès de blastes.

BACKGROUND: We describe an original case of a primary cutaneous mucinosis, associated with a refractory anemia with excess of blast. CASE REPORT: A 65 year-old female consulted for erythematous-purple blush reticulated and large plaques that progressively developed on the trunk and limbs. Biopsies showed abundant dermis mucin deposits with a perivascular lymphocytic infiltrate. The epidermis was normal. Laboratory evaluation showed refractory anemia with excess of blast, associated with cytogenetic abnormalities. After two years course, the progressive aggravation of the myelodysplastic syndrome was associated with a progressive extension of the cutaneous mucinosis. DISCUSSION: This is the first report of an atypical primary diffuse and extensive cutaneous mucinosis. Primary cutaneous mucinosis may be associated with systemic diseases. To our knowledge, the association with refractory anemia with excess of blast has not been described previously. Mucine deposits may be considered as a consequence of neutrophilic dysfunction that are observed in myelodysplastic syndromes.

[The proteasome and malignant hemopathies]. / Protéasome et hémopathies malignes.

Proteasomes are the main non lysosomal proteolytic structures of the cells. They correspond to the major system eliminating abnormal proteins, short half-life proteins and proteins controlling the cell cycle. They are essential for the production of peptides subsequently presented by the MHC-I. They are formed by a proteolytic core (the 20S proteasome) made of 4 rings of 7 proteic subunits associated with regulatory complexes (namely the 19S complex forming the 26S proteasome). Using classical cell biology techniques (cytometry, immunofluorescence microscopy, Western blot) our group has particularly studied the proteasome expression of leukaemic cell lines (U937 and CCRF-CEM) during in vitro differentiation induced by PMA and Vitamin D plus retinoïc acid. During differentiation, the level of proteasome expression and its localization vary. The various monoclonal antibodies used provided different patterns according to the different subunits. There was a general trend to a disappearance of nuclear proteasome and to a decrease in their cytoplasmic expression. In contrast, proteosomal antigens were increased on the cell membrane and in culture supernatants. We derived an ELISA test to measure plasma proteasome concentrations. Preliminary results showed differences between patients with haemopoietic malignancies or solid tumors and normal donors. Proteasome levels varied under treatment. They were correlated with LDH levels. Taken together, these results argue in favor of a role for cellular proteasomes in malignant differentiation process, and emphasize the qualitative changes in proteasome expression. Plasma proteasomes do not only reflect tumor cell mass and could play a role in addition to their proteolytic activity. They seem to be a relevant tool for diagnosis, prognosis and therapeutic monitoring.

[Urologic manifestation of Waldenström's disease. Apropos of a case with pyelo-ureteral location]. / Manifestations urologiques de la maladie de Waldenström. A propos d'un cas de localisation pyélo-urétérale.

The authors report a case of Waldenström's disease in which the initial staging assessment reveals an isolated tumour of the left upper urinary tract. Combination chemotherapy (6 courses of protocol M2) induced a marked reduction in the monoclonal IgM peak and in the tumour mass. In the light of this atypical case, which emphasises the diversity of the potential sites of Waldenström's macroglobulinaemia, the authors review its potential for progression and the various therapeutic modalities available.