Progression free survival of myeloma patients who become IFE-negative correlates with the detection of residual monoclonal free light chain (FLC) by mass spectrometry.

Deeper responses are associated with improved survival in patients being treated for myeloma. However, the sensitivity of the current blood-based assays is limited. Historical studies suggested that normalisation of the serum free light chain (FLC) ratio in patients who were negative by immunofixation electrophoresis (IFE) was associated with improved outcomes. However, recently this has been called into question. Mass spectrometry (MS)-based FLC assessments may offer a superior methodology for the detection of monoclonal FLC due to greater sensitivity. To test this hypothesis, all available samples from patients who were IFE negative after treatment with carfilzomib and lenalidomide-based induction and autologous stem cell transplantation (ASCT) in the Myeloma XI trial underwent FLC-MS testing. FLC-MS response assessments from post-induction, day+100 post-ASCT and six months post-maintenance randomisation were compared to serum FLC assay results. Almost 40% of patients had discordant results and 28.7% of patients with a normal FLC ratio had residual monoclonal FLC detectable by FLC-MS. FLC-MS positivity was associated with reduced progression-free survival (PFS) but an abnormal FLC ratio was not. This study demonstrates that FLC-MS provides a superior methodology for the detection of residual monoclonal FLC with FLC-MS positivity identifying IFE-negative patients who are at higher risk of early progression.

Report of Consensus Panel 3 from the 11th International workshop on Waldenström's Macroglobulinemia: Recommendations for molecular diagnosis in Waldenström's Macroglobulinemia.

Apart from the MYD88L265P mutation, extensive information exists on the molecular mechanisms in Waldenström's Macroglobulinemia and its potential utility in the diagnosis and treatment tailoring. However, no consensus recommendations are yet available. Consensus Panel 3 (CP3) of the 11th International Workshop on Waldenström's Macroglobulinemia (IWWM-11) was tasked with reviewing the current molecular necessities and best way to access the minimum data required for a correct diagnosis and monitoring. Key recommendations from IWWM-11 CP3 included: (1) molecular studies are warranted for patients in whom therapy is going to be started; such studies should also be done in those whose bone marrow (BM) material is sampled based on clinical issues; (2) molecular studies considered essential for these situations are those that clarify the status of 6q and 17p chromosomes, and MYD88, CXCR4, and TP53 genes. These tests in other situations, and/or other tests, are considered optional; (3) independently of the use of more sensitive and/or specific techniques, the minimum requirements are allele specific polymerase chain reaction for MYD88L265P and CXCR4S338X using whole BM, and fluorescence in situ hybridization for 6q and 17p and sequencing for CXCR4 and TP53 using CD19+ enriched BM; (4) these requirements refer to all patients; therefore, sample should be sent to specialized centers.

Progression of IgA gammopathy to myeloma following infliximab treatment for pyoderma gangrenosum.

Pyoderma gangrenosum (PG) may be associated with inflammatory disorders and haematological conditions such as monoclonal gammopathy of uncertain significance (MGUS). We report the case of a 53-year old man who had PG and MGUS. After treatment with infliximab for the PG, he developed myeloma. The course of events in this case suggests that infliximab facilitated the progression from MGUS to myeloma.

Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded?

BACKGROUND: It is routine practice to perform colonoscopy as a follow-up after an attack of diverticulitis, with the main aim to exclude any underlying malignancy. PURPOSE: This study aimed to determine whether colonoscopy is necessary and what additional information is gained from this procedure. DESIGN: This is a study of a retrospective cohort. SETTINGS AND PATIENTS: From January 2003 to June 2009, patients in whom left-sided diverticulitis was diagnosed on CT scan were matched with colonoscopy reports within 1 year from the date of CT by the use of radiology and endoscopy databases. Patients who had colonoscopy within 1 year before the CT scan were excluded. The Western Australian Cancer Registry was cross-referenced to identify patients who subsequently received diagnoses of cancers for whom colonoscopy reports were unavailable. MAIN OUTCOME MEASURES: The main outcome measures were the number of patients in whom colorectal cancers were diagnosed and other incidental findings, eg, polyps, colitis, and stricture. RESULTS: Left-sided diverticulitis was diagnosed in 1088 patients on CT scan, whereas follow-up colonoscopy reports were available for 319 patients. Eighty-two (26%) patients had incidental findings of polyps (9 polyps >1 cm), and 9 patients (2.8%) received diagnoses of colorectal cancers on colonoscopy. After cross-referencing with the cancer registry, the overall prevalence of colorectal cancer among the cohort within 1 year of CT scan was 2.1% (23 cases). The odds of a diagnosis of colorectal cancer were 6.7 times (95% CI 2.4-18.7) in patients with an abscess reported on CT, 4 times (95% CI 1.1-14.9) in patients with local perforation, and 18 times (95% CI 5.1-63.7) in patients with fistula compared with patients with uncomplicated diverticulitis. LIMITATIONS: This study was limited by the unavailability of data for private/interstate hospitals, and the relatively small number of cancer cases reduced the statistical power of the study. CONCLUSIONS: We recommend routine colonoscopy after an attack of presumed left-sided diverticulitis in patients who have not had recent colonic luminal evaluation. The rate of occult carcinoma is substantial in this patient population, in particular, when abscess, local perforation, and fistula are observed.

Prediction of outcome in newly diagnosed myeloma: a meta-analysis of the molecular profiles of 1905 trial patients.

Robust establishment of survival in multiple myeloma (MM) and its relationship to recurrent genetic aberrations is required as outcomes are variable despite apparent similar staging. We assayed copy number alterations (CNA) and translocations in 1036 patients from the NCRI Myeloma XI trial and linked these to overall survival (OS) and progression-free survival. Through a meta-anlysis of these data with data from MRC Myeloma IX trial, totalling 1905 newly diagnosed MM patients (NDMM), we confirm the association of t(4;14), t(14;16), t(14;20), del(17p) and gain(1q21) with poor prognosis with hazard ratios (HRs) for OS of 1.60 (P=4.77 × 10-7), 1.74 (P=0.0005), 1.90 (P=0.0089), 2.10 (P=8.86 × 10-14) and 1.68 (P=2.18 × 10-14), respectively. Patients with 'double-hit' defined by co-occurrence of at least two adverse lesions have an especially poor prognosis with HRs for OS of 2.67 (P=8.13 × 10-27) for all patients and 3.19 (P=1.23 × 10-18) for intensively treated patients. Using comprehensive CNA and translocation profiling in Myeloma XI we also demonstrate a strong association between t(4;14) and BIRC2/BIRC3 deletion (P=8.7 × 10-15), including homozygous deletion. Finally, we define distinct sub-groups of hyperdiploid MM, with either gain(1q21) and CCND2 overexpression (P<0.0001) or gain(11q25) and CCND1 overexpression (P<0.0001). Profiling multiple genetic lesions can identify MM patients likely to relapse early allowing stratification of treatment.

A fatal case of transplantation-mediated alloimmune thrombocytopenia following liver transplantation.

OBJECTIVE AND IMPORTANCE: Transplantation-mediated alloimmune thrombocytopenia (TMAT) occurs when leukocytes transferred in a donor organ from a patient with immune thrombocytopenia (ITP), mount a response against recipient platelets. We present the first fatal case of TMAT following liver transplantation and review its aetiology and treatment. CLINICAL PRESENTATION: The liver donor had ITP and died from an intracranial haemorrhage. The recipient platelet count fell to 2 × 109/l on post-operative day 2. Treatment refractory thrombocytopenia resulted in pulmonary haemorrhage and death. TMAT did not occur in a kidney recipient from the same ITP donor. INTERVENTION: Extramedullary haematopoiesis was identified in the donor liver biopsy. Antibodies against platelet GPIb/IX were demonstrated in both donor and recipient. The thrombocytopenia was refractory to platelet transfusions, intravenous immunoglobulin, methylprednisolone, rituximab, romiplostim, plasmapheresis, vincristine and splenic artery embolization. On review of the literature, severe thrombocytopenia (<10 × 109/l) has started within 3 days of transplantation in all reported TMAT cases. Serious non-fatal bleeding was observed in 3/5 previously reported cases. The optimal treatment is unclear. TMAT should resolve as donor lymphocytes are eliminated but re-transplantation may be required in severe refractory cases. TMAT has been reported in recipients of a liver but not kidney or heart transplant from ITP donors, probably because of the greater burden of co-transplanted lymphoid tissue. CONCLUSION: Before using the liver of an ITP donor, the recipient's fully informed consent is required. However, the risk of TMAT from an ITP donor is currently unknown and systematic review of donor registries is needed.

Second malignancies in the context of lenalidomide treatment: an analysis of 2732 myeloma patients enrolled to the Myeloma XI trial.

We have carried out the largest randomised trial to date of newly diagnosed myeloma patients, in which lenalidomide has been used as an induction and maintenance treatment option and here report its impact on second primary malignancy (SPM) incidence and pathology. After review, 104 SPMs were confirmed in 96 of 2732 trial patients. The cumulative incidence of SPM was 0.7% (95% confidence interval (CI) 0.4-1.0%), 2.3% (95% CI 1.6-2.7%) and 3.8% (95% CI 2.9-4.6%) at 1, 2 and 3 years, respectively. Patients receiving maintenance lenalidomide had a significantly higher SPM incidence overall (P=0.011). Age is a risk factor with the highest SPM incidence observed in transplant non-eligible patients aged >74 years receiving lenalidomide maintenance. The 3-year cumulative incidence in this group was 17.3% (95% CI 8.2-26.4%), compared with 6.5% (95% CI 0.2-12.9%) in observation only patients (P=0.049). There was a low overall incidence of haematological SPM (0.5%). The higher SPM incidence in patients receiving lenalidomide maintenance therapy, especially in advanced age, warrants ongoing monitoring although the benefit on survival is likely to outweigh risk.

Residual disease detection using fluorescent polymerase chain reaction at 20 weeks of therapy predicts clinical outcome in childhood acute lymphoblastic leukemia.

PURPOSE: Ninety-five percent of children with acute lymphoblastic leukemia (ALL) will achieve a remission, but approximately 25% will relapse. Identifying these patients is difficult, as patients with adverse prognostic features at presentation are rare and the majority are standard risk. Analysis of minimal residual disease (MRD) may be able to determine those at risk of relapse, but the best method by which this can be accomplished has yet to be defined. The object of this study was to determine the predictive value of residual disease detection in a group of standard-risk patients with precursor-B ALL at a fixed point in therapy (week 20) using a simple fluorescent consensus immunoglobulin H (IgH) heavy chain polymerase chain reaction (PCR). PATIENTS AND METHODS: Forty-two patients who presented with precursor-B ALL with standard-risk clinical features and treated according to either the Medical Research Council (MRC) UKALL X or XI protocols were assessed using a combination of both fluorescent consensus framework I and framework III Ig heavy-chain PCR. The results of the PCR were analyzed on an ABI 373 gene sequencer with genescan software (Applied Biosystems, Foster City, CA). Clonal rearrangements detected at presentation were looked for at week 20. RESULTS: Of 42 patients, 35 had a clonal population detectable at presentation; of these, seven had more than two clonal rearrangements; this latter group showed a similar disease-free survival (DFS) to the group as a whole. Thirty of 35 patients were analyzed before their second course of intensification therapy at week 20. At this point, nine of 30 had a detectable clonal rearrangement, eight (89%) of whom have since relapsed with a median DFS of 27.5 months. Of the rest of the group (n=21), in whom no clonal rearrangement was detectable, only six (21%) have relapsed. CONCLUSION: Fluorescent IgH PCR at week 20 provides a sensitive and specific means to predict ultimate relapse (57% and 89%, respectively) and is a simple yet promising technique for the identification of patients at risk of poor outcome.

Engraftment and molecular monitoring of CD34+ peripheral-blood stem-cell transplants for follicular lymphoma: a pilot study.

PURPOSE: A pilot study to validate the use of CD34+ selection (Ceprate SC) of blood stem-cell collection in patients with advanced follicular lymphoma receiving myeloablative chemoradiotherapy. PATIENTS AND METHODS: Seventeen patients were entered onto the protocol. Thirteen of 17 patients have undergone transplantation; the median age is 42.5 years (range, 33 to 51), seven of 13 are stage IVB, two stage IVA, three stage IIIB, and one stage IIB. All except two patients were treated after first or subsequent relapses after receiving cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy to achieve a good partial (six of 13) or complete (seven of 13) response before stem-cell mobilization with cyclophosphamide 3 g/m2 and filgrastim 300 microg once daily. RESULTS: Eleven of 13 patients had a detectable t(14;18) by nested polymerase chain reaction (PCR). Median CD34+ count before selection was 2.9 x 10(6)/kg (range, 1.17 to 11.3) and after CD34+ selection was 1.54 x 10(6)/kg (range, 0.88 to 7.6) with a median CD34+ yield of 62.4% (range, 17% to 95%) and purity of 60% (range, 39.3% to 73%). Of the 11 patients known to have t(14;18), 10 had PCR-detectable contamination of stem-cell harvests that became PCR negative in six of the 10 after CD34+ selection. Engraftment was rapid with a median day to absolute neutrophil count (ANC) greater than 0.5 x 10(9)/L of 13 days (range, 11 to 21) and platelet count greater than 20 x 10(9)/L of 14 days (range, 10 to 44). With a median follow-up duration of 15 months, three patients have remained persistently PCR-positive, two of whom received PCR-positive stem cells. Two have relapsed. Of the seven patients who received PCR-negative stem cells, five have had no PCR-detectable disease in posttransplant bone marrow samples. CONCLUSION: Longer follow-up duration is required to determine the significance of these findings, but we have confirmed the feasibility of CD34+ selected cells to deplete peripheral-blood stem cells of tumor cells from patients undergoing high-dose therapy for follicular lymphoma.

Detection of clonal immunoglobulin gene rearrangements in the PBPC harvests of patients with acute lymphoblastic leukaemia.

We have used a fluorescently based PCR technique to detect rearrangements in the immunoglobulin heavy chain (IgH) gene in the presentation BM of five patients with adult ALL and have looked for similar rearrangements in their PBPC. Using this approach we have been able to demonstrate clonal rearrangements in the PBPC of two of five patients. Remission BM samples taken 6-12 weeks prior to leucapheresis failed to show a clonal rearrangement in either patient. The significance of these results is discussed.

Peripheral blood stem cell transplantation in myeloma using CD34 selected cells.

We have performed nine CD34 selection procedures on peripheral blood stem cells harvested from eight patients with myeloma using the Cellpro avidin-biotin immunoaffinity column (Ceprate). They all received CVAMP chemotherapy to maximum response prior to mobilisation. Six of the patients have been transplanted using these cells, one receiving successive autografts. Median absolute cell numbers processed and retrieved were: 31.1 x 10(9) pre-column, 2.07 x 10(8) in the final product and 30.4 x 10(9) in the column waste. Mean CD34 positivity in the product was 49% (range 18.4-98) with a median CD34+ yield of 31.4% (range 21-37.8). IgH PCR was performed and seven of the eight patients were amplifiable. Of these, two were positive in the pre-column product and both of these were successfully purged with a negative result in the final, post-column product. Patients were transplanted with a median of 2.0 x 10(6) CD34+ cells/kg (range 1.5-9.4) following conditioning with melphalan 200 mg/m2. The mean time to recovery of neutrophils to > 0.5 x 10(9)/l and platelets to > 20 x 10(9)/l was 16 and 17 days, respectively. At a mean follow-up of 9 months, four of the six patients transplanted are alive, three of them in complete remission and one in a clinically stable relapse. One has died of disease relapse and one of progressive neurological problems the aetiology of which was uncertain but there was no sign of progression of their myeloma. We conclude that PBSCT using CD34 selected cells is safe and practical in myeloma following remission induction with CVAMP chemotherapy.

Waldenström macroglobulinemia. Development of diagnostic criteria and identification of prognostic factors.

To establish whether a combination of morphologic and immunophenotypic criteria could be developed to more precisely define Waldenström macroglobulinemia (WM) and prognostic factors, we retrospectively assessed the clinical and laboratory features of 111 cases of WM. Bone marrow infiltration by small lymphocytes was documented in each case; and diffuse, interstitial, nodular, and paratrabecular patterns of infiltration were documented in 58%, 32%, 6%, and 4% of cases, respectively. Ninety percent were characterized by a surface immunoglobulin-positive, CD19+CD20+CD5-CD10-CD23- immunophenotype. The median overall survival from diagnosis was 60 months; univariate analysis revealed the following adverse prognostic factors: older than 60 years, performance status more than 1, platelet count less than 100 x 10(3)/microL (< 100 x 10(9)/L), pancytopenia, and diffuse bone marrow infiltration. Associated median survival was 40, 38, 46, 28, and 59 months, respectively. Multivariate analysis revealed age, performance status, and platelet count as prognostically significant, but stratification of patients according to the International Prognostic Index had limited value. We suggest defining WM by the following criteria: IgM monoclonal gammopathy; bone marrow infiltration by small lymphocytes, plasmacytoid cells, and plasma cells in a diffuse, interstitial, or nodular pattern; and a surface immunoglobulin-positive, CD19+CD20+CD5-CD10-CD23- immunophenotype.

Eosinophilic myelodysplasia transforming to acute lymphoblastic leukaemia.

A 43 year old male presented with a marked eosinophilia and associated systemic symptoms. A diagnosis of myelodysplasia was made on the basis of bone marrow morphology and karyotype. Over a 12 month period the disease transformed into acute lymphoblastic leukaemia, confirmed by flow cytometry, cytochemistry, and immunohistochemistry. Karyotyping was abnormal with 5q- and -7 which persisted from diagnosis through to blastic transformation. He died following initial induction chemotherapy. Eosinophilic myelodysplasia is an uncommon condition in haematological practice and no previous report of lymphoblastic transformation has been found.

Assessment of IgH PCR strategies in multiple myeloma.

AIMS: To compare the ability of four commonly used PCR techniques to demonstrate clonal IgH rearrangements in multiple myeloma. METHODS: Bone marrow samples (containing a minimum of 10% plasma cells) were obtained from 127 patients with confirmed multiple myeloma. Framework 3 (Fr3) PCR was performed in all cases and the Framework 1 (Fr1f) PCR, which utilises six VH family specific primers, in 98 cases. In addition, 44 cases were assessed by Fr3, Fr1f, Framework 2 (Fr2) and Framework 1 consensus (Fr1 con) PCR techniques. JH primer selection was also assessed such that each PCR strategy was performed twice in each of the 44 cases, using the JH consensus primer (JH con) alone and then repeated with an equimolar mixture of JH con, JH3 and JH6 (JH mix). RESULTS: Clonal rearrangements were demonstrated in 71 (56%) of 127 cases with the Fr3 PCR and in 52 (53%) of 98 with the Fr1f PCR. However, by using both techniques it was possible to demonstrate clonal IgH rearrangements in 92 (75%) of 122 cases. Forty four cases were assessed by all four PCR techniques; in these cases the Fr3 and Fr1f PCRs demonstrated clonal rearrangements in 26 (59%) cases with a combined yield of 34 (77%). The Fr2 and Fr1 con PCR techniques had inferior pick up rates, demonstrating clonal rearrangements in 21 (48%) of 44 cases and a combined yield of 28 (63%). The Fr2 PCR did, however, demonstrate a clonal rearrangement in one case negative by both Fr3 and Fr1f. Two additional rearrangements were demonstrated by using JH mix; one became positive by Fr3, Fr1f and Fr2 and the other positive by Fr1f, Fr1 con and Fr2. CONCLUSIONS: By utilising both the Fr3 and Fr1f PCR techniques it is possible to demonstrate definitive clonal rearrangements in the majority of patients with multiple myeloma. The Fr1 con and Fr2 PCR techniques have inferior pick up rates but may detect some additional rearrangements.

Clinicopathological correlates of IgM paraproteinemias.

IgM paraproteinemia is considered to be the major defining feature of Waldenström's macroglobulinemia (WM), but it may also occur in other B-cell lymphoproliferative disorders. In this study we have reviewed the final pathological diagnosis of 106 patients with IgM paraproteinemia investigated in our laboratories between April 1993 and May 1999. In 22 of the 106 patients (20.8%), there was no clinical or laboratory evidence of an underlying lymphoproliferative disorder, and a diagnosis of monoclonal gammopathy of undetermined significance (MGUS) was therefore made. In 60 cases (56.6%), a diagnosis of WM was made, while in the remaining 24 patients, the final diagnosis was chronic lymphocytic leukemia (n = 10), diffuse large B-cell lymphoma (n = 5), extranodal marginal-zone lymphoma (n = 3), follicular lymphoma (n = 3), and mantle-cell lymphoma (n = 3). The median paraprotein concentration in patients with WM, MGUS, and "other" lymphoproliferative disorders was 13 g/L (range, 2-54), 6 g/L (range, 3-30), and 4.5 g/L (range, 3-61), respectively. It is clear that IgM paraproteins are demonstrable in all subtypes of peripheral B-cell disorders and, although paraprotein concentrations are generally higher in WM, there is considerable overlap. Immunophenotypic criteria are therefore essential for the accurate diagnosis of WM.

Changes in size and shape of auditory hair cells in vivo during noise-induced temporary threshold shift.

In this study we describe changes in the size and shape of auditory hair cells of the alligator lizard in vivo during noise-induced temporary threshold shift. These changes consist of a decrease in cell volume, a decrease in cell length and an increase in cell width. We speculate that these changes are due to relaxation of cytoskeletal contractile elements and osmotic loss of intracellular water. We also describe a decrease in the surface area of the hair cell plasmalemma, and speculate that it is related to the endocytosis and intracellular accumulation of cell membrane during synaptic vesicle recycling. Finally we describe an increase in the endolymphatic surface area of the hair cell, and speculate that this could alter the micromechanics of the stereociliary tuft to attenuate the effective stimulus.

Treatment options in Waldenström's macroglobulinaemia: the role of the purine analogues.

The purine nucleoside analogues, either alone or in combination with other chemotherapeutic agents, are increasingly used in the treatment of patients with indolent B-cell lymphoproliferative disorders. The initial studies in Waldenström's macroglobulinaemia (WM) are very promising. Approximately 40% of patients who have received prior therapy with alkylating agents respond, while response rates of up to 90% have been documented in untreated patients. However, it is not known whether the purine analogues offer any significant advantage over alkylating agents such as chlorambucil. In this review the treatment options in WM and in particular the role of the purine analogues are discussed.

Hispanic and black American adolescents' beliefs relating to sexuality and contraception.

Popular beliefs and level of scientific knowledge regarding sexuality and contraception were elicited from black and Hispanic inner-city adolescents. Significant differences were found: Hispanic males were the most knowledgeable, Hispanic females the least, and black males and females were intermediate. A cultural basis for the dramatic difference between Hispanic male and female scores is suggested and the need to design culturally appropriate sexuality education classes is discussed. In addition, the data depicted two conflicting beliefs that were held simultaneously by many of the adolescents: Contraception is "good" because it prevents pregnancy, and it is "bad" because the various birth control methods carry serious health hazards for users.

PIP: Popular beliefs and level of scientific knowledge regarding sexuality and contraception were elicited from black and Hispanic adolescents in a major US inner-city area of Miami, Florida. Significant differences were found between the 2 groups. Hispanic males were the most knowledgeable, Hispanic females the least, and black males and females were intermediate. A cultural basis for the dramatic difference between Hispanic male and female scores lies in the Latin American belief that the woman should remain sexually naive (embodied in the Spanish words verguenza, marianismo and decente) and that the male role is one of sexual virility, courage, honor and a provider for his family ('machismo'). In addition, the data depicted 2 conflicting beliefs that were held simultaneously by many of the adolescents: Contraception is "good" because it prevents pregnancy, and it is "bad" because the various birth control methods carry serious health hazards for users. Data indicated that there was a very low level of scientific knowledge, even among those who were pregnant and/or had had a sex education course in school. Data from this and other studies indicate that sexuality and contraceptive education sessions may be made more effective by pretesting participants to determine their general level of knowledge as well as their misconceptions, and by using this information to tailor the content of the sessions to the specific needs of the groups. Differences in gender and ethnic group must also be considered in planning educational activities. (author's modified).