IgD multiple myeloma: biology, diagnosis, and treatment.

IgD multiple myeloma is uncommon. Patients generally present at a younger age and have shorter progression free and overall survivals (OSs). Its rarity has inhibited development of a specific risk stratification system or informed best treatment protocols. We present interphase fluorescence in situ hybridization results from a group of 29 cases. These showed evidence of a decreased male to female ratio, decreased OS in patients aged 70 and over, better outcomes in those with kappa light chain restriction, and CD56 positive patients had longer survivals than those lacking CD56. We discuss the biology of IgD multiple myeloma, the need for prospective studies, and challenges for improvements in diagnosis and treatment. We suggest an International Register to accelerate development of best practice guidelines for diagnosis, risk stratification, and treatment.

Clarithromycin with low dose dexamethasone and thalidomide is effective therapy in relapsed/refractory myeloma.

A combination of clarithromycin, low dose of thalidomide and low dose dexamethasone was used in a phase II study to treat patients with relapsed and refractory myeloma. Thirty patients received clarithromycin 250 mg twice daily and thalidomide 50 mg at night on an ongoing basis with 4-d pulses of 10 mg dexamethasone given monthly. Eight patients had permitted escalation of thalidomide dosage up to 200 mg daily. The combination was well tolerated and could be given to elderly, infirm and severely cytopenic patients. Response rates were high, with 89% achieving at least 50% reduction in paraprotein and a 96% overall response rate. Although clarithromycin has only minimal anti-myeloma properties when used as a single agent, its combination with thalidomide and dexamethasone appears very effective, allowing these to be used in lower and more tolerable doses with good clinical effects.

Telomeric IGH losses detectable by fluorescence in situ hybridization in chronic lymphocytic leukemia reflect somatic VH recombination events.

Routine interphase fluorescence in situ hybridization (FISH) analysis of chronic lymphocytic leukemia (CLL) with LSI IGH/CCND1 assay, applied to differentiate CLL from leukemic mantle cell lymphoma, identified a subset of cases (42/174) with translocation-like IGH signal pattern. To unravel the underlying 14q32/IGH aberrations, 14 of these cases were subjected to cytogenetic, detailed FISH, and V(H) mutation analyses. FISH identified cryptic losses of various portions of the IGHV region in all 14 cases. Fine mapping of these V(H) deletions revealed a strict correlation between their distal border and localization of the used VH gene, suggesting that they are not oncogenic but reflect physiological events accompanying somatic V-D-J assembly. This hypothesis was further supported by FISH analysis of 20 CLL and hairy cell leukemia cases with the known V(H) usage showing a constant loss of sequences proximal to the used gene, identification of V(H) deletions in normal B cells, and their exclusive demonstration in B cell malignancies, but not of T cell and myeloid linage. Given that these cryptic physiological VH losses in B cells may seriously complicate analysis of B cell leukemia/lymphoma and lead to false conclusions, FISH users should take them into consideration when interpreting IGH aberrations in these malignancies.

V(H)3-48 and V(H)3-53, as well as V(H)3-21, gene rearrangements define unique subgroups in CLL and are associated with biased lambda light chain restriction, homologous LCDR3 sequences and poor prognosis.

This study determined IgV(H) gene usage in 228 chronic lymphocytic leukaemia patients to investigate associations between gene usage and other biological or clinical characteristics. V(H)3-48 [N=8] and V(H)3-53 [N=4] gene rearrangements showed biased lambda light chain restriction and were predominantly found in female patients with short lymphocyte doubling time but without adverse prognosis cytogenetics. Overuse of V(L)3-21(Vlambda2-14) gene and highly homologous LCDR3 sequences were found in V(H)3-48 patients. V(H)3-21 gene usage [N=18, 7.9%] was associated with poor prognosis, overuse of V(L)3-21(Vlambda2-14) gene and highly homologous heavy- and light-chain CDR3 sequences, but was not associated with poor prognosis chromosomal aberrations.

MDR-1, but not MDR-3 gene expression, is associated with unmutated IgVH genes and poor prognosis chromosomal aberrations in chronic lymphocytic leukemia.

Two P-glycoprotein (P-gp) genes, MDR-1 (ABCB1) and MDR-3 (ABCB4), have been identified in humans. This study was designed to investigate whether associations exist between expression of MDR-1 and MDR-3 P-gp and other markers of poor prognosis and/or prior exposure to therapeutic agents in chronic lymphocytic leukemia (CLL). IgVH mutational status, gene usage, CD38 positivity, FISH analysis and clinical information were available on all patients. Twenty-one of 101 patients tested showed MDR-3 P-gp positivity. Associations with markers of poor prognosis or prior chemotherapy did not reach statistical significance, but MDR-3 P-gp positive patients had significantly shorter survivals than MDR-3 P-gp negative patients. MDR-1 P-gp expression (18/25) showed a strong association with unmutated IgVH genes and adverse prognosis cytogenetics (p = 0.015, p = 0.014, respectively), but was independent of prior exposure to chemotherapeutic agents. These results suggest a role for MDR-1 and MDR-3 in chemoresistant disease. This study highlights the value of determining MDR phenotype in CLL patients prior to treatment, to allow the design of novel drug regimens containing agents that reverse MDR function.

Detection of tumor-derived antigen receptor DNA by polymerase chain reaction in the serum of patients with B-cell chronic lymphocytic leukemia.

Tumor-derived DNA is detectable in the serum of patients. In this study, tumor derived and mononuculear cell DNA from 50 patients with B-cell chronic lymphocytic leukemia (B-CLL) was amplified by polymerase chain reaction (PCR) and analyzed using polyacrylamide electrophoressis and Genescan analysis. DNA was demonstrated in 86% of serum samples. Genescan analysis has significantly enhanced the sensitivity and specificity of detection of tumor-derived DNA.

Variation in dimethyl sulfoxide use in stem cell transplantation: a survey of EBMT centres.

The cryoprotectant dimethyl sulfoxide (DMSO) is known to have toxic side effects, yet guidelines for its use in stem cell transplantation do not exist. To assess current practice in the use of DMSO and the incidence of DMSO-related complications, a single page questionnaire was mailed to 444 EBMT centres involved in autologous transplantation. The responses from 97 centres showed a wide variation in practice between transplant units regarding the concentration of DMSO used, daily DMSO dose restriction and the use of cell washing. The overall incidence of DMSO toxicity was approximately one in 70 transplants and most cases were cardiovascular and respiratory in nature. There was a trend to reduced complication rates in centres using lower concentrations of DMSO or washing cells prior to return. A large-scale prospective study of the strategies for reduction in exposure to DMSO and reduction in toxic effects is required before guidelines in the use of DMSO in stem cell cryopreservation can be promulgated.

WHO reclassification of breast lymphomas.

Fourteen cases of breast lymphoma, identified from hospital records between 1990 and 2004, were reclassified according to the World Health Organisation criteria. Primary cases occurred more frequently and all cases were of B cell origin, predominantly involving the right breast. Most primary cases were diffuse large B cell lymphomas, whereas secondary cases were heterogeneous in type and most had a poor prognosis.

Myelodysplasia terminating in acute myeloid leukemia in a hairy cell leukemia patient treated with 2-deoxycoformycin.

Purine analogs are effective in the treatment of several chronic lymphoproliferative disorders (CLPD) including hairy cell leukemia (HCL). To date, little evidence exists that these drugs are oncogenic. We report a case of HCL in a 66-year-old male treated with 2-deoxycoformycin. Just over 1 year following completion of his treatment, falling platelet and white cell counts were associated with the development of dysplastic features in his bone marrow and a rising blast cell count, culminating in the development of acute myeloid leukemia (AML). To the best of our knowledge only two previous cases of AML have been linked to treatment of HCL with purine analogs, both with 2-chlorodeoxyadenosine. We emphasize the need for long term follow up of patients treated with purine analogs and suggest that even those who are apparently cured be monitored periodically.

Red cell aplasia due to erythrovirus parvovirus B19 infection in a Jehovah's witness with post-transplant EBV-induced aggressive lymphoma: management considerations.

The refusal of Jehovah's Witnesses to accept blood and blood products often poses a clinical dilemma to present day medicine. We present a case of a Jehovah's Witness who had undergone renal transplantation, only to develop an Epstein-Barr virus associated aggressive lymphoma post-transplant. His condition was further complicated by erythrovirus (parvovirus) B 19 infection resulting in red cell aplasia and severe anemia. The management of this difficult clinical situation is discussed together with a review of recommendations for chemotherapy treatment in Jehovah's Witnesses.

Routine analysis of IgVH mutational status in CLL patients using BIOMED-2 standardized primers and protocols.

Current methods for the detection of IgVH mutational status in chronic lymphocytic leukemia (CLL), which identifies 2 subgroups of patients with significantly different outcomes, are laborious, expensive and do not lend themselves to a routine diagnostic setting. With the introduction of BIOMED-2 primers, a rapid protocol is now available. This study evaluated the protocol by examining DNA from 100 CLL patients. Conventional methods using RNA, and fluorescence in-situ hybridization (FISH) analysis for recurring chromosomal abnormalities, were carried out on 30 and 60 of these patients, respectively. There was complete concordance between the BIOMED-2 protocol and the RNA based method, both in mutational status and gene usage, whilst unmutated IgVH genes showed association with 17p13 and 11q23 deletions, and trisomy 12, associated with poor and intermediate outcomes, respectively. This study demonstrates that it is feasible to use the BIOMED-2 protocol in the diagnostic profile of CLL patients, obviating the need for inclusion of surrogate markers such as ZAP-70.

Immunoglobulin gene rearrangement investigations in the diagnosis of lymphoid malignancies from formaldehyde-fixed biopsies.

Determination of the biologic potential of lymphoid proliferations in biopsies can be difficult by standard histological or even immunohistochemical examination. Polymerase chain reaction (PCR) has been used with increasing frequency to detect clonal rearrangements of the immunoglobulin heavy chain (IgH) in formaldehyde fixed, paraffin wax embedded tissues. Sensitivity ranges between 50 and 80%, and therefore at least 20% of neoplasms remain undetected by these approaches. Few investigators have attempted to detect immunoglobulin light chain (IgL) gene rearrangements by PCR using paraffin wax embedded samples. We studied 29 cases of B-cell neoplasms, along with 21 cases with equivocal histology and 4 reactive biopsies, using degenerate oligoprimers to amplify Ig(kappa) and Ig(lambda) light chain genes, along with IgH (Fr 1, 2 and 3) gene rearrangement analysis. The combination of these methods detected clonality in 93% of cases (27/29) with histological diagnosis of B-NHL. Fr2 and Fr3 primers detected clonality in 79% (23/29) of cases. IgL chain rearrangements detected 4 cases (14%), negative for IgH rearrangements, improving sensitivity from 79 to 93%. Clonality was detected in 52% (11/21) of histologically equivocal lymphoid proliferations, including one case detected by IgL rearrangements which was negative for IgH rearrangements. Archival material from 4 cases with reactive histology produced polyclonal results. These results confirm that PCR based immunoglobulin gene rearrangement is a sensitive and specific method for demonstrating B-cell clonality in paraffin-wax embedded sections. The addition of IgL analysis to the IgH assay allows the detection of greater than 90% of B-cell lymphoproliferative disorders from routine histological specimens with poor preservation of genomic DNA.

Aggressive natural killer cell leukemia/lymphoma: case report, use of telesynergy and review of the literature.

Natural killer cell malignancies, although increasingly recognized, remain rare tumors within the USA and Europe. They are somewhat more common in Asia, and have been best characterized within this population. We present a case of a young Caucasian woman who presented acutely with an aggressive natural killer cell leukemia/lymphoma. Use of Telesynergy technology enabled a transatlantic telemedicine conference with colleagues in a center of expertise. Unfortunately the patient was ultimately refractory to both conventional chemotherapy and Campath-1H and her disease course was fulminant, as has been described previously in this condition. We review the possible therapeutic options for this extremely aggressive malignancy and briefly discuss our center's experience of telemedicine technology.

Improved laboratory diagnosis of bacterial and fungal infections in patients with hematological malignancies using PCR and ribosomal RNA sequence analysis.

During October 1999 to November 2000, 98 blood culture specimens from the same number of febrile episodes originating from 49 patients with hematological malignancies were examined for the presence of eubacteria and fungi based on 16S rRNA gene and the 5.8, 18 and 28S rRNA combined with in vitro PCR amplification and sequencing, in addition to conventional blood culture laboratory techniques. Nineteen of the samples were associated with positive blood cultures. Eubacterial (16S rRNA) PCR detected bacterial DNA in 26 febrile episodes, i.e. in an additional 7 febrile episodes than blood-culture alone. The species identified by partial 16S rRNA gene sequencing were as follows Staphylococcus spp (n = 6), Staphylococcus epidermidis (n = 5), Acinetobacter spp (n = 5), Escherichia coli (n = 2), Enterobacter agglomerans (n = 2), Campylobacter spp (n = 1), Citrobacter spp (n = 1), Corynebacterium spp (n = 1), Enterobacter faecium (n = 1), Ralstonia spp (n = 1), Acidovorax spp. (n = 1) and Stenotrophomonas maltophilia (n = 1). Gram-positive bacteria were found in 12/27 (44.6%) and gram-negative bacteria were found in 15/27 (55.6%). After optimization of a PCR-based fungal detection method, none of the febrile episodes were shown to be attributable to fungi. The results of this study suggest that fungi are not common causal agents of febrile episodes in patients with a hematological malignancy at this centre and that molecular techniques can augment cultural methods in the diagnosis of causal agents of bacteremia in patients, so that appropriate antibiotic regimens may be commenced in patients with culture-negative episodes of infection.

Catheter-related bloodstream infection in adult haematology patients: catheter removal practice and outcome.

The aim of the present study was to describe the practice of central venous catheter (CVC) removal and outcomes of catheter-related bloodstream infection (CR-BSI) in adult haematology patients. Patients were identified retrospectively according to diagnosis coding of inpatient episodes and evaluated when, on examination of medical records, there had been evidence of sepsis with strong clinical suspicion that the source was the CVC. Demographic and bacteriological data, as well as therapeutic measures and clinical outcomes, were recorded. One hundred and three patient episodes were evaluated. The most frequent type of CVC was the Hickman catheter and the most frequently isolated pathogen was coagulase-negative staphylococci. Twenty-five percent of episodes were managed with catheter removal. Treatment failure, defined as recurrence of infection within 90 days or mortality attributed to sepsis within 30 days, occurred significantly more frequently in the group managed without catheter removal (52.5% versus 4%, P < 0.05). Specifically, 90-day recurrence was more common when the catheter was retained (46% versus 0%). However the difference in 30-day attributable mortality (7% versus 4%) was not significantly different. Notably, no significant difference between the two groups emerged in respect of other measured characteristics that had been considered as potential determinants of outcome. More frequent CVC removal for CR-BSI, in this population, should be considered. Management of CR-BSI without catheter removal is associated with treatment failure, morbidity and carries significant resource implications.

Trends in bacteraemia on the haematology and oncology units of a UK tertiary referral hospital.

As part of ongoing surveillance of infection in the haematology and oncology units at Belfast City Hospital, microbiologically documented bloodstream infections over three 12-month periods 1994/5, 1998/9 and 1999/00 were reviewed. Gram-positive organisms were the most common cause of blood stream infection in the haematology unit causing 66%, 56% and 64% of episodes of monomicrobial bacteraemia in 1994/5, 1998/9 and 1999/00, respectively. In haematology patients, enterococci have emerged as an important cause of bacteraemia, with increasing levels of glycopeptide resistance, and the 'non-fermenting Gram-negative rods other than Pseudomonas aeruginosa' are an increasingly common cause of monomicrobial and polymicrobial bacteraemia. In oncology patients, Gram-negative organisms (predominantly enterobacteriaceae) were more common than Gram-positive organisms, causing 50% and 54% of monomicrobial bacteraemia in 1998/9 and 1999/00, respectively. Changes in patient population, underlying diseases and chemotherapeutic agents may explain these findings. The spectrum of infection seen in haematology and oncology patients changes as management evolves. Ongoing co-operation between haematologists, oncologists and microbiologists is important to detect trends in epidemiology, which can be used to design empirical antibiotic regimens and guide infection control policies.

Spontaneous splenic rupture in atypical (Philadelphia chromosome negative) chronic myeloid leukaemia following blastic crisis.

Philadelphia chromosome negative and bcr/abl negative chronic myeloid leukaemia (CML) is an uncommon atypical CML. We describe a patient with this disorder who experienced an acute blastic transformation that resulted in rapid splenic enlargement and subsequent atraumatic splenic rupture. Clinically, spontaneous splenic rupture may be a difficult diagnosis to make and this case highlights the importance of considering atraumatic splenic rupture as a cause for unexplained abdominal pain in a patient with a haematological malignancy.